dental materials 38 (2022) 680–688

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Clinical performance of posterior resin composite

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restorations after up to 33 years

Paullo A. Da Rosa Rodolpho a, Bruna Rodolfo b, Kauê Collares c,

Marcos B. Correa b, Flavio F. Demarco b, Niek J.M. Opdam d,
⁎
Maximiliano S. Cenci b,d, Rafael R. Moraes b, ,1
a
Private Practice, Caxias do Sul, Brazil
b
School of Dentistry, Universidade Federal de Pelotas, Brazil
c
School of Dentistry, Universidade de Passo Fundo, Brazil
d
Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Dentistry, The Netherlands

ar ti cl e i n f o ab stra ct

Article history: Objectives: This retrospective study evaluated the performance of posterior composites
Received 23 November 2021 after up to 33 years of clinical service and investigated factors associated with the risk of
Received in revised form 24 January failures over time including patient- and tooth-related variables.
2022 Methods: Patients who received at least one Class I or Class II direct composite restoration
Accepted 19 February 2022 in a private office in 1986–1992 and had follow-up appointments were included. Failures
and interventions over time were investigated using the dental records. A follow-up clinical
Keywords: recall was carried out in 2020. Two scenarios were considered: restorations that did not
Resin-based composites require any intervention (success) or restorations that were repaired and still functional
Restorative dentistry (survival). Multivariate Cox regression analyses and Kaplan-Meier curves were performed
Longevity using success and survival rates (p < 0.05).
Clinical study Results: One hundred patient records and 683 restorations were included. A total of 353
Patient records failures were reported (success rate= 48%). Main reasons for failure were fracture and
Survival analysis secondary caries. Most interventions after failures were repairs. Replacements were re­
gistered in 183 cases (survival rate= 73%). Annual failure rates were below 2.5% (success)
and 1.1% (survival). Larger restorations and maxillary molars had higher failure risks. No
significant differences in success rates among different resin composites was observed. A
typical observation in this sample of restorations was the presence of moderate to ad­
vanced signs of aging, including marginal and surface staining, wear, chipping, changes in
anatomical shape and translucency. Clearly aged restorations were still clinically sa­
tisfactory. Significance: This long-term, practice-based study indicates that resin compo­
sites can be used to restore posterior teeth with a long-lasting durability.
© 2022 The Academy of Dental Materials. Published by Elsevier Inc. All rights reserved.

⁎
Correspondence to: Universidade Federal de Pelotas, Rua Gonçalves Chaves 457, sala 505, 96015–560 Pelotas, RS, Brazil.
E-mail address: rafael.moraes@ufpel.edu.br (R.R. Moraes).
1
ORCID: 0000-0003-1358-5928

https://doi.org/10.1016/j.dental.2022.02.009
0109-5641/© 2022 The Academy of Dental Materials. Published by Elsevier Inc. All rights reserved.
 dental materials 38 (2022) 680–688
1. Introduction
Resin-based composites are used for multiple clinical proce­
dures in dentistry. In restorative dentistry, direct, semidirect,
and indirect restorations are routinely performed using resin
composites bonded to teeth and other supporting structures.
Although discussion on the clinical performance in posterior
teeth between resin composite vs. amalgam can still be found
[1], abundant evidence shows that composites can be used in
the posterior dentition with a long-lasting survival [2–13].
In recent clinical literature, it is increasingly evident that
the longevity of posterior restorations is not only a matter of
choosing appropriate restorative materials, bonding agents,
and techniques [14,15]. Several additional variables may af­
fect the durability of restorations, including tooth-related
factors [4,7–9,16,17], patient’s risks [18–21], socioeconomic
aspects [19,22,23], and factors related to the dentists who are
performing or assessing the restorations [8,13,16,24,25]. An­
other recent important topic on longevity studies is the po­
sitive impact that repairs may have in improving the clinical
durability of aging restorations in both posterior and anterior
areas [14,26–28].
The longest clinical follow-ups of posterior resin compo­
site restorations published to date investigated the durability
after 27–30 years of clinical service [5,6,11], and reported 1–2%
annual failure rates (AFR). The question is not whether pos­
terior resin composites can last long anymore, but it is still
relevant to address factors associated with the risk of re­
storation failures during prolonged periods and estimate
survival rates after more than three decades in the mouth.
For example, in a previous study with 22 years of follow-up,
minor differences between two resin composite materials
were observed in later stages of the clinical service. Practice-
based retrospective studies have the advantage of making
the investigation of more extended follow-up periods fea­
sible [29,30].
This practice-based, retrospective longitudinal clinical
study evaluated the performance of posterior resin compo­
site restorations placed in a private dental office after up to 33
years of clinical service. In addition, factors associated with
the risk of failures over time were investigated, including
patient-related variables (sex, age) and tooth-related vari­
ables (tooth type, dental arch, number of restored surfaces,
and resin composite used).
2. Materials and methods
2.1. Study design and eligibility criteria
In this practice-based, retrospective longitudinal clinical
study, all clinical records of patients attending a private
dental office between January 1986 and December 1992 were
searched. The office is located in southern Brazil and has
generally well-documented records of patients' clinical his­
tories, including the adhesives and composites used over
681
time. Patients who had received at least one Class I or Class II
direct resin composite restoration in molar or premolar teeth
in the period (1986–1992) were eligible. Another inclusion
criterion was that the patient should have at least one follow-
up clinical appointment in the same office for a longitudinal
analysis of restorations. Typically, all patients were regularly
attending this single dental practice. Restorations that had
been replaced by another dentist were excluded, e.g., when a
crown was installed. Out of 2370 records from patients who
attended the office in the period, 18 records were excluded
due to the absence of a follow-up appointment, and 100 re­
cords met the inclusion criteria and were used for retrieving
longevity data. The clinical records were screened by one
researcher (BR) and checked by another (PARR). The study
protocol was approved by the Institutional Research Board,
Universidade Federal de Pelotas, Brazil (protocol #0222008).
2.2. Restorative procedures
The restorations were performed, monitored, and evaluated
over time by the single dentist in that practice (PARR). The
baseline restorations evaluated in this study were performed
in the first seven years since the dentist graduated from
dental school. The reasons for restorative needs at the time
generally involved primary caries lesions or substitution of
restorations, often amalgam fillings, that had failed by frac­
tures or secondary caries. The new restorations were per­
formed using resin composites, adhesive systems, and
accessory materials (i.e., matrices, wedges, spatulas, and
light-curing units) available in Brazil between 1986 and 1992,
with technical procedures that were state-of-the-art at the
time. Most of the clinical steps were carried out under rubber
dam isolation.
The cavities were prepared using high-speed diamond
burs in enamel and low-speed steel burs in dentin to remove
carious tissue, carbide burs were used for removing old re­
storations. Preparation was restricted to removing carious
tissue or removing old failed restorations without bevel at the
cavosurface angle. In deep cavity portions, a thin layer of
calcium hydroxide cement was applied. In all cavities, the
pulp floor was covered with glass ionomer cement. The en­
amel margins were etched with phosphoric acid, washed,
and dried. The dentin was not acid etched. The adhesive was
selected according to the photoactivated resin composite
selected for the case, and was applied on the etched enamel
and glass-ionomer cement. There was no standardization or
randomization in the selection of composites; most restora­
tions were carried out by using the composite P-50 APC (3M)
associated with the adhesive Scotchbond 2 (3M) or Herculite
XR (Kerr, Orange, CA, USA) with the adhesive XR prime/XR
bond (Kerr). P-50 is a midifilled hybrid composite with 70 vol%
inorganic filler load and a 2.1 µm average particle size,
whereas Herculite is a minifilled hybrid composite with
55 vol% filler load and 1 µm average particle size [31–33]. Z100
(3M) and Renamel (Cosmedent, Chicago, IL, USA) were used
less frequently and categorized as other resin composite. In
682 dental materials 38 (2022) 680–688
some cases, information about the composite was not avail­
able in the records and the restorative material was cate­
gorized as unknown.
The materials were applied following the manufacturers'
recommendations. In general, the primers were applied
with microbrush, dried with air stream, the adhesive was
subsequently applied and photoactivated. The composites
were placed using up to 2-mm-thick increments and pho­
toactivated using a quartz-tungsten-halogen light-curing
unit (Visilux; 3M). The light irradiance was not measured
regularly, but the lamp was generally changed every six
months. The restorations were finished and polished one
week later by using fine-grit diamond burs and rubber cups
with aluminum oxide polishing paste. Aluminum oxide
disks were used in the proximal surfaces. When necessary,
abrasive strips were used on the proximal surfaces until
the operator judged that the adaptation was clinically
satisfactory.
2.3. Longitudinal follow-up of restorations and clinical
interventions
Failure events over time and types of interventions carried
out when failures occurred were investigated using the
dental records. Patients who participated in the study did not
need to return for specific check-up appointments. Still, most
returned to the office after intervals varying between 6
months and 3 years as regular patients. At each return, the
same dentist who performed the restorations carried out a
complete clinical examination, in addition to providing gen­
eral instructions on hygiene, diet, and oral health.
Professional prophylaxis, polishing of restorations and teeth
were routine in the follow-up visits, periapical radiographs
were taken when necessary. In February 2020, all 100 patients
with dental records used in the longitudinal analysis were
invited to a follow-up clinical examination recall after up to
33.6 years since the original restorations had been placed.
Invitations were made through phone calls or text messages.
Participants signed a consent form before the clinical eva­
luation. In addition, photographic records of the upper and
lower dental arches were taken. All data management was
carried out according to the Helsinki declaration.
The need for interventions in the restorations and reasons
for failure were longitudinally registered in the dental re­
cords. The decision to intervene or not was made by the
dentist, who took into consideration patient complaints. The
presence of a marginal gap was not a reason for intervention,
whereas the presence of secondary caries and fractures were.
Dates and reasons for the necessary interventions were col­
lected in the patient file. When a decision of intervention was
reached, repair procedures were the first option over re­
storation replacement. A replacement was carried out when
a repair was not judged feasible, usually due to extension of
the failure. Two scenarios were considered in the analysis:
restorations that did not require any intervention in the
follow-up period (success) or restorations that were repaired
and still functionally present (survival). End of the observa­
tion time was February 2020 for the patients who participated
in the recall. Failure was defined as replacement of the entire
restoration with resin composite or tooth extraction.
2.4. Data analysis
Descriptive statistics were used for distributions of fre­
quencies, AFR, reasons for failures, and interventions per­
formed on the restored teeth. Multivariate Cox’s regression
models with shared frailty were performed using success and
survival rates (p < 0.05). The shared frailty accounts for the
intraclass correlation between the restorations placed in a
same patient. Since Z100 and Renamel accounted only for
nine restorations, these two materials were grouped with the
composites categorized as unknown. All variables of interest
were included in the multivariate models. Hazard ratios and
95% Confidence intervals were estimated. Kaplan-Meier sur­
vival curves were constructed using success and survival
rates. The analyses were performed using Stata v.14 software
(StataCorp LLC, College Station, TX, USA).
3. Results
One hundred patient records and 683 direct resin composite
restorations in posterior teeth were included. The recall rate
was 84% after up to 33 years. Table 1 presents the char­
acteristics of the sample. Most patients were females, their
age when the restorations were last evaluated ranged from 39
to 89 years (mean 60 ± 8 years). The number of restored
teeth per patient ranged from 1 to 18 (mean 7 ± 4). There was
a similar distribution of restorations in premolars and molars
and upper and lower arches. More than 70% of the restora­
tions involved two or more dental surfaces, and more than
80% were carried out using the composites Herculite or P-50.
A total of 353 failures was reported in the period, re­
presenting a success rate of 48.3% after up to 33 years. The
main reasons for failure were fracture (60.3%) and secondary
caries (27.8%). Other failure reasons included tooth extrac­
tion (6.2%) and esthetics due to patient complaints (5.7%).
The most common intervention performed after the failures
was repair (63.5%). In 183 cases, the restorations were even­
tually replaced; thus, the survival rate was 73.2% after up to
33 years.
Table 1 also summarizes the results of the multivariate
analyses. The patient’s sex and age were not identified as risk
factors for the restorations' success or survival. Restorations
in molars vs. premolars had 56% (success) and 61% (survival)
higher risks of failure over the follow-up time. Restorations in
the upper arch had 27% (success) and 55% (survival) higher
risks of failure than those in the lower arch. In addition, the
number of restored surfaces had a significant influence on
success rates over time, with 100–116% higher risk of failure
in restorations involving 3 or more surfaces compared with 1
surface. The result for the number of surfaces was not sig­
nificant when the survival of restorations was considered.
Kaplan-Meier curves for the success and survival of restora­
tions and tooth-related variables are presented in Fig. 1.
The multivariate analysis showed no significant differ­
ence in risk of failure across the resin composites when the
success of restorations was considered. In contrast, when
survival was considered, a 104% higher risk of failure was
observed for the composites categorized as other/unknown
compared with Herculite. Fig. 2 presents Kaplan-Meier
 dental materials 38 (2022) 680–688 683

Table 1 – Results of the multivariate analyses for variables related to success and survival of posterior resin composite
restorations after up to 33 years of clinical service (N = 683 restorations in 100 patients).
Variable/category n (%) Successa Survivalb
HR (95% CI) p-value HR (95% CI) p-value
Patient-related variables
Sex
Male 206 (30.2) ref ref
Female 477 (69.8) 1.11 (0.74; 1.67) 0.621 1.22 (0.73; 2.05) 0.443
Age
39–55 183 (26.8) ref ref
56–59 162 (23.7) 0.63 (0.37; 1.05) 0.078 0.92 (0.48; 1.75) 0.796
60–64 171 (25.0) 0.76 (0.46; 1.27) 0.293 0.78 (0.40; 1.50) 0.451
65–89 167 (24.5) 1.03 (0.61; 1.72) 0.924 1.24 (0.67; 2.31) 0.496
Tooth-related variables
Tooth
Premolar 323 (47.3) ref ref
Molar 360 (52.7) 1.56 (1.23; 1.97) <0.001 1.61 (1.17; 2.22) 0.004
Dental arch
Lower 336 (49.2) ref ref
Upper 347 (50.8) 1.27 (1.01; 1.60) 0.043 1.55 (1.13; 2.12) 0.007
Restored surfaces
1 199 (29.1) ref ref
2 185 (27.1) 1.25 (0.88; 1.76) 0.215 0.97 (0.62; 1.53) 0.906
3 203 (29.7) 2.00 (1.44; 2.77) <0.001 1.24 (0.81; 1.89) 0.326
4 or 5 96 (14.1) 2.16 (1.46; 3.19) <0.001 0.72 (0.40; 1.27) 0.253
Resin composite
Herculite 220 (32.2) ref ref
P-50 335 (49.0) 0.87 (0.61; 1.24) 0.430 1.09 (0.68; 1.75) 0.711
Other or unknownc 128 (18.8) 1.45 (0.91; 2.32) 0.120 2.04 (1.15; 3.63) 0.015
HR: Hazard ratio; CI: Confidence interval; ref = reference.
a
Restorations that did not require any intervention in period;
b
Also includes restorations that had been repaired.
c
Other: Z100 or Renamel, unknown: the composite was not registered in the record.

survival curves for the different composites used to restore
the posterior teeth. Table 2 shows AFR calculated at 10, 20,
and 30 years of clinical service. The overall AFR of all re­
storations in this sample was below 2.5% for success and
below 1.1% for survival in the three periods. Minor differ­
ences were observed between restorations made with Her­
culite and P-50: at 10 years, the success and survival rates of
Herculite were slightly higher, and AFR slightly lower than P-
50. At 30 years, the opposite was observed: the AFR of P-50
was lower, and success and survival rates were slightly
higher than Herculite.
Fig. 3 shows clinical examples of restorations after up to
33 years of clinical service. All resin composite restorations
showed at least minor signs of aging, but excellent pheno­
types could be observed even after more than three decades
(pictures in top row). These restorations showed good oc­
clusal anatomical shape, well preserved margins, almost no
pigmentation, and only slight wear and color changes. How­
ever, this was not the case for the majority of restorations in
this sample of patients. A typical observation was the pre­
sence of moderate to advanced signs of aging, including
marginal staining, generalized wear, chipping fractures, sur­
face pigmentation, changes in anatomical shape, and differ­
ence in translucency between the composite and the
adjacent dental structure. Despite the clear signs of aging
observed, all restorations in Fig. 3 were considered clinically
satisfactory, especially considering that they had been in the
mouth for more than 30 years. In some cases, it is also pos­
sible to observe portions of the composite that had been re­
paired over time.
4. Discussion
In the present study, the long-term results of posterior com­
posite restorations placed by a high-quality practitioner are
shown and demonstrate an excellent performance after up to
33 years, with AFR below 2.5%. Previous studies also have
shown good performance for posterior composites after 27
years [5], 29 years [11], and 30 years [6], but those were pro­
spective, controlled studies whereas the present investiga­
tion is a practice-based study on routine dental care. Other
long-term studies on posterior composites placed by general
practitioners showed comparable [3] or slightly higher sur­
vival rates [8]. Therefore, the present study confirms the
growing body of evidence that posterior composite restora­
tions have the potential to function for decades.
It is remarkable that most if not all materials used in the
present and other longitudinal studies are not available in
the market anymore. In addition, the techniques applied
such as the use of calcium hydroxide liners, glass ionomer
cement bases, and adhesives that are now considered ob­
solete have apparently not reduced the survival rates of re­
storations. This finding may raise questions on the
684 dental materials 38 (2022) 680–688

Fig. 1 – Kaplan-Meier survival curves for tooth-related variables. HR=Hazard ratio (95% Confidence interval). Restorations in
molars and upper teeth had higher risks of failure over time compared to premolars and lower teeth, for both success and
survival of restorations. The number of restored surfaces had a significant influence on success, with a higher risk of failure
in restorations involving 3 or more surfaces than 1 surface.

importance of several material properties for restoration
survival. Manufacturers of dental products often release up­
dated versions of their materials, usually claiming better
performance. However, in a recent split-mouth study, no
significant difference was detected after 5 years between an
'old' composite formulation compared to its successor ma­
terial used in posterior restorations [34]. It remains a ques­
tion whether up-to-date composites and adhesives may show
survival rates higher than 73% after three or more decades in
posterior teeth. Several studies indicate that other risk
factors, such as characteristics of the restored teeth, dentists,
and patient factors such as caries risk and bruxism may be
more relevant to the clinical performance of restorations
than the selection of specific materials [13–16,18,20].
In the present study, molars, upper teeth, and restorations
involving 3 or more tooth surfaces were factors that in­
creased the risks of failure over time. These findings are in
line with previous studies [8–10,16,20] and could be explained
by mechanical aspects, i.e., a greater loss of dental structure
and cavity walls interfering negatively with the capacity of
 dental materials 38 (2022) 680–688 685

Fig. 2 – Kaplan-Meier survival curves for restorations using different resin composites. HR=Hazard ratio (95% Confidence
interval). Other: Z100 or Renamel. Unknown: the composite was not registered in the record. No significant difference in risk
of failure was detected for success. When survival was considered, a higher risk of failure was observed for the composites
categorized as other/unknown compared with Herculite.

Table 2 – Annual failure rates (AFR, %) calculated for success and survival of restorations at 10, 20, and 30 years of clinical
service for all posterior composites (N = 683) or restricted to restorations with Herculite and P-50.
Resin composite 10 years 20 years 30 years

Estimate AFR Estimate AFR Estimate AFR

Overalla Success 79% 2.32 60% 2.49 48% 2.43
Survival 94% 0.66 83% 0.91 73% 1.07
Herculiteb Success 83% 1.88 60% 2.51 46% 2.56
Survival 96% 0.37 87% 0.72 73% 1.04
P-50c Success 78% 2.50 63% 2.28 52% 2.13
Survival 92% 0.87 85% 0.83 76% 0.90
a
Restorations with Herculite, P-50, Z100, Renamel, and unknown resin composite;
b
Minifilled hybrid with 55 vol% filler loading;
c
Midifilled hybrid with 70 vol% filler loading.

the underlying structure to withstand mechanical loading.
Mechanical demands are higher in molars than in premolars,
with a report indicating the first molar as the tooth with most
restorative failures [7]. Another study observed that, after 5
years, direct composite restorations showed more wear when
located in the upper than in the lower dental arch [35]. Other
risk factors for restoration failures that have been reported in
the literature are patient’s caries risk and parafunctional
habits [18,20,36,37], and indirect factors indicating the risk for
tooth failure such as deep periodontal pockets [38], number
of teeth in the mouth [38,39], and socioeconomic factors
[19,22,23,40].
Patient’s sex and age were not variables associated with
failures, a finding that disagrees with other studies showing
more restorative failures in men and patients in younger or
older age groups [8,9,13,20]. A possible explanation for this
difference may be the predominance of females in the present
patient population, reducing the statistical power and in­
creasing the likelihood of an atypical population visiting the
dental office with different wishes and demands. Moreover, the
absence of an obligation to visit the office for regular checkups,
which was also the case in other practice-based studies [3,8],
also could have resulted in male patients having less frequent
appointments. In addition, a limitation of the present study is
that patients’ risk factors that could significantly affect the
longevity of restorations, including caries and occlusal stress
risks [3,18], were not investigated because of insufficient in­
formation in the dental records. The likelihood that the
patients in this practice are well motivated and seeking for the
best care for their oral health may have resulted in a situation
where the most relevant patient risks were not well re­
presented in the sample. This could also help to understand
the optimal clinical performance of restorations over more
than three decades as patients received hygiene instructions
including the use of dental floss, professional prophylaxis, and
polishing of restorations in the appointments.
Another important aspect underlying the high survival
rates reported herein is how the dentist reacted to the
clinical aging of restorations over time. As shown in Fig. 3,
most restorations after up to 33 years in the mouth showed
several signs of aging. These signs are deterioration features
caused by the harsh oral environment. However, the dentist
686 dental materials 38 (2022) 680–688

Fig. 3 – Clinical examples of resin composite restorations after up to 33 years of clinical service. All restorations showed at
least minor signs of aging, but excellent phenotypes could be observed even after more than three decades (pictures in top
row). The majority of restorations showed a typical observation of moderate to advanced signs of aging (pictures in other
rows), including marginal staining, generalized wear, chipping fractures, surface pigmentation, changes in anatomical
shape and translucency. Despite the clear signs of aging, all restorations were considered clinically satisfactory. In some
cases, it is also possible to observe portions of the composite that had been repaired over time.

did not decide to intervene proactively when the signs of
aging were present, for example when surface or marginal
pigmentation, wear, color changes, chipping, and other
minor problems were observed. Interventions occurred only
in a reactive fashion, i.e., when unacceptable clinical issues
were present, usually fractures and secondary caries.
Esthetic complaints by the patients were also reasons for
intervention, but those failures were not common since the
sample is composed of posterior teeth. A 20-year clinical
study comparing anterior and posterior composites showed
that esthetic failures were predominant in the anterior
teeth, whereas posterior restorations failed mainly due to
fractures [41]. The attitudes when clinically evaluating old
restorations may vary among professionals and affect
their clinical decisions, ultimately influencing the durability
of treatments. In a recent multicenter study, anterior
composite restorations were judged differently in relation to
maintenance, repair, or replacement depending on the
dentists evaluating the restorations [25]. In addition, it
should not be ruled out a possible influence of the fact that
previous longevity studies have been carried out with pa­
tients from the same dental office reported herein. These
previous studies showing good clinical performance of
posterior restorations after 17 and 22 years [2,4] could have
further influenced the dentist to be strict and intervene in
restorations only when monitoring was not a clinical option.
In addition to the conservative approach seeking minimal
intervention, the dentist also prioritized minimally-invasive
procedures when dealing with defective restorations. Repair
being a first intervention option over replacement resulted
in further improvement of longevity, which corroborates the
findings of previous investigations [14,26–28].
 dental materials 38 (2022) 680–688
Large clinical follow-up studies showed no differences in
performance among different resin composites [5,6] and even
reported that a chemically-activated composite showed
better performance than a photoactivated composite [6]. In a
previous study with patients in the same office reported here
[4], a slightly superior performance after 22 years was ob­
served for the composite P-50 compared to Herculite. This
result was possibly attributed to the higher inorganic filler
loading and elastic modulus of P-50. However, the difference
between the two composites was only detectable when the
comparison was made after the first 10 years of clinical ser­
vice. In the present study, the difference between these two
composites was revisited as a secondary outcome. Interest­
ingly, the present results disagree that distinct behaviors
were observed over the up to 33 years of follow up. However,
it should be acknowledged that most restorations in this
sample were placed in relatively small tooth cavities, re­
sulting in lower magnitudes of mechanical loading directed
to the resin composite. In addition, higher risk of failure was
observed when the restorations were prepared using resin
composites classified as other or unknown as compared with
Herculite, but not as compared with P-50. This finding raises
questions that are difficult to respond to in a retrospective
study and somehow highlights that differences across ma­
terials may have a role in longevity. There is still room for
long-term studies with new resin composite formulations,
such as bulk fill composites, although it is difficult to imagine
survival rates much higher than 70% after 33 years.
Retrospective studies have disadvantages that should be
considered when extrapolating the present findings to other
clinical scenarios. The main limitations herein were missing
data in the records, including the restorative composite in
some cases, and the lack of evaluation of patient variables
that could potentially impact the longevity, such as their
habits and risks. Another limitation is that one professional
performed all restorations and their evaluations over the
course of 33 years, meaning that the results may not be di­
rectly applied to other clinical realities. Variability in the
clinical decision-making regarding when and how to inter­
vene in composite restorations may lead to large differences
in failure rates between different dental professionals.
Recent studies reported a variability between 2% and 12% in
AFR of restorations across dentists [7,8,16], i.e., the durability
of dental restorations may be up to 6 times lower depending
on the professional and their clinical decisions. This topic
also has room for further studies on factors influencing the
decision-making process of dentists concerning their atti­
tudes when assessing old, aging restorations. In addition,
research is welcome on how professional decisions can affect
the clinical performance of restorations and maintenance of
teeth in the mouth of patients during their life course.
5. Conclusion
The overall findings of this practice-based study indicate that
resin composites can be used to restore posterior teeth with a
long-lasting durability. After up to 33 years, the success rate
was 48% and annual failure rates were 2.4% (success) and
1.1% (survival), with fracture and secondary caries as the
687
main reasons for failure. Clinically-acceptable restorations
showed clear signs of aging after up to 33 years of service. In
general, molars, upper teeth, and teeth with 3 or more re­
stored surfaces had higher risks of failure over time.
CRediT authorship contribution statement
Paullo A. Da Rosa Rodolpho: Investigation, Resources,
Methodology. Bruna Rodolfo: Methodology, Validation,
Investigation, Data curation, Writing – original draft prepara­
tion. Kauê Collares: Validation, Formal analysis, Writing –
review & editing. Marcos B. Correa: Formal analysis, Writing –
review & editing. Flavio F. Demarco: Conceptualization,
Writing – review & editing. Niek J.M. Opdam: Writing –
review & editing. Maximiliano S. Cenci: Conceptualization,
Supervision, Writing – review & editing. Rafael R. Moraes:
Methodology, Validation, Investigation, Data curation,
Visualization, Supervision, Project Administration, Writing –
original draft preparation, Writing – review & editing.
Acknowledgments
This study was financed in part by Coordenaç ão de
Aperfeiçoamento de Pessoal de N í vel Superior (CAPES),
Brazil (Finance Code 001). The authors thank Ms. Gleise
Cristina Vanz and Ms. Dayane Soares for their support with
the dental records.
Declaration of interest
The authors declare no conflicts of interest associated with
this manuscript.
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