Amal et al.

Int Chin J Dent 2005; 5: 43-46.

Three-year clinical evaluation of posterior inlay restorations madeof three different composite materials
Amal Abd El-Samad Sakrana, DDS, PhD,a Hiroyasu Koizumi, DDS, PhD,b Hideo
Matsumura, DDS, PhD,b Naomi Tanoue, DDS, PhD,c and Ossama Badie Abouelatta,BSc, MSc, PhDda

Department of Crown and Bridge Prosthodontics, Mansoura University Faculty of Dentistry, Mansoura,bEgypt, Department of Crown and Bridge Prosthodontics, Nihon University School of Dentistry, Tokyo,cJapan, Department of General Dentistry, Nagasaki University Hospital of Medicine and Dentistry,dNagasaki, Japan, and Department of Production Engineering and Mechanical Design, Mansoura
University Faculty of Engineering, Mansoura, Egypt.
Purpose: The purpose of this study was to evaluate clinical performance of posterior inlay restorations made ofdifferent three composite materials.
Materials and Methods: A total of 156 posterior cavities were restored with inlay restorations made of different
brands of composite (Filtek Supreme, Z250, and Pertac II, n=52 each). These teeth were restored according tothe universal methodology of inlay restorations. Surface texture, anatomic form, marginal integrity,discoloration, occlusion, and pulp sensitivity were evaluated on the basis of the modified United States Public
Health Service (USPHS) criteria immediately after insertion and after three years. The data were analyzed by
Kruskal-Wallis test.
Results: Restorations made of the Filtek Supreme composite overall exhibited better clinical performance thanthose made of the other two composites especially after 3-year service period.
Conclusion: It can be concluded that the Filtek Supreme nanocomposite is clinically improved and reliablematerial for use as indirect composite restoratives. (Int Chin J Dent 2005; 5: 43-46.)
Key Words: hybrid composite, indirect composite, nanocomposite.

Introduction
Esthetic alternatives to amalgam filling and cast gold inlays include direct composite restoratives, composite
and ceramic inlays.

Composite materials are being widely used for both direct and indirect restorations,although there is a room for improvement in material properties.1,2 Indirect composite restorative systems weredeveloped to overcome problems associated with direct composite systems.
Composite restorative materials are categorized according to their filler size and loading. Traditionally,composites have been classified as; macrofilled composites with high inorganic filler loading up to about 86
wt% and 1-70 µm particles sizes; microfilled composites including 0.04 µm grain sized colloidal silica
incorporated into the prepolymerized filler particles; and hybrid composites consist of both macro- andmicrofillers with total inorganic filler loading of 80 wt%.3 Improvement in properties of composite is essential
to reduce complications associated with their application in the oral cavity. Nanotechnology was applied
recently for the production of new material categorized as nanocomposite restorative material. The difference
between nanocomposite and conventional composite is the presence of nanofillers and nanoclusters to improve
the loading of filler particles, wear resistance, strength, polishing, and other properties. This study clinicallyevaluated posterior inlay restorations made of nanocomposite and two hybrid composite materials.

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Int Chin J Dent 2005; 5: 43-46.

Materials and Methods
Three composites were selected as indirect restorative materials; the Filtek Supreme nanocomposite (3MESPE Dental Products AG, Seefeld, Germany), the Filtek Z250 composite (3M Dental Products Division, St.
Paul, MN, USA), and Pertac II Aplitip composite (3M ESPE Dental Products AG). A total of 156 posterior
cavity preparations were restored with these composite inlay restorations (n=52 each). The inlay restorations
were placed in 62 premolar and 94 molar teeth. The 85 inlays were placed in mandibular teeth and 71 inmaxillary teeth.
All cavities were prepared under local anesthesia according to the common principles for adhesive inlays. Toachieve convergence angles between opposing walls from 10 to 12 degrees, 80 µm diamond burs were used forcavity preparations. These cavities were then finished with 25 µm slight taper grit diamond burs. Internal line
and point angles were rounded. The finishing lines of the cavities were completely prepared within enamel layer.
The margins of enamel were not beveled. The finish line was about 1 mm over the mucosal line to avoid thepossible gingival bleeding and fluids. After placement of rubber dam, the cavities were rinsed and air-dried. Acalcium hydroxide liner base (Alkaliner, 3M ESPE Dental Products AG) was placed onto deep dentinal surface.
A glass ionomer base (Ketac-Bond Aplicap, 3M ESPE Dental Products AG) was placed to eliminate undercutsof the cavities. An impression was made using acrylic tray and a polyether material (Impregum F, 3M ESPE
Dental Products AG). Temporary restorations were cemented with non-eugenol cement. Each inlay waslight-polymerized then post-cured for 10 minutes in light-curing unit (Degulux, Degussa Hüls, Frankfurt,Germany) to reduce polymerization shrinkage and to improve their physical properties.

At the second

appointment, the temporary filling was removed and the prepared tooth was cleaned with rubber cup and pumiceslurry. The cavities were isolated with a rubber dam. The anatomic form, marginal fit, and color match wereassessed at try-in. The adhesive surfaces of the inlays were etched for 15 s with 5% hydrofluoric acid (Ceramics
Etch, Vita, Bad Säckingen, Germany), rinsed with water, and air-dried.

A silane primer (Monobond S,Ivoclar-Vivadent, Schaan, Liechtenstein) was applied to etched surfaces of the restorations. All enamel anddentin surfaces were etched with 37% phosphoric acid for 20-30 s, washed under a constant jet of water for 20 sand dried with compressed air. The preparations were coated with an enamel-bonding agent (Mirage bonding
agent, Chamelon Dental Products, Kansas City, KS, USA), which was not light-cured. The dual-activated luting
composite (SonoCem, 3M ESPE Dental Products AG) was applied to the restoration and preparation with adisposable brush or application syringe. The composite cement was light-polymerized for 60 s from each of theocclusal, buccal and lingual aspects. Occlusion and articulation were corrected carefully after placement. Theinlays were finished with 40 µm and 15 µm diamond burs, polishing disks and strips (Sof-lex, 3M ESPE Dental
Products AG), and a composite polishing kit (Enhance, Dentsply, Milford, DE, USA).
Each restoration was checked by two experienced examiners separately.

The restorations were assessed

immediate after insertion (baseline) and yearly up to three years using modified United States Public HealthServices (USPHS) criteria for direct evaluation. The data were statistically analyzed with Kruskal-Wallis test.
Interexaminer reliability was determined by calculating Cohen’s kappa value, which measures agreement
between the evaluations of two raters when both are rating the same object.

Results
One hundred fifty inlays were evaluated for 3-year recall. Six restorations were excluded from the study; one44

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Int Chin J Dent 2005; 5: 43-46.

case was extracted for periodontal reason and the other five restorations could not participate at the 3-year recalls.
Determination of the interexaminar reliability kappa values showed above 0.65 for all criteria.
Table 1.

Clinical performance of inlay restorations made of different three composite materials.

Criterion

Material

Baseline (%)
Alfa
Bravo

After three years (%)
Alfa
Bravo Charlie Delta

Surface texture

Supreme
Z250
Pertac II8684
8014162082
70
68

1830
32

Anatomic form

Supreme
Z250
Pertac II7062
62

30
38
38

66
40
34346064

Supreme
Z250
Pertac II848284

16
1816745052244440Marginal discoloration

Supreme
Z250
Pertac II100100100

686264323836Occlusion

Supreme
Z250
Pertac II888690806244203252

Supreme
Z250
Pertac II100
100
100

92888661214

Marginal integrity

Pulp sensitivity

Table 2.

1214
102268642

Summary of failure.

Service period

ToothCavity

Material

Reason of failure

10 months
15 months
17 months
25 months
26 months
30 months
33 months
34 months

Right maxillary first molar
Right maxillary second molar
Left maxillary second premolar
Left mandibular first molar
Right maxillary second premolar
Left maxillary second molar
Left maxillary first molar
Left mandibular second molar

MODMODODMOMODOBMODMOD

Pertac IIZ250
Pertac IIPertac IIZ250
Pertac IISupremeZ250

Secondary dental caries
Secondary dental caries
Inlay fracture
Secondary dental caries
Loss of pulp vitality
Inlay fracture
Secondary dental caries
Secondary dental caries

Results of the clinical evaluation comparing composite inlays at baseline and 3-year follow-up are presented
in Tables 1 and 2. Kruskal-Wallis test revealed the significant difference between alfa-bravo rating among theinlays in the criteria of surface texture (p=0.0039). Restorations made of the Filtek Supreme material exhibited
significantly smoother surface texture (82% alfa) than those made of the Filtek Z250 (70% alfa) and Pertac II(68% alfa) materials. Assessment of the criterion of anatomic form presented significantly better results for theFiltek Supreme material than for the Z250 and Pertac II materials at 3-year recall. Many bravo results for Z250(60%) and Pertac II (64%) were scored (p=0.1006).
A statistically significant better marginal integrity was found at 3-year recall for the Filtek Supreme inlays.
The parameters exhibited 24% bravo and 2% charlie scores for the Supreme inlays, 44% bravo and 6% delta for
Z250; and 40% bravo and 8% delta for Pertac II (p=0.0065).

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Int Chin J Dent 2005; 5: 43-46.

The Filtek Supreme inlays were significantly better for the parameter occlusion than other inlays (p=0.0058).
Of the 150 restorations, eight inlays were judged as unacceptable; five inlays due to marginal opening withsecondary caries, two inlays due to fracture, and one inlay due to loss of pulp vitality. Normal sensitivity could
be detected for all teeth after 3-year recall except for slight post-operative sensitivity to masticatory forces in thedeep cavities during the first year. One premolar restored with the Z250 inlay required endodontic treatment
after 26 months because of loss of pulp vitality.

Discussion
The 4-step USPHS rating system is designed to reflect absolute differences between the acceptable andunacceptable categories. Specifically, restorations scored with alfa and bravo are clinically acceptable whilecharlie and delta scores are unacceptable.4
At the baseline, surface texture among inlays seemed to be similar because the polishing technique employed
was identical. Proper finishing and polishing of composite restorations are important steps that enhance bothaesthetics and longevity of restored teeth. Absolute smooth composite surface, however, cannot be achieved by
the currently established polishing systems.

Surface roughness may enhance plaque accumulation andantagonist wear rate. On 3-year recall, the result of surface texture exhibited a significantly smoother surface
texture of the Supreme material compared with those of the Z250 and Pertac II material. This is probably
attributed to nanometer (10-9 m)-size of the inorganic filler incorporated into the Supreme material.
Results of evaluation of anatomic form, marginal integrity, and occlusion suggest that the Supreme material ismore resistant to wear and fracture than the two materials. Improved filler loading of nanofiller through the useof the cluster may contribute to improved properties of the composite material. Also, reduced discoloration of
the Supreme material indicates improved conversion of matrix monomer contained in the composite component.
On the basis of the results of 3-year clinical evaluation, it can be concluded that the Filtek Supreme
nanocomposite is more clinically reliable indirect composite material than the two conventional composite.
Further evaluation should be continued for long-term success of composite inlay restorative systems.
Acknowledgment
This work was supported in part by a Grant-in-Aid for Young Scientists (B) 16791210 (2005) from the MEXT-Japan.

References
1. Anusavice KJ. Criteria for selection of restorative materials: properties versus technique sensitivity. In: Anusavice KJ, Ed.
Quality evaluation of dental restorations: criteria for placement and replacement. Chicago: Quintessence; 1989. p. 15-59.
2. Freilich MA, Goldberg AJ, Gilpatrick RO. Simonsen RJ. Direct and indirect evaluation of posterior composite restorations atthree years. Dent Mater 1992; 8: 60-4.
3. Mjor IA, Pakhomov GN. Dental amalgam and alternative direct restorative materials. Oral Health Division ofNoncommunicable Diseases World Health Organization: Geneva; 1997. p. 17.
4. Ryge G, Cvar JF. Criteria for the clinical evaluation of dental restorative materials. US Dental Health Center, San Francisco:
US Government Printing Office; 1971. Publication No. 7902244.

Reprint request to:
Dr. Amal Abd El-Samad Sakrana
Department of Crown and Bridge Prosthodontics, Mansoura University, Faculty of Dentistry
Mansoura 35516, Egypt
FAX: 2050-2216099, E-mail: shalsakran123@yahoo.com
Received April 24, 2004. Revised May 10, 2005. Accepted June 8, 2005.
Copyright ©2005 by the Editorial Council of the International Chinese Journal of Dentistry.

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