24 JADA, Vol.

122, July 1991


ABSTRACT
The status, advantages,
disadvantages and potential
future of amalgam, cast
alloys, cohesive gold, resins,
glass ionomer materials and
porcelain are reported and a
bright future for light-cured
glass ionomer and
reinforced direct composite
resin technologies is
predicted.
R IC H A R D J. S IM O N S E N , D.D .S.,
M .S .
MATERIALS
N EW
HORIZON
his article reviews the status of
preventive and restorative dental
materials, and predicts which
areas will develop significantly in
the future. Although the status quo
of m aterials perform ance is
empirical, the future, limited by
speculative ability, is difficult to
predict. The status, advantages,
disadvantages and potential future
of amalgam, cast alloys, cohesive
gold, resins, glass ionomer
m aterials and porcelain are
discussed.
AMALGAM
As a restorative material, dental
amalgam has served the profession
well for approximately 150 years.
Repeated controversies concern­
ing the safety of the m ercury
content of amalgam continue and
have affected material usage, but
such controversies have not sunk
the amalgam ship—yet.
Amalgam has some clear
advantages, as well as some
distinct disadvantages, in clinical
use. Clinical data on the longevity
of amalgam restorations show a
relatively short half-life.1It seems
clear, however, th at if clinicians
allow im perfect m argins to rem ain
an acceptable part of an older
amalgam restoration, and then
only replace amalgam restorations
based on the diagnosis of
secondary caries or catastrophic
restoration failure, the clinical
serviceability of amalgam restora­
tions could increase substantially.
Clinicians do not agree about the
criteria for amalgam restoration
replacem ent, making studies of
restoration longevity subjective.2
The long history of clinical use,
and the relative ease of placem ent
as a result of this long experience,
is an advantage to the use of dental
amalgam. In addition, the clinical
technique has been developed
over many years and the m aterial
is convenient and efficient to use.
Compared w ith competitive
materials, amalgam is an
inexpensive restorative m aterial
JADA, Vol. 122, July 1991 25
for the patient because of place­
m ent speed.
Perhaps the major disadvantage
of amalgam at this tim e is w hat can
be called the “ ‘60 M inutes’ syn­
drom e.” The television program,
aired in December 1990, was
m erciless in attacking dental
amalgam. The presentation
pam pered advertisers and ratings
while attacking the credibility of
the profession. This angle was
probably used to capture viewer
interest. This, and other negative
m edia events, along with
environm ental concerns could
eventually spell the death of
amalgam as it is used today—the
leading restorative m aterial for
dental caries.
A recent publication by
Consum er Reports provided a
m ore balanced and rational
approach to the issue than did the
“60 M inutes” program .3Negative
m edia reports can, and probably
will, have a considerable negative
im pact on amalgam restoration
use, no m atter w hat the scientific
evidence to the contrary may be.
Additionally, amalgam is more
unattractive than other restorative
m aterials. Its dark color and
propensity to stain teeth dark gray
can be a major problem in areas of
the m outh w here appearance is
im portant.
Tooth preparation for any
restorative procedure weakens the
structural integrity of the
rem aining tooth, particularly with
preparations for amalgam in
which the preparation m ust
incorporate mechanical
undercuts. Removing such tooth
structure can predispose the tooth
to subsequent fracture because the
amalgam restorative m aterial
cannot strengthen the rem aining
tooth structure.
Additionally, the m aterial
properties of amalgam determ ine
cavity preparation size. For
26 JADA, Vol. 122, July 1991
example, all dental students are
taught to prepare Class I cavities
for amalgam into dentin, even if
the caries is only in enamel. Since
amalgam is not strong in a thin
layer, it m ust be placed in a layer
thick enough to w ithstand
fracture. To have space for this
sufficiently thick layer of
amalgam, healthy tooth structure
m ust be removed in addition to
carious tissue removal.
Similarly “extension for
prevention,” removing healthy
tooth structure to prevent caries
from attacking adjacent caries-
susceptible pits and fissures, is an
integral part of amalgam prepara­
tions. Again, this is perform ed to
accommodate another amalgam
deficiency—its lack of cariostatic
properties. If adjacent caries-
susceptible pits and fissures are
not incorporated into the cavity
preparation for amalgam
restorations in the extension-for-
prevention technique, further
caries is likely to develop adjacent
to the amalgam restoration,
resulting in additional need for
restorative intervention.
The paradox is clear; healthy
tooth structure is removed and
replaced with a restorative
m aterial. While it makes little
sense to further weaken rem aining
tooth structure to make the restor­
ative m aterial successful, this is
essential for the clinical success of
amalgam. A restorative m aterial
that allows the rem aining healthy
tooth structure to be left intact,
while removing only diseased
tissue, would be preferable.
If an amalgam restoration is
replaced, the restoration increases
to the “next size,” initiating the
“molar life cycle.” The life cycle is a
facetious look at w hat is routinely
perform ed in operative dentistry.
As small restorations are replaced
with increasingly larger ones, the
rem aining tooth becomes weaker
and fatigue causes cusp fractures.
Perhaps the pulp is exposed and a
crown is needed after endodontic
treatm ent.
Subsequent problem s of perio­
dontal disease or endodontic
failure may result in the eventual
loss of the tooth—a loss th at can
stem directly from the initial
restoration and the radical
restorative procedures th at were
the only alternative to short-term
tooth loss. Then, as a recently
docum ented last-resort treatm ent,
an im plant may stave off remov­
able dentures.
If the first restoration on a tooth
can be avoided by the use of
preventive m aterials such as
fluoride and p it and fissure
sealant, or m inimized in size and
restored with a bonded m aterial
such as composite resin in a
preventive resin restoration, the
long-term potential for successful
tooth m aintenance is increased.
The m olar life cycle is a chain of
events th at clinicians should
prevent.
Finally, amalgam placem ent
requires two visits to polish and
finish the restoration. Few
practitioners, however, polish
amalgam restorations, despite the
fact th at m ost educational
program s teach the procedure" as a
part of the complete restoration.
Scientific studies support the
prevailing clinical approach of not
routinely polishing amalgam
restorations because the longevity
of the restoration is not affected.4,5
Amalgam corrodes, stains and
has lim ited bonding potential. The
clinical efficacy and longevity of
some recently m arketed amalgam
adhesives are undeterm ined.
Conservative cavity preparation or
preventive resin restoration
concepts are not attainable with
amalgam and the future improve­
m ent or developm ent of amalgam
is, therefore, limited in restorative
dentistry.
CAST ALLOYS
Cast alloys w ere the foundation of
prosthetic dentistry for many
years. With the advent of the
stronger nonprecious alloys, cast
gold is used less frequently, bu t is
still one of the best restorative
materials. The higher strength of
the nonprecious alloys, and the
developm ent of composite resin
luting cements, has led to
heretofore impossible conserv­
ative applications of alloys such as
for the etched-cast restoration,
commonly referred to as the
“Maryland bridge.”6Concerns
about biocompatibility and the
inevitable problems with
appearance rem ain disadvantages
with the alloys.
The major advantage of the cast
alloys is the strength of the
m aterials, w hen com pared with
m ore esthetic options. The long­
term , high-gloss finish and
polishing ease after occlusal or
m arginal adjustm ent are
significant benefits. The alloys
w ear well and are especially
compatible with opposing tooth
enamel, unlike the well-known
ravages of porcelain.
Disadvantages of alloys, in
addition to biocompatibility of the
nonprecious alloys and the ever­
present esthetic problem, center
around the extensive laboratory
support required and procedural
complexity. These problems result
in higher consum er costs. While
m icrom echanical retention with
m ost resin systems is easily
attainable, it is still difficult to
routinely couple the alloys with
adhesive systems. Additionally,
some base metals may stain the
oral tissues, and more im portantly,
a considerable am ount of hard
tissue is usually removed when
preparing a tooth for a cast alloy
restoration. Tooth structure loss is
a significant disadvantage of the
cast alloys—a disadvantage that
will rem ain no m atter how m uch
the m etals are improved.
The “Maryland bridge” was a
major advance in using alloys
conservatively, but the future of
restorative m aterials lies in metal
replacem ent, rather than in alloy
improvement. For the foreseeable
future, however, cast alloys are
here to stay. For the long term , the
im pact of cast alloys will decrease
to the point w hen one day the
profession may practice metal-free
dentistry.
COHESIVE GOLD
Few valid reasons support the
routine use of cohesive gold in
dentistry today, although the
m aterial has a fervent following
among a small m inority in the
profession. It is a fine restoration,
but the alternative m aterials
provide major advantages, m aking
cohesive gold obsolete.
The competitive m aterials
described later provide more
conservative, m ore esthetic, less
traum atic and much less costly
alternatives. The gold foil restora­
tion may have a longer life than,
for example, a bonded composite
JADA, Vol. 122, July 1991 27
resin restoration, but this assum p­
tion m ust be confirm ed by long­
term studies of conservative
composite resin restorations that
consider the fact th at less tooth
structure is removed in the
preparation. The two restoration
types cannot, in reality, be
com pared because it is not
possible to pu t a value on saving
tooth structure.
University classes in cohesive
gold restorations are
usually elective
courses. As
the
of operators
skilled in this techni­
que decreases, it is
likely th at the restoration
will rem ain the dom ain of
a few skilled clinicians.
RESIN SYSTEMS
The resin systems constitute
an increasingly im portant
role in preventive and
28 JADA, Vol. 122, July 1991
restorative dentistry. Preventive necessity for carious tooth
dentistry affords a look at the structure to be removed. This
present status of pit and fissure technique was made famous by
sealant. Thaddeus P. Hyatt in his article on
the prophylactic odontotomy.9
PIT AND FISSURE
SEALANT
Unfortunately, the routine Class I
prophylactic odontotomy was no
Pit and fissure sealant was first more conservative, in m any cases,
m arketed in 1971, and many than later caries restoration
studies have docum ented its reten­ techniques, and it was invasive
tion and caries prevention effica­ and injurious to individuals who
cy.78 Sealants prevent dental caries may never have developed caries.
in pits and Pit and fissure sealant
fissures where application requires m eticulous
the sealant is technique for success. Ten-year
applied and re­ results have been published in
tained. F urther­ JADA10and 15-year results from the
more, the seal­ sam e study are in press. Prelim ­
ant, if properly inary exam ination of the 15-year
applied under data is prom ising with continued
norm al clinical great differences betw een the
conditions, sealed and the control groups th at
should be were presented in the 10-year
retained in report. Two other studies have
m ost cases for reported retention data over (not
approxim ately after) 10 years, in private practice
10 years
or public be­ settings, with
health
fore reappli­ positive results.1112
cation It is hard to find disadvantages
becomes for the pit and fissure sealant
necessary. prevention technique. The
Addi­ m eticulous technique necessary is
tionally, perhaps a disadvantage, b u t the
sealant skill level required is not unusually
on the high and all m em bers of the dental
occlu­ 'team, including dentists,
sal hygienists or assistants, can be
pits trained to apply pit and fissure
and sealant.13
fis­ Regrettably, the latest national
sures data available indicate th at only
prevents 7.6 percent of five- to 15-year-old
the restora­ children in the United States have
tion of such teeth. The belief that had sealants applied.“1It would be
the perm anent molars would even­ satisfying to see the molar life
tually become carious and need cycle changed to a preventive life
restoration was so pervasive that cycle—let’s say for generations
some clinicians routinely born after 1970. In this scenario,
prescribed restoration of such the tooth gets sealed, the sealant is
teeth in the belief that it was better reapplied 10 to 15 years after initial
to restore a tooth w ith a small application, and the restorative life
restoration immediately, than wait cycle is avoided.
for caries to develop and the The future im pact of pit and
fissure sealant will be great. The
need for prevention is still high in
the United States. Only 16 percent
of 17-year olds are caries-free and
84 percent of the caries experience
of five- to 17-year-olds is on pit and
fissure (sealant protectable)
surfaces.'4
The developing nations of the
world th at have yet to experience
the ravages of dental caries
associated with the W estern diet,
will be challenged to adopt
prim ary prevention program s to
avoid the massive cost to society
and to individuals of restoring the
teeth th at could rem ain caries-free
w ith judicious pit and fissure
sealant application and fluoride
use.15
BONDING AGENTS
Enamel and dentinal bonding
agents are confusing and require
more space than is available here
to discuss thoroughly. The
advantages of bonding to enam el
are clear. Of m ajor im portance is
th at bonding to enamel allows
conservative cavity preparation
which m eans th at the inherent
structural integrity of the tooth
will be minimally compromised.
Additionally, microleakage
prevention is a major benefit of
bonding to enamel.
Dentinal bonding agents are
still in their infancy, relying on
m icrom echanical bonding rath er
than any true chemical bond. Yet,
an ideal system is one that
provides routine reliable bonding
to dentin and can be perform ed by
the average practitioner under
normal, or even difficult, clinical
conditions. Too often, the operator
is faced with m oisture control
problems th at are anathem a to
reliable dentinal bonding. The use
of the rubber dam for m oisture
control is, regrettably, low for
routine operative dentistry.
Two dentinal bonding agents
have received ADA Provisional
Acceptance (Scotchbond 2, 3M
Dental Products, and Tenure, Den-
Mat Corporation). Recently
Scotchbond 2 was aw arded full
acceptance by the American
Dental Association Council on
Dental Materials, Instrum ents and
Equipment.
The future of bonding agents is
bright, at least until m aterial
im provem ents based on simplif­
ication of the clinical techniques
elim inate the bonding agent step.
Improvements in the reliability of
the bond and the user-friendliness
of the m aterials should secure the
short-term future for these
materials.
Conserving tooth structure
through the acid-etch tech­
nique remains the major
benefit of the composite
resin systems over some of
the stronger, but more
radical alternative
materials requiring tooth
structure removal.
ANTERIOR AND
POSTERIOR COMPOSITE
RESINS
Light-curing technology has been
an im portant advance th at has
affected both anterior and
posterior resin systems. Light
curing has simplified the proce­
dure for clinicians and increased
the color stability of the
restoration for the patient.
Appearance is a major
advantage of the composite resin
systems over the previously
discussed materials. Composite
resins, with the aid of bonding
resins, can be bonded to enamel
thus allowing conservative cavity
preparation, such as the prevent­
ive resin restoration,16and saving
tooth structure. Conserving tooth
structure through the acid-etch
technique rem ains the major
benefit of the composite resin
systems over some of the stronger,
but m ore radical alternative
m aterials requiring tooth structure
removal. For inter proxim al restor­
ations, conservative preparations
such as the tunnel preparation
have been advocated.17
Perhaps the major disadvantage
of composite resin systems is the
polym erization shrinkage of the
resin. This shrinkage can lead to
marginal leakage as the force of
the resin shrinkage may, under
certain circum stances, exceed the
bond strength of resin to tooth
structure and cause the m arginal
seal to fracture. Additionally, the
technique-sensitivity of the acid-
etch technique can be regarded as
a disadvantage in the use of
composite resin systems inasm uch
as the procedure is clinically
dem anding and more time-
consum ing than an amalgam
restoration. Another disadvantage
is the cost to the patient which will
be higher than th at for a simpler,
faster procedure.
Some simplification of clinical
procedures, m aking resin bonding
to tooth structure a m ore user-
friendly procedure, is likely to
occur soon. F uture developments,
particularly in the area of filler
particles and in filler particle size
distribution, will improve clinical
performance. Hopefully, the
polymerization shrinkage problem
will be solved or minimized.
GLASS IONOMER
MATERIALS
This group of m aterials has m et
with greater clinical success than
clinical acceptance by the
profession. The limited acceptance
can be traced to the dem anding
clinical technique and the
JADA, Vol. 122, July 1991 29
 relatively long setting tim e for
glass ionom er m aterials in the
mouth. Recent developments that
have modified the glass ionomer
m aterial with resin, thus allowing
light curing of the material,
indicate a bright future for this
group of m aterials. Restorative
m aterials and bases based on the
light-cured glass ionom er
technology will be particularly
beneficial in the restorative
treatm ent of young children and
geriatric adults, w here a simple-to-
use, fast-setting, strong, fluoride-
releasing m aterial is ideal.
Although glass ionomer
m aterials have been used as
sealants, the retention rates have
been low.18-19The glass ionomer
sealants cannot m atch the
docum ented retention rates of the
resin sealants. Additionally, the
clinical technique for glass
ionom er m aterials use as initially
developed is cumbersome
com pared w ith the comparable
technique for resins.
The major advantage of using a
glass ionom er m aterial as a
restorative m aterial is that fluoride
is released from the material and
the m argins of the restoration are,
therefore, less caries-susceptible.
Glass ionom er restorations are
microleakage resistant inasm uch
as they bond to enamel and dentin
and are kind to the pulp. Without
the benefit of fluoride release,
however, glass ionomer m aterials
should not be used, except in the
restoration of root caries, for they
are not as strong or as esthetically
pleasing as competitive resin
materials.
The developm ent by Mitra of
the resin-modified glass ionomer
m aterials has been one of the most
im portant recent developments in
dental m aterials research and will
have a great im pact on this group
of m aterials.20'22Mitra’s
developm ent resulted in the
30 JADA, Vol. 122, July 1991
production of a light-cured glass
ionom er liner base. When used as
a lining m aterial, such resin-
modified glass ionom er materials
bond to dentin with considerably
higher bond strength (approxi­
m ately 11 megapascals shear bond
strength to dentin), than
conventional glass ionomer
m aterials (approximately 4 MPa
shear bond strength). Much of this
difference is caused by the greater
cohesive strength of the resin-
modified glass ionomer material.
Applying this technology to
light-cured glass ionomer restor­
ative m aterials would radically
alter the caries treatm ent of the
prim ary dentition and treatm ent
of root caries in elderly patients.
Conventional glass ionomer
restorative m aterials are
ham pered by the sometimes
inconvenient technique—the
m aterials m ust neither become
dehydrated, nor become too wet
during curing, and conventional
setting can take four to five
m inutes. Incorporating light-
curing technology into glass
ionomer restorative materials
would elim inate these disadvant­
ages, while m aintaining the
advantages of fluoride release, and
of a strong bond to dentin. When
this is done, the im portance of
glass ionom er m aterials in restora­
tive dentistry will increase greatly.
PORCELAIN
For crown and bridge, porcelain
has the advantages of appearance,
strength (single units), and a long
history of clinical success. Recent
development in fine-particle
ceramics, where fine particles of
alum inum oxide are infiltrated
with glass for use as a core under
conventional porcelain, has
greatly improved strength. If
clinical testing is favorable, this
developm ent may expand the
general use of porcelain, after
appropriate
clinical testing,
into short-span
anterior, and
perhaps even
posterior,
Dr. Simonsen is
bridges.
professional
services manager, The
Dental Products
development of
Division, 3M Health
Care, 3M Center
etching
Bldg. 225-4S-11, St. porcelain has
Paul, Minn. 55144-
increased
10OO and is currently
on a leave of ab­ applications for
sence as professor,
this material. It
Department of
General Dentistry, was stated as a
College of Dentistry, conclusion of
University of Tenne­
ssee, Memphis.
the original 1983
Address requests for presentation of
reprints to the
the etched
author.
porcelain
research that “bond strengths of
the m agnitude reported here are
expected to be clinically
significant for the retention of
porcelain veneers and for other
intraoral uses of porcelain.”23
While porcelain has been
increasingly used in recent years
in bonded inlays and onlays, it is
only as a labial veneer that the
material has met with incontro­
vertible success as a bonded
restoration.
The fragile nature of a thin
veneer is not a problem during
clinical bonding and the adoption
of the porcelain veneer procedure
prom oted esthetic dentistry
consciousness by both dentists and
the public. However, the fragility
of an inlay or onlay is a significant
disadvantage because the
restoration m ust be bonded before
occlusal adjustm ent. Necessary
occlusal adjustm ent removes the
glaze, exposing the particulate
nature of the material, thus
causing potentially disastrous
consequences in wear on the
opposing enamel, depending on
the porcelain used.
The disadvantages, therefore, of
porcelain are related mainly to the

wear on opposing enamel and to
the material’s brittleness. In the
future, some of the current wear
problems will be eliminated by a
reinforced resin system that will
not have the brittleness of current
porcelains.
INDIRECT RESTORATIVE
MATERIALS
Burke and others evaluated five
indirect composite resin inlay
systems.24The authors had
generally positive conclusions
about the indirect systems. Based
on the current poor acceptance,
however, by the profession for the
commercially available indirect
composite inlay systems, it is
doubtful that such systems will
become well accepted at this time.
The techniques increase cost with
little time savings or performance
improvement of the restorations.
SUMMARY
Two areas of research will prosper
and change operative dentistry in
the future: developing light-cured
glass ionomer technology further,
and reinforcing direct composite
resin technology. Successful
development of restorative
materials in these areas will have
an immediate and long-term effect
on the practice of operative
dentistry in both affluent and poor
countries of the world. ■
Publication of names of products does not imply
endorsement by the American Dental Association.
This paper was presented April 25,1991 at the Scientific
Frontiers in Clinical Dentistry Symposium, National
Institute for Dental Research, Bethesda, MD.
The author thanks Dr. William H. Douglas for his
contributions during the planning of the oral presentation
of this paper.
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