1

Longevity of Composite Resin and Amalgam Restorations in Posterior Teeth:

An Evidence-Based Review of the Literature.

Mario Corbo, Elias Fahed, Sari Hershenfield, Lisa Paige and Ogi Pani

DEN300Y Community Dentistry, winter 2009

Group Facilitator: Dr. Carlos Quionez
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Abstract

Longevity of dental restorations is dependent on a wide variety of aspects including patient

factors, operator skill and the restorative material itself. An understanding of longevity and the

clinical circumstances in which certain restorative materials should be used allows both the

clinician and patient to make appropriate informed decisions. This evidence-based study of the

literature investigated the longevity of posterior amalgam and composite resin restorations. The

review was based on evidence from two main sources: a search of several electronic

bibliographic databases and a review of the references from relevant studies to identify further

papers of potential significance. A total of 33 articles were reviewed and of these, 6 articles were

deemed relevant, critically appraised, and scored using an assessment checklist comprised of 10

items. Of the six studies, three were randomized controlled trials, and three were retrospective

cross-sectional surveys. Although longevity was the main outcome for the majority of the

studies, not all defined longevity in the same manner. Furthermore, only two studies were of a

split-mouth design in which each patient received both amalgam and composite resin restorations

when possible. Overall, the evidence assimilated in this review does not strongly suggest that

amalgam has a greater longevity than composite resin in posterior restorations. Due to the

various flaws recognized in each of the studies, however, it is not possible to draw any

conclusions until further research is conducted.

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It is well accepted that the lifespan of dental restorations is limited, with recurrent caries

and material failure often necessitating their replacement throughout a patients lifetime.1,2,3

Restoration longevity therefore has implications at a variety of levels. An understanding of

longevity assists dentists in treatment planning and informed decision making. In turn, realistic

expectations and long-lasting restorations foster patient confidence in the operator.4,5 For

patients, durable restorations mean greater satisfaction with respect to comfort and utility, as well

as reduced costs and the preservation of tooth structure.6 For insurance purposes, longevity can

also influence the financing of specific services.4,7

Many factors contribute to a restorations longevity, including operator skill and a

patients caries risk;8 however, the dental material selected is a major determinant. For the last

100 years, the most widely used material for posterior load-bearing restorations has been silver

amalgam.9 A recent decline in amalgam use has been noted in many parts of the world,10,11

including Canada,6 likely influenced by inferior esthetics and patients mercury concerns.12 A

shift towards the replacement of posterior amalgam restorations with composite resin has

therefore developed, accelerated by improvements to composite materials and bonding strength.8

There is relatively little summary evidence concerning the difference in longevity between these

two types of restorative materials. Although resin composites have yielded excellent results in

controlled clinical studies, cross-sectional general practice investigations have deemed the mean

survival times of amalgam superior to direct composite restorations.13 The precise longevity of

these direct dental materials therefore remains unclear.

An evidence based review of the literature was performed to investigate the following

question: What is the longevity of posterior amalgam and resin composite restorations? This
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paper summarizes the strongest evidence comparing posterior amalgam and composite resin

restorations.

Methods

A systematic method was used to research, identify, select, and critically appraise the

relevant literature in order to answer the research question in an evidence-based manner. Three

searches were conducted on Ovids MEDLINE (1966 to present), Pubmed (1966 to present) and

Scopus (1996 to present) electronic databases to locate relevant published articles. The following

key words were used in the searches: amalgam, composite resin, longevity, time to failure,

restoration failure and replacement needed. After sorting the search results by title, 49, 169, and

82 articles were deemed relevant from the three search engines respectively. The abstracts of

these articles were carefully read and evaluated based on the following inclusion criteria:

primary research of human clinical studies written in English, studies conducted on posterior

permanent teeth in a private practice setting, subjects were healthy patients with no underlying

oral or medical complications and the studies were published from 1950 onwards. Similarly,

articles were excluded based on the following criteria: studies conducted on primary teeth,

studies conducted on anterior teeth, in vitro studies, articles not written in English, articles

published before 1950 and studies conducted in a dental school setting. This systematic process

yielded 33 articles of potential relevance. The reference lists from these 33 articles were

reviewed to identify further articles. This process yielded one additional article which was

subjected to the same aforementioned inclusion/exclusion criteria. A list of the excluded articles

and their reasons for exclusion can be found in Appendix 1. Subsequent to the identification of

pertinent articles based on the abstract, the full text of the articles was reviewed. This stage
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yielded 6 articles14-19 which were further scored, to assess validity, based on a checklist adapted

from Azarpazhooh20 (Table 1). The highest possible score an article could receive was 10.

Results

The six selected studies presented evidence from the United States, the United Kingdom

and Europe. Evidence from these studies is presented in Table 2. Sample sizes ranged from 73

to 9031 class I and class II restorations. The studies were scored using an assessment checklist

(Table 1), and the results are shown in Table 3. None of the studies scored higher than 7 out 10,

with the lowest score achieved being a 3. Only two of the studies observed significant

differences in longevity between amalgam and composite resin restorations.14,15 The study by

Letzel16 did not have enough amalgam data to calculate survival rates, but found that composite

resin restorations were more likely to need replacement compared to amalgam.

Restoration longevity, defined in this review as time to failure or survival rate, was the

main outcome measured in five of the six studies examined.14-18 Not all of the studies defined

longevity in the same way. For example, Tobi and others19 defined longevity by marginal

adaptation, whereas Mjor15 gave several specific definitions, such as secondary caries, marginal

fracture and bulk fracture. In other cases, longevity was simply defined as need for

replacement.14,16,17,18

Of the six studies, three were randomized controlled trials,16,17,19 and three were

retrospective cross-sectional surveys.14,15,18 In the two highest-scoring studies,17,19 a split-mouth

design, where each patient received both amalgam and composite resin restorations, was used

whenever possible. As a result, the evidence presented in these studies was considered stronger

than that presented in the other four. In the multicentre trial by Letzel,16 only five out of the ten

centres had an amalgam comparison group, the other five used composite resin only. This
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weakened the evidence presented by the study, resulting in a lower score being assigned to the

article.

Of the two properly controlled randomized trials, the study by Tobi and others19 was

given the higher score. Although there was no dropout among the study participants, and the

authors controlled for outside care and other confounding factors such as oral hygiene and

socioeconomic status, the evidence presented should be considered with caution due to the small

sample size of 73 restorations, as well as the relatively short duration of the study (5 years).

In the three cross-sectional surveys,14,15,18 randomization, proper amalgam controls, and

control for outside care or other confounders were not possible. The main advantage of these

studies was the long duration of investigation, which allowed the authors to draw substantial

conclusions regarding longevity differences between amalgam and composite resin restorations.

Practitioner differences, such as the school of training, materials, and technique

preferences were not accounted for in any of the studies.14-19 Patient factors, including oral

hygiene practices, frequency of dental visits, or socioeconomic status were controlled for only by

Tobi and others.19

Discussion

The evidence compiled in this literature review does not strongly suggest that amalgam

has a greater longevity than composite resin in posterior restorations. As such, it is not possible

to conclusively recommend the use of one material over the other.

One of the major flaws observed in the studies had to do with the type of study designs

used. The best study design for testing the efficacy of a treatment is usually a randomized

controlled trial (RCT).21 Due to the nature of the enquiry, only half of the studies were
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prospective and included randomization.16,17,19 The rest of the studies were forms of cross-

sectional surveys.14,15,18. Although not considered as reliable as RCTs, surveys give a broad

overview of the correlation between material choice and restoration longevity. These types of

studies avoid ethical issues and are easy to use, as well as being cost-effective. The cross-

sectional analyses also allowed for very large sample sizes, thus enabling generalizations of the

results (increased external validity). Unfortunately, these studies are less internally valid and

reliable than RCTs since confounding factors cannot be easily controlled. If large enough

sample sizes are used in an RCT, confounders may be distributed evenly between treatment

groups and generalizations can be made.21 Most of the studies reviewed here did not control for

confounding factors, practitioner differences, or outside care. Such variables can significantly

influence the outcomes observed, and could have been avoided through the use of surveys or

questionnaires to determine additional information that could then be included in the analyses.

Although within-patient comparisons are the most valuable, a split-mouth design is not

always achievable. Patients often have personal preferences, based on aesthetics or the inherent

properties of the materials, such as mercury in amalgam and bisphenol-A in composite resin.12,22

Comparing different materials in different individuals results in confounding variables and

makes the comparison more complicated. Large sample sizes could have helped to solve such

issues.

In addition to the weaknesses in study designs, the outcomes were also not always validly

measured. The country in which the study was conducted may have affected the outcomes

observed. For instance, Opdam and others18 did not detect a significant difference in longevity

between amalgam and composite resin restorations, however the study took place in the

Netherlands where oral hygiene is known to be good and caries rates fairly low. This makes it
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difficult to generalize the results to other populations.23 In addition, two of the studies were

sponsored by dental materials companies, which may have resulted in funding biases.16,17

Although longevity was the main outcome for most of the studies, it was not always

defined in the same manner. As such, the practitioners judgements may have differed

significantly when determining the need for replacement of a restoration. Clearly it would be

difficult to compare average longevity of restorations in a systematic review if such outcomes

were not reliably measured.

Based on the above considerations, the evidence level of the studies was ranked (Table

2). One might observe that of the four highest ranking studies,15,16,17,19 only Mjor15 found a

significant difference in longevity between amalgam and composite resin restorations. This

study was cross-sectional in nature, whereas the other three were all RCTs and found no

significant differences between the two materials. Based on the evidence gathered, it would seem

that both amalgam and composite resin have similar times to failure. Due to the various flaws

recognized in each of the studies, however, it is not possible to draw any conclusions until

further research is conducted.

Many of the aforementioned problems in the studies could be rectified. It would be

advantageous for studies to control for external confounding factors, as well as to account for

differences within the designs. For example, the size of the restorations to be replaced could be

recorded, in addition to patient characteristics and operator variables. It would also be useful to

compare several sites and even specific types of amalgam and composite resin since the

materials themselves may differ in many respects; for instance filler content or bonding

technique. To improve internal validity and outcome reliability, time to failure might be defined

specifically in terms of different types of failures, which could subsequently be analyzed for
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statistical differences by failure type. Examinations of past versus more recent studies in another

systematic review would also be interesting since material composition, dental education and

oral hygiene levels may have changed over time, thereby affecting longevity of restorations.

Despite the inconsistencies between and within the research examined, the results of

these studies would be beneficial for improving patient care. The findings would help

practitioners and patients decide between amalgam and composite resin as materials for

restorations. This would be important, for instance, in patients with poor oral hygiene, where the

risk of restoration failure is higher. It would also help with lower income patients since the

dentist could consider using a material that would last longer, thus avoiding costs of

replacement.24,25 Future research will allow dentists to make a more educated and evidence-

based decision when choosing restorative materials.

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Acknowledgement

The authors of this review would like to thank Dr. Carlos Quionez for all of his help and

guidance in this report.

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References

1. Chadwick BL, Dummer PM, Dunstan FD, Gilmour AS, Jones RJ, Phillips CJ, Rees J,
Richmond S, Stevens J, Treasure ET. What type of filling? Best practice in dental restorations.
Qual Health Care 1999; 8(3):202-207.

2. Deligeorgi V, Mjor IA, Wilson NH. An overview of reasons for the placement and
replacement of restorations. Prim Dent Care 2001; 8(1):5-11.

3. Elderton RJ, Nuttall NM. Variation among dentists in planning treatment. Br Dent J 1983;
154(7):201-206.

4. Burke FJ, Lucarotti PS. How long do direct restorations placed within the general dental
services in England and Wales survive? Br Dent J 2009; 206(1):E2; discussion 26-7.

5. Downer MC, Azli NA, Bedi R, Moles DR, Setchell DJ. How long do routine dental
restorations last? A systematic review. Br Dent J 1999; 187(8):432-439.

6. Adegbembo AO, Watson PA. Removal, replacement and placement of amalgam restorations
by Ontario dentists in 2002. J Can Dent Assoc 2005; 71(8):565.

7. Leempoel PJ, Van't Hof MA, de Haan AF. Survival studies of dental restorations: criteria,
methods and analyses. J Oral Rehabil 1989; 16(4):387-394.

8. McComb D. Class I and Class II silver amalgam and resin composite posterior restorations:
teaching approaches in Canadian faculties of dentistry. J Can Dent Assoc 2005; 71(6):405-406.

9. Roulet JF. Benefits and disadvantages of tooth-coloured alternatives to amalgam. J Dent 1997;
25(6):459-473.

10. Christensen GJ. The state of the art in esthetic restorative dentistry. J Am Dent Assoc 1997;
128(9):1315-1317.

11. Mitchell RJ, Koike M, Okabe T. Posterior amalgam restorations--usage, regulation, and
longevity. Dent Clin North Am 2007; 51(3):573-89, v.

12. Burke FJ. Amalgam to tooth-coloured materials--implications for clinical practice and dental
education: governmental restrictions and amalgam-usage survey results. J Dent 2004; 32(5):343-
350.
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13. Manhart J, Chen H, Hamm G, Hickel R. Buonocore Memorial Lecture. Review of the
clinical survival of direct and indirect restorations in posterior teeth of the permanent dentition.
Oper Dent 2004; 29(5):481-508.

14. Burke FJ, Cheung SW, Mjor IA, Wilson NH. Restoration longevity and analysis of reasons
for the placement and replacement of restorations provided by vocational dental practitioners and
their trainers in the United Kingdom. Quintessence Int 1999; 30(4):234-242.

15. Mjor IA. The reasons for replacement and the age of failed restorations in general dental
practice. Acta Odontol Scand 1997; 55(1):58-63.

16. Letzel H. Survival rates and reasons for failure of posterior composite restorations in
multicentre clinical trial. J Dent 1989; 17 Suppl 1:S10-7; discussion S26-8.

17. Norman RD, Wright JS, Rydberg RJ, Felkner LL. A 5-year study comparing a posterior
composite resin and an amalgam. J Prosthet Dent 1990; 64(5):523-529.

18. Opdam NJ, Bronkhorst EM, Roeters JM, Loomans BA. A retrospective clinical study on
longevity of posterior composite and amalgam restorations. Dent Mater 2007; 23(1):2-8.

19. Tobi H, Kreulen CM, Vondeling H, Van Amerongen WE. Cost-effectiveness of composite
resins and amalgam in the replacement of amalgam Class II restorations. Community Dent and
Oral Epidemiol 1999; 27(2):137-143.

20. Azarpazhooh A. Department of Community Dentistry, Faculty of Dentistry, University of

Toronto. Unpublished document. Course notes DEN 300Y 2008. The checklist was adapted from
Fletcher RH, Fletcher SW, Wagner EH. Clinical epidemiology. The essentials. 3rd ed. Baltimore:
Williams and Wilkins, 1996; and Sacket DL, Richardson WS, Rosenberg W, Haynes RB.
Evidence-based medicine: how to practice and teach EBM. 2nd ed. New York: Churchill
Livingstone, 1997.

21. Lachin JM, Matts JP, Wei LJ. Randomization in clinical trials: conclusions and
recommendations. Control Clin Trials 1988; 9(4):365-374.

22. Sasaki N, Okuda K, Kato T, Kakishima H, Okuma H, Abe K, Tachino H, Tuchida K,

Kubono K. Salivary bisphenol-A levels detected by ELISA after restoration with composite
resin. J Mater Sci Mater Med 2005; 16(4):297-300.

23. Truin GJ, Konig KG, Kalsbeek H. Trends in dental caries in The Netherlands. Adv Dent Res
1993; 7(1):15-18.
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24. Eley BM, Cox SW. The release, absorption and possible health effects of mercury from
dental amalgam: a review of recent findings. Br Dent J 1993; 175(10):355-362.

25. Mortensen ME. Mysticism and science: the amalgam wars. J Toxicol Clin Toxicol 1991;
29(2):vii-xii.
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Table 1 Checklist for assessing validity of each relevant article

1. Was the study ethical?

2. Was a prospective study design used?
3. Was proper randomization carried out?
4. Was loss to follow-up accounted for?
5. Was dental care completed outside of the study accounted for?
6. Was at least one amalgam and one composite resin filling placed in each subject?
7. Did the researchers control for possible confounding variables?
8. Were the results externally valid?
9. Was the duration of the study sufficient?
10. Was longevity one of the main outcome measures of the study?
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Table 2 Evidence table

Author, Population Test Comparison Outcome Critical appraisal comments Conclusion, strength of
date, (age, sex, treatment (# treatment (ie checklist) evidence and
location etc.) studied) (# studied) classification
CR Amalgam
Burke and 9031 - 27 Class I -268 Class I Mean age Mean age of - Cross-sectional survey examining the age of - Significant difference in
others, 1999; restorations and 71 Class II and 1142 Class of 4.5 6.8 years replaced restorations and the reasons for longevity between amalgam
UK. placed, 4423 composite II amalgam years. (7.4years for placement and replacement and composite resin.
(49%) were resin (CR) restorations (3.3 years class I; 6.6 - Data gathered from 73 practitioners, did not -the longevity of composite
initial, 4608 restorations. for class I; years for compare the results from different practitioners. restorations placed in load-
(51%) were 4.6 years class II) - Patient groups may have differed (age, oral bearing areas was shorter than
replacements. for class hygiene, SES, etc.) that of amalgam restorations
II) - Care received outside study not controlled for. in similar situations
- Examined longevity by restoration class,
significance of findings was not indicated, class I - Evidence level II-3.
longest for amalgam (7.4 yrs).

Letzel, 1989; 1164 class I CR Amalgam 232 92 12 - RCT - RR for failure of CR is 1.9
USA, UK, and II (Occlusin) restorations. restoration restorations - Amalgam comparison group in only half of the (p<0.05).
The restorations in 932 s needed needed centres. - No analysis of reasons for
Netherlands, 447 adult restorations. replaceme replacement - Analyzed reasons for failure of CR by centre. failure by material, because
Sweden, patients at 10 nt by 4 or by 4 or 5 - Classified reasons for failure. too few amalgams were
Belgium; centres. 5 year years post- - More recurrent caries in CR. No poor margins replaced.
(multi- (Survival insertion. in amalgam.
centre). rate: 94%) - Funded in part by ICI Dental. - Level: II-1.
- Randomized amalgam vs. CR.
- Accounted for drop-out.

Mjor, 1997; Adult 2431 CR 1062 amalgam Average Average - Cross-sectional survey examining the age of - Significant difference in
Sweden. number of restoration. restoration. longevity longevity of failed restorations and the reasons for failure. longevity between amalgam
participants of 6 years. 9 years. - Large sample size. and composite.
not specified. - Classified reasons for failure.
- Interventions may have differed due to - Evidence level II-3.
technique differences in placement between
practitioners.
- 70% response rate.
- Practitioner groups may have differed (age,
education, brands used, etc.)
- Patient groups may have differed (age, oral
hygiene, SES, etc.)
- Care received outside study not controlled for.
 16
Table 2 Evidence table - continued
Author, Population Test Comparison Outcome Critical appraisal comments Conclusion, strength of
date, (age, sex, treatment (# treatment (ie checklist) evidence and
location etc.) studied) (# studied) classification
CR Amalgam
Norman and Composite: CR (occlusin) Amalgam 5 CR 3 amalgam - RCT - No significant difference in
others, 1990; 18M, mean 80 (Dispersalloy) failures at failures at 5 - Used random selection chart to determine class I vs. II or premolar vs.
USA. 28.9yr restorations 43 5 years years post- material of filling Molar with respect to wear.
31F, mean restorations post- insertion. - Maximum 4 restorations per patient, at least 1
30.1 yr insertion. CR. - Evidence level I.
Amalgam: - Sponsored by a dental materials company.
15M, mean - No statistical evaluation of longevity.
30.4yr - Wear was assessed by 2 operators.
23F, mean - Followed patients for 5 years (80.6% follow-
30.2yr up, only those were included in the evaluation)
Class I and II - 5 years follow-up period is not long enough to
molars and assess longevity.
premolars - Care received outside study was not controlled
followed over for.
5 years

Opdam and 2867 class I CR 1955 Amalgam -259 CR 182 - Retrospective cross-sectional clinical study. - No significant difference in
others, 2007; and II restorations 912 failures amalgam - General practice setting (1990-1997) longevity between composite
The restorations restorations -91.7% failures - Large sample size, however the results are resin and amalgam
Netherlands. placed in 621 survival at -89.2% difficult to generalize due to very good oral restorations (not consistent
patients 5 years. survival at 5 hygiene practices in Netherlands. with other comparable
between 1990- -82.2% years. - Classified reasons for failure. retrospective studies;
1997 survival at -79.2% - Prior to 1994, amalgam was only used in large amalgam usually has lower
-274 males 10 years. survival at restorations and CR for small ones. failure rate)
-347 females 10 years. - After 1994 amalgam was no longer used in the
patients in the study (did not control for size of - Evidence level II-3.
restoration which affects longevity)
- Concluded that operators skilled in both
amalgam and CR placement can achieve
comparable longevity results.
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Table 2 Evidence table - continued

Author, Population Test Comparison Outcome Critical appraisal comments Conclusion, strength of
date, (age, sex, treatment (# treatment (ie checklist) evidence and
location etc.) studied) (# studied) classification
CR Amalgam
Tobi and 73 53 CR 20 amalgam No signs No signs of - RCT - No significant difference in
others, 1999; conservative restorations restorations of marginal - Marginal adaptation (not discolouration) was longevity between the two
The Class II marginal break-down used to evaluate longevity by 2 trained and 2 groups (all showed some
Netherlands restorations in break- at 5 years calibrated dentists. failure at the margin).
56 patients. down at 5 post- - 4 common types of CR were used
years insertion. - Maximum 1 amalgam restoration per patient. - Evidence level I.
post- - No reference to other similar studies.
insertion. - No loss to follow-up.
- Although a RCT, the strength of evidence is
poor because the primary question was treatment
cost effectiveness (found not to be associated
with restoration quality and longevity).
- 5 year follow-up duration too short to draw
conclusions regarding the longevity of the 2
materials.
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Table 3 Results of validity assessment, based on the checklist adapted from Azarpazhooh20

Ethical Prospective Randomization Loss to Outside Amalgam Control for External Duration Longevity Score
design design follow-up care and confounding validity sufficient one of the (max=10)
accounted accounted composite factors (e.g. main
for for in each oral outcomes
patient hygiene,
habits, SES)
Burke 3 3 3 3
and
others,
1999

Letzel, 3 3 3 3 3 5
1989

Mjor, 3 3 3 3 3 5
1997

Norman 3 3 3 3 3 3 6
and
others,
1990

Opdam 3 3 3 3
and
others,
2007

Tobi 3 3 3 3 3 3 3 7
and
others,
1999
 19

Appendix 1 Reasons for exclusion and examples of articles excluded

Articles Reason for Exclusion

Bernardo and others 2007; Bryant and Hodge Study population includes individuals younger

1994; Collins and others 1998; Forss and than 18 years old

Widstrom 2001; Forss and Widstrom 2004;

Gibson and others 1982

Deliperi and Bardwell 2006; Khler and others Did not examine both amalgam and composite

2000; Miyamoto and others 2007; Rosenstiel

and others 2004

Mjor and others 1990 Not a study but a review

Raj and others 2007 Not a study but a commentary

Sjogren and Halling 2002 Article not in English

Mair 1998 Conducted in a dental school setting

Levin and others 2007; Mjor and Qvist 1997 Did not examine longevity

Sjogren and Halling 2002; York and Arthur Could not be located

1993

Bernardo M, Luis H, Martin MD, Leroux BG, Rue T, Leito J, Derouen TA. Survival and
reasons for failure of amalgam versus composite posterior restorations placed in a randomized
clinical trial. J Am Dent Assoc 2007; 138(6):775-783.

Bryant RW, Hodge KL. A clinical evaluation of posterior composite resin restorations. Aust Dent
J 1994; 39(2):77-81.

Collins CJ, Bryant RW, Hodge KL. A clinical evaluation of posterior composite resin
restorations: 8-year findings. J Dent 1998; 26(4):311-317.

Deliperi S, Bardwell DN. Clinical evaluation of direct cuspal coverage with posterior composite
resin restorations. J Esthet Restor Dent 2006; 18(5):256-265.
 20

Forss H, Widstrom E. Reasons for restorative therapy and the longevity of restorations in adults.
Acta Odontol Scand 2004; 62(2):82-86.

Forss H, Widstrom E. From amalgam to composite: selection of restorative materials and

restoration longevity in Finland. Acta Odontol Scand 2001; 59(2):57-62.

Gibson GB, Richardson AS, Patton RE, Waldman R. A clinical evaluation of occlusal composite
and amalgam restorations: one- and two-year results. J Am Dent Assoc 1982; 104(3):335-337.

Kohler B, Rasmusson CG, Odman P. A five-year clinical evaluation of Class II composite resin
restorations. J Dent 2000; 28(2):111-116.

Levin L, Coval M, Geiger SB. Cross-sectional radiographic survey of amalgam and resin-based
composite posterior restorations. Quintessence Int 2007; 38(6):511-514.

Mair LH. Ten-year clinical assessment of three posterior resin composites and two amalgams.
Quintessence Int 1998; 29(8):483-490.

Miyamoto T, Morgano SM, Kumagai T, Jones JA, Nunn ME. Treatment history of teeth in
relation to the longevity of the teeth and their restorations: outcomes of teeth treated and
maintained for 15 years. J Prosthet Dent 2007; 97(3):150-156.

Mjor IA, Jokstad A, Qvist V. Longevity of posterior restorations. Int Dent J 1990; 40(1):11-17.

Mjor IA, Qvist V. Marginal failures of amalgam and composite restorations. J Dent 1997;
25(1):25-30.

Raj V, Macedo GV, Ritter AV. Longevity of posterior composite restorations. J Esthet Restor
Dent 2007; 19(1):3-5.

Rosenstiel SF, Land MF, Rashid RG. Dentists' molar restoration choices and longevity: a web-
based survey. J Prosthet Dent 2004; 91(4):363-367.

Sjogren P, Halling A. Survival time of Class II molar restorations in relation to patient and dental
health insurance costs for treatment. Swed Dent J 2002; 26(2):59-66.

York AK, Arthur JS. Reasons for placement and replacement of dental restorations in the United
States Navy Dental Corps. Oper Dent 1993; 18(5):203-208.