655

Treatment Outcome of Posterior Composite

Indirect Restorations: A Retrospective
20-Year Analysis of 525 Cases with a
Mean Follow-up of 87 Months
Francesco Ravasini, DDS1 Over the past two decades, com-
Dario Bellussi, DDS2/Mario Pedrazzoni, MD3 posite materials have become an in-
Tommaso Ravasini, DDS4/Pietro Orlandini, DDS5 creasingly common solution, mainly
Marco Meleti, DDS, PhD6/Mauro Bonanini, DDS, MD7 because of their high esthetic qual-
ity and their improved mechanical
properties.1 In fact, they have been
The purpose of this study was to evaluate the survival of 525 composite indirect recommended by Lynch et al2 as
restorations in premolars and molars after a follow-up of 20 years. For each the elective material for restora-
patient, the following variables were recorded and analyzed: age, sex, smoking tion of teeth in the posterior sector.
status, presence of plaque according to O’Leary index, and presence of bruxism.
Ever-increasing esthetic demands
For each restoration, the following variables were collected: restoration class,
tooth type (premolar or molar), and restoration material. Mean 20-year survival have led to the shift from gold as
rate of composite restorations was 57%, ranging from 44% to 75%. The Kaplan- the preferred material for construct-
Meier method demonstrated a probability of survival at 10 years of 80% and ing indirect dental restorations3,4 to
90%. Surviving restorations kept their clinical characteristics extremely well, materials with a better esthetic per-
as assessed on the basis of the United States Public Health Service criteria. formance, such as ceramic and com-
The results of this study demonstrate the efficacy of indirect composite
posites. The evolution of composite
restorations, confirming their reliability as a posterior prosthetic clinical option.
Int J Periodontics Restorative Dent 2018;38:655–663. doi: 10.11607/prd.3471 materials and adhesive cementation
methods have played a leading role
in the spread of the indirect com-
posite technique. When compared
to direct restoration, indicated for
repair of small to medium caries
lesions, composite indirect restora-
tion offers higher probability of ob-
taining a better anatomical shape
Consultant Professor, Unit of Prosthetic Dentistry, Academic Center of Dentistry,
1 of the restoration, an excellent oc-
Department of Medicine and Surgery, University of Parma, Italy. clusal morphology, better contact
2Private Practice, Venice, Italy.
points, and good marginal adapta-
3Professor, Unit of Clinical and Experimental Medicine, Department of Medicine and Surgery,
tion.5 Other advantages of indirect
University of Parma, Italy.
4Private Practice, Parma, Italy. composite over direct restorations
5Private Practice, Parma, Italy.
include the possibility of avoiding
6Assistant Professor, Academic Center of Dentistry, Department of Medicine and Surgery,
direct contraction of the material,
University of Parma, Italy.
7Professor and Dean, Unit of Prosthetic Dentistry, Academic Center of Dentistry, a higher resistance to fracture, bet-
Department of Medicine and Surgery, University of Parma, Italy. ter adaptation to the cavity, and
excellent biocompatibility due to
Correspondence to: Dr Francesco Ravasini, Viale Mentana, 41, 43121 Parma, Italy.
the treatment of the material. Main
Fax: +00 390 521 272 626. Email: francesco@studiodentisticoravasini.it
disadvantages of the indirect con-
 ©2018 by Quintessence Publishing Co Inc. struction technique are the need for

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656
two sessions in the dental chair and
higher costs for patient and opera-
tor. According to their preparation,
restorations can be classified into6
inlays, onlays, and overlays. The pur-
pose of this study was to determine
the survival of 525 composite indi-
rect restorations in premolars and
molars with a 20 years of follow-up.
Materials and Methods
A total of 500 patients under clinical
follow-up at a private dental practice
with at least one checkup per year
were randomly selected. Among
these, 155 patients presented at
least 1 composite indirect restora-
tion and 150 agreed to be enrolled
in the present study, undergoing
a specific evaluation to determine
the status of the indirect composite
restoration. Before each checkup,
each patient was provided with an
explanation of the purpose of the
study and asked to sign a written in-
formed consent form. Restorations
were performed between 1995 and
2015 by three operators with proven
postgraduate board certification in
prosthodontics: operator A (gen-
eral dentist, with experience in fixed
prosthesis), operator B (general den-
tist, with experience in prosthodon-
tics and conservative dentistry), and
operator C (general dentist, mainly
performing surgery and implantol-
ogy procedures). A total of 525 res-
torations were eventually included
in the present analysis. Tetric Ceram
(Ivoclar Vivadent), Sinfony (3M ESPE),
Signum Ceramis (Heraeus Kulzer),
and Enamel Plus Hri (Micerium) were
used in 33, 80, 299, and 113 cases,
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respectively. All restorations were
produced with light-curing and post-
cure heating treatment. All intaglio
surfaces were treated by sandblast-
ing with aluminum oxide particles for
10 seconds, followed by application
of silane. All cementations were per-
formed through a three-step tech-
nique (Syntac, Ivoclar Vivadent). The
variables collected for each patient
in this study included the presence
of probable bruxism,7 age, sex, and
smoking status. A questionnaire like
that reported by Paesani et al,7 in line
with a recent international consen-
sus,8 was used to identify patients
with probable sleep bruxism. In
each patient, plaque status was as-
sessed through the O’Leary plaque
control index,9 using a disclosing
solution. Patients with an O’Leary
plaque control index not exceed-
ing 10% were classified as CODE 1,
those with an index between 11%
and 25% were classified as CODE 2,
those between 26% and 40% were
classified as CODE 3, and those with
an index higher than 40% were clas-
sified as CODE 4. Cavity class and
type of tooth (molar or premolar) on
which the restoration was cemented
was recorded for each restoration.
Procedure and materials adopted in
each restoration was retrieved from
the medical record. Data on cemen-
tation and data on subsequent oper-
ations performed on the restoration
were recorded. Failure of restoration
was recorded in case of replace-
ment or repair; cause of failure was
available in each case. To assess the
status of restorations, we used the
United States Public Health Service
(USPHS) criteria.10,11 Surfaces of the
restorations were dried with an air
jet before assessment of the state of
the restoration and assessed using
a mirror and probe. All interproxi-
mal contacts were evaluated using
waxed dental floss12: contact present
= good interproximal status; con-
tact absent = bad interproximal sta-
tus. Intraoral x-rays were performed
when presence of caries lesions un-
der the restorations was suspected
and if they had not been performed
for 2 years or more. The assess-
ment criteria used in this study10,11
served to assess important clini-
cal characteristics of restorations.
The characteristics to be assessed
were established and organized in
such a way that the assessor would
make a final assessment after a se-
ries of dichotomous decisions. The
six variables assessed were color of
the restoration (Fig 1a), marginal dis-
coloration (Fig 1b), anatomical shape
(Fig 1c), marginal adaption (Fig 1d),
surface roughness, and secondary
caries (Fig 1e). The Kaplan-Meier
method has been adopted in this
study to assess the survival of the
composite restorations.
Statistical Analysis
The influence of the single variables
on survival was determined using
Cox’s multivariate regression model.
The descriptive statistical analysis
was conducted using SPSS Statis-
tics 22.0 (IBM), while the restoration
survival time periods were analyzed
using the R 3.1.2 software survival
package (R Core Team 2014). Sur-
vival of a restoration was measured
in months, as the difference be-
tween the date of cementation and
 657

Marginal
Color
discoloration
Is there a mismatch in
Is there discoloration
color, shade, and/or
No Code anywhere on the margin No Code
translucency between
Alpha A between the restoration Alpha A
the restorations and the
and the tooth structure?
adjacent tooth structure?

Visual Visual
inspection Yes inspection Yes
with a mirror with a mirror

Is there a mismatch No Code No Code

Bravo B Has the discoloration Bravo B
between restoration and
penetrated along the
adjacent tooth structure
margin of the restorative
outside the normal range
material in a pulpal
of color, shade, and/or Code Code
Yes direction? Yes
translucency? Charlie C Charlie C

a b

Anatomical Marginal
form adaption Is there evidence of
Is the restoration
crevice along the margin Code
undercontoured or Lightly No
No Code into which the explorer Alpha A
discontinuous draw a sharp
Alpha A will penetrate?
with existing explorer
anatomical form? back and
forth across
Visual the margin; Yes
inspection Yes if it catches,
with a mirror inspect with
mirror
No Code
Is dentin or Bravo B Visually Is the dentin or No Code
base exposed due to an inspect base exposed? Bravo B
insufficient presence of Yes
restorative material? Code
Yes Code
Charlie C No
Visually Is dentin or base Charlie C
inspect or test exposed due to an
c mobility with insufficient presence of
explorer restorative material? Yes Code
Fig 1  (a) Color, considered the most crucial factor in esthetics, Delta D
is evaluated through a visual examination. An off-color tooth is d
esthetically unpleasant and could indicate chemical alterations
suffered by the restoration material. The rating given for color is
reached after several dichotomous decisions, as shown. (b) Marginal
discoloration is the second feature considered. It is represented Caries
by color variation at the margin between the tooth structure and
the restoration. If the discoloration is important, it may represent No Code
Visual Is there evidence of Alpha A
an esthetic problem, while if it penetrates along the margin in a inspection caries contiguous
pulpar direction it could create the conditions for secondary caries. with explorer with the margin of
Marginal discoloration could be the result of a chemical process and mirror restoration? Code
Yes
between the resin and the liners. (c) Anatomical form is an indicator Bravo B
of loss of material and is useful in the clinical evaluation of materials e
subject to abrasion. Loss of substance may have different clinical
meanings, because some materials abrade, losing volume but maintaining a good marginal adaptation to the tooth surface. (d) Marginal
adaption is very important. Exposed dentin is subject to the action of oral fluid, bacteria, and thermal changes, offering opportunities for
the caries to recur. Composite materials and adhesive techniques are used largely for these reasons, because they maintain a close link
with the tooth surface. In this case, in addition to clinical observations an explorer was used to follow the margins and feel for any crevices,
dentin exposures, or cracks. All the margins had to be carefully examined. In case of clear secondary caries, the restoration was rated as a
code Delta (D), while if the caries were limited to the margin it was rated a code Charlie (C). (e) Secondary caries was the fifth feature rated.
In this case, too a sharp explorer was used in addition to visual inspection.

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658

(35.4%) on premolars. Among mo-

Table 1  Type of Teeth by Type of Restoration
lar restorations, 109 were mesio-
Molars (n) Premolars (n) Cases (n) occlusal-distal (MOD), 18 were
MOD 109 79 188 occlusal (OCC), 27 were occluso-
OCC 18 1 19 distal (OD), 88 were occluso-mesial
OD 27 61 88 (OM), 91 were onlays, and 6 were
OM 88 15 103 overlays. Among premolar restora-
Onlay 91 28 119 tions: 79 were MOD, 1 was OCC, 61
Overlay 6 2 8 were OD, 15 were OM, 28 were on-
Total 339 186 525 lays, and 2 were overlays. A total of
MOD = mesio-occluso-distal; OCC = occlusal; OD = occluso-distal; OM = occluso-mesial. 500 restorations were performed on
vital teeth; 25 were performed on
teeth previously subjected to root
Table 2 Evaluation of Restorations According to the
canal treatment. Out of 525 resto-
USPHS Criteria (%)
rations, 77 failures were recorded.
A B C D Among these, 49 (9.3%) were as-
Anatomical shape 95.3 4.5 0.2 – sociated with fracture, 11 (2%) with
Marginal adaptation 85.9 13.4 – 0.7 an endodontic cause, 10 (1.9%)
Color 94.9 4.7 0.4 – with secondary caries, and 7 (1.3%)
Marginal discoloration 71.4 28.4 0.2 – were considered failures because
Surface roughness 97.1 2.9 – – a repair was detected. Failures oc-
Secondary caries 98.1 1.9 – – curred over a period ranging from
1 to 191 months. Endodontic fail-
ures occurred at a mean time of 43
the date of observation or failure. with a mean age of 46 years (SD months after the date of cementa-
To assess the possible influence of 14.3 years). Of the patients, 129 tion (range: 1 to 176 months).
a series of variables evaluated (age, (86%) were nonsmokers. A diagno-
sex, smoking status, probable brux- sis of sleep bruxism was probable in
ism, O’Leary plaque control index, 21 patients (14%). Regarding plaque USPHS Criteria
tooth type (premolar/molar), resto- control, 25 patients (16.7%) were
ration class, material used, operator) classified with CODE 1, 80 (53.3%) The surviving restorations were
on the survival of restorations, the with CODE 2, 37 (24.7%) with CODE subjected to an assessment of their
Cox proportional hazards model, 3, and 8 (5.3%) with CODE 4. color, marginal discoloration, mar-
corrected for the correlation of the ginal adaptation, anatomical shape,
restorations in each individual pa- surface roughness, and second-
tient was performed. P < .05% was Type of Teeth and Restorations ary caries, in accordance with the
assumed as significant. USPHS criteria. The resulting data
A total of 525 restorations were as- are summarized in Table 2. As far
sessed with a mean follow-up period as anatomical shape is concerned,
Results of 87 months (minimum follow-up: 95.3% of restorations were classified
1 month; maximum follow-up: 240 as A, 4.5% as B, and 0.2% as C. Re-
Patient Features months). Table 1 summarizes type garding marginal adaption, 85.9%
of teeth and restorations. Of the 525 of restorations were evaluated as A,
This study was conducted on 150 restorations assessed, 339 (64.6%) 13.4% as B, and 0.7% as D. For color,
patients (57 men and 93 women) were performed on molars and 186 94.9% of restorations were classified

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 659

as A, 4.7% as B, and 0.4% as C. In

Table 3 Survival Rates of Restorations, According to the
the matter of marginal discoloration,
Kaplan-Meier Estimator
71.4% of restorations were evalu-
ated as A, 28.4% as B, and 0.2% as Time Risks Events Survival SE 95% CI 95% CI
C. Regarding surface roughness, (mo) (n) (n) (%) (lower) (lower) (upper)
97.1% of restorations were classified  12 497 11 98 0.00639 97 99
as A and 2.9% as B. As regards sec-  24 448 10 96 0.00899 94 98
ondary caries, 98.1% of restorations  36 405 14 93 0.01193 90 95
were assessed as A and 1.9% as B.  48 370 7 91 0.01327 89 94
 60 330 6 90 0.01443 87 92
 72 250 6 88 0.01624 84 91
Survival Rate  84 192 3 86 0.01752 83 90
 96 133 10 81 0.02286 77 86
When each restoration was evalu- 108 113 1 81 0.02357 76 85
ated singularly, the Kaplan-Meier 120 86 0 81 0.02357 76 85
estimator showed a probability of 132 73 1 79 0.02548 75 85
survival of 81% at 10 years and of 144 52 2 77 0.02948 72 83
57% at 20 years, the mean follow-up 156 33 2 74 0.03786 66 81
time being 87.2 months (Table 3 and 168 20 0 74 0.03786 66 81
Fig 2). Up to 12 months from place- 180 16 3 62 0.06923 50 77
ment, the survival rate of restorations 192 13 1 57 0.0771 44 75
was 98%, with a 95% confidence in- 204 11 0 57 0.0771 44 75
terval (CI) of 97% to 99%. Up to 120 216 10 0 57 0.0771 44 75
months (10 years) of follow-up, the 228 10 0 57 0.0771 44 75
survival rate was 81%, with a 95% 240 6 0 57 0.0771 44 75
CI of 76% to 85%. Probability of sur- SE = standard error; CI = confidence interval.
vival at 10 years was between 80%
and 90%. After 120 months, the sur-
100
vival curve becomes uncertain as the
analysis is performed on the very
few cases and failures remaining. 80
The CI is very broad; at 240 months’
follow-up, probability of survival is
60
Survival (%)

57%, ranging from 44% to 75%.

40
Other Variables

20
The Cox model showed no statisti-
cal significance for age (P = .440),
sex (P = .270), probable bruxism 0
(P = .860), or restoration material 0 24 48 72 96 120 144 168 192 216 240 264
(P > .25 for all materials). Regarding Follow-up (mo)
the effect of the restoration class, Fig 2  Kaplan-Meier curve showing the overall restorations survival (percentage drops with
no statistically significant difference time, as the failure occurs).

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660

Fig 3  (a) Before cementation, teeth were isolated through a dental

dam to protect the preparations from saliva and moisture. (b) Indirect
composite restorations were prepared and tried on master models to
verify their precision. (c) Composite inlays after the cementation. (d)
The bitewing radiograph proved the perfect marginal adaption of the
restorations.

a b

in terms of survival was found be-
tween the single classes (OM vs
OD vs MOD vs OCC vs onlay vs
overlay). The classes not covering
cusps (OM, OD, MOD, and OCC)
were grouped and compared with
the group of classes covering cusps
(onlay and overlay). Also in this case,
restoration class was not found to
be statistically significant (P = .960).
The operator variable was found to
be highly significant. Operators A
and C, compared to operator B, had
hazard ratios (HR) of 4.10 (95% CI: 1.9
to 8.8; P < .001) and 4.2 (95% CI: 1.7
to 10.1; P = .001), respectively. Such
a finding may indicate that, on aver-
age, operator A had a risk of failure
of restorations 4.1 times higher than
operator B. The same applies to op-
erator C, who on average had a risk
of failure 4.2 times higher than op-
erator B. Tooth type (molar vs pre-
molar) and O’Leary plaque control
index were found to be statistically
significant (P = .036 and P = .050,
respectively). The risk of failure in
premolars was lower than the risk
in molars (55%). The risk of failure in
Class 2 and Class 3 to 4 was 63%,
higher than in Class 1. The effect of
smoking was found to be close to
significance (HR = 1.97, 95% CI: 0.89
to 4.32; P = .093). The risk of failure
in smokers seems to be approxi-
mately twice (1.97) as high as in non-
smokers. Fig 3 shows different steps
of teeth preparations for multiple in-
direct composite restorations.

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 661

Discussion
Table 4 Results of Studies Assessing the Survival of Indirect Composite
Restorations over the Short, Medium, and Long Term
To the best of our knowledge, there
are only few systematic reviews Observation Restorations Failure rate
evaluating the long-term survival Author period (y) (n) (%)
of composite indirect restorations. Krejci et al22 1 29 0
Grivas et al,13 in their systematic re- Thordrup et al 23 10 14 28.5
view, reported that composite inlays Scheibenbogen et al 24 1 47 3
seem to be a promising material for Motokawa et al 25
2 50 4
the restoration of posterior teeth,
Alhadainey et al 26
2 42 1
despite the heterogeneity of the
Donly et al 19 7 36 25
evidence. With regard to longevity
and esthetics, they conclude there Chrepa et al27 3 189 3
is insufficient evidence to establish D’Arcangelo et al28 5 79 9
whether there are any differences Manhart et al29 3 75 7
between composite and ceramic/ Manhart et al29 3 80 12
gold inlays.13 Moreover, the authors
Barone et al30 3 113 3
assessed that composite inlays can
Dukic et al31 3 71 0
compete with ceramic inlays, gold
inlays, and direct composite fillings, Pallesen et al32 11 84 17
although many limitations described
exhaustively in the study must be
considered.13 Most of the reviews al of restorations: age, sex, probable ure for operators A and C was about
available take into consideration in- bruxism, and restoration material. four times higher than operator B. It
direct restorations performed with Regarding sleep bruxism, some au- is interesting to note that operator B
ceramic materials.14–16 Survival of thors34 did find an inverse relation- is the only one who practices con-
composite restorations has been ship with the long-term success of a servative dentistry. This is probably
evaluated both in short- and long- restoration, which was not the case because an operator that dedicates
term studies.17–21 Some short-term in the present study. According to a large part of his working time to
studies reported results indicating Opdam et al,35 the number of sur- restorative dentistry is likely to have
low or even absent failure rates.17,18 faces restored plays a major role in a better technical background and
On the other hand, in long-term the survival of a restoration. In the experience with management of
studies,19–21 more meaningful results present study, samples for each adhesive cementation of compos-
in terms of failure have been re- class of restoration are admittedly ite materials and consequently a
ported. Table 4 summarizes results few. Therefore, a statistical influence higher success rate, both over the
of studies assessing the survival of of restoration class on the survival medium and the long term. In fact,
indirect composite restorations over of the prosthesis could not be dem- as shown in several studies, opera-
the short, medium, and long term. onstrated. Similar to other research- tor experience is a decisive factor
According to Brunthaler et al,33 res- es,34,36,37 the type of composite used for the survival of a prosthesis, such
toration fractures were found to be did not seem to play a fundamental as an indirect restoration: composite
the main cause of failure, particularly role in the long-term survival of a restorations performed by expert,
within 5 years of cementation. Ac- restoration. In the present analysis, recognized operators seem to last
cording to the Cox model, the fol- the operator variable was found to longer.36,38 In the present study, 500
lowing variables were found to be be highly significant from a statistical restorations were performed on vi-
not statistically associated to surviv- point of view. The prevalence of fail- tal teeth and 25 restorations were

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662
performed on nonvital teeth. End-
odontic failures occurred at a mean
of 43 months after the date of ce-
mentation (range: 1 to 176 months).
Such a result is slightly different from
the data reported in the systematic
review and meta-analysis per-
formed by Opdam et al,35 according
to which endodontic complications
are typically seen within the first
year after restoration. This phenom-
enon is related to the pulp damage
caused by the restoration proce-
dures themselves. Tooth type (mo-
lar vs premolar) and O’Leary plaque
control index variables were found
to be statistically significant when
compared to restoration survival.
Several studies,29,36,39 in agreement
with this one, indicate that resto-
rations performed on molars are
more prone to fracture than those
performed on premolars, probably
due to the greater occlusal load in
the molar region. According to this
study, patients with CODE 1 for
O’Leary plaque control index have a
lower probability of restoration fail-
ure than patients with CODES 2, 3,
and 4. Such a finding was also evalu-
ated by Opdam et al,35 The risk of
caries has been assessed in several
studies, but only some of them in-
cluded it as a variable in the statis-
tical analysis.34,40,41 Nevertheless, it
seems well established that the risk
of caries plays a fundamental role in
the survival of a restoration. With re-
gard to the abovementioned results
and in agreement with most of the
studies addressing this topic,40,42,43
it is important to check the degree
of patients’ oral hygiene and to
teach them to maintain a high level
of oral hygiene. It has indeed been
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demonstrated that restorations last
a shorter time in patients suscep-
tible to caries. In some studies, the
longevity of composite resins was
found to be inferior to that of amal-
gam fillings in patients susceptible
to caries.40,42,43 On the other hand,
in patients not susceptible to caries,
composite restorations have given
equivalent or better results than
amalgam restoration over a period
of 10 to 12 years.40,44
Conclusions
Results from this study demon-
strate that the indirect composite
technique has a high success rate
over the long term, having a prob-
ability of survival at 10 years of 81%.
The 20-year probability of survival
ranges from 44% to 75%. Surviving
restorations showed excellent pres-
ervation of clinical characteristics
(color, marginal discoloration, mar-
ginal adaption, anatomical shape,
surface roughness, and secondary
caries). The low incidence of second-
ary caries is associated with a good
marginal seal that remained unal-
tered during the follow-up period.
Further studies in the form of ran-
domized controlled clinical trials are
necessary to confirm the findings of
the present retrospective analysis.
Acknowledgments
The authors thank Dr Giuseppe Ravasini for
his invaluable cooperation and Dr Perakis
Nikolaos for his critical reading. The authors
reported no conflicts of interest related to
this study.
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Volume 38, Number 5, 2018
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