Journal of Dental Research

http://jdr.sagepub.com/

12-year Survival of Composite vs. Amalgam Restorations

N.J.M. Opdam, E.M. Bronkhorst, B.A.C. Loomans and M.-C.D.N.J.M. Huysmans
J DENT RES 2010 89: 1063 originally published online 26 July 2010
DOI: 10.1177/0022034510376071

The online version of this article can be found at:

http://jdr.sagepub.com/content/89/10/1063

Published by:

http://www.sagepublications.com

On behalf of:
International and American Associations for Dental Research

Additional services and information for Journal of Dental Research can be found at:

Email Alerts: http://jdr.sagepub.com/cgi/alerts

Subscriptions: http://jdr.sagepub.com/subscriptions

Reprints: http://www.sagepub.com/journalsReprints.nav

Permissions: http://www.sagepub.com/journalsPermissions.nav

>> Version of Record - Sep 27, 2010

OnlineFirst Version of Record - Jul 26, 2010

What is This?

Downloaded from jdr.sagepub.com at NATIONAL CHUNG HSING UNIV on April 11, 2014 For personal use only. No other uses without permission.

© 2010 International & American Associations for Dental Research

 RESEARCH REPORTS
Biomaterials & Bioengineering

N.J.M. Opdam*, E.M. Bronkhorst,

B.A.C. Loomans,
12-year Survival of Composite
and M.-C.D.N.J.M. Huysmans vs. Amalgam Restorations
College of Dental Science, Department of Preventive and
Restorative Dentistry, Radboud University Nijmegen Medical
Centre, PO Box 9101, NL 6500 HB Nijmegen, The
Netherlands; *corresponding author, n.opdam@dent.umcn.nl

J Dent Res 89(10):1063-1067, 2010

Abstract
Information about the long-term clinical survival of
large amalgam and composite restorations is still
lacking. This retrospective study compares the lon-
gevity of three- and four-/five-surface amalgam
and composite restorations relative to patients’ car-
ies risk. Patient records from a general practice
were used for data collection. We evaluated 1949
large class II restorations (1202 amalgam/747 com-
posite). Dates of placement, replacement, and fail-
ure were recorded, and caries risk of patients was
assessed. Survival was calculated from Kaplan-
Meier statistics. After 12 years, 293 amalgam and
114 composite restorations had failed. Large com-
posite restorations showed a higher survival in the
combined population and in the low-risk group.
For three-surface restorations in high-risk patients,
amalgam showed better survival.
KEY WORDS: amalgam, clinical trials, compos-
ite materials, risk factor, caries, longevity
DOI: 10.1177/0022034510376071
Introduction
C omposite resin and amalgam are both considered as suitable materials for
direct posterior filling. Presently, the use of amalgam is declining, and
composite resin is used more often. Prospective clinical studies have shown
comparable annual failure rates of both materials (Manhart et al., 2004).
However, three recently published studies reported better longevity of amal-
gam restorations compared with composite restorations (Van Nieuwenhuysen
et al., 2003; Bernardo et al., 2007; Soncini et al., 2007). In the retrospective
study (Van Nieuwenhuysen et al., 2003), this was due to an increased fracture
rate of composite restorations. In the other studies, a higher prevalence of
secondary caries was found next to composite restorations. Another retrospec-
tive study comparing posterior composite and amalgam restorations placed
in a general dental practice found no differences in longevity, but observed
relatively more secondary caries in relation to composite and more fracture
failures related to amalgam restorations (Opdam et al., 2007a).
Although the initial indication for posterior composite restorations
included only small restorations, the material is increasingly used for large
restorations. In some retrospective studies, larger-sized restorations were
included, and it was found that more extensive restorations showed reduced
longevity (Van Nieuwenhuysen et al., 2003; Opdam et al., 2007a). This may
be related to large restorations being more prone to fracture. The higher sus-
ceptibility of composite restorations to fracture has been attributed to the
routine use of glass-ionomer lining cement (Opdam et al., 2007b). It may be
expected that composite restorations placed with a total-etch technique are
less prone to fracture in the long term.
Differences in the prevalence of (secondary) caries as a reason for restoration
failure are probably related to the caries risk status of the study population. Many
randomized controlled trials (RCTs) have used low-risk groups, such as dental
students. This may be the reason that, even in the long term, no secondary caries
has been found in some clinical studies (Raskin et al., 1999; Gordan et al., 2007).
Several other studies showed that the caries risk of the patient plays a significant
role in restoration longevity (Köhler et al., 2000; Van Dijken and Sunnegårdh-
Grönberg, 2006; Opdam et al., 2007b), and in some studies more secondary
caries has been found next to composite restorations compared with amalgam
restorations (Mannocci et al., 2005; Bernardo et al., 2007; Opdam et al., 2007a).
The aim of the present retrospective practice-based study is to compare
long-term clinical performance of large class II amalgam and composite res-
torations in relation to the individual caries risk of the patient.

Received May 26, 2009; Last revision May 18, 2010; Materials & Methods
Accepted May 19, 2010
Patient files from a Dutch general practice, owned by one of the authors
© International & American Associations for Dental Research (NJMO), were used for collecting data for this study. Design and protocol

1063
Downloaded from jdr.sagepub.com at NATIONAL CHUNG HSING UNIV on April 11, 2014 For personal use only. No other uses without permission.

© 2010 International & American Associations for Dental Research

1064  Opdam et al. J Dent Res 89(10) 2010
were approved by the local ethics committee, METC (CMO file
nr. 2008/150). Included in the study were all patients who vis-
ited the practice for a check-up visit between May and November
2008 and already had attended the practice for check-up and
follow-up treatment without interruption for at least 5 years. At
this last check-up visit, the treating dentist (NJMO) assessed the
caries risk status of the patient based on the history of occur-
rence of new lesions over the entire period. When patients
arrived in the practice with caries lesions, but after treatment in
subsequent years did not show continued high caries activity,
they were assessed as “low risk”. If patients continued to show,
yearly, one or more new caries lesions during the entire period,
they were assessed as “high risk”.
From the files, data were collected on all three-surface and
four-/five-surface composite and amalgam Class II restorations
placed between 1983 (practice opened) and 2003 (inclusion
limit, allowing for a minimum of 5 years’ follow-up). Dates of
restoration-placement and last check-up visit were recorded.
Composite and bonding materials were recorded, as well as
tooth-localization and restored tooth-surfaces. Composite resto-
rations placed with a glass-ionomer liner were excluded.
Whenever a restoration was either replaced, repaired, or sched-
uled for replacement at the last check-up (for which an appoint-
ment was then made with the patient), or when a tooth was
extracted, the restoration was considered as failed. Date and
reason for failure were recorded. When a restoration was still in
function at the last check-up visit and found to be clinically
acceptable, it was considered successful. Restored teeth on
which a crown was placed in the investigated period, not related
to a direct restoration failure, were not considered as failed, but
the observation period was then censored.
In the practice investigated, before 1994, almost all large
class II cavities were restored with amalgam, whereas after 1995
amalgam restorations were no longer made. In the years 1994-
1995, a shift from amalgam toward composite for large restora-
tions took place. To avoid possible confounding by selective
indication for amalgam or composite, all restorations placed in
1994-1995 were excluded from the study. Moreover, since no
survival data for composite restorations were available after 12
years, the calculation of survival was limited to 12 years.
Statistical analyses were performed with SPSS 16. Kaplan-
Meier analysis was used to create survival curves. Since most
patients contributed multiple restorations to this study, the
method described by Chuang et al. (2001) was used to produce
statistically valid standard errors for the estimates of survival.
With these estimates for a given point in time, testing for differ-
ences between two survival curves reduced to a straightforward
t test. In this study, comparisons were made at 5 and 12 years.
The mean annual failure rate (AFR) of the investigated restora-
tions was calculated according to the formula: (1-y)z = (1-x), in
which ‘y’ expresses the mean AFR, and ‘x’ the total failure in ‘z’
years.
Results
We evaluated 1949 large class II restorations placed between
1983 and 2003 in 273 patients (116 males, 157 females; ages,
23-77 yrs; mean age, 48 yrs). Of these, 103 patients received 1-4
Downloaded from jdr.sagepub.com at NATIONAL CHUNG HSING UNIV on April 11, 2014 For personal use only. No other uses without permission.
© 2010 International & American Associations for Dental Research
restorations, 93 patients 5-8 restorations, and 77 patients more
than 9 restorations. Between 1983 and 1993, 1202 amalgam
restorations were placed (389 premolars; 813 molars), while
between 1996 and 2003, 747 posterior composite restorations
were placed (234 premolars; 513 molars). One thousand two
hundred forty three-surface Class II restorations (805 amal-
gam/435 composite) and 709 four-/five-surface restorations
(397 amalgam/312 composite) were placed. The 49 patients
assessed as having a high caries risk (17.9%) received 455 res-
torations (250 amalgam/205 composite), while 224 patients
(82.1%) assessed as having a low risk received 1494 restora-
tions (952 amalgam/542 composite). Dispersalloy (Dentsply,
York, PA, USA) was used for all amalgam restorations.
Composite restorations were placed with a three-step etch-and-
rinse adhesive (PhotoBond/SA Primer, Kuraray, Osaka, Japan)
in 93% of the restorations; 7% were placed with other adhe-
sives. Composites used were Clearfil PhotoPosterior (44%) and
AP-X (32%) (Kuraray) and other hybrid composites (24%). At
the time of observation, 407 restorations had failed (293 amal-
gam/114 composite). The reasons for failure show that, in the
high-risk group, more caries was found (high risk, 55.9%; low
risk, 21.1%). Furthermore, in the low-risk group, fracture and
‘cracked tooth syndrome’ were more common with amalgam
restorations (Table).
Sixty-nine amalgam restorations received a crown not related
to restoration failure and were censored in the survival analysis.
No crowns were placed on composite-restored teeth.
Restorations placed in the high-risk group showed a signifi-
cantly lower survival rate compared with those placed in the
low-risk group after 5 (p = 0.04), as well as after 12 yrs (p <
0.01) (Fig. 1a). In the comparison between amalgam and com-
posite for all risk groups, amalgam (AFR = 1.25%) and compos-
ite (AFR = 1.78%) showed a comparable performance at 5 yrs
(p = 0.18), whereas after 12 yrs, composite (AFR = 1.68%)
showed a higher survival than amalgam (AFR = 2.41%) (p =
0.013) (Fig.1b). Due to the significant difference in survival
between high- and low-risk patients, all other comparisons were
made for separate patient groups.
Differences between materials in the high-risk group were
not significant at 5 yrs (p = 0.22) or 12 yrs (p = 0.78), although
the AFR for composite was higher (Fig. 2a). However, in the
high-risk group, the 12-year survival of the three-surface amal-
gam restoration subgroup was significantly better (p = 0.03),
which was not the case for the four-/five-surface restorations
(p = 0.69). In the low-risk group, composite restorations showed
a better survival after 12 yrs (p < 0.01) for both three-surface
(p = 0.03) and four-/five-surface restorations (p = 0.02) (Fig. 2b).
Differences in survival were absent at 5 yrs (p = 0.73). The AFR
of composite resin decreased from 1.06% at 5 yrs to 0.88% at 12
yrs, whereas the AFR of amalgam doubled in that time interval,
from 0.98% to 2.05%. For both caries risk groups, no differ-
ences in performance in premolars and molars were found.
Discussion
In this study, we found a better 12-year survival rate of large
posterior composite restorations compared with amalgam. For
comparing two treatments, a randomized clinical trial (RCT) is
J Dent Res 89(10) 2010 12-year Survival of Composite vs. Amalgam Restorations   1065

Table.  Reasons for Failure of Amalgam and Composite Restorations after 12 Years’ Clinical Service

Amalgam Composite 
High Caries High Caries
  All Risks Risk Low Caries Risk All Risks Risk Low Caries Risk

  % n % n % n % n % n % n
Clinically acceptable 75.6 909 62.8 157 79.0 752 84.7 633 66.8 137 91.5 496
Secondary caries 5.7 69 14.0 35 3.6 34 6.6 49 19.0 39 1.8 10
Primary caries 1.1 13 3.2 8 0.5 5 1.6 12 3.9 8 0.7 4
Fracture tooth 5.9 71 5.2 13 6.1 58 1.3 10 2.4 5 0.9 5
Fracture restoration 0.9 11 1.2 3 0.8 8 0.9 7 1.5 3 0.7 4
Cracked tooth 4.5 54 1.6 4 5.3 50 0.1 1 0.0 0 0.2 1
Endo/pain 2.5 30 4.8 12 1.9 18 3.5 26 3.9 8 3.3 18
Other1 2.2 271 4.0 10 1.8 17 0.9 7 2.4 5 0.4 2
Unknown 1.5 18 3.2 8 1.1 10 0.3 2 0.0 0 0.4 2
Total 100.0 1202 100.0 250 100.0 952 100.0 747 100.0 205 100.0 542
1
Aesthetic reasons, n = 9; health concern, n = 1.

considered to be the best study design. However, RCTs have
certain limitations and are not optimal for all research questions.
Observation times of longer than 5 yrs are hardly feasible in
most RCTs, considering the expected population attrition rate.
From our results, it is obvious that follow-up time needs to be
longer, since differences between the materials emerge only
after more than 5 yrs.
The chosen practice-based and retrospective design for the
present study gave more insight into ‘real world dentistry’. It
should be noted that results as shown were achieved in one den-
tal practice, owned by a part-time dental school employee
(NJMO), and cannot be generalized. Several sources of possible
confounding can be identified. Failure and survival statistics are
based upon clinical service of dental restorations, on the basis of
the judgment of the practitioner during check-up rather than on
strict criteria such as USPHS criteria (Ryge, 1980). However,
this would concern both materials and would have influenced
only recorded failure rates of the total restoration population,
rather than affecting differences between the two materials.
In the dental practice investigated, crowns were placed on
amalgam-restored teeth only. This is a confounding issue in the
analysis, but the relevance is probably limited, due to the rela-
tively few teeth involved (69 out of 1202). However, the fact
that in these patients only a few crowns were placed in teeth
with large-size restorations illustrates the context of the study, in
which the largest possible sized amalgam and composite resto-
rations were compared in the same patient group.
Only 10 out of 293 failed amalgam restorations were replaced
due to aesthetic reasons or health concerns. Therefore, the risk
for confounding will be very limited in that respect.
A major drawback of the present study was the separation of
the two treatments in time: Amalgam restorations were made
between 1983 and 1993, and composite restorations between
1996 and 2003. In this period, the indication for replacement or
repair may have changed. If we look at the reasons for failure,
indication shifts are plausible only in the caries factors, since there
was a general trend toward a later/more restricted indication of
operative care. However, in this practice, already in the 1980s,
marginal deterioration of amalgam was not considered an indi-
cation for re-restoration. Also, the trend for caries-related failure
was rather higher in the more recent (composite) restorations.
Caries-risk assessment is mostly used for predicting caries
activity for patients and can be done by the treating clinician (Seppä
et al., 1989; Alanen et al., 1994). In the present study, patients
were assigned retrospectively to a low- or a high-caries-risk
group, thus eliminating inaccuracies of prediction and reflecting
the historical average caries activity over the follow-up period.
The results for restoration failure reasons support the subjective
risk assessment, since restorations in the high-risk group had 2.5
times the chance for failure due to caries compared with restora-
tions in the low-risk group.
The present study had two major outcomes. First, there was a
clear difference between restoration performance in high-risk and
low-risk patients. This is consistent with results of other studies
showing that a high caries risk has a negative influence on restora-
tion performance (Köhler et al., 2000; Andersson-Wenckert et al.,
2004; Lindberg et al., 2007; Opdam et al., 2007b).
The second major outcome of the present study was the dif-
ference in failure characteristics of large amalgam and posterior
composite restorations. As expressed in the Kaplan-Meier sur-
vival curves and AFRs, amalgam had an increasing failure rate
in the long term, whereas composite showed a more constant
failure rate, especially in the low-risk patients. In the high-risk
groups, amalgam showed a tendency for better performance,
especially after 5-8 yrs and, in this study, especially with the
smaller-sized three-surface restorations. Caries as a reason for
failure was more frequent with composite than with amalgam,
especially in the high-risk group. This trend was consistent with
other studies showing more secondary caries next to composite
restorations where high-risk (child/adolescent) populations were
used (Bernardo et al., 2007; Soncini et al., 2007). In the present
study, a large number of amalgam restorations failed in the long
term due to tooth fracture and cracked-tooth symptoms. Both
phenomena are thought to be related to fatigue of the tooth

Downloaded from jdr.sagepub.com at NATIONAL CHUNG HSING UNIV on April 11, 2014 For personal use only. No other uses without permission.

© 2010 International & American Associations for Dental Research

1066  Opdam et al. J Dent Res 89(10) 2010

a Combined amalgam and composite High-risk group

a
100

100
Low-risk patients n = 1494
Cumulative survival of restorations (%)

Cumulative survival of restorations (%)

90

90
Amalgam n = 250
80

80
70

70
High-risk patients n = 455
Composite n = 205
60

60
AFR 5 low: 1.01% AFR 12 low: 1.83% AFR 5 am: 2.27%
AFR 12 am: 3.85%
AFR 5 high: 2.94% AFR 12 high: 4.14% AFR 5 co: 3.79% AFR 12 co: 4.19%
50

50
0 2 4 5y 6 8 10 12 5y
0 2 4 6 8 10 12
Follow-up time (yrs) Follow-up time (yrs)
b Low-risk group
b Combined high and low risk

100
100

Composite n = 542

Cumulative survival of restorations (%)

Cumulative survival of restorations (%)

Composite n = 747

90
90

80
80

Amalgam n = 952

Amalgam n = 1202
70
70

60
60

AFR 5 am: 0.98% AFR 12 am: 2.05%

AFR 5 c0: 1.78% AFR 12 co: 1.68%
AFR 5 co: 1.06% AFR 12 co: 0.88%
50

AFR 5 am: 1.25% AFR 12 am: 2.41%

50

5y 5y
0 2 4 6 8 10 12
0 2 4 6 8 10 12
Follow-up time (yrs) Follow-up time (yrs)

Figure 1.  Kaplan-Meier survival graphs for restorations placed in high- Figure 2.  Kaplan-Meier survival graphs for amalgam vs. composite in
risk patients vs. low-risk patients (a) and for amalgam vs. composite (b). high-risk patients (a) and low-risk patients (b).

material. The lower fracture rate of composite-restored teeth in both materials (Mair, 1998) or better performance of amalgam
this study supports the hypothesis that adhesive restorations restorations (Collins et al., 1998; Van Nieuwenhuysen et al.,
strengthen tooth structure. 2003). The present study is the first one to show better survival
Composite resin restorations in the present study were all of composite restorations compared with amalgam, a difference
placed without liner or base. In longitudinal studies where a especially apparent after a longer observation period. This
base or lining was applied, relatively more fractures were found emphasizes the need for more long-term clinical studies.
(Gaengler et al., 2001; Pallessen and Qvist, 2003; Van The conclusion of this study is that caries risk of patients
Nieuwenhuysen et al., 2003; Andersson-Wenckert et al., 2004; plays a significant role in restoration survival. In the high-risk
DaRosa Rodolpho et al., 2006; Opdam et al., 2007b), while group, composite and amalgam restorations showed comparable
studies that reported on composite resin restorations without performance, with amalgam performing better on smaller resto-
lining showed fewer fractures (Baratieri and Ritter et al., 2001; rations. For the combined risk groups and the low-risk group,
Bernardo et al., 2007; Soncini et al., 2007). This is consistent composite restorations showed better survival at 12 yrs.
with results from the present study, since few composite restora-
tions failed due to fracture (1.8% in the low-risk group).
Acknowledgment
Until now, comparative studies on the performance of amalgam
and composite restorations showed either comparable survival for The study was supported by the authors’ institution.

Downloaded from jdr.sagepub.com at NATIONAL CHUNG HSING UNIV on April 11, 2014 For personal use only. No other uses without permission.

© 2010 International & American Associations for Dental Research

J Dent Res 89(10) 2010 12-year Survival of Composite vs. Amalgam Restorations   1067
References
Alanen P, Hurskainen K, Isokangas P, Pietilä I, Levänen J, Saarni UM, et al.
(1994). Clinician’s ability to identify caries risk subjects. Community
Dent Oral Epidemiol 22:86-89.
Andersson-Wenckert IE, Van Dijken JW, Kieri C (2004). Durability of
extensive Class II open-sandwich restorations with a resin-modified
glass ionomer cement after 6 years. Am J Dent 17:43-50.
Baratieri LN, Ritter AV (2001). Four-year clinical evaluation of posterior
resin-based composite restorations placed using the total-etch tech-
nique. J Esthet Restor Dent 13:50-57.
Bernardo M, Luis H, Martin MD, Leroux BG, Rue T, Leitão J, et al. (2007).
Survival and reasons for failure of amalgam versus composite posterior
restorations placed in a randomized clinical trial. J Am Dent Assoc
138:775-783.
Chuang SK, Tian L, Wei LJ, Dodson TB (2001). Kaplan-Meier analysis of
dental implant survival: a strategy for estimating survival with clustered
observations. J Dent Res 80:2016-2020.
Collins CJ, Bryant RW, Hodge KL (1998). A clinical evaluation of posterior
composite resin restorations: 8-year findings. J Dent 26:311-317.
DaRosa Rodolpho PA, Cenci MS, Donassollo TA, Loguércio AD, Demarco
FF (2006). A clinical evaluation of posterior composite restorations:
17-year findings. J Dent 34:427-435.
Gaengler P, Hoyer I, Montag R (2001). Clinical evaluation of posterior
composite restorations: the 10-year report. J Adhes Dent 3:185-194.
Gordan VV, Mondragon E, Watson RE, Garvan C, Mjör IA (2007). A clini-
cal evaluation of a self-etching primer and a giomer restorative mate-
rial: results at eight years. J Am Dent Assoc 138:621-627.
Köhler B, Rasmusson CG, Odman P (2000). A five-year clinical evaluation
of Class II composite resin restorations. J Dent 28:111-116.
Lindberg A, Van Dijken JW, Lindberg M (2007). Nine-year evaluation of a
polyacid-modified resin composite/resin composite open sandwich
technique in Class II cavities. J Dent 35:124-129.
Downloaded from jdr.sagepub.com at NATIONAL CHUNG HSING UNIV on April 11, 2014 For personal use only. No other uses without permission.
© 2010 International & American Associations for Dental Research
Mair LH (1998). Ten-year clinical assessment of three posterior resin com-
posites and two amalgams. Quintessence Int 29:483-490.
Manhart J, Chen H, Hamm G, Hickel R (2004). Buonocore Memorial Lecture.
Review of the clinical survival of direct and indirect restorations in pos-
terior teeth of the permanent dentition. Oper Dent 29:481-508.
Mannocci F, Qualtrough AJ, Worthington HV, Watson TF, Pitt Ford TR
(2005). Randomized clinical comparison of endodontically treated
teeth restored with amalgam or with fiber posts and resin composite:
five-year results. Oper Dent 30:9-15.
Opdam NJ, Bronkhorst EM, Roeters JM, Loomans BA (2007a). A retrospec-
tive clinical study on longevity of posterior composite and amalgam
restorations. Dent Mater 23:2-8.
Opdam NJ, Bronkhorst EM, Roeters JM, Loomans BA (2007b). Longevity
and reasons for failure of sandwich and total-etch posterior composite
resin restorations. J Adhes Dent 9:469-475.
Pallesen U, Qvist V (2003). Composite resin fillings and inlays. An 11-year
evaluation. Clin Oral Investig 7:71-79.
Raskin A, Michotte-Theall B, Vreven J, Wilson NH (1999). Clinical evalu-
ation of a posterior composite 10-year report. J Dent 27:13-19.
Ryge G (1980). Clinical criteria. Int Dent J 30:347-358.
Seppä L, Hausen H, Pöllänen L, Helasharju K, Kärkkäinen S (1989). Past
caries recordings made in public dental clinics as predictors of caries
prevalence in early adolescence. Community Dent Oral Epidemiol
17:277-281.
Soncini JA, Maserejian NN, Trachtenberg F, Tavares M, Hayes C (2007).
The longevity of amalgam versus compomer/composite restorations in
posterior primary and permanent teeth: findings from the New England
Children’s Amalgam Trial. J Am Dent Assoc 138:763-772.
Van Dijken JW, Sunnegårdh-Grönberg K (2006). Fiber-reinforced packable
resin composites in Class II cavities. J Dent 34:763-769.
Van Nieuwenhuysen JP, D’Hoore W, Carvalho J, Qvist V (2003). Long-term
evaluation of extensive restorations in permanent teeth. J Dent 31:
395-405.