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1.
VOLUME 36 •
NUMBER 5 • MAY 2005 365 QUINTESSENCE INTERNATIONAL The treatment of posterior teeth with resin composites has become a routine procedure in dental practices. This procedure is accepted as an esthetic and minimally inva- sive restorative concept, as well as a substi- tute for amalgam.1 However, use of the resin composites can present some difficulties. The limited longevity of posterior composite resins relates not only to the lack of a durable material, but also to other factors, such as postoperative sensitivity, difficulty in achieving proximal contacts, marginal leakage, and recurrent caries. However, attention to materi- als used, selection of teeth to be restored, and clinical application techniques can overcome most of these problems.2 Many clinical investigations confirmed that the adhesive technique in posterior teeth3,4 provides acceptable performance, although these materials are very technique- sensitive5 and cannot completely prevent leakage at cervical margins.6 As nonshrinking resin-composites are not available on the mar- ket yet, other efforts have been made to ease Clinical performance of a packable resin composite for a period of 3 years L. S¸ebnem Türkün, DDS, PhD1 /Murat Türkün, DDS, PhD2 / Ferit Özata, DDS, PhD2 Objective: The purpose of this clinical study was to evaluate SureFil packable resin com- posite for posterior restoration of permanent teeth for a period of 3 years. Method and materials: Fifty-five resin composite restorations were placed in 36 patients (16 Class I and 39 Class II restorations). After cavity preparation, the enamel was etched with 34% phosphoric acid. Prime & Bond NT was applied 20 seconds to dentin and etched enamel and cured for 20 seconds. The teeth were restored in 3- to 5-mm incre- ments. The restorations were assessed after placement, at 6 months, 1 year, 2 years, and 3 years for color stability, marginal discoloration, marginal adaptation, secondary caries, surface texture, anatomic form, and postoperative sensitivity according to Ryge’s criteria. The changes in the parameters were assessed with Friedman test analysis with a Bonferroni correction at a significance level of .05. Results: Forty of the monitored 47 restorations were classified as excellent after 3 years. Thirty-one restorations were graded Bravo at baseline for color match. At the 3-year assessment (n = 47) the color of the 31 restorations had not changed. Two restorations (same patient) were lost after 1 month and were scored as Charlie until the end of the study. After 3 years there were five Bravos and one Charlie with marginal discoloration, five Bravos with marginal adaptation, and three Bravos with anatomic form (P < .05). Conclusion: After 3 years of clinical service, SureFil packable resin composite, with a failure rate of 6%, was considered to be successful in Class I and II restorations. (Quintessence Int 2005;36:365–372) Key words: clinical performance, packable resin composite, Ryge’s criteria 1 Associate Professor, Ege University, School of Dentistry, Department of Restorative Dentistry and Endodontics, Izmir, Turkey. 2 Professor, Ege University, School of Dentistry, Department of Restorative Dentistry and Endodontics, Izmir, Turkey. Reprint requests: Dr L. S¸ebnem Türkün, Ege University School of Dentistry, Department of Restorative Dentistry and Endodontics, 35100 Izmir, Turkey. E-mail: sebnemturkun@ hotmail.com COPYRIGHT © 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
2.
366 VOLUME 36
• NUMBER 5 • MAY 2005 QUINTESSENCE INTERNATIONAL Türkün et al the handling of resin-based composites by means of packable restorative materials.7,8 Some claim that packable composites, which have less technique-sensitive application pro- cedures, are easier to place and adapt better in posterior cavities, especially for dentists not highly experienced in posterior restorations. This hypothetical advantage of packability is often seen in addition to a lower adhesive- ness of the restorative material.9–11 As these materials do not slump, the entire occlusal/ proximal increment of the restorations can be placed and sculpted to the final anatomy at once. This procedure reduces the amount of final adjusting and finishing. The higher viscosity of packable resin composites is mostly achieved by increasing the volume of filler particles, varying the size and type of the particles, alternating the chemistry of the resin matrix, or a combina- tion of any of the above.9–11 The packability of the restorative material SureFil (Dentsply, DeTrey), introduced to the market in 1998, was due to a wide range of irregularly-shaped and different-sized filler particles which, according to the manufactur- er, produce an “interlocking” effect between the larger and smaller particles.12 According to Combe and Burke,13 this is possibly achieved because of the large variation in particle sizes (0.04 to 10.0 µm), with the larg- er particles preventing the flow of smaller par- ticles. This coupling of filler and resin tech- nologies endows SureFil with the posterior composite attributes of packability, carvabili- ty, nonslumping, and polishability. Manufacturers claim that, for the most part, because of their high density, packable resins result in less volumetric shrinkage than standard restorative resins.12 These properties, combined with a greater depth of cure (up to 5 mm for some materials, accord- ing to the manufacturers12), enable the clini- cian to often place and sculpt the entire dentin replacement in one increment. Accor- ding to the technical protocol of the manu- facturer, the material exhibits a lower modu- lus of elasticity than comparable hybrid resin- based composites, which is due to the mod- ified filler structure in contrast to higher filler content in other packable composites. The claims that packable composites solve many of the clinical problems associat- ed with current resin-based composites used in posterior restorations are attractive.7-9 Only long-term clinical data, however, will indicate whether the different handling characteristics of condensable materials can be used suc- cessfully in an oral situation. Clinical studies to test these properties with packable resin composites were not yet longitudinal14–18 because these materials were introduced to the market as late as 1997. The aim of this study was to determine the clinical performance of SureFil packable resin-based composite in posterior restora- tions for a period of 3 years. METHOD AND MATERIALS In this clinical study, 55 resin composite restorations were placed in 36 patients (22 females and 14 males with an average age of 39.4 years). Written patient consent was obtained at the start of the project and the Human Ethical Research Committee of Ege University (Izmir, Turkey) approved the proto- col. All patients received no more than two restorations; 71% were Class II (39 restora- tions) and 29% were Class I (16 restorations). Thirty-two restorations were placed in the maxilla and 23 in the mandible. Thirty-four molars and 21 premolars were restored with the packable resin composite SureFil. The properties of this material are shown in Table 1. The indications for placing the restorations were primary caries or replacement of exist- ing restorations. All the teeth were prepared, restored, and finished by the same operator (Dr LS¸T), who followed standard procedures and the manufacturers’ recommendations. Vitality test scores of the teeth were recorded before any preparations were done. Adhesive cavity design—no additional “extension for prevention,” no preparation of undercuts, round-shaped cavity walls, no beveling—was prepared and finished using diamond burs (80 and 30 µm) under constant water cooling (120,000 rpm) for previously unrestored teeth. COPYRIGHT © 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
3.
VOLUME 36 •
NUMBER 5 • MAY 2005 367 QUINTESSENCE INTERNATIONAL Türkün et al The existing restorations and caries were removed and the cavities were not modified. Nearly all cavities extended between one- quarter and no more than one-third of the way up one or more of the cuspal slopes. The proximal portion of the Class II cavities extended into the interproximal embrasures but the margins did not end below the cementoenamel junction. Forty-nine restora- tions can be qualified as small to moderate and six as large. Prewedging with an anatom- ically contoured interdental wedge (Hawe Neos Dental) was made before Class II cavity preparation. A rubber dam was only used in situations (n = 5, < 10% of total number of restorations) where contamination of the cav- ity with saliva, blood, or sulcus fluid could not be prevented by means of cotton rolls and suction, in lower molars. Following completion of preparation, hard- setting calcium hydroxide cement (Dycal, Dentsply, DeTrey) was placed over the deep- est dentin part of the cavity to provide appro- priate pulpal protection. The cavosurface mar- gins of enamel were then etched for 15 seconds and dentin for 20 seconds with 34% phosphoric acid gel, washed (15 sec- onds), and dried with oil-free air according to the manufacturers’ recommendations. A thin layer of unfilled resin (Prime & Bond NT, Dentsply, DeTrey) was immediately applied over the entire surface of the etched prepara- tion for 20 seconds, dried gently, and light- cured for 20 seconds. The light from the Luxor light-activating unit (ICI Dental) was tested prior to each placement to ensure an output in excess of 450 mW/cm2. A thin stainless-steel matrix band held in a Tofflemire retainer (Hawe Neos Dental) was adapted and firmly wedged to closely adapt the matrix to the gin- gival margin of the Class II preparations. The packable composite SureFil was placed in bulk of 3- to 5-mm depth in the proximal box of Class II preparations, as per the manufacturer’s recommendation, and in increments of < 3 mm on the other sides of the cavities, with each increment being cured for 40 seconds. SureFil was manufactured for use in accordance with the indications for amalgam posterior restorations with a metal matrix system, using a horizontal-layer tech- nique, mostly without the use of rubber dam. Contouring and immediate finishing of the restorations was done using water-cooled microfine diamond finishing burs (Intensiv Composhape, Intensiv) followed by abrasive aluminum oxide discs (3,000 to 6,000 rpm, Sof-Lex discs, 3M Dental Products). Proximal finishing and polishing were carried out using finishing strips (3M Dental Products). Articulating paper (Bausch) was used to identify appropriate occlusal morphology and contacts. Clinical evaluation The restorations were evaluated by two inde- pendent clinicians not involved in the original placement. The ratings were made with mir- ror and probe according to the method developed by Ryge and well-known as USPHS (United States Public Health Service) criteria.19 Evaluation parameters included: color-matching ability, marginal adaptation, anatomic form, cavosurface marginal discol- oration, secondary caries, surface texture, and postoperative sensitivity. For each of the criteria, Alpha was used to indicate the high- est degree of clinical acceptability, and Bravo, Charlie, and Delta were used to indi- cate progressively lessening degrees of clini- cal acceptability (Table 2). In cases where the two examiners dis- agreed on a rating, both re-examined the restoration and arrived at a consensus. The restorations were assessed immediately after insertion at baseline, at 6 months, at 1 Lot number 981116 Composite type Packable composite (high-density posterior composite) Resin type Urethane modified bis-GMA Filler type Barium fluoroalumino borosilicate glasses and fumed silica Filler particle size (µm) 0.04–10 (average: 0.8) Filler content (per weight ) 82% Modulus of elasticity (GPa) 11.440 Barcol hardness (kg/mm2) 103 Compressive strength (MPa) 331 bis-GMA = bisphenol glycidyl methacrylate. Table 1 Properties of SureFil packable resin composite12 COPYRIGHT © 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
4.
368 VOLUME 36
• NUMBER 5 • MAY 2005 QUINTESSENCE INTERNATIONAL Türkün et al year, at 2 years, and at 3 years. Bitewing radiographs for secondary caries detection were taken, vitality tests were recorded, and color photographs were taken (Agfa Chrome RSX 50, AGFA; Nikon F4 for medical Niccor 120 mm) at every recall. Alpha and Bravo scores for all the criteria, except secondary caries, mean “excellent” and “clinically acceptable” results, respec- tively. Scores of Charlie and Delta mean “clin- ically unacceptable.” Restorations that have been replaced during the 3-year period were regarded as having failed. The changes in the parameters during the 3-year period were assessed using SPSS software program (SPSS) with Friedman test analysis. The baseline scores were com- pared with those of the recalls, using Wilcoxon signed rank test with Bonferroni correction. The influence of the teeth and restoration type to the performance was test- ed with Fisher’s exact test. The significant level was set at .05. RESULTS At the 3-year follow-up examination, 47 of the 55 restorations were evaluated (85.4%). Patient dropout preliminarily caused missing restorations, whereas two restorations of the same patient had to be replaced after 1 month due to his bruxism habits. These failed Test Criteria procedure Score Color-matching Visually inspect A: The restoration matches the adjacent tooth in color and ability with mirror at 18 in. translucency B: Light mismatch in color, shade and/or translucency between the restoration and the adjacent tooth C: The mismatch in color and translucency is outside the acceptable range of tooth color and translucency Cavosurface margin Visually inspect A: No discoloration anywhere along the margin between the discoloration with mirror at 18 in. restoration and the adjacent tooth B: Slight discoloration along the margin between the restoration and the adjacent tooth C: The discoloration penetrated along the margin of the restorative material in a pulpal direction Marginal Visually inspect A: No visible evidence of crevice along the margin adaptation with explorer and B: Visible evidence of a crevice along the margin into which (occlusal and proximal) and mirror if needed the explorer will penetrate C: The dentin or the base is exposed D: The restoration is fractured, mobile or missed Secondary caries Visually inspect A: No evidence of caries with explorer and B: Evidence of caries along the margin of the restoration mirror if needed Surface texture Visually inspect A: The restoration surface is as smooth as the surrounding with explorer and enamel mirror if needed B: The restoration surface is more rough than the surrounding enamel C: There is crevice and fracture on the surface of the restoration Anatomic form Visually inspect with A: The restoration is continuous with existing anatomic form (occlusal and proximal) explorer and mirror B: The restoration is discontinuous with existing anatomic if needed form but the material is not sufficient to expose dentin or base C: Sufficient material lost to expose dentin or base Postoperative Ask the patients A: No postoperative sensitivity at any time of the restorative sensitivity process and during the study period B: Experience of sensitivity at any time of the restorative process and during the study period Table 2 Ryge’s direct (USPHS) evaluation criteria10 COPYRIGHT © 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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NUMBER 5 • MAY 2005 369 QUINTESSENCE INTERNATIONAL Türkün et al restorations were scored as Charlie and were included in the 47 rated restorations. The vitality of the restored teeth had not changed during the 3-year period. None of the patients complained about postoperative sensitivity during the study. According to the bitewing radiographs taken, there was no evi- dence of secondary caries in any of the restorations. After the 3-year recall period, surface texture was classified as excellent for all restorations (P > .05) (Table 3). Figures 1 and 2 show restorations classified as excel- lent after the 3-year period for all the USPHS criteria assessed. Relative to marginal adap- tation, five restorations showed evidence of a slight crevice along the marginal inter- face (Fig 3) after 3 years (10.6%) (P < .05). Five restorations had marginal discoloration with Bravo scores and one was rated as “clin- ically unacceptable” at the 3-year recall (Fig 4) (12.7%) (P < .05). Two proximal and one occlusal restorations were graded Bravo for anatomic form at the 1-year recall (P > .05) (Fig 5). The color match of 31 restorations (n = 55) was scored as Bravo at the baseline examinations. These criteria had not changed during the 3-year period for the monitored restorations (Figs 3 to 5). There was no statistically significant differ- ence between Class I and Class II restora- tions (P > .05). Similar results were obtained when the findings of premolar and molar restorations were compared (P > .05). Baseline 6 mo 1 y 2 y 3 y Color match A 24 23 23 22 20 B 31 30 30 28 27 C 0 0 0 0 0 Cavosurface margin discoloration A 55 53 52 45 41 B 0 0 1 5* 5* C 0 0 0 0 1 Secondary caries A 55 53 53 50 47 B 0 0 0 0 0 Surface texture A 55 53 53 50 47 B 0 0 0 0 0 C 0 0 0 0 0 Anatomic form (O) A 16 16 16 15 13 B 0 0 0 0 1 C 0 0 0 0 0 Anatomic form (P) A 39 37 34 32 29 B 0 0 1 1 2 C 0 2 2 2 2 Marginal adaptation (O) A 16 16 16 15 14 B 0 0 0 0 0 C 0 0 0 0 0 Marginal adaptation (P) A 39 37 34 30 26 B 0 0 1 3* 5* C 0 2 2 2 2 *P < .05. 0 = occlusal; P = proximal. Table 3 Summary of the clinical assessment findings and number of restorations COPYRIGHT © 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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• NUMBER 5 • MAY 2005 QUINTESSENCE INTERNATIONAL Türkün et al DISCUSSION Following in vitro tests (still widely employed for preclinic investigations), the clinical test is the final one for dental restorative material. The evaluation period for clinical investiga- tions on resin composites usually lasts from 1 to 3 years14–22 and the Ryge criteria19 have been used for most of the clinical studies. The score changes at 3 years were statis- tically significant. However, as Bravo-scored restorations are not considered to be clinical- ly unacceptable, we can affirm that SureFil packable resin composite did fulfill the ADA acceptance criteria for restorative materials, which is 95% acceptable restorations rates at the 2-year recall.23 The results of this clinical investigation were good regarding the total failure rate of 6%. Two adjacent restorations were missing and replaced with amalgam after 1 month of insertion. Due to the occlusion of the patient, the amalgam restorations fell out 1 week later. The depth and the design of the cavity had to be modified, and the two restorations had been scored as Charlie and considered as failed. The slight color change at the restoration margins is not associated with secondary caries. It may be due to the polymerization shrinkage of the 5-mm proximal composite increment, leading to leaking gaps colored due to the eating habits of the patients.13 The slight crevice along the marginal interface observed in five overextended Class II cavi- ties was probably a result of a fracture of overlapping fine-type marginal excess. This fracture formed a ledge that caught the Fig 1 (left) A Class II (occlusodistal) restoration of SureFil in the mandibular right second premolar at the 3-year recall appointment clinically rated as Alpha for all the USPHS criteria evaluated. Fig 2 (center) A successful Class II restoration (occlusodistal) on a first molar of the right maxilla at 3 years. Fig 3 (right) An occlusal restoration on the left second molar at 3 years.This restoration had marginal discoloration all around the cavity and a crevice on the mesial part.This was the only occlusal restoration scoring a Charlie for anatomic form. Fig 4 (left) A Class II restoration in the right mandibular second premolar.This restoration had unacceptable marginal discolorations after the 3-year period. Fig 5 (right) A large Class II (OM) restoration of SureFil with marginal adaptation problem in the right maxillary first molar teeth. COPYRIGHT © 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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NUMBER 5 • MAY 2005 371 QUINTESSENCE INTERNATIONAL Türkün et al explorer during the follow-up examination. The color match of 31 restorations was scored as Bravo at the baseline examination and remained stable for the controlled restorations during the 3-year period. This was due to the limited (only 3) color shade available of SureFil packable resin compos- ite. The restorations were predominantly lighter and more translucent than the adja- cent tooth structure. According to the manu- facturers, the shades were deliberately selected to be lighter than the corresponding Vita shades so that marginal areas could be visualized during placement. No correlation was investigated between the success rate and the use of rubber dam. The low number of restorations placed under rubber dam (n = 5) would not have provided a sufficient statistical base for an evaluation. As there is no study published that shows a better clinical survival rate of resin-composite restora- tions placed under rubber dam isolation in contrast to isolation with cotton rolls, there was no influence expected in this study.24 Long-term clinical studies involving pack- able resin-based composites are not pub- lished yet as these materials were introduced only 5 to 6 years ago. Perry and Kugel,14 Suzuki et al,25 and Türkün et al18 evaluated the clinical performance of SureFil. Perry and Kugel14 found six restorations scored Bravo for surface staining and no secondary caries after 2 years. Türkün et al18 observed five Bravo for marginal discoloration, three Bravo for marginal adaptation, and one Bravo for anatomic form after a period of 2 years. Suzuki et al’s25 study was the longest investi- gation with SureFil. In 1 year, they found that one restoration failed due to cusp fracture. At the 4-year recall, they found one recurrent decay and half of the restorations evaluated had Bravo scores for marginal adaptation. They associated the marginal discoloration observed to the smoking habits of some patients. They concluded that SureFil demonstrated excellent clinical acceptability comparable to that experienced with Spectrum TPH (Dentsply, DeTrey). All these investigators concluded that SureFil high- density composite material demonstrated good clinical performance and acceptability after a 2- to 4-year period. Ernst et al16 evaluated the clinical perform- ance of Solitaire packable resin composite (Heraeus Kulzer) over 3 years. At the end of the study, 79% of the restorations were per- forming at clinically acceptable levels. However, Solitaire failed the ADA criteria for acceptable resin restoratives for posterior restorations.23 Oberlander and coworkers17 evaluated the clinical performance of two packable composites, Definite (Degussa Dental) and Solitaire. After 1 year, both materials dis- played significant deterioration for marginal discoloration, approximal contact, and frac- ture. According to their results, Definite, with a failure rate of 9.6%, did not fulfil ADA acceptance criteria for restorative materials.23 Loguercio et al15 compared the clinical performance of four packable resin compos- ites (Solitaire; Alert, Jeneric Pentron; Filtek P60, 3M Dental; SureFil) with one hybrid composite (Spectrum TPH). After 1 year, they concluded that SureFil and Filtek P60 showed excellent clinical performance, scor- ing even better than the hybrid composite tested. The service life of dental restorative materials depends on a number of patient-, material-, and procedure-related factors.26,27 Patients and practitioners have a variety of options when choosing materials and proce- dures for restoring carious lesions. The choice of materials and procedures to restore form, appearance, and function to the dentition is an important health-care decision that is ultimately made by the patient after consultation with his or her dentist. Dentists should realize that placing a posterior com- posite requires approximately 2.5 times as much time as placing a similar amalgam28–30 and that there are no shortcuts with these materials—any compromise in the placement technique will have serious consequences for clinical performance. However, for reduc- ing the application time and obtaining a better contact point, and with careful case selection and meticulous attention to the restorative technique, packable resin com- posite SureFil can be used confidently for a period of 3 years in posterior Class I and II restorations. COPYRIGHT © 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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• NUMBER 5 • MAY 2005 QUINTESSENCE INTERNATIONAL Türkün et al CONCLUSION After 3 years of clinical service, SureFil pack- able resin composite, with a success rate of 94%, was considered to be successful in restoring carious lesions in posterior teeth. ACKNOWLEDGMENTS The authors of this study would like to thank Dr Timur Köse for the statistical analysis and Dr Atakan Kalender for his help on the photographs. REFERENCES 1. Christensen GJ. Amalgam vs composite resin. J Am Dent Assoc 1998;129:1757–1759. 2. Lacy AM. A critical look at posterior composite restorations. J Am Dent Assoc 1987;114:357–361. 3. Fukushima M, Nakamaha T, Ishizaki H, Okomoto A, Iwaku M. Three-year clinical study of resin compos- ites with different monomer types [abstract 2179]. J Dent Res 1996;75:290. 4. Geurtsen W, Schoeler U. A 4-year retrospective clin- ical study of Class I and Class II composite restora- tions. J Dent 1997;25:229–232. 5. Miyazaki M, Onose H, Moore K. Effect of operator variability on dentin bond strength of two-step bonding systems. Am J Dent 2000;13:101–104. 6. Da Cunha Mello FS, Feilzer AJ, DeGee AJ, Davidson CL. Sealing ability of eight resin bonding systems in a Class II restoration after mechanical fatiguing. Dent Mater 1997;13:372–376. 7. Jackson RD, Morgan M. The new posterior resins and a simplified placement technique. J Am Dent Assoc 2000;131:375–383. 8. Leinfelder KF, Bayne SC, Swift EJ Jr. Packable com- posites: Overview and technical considerations. J Esthet Dent 1999;11:234–249. 9. Freedman G. Condensable composites: The new paradigm in amalgam alternatives. Dent Today 1998;17(10):72–74. 10. Hoang A, Koh S, Bebermeyer R, Johnson C. A review of condensable composite. J Gt Houst Dent Soc 1999;71:15–17. 11. Leinfelder K, Prassad A. A new condensable com- posite for the restoration of posterior teeth. Dent Today 1998;17:112–116. 12. SureFil Product Profile 1998. Dentsply UK, Addlestone,Weybridge, United Kingdom. 13. Combe EC, Burke FJ. Contemporary resin-based composite materials for direct placement restora- tions: Packables, flowables and others. Dent Update 2000;27:326–336. 14. Perry RD, Kugel G. Two-year clinical evaluation of a high-density posterior restorative material. Compend Contin Educ Dent 2000;21(12):1067–1072. 15. Loguercio AD, Reis A, Rodrigues Filho LE, Busato AL. One-year clinical evaluation of posterior packable resin composite restorations. Oper Dent 2001;26(5): 427–434. 16. Ernst CP, Martin M, Stuff S, Willershausen B. Clinical performance of a packable resin composite for pos- terior teeth after 3 years. Clin Oral Invest 2001;5(3): 148–155. 17. Oberlander H, Hiller KA, Thonemann B, Schmalz G. Clinical evaluation of packable composite resins in Class II restorations. Clin Oral Investig 2001;5(2): 102–107. 18. Türkün LS¸, Türkün M, Özata F. 2-year clinical evalua- tion of a packable resin composite.J Am Dent Assoc 2003;134;1205–1212. 19. Ryge G, Snyder M. Evaluating the clinical quality of restorations. J Am Dent Assoc 1973;87:369–377. 20. Klinge S, Schmidt G, Frankenberger R, Pelka M. Clinical behavior of Solitaire: 1-year results [abstract 332]. J Dent Res 2000;79:185. 21. Türkün LS¸, Aktener BO. Twenty-four month clinical evaluation of different posterior composite resin materials. J Am Dent Assoc 2001;132:196–203. 22. Rasmusson CG, Kohler B, Odman P. A 3-year clinical evaluation of two composite resins in Class II cavi- ties. Acta Odontol Scand 1998;56:70–75. 23. American Dental Association Council on Scientific Affairs: ADA Council on Dental Benefit Programs. Statement on posterior composites. JADA 1998; 129:1627–1628. 24. Raskin A, Setcos JC, Vreven J, Wilson NHF. Influence of the isolation method on the 10-year clinical behaviour of posterior resin composite restora- tions. Clin Oral Invest 2000;4:148–152. 25. Suzuki M, Davidson D, Stockton L. Four-year clinical evaluation of a packable composite resin in posteri- or dentition [abstract 2362].J Dent Res 2003;82(Spec Issue B):306. 26. Burke FJT, Wilson NHF, Cheung SW, Mjör IA. Influence of patient factors on age of restorations at failure and reasons for their placement and replace- ment. J Dent 2001;29:317–324. 27. ADA Council on Scientific Affairs.Direct and indirect restorative materials. J Am Dent Assoc 2003;134: 463–471. 28. Leidal TI. Accomplishments and expectation with posterior composite resins. In: Vanherle G, Smith DC (eds). Posterior Composite Resin Dental Restorative Materials. 3M, St Paul: 1985:541–547. 29. Mjör IA. Long term cost of restorative therapy using different materials.Scand J Dent Res 1992;100:60–65. 30. Mjör IA. Clinical longevity of amalgams and com- posites. IADR-Symposium, direct restorative materi- al’s longevity in first, second, and third world coun- tries. Singapore, 30 June 1995. COPYRIGHT © 2005 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
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