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Direc and Indirct RSTRTN PDF
Direc and Indirct RSTRTN PDF
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nated the usefulness of more traditional
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restorative materials such as gold, base
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metal alloys and dental amalgam. U
A ING EDU 1
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Direct and indirect Overview. This report outlines T Iimportant
CLE
features of direct and indirect restoratives,
with an emphasis on the safety and efficacy
restorative materials of each material.
Conclusions and Practice
Implications. This article was developed
ADA COUNCIL ON SCIENTIFIC AFFAIRS to help dentists explain to their patients the
relative pros and cons of various materials
used in dental restorations, which include
atients and practitioners have a variety of fillings, crowns, bridges and inlays. The
P options when choosing materials and proce- weight of the scientific evidence indicates
dures for restoring carious lesions or missing that all of these materials are safe and effec-
teeth. This report outlines important features tive for their intended use. Patients, in con-
of many of the most popular restorative choices sultation with their dentists, are free to
and is intended as a communication tool for dentists to choose the most appropriate among them for
use in discussing the options available for a particular their particular needs.
restoration with their patients. This is not a comprehen-
sive literature review and, due to space
limitations, it covers only the most com-
The weight of monly used restorative materials. The to explain the differences between the
the scientific choice of material and procedures to two categories thus: Direct materials
evidence restore form, appearance and function are those that can be placed directly in
to the dentition is an important health the tooth cavity during a single appoint-
indicates that
care decision that is ultimately made by ment. Indirect materials are used to
all of the the patient after careful consultation fabricate restorations in the dental lab-
various dental with his or her dentist. It is imperative oratory that then are placed in or on the
restorative that dentists provide this information in teeth; placement of indirect materials
materials a manner that is clear, concise and generally requires two or more visits to
are safe and based on the best available scientific complete the restoration. Table 3 (page
information. 466) lists commonly used direct and
effective for
This article is a companion piece to indirect materials.
their intended the chart comparing the important fea- The service life of dental restoratives
use. tures of many frequently used restora- depends on a number of patient-, ma-
tive materials that appeared in the terial- and procedure-related factors.
March 18, 2002, issue of ADA News1 Patient-related factors include the size
(Tables 1 and 2). The chart tabulated physical and clin- and location of the restoration, chewing
ical characteristics of the two common categories of habits and loads, the level of oral
materials: direct and indirect. Practitioners might wish hygiene and maintenance, and systemic
“Practical Science” is prepared each month by the ADA Council on Scientific Affairs and Divi-
sion of Science, in cooperation with The Journal of the American Dental Association. The
mission of “Practical Science” is to spotlight what is known, scientifically, about the issues
and challenges facing today’s practicing dentists.
TABLE 1
Principal Uses Dental fillings and Esthetic dental fill- Small non–load-bearing fillings, cavity liners and
heavily loaded back ings and veneers. cements for crowns and bridges.
tooth restorations.
Leakage and Leakage is mod- Leakage low when Leakage is generally low; Leakage is low when
Recurrent Decay erate, but recurrent properly bonded to recurrent decay is com- properly bonded to the
decay is no more underlying tooth; parable to other direct underlying tooth;
prevalent than other recurrent decay materials, fluoride release recurrent decay is
materials. depends on mainte- may be beneficial for comparable to other
nance of the tooth- patients at high risk for direct materials; fluo-
material bond. decay. ride release may be
beneficial for patients
at high risk for decay.
Cavity Requires removal of Adhesive bonding permits removing less tooth structure.
Preparation tooth structure for
Considerations adequate retention
and thickness of the
filling.
Clinical Tolerant to a wide Must be placed in a well-controlled field of operation; very little tolerance to
Considerations range of clinical presence of moisture during placement.
placement condi-
tions, moderately
tolerant to the pres-
ence of moisture
during placement.
Resistance to Highly resistant to Moderately resistant, High wear when placed on chewing surfaces.
Wear wear. but less so than
amalgam.
Esthetics Silver or gray Mimics natural tooth Mimics natural tooth color, but lacks natural
metallic color does color and translu- translucency of enamel.
not mimic tooth cency, but can be
color. subject to staining
and discoloration
over time.
Relative Cost to Generally lower; Moderate; actual cost of fillings depends on their size and technique.
Patient actual cost of fillings
depends on their
size.
TABLE 2
General Porcelain, ceramic Ceramic is fused to Alloy of gold, copper and Alloys of non-noble
Description or glass-like fillings an underlying metal other metals resulting in metals with silver
and crowns. structure to provide a strong, effective filling, appearance resulting
strength to a filling, crown or bridge. in high-strength
crown or bridge. crowns and bridges.
Principal Uses Inlays, onlays, Crowns and fixed Inlays, onlays, crowns Crowns, fixed bridges
crowns and bridges. and fixed bridges. and partial dentures.
esthetic veneers.
Leakage and Sealing ability The commonly used methods used for placement provide a good seal against
Recurrent Decay depends on leakage. The incidence of recurrent decay is similar to other restorative
materials, under- procedures.
lying tooth structure
and procedure used
for placement.
Durability Brittle material, Very strong and High corrosion resistance prevents tarnishing; high
may fracture under durable. strength and toughness resist fracture and wear.
heavy biting loads.
Strength depends
greatly on quality of
bond to underlying
tooth structure.
Cavity Because strength Including both The relative high strength of metals in thin sections
Preparation depends on ad- ceramic and metal requires the least amount of healthy tooth structure
Considerations equate ceramic creates a stronger removal.
thickness, it restoration than
requires more ceramic alone; mod-
aggressive tooth erately aggressive
reduction during tooth reduction is
preparation. required.
Clinical These are multiple-step procedures requiring highly accurate clinical and laboratory
Considerations processing. Most restorations require multiple appointments and laboratory fabrication.
Resistance to Highly resistant to Highly resistant to Resistant to wear and gentle to opposing teeth.
Wear wear, but ceramic wear, but ceramic
can rapidly wear can rapidly wear
opposing teeth if its opposing teeth if its
surface becomes surface becomes
rough. rough.
Esthetics Color and translu- Ceramic can mimic Metal colors do not mimic natural teeth.
cency mimic natural natural tooth appear-
tooth appearance. ance, but metal
limits translucency.
Relative Cost to Higher; requires at Higher; requires at least two office visits and laboratory services.
Patient least two office visits
and laboratory
services.
quent.11 A 1986 review of the literature spanning fillings to the tooth. Shrinkage of the composite
a time frame of 1905 to 1986 turned up only 41 on curing can induce stress on the
cases of amalgam allergy.12 Considering the hun- restoration/tooth bond, resulting in strain or
dreds of millions of amalgams that were placed bending of the tooth and in rare instances frac-
over this period, amalgam allergy can be consid- ture. Failure of the tooth/composite bond also can
ered very rare. be a source of early postoperative sensitivity.
Efficacy of dental amalgam. Until the advent of Recent improvements in composites and the
resin-based composites in the late 1960s, adhesives used to place composites have mini-
amalgam was the restorative material of choice mized the occurrence of these adverse events.
for all but the most esthetically demanding resto- Composite restorative materials are rarely
rations. For example, the total number of placed without the use of an adhesive. The cavity
amalgam restorations placed in 1979 in the preparation is cleaned, etched with phosphoric
United States was estimated to be 157 million.13 acid or similar etchant and impregnated with a
That number had declined to about 66 million in bonding resin to adhere mechanically to the
1999. The relative number of microporosities created by etching
amalgam restorations placed was the dentin and enamel. Bonding
surpassed by resin-based composite Like other restorative resins typically contain low–molec-
restorations in the late 1990s, and ular-weight resin monomers, and
materials currently
the use of amalgam continues to some of these have been implicated
decline at a fairly constant rate. approved for use in in allergic reactions. Sensitization
This decline can be attributed to dentistry, resin-based to compounds such as hydroxyethyl
several factors, including the composites are methacrylate have been reported,
increase in the demand for esthetic considered safe. but the problem is actually more
restorations, the reduction in dental common among dentists than it is
caries and its severity, improve- among patients.16 Frequent expo-
ments in composite technology and sure to these resins have been
improved training and experience of the clinician reported to cause allergic dermatitis on the fin-
in the placement of composite restorations. gertips of clinicians who have had repeated direct
Resin-based composites. Composite restora- contact with these unreacted monomers.18
tive materials are complex blends of polymeriz- Another safety concern regarding resin-based
able resins mixed with glass powder fillers. To composites arose in the mid-1990s, when some
bond the glass filler particles to the plastic resin researchers claimed to have detected the presence
matrix, the filler particles are coated with silane, of bisphenol A, which is known to have an estro-
an adhesive coupling molecule. Other additives genic potential, in the saliva of patients who
also are included in composite formulations to recently had received pit-and-fissure sealants.19
enhance radiographic opacity for better diagnostic The presence of bisphenol A in the dental
identification, to facilitate curing and to adjust sealants in this study was thought to have origi-
viscosity for better handling. Color and translu- nated from the breakdown of bisphenol A
cency of dental composites are modified to mimic glycidyl dimethacrylate, or Bis-GMA, a monomer
the color and translucency of teeth, making them commonly used in composite and sealant formula-
the most esthetic direct filling material available. tions. Two recent studies disputed this con-
Safety of resin-based composites. Like other tention. A study published in 2000 demonstrated
restorative materials currently approved for use that a small amount of bisphenol A could be
in dentistry, resin-based composites are consid- detected in saliva immediately after placement of
ered safe. Allergic reactions to resin-based com- a particular pit-and-fissure sealant, but this pres-
posites have been noted in a very small number of ence was very transient and no detectable level
people.14-16 Postoperative tooth sensitivity after was measured in the blood of these patients.20 The
the use of composite materials is not uncommon, authors of this study concluded that the suspi-
but it usually is transient and related to leakage cions of sealants’ potential for estrogenicity was
next to the margins of the filling or, occasionally, unfounded. A second study, published in 2001,
to mechanical stress placed on the tooth as the demonstrated that the bisphenol A measured in
filling material cures.17 Highly effective bonding these clinical trials19,20 most likely was derived
resins are used to provide adhesion of composite from the enzymatic cleavage of a different
ture and contamination within the cavity. of materials with different working characteris-
Resin-modified glass ionomers. Resin- tics and properties from which to choose. The
modified glass ionomers are similar to conven- choice often depends on the type of material
tional glass ionomers but have better properties selected for the indirect restoration and the clin-
and handling characteristics.28 Acrylic resins sim- ical requirements, such as setting characteristics,
ilar to those used in resin-based composites are film thickness, setting rates and adhesion to the
added to the material to reduce sensitivity to the underlying tooth.
setting environment and to provide the ability for All-ceramic. Dental ceramic materials are
the material to be rapidly cured (hardened). used to fabricate lifelike restorations. Ceramic’s
Resin-modified glass ionomers (sometimes called translucency and toothlike color contribute to
“hybrid ionomers”) have two curing systems, highly esthetic restorations. Ceramic is a very
light-curing and self-curing. The light-curing hard and strong material capable of sustaining
system enables the material to be cured on biting forces but, being a brittle glasslike ma-
demand with a visible light-curing unit. The terial, can fracture when subjected to extreme
mechanical properties of resin-modified glass forces or sharp impact. Because of the natural
ionomers are similar to those of conventional hardness of ceramic, these restorations are highly
ionomers, thus preventing them from serving resistant to wear. However, if they are not highly
effectively in permanent load-bearing restora- polished and smooth, they rapidly can wear
tions. They are tooth-colored and have a slightly opposing restorations or natural teeth. Over the
better enamel-mimicking translucency than that years, laboratory-fabricated all-ceramic restora-
of conventional glass ionomers. tions have become very popular owing to their
Safety of resin-modified glass ionomers. Resin- excellent esthetic properties, high strength and
modified glass ionomers are well-tolerated when excellent biocompatibility.
properly placed.27 However, the addition of the Safety of ceramic materials. These materials
acrylic monomers slightly increases the potential are composed largely of fused natural oxides.
for irritation or allergenic response when com- Their glasslike properties render them very inert,
pared with conventional glass ionomers without and they tend to be highly biocompatible and
resins. These materials are not indicated for well-tolerated.29,30 However, all-ceramic restora-
patients who have a demonstrated allergenic tions rely on technique-sensitive resin-based
response to resin-based composites. cements and adhesives to hold them in place and
Effectiveness of resin-modified glass ionomers. to seal the tooth against leakage. Rare allergies
The clinical uses of resin-modified glass ionomers or sensitivities to the resin components of the
are the same as those of conventional glass cements and adhesives can occur. There are a few
ionomers. Unlike conventional glass ionomers, nonresin cements that can be used with all-
which suffer from short working and long setting ceramic restorations, but they may reduce the
times, the working and setting times of these overall strength of the restoration owing to their
materials are under better control by the dentist. lack of adhesion to the ceramic and the tooth.
This removes some of the technique sensitivity Effectiveness of ceramic restorations. Dental
from this material, making it easier to achieve a ceramics are indicated for crowns, inlays, onlays
successful restoration. For this reason, resin- and veneers in areas where the highest level of
modified glass ionomers have largely replaced esthetics is desired. Although ceramic is a natu-
conventional glass ionomers for most indications. rally strong material, crowns on posterior teeth
In addition, the improved translucency results in composed entirely of ceramic have lower success
a better esthetic match to natural tooth enamel. rates than those of metallic restorations because
of the material’s brittleness.31 The low fracture
INDIRECT RESTORATIVE MATERIALS resistance of all-ceramic restorations also limits
All indirect restorations require a cement for the them primarily to single-tooth restorations.
prepared teeth to retain them. The cement can Ceramic veneer restorations replace a very
have a large influence on the performance and thin layer of enamel on the front of teeth to
biocompatibility of the overall restoration. Two improve the appearance or color of the teeth.
broad categories of available cements are water- These restorations are only approximately 0.5
based cements and resin-based cements. From millimeter in thickness, but because they are
these two categories, a dentist has a wide variety bonded to the underlying tooth with resin-based
cements and adhesives, they have proven to be cian can overcome this drawback to some degree.
very durable. All-ceramic crowns, inlays and The metal-ceramic restoration cannot provide
onlays can be similarly bonded to teeth to the high level of esthetics achievable with an all-
improve their strength and performance. A prop- ceramic restoration, but it can provide much
erly constructed and bonded all-ceramic restora- better durability for posterior restorations. Very
tion can provide many years of service with very high-strength metal alloys also can be used to
little change in color or appearance. fabricate larger multiple-tooth bridges using this
Metal-ceramic. The technology for effectively option. Metal-ceramic restorations provide a very
bonding porcelain to dental metal alloys was durable, long-lasting option for the restoration of
developed in 1962 in an attempt to improve the posterior teeth or teeth with a great deal of struc-
strength and durability of these restorations.32,33 tural damage.
These restorations are made by thermally Cast-gold (high noble metal) alloys. One of
bonding dental porcelains to an underlying metal the most serviceable dental restorations available
framework that has been cast to fit the tooth or is the cast-gold (high noble metal) restoration.
bridge preparation. The high supportive strength Gold alloys provide a strong, biocompatible, long-
of the underlying metal allows lasting option with a long history of
metal-ceramic restorations to pro- outstanding service to dentistry.
vide full coverage of posterior teeth The relative high strength of cast-
One of the most
and to be used for multiple-tooth gold alloys allows for a minimal
bridges. The natural tooth color of serviceable dental reduction of tooth structure to
ceramic masks the unnatural restorations available achieve adequate thickness for the
appearance of the underlying metal is the cast-gold restoration. The long survival time
to provide excellent toothlike color restoration. and the low wear of both the resto-
and appearance. ration and opposing natural tooth
Safety of metal-ceramic restora- structure establish cast gold as the
tions. These restorations generally are well- standard by which other dental materials are
tolerated except for the moderately rare incidence measured.
of allergy to the metal portion of the restoration. Safety of cast-gold alloys. By their nature,
High-noble alloys are better tolerated than the noble metals are chemically nonreactive with
base alloy metals when used for these restora- little potential for adverse biological response.
tions. For this reason, the proper choice of metal Allergenic reaction to gold is rare, but it can occur
becomes an important consideration when using in the form of localized inflammation.34 Non-noble
this option. metals are added to improve the strength of cast-
Another clinical consideration when choosing a gold alloys, and these additions tend to reduce the
metal-ceramic restoration is the additional noble nature of the alloy. However, even at noble
amount of tooth reduction necessary to accommo- metal content below 75 percent, these alloys gen-
date the proper thickness of metal and ceramic erally are well-tolerated.
needed to fabricate the crown. Care also must be The high strength and toughness exhibited by
taken to achieve a smooth ceramic surface to these metals allows for the fabrication of thinner
reduce the potential for excessively wearing restorations, thus reducing the amount of tooth
opposing teeth. Metal-ceramic restorations reduction required during preparation. Cast-gold
generally do not rely on adhesion to the tooth for alloys also can be cemented with practically any
strength and can be cemented with a wide effective cement, providing the dentist a wide
variety of dental cements. The resin-based variety from which to choose. Cast-gold alloys
cements, in rare occasions, may induce allergies still are considered the standard against which
and sensitivities. other restorative materials are compared clini-
Effectiveness of metal-ceramic restorations. The cally in terms of fit, biocompatibility and clinical
longevity of a metal-ceramic crown or bridge is service.35
somewhat less than that of an all-metal restora- Effectiveness of cast-gold alloys. Noble alloys
tion because of ceramic’s potential to fail. The are used to fabricate inlays, onlays, crowns and
opacity of the underlying metal tends to render bridges. Longevity is difficult to measure because
the restoration somewhat less lifelike than the of the many human factors that affect an indi-
all-ceramic restoration. However, a skilled techni- vidual restoration, but it generally is agreed that
cast-gold alloy restorations have a typical service looking restorations. This article has presented
lifetime of 20 years or more.35 These restorations many of these options, along with their indica-
owe their longevity to a high resistance to tions for use and possible safety concerns. On the
mechanical failure, excellent fit to the tooth basis of current knowledge from laboratory and
preparation and resistance to recurrent decay. clinical studies, the choices discussed in this
The largest disadvantage of cast-gold alloys is the report, when placed properly, can provide the
inability to match natural tooth color. However, patient, in almost all cases, with a safe and effec-
small restorations often can be conservatively tive treatment in the repair of missing, worn,
placed in locations in which little or no metal can damaged or decayed teeth. ■
be seen under normal conditions.
Base metal casting alloys. Base metal, or Address reprint requests to the ADA Council on Scientific Affairs,
non-noble, alloys were developed to provide a 211 E. Chicago Ave., 4th Floor, Chicago, Ill. 60611.
25. Mjör IA. Glass-ionomer cement restorations and secondary caries: 34. Laeijendecker R, van Joost T. Oral manifestations of gold allergy.
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26. Bayne SC. Dental composites/glass ionomers: clinical reports. Adv 35. Morris HF, Manz M, Stoffer W, Weir D. Casting alloys: the ma-
Dent Res 1992;6:65-77. terials and the clinical effects. Adv Dent Res 1992;6:28-31.
27. Council on Dental Materials and Devices. Status report on the 36. Downer MC, Azli NA, Bedi R, Moles DR, Setchell DJ. How long do
glass ionomer cements. JADA 1979;99:221-6. routine dental restorations last? A systematic review. Br Dent J
28. Mitra SB. Adhesion to dentin and physical properties of a light- 1999;187:432-9.
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Philadelphia: Saunders; 1996:660. matol 2000;136(2);272-3.
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metal teeth. U.S. patent no. 3,052,98. September 1962. 40. Council on Dental Materials, Instruments, and Equipment. Bio-
33. Weinstein M, Weinstein A, Katz S, inventors. Porcelain covered logical effects of nickel-containing dental alloys. JADA 1982;104:501-5.
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