journal of dentistry 35 (2007) 231237

available at www.sciencedirect.com

journal homepage: www.intl.elsevierhealth.com/journals/jden

Class II composite restorations with metallic and translucent

matrices: 2-year follow-up findings

Flavio Fernando Demarco a,*, Maximiliano Sergio Cenci b, Fabio Garcia Lima c,
Tiago Aurelio Donassollo c, Darvi de Almeida Andre d, Ferdinan Lus Leida d
a
Department of Operative Dentistry, School of Dentistry, Federal University of Pelotas, RS, Brazil
b
Graduate Program in Dentistry, Cariology Area, Faculty of Dentistry of Piracicaba, State University of Campinas, Piracicaba, SP, Brazil
c
Graduate Program in Dentistry, Operative Dentistry Area, School of Dentistry, Federal University of Pelotas, RS, Brazil
d
Undergraduate Students School of Dentistry, Federal University of Pelotas, RS, Brazil

article info abstract

Article history: Objective: The aim of this randomized, clinical study was to evaluate the performance of
Received 20 March 2006 composite restorations placed with two matrix and wedge systems after a 2-year follow-up.
Received in revised form Methods: Twenty-three patients were selected, and received at least two Class II restora-
25 July 2006 tions, one with metallic matrix and wooden wedge and other with polyester matrix and
Accepted 29 July 2006 reflective wedge. One dentist placed all the 109 restorations. All cavities were restored using
Single Bond and P-60 (3M ESPE), according to manufacturers instructions. In the metal
matrix group, polymerization was performed from occlusal, and in the polyester group,
Keywords: through the reflective wedge. Restorations were evaluated at baseline and after 12 and 24
Composite resin months by the modified USPHS criteria, and data were analyzed with MannWhitney and
Matrix systems Wilcoxon Signed Rank tests (a = 0.05).
Posterior restorations Results: Fifteen subjects and 78 restorations were re-evaluated after 24 months. A significant
Clinical trial decrease in the quality of cervical adaptation and proximal contacts by radiographic
evaluation was evidenced ( p < 0.05), but no differences between the two matrix systems
were detected ( p > 0.05). In the clinical evaluation there were no significant differences
between matrices after 2 years ( p > 0.05). A compromising of marginal adaptation, marginal
staining and proximal contacts aspects for both matrix systems was evidenced, and
restorations placed with translucent matrices showed loss of color stability ( p < 0.05).
Conclusions: Whereas restorations presented some clinical aspects somewhat compromised
after 2 years, the matrix and wedge systems evaluated showed similar clinical performance.
# 2006 Elsevier Ltd. All rights reserved.

1. Introduction preservation of sound dental structure and reinforcement of

Increased aesthetic concerns have conducted to the applica-
tion of tooth-colored materials in posterior teeth, replacing
metallic restorations. Besides esthetic properties, composite
resin restorations have additional advantages, such as the
the restored tooth, which are decurrently of the adhesive
capacity of these materials.1,2
However, some criticisms have arisen against the applica-
tion of composite resin in posterior teeth, especially in Class II
cavities. The inherent polymerization shrinkage could cause

* Corresponding author at: Departamento de Odontologia Restauradora, UFPel, Rua Goncalves Chaves, 457, 58 andar, CEP 96015 560, Pelotas,
RS, Brazil. Tel.: +55 5332224439; fax: +55 53 32255581.
E-mail addresses: fdemarco@ufpel.tche.br, flavio.demarco@pesquisador.cnpq.br (F.F. Demarco).
0300-5712/$ see front matter # 2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2006.07.011
232 journal of dentistry 35 (2007) 231237
the marginal adhesion breakdown at the cervical margin, and
therefore conduct to the restoration failure.3 It is noteworthy
that the main location of the secondary caries in composite
resin restorations is the cervical wall.4 Not only an improper
restorative technique could contribute to failure at the
adhesive interface, but also the negligent patient attitudes
regarding oral hygiene, leading to microbial biofilm accumu-
lation at cervical region.5,6 In several studies secondary caries
has been considered the most prevalent reason for restoration
replacement.46 In addition, the difficulty of adapting resin to
cervical walls, as well as the correct adjustment of proximal
contacts and cervical fit are other reported problems asso-
ciated to composite placement.7 In some instance, the
proximal contour in a direct restoration depends on the type
and shape of the matrix system employed.810
Various restorative techniques have been suggested aim-
ing to reduce the polymerization shrinkage stress at the
cervical interface in composite resin Class II restorations.
Among these methods are the use of translucent matrix bands
and reflective wedges.11 This technique was initially sup-
ported by the presumption that it would be possible to control
the directional shrinkage of resin-based composites.1214
However, the proximal contacts achievement could be more
difficult with this technique when compared to metallic
matrix use,9,10,15 and higher amounts of proximal excesses
could be expected.16 In addition, the belief that composite
resins shrinkage towards the light has been questioned.17
In previous studies, no significant differences were observed
in Class II composite restoration performance regardless of the
matrix system used at the baseline,18 and after 1-year follow-
up.19 Nevertheless, long time evaluations are mandatory, since
a significant increase in restorations failure rates are observed
with aging,1,6,20,21 and the oral cavity represents an extremely
adverse environment for restorative materials.22
The purpose of this randomized clinical trial was to
compare the performance of Class II composite restorations
placed with two matrix and wedge systems after 2 years,
according to the modified USPHS criteria. The null hypothesis
tested was that there is no influence of matrix systems on the
clinical performance of posterior composite restorations.
2. Materials and methods
2.1. Experimental design
This study involved a randomized, double-blinded, prospec-
tive clinical trial design, where each patient received restora-
tions with the two experimental conditions under evaluation.
Ethical approval was obtained from the Research and Ethics
Committee of Federal University of Pelotas. Twenty-three
patients were selected from the clinics of the Federal
University of Pelotas Dental SchoolPelotas, RS, Brazil, and
were free to withdraw from the trial, without justification, at
any stage of the evaluation. Each patient received at least two
restorations, one with metallic matrix and wooden wedge and
another with polyester matrix and reflective wedge. One
operator (MSC) placed all restorations with the same adhesive
system (Single Bond3M ESPE, St. Paul, MN, USA) and
composite resin (Filtek P-60, 3M ESPE). Restorations were
evaluated by bitewing radiographies and modified USPHS
codes and criteria at baseline, 12 months and 2 years by two
calibrated examiners.
2.2. Clinical procedures
Experimental design was conducted as previously described,18
and clinical procedures are briefly presented here. All
restorations were placed using rubber dam isolation, and
the cavities were prepared with conservative design, restricted
to the carious tissue or old restorations removal. In very deep
cavities, a closed sandwich technique was used, and a calcium
hydroxide cement (Hydro C, Dentsply, Petropolis, RJ, Brazil)
plus a glass-ionomer cement (Vitrebond, 3M ESPE) were
applied. Each patient received at least two restorations, one
with metallic matrix (Sectional Retainer System, 3M ESPE) and
wooden wedge (TDV, Pomerode, SC, Brazil) and another with
polyester matrix and reflective wedge (Light Curing System,
TDV, Pomerode). A light curing unit XL 3000 (3M ESPE), was
used during the study.
After application of the matrix, the cavity walls were
etched with 35% phosphoric acid for 30 s in enamel and 15 s in
dentine, washed for 30 s, and water excess was removed with
an endodontic suction cannula for 5 s. Two consecutive layers
of Single Bond were applied in cavity walls with a microbrush
applicator, excess was removed with a new applicator, and the
product was gently air-dried for 5 s and light-cured from
occlusal for 20 s. Composite increments insertion (less than
2 mm thickness) were the same in both groups (Fig. 1), with
different light-curing techniques: in the metallic matrix and
wooden wedge group, each composite increment was light-
cured from occlusal for 20 s; and in the polyester matrix and
reflective wedge group, the first layer was light-cured
indirectly through the reflective wedge for 60 s; the second
and third layers were light-cured from the buccal and lingual
directions for 60 s, respectively. Additional layers were light-
cured from occlusal for 20 s. As the teeth were not pre-wedged,
the construction of the contact between the restoration and
Fig. 1 Composite increments insertion in the proximal
boxes and polymerization techniques in the translucent
matrix and reflective wedge group (a and b), and in the
metallic matrix and wooden wedge group (c).
 journal of dentistry 35 (2007) 231237
the proximal tooth was carried out with a pre-cured composite
sphere, which was firmly squashed with an amalgam
condenser against an increment of non-polymerized compo-
site and the proximal tooth, while light curing was performed.
In both groups, after removal of the matrix system the
restorations were additionally light-cured for 20 s from the
buccal, lingual and occlusal aspects. The utmost care was
taken during the composite insertion to keep the finishing to
minimum, and all restorations were finished immediately
after placement, with a sequential technique.18,23
A randomization table assured that the matrix systems
were symmetrically distributed so that each patient had all the
treatments previously distributed according to his/her
demands by chance, and necessary adjustments were made
to assure an equal treatment distribution. Thus, matrix
systems were systematically allocated to minimize the
influence of tooth type and position, and restoration size on
the experiment.18,19
2.3. Assessment procedures
The baseline evaluation was conducted at least 1 week after
and up to 1 month of post-placement, including an assess-
ment of the functional characteristics according to modified
USPHS codes and criteria,24,25 and a bitewing radiograph of
each evaluated restoration (Table 1).18,19
Two calibrated investigators working independently com-
pleted the assessment of the restorations, at baseline, 12- and
24-month evaluations. Radiographic examination was again
carried out at the 24-month evaluation. When disagreement
occurred, a consensus rating was determined prior to the
patient being dismissed. The MOD restorations were analyzed
independently for both MO and OD surfaces. The results were
tabulated and submitted to statistical analysis using Mann
Whitney Rank Sum Test for comparison between matrix
systems at different evaluation times and using Wilcoxon
Signed Rank Test for comparisons between evaluation periods
for each experimental group.25 Significance level was set at 5%.
3. Results
3.1. Baseline evaluation
Twenty-three patients were selected (82.6% females) with an
age range of 1350 years (mean age 34.4  10.7). Of the 109
placed restorations 75 (68.8%) were replacements of unsatis-
factory amalgam or composite restorations, and 34 (31.2%)
were initial restorations, while 41 were mesio-occluso-distal
(MOD) cavities. Nine restored cavities had cervical margin
located in dentine/cementum (four placed with translucent
matrices and reflective wedges and five placed with metallic
matrices and wooden wedges); remaining cavities had cervical
margins located in enamel. The summary of teeth and cavity
types at baseline, 12 and 24 months are presented in Table 2.
There were no significant differences between matrix sys-
tems, neither among tooth groups nor cavity types (Tables 3
and 4). Two restorations presented post-operative sensitivity
(low to moderate), one placed with each matrix system, but
without need of replacement.18
233
3.2. 12-month evaluation
Eighteen patients were able to participate of the recall. Ninety-
four (86.2%) restorations were evaluated, 50 of the metal
matrix group and 44 of the polyester matrix group. There were
no differences between matrix systems ( p > 0.05), even when
considering teeth groups or cavity designs (Tables 3 and 4).
Two restorations had failed after 12 months of clinical service,
and the failure causes were a caries lesion adjacent to the
restoration in one tooth (MO restorationtranslucent matrix
system), and a pulpal necrosis in the other one (MOD
restorationmetallic matrix system). Both restorations were
replaced.19
3.3. 24-month evaluation
Fifteen patients attended to the 2-year recall with 78 (71.5%)
restorations evaluated, 41 of the metal matrix group and 37 of
the polyester matrix group. Some restorations could not be
evaluated in the criteria occlusal (3 restorations) and proximal
contacts (5 restorations), due to the loss of the neighbor or
antagonist teeth (Table 3). After 2-year follow-up there were
still no differences between metallic and translucent matrices
( p > 0.05) in relation to any criteria evaluated (Table 3).
The influence of clinical service (time) on each matrix
system, comparing the 1-year to 2-year follow-up showed a
statistically significant decrease in restorations quality after 2
years regarding marginal adaptation, marginal staining and
proximal contact aspects for both matrix systems ( p < 0.05)
(Table 3). Additionally, translucent matrices had presented
higher degree of color mismatch ( p < 0.05) (Table 3). Compar-
ison between baseline and 2-year data evidenced a statistically
significant loss of restorations quality concerning color match,
marginal adaptation and marginal staining aspects for both
matrix systems ( p < 0.05), whereas translucent matrices and
reflective wedge group presented decrease in proximal
contacts quality ( p < 0.05) (Table 3).
In the radiographic examination, there was no difference
between metallic and translucent matrices after the 2-year
follow-up regarding proximal contacts and cervical adaptation
evaluated ( p > 0.05). However, both radiographic aspects
presented a statistically significant decrease in quality after
2 years ( p < 0.05), which was not dependent on the matrix
system (Table 4).
4. Discussion
Randomized controlled clinical trials has been pointed out as
the outstanding evidence in the evaluation of the medical
technologies and health care interventions, reducing the
possible confounding variables by controlling size and intra-
oral location of the restorations, operator, working environ-
ment and patients. This study was designed to reduce these
confounding variables. All the restorations were placed with
both matrix systems tested in the same subject, and with the
same incremental technique. For restoration evaluation,
modified USPHS criteria were selected. Despite being a
subjective method, they are largely recommended for clinical
comparison between materials and techniques.1,6,25
234 journal of dentistry 35 (2007) 231237

Table 1 Codes and criteria for the clinical and radiographic assessment of the restorations
Criteria Code Definition

Clinical criteria
Color match A Restoration matches adjacent tooth structure in color and translucency
B Mismatch is within an acceptable range of tooth color and translucency
C Mismatch is outside the acceptable range

Marginal adaptation
A Restoration closely adapted to the tooth. No crevice visible. No explorer
catch at the margins, or there was a catch in one direction
B Explorer catch. No visible evidence of a crevice into which the explorer
could penetrate. No dentin or base visible
C Explorer penetrates into a crevice that is of a depth that exposes dentin
or base

Anatomic form A Restorations continuous with existing anatomic form

B Restorations discontinuous with existing anatomic form but missing
material not sufficient to expose dentin base
C Sufficient material lost to expose dentin or base

Surface roughness A Surface of restoration is smooth

B Surface of restoration is slightly rough or pitted, but can be refinished
C Surface deeply pitted, irregular grooves and cannot be refinished
D Surface is fractured or flaking

Marginal staining A No staining along cavosurface margin

B <25% of cavosurface affected by stain
C >25% <50% of cavosurface affected by stain
D >50% of cavosurface affected by stain

Occlusal contacts A Normal

B Heavy
C Light
D Absent

Proximal contacts A Normal

B Heavy
C Light
D Open

Sensitivity A None
B Mild but bearable
C Uncomfortable, but no replacement is necessary
D Painful. Replacement of restoration is necessary

Secondary caries A Absent

B Present

Radiographic criteria
Proximal contour A Proximal contour is correct, with adequate convexity and proximal
contact
B Convexity lightly compromised
C Convexity moderately compromised (Tofflemaire contour)
D Convexity and proximal contact compromised, repair is necessary

Marginal fit A Marginal fit is correct

B Restoration marginal fit is likely overfilled
C Restoration marginal fit is likely underfilled or an adhesive line can be
observed
D Restoration marginal fit is severely underfilled, or presence of open
margins

Adapted of Wilson et al.24

Comparison between the two matrix systems tested after 2
years showed no significant differences in the clinical perfor-
mance between both systems in any investigated condition,
confirming the null hypothesis. These findings follow the same
trend of the baseline18 and 1-year evaluations,19 where matrix
systems were not a significant factor affecting the clinical
performance of Class II composite restorations, which is in
agreement with another clinical study.15
The radiographic examination has not disclosed superior
proximal contacts obtained with metallic matrix and the
ringer retainer device, as could be supposed and is demon-
strated in other studies.810 The main clinical advantage
obtained with metallic matrices is the easier handling. It
should be highlighted that the application of a pre-contoured
composite sphere to establish proximal contacts somewhat
may have affected the proximal contour, improving the
 journal of dentistry 35 (2007) 231237 235

Table 2 Summary of tooth type and cavity design included in the study, at baseline, 12- and 24-month evaluations
Groups Tooth Baseline 12-month 24-month

MO/OD MOD MO/OD MOD MO/OD MOD

Metal matrix/wooden wedge Molars Maxillary 7 4 6 4 5 4

Mandibular 13 9 9 6 8 3

Premolars Maxillary 11 6 11 6 9 4
Mandibular 9 0 8 0 8 0

Polyester matrix/reflexive wedge Molars Maxillary 6 4 5 3 4 3

Mandibular 8 7 7 6 7 5

Premolars Maxillary 9 9 8 8 6 8
Mandibular 5 2 5 2 4 0

Total 68 41 59 35 51 27

translucent matrices performance, but studies should be
conducted to clarify this hypothesis. Moreover, there was a
reduction in proximal contact quality and marginal adapta-
tion, without significant differences in relation to the matrix
system employed.
Restorations placed with translucent matrices underwent a
decrease of proximal contacts quality after 1 year of clinical
evaluation, which was not observed for restorations carried
out with metallic matrices. However, after 2 years the two
matrix and wedge systems presented the same compromising
of the proximal contacts. This clinical finding could be related
to the composite mechanical properties more than to the
difference in polymerization kinetics induced by the distinct
polymerization techniques used with the matrix systems.
Nevertheless, longer periods of evaluation are necessary to
determine if this quality decrease will result in differences of

Table 3 Results of clinical evaluation according to modified USPHS codes and criteria at baseline, 12- and 24-month
evaluations
Criteria Code Baseline 12-month 24-month

Metallic Transparent Metallic Transparent Metallic Transparent

matrix matrix matrix matrix matrix matrix

Color match A 32 31 25 25 11 10
B 46 41 39 38 39 41
C 0 0 2 0 2 2

Marginal adaptation A 78 72 56 53 21 27
B 0 0 10 10 30 23
C 0 0 0 0 1 3

Anatomic form A 78 72 63 61 49 49
B 0 0 3 2 2 2
C 0 0 0 0 1 2

Surface roughness A 78 72 64 57 49 52
B 0 0 2 6 3 1
C 0 0 0 0 0 0

Marginal staining A 78 72 51 52 19 22
B 0 0 13 10 24 25
C 0 0 2 1 9 6

Occlusal contacts A 74 72 64 63 50 49
B 3 0 1 0 0 0
C 1 0 1 0 0 0
D 0 0 0 0 1 2

Proximal contacts A 56 65 59 62 36 39
B 5 2 3 1 7 4
C 7 5 4 0 5 6
D 0 0 0 0 2 1

Sensitivity A 77 71 66 63 52 53
B 1 1 0 0 0 0

Secondary caries A 78 72 66 62 52 53
B 0 0 0 1 0 0
236 journal of dentistry 35 (2007) 231237
Table 4 Results of radiographic evaluation according to modified USPHS codes and criteria at baseline and 24-month
evaluations
Criteria Code Baseline
Metallic matrix Transparent matrix
Proximal contacts A 48
B 26
C 4
D 0
Cervical adaptation A 65
B 12
C 1
D 0
performance between matrix systems. Proximal wear is a
matter of concern and it could be a more important problem
than occlusal wear when dealing with composite restora-
tions.26
The similar performances of both matrix systems suggest
no clear evidence of a lower polymerization shrinkage
produced by the three-sited technique with clear matrix
and reflexive wedges. This way, the curing method may have
little influence on the direction of shrinkage and the marginal
sealing or bonding capacity could be similar in proximal
composite restorations carried out with the two matrix
systems tested.13,14
The findings of the current study showed a significant
decrease in restoration quality after the evaluated period for
marginal adaptation, marginal staining and proximal contacts
aspects for both matrix systems, and color match for
translucent matrices. As previously demonstrated, there is
some evidence of a drop in restoration quality and survival
with time.1,6,21,22
In relation to color stability, Filtek P-60 is commercially
available with only three shades, making difficult to recover
the tooth structure characteristics. Only restorations perfectly
adapted in color, translucence and opacity were scored as A
(Alpha) at baseline and subsequent evaluations. The dete-
rioration of color match was noticed for the group of
translucent matrices remaining unchanged for the metallic
matrix group. The color alterations could be associated to the
pigments absorption, from dietary and oral hygiene habits of
the patients,22 instead of the polishing treatment, which was
the same for all restorations in the present study.
Marginal adaptation was impaired for clinical service,
according to previous reports in similar follow-up.27 The slight
crevice along marginal interface could be the result of fracture
of overlapping fine type marginal excess, which formed a
ledge that caught the explorer during the follow-up evalua-
tion.27 Also, the differences in polymerization kinetics caused
by the different restorative techniques could somewhat
contribute to gap production and affect sealing ability of
composite restorations,28 which could be better observed in
long-term evaluations. Marginal staining has significantly
increased after 2 years. This finding is not directly related to
the matrix system used and probably happened due to the
degradation potential of the hydrophilic adhesive system,
which has been evidenced both in vivo and in vitro.29 However,
if the three-sited polymerization technique used with the
translucent matrices and reflective wedges cause some
24-month
Metallic matrix Transparent matrix
52 21 26
19 19 16
1 10 9
0 2 2
64 30 33
5 5 4
3 12 14
0 5 2
attenuation on the polymerization stress, lower gap formation
could be expected with this technique, which could contribute
to a lower marginal staining. Our results do not support this
hypothesis, since no difference was evidenced between
matrix systems at baseline, 1- or 2-year evaluations. Addi-
tionally, the presence of marginal staining is observed with
restoration aging, but is not a solely reason for restoration
replacement.1
The anatomic form has not suffered significant alterations
during the first 2 years. The improvement in materials
technology resulted in the production of composites with
better mechanical properties, such as wear resistance, leading
to the maintenance of occlusal anatomy, with major dete-
riorations appearing after 10 years of clinical service.1 Also,
restorations maintained the surface texture during the 2-year
period, as the immediate polishing sequential technique
employed ensures a highly polished surface.23 A more
polished surface will provide a lower abrasive effect of food
during mastication, keeping the surface quality for longer
periods, contributing with the maintenance of the anatomic
form due to the wear reduction.
The presence of sensitivity was not a concern in this study
and could be attributed to the careful technique employed,
avoiding extensive dehydration of dentin and disruption of the
sealing, which are the main causes of post-operative sensi-
tivity.30 Furthermore, secondary caries was not a reason for
restoration failure in this study. Secondary caries could be a
significant reason for restoration replacement in periods over
5 years.23 However, even studies with very long clinical service
demonstrated that in a dental clinic based on a health
promotion approach secondary caries will not be the reason
for restoration failure.1
Although a decrease in restoration quality has been
detected, all restorations were clinically acceptable at the 2-
year recall, confirming the improved performance of compo-
sites in posterior teeth.6 Even restorations placed with old
generation composite resins could present a satisfactory
performance in periods over 15 years.1,2 Therefore, it could
be hypothesized that restorations carried out with modern
composites may present a better performance.
5. Conclusion
The results of the present study showed similar clinical
performance between the two matrix systems tested. The
 journal of dentistry 35 (2007) 231237
Class II composite restorations evaluated showed reduction in
restoration quality after 2 years, but all restorations evaluated
remained acceptable.
Acknowledgements
The authors are grateful to CNPq (Conselho Nacional de
Desenvolvimento Cientfico e Tecnologico, Brazil) and CAPES
(Coordenacao de Aperfeicoamento de Pessoal de Ensino
Superior) for the financial support and scholarships.
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