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Longevity of posterior resin composite restorations in permanent teeth in

Public Dental Health Service: A prospective 8 years follow up

Article in Journal of Dentistry · December 2012

DOI: 10.1016/j.jdent.2012.11.021 · Source: PubMed

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 journal of dentistry 41 (2013) 297–306

Available online at www.sciencedirect.com

journal homepage: www.intl.elsevierhealth.com/journals/jden

Longevity of posterior resin composite restorations in

permanent teeth in Public Dental Health Service:
A prospective 8 years follow up

Ulla Pallesen a,*, Jan W.V. van Dijken b, Jette Halken c,d, Anna-Lena Hallonsten c,
Ruth Höigaard c
a
Institute of Odontology, Faculty of Health and Medical Sciences, University of Copenhagen, Nörre Allé 20, DK-2200 Copenhagen, Denmark
b
Department of Odontology, Umeaa University, SE-901 87 Umeaa, Sweden
c
Public Dental Health Service, Copenhagen, Denmark

article info abstract

Article history: Objectives: To investigate in a prospective follow up the longevity of posterior resin com-
Received 14 August 2012 posites (RC) placed in permanent teeth of children and adolescents attending Public Dental
Received in revised form Health Service.
7 November 2012 Methods: All posterior RC placed, in the PDHS clinics in the cities of Copenhagen and
Accepted 28 November 2012 Frederiksberg in Denmark between November 1998 and December 2002, in permanent
teeth of children and adolescents up to 18 years, were evaluated in an up to 8 years follow
up. The endpoint of each restoration was defined, when repair or replacement was per-
Keywords: formed. Survival analyses were performed between subgroups with Kaplan–Meier analysis.
Children The individual contribution of different cofactors to predict the outcome was performed
Clinical with Cox regression analysis.
Longevity Results: Totally 2881 children with a mean age of 13.7 years (5–18) received 4355 RC restora-
Posterior tions placed by 115 dentists. Eighty percent were placed in molars and 49% were Class I. Two
Resin composite percent of restorations with base material and 1% of the restorations without base material
Restorations showed postoperative sensitivity (n.s.). Replacements were made in 406 and repairs in 125
restorations. Kaplan–Meier analysis showed a cumulative survival at 8 years of 84.3%,
resulting in an annual failure rate of 2%. Lower patient age, more than one restoration per
patient, placement of a base material and placement of RC: in molars, in cavities with high
number of surfaces, in lower jaw teeth, showed all significant higher failure rates. Five
variables had significant importance for the end point, replacement/repair of the resin
composite restorations: age of patient, age of operator, jaw, tooth type and cavity size.
Significance: Posterior RC restorations placed in children and adolescents in Public Dental
Health clinics showed an acceptable durability with annual failure rates comparable with
those of randomized controlled RC studies in adults.
# 2012 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: +45 35326823.

E-mail address: ul@sund.ku.dk (U. Pallesen).
d
Deceased.
0300-5712/$ – see front matter # 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jdent.2012.11.021
298 journal of dentistry 41 (2013) 297–306
1. Introduction
During the last decade new dental materials, operative
techniques and treatment strategies have been introduced
due to the environmental concern of mercury, the claimed
toxicity of amalgam and the increased demand for aesthetic
restorations. During the late nineties it was decided in many
countries to replace amalgam by resin composite (RC) as main
restorative without any longevity evidence. Tooth coloured
materials replaced amalgam successively as a restorative in
all indication areas.1–3 In longitudinal trials, carried out under
well defined conditions and performed by few operators with
small numbers of patients, resin composite restorations have
shown durability almost similar to amalgam.4–8 These well
controlled studies reflect the potential of the studied
restorative material performed by the individual dentist. To
get information about the performance of restoratives in
general practice, used by many operators, cross-sectional
studies have been recommended.9,10 Cross-sectional studies
from the nineties reported large differences in durability of
replaced RC and amalgam restorations.9–13 Unfortunately,
cross-sectional studies report the status of replaced restora-
tions only and can therefore not be used to calculate longevity
of the RC material. These studies have also often been based
on replies of selected operators with special interest in
operative dentistry and do therefore not mirror general
practice.10–13 There is a need of confirment and prospective
follow ups of restorations placed in Public Dental Health
Service (PDHS) clinics are still missing. In the Danish National
Health Service children and adolescents receive dental care
free of charge up to the age of 18 years including individually
planned recalls. After this age dental care continues in private
practice, with rather low public reimbursement. The aim of
this study was to evaluate the durability of Class I and II resin
composite restorations in children and adolescents placed in
PDHS clinics. The null hypothesis stated was that no
significant differences existed between cavity classes regard-
ing longevity.
2. Materials and methods
2.1. Participants and design
The study design was a prospective longitudinal structured
data collection study applied to all consecutive children and
youngster patients in the municipalities of Copenhagen and
Frederiksberg, Denmark. All children and adolescents up to 18
years treated between November 1998 and December 2002 in
all PDHS clinics, in need of one or more Class I and Class II
restorations in permanent teeth, where resin composite was
chosen, were included in the follow up. After the decision to
make a posterior restoration the choice of using RC was either
requested by the patients or their parents because of aesthetic
or non-metallic reasons, or proposed by the dentist for
stabilizing weakened cusps by adhesive technique. The
reasons for placement were primary caries or replacement
of restorations because of secondary caries, fracture of
restoration or fracture of tooth. Excluded were participants
with known allergic symptoms for dental resins and teeth
with cavity margins deep below the gingival margins or
cavities with difficult access where moisture could not be
controlled during the restorative procedure. The study was
performed during ordinary public dental service and therefore
no approval by the ethical committee was needed. Accept
from the Danish Data Protection Agency was obtained.
2.2. Clinical procedures
Before start of the study, dentists in the PDHS clinics in
Copenhagen and Frederiksberg participated in an educative
and calibrating course concerning placement of posterior RC
restorations to ensure a high uniformity of the technical
procedure and a high quality of performance.
The following recommendations to the treating dentists
concerning clinical procedures were made: Preparations with
high speed and micro-motor with rounded cylindrical and
round burs. No bevel preparation was performed and the
outline of the cavity was determined by the caries lesion or the
size of the restoration to be replaced. Caries excavation was
done by round burs at low speed and/or manually with hand
instruments. Calciumhydroxide (Dycal, DeTrey Dentsply,
Konstanz, Germany; Alkaliner, 3M ESPE, Seefeld, Germany)
was used for lining of cavities with close relation to the pulp.
After colour selection, isolation of the operative field was
performed with cotton rolls and suction device. Metallic or
celluloid matrix bands in Nyströms matrix retainer and
wooden wedges were placed. Cavity-etching with 35%
phosphoric acid gel, applied first on the enamel for 20 s as
possible, followed by 10 s on both enamel and dentine. After
rinsing with water and carefully drying with air of the cavity
(wet bonding technique), a total etch adhesive bonding system
was applied and light cured according to the manufacturer’s
instructions. The resin composite was applied in 2 mm thick
oblique layers which were light cured for 40 s. The adhesives
and resin composites applied were those commonly used at
the clinics. An additional gingival cure of 2 20 s was
performed after removal of wedges and matrix retainer. After
curing, finishing and polishing was done under water cooling
with finishing diamond burs, silicone polisher, polishing discs
and strips. Control of marginal adaptation, anatomic form,
occlusion- and articulation contacts and proximal contacts
was done by probing, articulation foil and dental floss. Directly
after polishing, etching of the margins of the restorations with
35% phosphoric acid during 10 s, followed by water rinse,
intensive air drying and application of 99% ethanol according
to Qvist and Strøm14 followed by a hydrophobic bonding agent
(Concise Enamel Bond, 3M ESPE) applied with a foam pellet in a
thin layer. Overhang was removed with a cotton roll, dental
floss and probe. The resin was allowed to cure for at least one
minute in the isolated operative field.
2.3. Data collection
For each placed restoration a data collection sheet was
completed at baseline and annual registrations were per-
formed by the treating dentists at the same sheet while the
treatment was still performed in the PDHS. For each restora-
tion a set of patient-related variables was collected on a record
 journal of dentistry 41 (2013) 297–306
form. After leaving PDHS at 16–18 years, the adolescents were
contacted by mail when the restoration became 5 and 8 years
old and asked to report, if a consultation to private dentist
after leaving PDHS had been performed. After report of the
name of the dentist, the private dentist was contacted by mail
and if necessary later by phone. The dentist was asked to fill
out a questionnaire from data in the file using the last visit as
date for the evaluation.
2.4. Evaluation
Baseline registrations were made right after finishing of the
restorations. Small defects observed like porosities, smaller
gaps, missing proximal contacts and lack of colour match
were registered on the data collection sheets as well as repairs
of the defects if performed. The following baseline data were
registered in the sheets: name, gender, age of the participant,
day of placement, operator, indication for placement patient
request for aesthetic or non-metallic restoration, dentist
indication for an adhesive restoration (caries, fracture of
tooth or restoration, reinforcement of tooth, aesthetics), tooth
number and surfaces involved, cavity base material, dentine
bonding system, resin composite material and post-operative
sensitivity. Postoperative sensitivity was recorded when the
adolescents addressed themselves to the PDHS with minor or
severe pain. Most teeth with sensitivity received no treatment.
When restorations in teeth with symptoms were re-sealed
along the margins or corrected for supra contacts, they were
recorded as repaired. Failures were when severe symptoms
persisted and RC had to be removed.
At the following recalls up to the age of 16–18 years which
was the final year the adolescents received free dental care at
the PDHS clinics, restorations were evaluated clinically and by
X-rays. Interventions observed varied from repairs, when
polishing small chip fractures or sealing of small marginal
defects with bonding resin to replacement of the restoration.
Date, type and reason of intervention and replacement
material were recorded. When the adolescents finished in
the PDHS, the evaluation was continued by the new private
dentist, who was informed about their participation in the
resin composite research and the planned recalls. The present
paper focuses on the analysis of materials and the longevity of
the restorations. Analysis of reasons for replacement will be
reported in a subsequent paper.
2.5. Statistical analysis
The data were recorded and analyzed in SAS, version 9.2. The
endpoint of each restoration was defined as a failed, non-
acceptable, restoration which was repaired or replaced.
Replacements or repairs due to caries in a non-filled surface
of a tooth with an acceptable RC were not considered as
reasons for failures. Descriptive statistics was used to describe
data concerning participants and dentists involved type of
tooth, cavity type, materials used, post operative symptoms,
repair or replacement. Survival analysis of restorations and
differences between subgroups (patient age, gender, jaw,
tooth type, cavity, dentine bonding, base material) was
performed with Kaplan–Meier. Differences between cofactors
of subgroups at the different years of evaluation were tested
299
with Cox regression analysis. Consideration was taken for
dependence between restorations within each individual. The
cumulative probability of restorations in different subgroups
to survive for the event times 5 and 8 years and their 95%
confidence intervals were calculated.
To determine the individual contribution of the different
cofactors to predict the outcome of the resin composite
restoration, an univariate and a multiple Cox regression
analysis was performed with a forward selection. The
regression parameters in the Cox model were estimated by
the maximum partial likelihood estimates under an indepen-
dent working assumption and of a robust sandwich covari-
ance matrix estimate to account for the intracluster
dependence.15 The dependent variable was the failure of
the restoration, replacement or reparation, and as predictor
variables all factors which could influence the outcome with
the end of the study as endpoint: patient age, gender, jaw,
tooth type, cavity, resin composite material, dentine bonding,
base material, number of restorations per patient, dentist age,
dentist RC education level, number of placed restorations per
dentist. The null hypothesis was rejected at 5% level.
3. Results
Totally 2881 children and adolescents participated in the
follow up (57.2% girls and 42.8% boys). The mean age of the
participants at baseline was 13.7 years (median 14.1 years;
min–max: 5–19). Seventy-eight percent of the RC restorations
were placed in 12–19 years olds. The total number of placed
restorations was 4355 (3794 Copenhagen, 561 Frederiksberg).
The 115 dentists involved placed a mean of 37.4 (min–max: 2–
388) restorations. Ten dentists placed more than 100
restorations each, while 71 dentists placed < 25 restorations.
Fifty-nine percent were placed in girls and 41% in boys.
Absolute frequencies of occlusal, mo/do/mod and 4 surface
cavities were for girls 1285, 1071, 219 and for boys 849, 745, 186,
respectively. Forty-nine percent of all cavities were Class I
and 41.7% Class II restorations (mo: 23.9%, do: 15.6%, mod:
2.2%, 4 surfaces 9.3%). Most of the children received one
(2020), two (527), three (187) or four (89) restorations. The
majority of the restorations were placed in molars (3507)
versus 19.5% in premolars (848), 51% (2216) were in the upper
jaw and 49% (2139) in the lower jaw. The number of dentist
involved, mostly women, in different age groups were: 19 in
<30 years, 19 in 31–39 years, 43 in 40–54 years, and 14 in
>55 years group.
After the decision to make a posterior restoration the
reasons to choose a RC restoration were patient demands
(47.5%), dentist indication for aesthetic restorations (33.8%)
and request for metal-free restorations (5.9%). The most
frequent resin composite used was Spectrum TPH (88.2%;
Dentsply DeTrey), followed by Herculite (5.4%; Kerr Co.,
Bioggio, Switzerland), and other materials in 6.4%. The most
frequent used bonding resin system was Prime & Bond NT
(94.1%; Dentsply DeTrey), followed by ScotchBond Multipur-
pose (3.9%; 3M ESPE, Seefeld, Germany), classic Gluma (0.2%;
Bayer/Hereus Kulzer, Dormhagen, Germany), other bonding
systems (1.1%) and no bonding (0.5%). Cavity base materials
were used in 73.4% (35.7% Alkaliner, 3M ESPE; 30.0% Dycal,
300 journal of dentistry 41 (2013) 297–306

4500 700
4000 84% 600
3500 77%
66% 500
3000
59%
2500 400
52%
2000 300
43%
1500
200
1000 30%
32% 100
500 17%
25%
37%
24%
25%
22%
20%
10%
15%
10%
13%
9%
11%

0 0
1 2 3 4 5 6 7 8 5 7 9 11 13 15 17+
Year Age (year)
Fig. 1 – The number of placed restorations and their relative Fig. 2 – Number of restorations and relative frequencies of
frequencies (in bars) of evaluated restorations for each of replaced or repaired (in bars) restorations for the age of the
the follow up years after placement. children at the start of the study.

DeTrey Dentsply; 2.3%, Calasept, Nordiska Dental, Sweden),
other materials in 5.4% and no base material in 26.6%.
Baseline defects were observed in 3.3% (porosities 0.2%,
marginal gaps 0.4%, no proximal contact 0.9%, lack of colour
match 0.7%, others 1.3%) of which 0.7% needed repair. Post
operative sensitivity was observed in 1.5% of the evaluations
(13 premolars, 52 molars; 23 Class I, 35 Class II and 7 cusp
replacements). Of the 65 teeth with symptoms, 6 recieved no
treatment, 6 teeth had restorations repaired and 46 had
restoration replaced. No teeth were endodontic treated. Two
percent of restorations with base material and 1% of the
restorations without base material showed postoperative
sensitivity (n.s.). No significant differences were seen between
the different patient age groups.
The relative frequencies evaluated restorations for each of
the follow up years after placement are shown in Fig. 1. The
mean number of evaluations per restoration was 2.2 (SD 1.7).
In the follow up replacements were made in 406 restora-
tions (girls 253, boys 153). Repairs were performed in 125
restorations (girls 76, boys 49). Relative frequencies of replaced
or repaired restorations for each of the different age groups of
the children at the start of the study are shown in Fig. 2.
Kaplan–Meier survival analysis showed a cumulative survival
rate until repair or replacement at 8 years of 84.3%, resulting in
an annual failure rate of 2% (Fig. 3).
The differences between cofactors associated with the
need of replacement or repair of the RC restorations as end
point at 1, 3, 5 and 8 years are shown in Table 1. Lower patient
age, more than one restoration per patient, placement of
restoration: in molars, in cavities with high number of
surfaces, in lower jaw teeth, placement of a base material,
restorations placed in Copenhagen showed all significant
higher failure rates (Table 1). An increased number of failed
restorations was observed with a higher number of restored
teeth per patient.
Relative failure frequencies of restorations placed in the
patient age groups 5–11 years at the start of the study varied
between 17% and 37% and in the 12–19 years age groups
between 9% and 15% (Fig. 4). The cumulative probabilities to
survive at years 5 and 8 and the 95% confidence intervals are
given in Table 2. Kaplan–Meier survival analysis of all resin
composite restorations comparing the cofactors cavity types,
tooth type and use of base material are shown in Figs. 5–7.
The results of the univariate and multiple Cox regression
analysis are given in Table 3. The multiple Cox regression
analysis showed that five variables had significant importance
for the end point, replacement/repair of the resin composite
restorations: age of patient, use of base material, jaw, tooth
type and cavity size. Patients in the age group 12–19 showed a
lower probability to replace/repair their restorations. Restora-
tions placed in molars showed a higher probability to be
replaced or repaired as well as restorations placed in the lower
jaw and restorations placed with a base.
100
90
80
70
60
Cum. Survival (%):
97.7 92.8 87.5 84.3
50
0 1 2 3 4 5 6 7 8
Time after restoration (year)
Fig. 3 – Kaplan–Meier survival analysis of all resin
composite restorations. Relative frequencies replaced or
repaired restorations. Cumulative survival rates at years 1,
3, 5 and 8 years are indicated.
 journal of dentistry 41 (2013) 297–306 301

Table 1 – Differences at years 1, 3, 5 and 8 of the resin composite restorations between different subgroups cofactors
associated with the need of replacement or repair of the restoration as endpoint.
Cofactors Significance level ( p) at restoration age

Year 1 Year 3 Year 5 Year 8

Boys vs girls 0.54 0.25 0.41 0.39
Age of patient at baseline 5–11 years vs 12–19 years 0.43 0.005 <0.001 <0.001
Number of restoration per patient 1 vs 2 0.29 0.05 0.03 0.041
Resin composite materials used: sectrum vs hrculite vs others 0.74 0.09 0.16 0.22
Adhesive systems used 0.08 0.79 0.54 0.61
Use of base vs no base 0.009 0.008 0.03 0.05
Upper vs lower jaw teeth 0.26 0.03 0.005 0.02
Premolar vs molar teeth 0.67 0.91 0.04 0.006
Cavity type, 1 vs 2–3 vs >3 surfaces 0.001 <0.001 <0.001 <0.001
Restorations performed in Copenhagen vs Fredriksberg 0.05 0.09 0.12 0.12

with small numbers of patients reflect the potential of the

4. Discussion
During the early nineties RC was the major used material in
anterior cavities, while posterior cavities still were restored
with amalgam.9–13,16,17 A marked change in selection of dental
restorative materials started in Scandinavia during the late
nineties following recommendations in different countries to
use other restorative materials than amalgam as the first
choice materials. As a result the use of RC increased in
posterior teeth.10,18 Recent studies from Scandinavian coun-
tries showed the predominant use of posterior RC and an
almost negligible use of amalgam.3,18 The longevity of
posterior RC has been studied extensively during the early
2000, but only a small number of the studies were long-term
evaluations with large number of subjects. Despite the
predominant use of RC in general practice, information
concerning the longevity in Public Dental Health clinics is
poor. Restoration longevity may be assessed in a variety of
ways, including randomized controlled clinical trials, pro-
spective and retrospective studies, cross-sectional analysis,
cohort studies and analysis of databases. Longitudinal clinical
evaluations of new materials and techniques carried out
under well defined conditions and performed by few operators
100
12-19 year
90
5-11 year
80
70
60
P=0.43 0.005 <0.001 <0001
50
0 1 2 3 4 5 6 7 8 in posterior teeth in practice based dentistry, expected
Time after restoration (year)
Fig. 4 – Kaplan–Meier survival analysis of all resin
composite restorations for two age groups. Relative
frequencies replaced or repaired restorations.
restorative materials. This may also be obtained in retrospec-
tive studies if conditions are well described in the patients’
journals. Cross-sectional studies performed in PDHS clinics
mirror real-life dentistry and have suggested giving more
information about the performance of restorations in general
practice when used by many operators.10 However, the
reported longevity figures of posterior restorations in cross-
sectional studies showed much lower survival figures com-
pared to these reported in longitudinal trials.3 Sunnegårdh-
Grönberg et al. reported recently longevity of replaced
posterior restorations with a median of 5 years for Class II
and of 7 years for Class I restorations.3 In a systematic review
Downer et al. pointed out that cross-sectional studies give an
underestimation of the average lifetime of routine restora-
tions.19 Two recent articles showed that the survival figures
reported in cross-sectional studies, which concern replaced
restorations, are badly correlated to prospective failure
figures.20,21 Longevity figures of cross-sectional studies be-
came still more uncertain due to low recording response rates
of the general practitioners in these studies, while the age of
the restorations in many studies had been based on only 60%
of the studied restorations, varying between 25% and
79%.3,11,17,22 However, the value of cross-sectional studies is
that they shed light on the reasons for replacement and the
use of restorative materials made by practitioners in everyday
clinical practice. It is therefore important to involve general
dentists also in the longitudinal follow up of restorative
materials. The present study concerns a prospective evalua-
tion involving all posterior resin composite restorations,
placed during 4 years, in all children attending Public PDHS
in Copenhagen and Frederiksberg, involving the whole
population of PDHS dentists working in this field. The study
reflects therefore everyday clinical practice and can be
categorized as practice-based. During the placement period,
part of the participating dentists still placed many amalgams
and rather few RC restorations. The reasons for the partial
continuing use of amalgam in children during the placement
period may be several, like lack of evidence for resin composite
secondary caries risk, and operators feeling uncertain using
resin composites in posterior cavities.23
For each time interval the Kaplan–Meier analysis estimated
the probability that restorations that have survived the start
would survive to the end. The survival time of the RC
302 journal of dentistry 41 (2013) 297–306

Table 2 – The cumulative probability of restorations in different subgroups to survive to the event times 5 and 8 years and
their 95% confidence intervals (CI).
Subgroup 5-year survival estimate 8-year survival estimate

Survival Survival distribution Survival Survival distribution

probability 95% CI probability 95% CI
Age: 12–19 years 0.90 0.89–0.91 0.88 0.87–0.89
Age: 5–11 years 0.81 0.79–0.84 0.75 0.72–0.78
Gender: boys 0.88 0.87–0.90 0.85 0.83–0.87
Gender: girls 0.87 0.86–0.89 0.84 0.83–0.86
Number restorations per patient: 1 0.89 0.88–0.91 0.85 0.83–0.87
Number restorations per patient: >1 0.87 0.85–0.88 0.85 0.83–0.86
Jaw: maxilla 0.89 0.88–0.91 0.86 0.84–0.88
Jaw: mandible 0.86 0.85–0.88 0.84 0.83–0.85
Tooth type: molar 0.87 0.86–0.88 0.84 0.82–0.85
Tooth type: premolar 0.91 0.88–0.93 0.90 0.87–0.92
Cavity; >3 surfaces 0.81 0.77–0.85 0.79 0.74–0.83
Cavity: mo/do/mod 0.85 0.83–0.87 0.82 0.79–0.84
Cavity: occlusal 0.91 0.89–0.92 0.88 0.86–0.89
RC: Herculite 0.84 0.78–0.88 0.82 0.76–0.87
RC: Spectrum 0.88 0.87–0.89 0.85 0.84–0.86
Adhesive: Prime and Bond NT 0.88 0.87–0.89 0.85 0.84–0.86
Adhesive: Scotchbond MP 0.83 0.76–0.88 0.79 0.72–0.85
Restorations placed with base material 0.87 0.86–0.88 0.84 0.83–0.86
Restorations placed without base material 0.90 0.88–0.92 0.87 0.84–0.89
Base: Alkaliner 0.88 0.86–0.90 0.85 0.83–0.87
Base: Calasept 0.82 0.73–0.88 0.74 0.60–0.83
Base: Dycal 0.87 0.85–0.89 0.85 0.82–0.87

restorations was obtained after estimation of all observations, Two practice based studies reported the durability of posterior
including the censored ones. We observed an 84% survival rate RC restorations in children and adolescents. Bernardo et al.26
at 8 years, which result in an annual failure rate of 2%. This can randomly placed 1748 posterior amalgam and RC restorations
be compared with earlier reported annual failure rates in in 8–12 years old children in Portugal, and followed these for
randomized long-term longitudinal evaluations between 0.5% up to 7 years. Overall 10.1% failed. The survival rate of
and 3%.4–9,24,25 The found results are largely in contrast to the amalgam was 94.4% and for RC 85.5%.25 In a shorter follow up,
findings of Levin et al. who examined bitewing radiographs of Soncini et al.27 randomly placed 1262 RC and amalgam
subjects 18–19-year old, who arrived for dental screening prior posterior restorations in permanent teeth of 6–10-year-old
to their military service.23 A high percentage (43%) of the USA children. The replacement/repair rate during the 3.4  1.9
youngster’s interproximal RC surfaces placed earlier in year follow-up was 17.7% for RC and 11.2% for amalgam. It
general practice showed secondary caries and overhangs.23 may be assumed that these high replacement rates of occlusal
restorations were observed in high caries risk subjects.
However, the large differences in outcome found for the RC
100 material in these children and adolescents age populations
O may probably also be the result of operator influences. In the
90 Bernardo et al. study26 which had almost similar evaluation
years and clinical outcome as the present study, the dentists
MO/OD+MOD
used rubberdam whenever possible. However, the use of
80 rubberdam by the general dentists in Europe is very limited. In
other
the present study moisture control was obtained with cotton
rolls and saliva suction device. Despite the different methods
70
used, both studies showed the same clinical outcome at the
end of the 7–8 years follow up. The equal results obtained with
60 both control methods confirm that it was possible for the
participating dentists to maintain a dry operative field.28 This
P=0.001 <0.001 <0.001 <0.001 good clinical performance of RC obtained with cotton rolls and
50
0 1 2 3 4 5 6 7 8 saliva suction device has also been shown in many recent
Time after restoration (year) prospective studies.4–8,20
Many factors influence restoration survival, including
Fig. 5 – Kaplan–Meier survival analysis of all resin patient factors, dentist factors and choice of restorative
composite restorations comparing the different cavity materials.29 Dentist’s factors which may be correlated with
types. Relative frequencies replaced or repaired longevity of the restoration and have rarely been analyzed as
restorations. confounders are: age, gender, RC education level, time since
 journal of dentistry 41 (2013) 297–306 303

100
Premolars 100 No base

90
90
Molars
80 Base
80

70
70

60
60
P=0.67 0.91 0.04 0.006 P=0.009 0.008 0.03 0.06
50
0 1 2 3 4 5 6 7 8 50
0 1 2 3 4 5 6 7 8
Time after restoration (year)
Time after restoration (year)
Fig. 6 – Kaplan–Meier survival analysis of all resin
Fig. 7 – Kaplan–Meier survival analysis of all resin
composite restorations comparing restorations placed in
composite restorations comparing restoration with or
premolars vs molars. Relative frequencies replaced or
without base material. Relative frequencies replaced or
repaired restorations.
repaired restorations.

Table 3 – Cox univariate and multiple regression analysis, by forward selection, of subgroup variables which may predict
failure or repair of the resin composite restorations at the end of the follow up.
Univariate regression analysis Multiple regression analysis

Hazard ratio 95% hazard ratio CI Sign Hazard ratio 95% hazard ratio CI Sign
Patient age at baseline
5–11 years 1 1
12–19 years vs 0.46 0.38–0.55 <0.0001 0.43 0.36–0.52 <0.0001
Gender
Girls 1
Boys 0.92 0.75–1.12 0.40
Number fillings per patient
2 surfaces 1
1 0.94 0.78–1.13 0.51
Resin composite
Spectrum 1
Other RC 1.27 0.95–1.69 0.11
Base
Ca(OH)2 1 1
No base 1.52 1.01–2.29 0.04 1.39 1.09–1.75 0.007
Jaw
Mandible 1 1
Maxilla 0.82 0.69–0.97 0.02 0.76 0.63–0.91 0.002
Tooth type
Premolars 1 1
Molars 1.51 1.13–2.02 0.006 1.45 1.08–1.06 0.01
Cavity
1–3 surfaces 1 1
>3-Surfaces 1.94 1.46–2.57 <0.0001 1.83 1.38–2.43 <0.0001
1 and >3surfaces 1 1
2–3 surfaces 1.56 1.28–1.91 <0.0001 2.31 1.87–2.86 <0.0001
Dentist age
1945–59, 1960–69, 1970– 1
–1944 0.56 0.37–0.87 0.009
Number restorations per dentist
>50 1
1–10, 11–25, 25–50 0.52 0.28–0.97 0.04
Dentist RC education
Anterior RC and posterior RC 1
No RC education 0.73 0.51–1.05 0.093
304 journal of dentistry 41 (2013) 297–306
education, experience and practice characteristics, associated
with for example different levels of performance of the
restorations and criteria of replacement/repair. It is well
accepted today, but with little evidence, that the operator is
one of the most important variables determining the diagno-
sis, selection of the material, the quality of the restoration and
instructions to the patients. Lucarotti et al.30 observed that the
age and experience of the dentist placing restorations was
related to the survival of the original restoration. Older
dentists had shorter intervals from placement of restorations
to re-intervention, which was also reflected in the relationship
between dentist experiences measured in years since qualifi-
cation. Two cross-sectional studies reported that the least
experienced dentists replaced restorations at a lower age than
the most experienced dentists.3,13,31 They explained this by
differences in criteria used between the dentist’s age groups.
In the present study the number of replaced restorations was
lowest for the most experienced dentist, despite that they had
not received RC-education during their basic education. No
analysis for dentist gender could be made because almost all
dentists were female. Some studies reported gender depen-
dence,30 while others did not.3,13
The patient plays an important role in the durability of the
restoration.32 Patient’s factors which may be correlated with
longevity of the restoration are age, gender, caries risk,
parafunctional habits, associated with for example different
levels of cooperation and compliance with advice of the
dentists. In adults, patient age has been observed to be an
important factor for the longevity of the restoration. Burke
et al. observed older patients having a shorter interval to re-
intervention, while they indicated gender to be of little
significance for the long-term survival of the restorations.33
We observed that patients in the age group 5–11 years at
baseline showed a higher re-intervention rate compared to the
older children. This can partly be explained by differences in
caries risk and more difficult cooperation and possibilities to
perform a quality restoration. No differences in the longevity
of the posterior resin composite restorations were seen for
patient gender, a finding common with other practice based
studies observing adults.33–35
Dental factors considered to be associated with the re-
intervention of the restoration are the type of tooth, tooth’s
position in the dental arch, cavity size and the number of
restored surfaces, restorative material, adhesive and place-
ment of base material. We observed that restorations in
molars had a higher probability to be replaced or repaired than
premolar ones, which is in accordance with recent find-
ings36,37 and can be explained by an easier operative field for
premolar teeth combined with less intra oral stress during the
follow up. However, another practice based children study
found no differences in failure rate between premolar and
molar teeth.26 Similar surviving figures for restorations in
premolar and molar teeth were also found in an evaluation of
adult patients in general dental practice in England and
Wales.17
Single surface resin composite restorations were found to
have the longest survival compared to multi-surface restora-
tions as also shown in two earlier practice based evaluations
on children.26,27 The null hypothesis was therefore not
accepted. Also RC restoration evaluations in adult subjects
confirmed the higher failure risk of multi-surface restora-
tions.17,36,37 The Class I cavity with its high configuration
factor has been considered to be the cavity with the highest
risk to develop shrinkage stress. A low 0.2% annual failure rate
observed for Class I cavities in a 12-year longitudinal
randomized evaluation showed that the influence of poly-
merization shrinkage stress on the longevity of the Class I
resin composite restoration was far less as expected and
indicated the role of other factors.38 A higher number of placed
restorations per patient increased the risk of failure, as also
reported in two recent studies.27,36 Relative frequencies of
failed restorations for patients with two restorations in-
creased successively from 22.5% to 61.5% for patients with
seven placed restorations. It can be assumed that the children
with increased number of restorations who had an increased
caries activity at the start of the study still had an increased
caries risk during the follow up period. Lower survival was
found for teeth in the mandible, which may be explained by a
more difficult operative field caused by saliva, presence of
tongue and not optimal insight in the cavity especially in the
younger participants. A better survival of restorations in
mandibular teeth was observed for restorations placed in
patients 18 years and older in general service in England and
Wales,17 in contrast to observations of other practice based
studies involving adults35 or children,26 who found no
difference between teeth in the mandible and maxilla.
Due to concerns about shrinkage of RC material, main-
taining adhesion to dentine and risk for postoperative
sensitivity, different base materials like GIC and Ca(OH)2
cements have been used below RC restorations during the
years. It has been suggested that the base will decrease the
strength and durability of the restoration but there is no good
evidence for this statement.32 Burrow et al.39 found no
difference in postoperative sensitivity between GIC lined RC
and non-lined RC restorations. Opdam et al.36 observed that
glass ionomer cement bases decreased survival compared to
total-etch RC restorations. In the present study, calcium
hydroxide cement bases were the most frequently placed base
materials (68%). A significant higher failure rate was observed
for the restorations with a base compared to those without.
The restorations with a base showed twice as many teeth with
persisting post operative sensitivity.
Postoperative sensitivity after placing posterior RC restora-
tions has been a problem experienced in general practice
during many years.40 It has been attributed to several factors
like effects of shrinkage stress on the marginal integrity,
etching of dentine, cusp deformation and interfacial bacterial
penetration. Overall, the prevalence of postoperative sensitiv-
ity in the present study was 1–2% and no clinical problem. The
low frequency reported is in accordance with recent studies of
the effect of different placement techniques on postoperative
sensitivity.39,41 Perdigão et al. concluded that postoperative
sensitivity depends more on the restorative technique rather
than on the type of adhesive.41 It seems that experience and
increased knowledge of adhesive procedures of dentists
involved makes the sensitivity problem less prominent.32
It was concluded that posterior RC restorations placed in
children and adolescents in Public Dental Health clinics in
Denmark showed an acceptable durability with annual failure
rates comparable with those of randomized controlled RC
 journal of dentistry 41 (2013) 297–306
studies in adults. Five variables had significant importance for
the end point, replacement/repair of the RC restorations: age
of patient, age of operator, jaw, tooth type and cavity size.
Acknowledgements
The authors sincerely thank the clinicians for all time and
effort spent in completing the recordings. The support from
the New Danish Dental Association, the Danish Dental
Association, the Swedish Medical Research Council and the
County Council of Västerbotten is gratefully acknowledged.
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