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Defective dental restorations: to repair or not to repair? Part 1: direct

composite restorations

Article in SADJ: journal of the South African Dental Association = tydskrif van die Suid-Afrikaanse Tandheelkundige Vereniging · April 2011
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 RestorativeDentistry

Igor R Blum

Daryll C Jagger and Nairn HF Wilson

Defective Dental Restorations: To

Repair or Not To Repair? Part 1:
Direct Composite Restorations
Abstract: The presentation of patients with failing dental restorations that exhibit minor defects is a common clinical situation in everyday
dental practice. The repair of such restorations, rather than replacement, is increasingly considered to be a viable alternative to the
replacement of the defective restoration. This first of two papers considers indications and techniques for the repair of defective direct
composite restorations.
It is possible that some dental practitioners are unaware of the option of repair rather than replacement of composite restorations. This
article provides an overview of contemporary knowledge and understanding of restoration repair in the clinical management of defective
composite restorations.
Clinical Relevance: A sound understanding of the indications, benefits and techniques of direct composite restoration repair could allow
the longevity of the existing restoration to be extended without unnecessarily sacrificing healthy tooth structure.
Dent Update 2011; 38: 78–84

There is clearly an increasing
demand for aesthetic dental restorations
from the general public and dentists are
spoilt for choice as to which materials to
use and how best to use them. There is
Igor R Blum, DDS, PhD, Dr Med Dent,
MSc, MFDS RCS(Eng & Edin), PGCertHE,
FHEA, Clinical Lecturer/Hon Specialist
Registrar in Restorative Dentistry,
University of Bristol Dental Hospital
& School, Daryll C Jagger, BDS, PhD,
MSc, FDS RCS(Eng), FDS RCS(Rest Dent),
Professor of Restorative Dentistry,
Glasgow Dental School and Hospital and
Nairn H F Wilson CBE, FKC, DSc(hc), BDS,
MSc, PhD, DRD, FDS RCS(Eng & Edin),
FFGDP(UK), Professor of Restorative
Dentistry and Dean and Head of King’s
College London Dental Institute at Guy’s,
King’s College and St Thomas’ Hospitals,
London, UK.
78 DentalUpdate
no disputing the excellent aesthetics
that can be achieved with composite
resin as a restorative material; however,
the longevity of these materials can be
disappointing, especially if not placed
using a careful incremental technique.1
With the increasing use of these materials
for the restoration of large defects in
posterior teeth, these materials are tested
to the maximum.
The management of
composite restorations with localized
defects is a common challenge in clinical
practice. While some restorations will
inevitably require replacement, it has
been suggested that some deteriorating,
yet serviceable, restorations may be given
extended longevity through the use of
repair procedures.2 This comparatively
more conservative approach to the
management of defective restorations,
if appropriate, has the potential to
be less costly in terms of time and
financial resources, less traumatic for
patients, less likely to result in iatrogenic
damage, possibly obviate the need for
the use of local anaesthesia and be
more conservative of tooth tissue.3–5
It is clearly preferable, therefore,
to perform a restoration repair (ie
partial replacement of the composite
restoration allowing preservation
of that portion of the composite
restoration which presents no clinical or
radiographic evidence of failure) as an
alternative to restoration replacement
(removal of an entire composite
restoration followed by the placement
of a new composite restoration)
wherever possible. It is accepted that
removal of part of the restoration
without the aid of magnification loupes
can further result in removal of sound
tissue and subsequent increase in the
size of the cavity.
It has been suggested
that repair procedures may be most
effective when they correct placement
defects in otherwise high quality
restorations.6 This is possible given
March 2011

that a placement defect, for example
chipping of a margin on finishing, or
early signs of deterioration in clinical
service, tend to be limited to a small
part of the restoration, typically a short
section of the cavosurface margin. The
repair of a composite restoration may
include an element of refurbishment – a
procedure that should normally pre-empt
and delay repair, let alone replacement.
Refurbishment procedures typically
involve the refinishing or resurfacing
of a restoration, with or without
recontouring.3 Refinishing may be limited
to the margins of a restoration, while
resurfacing may involve part or all of the
exposed surfaces of the restoration.
Rationale for restoration
repair
The main reasons
reported3,7 for the repair, rather than
the replacement, of defective direct
composite restorations include:
„ Preservation of tooth structure;
„ Increased longevity of the restoration;
„ Reduction of potentially harmful
effects on the dental pulp;
„ Reduction in treatment time;
„ Reduced cost to the patient;
„ Good patient acceptance;
„ No need for local anaesthesia, provided
the repair is not extensive;
„ Less risk of iatrogenic damage to
adjacent teeth.
Criteria for repair of
restorations
The criteria which play a role
in the choice of repair as opposed to the
replacement of defective restorations
include patient-centred and tooth-
specific criteria.
Patient-centred criteria
Dentally motivated patients
who attend on a regular basis, and
maintain a good standard of oral health,
have been deemed good candidates for
restoration repair procedures.7 Patients
who have complex medical histories or
limited capacity to co-operate may also
be viewed as suitable candidates for
the repair rather than the replacement
March 2011
of failing restorations, in particular if
operating time needs to be kept to a
minimum. Repair procedures can often
be accomplished without the need for
local anaesthesia and complex operative
procedures. It has also been suggested
that, in situations in which there is a
risk of inappropriately extending the
operating time, and possibly causing
distress to the patient, it may be sensible
to complete an effective repair rather
than attempt a replacement restoration.4
It is appreciated however that, under
these circumstances, the replacement
restoration may be considered to be
more of a ‘patch and make good’ than a
good quality repair.
In planning to undertake a
repair of a restoration, it is important
that the patient is fully informed of the
advantages and possible limitations
of the repair procedure and how this
procedure differs from replacement of
the restoration. In obtaining informed
consent for a restoration repair
procedure, the patient must understand
that he/she will not be receiving a new
restoration and that a repair may be
subject to early failure, given that a
repair may not correct a fundamental
flaw in the design of a restoration.4
Tooth-specific criteria
Tooth-specific criteria for the
repair of direct composite restorations
include:
„ Localized marginal defects and
marginal staining;
„ Bulk fracture of a limited portion of
the restoration;
„ Secondary caries, as diagnosed
clinically;
„ Colour correction;
„ Localized wear of the restoration;
„ Fracture of adjacent tooth tissue.
Localized marginal defects and marginal
staining
The presence of limited
marginal defects does not necessarily
indicate the presence or likelihood of
secondary caries.8 Many marginal defects
in direct composite resin restorations can
be simply managed using refurbishing
procedures (Figures 1 and 2), given that
the overcontouring associated with
RestorativeDentistry
many direct composites results in
chipping and in marginal overhangs.
Such overhanging margins may be
removed using a fine-grit diamond
finishing bur. This will also remove
any superficial staining which may
have accumulated in the angle of
the overhang and help harmonize
the contour of the restoration and
the adjacent tooth surface. Great
care must, however, be taken not to
damage the adjacent enamel surface
iatrogenically. The composite resin
surface is subsequently polished
using appropriate composite finishing
systems, possibly followed by the
application and photopolymerization
of an unfilled resin which may seal over
any marginal cracking of the composite
and enamel and provide a surface glaze
which will, in all probability, wear away
relatively rapidly in clinical service.
Minor marginal defects
on the occlusal surfaces of posterior
composite restorations, which
are imperceptible to the patient,
are usually best monitored, with
intervention being delayed until there
is evidence of plaque accumulation
or food stagnation, with associated
Figure 1. Stained margins visible around
composite restorations.
Figure 2. Removal of stained margins by refinishing
and polishing of restoration (=refurbishment).
DentalUpdate 79
 RestorativeDentistry
discoloration, which may result in
secondary caries.6 Marginal defects in
anterior composite restorations are more
problematic because of their tendency
to pick up exogenous stain, in particular,
in smokers and individuals who
consume large amounts of, for example,
black coffee. Refinishing coupled,
where necessary, with refurbishment
of the restoration is typically the
most effective way to manage such
staining successfully. However, if a
heavy, interface penetrating stain is
present, then the restoration may not
be amenable to repair procedures and
total restoration replacement will then
be necessary to obtain a high quality
aesthetic outcome. In such situations,
careful bevelling of cavity margins and
meticulous finishing of the replacement
restoration may minimize the risk of
early recurrence of the problem. In cases
in which staining is heavy and returns
quickly following corrective procedures,
and in situations in which the anterior
teeth are heavily restored, the patient
should be encouraged to at least reduce
or discontinue the habit or consumption
of whatever is considered to cause the
staining.
Bulk fracture
When a patient presents
with a bulk fracture of a composite resin
restoration, in particular, soon after
restoration placement, it is important
to diagnose and eliminate the reason
for the fracture; for example, excess
occlusal loading or inappropriate or
excessive use of a liner or base, resulting
in the restoration lacking support or
thickness sufficient to withstand normal
loading. Diagnosis and correction of the
underlying problem is necessary to avoid
recurring bulk fracture, or a fracture
involving remaining tooth tissue. Bulk
fracture of a composite restoration that
has been in clinical service for many
years is likely to be the result of stress
fatigue within the composite material.
If the bulk fracture is limited (up to half
of the restoration) and the restoration is
months rather than years old, repair may
be indicated; however, the integrity of
the remaining portion of the restoration
should be carefully assessed clinically
80 DentalUpdate
Figure 3. Clinical appearance of first premolar Figure 4. Restoration following repair procedure.
with removed distal portion of three surface
composite restorations due to secondary caries at
the distal floor.
removal and the placement of an effective
repair (Figures 3 and 4). The portion of the
composite restoration which presents no
and possibly radiographically. Repair of
clinical or radiographic evidence of failure
a bulk fracture, for example, loss of an
should be left in place, unless there is
incisal corner of a large incisal proximal
good clinical indication to resort to total
composite, is to be favoured over total
restoration replacement with its various
restoration placement, in particular
consequences. With a tendency to practise
when the repair will avoid disturbing a
‘defensive dentistry’ in a society which is
successfully treated pulp exposure.9
increasingly litigious, it is regrettable that
restorations affected by early forms of
secondary caries, which are amenable to
Secondary caries
repair, may continue to be managed by
Caries adjacent to the
total replacement.
margin of a composite restoration
If there is good reason to
(secondary caries) should be treated
suspect that leakage has occurred along
as a new primary lesion.10 As with all
the tooth/restoration interface of the
patients who present with a new lesion,
part of the restoration unaffected by the
preventive measures should be initiated,
lesion of secondary caries, then total
followed by operative intervention as,
replacement should be undertaken.
and when, the lesion is shown to be
Similarly, if it is anticipated to be difficult
active and progressing through dentine,
to achieve a good marginal seal to a repair,
or cavitation has occurred. Operative
which would prevent the progress of any
intervention should be minimally
residual caries, then total replacement may
interventive, coupled with partial
be indicated.
replacement of that portion of the
adjacent composite restoration which
is undermined by caries, or hinders the Superficial colour correction
access required for necessary caries On occasions, an incorrect
March 2011
 RestorativeDentistry
shade may have been selected
for a previously placed composite
restoration. If the mismatch in shade
is limited, this may be managed by
resurfacing the restoration using
a different shade of composite
material. Wherever possible, the same
restorative material should be used
as the composite substrate, but this
might not be possible if the restoration
was placed by a different practitioner,
details of the material used were not
recorded in the patient’s notes, or
the previously placed material is no
longer commercially available. Success
in such colour correction procedures
requires an understanding of the
optical properties of restorations
and remaining tooth tissues and the
effects of layering different shades
of composites. In certain situations,
for example, where a relatively light,
translucent shade of composite has
been used on its own to restore a
large ‘through-and-through’ anterior
proximal restoration, total replacement
may be the only solution to achieving
a good aesthetic outcome. This
assumes that there would be some
contra-indication to attempting to
resolve the situation by means of
a palatal access colour correction
using, in all probability, a dentine
shade of the relevant composite. In
many situations, a colour correction
can be attempted before taking the
decision to resort to a total restoration
replacement procedure.
Wear of the restoration
As wear of composite
resin restorations may have been
accompanied by passive eruption, or
tilting of opposing and adjacent tooth
or teeth, the situation needs to be
assessed carefully. If the wear of the
restoration is of a limited nature, for
example, shallow faceting confined
to a section of the occlusal surface,
and space exists to perform a repair,
then the situation may be resolved
by resurfacing the restoration. This is
possible typically where the wear has
been caused by three-body abrasion
during chewing rather than by, for
example, a parafunctional attrition. If
82 DentalUpdate
the wear involves a proximal surface and
no space exists to restore anatomic form,
then an alternative restorative approach
may be indicated.
While developments in the
physical qualities of dental composite
resins have largely overcome problems of
functional wear in composite restorations
under normal loading conditions, it
remains prudent to adopt operative
techniques which maintain enamel-to-
enamel contacts between opposing teeth.
Such contacts should be identified pre-
operatively using articulating paper and
then preserved by careful planning of the
outline of the preparation.11
Fracture of adjacent tooth tissue
Fracture of tooth tissue
adjacent to a composite resin restoration
may occur for various reasons, including:
„ Inappropriate location of loading;
„ Bearing occlusal contacts;
„ Insufficient or unsupported tooth tissue;
„ Parafunctional activity;
„ Trauma; or
„ Subsequent to damaging polymerization
stresses at the time of restoration
placement.
A repair may be indicated if the
cause of the fracture can be diagnosed
and, as a consequence, the risk of further
fracture minimized by redesigning the
restoration to improve the biomechanical
properties of the restored tooth unit.
In this process, a key consideration is
the design of the occlusal morphology.
Wherever possible, occlusal contacts
should be left in a central location to
ensure that functional loading will be
predominantly axial rather than lateral in
nature.12
Contra-indications for repair
Repairs are not without contra-
indications. In many cases, the contra-
indications are multifactorial, with two or
more negative features collectively making
a repair an unattractive, relatively high risk
option. Specific contra-indications include:
„ Patient reluctance to accept a repair as
an alternative to restoration replacement;
„ Irregular attenders;
„ High caries risk patients;
„ Presence of caries undermining the
restoration;
„ History of failure of a previous repair.
In addition, repairs should not
be contemplated if there is uncertainty
as to the type of material from which
the restoration is formed, or as to the
procedure to be followed to ensure a
satisfactory clinical outcome.
Clinical procedure for
composite restoration repair
As previously reinforced,
before undertaking treatment which
includes the repair of one or more
restorations, it is important that the
limitations and possible consequences of
the proposed repairs are explained to the
patient as part of the consent procedure.
Two repair methods are now
described, one using an air–abrasion
technique based on silica-coating and
one for using a conventional adhesive
bonding system.
The following steps apply
equally to both techniques:
„ Administer local analgesia, as indicated
clinically.
„ Clean the tooth or teeth to be repaired,
together with the adjacent teeth, using
pumice.
„ Remove the defective part of the
composite restoration and any adjacent
lesions of secondary caries.
„ Ensure adequate moisture control
(rubber dam isolation).
„ Pulp protection, if indicated, according
to contemporary regimes.
„ Bevel the margins of the preparation,
as indicated clinically, and place a long
(1.0 mm wide) deep bevel on the margin
of the composite resin to be repaired.
Appropriately prepared bevels increase
the available surface area for bonding
and facilitate a more aesthetic clinical
outcome, as the composite resin to be
used for the repair will blend in more
effectively with the existing composite
resin and remaining tooth tissues.
Method 1: Composite repair based on
sandblasting with silica-coated particles
This technique involves
blasting the composite substrate surface
using the CoJet surface treatment system
(CoJet System, 3M ESPE, Germany). This
system includes the CoJet Prep Particle
March 2011

Micro-blaster, CoJet Sand, with a mean
particle size of 30 μm, a silane (3M ESPE
– SIL) and the corresponding unfilled
resin adhesive (Visio Bond, 3M ESPE). This
system is based on the working principle
that it increases the bond strength of the
repair composite resin to the composite
resin substrate owing to an increase in
silica content of the substrate surface;
thereby rendering the substrate chemically
more reactive to resin, via a silane coupling
agent which provides a chemical basis
for enhanced resin bonding. The ensuing
clinical steps are as follows:
„ Sandblast the composite resin
substrate surface and, if present, any
exposed adjacent tooth tissue using the
CoJet micro-blaster, according to the
manufacturer’s directions for use. The
blasting pressure results in embedding
of CoJet silica particles in the substrate
surface to a depth of up to 30 μm. This
increases the surface area available for
bonding and facilitates micromechanical
retention. After a brief (approximately 5
seconds) blasting of the silica particles,
excess powder is dispersed using a three-
in-one syringe. It is important that any
powder on the margins of the remaining
tooth tissues is removed. It is imperative
that sandblasting takes place under rubber
dam isolation.
„ The silica-coated composite substrate
surface is silanized by the application of
the silane, according to the manufacturer’s
directions for use. The silane acts as a
bifunctional molecule which chemically
binds to the silica-coated composite
substrate.
„ The corresponding adhesive is then
applied to the silanated composite
substrate and a conventional adhesive
bonding system to the adjacent tooth
tissue, if present, according to the
manufacturer’s directions for use.
„ Following the placement of matrices and
wedges, as indicated clinically, a composite
resin material is applied using an
incremental technique to repair the defect.
Each increment must be polymerized
using a visible light-curing unit. Ideally,
the same type and brand of composite
resin material should be used for the
repair as the composite resin substrate,
provided this information is known to the
dental practitioner. The composite resin
substrate must be at least 2 mm thick for
March 2011
RestorativeDentistry
the repair procedure to be successful. If the repair to be integrated imperceptibly
circumstances dictate that the required into the restored tooth unit.
matrix is placed prior to sandblasting, „ The occlusion is then checked to
it may prove necessary to replace the ensure that the repaired restoration will
matrix subsequent to the sandblasting, not be subjected to adverse occlusal
if particles of sand accumulate and resist loading.
removal interproxmally.
„ The rubber dam is then removed.
„ The repair is then carefully contoured Which repair system?
and finished using contemporary While some in vitro
composite finishing systems, to leave the studies report higher repair bond
repair integrated imperceptibly into the strengths using the CoJet system,13–15
restored tooth unit. Padipatvuthikul and Mair16 showed
„ The occlusion is then checked to ensure in vitro that the application of a
that the repaired restoration will not be dentine bonding agent, even without
subjected to adverse occlusal loading. mechanical treatment of the original
composite surface, significantly
enhanced the repair bond strength.
Method 2: Composite repair based on
Thus, the data available to date remain
conventional adhesive bonding systems
relatively limited. More importantly,
This technique should be
long-term in service data on the
performed under rubber dam or with the
clinical performance of different types
judicious use of cotton wool rolls, salivary
of surface conditioning methods for
ejectors and other means to ensure
composite resin repair remain to be
moisture isolation. The clinical steps are
generated. As in all bonding procedures,
as follows:
attention to detail, strict compliance
„ Acid etch the composite resin substrate
with manufacturer’s directions for use
together with the adjacent tooth tissue
and careful operative technique, based
preparation margins for 15–30 seconds
on knowledge and understanding of the
and wash thoroughly and dry the area
materials being used, is as important, if
using a three-in-one syringe. In addition
not more important, than the selection
to producing a favourable substrate
of the material from the range of
surface for bonding, acid etching has a
products available from reputable
favourable cleansing effect.
manufacturers.
„ An adhesive bonding system should
be applied to the acid-etched composite
substrate and adjacent tooth tissues Concluding comments
and preparation margins, according to
The decision to repair rather
the manufacturer’s directions for use.
than replace a defective or failing
Alternatively, a commercially available
restoration is multifactorial. While much
composite repair system (eg Ecusit-
remains to be investigated in respect
Composite Repair, DMG, Germany; Clearfil
of the repair of restorations, it is likely
Repair Kit, Kuraray, Japan), which includes
that the replacement of restorations will
its own specifically formulated adhesive
continue to be a common procedure
agent, may be used.
in the everyday clinical practice of
„ A composite resin restorative material,
dentistry for many years to come.
compatible with the adhesive bonding
Repair, as opposed to replacement, of
system, is applied using an incremental
restorations aids the preservation of
technique to repair the defect, with each
natural tooth tissue, which is desirable.
increment being fully photo-polymerized.
Thus, wherever possible, repair rather
Again, the same type and brand of
than replacement should be undertaken.
composite material should be used as
However, repair of a restoration can be
the composite substrate, provided this
clinically and technically demanding and
information is known to the practitioner.
restorations will fail if not carried out
„ The repair is then carefully contoured
with appropriate skill and understanding
and finished using contemporary
of the materials and procedures
composite finishing systems, which allows
involved.
DentalUpdate 83
RestorativeDentistry
VITALITY – BY DESIGN
STRAUMANN ® BoneCeramic
FOR BONE VOLUME
RESTORATION
AND PRESERVATION
Contact Straumann on
01293 651230 or visit
www.straumann.co.uk
84 DentalUpdate
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Acknowledgements
The authors would like to thank Dr Siegwald Heintze
(Ivoclar Vivadent, Liechtenstein) for providing the photographs.
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