Clin Oral Invest (2003) 7:63–70
DOI 10.1007/s00784-003-0206-7
REVIEW
A. Brunthaler · F. K
nig · T. Lucas · W. Sperr ·
A. Schedle
Longevity of direct resin composite restorations
in posterior teeth
Received: 21 May 2002 / Accepted: 25 May 2003 / Published online: 27 May 2003

Springer-Verlag 2003
Abstract This review is a survey of prospective studies
on the clinical performance of posterior resin composites
published between 1996 and 2002. Material, patient- and
operator-specific data, observation periods, isolation
methods of the operative field, and failure rates are
detailed in tables. The data were evaluated statistically in
order to assess the role of materials (filler size, bonding
system, base materials [e.g. glass ionomer cements], and
lining materials), study design, and personnel on failure
rates. The primary reasons for composite failure were
secondary caries, restoration fracture, and marginal
defects. The influence of different commercial material
brands on failure rates was not evaluated due to the great
variety of test substances and the lack of material-specific
documentation. Effects of the isolation method of the
operative field (rubber dam or cotton rolls) and the
professional status of operators (university or general
dentist) on composite failure rates were not found to be
significant. Observation periods varied from 1 to 17 years,
and failure rates ranged between 0% and 45%. A linear
correlation between failure rate and observation period
was found (P<0.0001). Thirteen of 24 studies were
A. Brunthaler · W. Sperr · A. Schedle
School of Dentistry,
University of Vienna,
Vienna, Austria
F. Knig
Department of Medical Statistics,
University of Vienna,
Vienna, Austria
T. Lucas
Department of Clinical Pharmacology,
University of Vienna,
Vienna, Austria
A. Schedle ())
Universittsklinik fr Zahn-, Mund-, und Kieferheilkunde,
Whringerstrasse 25a, 1090 Vienna, Austria
e-mail: andreas.schedle@univie.ac.at
Tel.: +43-1-4277-67150
Fax: +43-1-4277-67159
terminated after 3 years, while seven studies continued for
more than 10 years, indicating that favourable results for
composite materials are frequently based on short-term
results, despite higher dropout rates in longer studies. To
determine accurately the risk for patients, long-term,
randomised, controlled clinical trials of treatment out-
comes with composites used in posterior teeth are clearly
needed.
Keywords Clinical trials · Longevity · Posterior resin
composites · Review
Introduction
Amalgam is currently the most widely used dental filling
material worldwide for the restoration of posterior teeth
due to straightforward handling procedures, well-tested
material properties, and clinical success which has been
documented for over a century. Low material price and
rapid application also make it the most economic dental
filling material. In recent years, however, patient demands
for nonmetallic restorations have also increased for
aesthetic reasons, even in posterior teeth, and due to the
questionable biocompatibility of mercury-containing al-
loys. In parallel, resin-based composites have been
increasingly used for the restoration of posterior teeth,
and new compounds have been developed with simplified
handling procedures known as amalgam alternatives, such
as packable composite resins. With the increasing use of
composites, it is important for dentists to be aware of the
probable longevity and likely modes of failure of
posterior restorations. In studies on the longevity of
composites in posterior teeth restoration, survival rates
between 55% and 95% during an observation period of
5 years have been documented [9]. The aims of this study
were to review all available publications from 1996 to
2002 on the clinical performance of dental composites
applied as direct filling material for posterior teeth and to
evaluate failure rates and study designs.
64
Materials and methods
The dental literature from 1996 to 2002 (24 scientific papers
available in MEDLINE) on the performance of direct composite
restorations in permanent posterior teeth was reviewed. Inclusion
criteria were prospective clinical studies and direct application of
resin composite materials in permanent posterior teeth; exclusion
criteria were retrospective studies, open laminate studies (margins
of restoration also formed by glass ionomers or resin-modified
glass ionomers), tunnel restorations, and class V restorations. Data
were restructured according to observation periods, brand name,
filler composition, study design, and failure and wear rates per
observation period. The total number of fillings examined (includ-
ing several brands in single studies) and the total failure rate (all
brands) were also evaluated. Failure rates in all studies were
determined according to the modified United States Public Health
Service (USPHS) criteria [6, 25, 26, 27]. Patient-specific data such
as total number of patients treated at baseline, average age, and
recall rate during evaluation were also recorded. Data on the
professional status and total number of participating dentists were
extracted. The method of operative field isolation (rubber dam or
cotton rolls) in each study was included. Causes of restoration
failure, the exact number of premolar and molar fillings investi-
gated, extension of fillings, and respective failure rates in each
evaluation period were recorded. The role of materials was
evaluated as accurately as possible, including filler size, bonding
system, use of base, lining materials, and glass ionomer cement.
Statistical evaluation
Spearman’s correlation coefficients were performed for
correlation analyses between specified variables. The
influence of operator, operative field isolation, packable
fillings, bonding system, and filler size on failure rate was
evaluated by Wilcoxon’s two-sample test. A regression
Fig. 1 Correlation between ob-
servation period and failure rate
of composite restorations
for failure as a variable was performed. The observation
period was used as an independent variable.
Results
The results of selected clinical studies on the longevity of
direct posterior restorations are summarised in Table 1.
Observation periods ranged from 1 to 17 years, and
failure rates varied between 0% and 45%. This review
demonstrates that restoration failures in an observation
period from 0 to 5 years were primarily caused by
restoration fracture, followed by secondary caries. Be-
tween 6 and 17 years of observation, secondary caries was
the main reason for replacement of fillings (Table 2,
Table 3). In the majority of studies, operative field
isolation (20/24), professional status of the operating
dentist (20/24), bonding system (14/24), and filler size
(21/24) were also reported. Neither operator status,
isolation of the operative field with cotton rolls or rubber
dams, type of bonding system used, nor packability had
significant influence on failure rates (Table 4). Conven-
tional composites showed higher failure rates than hybrid
composites (Table 4). Filling extension also influenced
failure rates (class II fillings had higher failure rates,
P=0.03) (Table 5). The location of composite fillings in
premolars or molars (Table 2) was not a significant
influence on failure rates (Table 5). In contrast, the effect
of the observation period was highly significant (r=0.79,
P<0.0001) (Table 5), and a linear correlation between
failure and observation period was found in the regression
model (P<0.0001) (Fig. 1). This model explains 54% of
 65
Table 1 Longevity of direct composite restorations in posterior teeth.P General practitioner, Uuniversity dentist; + used, n not used,  no
information
66
Table 1 (continued)

1 f
Wear rate at the end of the study Kerr, Romulus, Minn., USA
2 g
Number of restorations per composite brand Degussa, Hanau, Germany
3 h
Failure rate at the end of the study of restorations per composite Kuraray, Osaka, Japan
i
brand Dentsply Caulk, Milford, DE, USA
4 j
Number of all restorations tested in the study Procter and Gamble, Schwalbach, Germany
5 k
Failure rate at the end of the study of all restorations tested in the Dental Material, Hamburg, Germany
l
study Coltne, Altsttten, Switzerland
a m
Vivadent, Schaan, Liechtenstein ESPE, Seefeld, Germany
b n
Heraeus Kulzer, Dormagen, Germany ICI Dental, Macclesfield, UK
c o
J eneric Pentron,Wallingford, Conn., USA Cavex, Haarlem, The Netherlands
d p
DeTrey/Dentsply, Konstanz, Germany Hereaus Kulzer, Irvine, Calif., USA
e q
3M Dental Products, St. Paul, Minn., USA ESPE America, Norristown, Penna., USA

failure variance. A negative correlation between recall Discussion

rate and observation period was found (long-term studies
had higher dropout rates, r=0.55, P=0.005) (Table 5). This review is a survey of research publications in
No relationship between recall and failure rates was MEDLINE on the longevity of direct resin composite
observed (r=0.26, P=0.22). restorations in posterior teeth between 1996 and 2002.

Table 2 Location and extension of fillings. Liner: cacalcium
hydroxide. co compomer,gic glass ionomer cement, d means that
liner material is used only in deep cavities near to the pulp. 1 one-
step system (etching/priming/bonding),2 two-step system (etching/
a
Vivadent, Schaan, Liechtenstein, b Heraeus Kulzer, Dormagen,
Germany, c Jeneric Pentron,Wallingford, Conn., USA, d DeTrey/
Dentsply, Konstanz, Germany, e 3M Dental Products, St. Paul,
Minn., USA, f Kerr, Romulus, Minn., USA, g Degussa, Hanau,
Germany, h Kuraray, Osaka, Japan, i Dentsply Caulk, Milford,
67
priming+bonding),3 three-step system (etching+priming+bonding).
Filler size: C conventional composite,H hybrid composite, Or
Ormocer;  no information
Del., USA, j Procter and Gamble, Schwalbach, Germany, k Dental
Material, Hamburg, Germany, l Coltne, Altsttten, Switzerland,
m
ESPE, Seefeld, Germany, n ICI Dental, Macclesfield, UK,
o
Cavex, Haarlem, The Netherlands, p Hereaus Kulzer, Irvine,
Calif., USA
68
Table 3 Distribution of main reasons for composite restoration failure rates was observed. The influence of different
failure in various studies over different time periods commercial material brands on failure rates was not
Main reasons for failure N evaluated overall because, in most studies, different
materials were tested and documentation was often not
0–5 years 6–17 years 0–17 years
material-specific. Filler size, bonding system, and types
Secondary caries 2 5 7 of lining material are documented in Table 2. The
Fracture of restoration 3 0 3 influence of lining materials was not statistically evalu-
Marginal defect 1 0 1
Hypersensitivity 1 0 1 ated due to the multitude of components utilised. Filler
Periapical abscess 1 0 1 size had a significant effect on failure rates (failure rates
Loss of anatomic form 0 1 1 were shown to be higher for conventional composites than
hybrids), whereas no such influence for different bonding
systems was detected. The influence of filler size may be
Table 4 Influence of operative field isolation, operator, and interpreted in that conventional composites were used
material properties on failure rates (medians and range) predominantly in studies with longer observation periods,
which may lead to higher failure rate data.
Variable Groups P value
As in a study by Raskin et al. [24], no significant
Drying Rubber 0a,
n=3 (21%, 9.6–27.6%) 0.16 influence of moisture control was seen. Some studies state
b
material Rubber 1 ,n=14 (87.3%, 0–27.3%) that the professional status of the operator does not
Operator General practitioner, n=4 (20.65%, 0–31%) 0.35
University dentist, n=16 (6.25%, 0–45%) significantly influence failure rates [17, 28, 29], which is
Packable No, n=18 (13.35%, 0–45%) 0.33 also supported by our data. Bayne [2] reported that
filling Yes, n=4 (4.8%, 0–21%) longevity in private practice may be only 35% of that
Bonding Type 1c, n=4 (18%, 0–27.6%) 0.65 predicted in academic clinical studies, although fillings
Type 2d, n=9 (7.5%, 0–45%)
Filler size Size 1e, n=7 (27.3%, 7.1–45%) 0.007
are often replaced before actual clinical failure occurs in
Size 2f, n=13 (4%, 0–25.8%) dental practice. Therefore, reported half-lives in clinical
a
practice may represent a replacement rate and not an
Only cotton rolls were used actual failure rate.
b
Only rubber dam was used
c
3-step procedure (etch+prime+bond) A total of four studies (nos. 3, 4, 8, and 11) (Table 1,
d
2-step procedure (etch/prime+bond) Table 2) on the performance of ’packable’ composites
e
Conventional composite were evaluated [7, 14, 20, 21]. Use of packable filling
f
Hybrid composite materials had no significant influence on failure rates,
although only a few short-term studies are available that
Retrospective studies, open laminate studies, tunnel investigated these materials. Solitaire showed a failure
restorations, and class V restorations were excluded. rate of 21% after 3 years [7], which is the highest
Reported failure rates varied between 0% and 45%. documented for this observation period. Solitaire in its
Studies were analysed in respect to the factors responsible original composition is no longer commercially available.
for different failure rates. This report was not limited to Alert, Surefill, and Filtek P-60 were observed for only
controlled clinical trials because of their lack of avail- 1 year [13]. No data from longer observation periods have
ability. Four of 24 studies were completely documented been published.
[11, 12, 23, 33] according to our analytical criteria. Collins et al. reported that composite restorations
Secondary caries and restoration fracture were found to be failed at a rate two to three times higher than that of
the main causes of restoration failure (Table 3). Gaengler amalgam restorations (5.8%) after 8 years of observation
et al. observed in a 10-year report that failures during the [5]. While the expected life span of correctly placed
first 5 years were primarily due to fracture or loss, posterior composites can be comparable to that of
whereas secondary caries was the main cause of failure in amalgam, the overall longevity of amalgam usually
the next 5 years [8]. Nordbø et al. reported a very high exceeds that of posterior and anterior resin-based com-
rate of secondary caries in a 10-year study (class II posites for most intervals beyond 3 to 5 years [10]. In
restorations) [19], whereas Raskin et al. described a low contrast to amalgam, after the termination of long-term
frequency of marginal caries lesions and no secondary studies, tested products may have been discontinued or
caries was found by Mair after 10 years [16, 23]. Mjr and compositions may have been changed without notifica-
Jokstad reported in an earlier study that secondary caries tion.
and bulk fractures were the main reasons for failure [18]. As expected, the observation period of restorations
Long-term studies on amalgam still represent longer correlated positively with failure rate (Fig. 1) and
observation periods (up to 20 years) than long-term consequently, short-term studies are more likely to
studies on the performance of direct composite restora- produce favourable results for the tested materials. Such
tions [9] and, possibly due to different study designs, the studies frequently accompany the introduction of new
results are still controversial. In this review, the recall rate products to the market. On the other hand, only one of the
demonstrated a negative correlation with length of the long-term studies available (no. 22) is completely docu-
observation period, but no relationship between recall and mented [23], so that the effect of the materials tested or
handling procedures on clinical outcome is often not
Table 5 Spearman’s correlations between variables. SSpearman’s correlation, Failure number of patients, Age average age of patients, Recall recall rate of fillings in %, PM
failure rate for all types of restorations and brands in %, Failure M number of failures for number of premolars at baseline, M number of molars at baseline, Class I number of class I
molar fillings, all brands, Failure PM number of failures for premolar fillings, all brands, fillings at baseline, Class II number of class II fillings at baseline
Obs. period observation period in years, Restorations number of all restorations, Patients
Failure M Failure PM Obs. period Restorations Patients Age Recall PM M Class I Class II
Failure S 0.93303 S 0.84072 S 0.79392 S 0.23036 S 0.33636 S 0.47826 S 0.26074 S 0.45870 S 0.11546 S 0.09410 S 0.48340
P<0.0001 P=0.0003 P<0.0001 P=0.2788 P=0.1360 P=0.0713 P=0.2185 P=0.0640 P=0.6590 P=0.7016 P=0.0308
N=13 N=13 N=24 N=24 N=21 N=15 N=24 N=17 N=17 N=19 N=20
Failure M S 0.89325 S 0.86460 S 0.21987 S 0.37375 S 0.76465 S 0.52310 S 0.54789 S 0.14040 S 0.19270 S 0.60743
P<0.0001 P=0.0001 P=0.4704 P=0.2084 P=0.0164 P=0.0666 P=0.1011 P=0.6989 P=0.5485 P=0.0362
N=13 N=13 N=13 N=13 N=9 N=13 N=10 N=10 N=12 N=12
Failure PM S 0.83339 S 0.38943 S 0.34679 S 0.78725 S 0.45728 S 0.53626 S 0.12375 S 0.18893 S 0.59642
P=0.0004 P=0.1884 P=0.2457 P=0.0118 P=0.1162 P=0.1101 P=0.7334 P=0.5565 P=0.0407
N=13 N=13 N=13 N=9 N=13 N=10 N=10 N=12 N=12
Observation period S 0.31172 S 0.36870 S 0.27819 S 0.55331 S 0.26811 S 0.05769 S 0.05538 S 0.29562
P=0.1381 P=0.1000 P=0.3154 P=0.0050 P=0.2981 P=0.8259 P=0.8219 P=0.2057
N=24 N=21 N=15 N=24 N=17 N=17 N=19 N=20
Restorations S 0.52510 S 0.22282 S 0.43076 S 0.55166 S 0.92076 S 0.80167 S 0.55008
P=0.0145 P=0.4247 P=0.0356 P=0.0217 P<0.0001 P<0.0001 P=0.0120
N=21 N=15 N=24 N=17 N=17 N=19 N=20
Patients S 0.11197 S 0.41227 S 0.45206 S 0.46721 S 0.34110 S 0.45313
P=0.7031 P=0.0633 P=0.0787 P=0.0681 P=0.1660 P=0.0590
N=14 N=21 N=16 N=16 N=18 N=18
Age S 0.04261 S 0.19279 S 0.19668 S 0.00709 S 0.10410
P=0.8801 P=0.5280 P=0.5196 P=0.9808 P=0.7232
N=15 N=13 N=13 N=14 N=14
Recall S 0.19889 S 0.62078 S 0.50029 S 0.17741
P=0.4441 P=0.0078 P=0.0291 P=0.4543
N=17 N=17 N=19 N=20
PM S 0.26290 S 0.22840 S 0.77150
P=0.3080 P=0.3779 P=0.0003
N=17 N=17 N=17
M S 0.86674 S 0.37791
P<0.0001 P=0.1348
N=17 N=17
Class I S 0.10350
P=0.6733
N=19
69
70
clear. Long-term randomised, controlled, clinical trials of
treatment outcomes are clearly needed to evaluate the
long-term performance of composites in posterior teeth
and to estimate the risk for patients.
Acknowledgements We wish to thank Dr. Wolfgang Ecker,
Ministry for Health and Women, for helpful discussion and Prof.
Dr. Peter Bauer, Department of Medical Statistics, University of
Vienna, for assistance with the statistical evaluation.
References
1. Abdalla AI, Alhadainy HA (1996) 2 year clinical evaluation of
Class I posterior composites. Am J Dent 9:150
2. Bayne SC, Taylor DF, Wilder AD, Heymann HO, Tangen CM
(1991) Clinical longevity of ten posterior composite materials
based on wear. J Dent Res 70:340 (abstract)
3. Braun AR, Frankenberger R, Krmer N (2001) Clinical
performance and margin analysis of Ariston pHc versus
Solitaire I as posterior restorations after 1 year. Clin Oral
Invest 5:139–147
4. Busato AL, Loguercio AD, Reis A, de Oliveira Carrilho MR
(2001) Clinical evaluation of posterior composite restorations:
6-year results. Am J Dent 14:304–308
5. Collins CJ, Bryant RW, Hodge KLV (1998) A clinical
evaluation of posterior composite resin restorations: 8-year
findings. J Dent 26:311–317
6. Cvar J, Ryge G (1971) Criteria for the clinical evaluation of
dental restorative materials. USPHS publ. no. 790–240. U.S.
Government Printing Office, San Francisco
7. Ernst C-P, Martin M, Stuff S, Willershausen B (2001) Clinical
performance of a packable resin composite for posterior teeth
after 3 years. Clin Oral Invest 5:148–155
8. Gaengler P, Hoyer I, Montag R (2001) Clinical evaluation of
posterior composite restorations: the 10-year report. J Adhes
Dent 3:185–194
9. Hickel R, Manhart J (2001) Longevity of restorations in
posterior teeth and reasons for failure. J Adhes Dent 3:45–64
10. Hondrum SA (2000) The longevity of resin-based composite
restorations in posterior teeth. Gen Dent 48:398–404
11. Hugo B, Stassinakis A, Hofmann N, Hausmann P, Kleiber B
(2001) In-vivo-Untersuchung von kleinen Klasse-II-Komposit-
fllungen. Schweiz Monatsschr Zahnmed 111:11–18
12. Khler B, Rasmusson C-G, dman P (2000) A five-year
clinical evaluation of Class II composite resin restorations. J
Dent 28:111–116
13. Loguercio AD, Reis A, Rodrigues Filho LE, Busato AL (2001)
One-year clinical evaluation of posterior packable resin com-
posite restorations. Oper Dent 26:427–434
14. Lopes LG, Cefaly DFG, Franco EB, Mondelli RFL, Lauris JRP,
Navarro MFL (2002) Clinical evaluation of two “packable”
posterior composites resins. Clin Oral Invest 6:79–83
15. Lundin SA, Koch G (1999) Class I and II posterior composite
resin restorations after 5 and 10 years. Swed Dent J 23:165–171
16. Mair LH (1998) Ten-year clinical assessment of three posterior
resin composites and two amalgams. Quintessence Int 29:483–
490
17. Manhart J, Neuerer P, Scheibenbogen-Fuchsbrunner A, Hickel
R (2000) Three-year clinical evaluation of direct and indirect
composite restorations in posterior teeth. J Prosthet Dent
84:289–296
18. Mjr IA, Jokstad A (1993) Five-year study of class II
restorations in permanent teeth using amalgam, glass polyalk-
enoate (ionomer) cement and resin-based composite materials.
J Dent 21:338–343
19. Nordbø H, Leirskar J, von der Fehr FR (1998) Saucer-shaped
cavity preparations for posterior approximal resin composite
restorations: observations up to 10 years. Quintessence Int
29:5–11
20. Oberlnder H, Hiller K-A, Thonemann B, Schmalz G (2001)
Clinical evaluation of packable composite resins in Class-II
restorations. Clin Oral Invest 5:102–107
21. Perry RD, Kugel G (2000) Two-year clinical evaluation of a
high-density posterior restorative material. Compend Contin
Educ Dent 21:1067–1072, 1074, 1076, 1080
22. Perry RD, Kugel G, Habib CM, McGarry P, Settembrini L
(1997) A two-year clinical evaluation of TPH for restoration of
Class II carious lesions in permanent teeth. Gen Dent 45:344–
349
23. Raskin A, Michotte-Theall B, Vreven J, Wilson NHF (1999)
Clinical evaluation of a posterior composite 10-year report. J
Dent 27:13–19
24. Raskin A, Setcos JC, Vreven J, Wilson NHF (2000) Influence
of the isolation method on the 10-year behaviour of posterior
resin composite restorations. Clin Oral Invest 4:148–152
25. Ryge G (1980) Clinical criteria. Int Dent J 30:347–358
26. Ryge G, Snyder M (1973) Evaluation of the clinical quality of
restorations. J Am Dent Assoc 87:369–377
27. Ryge G, Stanford JW (1977) Recommended format for protocol
for clinical research program. Clinical comparison of several
anterior and posterior restorative material. Int Dent J 27:46–50
28. Scheibenbogen A, Manhart J, Kunzelmann KH, Kremers L,
Benz C, Hickel R (1997) One year clinical evaluation of
composite fillings and inlays in posterior teeth. Clin Oral Invest
1:65–70
29. Scheibenbogen-Fuchsbrunner A, Manhart J, Kremers L, Kun-
zelmann KH, Hickel R (1999) Two year clinical evaluation of
direct and indirect composite restorations in posterior teeth. J
Prosthet Dent 82:391–397
30. Schoch M, Kramer N, Frankenberger R, Petschelt A (1999)
Direct posterior composite restorations with a new adhesive
system: one-year results. J Adhesive Dent 2:167–173
31. Trkn S, Aktener BO (2001) Twenty-four-month clinical
evaluation of different posterior composite resin materials. J
Am Dent Assoc 132:196-203
32. van Dijken JWV (2000) Direct resin composite inlays/onlays:
an 11-year follow-up. J Dent 28:299–306
33. Wassel RW, Walls AW, McCabe JF (2000) Direct composite
inlays versus conventional composite restorations: 5-year
follow-up. J Dent 28:375–382
34. Wilder AD Jr, May KN Jr, Bayne SC, Taylor DF, Leinfelder
KF (1999) Seventeen year clinical study of ultraviolet-cured
posterior composite Class I and II restorations. J Esthet Dent
11:135–142
35. Wilson MA, Cowan AJ, Randall RC, Crisp RJ, Wilson NHF
(2002) A practise-based, randomized, controlled clinical trial of
a new resin composite restorative: one-year results. Oper Dent
27:423–429