Preventive Dentistry

The preventive resin (composite resin/sealant) restoration:Nine-year resnltsMilton Houpt* / Anna Fuks** / Eliezer Eidelman***

Thi.i study vfflj performed to examine the 9-year .success of the composite resin/seaUmt res-toration, which uses "sealing for prevention" of fissure caries rather than "cavity extensionfor prevention. " Three htindred thirty-two Class I restorations were placed in the occhtsal sur-faces of 240 permanent molar teeth in ¡14 children aged 6 to 14. Cavity preparations weremade in occlusai surfaces, and caries was removed with no attempt to create any additionalretention or remove undermined enamel. Exposed dentin was covered with Dycal and thecavity was restored with Radiopaque Adaptic, which was then covered with Delton fissuresealant. Incipient lesions confined to the enamel were restored only with Delton. Afier9years,79 restorations in 28 subjects were examined for sealant retention, marginal staining, and thepresence of dental caries. Forty-three restorations (54%) had completely retained sealants. 20(25%) had sustained partial loss, and 16 ¡20%) of the restorations had lost all sealant. Dentalcaries occurred in 19 ¡25%) of the restorations that had sealant ¡o.ss. An additional Jó teethhad proximal caries unrelated to the occhisal restoration. These findings demonstrated thatthe composite resin/sealant ¡preventive resin) restoration produced excellent long-termresults. (Quintessence Int ]994;25:!55-159.)

Introduction

Classic restorative dentistry dictates that an occlusaicavity preparation should extend into all pits and fis-sures, whether or not they are carióos.' Although suchextension is performed to prevent future caries, soundtooth structure is usually destroyed, thereby weaken-ing the tooth and increasing the perimeter of the resto-rative material. In adults, permanent first molars fre-quently have cuspal fracture, and extensive restorativeor endodontic treatment often becomes necessary Thisproblem may be inadvertently caused when conscien-

Profcssor and Chairman, Department of Pcdiatm: Dentistry,University ot Medicine and Dentistry of New Jersey. New Jer-sey Dental School, ltO Bergen Street, University Heights,Newark, New Jersey 07103-2400.Protcssor,DepartmentofPediatric Dentistry. Hebrew Univer-sity, Hadassah Faculty of Dental Medicine, Jerusalem, Israel,Professor and Chairman, Department of Pcdiatrit Dentistry,Hebrew University, Hadassah Faculty of Dental Medieine, Je-rusalem, Israel.

tious practitioners use cavity "extension for preven-tion" in young patients. If the margins of the restora-tion break down and the restoration is replaced, thecavity becomes larger and the tooth becomes weakerunli! it subsequently fractures. Consequently, it tnightbe beneficial if sound tooth structure could be pre-served and another method of prevention were used.

A conservative occlusai preparation without exten-sion for prevention has been advocated, and excellentresults have been obtained in various studies of theprocedure."""' This paper reports 9-year results of astudy to determine the success of a conservative cavitypreparation that uses the principle of "sealing for pre-vention" rather than that of cavity "extension for pre-vention."

Method and materials

The present study was conducted at the New JerseyDental School and at the Hebrew University HadassahSchool of Dental Medicine, Jerusalem. A total of 332Class I restorations were placed in 240 teeth of 11Ü sub-

, Number 3/1994 155

Preventive Dentistry

Fig 1 Maxillary permanent first molar with occlusal pit andfissure caries.

Fig 2 Minimal cavity preparation (outiined) v ithout exten-sion for prevention. Calcium hydroxide pulpal protectionhas been placed.

jects, aged 6 to 14 (mean age of S years). Almost all res-torations were placed in permanent first molars, and afew permanent second molars. The restorations werefairly well distributed among all four quadrants. Theteeth selected for treatment had incipient, minimal, ormoderate occlusal carious lesions (Fig 1 ). Extensive le-sions that involved all of the pits and fissures were ex-cluded, because there was no sound tooth structure topreserve with sealant.

The treatment procedure was similar to that used forroutine amalgam restorations in that local anesthesiaand rubber dam isolation were used. The tooth surfacewas cleaned with a rubber cup and prophylaxis paste,and the cavity was prepared with round or pear-shapedburs used at either high or low speed. The preparationconsisted only of caries removal. Grossly underminedor soft, demineralized enamel was removed, but therewas no attempt to remove slightly undermined enamel,make special retentive areas, or extend for preventioninto sound pits and fissures. Fissures that were stained,but firm, and without stickiness m underlying enameldiscoloration were left intact to conserve tooth struc-ture. The size of the resulting preparations with mini-mal or moderate decay averaged 1.5 x 2.0 mm with adepth of approximately 2.0 to 2.5 mm. Preparations forincipient lesions were less than 1 mm in cross section.

After removal of caries, calcium hydroxide pulpalprotection (Dycal, Caulk) was placed (Fig 2), followedby placement of a composite resin material. In thisstudy an autopolymeri^ed composite resin (Miradapt,Johnson & Johnson Dental) was applied with a syringe(Centrix, Centrix), obturating the cavity but avoiding

excess. The syringe was used to prevent voids at thebase of the cavity. Tlie material was then pushed intothe cavity with a plastic instrument and, if the restora-tion was large, a piece of plastic cellophane was placedon the tooth and held firmly with a cotton pellet untilthe material hardened. Those teeth with incipient le-sions had only small preparations and no compositeresin was placed. After the material had set, the occa-sionally small resulting excess was trimmed with smallwhite stones at high speed. Arficulation paper was notused because the rubber dam was left in place for thesealant application.

The occlusal surface was then washed, dried, etchedfor 60 seconds with 37% phosphoric acid, and washedand dried again. A self-polymerizing sealant (Delton,Johnson & Johnson Dental) was then mixed and ap-plied according to the manufacturer's instructions(Fig 3). Tinted sealant was used on approximately halfof the teeth, and clear sealant was used on the remain-der. In those minimal preparations that had no com-posite resin, the sealant served as the restorative mate-rial. After the sealant had set, it was tested by attempt-ing to pry it off wit h an explorer. Occasionally, the seal-ant was dislodged and was reapplied after re-etching ofthe tooth surface for 60 seconds.

The placement and subsequent examination of allrestorations in both countries was performed or super-vised hy the principal investigator, whose standardizedratings were reported in previous studies." The restora-tions were examined at 6 months, 1 year, and l'/;, 2,3,4, 5, ö'/j, and 9 years, and evaluated according to thefollowing criteria: sealant condition (no loss, pardal

156 Quintessence International Volume 25, Numbet 3/1994

Preventive Dentistry

CARIES

WEAR

COMPLETELOSSPARTIAL

LOSSCOMPLETERETENTION

^ ^ ^ ^ ^ ^ ^ ^ 1 25°'^ {19)

1 E% (5) (¡^RAWDATA

^ ^ ^ 1 20% (16)

^ ^ H ^ l 2i'.. 120)^ ^ ^ ^ • ^ ^ ^ ^ ^ ^ H 54" o (43)

10 20 30 40 50 60 70 BO eD 10D%

S YEAR RESULTS

7.REST0RAT,0Ns[------~

Fig 3 Clear fissure sealant placed over the composite res-in restoration.

Fig 4 Nine-year results for 79 restorations.

Fig 5 Composite resin/sealant restoration in a maxiiiarymolar after 9 years, (The extent of sealant coverage is out-lined.] Adjacent teeth have amalgam restorations with typi-cal extension for prevention. Fig 6 Success of the composite resin/sealant restoration.

loss, or complete loss); marginal staining (none, slight,or severe): anatomic wear (none, slight, or severe);marginal adaptation of the composite resin if the seal-ant was lost (no defect, slight catch, moderate catch,slight crevice, or extensive crevice); and dental cariesdevelopment (none or present).

Results

After 9 years, 79 restorations in 28 subjects in Israelwere available for examination. Forty-three restora-tions (54%) had sealants that were completely re-tained, 20 restorations (25%) had partially lost theirsealants, and 16 (20%) had lost all sealant (Figs 4 and

5). Dental caries occurred in 19 restorations (25%) inwhich there was some sealant loss, and an additional 1 fiteeth had proximal caries that was unrelated to the oc-clusal restoration. There was no loss of the compositeresin restoration and no occlusal caries whenever thesealant was intact. Sealant wear was slight and it oc-curred in five restorations.

Discussion

These restorations were examined annually 7 times inthe 9 years since their placement, and the longitudinaldata concerning their success are presented in Fig 6.Complete retention of the sealant declined approxi-

^ . . • .,„ , \/nliimfi 25. NurTiber 3/1994 157

Preventive Dentistry

Fig 7 Mandibular molar with a composite resin/sealantrestoration after 9 years, ¡The extent of sealant coverage isoutlined.) A conservative mesio-ccdusal amalgam restora-tion was placed, preserving much of the occlusal surface.

mately 5% each year for the first 5 years, followed by alarger decline during the next year and a half, and al-most no additional decline thereafter. Most of this de-crease in complete retention was due to partial loss ofthe sealant, which increased with time during the first 5years. Changes in sealant retention and partial or com-plete sealant loss occurred predominantly during thefirst 6 years with little change during the next 3 years.An almost identical pattern for sealant success was re-ported in a 6-year study of autopolymerized Delton fis-sure sealant,^ In that study, complete retention of thesealant was reported as 98%, 94%, 88%, 83%, 73%,67%, and 58% at the 5-month, 1-, 2-, 3-, 4-, 5-, and 6-year examinations, respectively. In the present study,the presence of the composite resin restoration did notappear to have affected sealant retention.

The results obtained in this study are similar to thoseobtained by others," ' showing that a conservative com-posite resin restoration can be used successfully to re-store minimally or moderately involved occlusal cari-ous lesions. Wear was slight because the preparationwas confined to non-stress-bearing areas of the occlu-sal surface. Recurrent caries was minimal and occurredin those areas in which some sealant loss had exposed asusceptible pit or fissure. Although reseahng was notused in this sttidy, it would be performed in clinicalpractice if partial sealant loss were detected on recallexamination to prevent recurrent caries,' An autopoly-merized material was used in this study; however, alight polymerized material could also be used.

I n this study etching of the tooth was performed aftercomposite resin placement and before sealant place-ment. Etching can be performed before placement ofthe composite resin as long as care is taken not to dam-age the etched enamel surface before sealant place-ment. If the etched surface is manipulated duringplacement or trimming of the composite resin, re-etch-ing of the enamel is necessary, Etehing before place-ment of the composite resin might ccmtribute to reten-tion of that material: however, in this study, after 9years, retention of the composite resin did not appearto be a problem.

If caries develops subsequently on the proximaltooth surface, it should be treated with as little involve-ment of the occlusal surface as possible, thereby pre-serving healthy tooth structure (Fig 7). Preliminary ev-idence indicates that there will be little, if any, leakageat the amalgam-sealant interface if amalgam is used torestore the proximal lesion and the occlusal compositeresin and sealant are left intact."

Glass-ionomer materials have been recommendedfor this procedure''"' because the material can bond tothe dentin, thereby increasing retention of the restora-tion, and because the fluoride content of the giass-ionomer cement is thought to inhibit recurrent caries atthe margin of the restoration. In this study, retentionof the restoration was not a problem. In addition, thecaries occurred predominantly in uncovered, intact pitsand fissures rather than at cavosurface margins; conse-quently, the ñuoride of the glass-ionomer materialmight not have had much influence on the develop-ment of caries. The suggested benefit of glass-ionomermaterials requires further study.

When the composite resin/sealant restoration wasfirst recommended more than a decade ago, some prac-titioners were skeptical and did not incorporate theprocedure into their practices because of the limiteddata available in regard to long-term success. This 9-year study demonstrates that the eomposite resin/seal-ant restoration can be used successfully to conservehealthy tooth structure when occlusal caries is treated.The technique is particularly recommended when oc-clusal carious lesions have not yet involved all pits andfissures, and these can be preserved in a stronger tooth.

Summary

A study was performed to determine the success of aconservative cavity preparation using the principle ofsealing for prevention rather than that of cavity exten-sion for prevention, A total of 332 restorations were

158 Quintessence International Volume 25, Number 3/1994

Preventive Dentistry

placed in 240 teeth of 110 subjects, aged 6 to 14. with amean age of S years. After 9 years, 79 restorations wereexamined. Caries appeared in 19 teeth {24% ofsample) and sealant wear occurred in 14 restorations(1S%). Complete sealant loss was observed in la res-torations (20% ) and partial loss in 20 (25 % ). leaving 43restorations (54%) with complete retention of the seal-ant. These results show that conservative cavity prepar-ation with sealing for prevention is a successful teeh-nique that conserves valuable tooth structure.

Ackoo wledgme nts

'She informed consent of all human subjects who partieipated in theexperitneDtal investigation reported in this manuscript was ob-tained after the nature of Ihe procedure and possible discomfortsand risks had been fully esplained.

The authors acknowledge the support of the Johnson & JohnsonDental Products Co, East Windsor, New Jersey. The authors furtheracknowledge the extensive contributions of Dr Zia Shey. New Jer-sey Dental School, and Drs Aubrey Chosack and Joseph Shapira ofthe Hebrew University in the original design and implemetltation ofthis study.

References1. Gilmore GW, Ltind MR. Operative Dentistry. St Louis: Mosby.

1973:82.2. Simonsen RJ. Preventive resin restorations: Three year resnlt.s.

J Am Dent Assoc 1980;t 00:535-539.3. Azdori S, Sveen OB, Buonocore MG. Evaluation of a restora-

tive teehrtjque for localized oeelusal caries [abstract 952]. JDent Res 1979;58:330.

4. Mertz-Fairhurst EJ. Newcomer AP, Callsmith MK. Caries ar-resimetit and prevention by sealed conservative filled resin res-torations [abstract 478]. J Dent Res 1983:62:222.

5. Walls AWG. Murray JJ, McCabo JF. The management of oeelu-sal caries in permanent molars. A clinical trial comparing a min-imal composite restoration with an oeelusal amalgam restora-tion. Br DentJ 1988;164:288-292.

6. Houpl M. Shey Z. The effectiveness of fissure sealant after sixyears. Pediair Dent 1983;5:104-106.

7. Isler SR. Doline S. Clinical application of pit and fissure seal-ants. Compend Contin Educ Dent 1981:2:207-211.

8- Fuks AB, Shey Z. in vitro assessment of marginal leakage ofcombirted amalgam-sealant restorations on oeelusal surfaees ofpermanent posterior teeth. J Dent Child 1983:50:425^29.

9. Garcia-Godoy F The preventive glass ionomer restoration.Quintessence Int 1986:17:617-619.

10. Ripa LW. Wolff MS. Preventive resin restorations: Indications,technique, and suecess. Quintessence Int 1992;23:307-315. •

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