Abstract
Composite restorations have shown excellent survival rates on anterior and posterior teeth, with secondary caries, tooth/restoration fracture and aesthetic demand being the main reasons for failures. Due to materials improvements overtime, current materials’ properties have revelated a minor influence on the survival of composites in clinical studies. When hybrid or nanohybrid composites are used, low AFR could be expected. Thus, patient-related factors and operators are fundamental to be considered on restoration longevity. Invasive behavior toward restoration replacement results in a decrease in the survival of restoration . Restorations should be carried out in a health promotion environment, emphasizing preventive practices. The adoption of healthy behaviors by patients will consequently led to “healthy” restorations, increasing the longevity of treatments. The adoption of minimally invasive dentistry for the management of deteriorated restorations, such as refurbishment or repair restorations, should be considered in routine practice. In this way, dentists should react less in front of small defects of restorations, indicating replacements only when other alternatives are not plausible.
This chapter explains long-term survival and reasons for the failure of composite restorations, including all correlated factors.
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Composite resin restorations have been the first choice by clinicians and patients for direct anterior [1] and posterior restorations [2] mainly due to optical characteristics, high longevity, adhesive properties, and preservation of sound tooth structure [3, 4]. Resin composite restorations have presented a lower annual failure rate (AFR) ranging from 1 to 3% in posterior teeth and 1–5% in anterior teeth [5]. Recent publications have shown that this material can be used to rehabilitate severely worn teeth with acceptable clinical success, with AFR ranging from 0.4% for microhybrid composites to 26.3% for microfilled materials [6]. Similarly, a network meta-analysis found an AFR of 2.2% for use in large posterior restorations [7].
The main reasons for failure in posterior restorations, both in adults [8] and children [9], are fractures and secondary caries. It has been discussed that material properties had a minor effect on longevity. At the same time, clinical-related factors (such as the position of the tooth in the tooth arc and dental type), the operator (age, country of qualification, and employment status), patient (caries risk, bruxing habits, parafunction, esthetic demand), and socioeconomic status might play essential roles in the longevity of composites [10]. Tooth structure or composite fractures are important factors for restorations failure, while esthetic demands could account for restoration replacement in anterior teeth [11].
To improve dental restorations’ longevity and under a minimally invasive dentistry philosophy, repair has been proposed as an interesting strategy over the replacement, avoiding the repetitive restorative cycle [12]. Removal of the sound dental structure occurs when the complete restoration is replaced. When the restoration needing replacement is near the vital pulp tissue, the risk of pulp exposure is elevated and can result in unnecessary endodontic treatments [13, 14]. Therefore, resin restorations can be repaired when a considerable part of restoration presents good condition to be maintained. Repair of defective restorations has exhibited good clinical performance, increasing dental restorations’ longevity (Fig. 10.1) [10, 15] and displaying better cost-effectiveness than replacement [16]. In this chapter, we will discuss the longevity of esthetic composite restorations, the reasons for failure, and exploring the repair of defective restorations as a treatment option to the replacement.
Clinical phenotypes of resin composite restorations in posterior teeth after at least two decades of clinical service. In (a) and (b), the restorations show typical signs of aging including loss of anatomical form, surface and marginal staining, color instability, and wear. In (c), restorations were repaired and still presented good clinical performance after several years in the mouth. In (d), restorations were repaired and subjected to polishing, which removed the extrinsic staining and improved appearance. (Photography courtesy of Dr. Paullo Rodolpho)
10.1 Expectation vs. Reality
Resin composites have undergone constant development, becoming the most used direct restorative material [2], mainly because of their esthetic properties, preservation of tooth structure, and the high success rates [3, 17]. Considering the results from clinical studies about the longevity of composite restorations, clinicians frequently expect a longevity of more than 20 years for their restorations. However, despite the excellent results showed in the literature, dentists should be aware that different aspects involving themselves, the tooth/cavity, and the patient can interfere with the durability of a restorations. The understanding of these factors can help professionals to predict better the probability of failure of a given restoration.
A vast number of systematic reviews have been published in recent literature presenting the AFR/success rate (SR) of resin composites [10, 11, 18,19,20,21,22,23,24,25,26,27,28] (Table 10.1). In general, the systematic reviews have presented similar results: AFR ranging from 1 to 3% in posterior teeth and from 1 to 5% in anterior teeth [5]. The AFR increases when endodontic treated teeth are investigated: ranging from 2 to 12.4% [10]. It is important to highlight that several systematic reviews are based exclusively on prospective clinical trials, including low-risk patients. On the other hand, practice-based studies have displayed AFR higher when patients with high risk are included [8, 35]. In 11 Dutch general practices, a Practice-Based Study evaluated 31,472 restorations observed an AFR of 7.8% at 2 years [35]. A similar practice-based retrospective study that assessed the survival of resin composite restorations in posterior teeth found that 30% of the restorations failed, of which 82% were found in patients with high-risk factors, being secondary caries the main reason for failure [8].
The expectation of longevity is often determined by empirical criteria or measures, such as the average age of a failed restoration. There are several factors associated with restorative failures that are important to be evaluated for each clinical situation and can more accurately predict the longevity of restorations. The clinician’s expectations should be based on the assessment of risk factors, which may help a more accurate estimate. Thus, when the restoration is placed on a patient with risk factors (sometimes more than one) it is expected that the durability of this restoration may be less than average observed. On the other hand, when few risk factors are found clinically, greater longevity can be expected. To predict better the likelihood of restoration failure and make the expectation closer to reality, we need to discuss the main factors associated with the failure of composite materials.
10.1.1 Long-Term Survival and Reasons for Failures
Data on composite resin restorations’ survival have been widely explored for posterior teeth, while data of anterior teeth is more limited in the literature [11]. The main reasons for failure in posterior restorations seem to be secondary caries and the fracture of teeth/restorations [3, 26, 27] (Table 10.2). When high-risk patients are included, secondary caries commonly is reported as the main reason for restoration failure [8, 35, 51]. Fractures are frequently linked with premature or long-term (fatigue of material) failures, while caries is related to long-term follow-ups [52].
Fracture and esthetic demand have been reported as the main failure reasons for anterior esthetic restoration. Indeed, when the anterior restoration is placed for an esthetic reason, the likelihood main reason for failure will be related to esthetics (such as color match, anatomical form, or surface stain) [11]. Although direct comparisons between anterior and posterior restorations are not appropriate, in general, anterior restorations behave differently from posterior restorations, presenting reduced failures for “loss of restoration” or caries. At the same time, esthetic appearance plays a prominent role in the patient’s desire to have a restoration replaced.
10.1.1.1 Dental Caries
Secondary caries are reported to be the main reason for restoration’s failure. By definition, secondary or recurrent caries are “lesions at the margins of existing restorations” or “caries associated with restorations or sealants” (CARS) [53, 54]. It is important to note that restoring a tooth is not the definitive treatment for caries disease—but it may be a part of the treatment. To be clear, it is necessary to control all the etiological factors that are causing the disease [55]. The understanding of the causal factors for caries development and their respective control is necessary. As it is well-established, caries is a sugar-biofilm-dependent disease, and epidemiological studies have shown that sugar consumption in the life course is associated with caries lesions [56, 57]. In addition to diet, fluoride consumption, hygiene habits, socioeconomic factors, among others, are essential to be investigated and influence restoration’s survival through secondary caries failures. Considering these aspects, it is possible to treat caries disease properly, preventing the occurrence of secondary caries.
The failure to interrupt the caries disease can contribute to the failure of the restoration [58]. After 18 years, a retrospective study found that 68.4% of failures were due to secondary caries [59]. Posterior restorations placed in children with high DMFT index displayed a high risk to fail [60], corroborating with a systematic review that observed caries as the main reason for the failure of posterior restoration in primary teeth, independently of restorative material [9]. On the other hand, considering anterior composite restorations in permanent teeth, caries has a low contribution in failures in a systematic review [11], probably due to a low incidence of caries in the anterior region compared to posterior teeth. Practice-based studies have already corroborated these findings [37, 61, 62].
10.1.1.2 Fracture
Tooth/restoration fracture has been highlighted as the main reason for failure in anterior teeth. In a systematic review that evaluated the longevity of anterior restoration, the fracture (tooth/restoration) was the most common reason for failure among all studies [11], with rates varying from 25 to 100% of all failures observed in the included studies.
Bruxism of parafunctional habits probably plays a significant role in the fracture of the tooth or restorations via tooth-restoration complex fatigue, resulting in a fracture as a long-term outcome. In addition to the complex etiopathogenic mechanisms of bruxism, which hinder its correct diagnosis, in general, studies do not use reliable instruments for their assessment. Also, quite often, studies excluded bruxism patients. Restorations performed in participants with severe tooth wear presented negative findings when compared to participants without bruxism habits in a clinical study with patients with severe tooth wear [63]. Indeed, when restorations are placed in individuals presenting bruxism symptoms, more failures due to fracture could occur [64]. In a practice-based study, when patients showed “occlusal-stress,” there was a 2.6-fold risk of failure than in individuals with “no risk” [8].
10.1.1.3 Esthetic Demand
Modern society has increased the demand for esthetics [65]. Especially the anterior teeth must be well-aligned and white, which impacts the oral health-related quality of life [66]. The high visibility and the importance of the smile’s appearance expose the anterior restorations to a greater risk of undergoing interventions due to esthetic demands. In this region, small marginal pigmentations observed with the natural degradation of the hybrid layer or small natural changes in color or shape resulting from the natural aging of composites can result in early interventions in these restorations. Especially in patients who exhibit a high esthetic demand. Unlike the posterior region, where color changes appear to be less important [49]. It is clear that these changes are linked to factors related to patients and may depend on cultural and contextual factors of these individuals, which are incredibly subjective.
Upper front teeth restorations exhibited a higher risk for failure when compared with lower front teeth, especially in young patients [37]. Color alterations, marginal mismatch, and surface staining are some of the motifs for patients to require replacement of their veneer restorations [67]. However, for posterior teeth, the esthetic demand is a less important factor to some patients. When evaluating restorations after 27 years in clinical service, the ones carried out with chemical-cured resin composite (which presents accelerate deterioration of color match linked to the non-color stable initiators of the peroxide-initiated curing mechanism) were 59% non-acceptable to the researchers who evaluated these restorations, while only 6.3% of light-cured materials were classified as non-acceptable. However, these restorations were not classified as a failure because no patients requested replacement of non-acceptable color restoration, which were in function [49].
10.1.2 Factors Involved in Esthetic Restorations Failure
Whereas most of the attention in the clinical studies in restorative dentistry is given to the restoration’s longevity and the failure causes, it is of utmost importance to study all the factors affecting the restoration’s failure. I this context, even if most clinicians give quite some importance to the dental material and dental techniques, factors related to the characteristics of the patient, operator, and tooth are critical in assessing the long-term survival of restorations [10]. Also, population studies found that socioeconomic and demographic factors influenced the choice of restorative materials, the patients’ risk status, and, consequently, the longevity of the dental restorations [58].
10.1.2.1 Tooth Factors
Restoration survival depends on several clinical-related factors for their longevity, including the tooth position in the dental ark, tooth type, cavity size, previous endodontic treatment, and substrate type [3, 10, 27].
Restorations in premolars have shown better survival results than those placed in molars, and the explanations are related to higher masticatory forces observed in the molar region [8, 10, 38, 68,69,70]. After 10 years, general practitioners’ restorations have a hazard ratio of 2.3 to fail in molar than premolar [36]. Similar results have been reported in other studies [8, 10, 38, 68,69,70]. After 27 years, class II restorations in molars presented a failure risk almost 5 higher than premolars [49]. However, some studies did not find significant differences [45, 71]. For restoration in anterior teeth, failures were more frequent in upper central incisors and upper canines, when evaluating both children and adults in a practice-based study [37].
The increase in the number of surfaces involved in the restorations has been associated with a higher risk of failure [10, 36, 38, 72]. Posterior restorations fail 3.3 times more often in teeth with fewer than 2 remaining walls than those with 4 [73]. For premolars, each surface included in the restoration introduces a hazard risk of 1.5, while for molars, the risk is 1.24 [27]. Opdam et al. [38] estimate that each restored surface’s addition leads to an increased 40% risk of failure. Similarly, it was reported that every extra missing wall increases the failure risk from 30 to 40% [74]. Thus, class II restorations present a higher risk than Class I. Also, class III restorations tend to fail less than other anterior restorations types [11]. Collares et al. [37] observed a high-risk of failure in anterior restorations with three or more involved surfaces (Class IV) than class III restoration, highlighting that restoration size is an important predictor of failure risk also in anterior teeth.
Glass ionomer cement sandwich-type restorations are frequently used to perform indirect pulp protection in deep caries lesions. Using a GIC liner or base under composite resin restorations has shown divergent results in the literature. In several studies, the use of an intermediate GIC liner negatively influenced the restorations’ survival, resulting in more fracture of composite resin [10, 27, 38, 75, 76]. An AFR of 3.8% was observed for class II restorations with glass ionomer bases while observing an AFR of 1.4% for restorations without a base material [38]. In opposite, other studies observed no effect on restoration longevity when using GIC liners [44, 68, 77]. The thickness and type of glass ionomer cement used could explain the different results observed [10, 44]. Therefore, there is no consensus in the literature about the influence of GIC under composite restorations.
The endodontic treatment represents a challenging situation for restoration longevity in both anterior and posterior teeth. The significant loss of dental structure in these teeth could be related to the main reason for reducing the success rate. A 13-year clinical trial comparing restorations in vital and endodontic treated teeth observed AFR of 0.08 and 1.78%, respectively [40]. An AFR of 4.9% was observed in vital teeth and 9.8% in non-vital teeth in evaluating anterior composite veneers. Veneers made in non-vital teeth had a higher risk of failure (HR 2.78; 95% CI 1.02–7.56) over time compared to those made in vital teeth [39].
The selective carious tissue removal of soft dentine has also been discussed. It is important to consider that selective caries removal decreases the risk of pulp exposition [41] and can improve the longevity of restorations [42]. A 5-years randomized trial observed that selective caries removal to soft dentin in deep caries did not affect the restoration survival when compared to stepwise excavation [43]. A systematic review observed that selective caries removal have similar results in restoration longevity than stepwise excavation and result in fewer pulp complications [42]. Similar results were observed in a multicenter clinical trial considering primary posterior teeth. The longevity of restorations was similar between non-selective and selective carious tissue removal over 33 months [78]; but a systematic review with a limited number of included articles with a high risk of bias have observed that—in primary teeth—selective caries removal decrease the restoration longevity [79]. Thus, for primary teeth, no definitive conclusion about the influence of selective caries removal on restoration longevity can be performed.
10.1.2.2 Patients’ Related Factors
The focus of a vast number of clinical trials investigating the survival of restorations is limited to comparisons between technic or materials [80, 81] while patients-related factors are not investigated. The contribution to patient-related factors on restoration survival cannot be ignored [11, 27, 28]. When patients are not mainly selected for inclusion criteria in clinical trials, some studies have observed that failures are linked to certain participants, independently of restorative material used [82]. Similar results are observed in epidemiological studies where caries is the central factor in explaining the failure and replacement of dental restorations [83, 84]. Corroborating, a birth cohort study, observed that unsatisfactory restorations at 24 years were more prevalent in individuals that presented a high number of decayed teeth at 15 years [58].
Caries risk of patients has been associated with higher restorations failure. Restorations placed in the high-risk group showed a lower survival rate than the low-risk group after 5 and 12 years. Considering 12 years of evaluation, AFR was 4.2% in the high-risk group and 0.9% in the low caries risk group [45]. In a clinical trial, corroborating that after 30 years, 64% of restorations that failed due to secondary caries were observed in the high-risk group [71]. A review observed that caries risk was associated with decreased restoration survival, including amalgam and composite resin [28]. In a cohort study evaluating posterior restorations (composite or amalgam), it was observed that individuals who had a higher trajectory of caries during their life were more likely to present failed restorations in adult life [47]. In another cohort study, in children at the age 12, the chances of presenting unsatisfactory restorations were 5.3 higher in children at high-risk for untreated dental caries in the permanent dentition than children at low risk. If the parents have received orientation from professionals on preventing caries development in their offspring, the children exhibited a 91.0% less chance of having an unsatisfactory restoration than children whose parents never received information [46]. Decayed, missing, filled teeth-surfaces (DMFT-S) have been used to evaluate caries experience, even as the component D of DMFT. Also, the number of the previous restoration was used to access caries risk. However, the use of a cumulative indicator could overestimate the caries risk. Therefore, identifying high-caries risk patients when the restoration is placed may provide a reasonable estimate, such as the lesion activity assessment [85].
Bruxism and parafunctional habits have been reported as factors that overload the restorations and increases the likelihood of restoration/teeth failure due to fatigue. Fracture of restorations is frequently reported as the second main reason for restorations failure. Fracture is the main failure of patients with habits of grinding and clenching teeth [8]. 70% of the restoration’s fractures occurred in patients with the parafunctional habit in a long-term follow-up (30 years) [71]. Patients with bruxism were also associated with a 37-fold more failed restoration or catastrophic fracture occurred whether the teeth presented root canal treatment [40]. In a practice-based retrospective study that evaluated the survival of resin composite restorations in posterior teeth, individuals with high occlusal-stress displayed three times higher risk to failure than individuals with low occlusal-stress; moreover, individuals with occlusal-stress and caries risk showed a cumulative effect and eight times more failures than individuals no risk [8].
Instruments for assessing bruxism habits used in studies that evaluate restorative materials are not objective, and they do not present standardized cutoff points, which limit their inference [10]. The most recent International Consensus [86] proposed a system for evaluating bruxism, considering that possible bruxism during sleep is based only on the author’s report (report of patients), probable sleep bruxism (with clinical inspection such as the presence of tooth wear), and definitive sleep bruxism (based on instrumental assessment, such as polysomnographic). Furthermore, bruxism’s etiology is considered to be multifactorial, and several underlying mechanisms may play a role in triggering and perpetuating events [87].
Post-operative sensitivity was one of the causes of patient-related failures in the first clinical studies evaluating composite restorations; however, such aspect is not observed in modern studies, primarily due to the improvements in adhesive systems [88] and restorative technique [89]. Several studies have found that participant’s age significantly influences restoration longevity [37, 90, 91]. The explanations are directed to the influence of age in other co-variables like dental caries, patient cooperation, among others, and it is not recommended to be considered as an isolated factor [5]. Caries activity has been reported to be the more frequent reason for making a dental restoration in the young population. Consequently, these restorations would be subject to higher risk due to individual factors. A study that followed 4355 restorations placed by 115 dentists in the Public Dental Health Service in Denmark observed that posterior composite resin restorations placed in children presented more likely to fail than those placed in the adolescent group [90].
10.1.2.3 Socioeconomic Status
Limited studies have investigated the influence of socioeconomic variables and their influence on the longevity of composite restorations. Most studies evaluating the longevity of restorations are carried out in private dental clinics or are performed under high control in randomized clinical trials, excluding patients with high-caries risk [10]. Frequently only individuals with high socioeconomic status are included. However, the findings of studies that investigate the influence of socioeconomic status suggest that it influences dental restorations survival via dental caries. One study carried out in a birth cohort investigate the influence of socioeconomic trajectory in the life course and found more unsatisfactory restorations in the low trajectory group. Individuals who always lived in the poorest stratus presented more failures than those who lived in the wealthiest layer [58]. A more recent follow-up of this cohort reported that posterior restorations’ failures were significant associated with socioeconomic status at age 30, with a prevalence ratio of 2.21 (95% CI 1.19–4.09) in low-income tertile [47]. In the same way, a recent study assessing restorations performed in the Brazilian public oral health service found that people with lower access to public services presented lower survival rates of composite restorations [92]. A practice-based study also observed that restorations performed by clinicians located in the more deprived region presented higher AFR than those found in areas of medium and high socioeconomic status [48]. Some studies have corroborated with the discussion of the influence of socioeconomic and behavioral factor on the survival of composite resins [93,94,95,96].
10.1.2.4 Restorative Material
Although in vitro studies have found considerable differences between the properties of commercially available restorative materials [97, 98], these findings are limited in predicting the clinical behavior of restorations [76]. In fact, in vitro and clinical studies have presented contradictory evidence of direct restorations’ clinical performance in posterior teeth [24]. Perhaps differences observed in laboratory tests will take decades to be observed clinically [17]. Yet, the differences can be so minor in clinical outcomes that they may not be statistically significant [71]. For posterior teeth, a retrospective study with data from one dentist’s private clinical practice followed two types of composites for long periods. No differences in performances were observed 17 years; however, after 22 years of follow-up, midfilled (70 vol% inorganic filler loading) composite showed superior performance than minifilled (55 vol% inorganic filler loading) [17]. Similar tendencies were observed to anterior restorations: only after 10 years of follow-up significative differences between restorative composites were clinically observed [61].
Another study that retrospectively evaluated for up to 20 years the longevity of restorations placed by one operator under rubber dam isolation and patients with regular check-up visits did not find differences between the composites placed in posterior teeth [99]. Similarly, after 30 years of another controlled trial, no differences between composite resins placed with chemical-cured and light-cured resin composite were observed regarding survival rate. Thus, to compare the clinical survival of restorations is necessary long-term studies. Moreover, these studies’ results are with materials that were developed decades ago and are expected to be inferior to the composite resins recently developed.
A wide number of composite materials have been introduced in the market, and the clinical trials’ design to compare these new materials present few years of follow-up. The main modification in the inorganic formulation of composites was the introduction of nanofiller composites. These materials were created to provide superior polish and gloss retention. A randomized 10-years trial of class II nanohybrid and conventional hybrid resin composite observed an overall AFR of 1.9% and no significant difference between the composites [100]. In another study, the overall success rate was 100% after 6 years of clinical evaluation for nanohybrid and hybrid composite [101]. At 8 years, the success rate was 98.5%, with no differences observed between materials [102].
A recent development in resin composite technology was the introduction of “bulk-fill” resin composites. Bulk-fill composites can be cured in up to 4 or 5 mm layers and include both low as high viscosity materials. A randomized clinical trial compared to class I and II restorations compared flowable bulk-filled resin composite (in increments up to 4 mm as needed to fill the cavity and 2 mm short of the occlusal cave surface with the occlusal part completed with nanohybrid resin composite) and resin composite-only placed in 2 mm increments. After 5 years of evaluation, bulk-filled presented an AFR of 1.1% and the resin composite-only restorations of 1.3%, with no significant differences detected between the materials [102].
Although the comparisons of direct and indirect composite restorations have similar performance and longevity [24], other factors related to the restorative technique have been reported to influence the clinical performance of composite materials. Adhesive systems are frequently evaluated in Class V restorations and also influenced the longevity of these restorations [103], even though, for anterior restorations, the degradation of the hybrid layer could affect more the esthetics, while such aspect seems not to be relevant for posterior composite restorations [88, 104, 105]. Regarding longevity or restorations, the gold standard dental adhesive technique is the use of a mild two-step, self-etch adhesive system with selective phosphoric acid enamel etching [50] and bevel are not indicated because they does not affect the clinical performance [34]. Moreover, the use of rubber dam isolation does not seem to affect the longevity of restorations, as long as it is applied effectively with cotton rolls and suction devices. Although some studies have observed better performances of restorations applied under rubber dam isolation [9, 34], the evidence shows that restorations placed using cotton rolls and suction device can also survive for long periods [49] and the use of appropriate suction device and working with the aid of a dental nurse are even more important for achieving good isolation from humidity in case rubber dam is not used.
10.1.2.5 Operator
Dentist-linked factors, such as operator skills, are considered important factors that influenced the survival of composite resin restorations [5]. Although a wide part of results is explained solely on the training level and accuracy of work, the decision-making process also can influence restoration survival and could combine as a complex process, ranging among clinicians according to co-variables, such as the type of practice, reimbursement system, competition environment among dentists, patients’ views and opinions, and cultural aspects.
The dentists are the ones who place the restorations, those who evaluate them, and, ultimately, decide when the restoration needs to be changed. Variability on diagnostic and decision-making has been elevated among dentists that frequently adopt an invasive approach to intervene in restorations, especially when they were performed by other professionals [13]. Invasive behavior toward restoration replacement results in a decrease in the survival of restoration. Chisini et al. [106] observed that the decision-making of dentists was influenced by patient skin color. Clinicians choose more to replace ill-adapted restoration in white patients while they decide not to intervene in restoration from dark-skinned individuals [106]. Dentists frequently choose to replace restorations with a small sign of marginal degradation or staining because they then confound with secondary caries. After 27 years of follow-up on posterior chemical-cured resin composite with the high color changed (classified as non-acceptable research evaluators) were maintained in function and classified as satisfactory to the patients [49]. Even secondary caries kept restricted in the enamel can be maintained and treated with non-operative treatments [107], and the repair can—preferably—choose if operative treatment is required.
Despite clinical studies with trained and calibrated operators maybe not observe significant associations between operator and success, practice-based studies have observed that age, country of qualification, and employment status of the operator could influence the survival of restoration [5]. Data from Washington dental service observed that restorations placed by efficient dentists survive almost 5 months more than restorations performed by inefficient dentists, and no differences between the restorations were observed when efficient dentists performed than [108]. Similarly, the longevity of restorations placed by more experienced clinicians was better than those placed for less experienced ones [109]. Restorations placed by the dentist with less practice workload presented a success rate of about twice than those slightly busy clinicians [110]. A geospatial analysis carried out in Canada observed more aggressive treatment choices were performed by dentists who feel under great competitive pressure and in low dentist density areas [111]. Therefore, all these issues and the differences in the decision-making process on judging restorations intensification the risk for replacement restorations and decrease the survival rates.
10.2 Repairing Esthetic Composite Restorations
Patients that changed the dentist have an increased chance to replace their restorations [93,94,95,96]. In fact, a cross-sectional study that included 194 dentists of the Dental Practice-Based Research Network observed that the decision to repair defective restoration instead to replace is influenced by who place the original one: clinicians are less demanding when evaluating their work [13]. The decision to replace a restoration relies on the dentist’s clinical expertise rather than on strict criteria. Thus, dentists adopt different approaches (repair or replacement) in cases of imperfect restorations [112], although the literature presents a consensus that, when possible, repaired restorations presents benefits and are more cost-effective than replacement [16].
10.2.1 Long-Term Survival and Reasons for Failures of Repaired Restorations
Replacement of a failed restoration is still one of the most frequent treatments performed in dental practice [113]. While most dentists state to perform repairs, and the vast majority of dental schools teach repairs, the proportion of truly repaired restorations is still very low [16]. A clinical trial assessed the longevity of repaired restorations and showed similar longevity than replaced restorations after 12 years of follow-up [15]. Repaired and replaced restorations presented similar behavior in marginal adaptation, marginal stain, teeth sensitivity, anatomic form, and luster parameter, although roughness was significative was significantly worse in the group of repaired restorations [15].
Casagrande et al. [114] estimated the reduction in AFR when repaired restorations were not considered as a “true failure” and observed that repair increases the longevity of direct posterior restorations. When repair was not considered as a failure, the survival of restoration changed from 83.1 (AFR = 3.6%) to 87.9% (ARF = 2.5%) at 5 years and from 65.9 (AFR = 4.1%) to 74.6% (AFR = 2.9%) at 10 years of follow-up. Reduction of AFR from 1.83 to 0.72% in composite resins repaired restorations after 12 years of follow-up was observed in another study [115]. A study that follows for 22 years posterior composite restorations performed by one dentist observed that a reduction from 1.9 to 0.7% on AFR when restorations repaired were not considered as failures [10, 17].
A study that evaluated 880 restorations placed in posterior and anterior teeth observed that repair increases the survival of restorations even after previous repairs or replacements [116]. A recent long-term practice-based clinical study carried out in a private dental practice followed class III and class IV for 15 years, and veneer restorations for 10 years. For class III and class IV restoration, AFR was 2.9%, and for veneers 9.2% when the repair was considered as failure. When repair was not considered as failure, class III and IV presented an AFR of 2.4% and veneers of 6.3% [117]. Thus, direct comparisons between the treatments (repair and replacement) presented comparable results.
In this way, secondary caries was the main reason for failure in both repaired and replaced restorations [15] while Opdam et al. [115] reported tooth fracture as the main reason for failure in the repaired restorations (41.1%) followed by dental caries (24.2%) [115]. These two reasons are the same observed for non-repaired restorations both in permanent [8, 10] and primary teeth [9].
10.2.2 Factors Involved in Repaired Restorations Failure
Regarding the main reasons for failures, studies have shown, in general, that the same factors known for non-repaired restorations seem to influence repaired restorations as well. Casagrande et al. [114] found that endodontic treatment, molar teeth, use of a prosthesis, and age were important risk factors for restoration failure. On the other hand, in one study, only sex was reported as associated as a risk factor to failure in repaired restorations, in which women presented a risk of failure twice higher when compared to men [115]. Cox regression analysis in a practice-based study found that class III and IV restorations placed in the upper jaw had a higher risk for failure compared to the lower jaw. Central incisors also had a higher failure risk for failed repaired restorations. Also, the type of composite influenced the survival rates [117]. The presence of endodontic treatment is a factor associated with a higher risk of failure for both repaired or replaced restorations [116].
10.2.3 Repairing Benefits Over Replacing Restorations
The comparison of the survival of replaced versus repaired restoration may be unfair. A repaired restoration is comprised mostly of the older and aged part of a restoration. It presents already signs of fatigue, differently from a replaced filling that is entirely new. Thus, a repaired and older restoration may fail before the replaced one. But even in this case, the survival of the original restoration is increased, and the removal of tooth tissue is postponed, which could be the main direct benefits. If the repaired restoration fails, the replacement is indicated and can be carried out without further problems. Repair is considered an approach of minimal intervention dentistry, being an alternative to easy, fast, and low-cost treatment [16]. The clinical time spent to replace a restoration is reported to be higher than the time required to repair the same restoration. Additionally, the repair of restoration seems to be more cost-effective than replacement, and thus repairs are drawn as an important strategy for public health services [16].
10.2.4 When Repairing Is Not a Solution?
Repair of defective restorations is not always possible. Like this, the Academy of Operative Dentistry European Section has indicated the restoration replacement when (a) restoration has unaccepted qualities (deterioration/secondary caries); (b) repair is contraindicated; (c) benefits of replacement are less than possible harm; (d) prospects for an acceptable clinical outcome are favorable; and (e) patient consents [118].
10.3 Replacing Esthetic Composite Restorations
As previously discussed, composites have shown considerable improvements since their introduction in the 1960s. Due to the improvement of the properties of the material, nowadays, most of the failures are related to factors related to the patient and the operator. When small changes in color, shape, or fractures are observed, repair should always be the first choice. However, in some situations where the remaining restoration is integrally degraded, replacement of the restoration can be indicated.
10.3.1 Restorations Do Not Last Forever
Composite resin restorations are materials that, like any other, present aging over time. The degradation of the hybrid layer and its respective pigmentation are the main surface changes in the medium term; together with small changes in surface roughness, they can be overcome with surface finishing and polishing. However, this marginal degradation or marginal staining cannot be mistakenly interpreted as secondary caries. Limited time is used to teach secondary caries diagnosis in dental schools and this fact could be a contributor for the lack of consensus among dentists regarding the interventions on restorative. Considering that criteria for repair/replacement are not clear among dentists, [118] suggest a shift from “in doubt, take it out” toward “as a last resort take it out” after considering monitoring, refurbishment, and repair as the first treatment options.
10.3.2 Aspects That Can Increase the Longevity of Esthetic Composite Restorations
Composite restorations have shown excellent survival rates on anterior and posterior teeth. Due to materials improvements overtime, current materials’ properties have revelated a minor influence on the survival of composites in clinical studies. When hybrid or nanohybrid composites are used, low AFR could be expected. To improve the longevity of these restorations, patient-related factors and operators are fundamental. Therefore, restorations should be carried out in a health promotion environment, emphasizing preventive practices. The adoption of healthy behaviors by patients will consequently led to “healthy” restorations, increasing the longevity of treatments. The adoption of minimally invasive dentistry for the management of deteriorated restorations, such as refurbishment or repair restorations, should be considered in routine practice. In this way, dentists should react less in front of small defects of restorations, indicating replacements only when other alternatives are not plausible.
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Demarco, F.F., Chisini, L.A., Correa, M.B., Cenci, M.S., de Moraes, R.R. (2022). Longevity of Resin Composite Restorations. In: Oliveira, D. (eds) Color Science and Shade Selection in Operative Dentistry. Springer, Cham. https://doi.org/10.1007/978-3-030-99173-9_10
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DOI: https://doi.org/10.1007/978-3-030-99173-9_10
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