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Clinical performance of posterior compomer


restorations over 4 years

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


composites in the posterior region, from the clinical point of
During the last decade, tooth-colored direct posterior view, quite promising clinical long-term results are reported
restorations achieved increasing popularity.1,2 Although no even with older resin composite materials.10
scientific evidence about the toxicity of amalgam seems to be Clinical reports about compomers are often restricted to
relevant, the acceptance of dental amalgam perceptibly primary molars3,11,12 and prospective studies dealing with
declined.3,4 The restoration of teeth with resin composites is compomers in permanent teeth are scarce.13 Therefore the aim
an appropriate alternative to amalgam, if minimally invasive of the present study was to clinically evaluate the suitability
preparation techniques are applied.5 of two different compomers for posterior restorations over an
In the mid-1990s, a modified class of composite materials observation period of 4 years.
was introduced, the so-called compomers. This group of The selected bonding procedure involved additional
materials was primarily designed to cover the advantages of enamel etching because from the data in the literature at that
glass-ionomer cements i.e. fluoride release, and of resin-based time it seemed to be mandatory to etch enamel for durable
composites i.e. excellent esthetic and flexural properties.6-8 marginal integrity in enamel.14,15 Eventual advantages of
The literature supports that compomers are much more compomers regarding the compatibility with recent all-in-one
related to resin composites than to glass-ionomer cements.9 adhesives were not known when the present study started.16
Altogether they are considered as hydrophilic resin compo- For clinical assessment, the United States Public Health
sites and therefore called polyacid-modified resin compo- Service (USPHS) investigation system was used (Table 1).17-19
sites.8,9 Regarding fluoride release, the amount of fluoride was In comparison to in vitro studies with repeated extensive
clinically negligible when a bonding agent was used.8 margin analyses, microscopic evaluations of the tooth-resto-
ration interface in vivo are very seldom reported in the litera-
Compomers have inferior overall properties compared to ture, commonly limited to the evaluation of tooth-colored inlay
conventional resin composites.7 Nevertheless, the easy systems.20
handling protocol of characteristically simplified adhesives Like in a previous study dealing with resin composites,
and at least initially good esthetic performance made these replicas were analyzed regarding marginal quality under a
materials very popular for the general dentist and sales light microscope to elucidate the bonding and wear per-
numbers confirm this. formance over time.21 This particular tool was intended to act
The predictability of in vitro studies is often limited, as additional aid to investigate the marginal areas subjected to
therefore controlled prospective clinical studies are necessary degradation and gap formation over the period of 4 years of
for a definitive assessment of dental materials.1-5 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 involving five appointments: The baseline investigation, 6-, 12-,
24-, and 48-month recalls.
Patient selection - Patients were selected for this study
Seventy one cavities in 30 patients (8 male, 22 female; aged
according to the following criteria:
18-60 years, average 32 years) were restored with polyacid-
; Absence of pain relating to the restored tooth; modified resin composite materials during the period of Feb-
; No pathologic periodontal or pulpal diagnosis; ruary through November 1998 (restorations with one surface:
; No cusp reconstruction required; and n=21; two surfaces: n=41; three surfaces: n=9). Seventeen of
; No known allergic reaction against any components of the the restorations were located in maxillary molars (~24%), 28 in
used materials. maxillary bicuspids (~39%), 12 in mandibular molars (~17%),
and 12 restorations were placed in mandibular premolars (~17
The patients were treated in the Department of Operative %). Local anesthesia (Ultracain DSa) was applied in all cases.
Dentistry and Periodontology, University of Erlangen- Thirty eight restorations were placed using Hytac bonded
Nuremberg (n=17) and in a private practice (n=13) by two with OSB.b Thirty-three restorations were made of Dyract AP
different clinicians having experience with direct posterior bonded with Prime&Bond 2.1.c
adhesive restorations. All treatment steps from the preparation to the polish were
Patients were required to sign a consent form indicating that performed by use of magnifying glasses providing 2.3-fold
the adhesive system and the dental restorative were recently magnification.d
developed and that no long-term experience was available at
baseline of the investigation. The clinical study was conducted Preparation - The cavities were prepared under pre-wedging
according to EN 540 (clinical investigation of medical devices with wooden wedges (Sycamore interdental wedgese) accord-
for human subjects according to the European Committee for ing to minimally invasive preparation rules, therefore pre-
Standardization). The patients agreed to a 4-year recall system ventive extension was avoided. The margins were not beveled
American Journal of Dentistry, Vol. 19, No. 1, February, 2006
Compomers after 4 years 63

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. Fig. 2. Gap formation at the margin of a Dyract AP restoration. SEM image,
final magnification 25x. CR: Compomer restoration. T: Tooth. Indicator:
(80 m diamond burf), and finished with a 25 m finishing Marginal gap formation.
diamond. Inner angles of the cavities were rounded. The
prepared teeth were additionally cleaned with pumice slurry. Clinical evaluation - At baseline, and after 6, 12, 24, and 48
All cavities were recorded photographically (camera: Nikon months, all restorations were clinically assessed according to
Medical 200,g color film: Agfachrome RSX 50 Professionalh).19 the modified USPHS criteria (Tables 1-3) by two independent
investigators not having placed the restorations. Evaluation
OSB treatment - The cavities were isolated with cotton rolls and tools were mirrors, probes, magnifying glasses, and intraoral
encircled with transparent matrix bande and enamel margins photographs. In the case of disagreement, a consensus was
were selectively etched for 30 seconds using orthophosphoric obtained between the examiners.19
acid (MiniTip etching gelb). The acid gel was rinsed off with In each recall appointment, color photographs of the resto-
air-water spray for 30 seconds and the cavities were dried until rations were taken with and without marked contact points.
the etch pattern of the enamel margins appeared. OSB was
applied with a mini-brush for 20 seconds. Margin analysis - At baseline, and after 6, 12, 24, and 48
The self-priming adhesive was dried to evaporate excess months, polyvinyl siloxane (Permagumb) impressions were
solvent and consequently light-cured for 20 seconds (Trilight taken of 40 restorations after thorough drying and cleaning.
curing unit,b standard mode). After polymerization, OSB was Replicas were made using an epoxy resin material (Epoxy-
applied again, immediately dried and light-cured for another 20 Dien). These restorations were observed over the whole
seconds. investigation period of 48 months. The replicas were
investigated under a light microscope (assessed at 130-fold
Prime and Bond 2.1 treatment - After isolation, the cavities magnification under a stereo light microscope (SV 11d) in
were etched, rinsed and dried like in the OSB groups. Prime & combination with a 3 CCD color camerao and a frame
Bond 2.1 was applied with a brush, left undisturbed for 30 grabber.p For digitization, the KS 100 software,d and for the
seconds and was subsequently dried, immediately air-thinned, margin analysis the software WinMes 2.0 was used. A semi-
and light-cured for 20 seconds. quantitative analysis of the margins using the criteria gap-
Compomer restoration - The corresponding polyacid-modi- free margin, marginal irregularity, gap, overhang, and
fied resin composite materials were layered incrementally in artifact was performed at x130 magnification.21 The criteria
layers of a maximum 2 mm thickness. Each layer was light- were calculated as percentage of the observed margin quality
cured for 40 seconds. After light-curing of the final increment, related to the entire length of the particular margin. Only the
the restoration surface was examined for defects like voids or accessible areas of the margins were analyzed, i.e. the
negative steps and corrected if necessary. Visible overhangs investigation of proximal-cervical margin areas was not
were removed with a scaler (A8 S204Si). Contacts in centric possible at all.
and eccentric occlusion were controlled with color foils, and Specimens exhibiting characteristic findings were
adjusted with diamond finishing burs, followed by flexible additionally sputter-coated with goldq and examined under a
discs (SofLex Pop-onj). Occlusal overhangs were removed SEM (Leitz ISI 50r) at different magnifications to illustrate
and polished in the same manner; proximal excess was the findings (Figs. 1,2).
reduced with interdental diamond polishing stripsk in Statistical evaluation - The statistical analysis was computed
descending grid sizes. with SPSS 10.0.s A statistical unit was one compomer resto-
Proximal contacts were evaluated using waxed dental floss ration, and differences in clinical performance were evaluated
and contact gauges (YS Contact Gaugel). Finally, the restored pairwise with Friedman and Wilcoxon tests. Differences
teeth were covered with a fluoride gel (Duraphatm). between materials were investigated using the Mann-Whitney
American Journal of Dentistry, Vol. 19, No. 1, February, 2006
64 Krmer et al

Table 4. Results of the light microscopic margin analysis.


_______________________________________________________________________________________________________________________________________________________________________________________________________________

Baseline (n=40) 6 Months (n=40) 12 Months (n=40) 24 Months (n=40) 48 Months (n=40)
Length (m) 11.7 x 103 11.6 x 103 11.5 x 103 12.9 x 103 12.0 x 103
Criterion Percentage of entire evaluable margin length (SD)
_______________________________________________________________________________________________________________________________________________________________________________________________________________

Perfect margin 62.6 (20.5) 74.5 (18.2) 80.0 (13.9) 53.9 (24.0) 59.1 (26.5)
Negative step formation 3.1 (4.8) 6.4 (8.4) 8.3 (8.6) 32.6 (25.4) 29.8 (24.8)
Gap formation 3.6 (1.4) 1.5 (3.4) 1.3 (3.2) 2.9 (7.6) 6.4 (17.1)
Overhang 24.3 (19.8) 12.7 (16.1) 6.9 (9.0) 2.5 (1.5) 8.0 (4.1)
Positive step formation 6.4 (2.2) 1.7 (4.9) 1.2 (3.9) 6.2 (14.5) 4.3 (8.5)
Artifact 8.9 (9.9) 3.1 (4.6) 2.3 (3.1) 1.4 (5.6) 6.6 (4.0)
_______________________________________________________________________________________________________________________________________________________________________________________________________________

U-test. Accordingly, occlusal contacts partially diminished over time


Any failures during the clinical study were counted as also from 2% (n=1) after 2 years to 68% Bravo (n=32) and
failures in all subsequent recalls. For the case that the criterion 6% Charlie (n=3) after 4 years.
Charlie or Delta was used in any recall, this particular
Margin analysis - The results of the light microscopic margin
restoration was counted as a failure within the survival
analysis are displayed in Table 4.
analysis. To assess the survival statistics of the materials, the
Both materials revealed no statistically significant
logarithm according to Kaplan-Meier was computed and
difference in any criterion (P> 0.05; Mann-Whitney U-test).
tested for equality of survival distributions using the
The margin analysis of the baseline replicas resulted in 24%
nonparametric logrank test ( = 5%).
marginal overhangs, significantly decreasing to 8% after 4
Results years (Friedman-test, P< 0.05). Due to the reduced length of
marginal overhangs, perfect margins significantly increased
Survival analysis - Eight patients representing 17 restorations from baseline (63%) to the 1-year evaluation (80%)
missed the 4-year recall (drop-out). (Friedman test, P< 0.05). The following decrease (after 2
After 4 years of clinical service, 14 restorations (Hytac: years) of gap-free margins is caused by a significant increase
n=11, Dyract AP: n=3) had to be replaced due to cusp or ridge of the criterion positive step formation (6% to 4%) and
fracture (n=4), gap formation (n=5), bulk fracture (n=2), loss above all for the criterion negative step formation (33% to
of occlusal contact (n=2), and loss of proximal contact (n=1). 30%; Friedman test, P< 0.05). Gap formation persisted at 1%
Forty restorations were still in function after 4 years (overall to 6% over the whole observation period (Friedman test; P>
failure rate: 13%; Hytac: 21%; Dyract: 9%; survival analysis 0.05; Table 4).
algorithm according to Kaplan/Meier, Fig. 3). The mean
survival time was significantly different between the materials Discussion
under investigation (Hytac: 4.23 years; 95% confidence
It was actually never proven that compomers reveal
interval 3.68-4.78 years; Dyract AP: 4.74 years; 95%
significant advantages when compared to resin-based compo-
confidence interval 4.44-5.03 years; Log rank test, P< 0.05).
sites.6,7 Nevertheless, facing the sales facts, this particular group
Clinical evaluation - The clinically observed results of Hytac of materials is definitely an important part of the worlds dental
and Dyract AP are displayed in Tables 2-4. Comparing the treatment concept and therefore it is mandatory to evaluate the
materials, no statistical differences were evident except for the potential under real clinical circumstances.
criteria surface roughness (from the 6 months recall) and Primarily, compomers are marketed with either all-in-one
anatomical shape (after 4 years) (Mann-Whitney U-test; P< adhesives e.g. Prompt L-Popb or with additional conditioning
0.05) with Hytac exhibiting inferior results. According to the aids like NRC (non rinse conditionerc). All attempts (and
criterion surface roughness, after 4 years Dyract AP marketing concepts) for pre-treatment of tooth hard tissues have
received 100% Alpha ratings whereas Hytac was judged with in common that etching with phosphoric acid should be
31%. Similar observations were evident for anatomical avoided to simplify the application protocol.14 From a
shape. The rating Alpha was given to 67% of Dyract AP micromechanical point of view, this is definitely questionable,
restorations, but only for 35% of the Hytac restorations. but the success on the market is different.
Evaluating the change within single criteria over time, In contrast, the present study was conducted with
only proximal contacts remained stable (P> 0.05; Friedman phosphoric acid etching of enamel margins due to two main
test), all other criteria deteriorated, above all between the 2- reasons. The authors did not believe that the former adhesives
and 4-year recalls. For both materials, several negative OSB and Prime&Bond 2.1 were able to prevent gap formation
changes were observed. The main reasons for a significant in enamel over time. Reports in the literature unanimously
performance loss regarding marginal quality were increasing exhibited far higher enamel bond strengths when enamel was
crevice (43%) and marginal gap formation (21%). Two etched prior to the application of these adhesives.14,15
patients suffered complaints at the recalls, probably caused by Furthermore, when enamel etching is carried out, flexural
severe gap formation and leakage. properties as well as wear resistance of the compomer materials
A common observation for both materials was a certain is more critical during overall evaluation of the clinical
deterioration for the criterion restoration integrity. After 2 performance over time. In this way, it was possible to actually
years, only 2% (n=1) of the restorations revealed visible wear. investigate the restorative material and not primarily whether
In contrast, after 4 years already 53% (n=25) of the the adhesive is capable of compensating for the materials
restorations showed wear which led to a Bravo rating. 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
American Journal of Dentistry, Vol. 19, No. 1, February, 2006
66 Krmer et al

Operative Dentistry and Periodontology, University of Erlangen-Nuremberg, 12. Gross LC, Griffen AL, Casamassimo PS. Compomers as Class II
Erlangen, Germany; Dr. Garca-Godoy is Professor and Associate Dean for restorations in primary molars. Pediatr Dent 2001;3:24-27.
Research, College of Dental Medicine, Nova Southeastern University, Fort 13. Cehreli ZC, Altay N. Three-year clinical evaluation of a polyacid-modified
Lauderdale, Florida, USA; Dr. Reinelt is in private practice in Nuremberg, resin composite in minimally invasive occlusal cavities. J Dent
Germany. 2000;28:117-122.
14. Rosa BT, Perdigo J. Bond strengths of nonrinsing adhesives. Quintessence
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