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Clinical performance of posterior compomer

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Article in American journal of dentistry February 2006

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Research Article
_______________________________________________________________________________________________________________________________________________________________

Clinical performance of posterior compomer restorations over 4 years

NORBERT KRMER, DMD, PHD, FRANKLIN GARCA-GODOY, DDS, MS, CHRISTIAN REINELT, DMD
& ROLAND FRANKENBERGER, DMD, PHD

ABSTRACT: Purpose: To clinically evaluate two polyacid-modified resin composites (Hytac and Dyract AP) for the
restoration of posterior teeth over a 4-year period and to investigate accessible margins by light microscopy. Methods:
In a controlled prospective clinical study, 71 cavities (21 occlusal, 41 MO/OD, 9 MOD) in 30 patients were restored
with compomers by three dentists. Thirty-eight restorations were placed with the combination OSB/Hytac, the same
patients received 33 restorations with Prime&Bond 2.1/Dyract AP. Enamel margins of the cavities were etched with
phosphoric acid. At baseline, after 12, 24, and 48 months, the restorations were examined by two independent
investigators according to modified USPHS-criteria. Focusing on the 40 restorations available at all recalls, a semi-
quantitative margin analysis was carried out at each recall using replicas and light microscopy at x130 magnification.
Results: Twenty restorations were not investigated at the 4-year recall (drop-out). After 48 months, 11 restorations
(Hytac: n=8, Dyract AP: n=3) had to be replaced due to tooth fracture (n=4), gap formation (n=5), and adhesive failure
(n=2). Forty restorations were still in function after 4 years (overall failure rate 16%; Hytac: 21%; Dyract: 9%).
Between the recalls, statistically significant differences were detected for the criteria marginal integrity (Alpha dropping
from 76% at baseline to 32% after 4 years), restoration integrity (Alpha ratings at baseline 99% vs. 40% after 4 years),
and occlusion (100% vs. 24%). For the criteria surface roughness (from the 6-month recall) and anatomical shape (after
4 years), a significant difference between the materials was evident in favor of Dyract AP. Except gap-free margins, the
predominant criterion in the microscopic analysis at baseline was marginal overhang (24%) and 30% negative step
formation after 4 years. (Am J Dent 2006;19: 61-66).

CLINICAL SIGNIFICANCE: Dyract AP achieved a 91% success rate after 4 years when enamel margins were etched.
Facing a 21% failure rate after 4 years of clinical service, the compomer material Hytac did not fulfill the ADA criteria
for direct posterior restorative materials.

: Prof. Dr. Norbert Krmer, Glueckstrasse 11, D-91054 Erlangen, Germany. E- : kraemer@dent.uni-erlangen.de

Introduction In spite of all reservations about the use of resin

During the last decade, tooth-colored direct posterior
restorations achieved increasing popularity.1,2 Although no
scientific evidence about the toxicity of amalgam seems to be
relevant, the acceptance of dental amalgam perceptibly
declined.3,4 The restoration of teeth with resin composites is
an appropriate alternative to amalgam, if minimally invasive
preparation techniques are applied.5
In the mid-1990s, a modified class of composite materials
was introduced, the so-called compomers. This group of
materials was primarily designed to cover the advantages of
glass-ionomer cements i.e. fluoride release, and of resin-based
composites i.e. excellent esthetic and flexural properties.6-8
The literature supports that compomers are much more
related to resin composites than to glass-ionomer cements.9
Altogether they are considered as hydrophilic resin compo-
sites and therefore called polyacid-modified resin compo-
sites.8,9 Regarding fluoride release, the amount of fluoride was
clinically negligible when a bonding agent was used.8
Compomers have inferior overall properties compared to
conventional resin composites.7 Nevertheless, the easy
handling protocol of characteristically simplified adhesives
and at least initially good esthetic performance made these
materials very popular for the general dentist and sales
numbers confirm this.
The predictability of in vitro studies is often limited,
therefore controlled prospective clinical studies are necessary
for a definitive assessment of dental materials.1-5
composites in the posterior region, from the clinical point of
view, quite promising clinical long-term results are reported
even with older resin composite materials.10
Clinical reports about compomers are often restricted to
primary molars3,11,12 and prospective studies dealing with
compomers in permanent teeth are scarce.13 Therefore the aim
of the present study was to clinically evaluate the suitability
of two different compomers for posterior restorations over an
observation period of 4 years.
The selected bonding procedure involved additional
enamel etching because from the data in the literature at that
time it seemed to be mandatory to etch enamel for durable
marginal integrity in enamel.14,15 Eventual advantages of
compomers regarding the compatibility with recent all-in-one
adhesives were not known when the present study started.16
For clinical assessment, the United States Public Health
Service (USPHS) investigation system was used (Table 1).17-19
In comparison to in vitro studies with repeated extensive
margin analyses, microscopic evaluations of the tooth-resto-
ration interface in vivo are very seldom reported in the litera-
ture, commonly limited to the evaluation of tooth-colored inlay
systems.20
Like in a previous study dealing with resin composites,
replicas were analyzed regarding marginal quality under a
light microscope to elucidate the bonding and wear per-
formance over time.21 This particular tool was intended to act
as additional aid to investigate the marginal areas subjected to
degradation and gap formation over the period of 4 years of
clinical service.
 American Journal of Dentistry, Vol. 19, No. 1, February, 2006
62 Krmer et al

Table 1. Pooled results for both restorative materials under clinical observation.
_______________________________________________________________________________________________________________________________________________________________________________________________________________

Criterion Baseline (n = 71) 6 Months (n = 69) 12 Months (n = 63) 24 Months (n = 54) 48 Months (n = 47)
Alpha Bravo Charlie Alpha Bravo Charlie Alpha Bravo Charlie Delta Alpha Bravo Charlie Alpha Bravo Charlie
in % in % in % in % in %
_______________________________________________________________________________________________________________________________________________________________________________________________________________

Surface roughness 97 3 - 81 19 - 54 46 - - 56 44 - 62 38 -
Color match 99 1 - 97 3 - 91 9 - - 85 15 - 89 11 -
Anatomical shape 90 10 - 94 6 - 95 5 - - 92 8 - 49 51 -
Marginal integrity 76 24 - 77 23 - 71 27 2 - 37 57 6 32 62 6
Integrity tooth 92 8 - 91 9 - 90 8 - 2 92 6 2 72 28 -
Integrity restoration 99 1 - 88 12 - 84 16 - - 82 18 - 40 60 -
Occlusion 100 - - 100 - - 100 - - - 98 2 - 24 70 6
Proximal contact 89 11 - 89 11 - 81 19 - - 89 11 - 78 19 3
Hypersensitivity 99 1 - 96 4 - 100 - - - 98 2 - 96 4 -
_______________________________________________________________________________________________________________________________________________________________________________________________________________

Table 2. Clinical results of all recalls for Hytac restorations.

_______________________________________________________________________________________________________________________________________________________________________________________________________________

Criterion Baseline (n = 38) 6 Months (n = 36) 12 Months (n = 32) 24 Months (n = 28) 48 Months (n = 26)
Alpha Bravo Charlie Alpha Bravo Charlie Alpha Bravo Charlie Delta Alpha Bravo Charlie Alpha Bravo Charlie
in % in % in % in % in %
_______________________________________________________________________________________________________________________________________________________________________________________________________________

Surface roughness 97 3 - 63 36 - 22 78 - - 21 79 - 31 69 -
Color matching 100 - - 97 3 - 91 9 - - 79 21 - 92 8 -
Anatomical shape 90 10 - 94 6 - 97 3 - - 89 11 - 35 65 -
Marginal integrity 79 21 - 83 17 - 69 31 2 - 39 50 11 23 69 8
Integrity tooth 90 10 - 86 14 - 84 13 - 3 89 11 - 73 27 -
Integrity restoration 97 3 - 92 8 - 87 13 - - 75 25 - 27 73 -
Occlusion 100 - - 100 - - 100 - - - 100 - - 34 58 8
Proximal contact 84 16 - 91 9 - 82 18 - - 80 20 - 80 15 5
Hypersensitivity 97 3 - 92 8 - 100 - - - 96 4 - 96 4 -
_______________________________________________________________________________________________________________________________________________________________________________________________________________

Table 3. Clinical results of all recalls for Dyract AP.

_______________________________________________________________________________________________________________________________________________________________________________________________________________

Criterion Baseline (n = 33) 6 Months (n = 33) 12 Months (n = 31) 24 Months (n = 26) 48 Months (n = 21)
Alpha Bravo Charlie Alpha Bravo Charlie Alpha Bravo Charlie Delta Alpha Bravo Charlie Alpha Bravo Charlie
in % in % in % in % in %
_______________________________________________________________________________________________________________________________________________________________________________________________________________

Surface roughness 97 3 - 100 - - 87 13 - - 92 8 - 100 - -

Color matching 99 1 - 97 3 - 90 10 - - 92 8 - 86 14 -
Anatomical shape 91 9 - 94 6 - 94 6 - - 96 4 - 67 33 -
Marginal integrity 73 27 - 70 30 - 74 23 3 - 35 65 - 43 52 5
Integrity tooth 94 6 - 97 3 - 97 3 - - 96 - 4 71 29 -
Integrity restoration 100 - - 85 15 - 81 19 - - 89 11 - 57 43 -
Occlusion 100 - - 100 - - 100 - - - 96 4 - 9 86 5
Proximal contact 96 4 - 86 14 - 80 20 - - 100 - - 77 23 -
Hypersensitivity 100 - - 100 - - 100 - - - 100 - - 95 5 -
_______________________________________________________________________________________________________________________________________________________________________________________________________________

Materials and Methods
Patient selection - Patients were selected for this study
according to the following criteria:
; Absence of pain relating to the restored tooth;
; No pathologic periodontal or pulpal diagnosis;
; No cusp reconstruction required; and
; No known allergic reaction against any components of the
used materials.
The patients were treated in the Department of Operative
Dentistry and Periodontology, University of Erlangen-
Nuremberg (n=17) and in a private practice (n=13) by two
different clinicians having experience with direct posterior
adhesive restorations.
Patients were required to sign a consent form indicating that
the adhesive system and the dental restorative were recently
developed and that no long-term experience was available at
baseline of the investigation. The clinical study was conducted
according to EN 540 (clinical investigation of medical devices
for human subjects according to the European Committee for
Standardization). The patients agreed to a 4-year recall system
involving five appointments: The baseline investigation, 6-, 12-,
24-, and 48-month recalls.
Seventy one cavities in 30 patients (8 male, 22 female; aged
18-60 years, average 32 years) were restored with polyacid-
modified resin composite materials during the period of Feb-
ruary through November 1998 (restorations with one surface:
n=21; two surfaces: n=41; three surfaces: n=9). Seventeen of
the restorations were located in maxillary molars (~24%), 28 in
maxillary bicuspids (~39%), 12 in mandibular molars (~17%),
and 12 restorations were placed in mandibular premolars (~17
%). Local anesthesia (Ultracain DSa) was applied in all cases.
Thirty eight restorations were placed using Hytac bonded
with OSB.b Thirty-three restorations were made of Dyract AP
bonded with Prime&Bond 2.1.c
All treatment steps from the preparation to the polish were
performed by use of magnifying glasses providing 2.3-fold
magnification.d
Preparation - The cavities were prepared under pre-wedging
with wooden wedges (Sycamore interdental wedgese) accord-
ing to minimally invasive preparation rules, therefore pre-
ventive extension was avoided. The margins were not beveled
American Journal of Dentistry, Vol. 19, No. 1, February, 2006
Fig. 1. Characteristic negative step formation due to wear, observed at the
margin of a Hytac restoration after 4 years. SEM image, final magnification
25x. CR: Compomer restoration. T: Tooth. Indicator: Pores in the compomer
surface indicate wear due to lost filler particles.
(80 m diamond burf), and finished with a 25 m finishing
diamond. Inner angles of the cavities were rounded. The
prepared teeth were additionally cleaned with pumice slurry.
All cavities were recorded photographically (camera: Nikon
Medical 200,g color film: Agfachrome RSX 50 Professionalh).19
OSB treatment - The cavities were isolated with cotton rolls and
encircled with transparent matrix bande and enamel margins
were selectively etched for 30 seconds using orthophosphoric
acid (MiniTip etching gelb). The acid gel was rinsed off with
air-water spray for 30 seconds and the cavities were dried until
the etch pattern of the enamel margins appeared. OSB was
applied with a mini-brush for 20 seconds.
The self-priming adhesive was dried to evaporate excess
solvent and consequently light-cured for 20 seconds (Trilight
curing unit,b standard mode). After polymerization, OSB was
applied again, immediately dried and light-cured for another 20
seconds.
Prime and Bond 2.1 treatment - After isolation, the cavities
were etched, rinsed and dried like in the OSB groups. Prime &
Bond 2.1 was applied with a brush, left undisturbed for 30
seconds and was subsequently dried, immediately air-thinned,
and light-cured for 20 seconds.
Compomer restoration - The corresponding polyacid-modi-
fied resin composite materials were layered incrementally in
layers of a maximum 2 mm thickness. Each layer was light-
cured for 40 seconds. After light-curing of the final increment,
the restoration surface was examined for defects like voids or
negative steps and corrected if necessary. Visible overhangs
were removed with a scaler (A8 S204Si). Contacts in centric
and eccentric occlusion were controlled with color foils, and
adjusted with diamond finishing burs, followed by flexible
discs (SofLex Pop-onj). Occlusal overhangs were removed
and polished in the same manner; proximal excess was
reduced with interdental diamond polishing stripsk in
descending grid sizes.
Proximal contacts were evaluated using waxed dental floss
and contact gauges (YS Contact Gaugel). Finally, the restored
teeth were covered with a fluoride gel (Duraphatm).
Compomers after 4 years 63
Fig. 2. Gap formation at the margin of a Dyract AP restoration. SEM image,
final magnification 25x. CR: Compomer restoration. T: Tooth. Indicator:
Marginal gap formation.
Clinical evaluation - At baseline, and after 6, 12, 24, and 48
months, all restorations were clinically assessed according to
the modified USPHS criteria (Tables 1-3) by two independent
investigators not having placed the restorations. Evaluation
tools were mirrors, probes, magnifying glasses, and intraoral
photographs. In the case of disagreement, a consensus was
obtained between the examiners.19
In each recall appointment, color photographs of the resto-
rations were taken with and without marked contact points.
Margin analysis - At baseline, and after 6, 12, 24, and 48
months, polyvinyl siloxane (Permagumb) impressions were
taken of 40 restorations after thorough drying and cleaning.
Replicas were made using an epoxy resin material (Epoxy-
Dien). These restorations were observed over the whole
investigation period of 48 months. The replicas were
investigated under a light microscope (assessed at 130-fold
magnification under a stereo light microscope (SV 11d) in
combination with a 3 CCD color camerao and a frame
grabber.p For digitization, the KS 100 software,d and for the
margin analysis the software WinMes 2.0 was used. A semi-
quantitative analysis of the margins using the criteria gap-
free margin, marginal irregularity, gap, overhang, and
artifact was performed at x130 magnification.21 The criteria
were calculated as percentage of the observed margin quality
related to the entire length of the particular margin. Only the
accessible areas of the margins were analyzed, i.e. the
investigation of proximal-cervical margin areas was not
possible at all.
Specimens exhibiting characteristic findings were
additionally sputter-coated with goldq and examined under a
SEM (Leitz ISI 50r) at different magnifications to illustrate
the findings (Figs. 1,2).
Statistical evaluation - The statistical analysis was computed
with SPSS 10.0.s A statistical unit was one compomer resto-
ration, and differences in clinical performance were evaluated
pairwise with Friedman and Wilcoxon tests. Differences
between materials were investigated using the Mann-Whitney

64 Krmer et al
Table 4. Results of the light microscopic margin analysis.
_______________________________________________________________________________________________________________________________________________________________________________________________________________
Baseline (n=40)
Length (m) 11.7 x 103
Criterion
_______________________________________________________________________________________________________________________________________________________________________________________________________________
Perfect margin 62.6 (20.5)
Negative step formation 3.1 (4.8)
Gap formation 3.6 (1.4)
Overhang 24.3 (19.8)
Positive step formation 6.4 (2.2)
Artifact 8.9 (9.9)
_______________________________________________________________________________________________________________________________________________________________________________________________________________
U-test.
Any failures during the clinical study were counted as
failures in all subsequent recalls. For the case that the criterion
Charlie or Delta was used in any recall, this particular
restoration was counted as a failure within the survival
analysis. To assess the survival statistics of the materials, the
logarithm according to Kaplan-Meier was computed and
tested for equality of survival distributions using the
nonparametric logrank test ( = 5%).
Results
Survival analysis - Eight patients representing 17 restorations
missed the 4-year recall (drop-out).
After 4 years of clinical service, 14 restorations (Hytac:
n=11, Dyract AP: n=3) had to be replaced due to cusp or ridge
fracture (n=4), gap formation (n=5), bulk fracture (n=2), loss
of occlusal contact (n=2), and loss of proximal contact (n=1).
Forty restorations were still in function after 4 years (overall
failure rate: 13%; Hytac: 21%; Dyract: 9%; survival analysis
algorithm according to Kaplan/Meier, Fig. 3). The mean
survival time was significantly different between the materials
under investigation (Hytac: 4.23 years; 95% confidence
interval 3.68-4.78 years; Dyract AP: 4.74 years; 95%
confidence interval 4.44-5.03 years; Log rank test, P< 0.05).
Clinical evaluation - The clinically observed results of Hytac
and Dyract AP are displayed in Tables 2-4. Comparing the
materials, no statistical differences were evident except for the
criteria surface roughness (from the 6 months recall) and
anatomical shape (after 4 years) (Mann-Whitney U-test; P<
0.05) with Hytac exhibiting inferior results. According to the
criterion surface roughness, after 4 years Dyract AP
received 100% Alpha ratings whereas Hytac was judged with
31%. Similar observations were evident for anatomical
shape. The rating Alpha was given to 67% of Dyract AP
restorations, but only for 35% of the Hytac restorations.
Evaluating the change within single criteria over time,
only proximal contacts remained stable (P> 0.05; Friedman
test), all other criteria deteriorated, above all between the 2-
and 4-year recalls. For both materials, several negative
changes were observed. The main reasons for a significant
performance loss regarding marginal quality were increasing
crevice (43%) and marginal gap formation (21%). Two
patients suffered complaints at the recalls, probably caused by
severe gap formation and leakage.
A common observation for both materials was a certain
deterioration for the criterion restoration integrity. After 2
years, only 2% (n=1) of the restorations revealed visible wear.
In contrast, after 4 years already 53% (n=25) of the
restorations showed wear which led to a Bravo rating.
American Journal of Dentistry, Vol. 19, No. 1, February, 2006
6 Months (n=40) 12 Months (n=40) 24 Months (n=40) 48 Months (n=40)
11.6 x 103 11.5 x 103 12.9 x 103 12.0 x 103
Percentage of entire evaluable margin length (SD)
74.5 (18.2) 80.0 (13.9) 53.9 (24.0) 59.1 (26.5)
6.4 (8.4) 8.3 (8.6) 32.6 (25.4) 29.8 (24.8)
1.5 (3.4) 1.3 (3.2) 2.9 (7.6) 6.4 (17.1)
12.7 (16.1) 6.9 (9.0) 2.5 (1.5) 8.0 (4.1)
1.7 (4.9) 1.2 (3.9) 6.2 (14.5) 4.3 (8.5)
3.1 (4.6) 2.3 (3.1) 1.4 (5.6) 6.6 (4.0)
Accordingly, occlusal contacts partially diminished over time
also from 2% (n=1) after 2 years to 68% Bravo (n=32) and
6% Charlie (n=3) after 4 years.
Margin analysis - The results of the light microscopic margin
analysis are displayed in Table 4.
Both materials revealed no statistically significant
difference in any criterion (P> 0.05; Mann-Whitney U-test).
The margin analysis of the baseline replicas resulted in 24%
marginal overhangs, significantly decreasing to 8% after 4
years (Friedman-test, P< 0.05). Due to the reduced length of
marginal overhangs, perfect margins significantly increased
from baseline (63%) to the 1-year evaluation (80%)
(Friedman test, P< 0.05). The following decrease (after 2
years) of gap-free margins is caused by a significant increase
of the criterion positive step formation (6% to 4%) and
above all for the criterion negative step formation (33% to
30%; Friedman test, P< 0.05). Gap formation persisted at 1%
to 6% over the whole observation period (Friedman test; P>
0.05; Table 4).
Discussion
It was actually never proven that compomers reveal
significant advantages when compared to resin-based compo-
sites.6,7 Nevertheless, facing the sales facts, this particular group
of materials is definitely an important part of the worlds dental
treatment concept and therefore it is mandatory to evaluate the
potential under real clinical circumstances.
Primarily, compomers are marketed with either all-in-one
adhesives e.g. Prompt L-Popb or with additional conditioning
aids like NRC (non rinse conditionerc). All attempts (and
marketing concepts) for pre-treatment of tooth hard tissues have
in common that etching with phosphoric acid should be
avoided to simplify the application protocol.14 From a
micromechanical point of view, this is definitely questionable,
but the success on the market is different.
In contrast, the present study was conducted with
phosphoric acid etching of enamel margins due to two main
reasons. The authors did not believe that the former adhesives
OSB and Prime&Bond 2.1 were able to prevent gap formation
in enamel over time. Reports in the literature unanimously
exhibited far higher enamel bond strengths when enamel was
etched prior to the application of these adhesives.14,15
Furthermore, when enamel etching is carried out, flexural
properties as well as wear resistance of the compomer materials
is more critical during overall evaluation of the clinical
performance over time. In this way, it was possible to actually
investigate the restorative material and not primarily whether
the adhesive is capable of compensating for the materials
shrinkage.
American Journal of Dentistry, Vol. 19, No. 1, February, 2006
Compomers after 4 years 65

Fig. 3. Survival rates for both materials under investigation according to the algorithm of Kaplan/Meier.

The authors decided to selectively etch the enamel margins based composites.7,24 This laboratory generated fact can be
instead of total etching to avoid rather complicated wet bonding confirmed facing the in vivo data of the present study, at least
procedures as described even later in the literature, facing the for the compomer material Hytac.
enormous technique sensitivity of these materials, above all The additionally performed margin analysis using a light
when acetone is the solvent of choice like in both adhesives microscope at x130 magnification delivers only a confirmation
used in the present study.22,23 of facts emerging from the clinical investigation.21 Microscopic
Regarding the clinical results, it is obvious that the higher investigations in vivo are always compromised due to the fact
surface roughness of Hytac in comparison to Dyract led to that the important proximal parts of the restorations cannot be
clinically detectable rougher restoration surfaces over the whole reproduced sufficiently and marginal gaps could theoretically
observation period.6 The reason for that observation lays in be obstructed by plaque, because no separate etching to clean
different filler sizes when Hytac and Dyract AP are compared.6 the margins could be carried out.20 Therefore, the margin
This was already significantly different at the 6-month analysis is at least a useful additional tool for the whole investi-
evaluation. A later sign of different filler concepts is evidently gation, but is not able to replace any clinical evaluation of
the loss of anatomical shape due to occlusal and proximal wear restorative materials after a certain time of clinical service.
between the 2-year and the 4-year recalls. This observation was Altogether, the present results indicated that it cannot be
significantly clearer for the Hytac restorations. Also the Dyract assumed that compomers per se can clinically work equally
AP restorations lost anatomical shape over time; however, this well as resin-based composites,1 even when the bonding
did not lead to Charlie ratings like for Hytac. protocol is similar. At least for Hytac, it was concluded that the
The clinical performance of Hytac compomer was not ADA requirements i.e. 90% success after 4 years was not
favorable. Even when treating the material as a resin-based fulfilled.26 Hytac is no longer in the market since January 2003.
composite. i.e. with phosphoric acid etching of the enamel mar-
a. Aventis, Frankfurt/Main, Germany.
gins, a failure rate of 21% after 4 years was observed. This b. 3M ESPE AG, Seefeld, Germany.
observed failure rate is only slightly better than comparable c. De Trey/Dentsply, Konstanz, Germany.
studies applying Dyract AP13 or Hytac24 without enamel etch- d. Jenoptik, Jena, Germany.
e. Kerr Hawe-Neos, Bioggio, Switzerland.
ing. It is interesting that only 28% of all observed failures were f. Komet Corp., Lemgo, Germany.
attributed to marginal gap formation. However, in another g. Nikon, Tokyo, Japan.
study without enamel etching, more than 80% of the failures h. Agfa Gevaert, Leverkusen, Germany.
were due to severe gap formation.24 Different recall protocols i. Hu-Friedy, Leimen, Germany.
j. 3M ESPE, St. Paul, MN, USA.
(number of investigators, modifications of USPHS criteria, k. GC Europe, Leuven, Belgium.
including Charlie and Delta into the survival algorithm, and l. YDM Yamamura, Tokyo, Japan.
finally the presence of an additional marginal analysis) tend to m. Colgate-Palmolive, Hamburg, Germany.
n. Ivoclar-Vivadent, Schaan, Principality of Liechtenstein.
complicate comparisons with other clinical studies reported in o. Sony, Cologne, Germany.
the literature. p. Matrox Meteor RGB, AVT Horn, Aalen, Germany.
An important point emerging from the clinical results is the q. Balzers SCD 40, Balzers, Principality of Liechtenstein.
r. Akashi, Tokyo, Japan.
wear behavior of the materials under investigation, above all of s. SPSS inc, Chicago, IL, USA.
Hytac. Betwen the 2- and 4-year recalls, a clear deterioration of
anatomical shape of the restorations was evident, leading to Acknowledgements - This study was supported by materials and a grant from
Charlie ratings due to missing occlusal and proximal contact 3M ESPE AG (Seefeld, Germany). The authors are grateful to Mrs. Gudrun
Amberger for the helpful assistance during the SEM processing.
points. It is known from several in vitro wear analyses that
compomer materials provide less abrasion resistance than resin- Dr. Krmer and Dr. Frankenberger are Associate Professors, Department of

66 Krmer et al
Operative Dentistry and Periodontology, University of Erlangen-Nuremberg,
Erlangen, Germany; Dr. Garca-Godoy is Professor and Associate Dean for
Research, College of Dental Medicine, Nova Southeastern University, Fort
Lauderdale, Florida, USA; Dr. Reinelt is in private practice in Nuremberg,
Germany.
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