d e n t a l m a t e r i a l s 2 5 ( 2 0 0 9 ) 750759

available at www.sciencedirect.com

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

Nanohybrid vs. ne hybrid composite in Class II cavities:

Clinical results and margin analysis after four years
Norbert Krmer a , Christian Reinelt b , Gert Richter c ,
Anselm Petschelt d , Roland Frankenberger d,
a

Department of Pediatric Dentistry, University Medical Center Carl Gustav Carus, Technical University Dresden, Germany
Private Practice, Nuremberg, Germany
c Department of Prosthetic Dentistry, University Medical Center Carl Gustav Carus, Technical University Dresden, Germany
d Dental Clinic 1 - Operative Dentistry and Periodontology, University Medical Center Erlangen, University of Erlangen-Nuremberg,
Glckstrasse 11, D-91054 Erlangen, Germany
b

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objectives. This controlled prospective split-mouth study evaluated the clinical behavior of

Received 2 July 2008

two different resin composites in extended Class II cavities over a period of four years.

Received in revised form

Methods. Thirty patients received 68 direct resin composite restorations (Grandio bonded

20 November 2008

with Solobond M: n = 36, Tetric Ceram bonded with Syntac: n = 32) by one dentist in a private

Accepted 17 December 2008

practice. All restorations were replacement llings, 24 cavities (35%) revealed no enamel at
the bottom of the proximal box, in 33 cavities (48%) the proximal enamel width was less than
0.5 mm. The restorations were examined according to modied USPHS criteria at baseline,

Keywords:

and after six months, one, two, and four years. At each recall, impressions were taken for

Resin composites

replica preparation. Replicas of 44 select subjects were assessed for marginal quality under

Nanoller

a stereo light microscope (SLM) at 130 and 22 replicas were assessed under a scanning

Marginal integrity

electron microscope (SEM) at 200.

Etch and rinse

Results. Both recall rate and survival rate were 100% after four years of clinical service. No
signicant difference was found between the restorative materials (p > 0.05; MannWhitney
U-test). Hypersensitivities were signicantly reduced over time (p < 0.05; Friedman test). A
signicant deterioration over time was found for the criteria marginal integrity (66% bravo
after four years), tooth integrity (15% bravo), lling integrity (73% bravo) and proximal contact
(p < 0.05; Friedman test). SLM and SEM analysis of restoration margins revealed differences
in the amount of perfect margins, in favor of Tetric Ceram (p < 0.05).
Signicances. Both materials performed satisfactorily over the four-year observation period.
Due to the extension of the restorations, wear was clearly visible after four years of clinical
service with 50% bravo ratings.
2009 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

1.

Introduction

Both anterior and posterior restorations are today predominantly made by use of resin composites [14]. Successful

adhesion to tooth hard tissues is a fundamental prerequisite for pit and ssure sealings, direct resin composites,
and bonded ceramics [59]. However, without successful
adhesion, gap formation and nally recurrent caries have a

Corresponding author. Tel.: +49 9131 8533693 fax: +49 9131 8533603.
E-mail address: frankbg@dent.uni-erlangen.de (R. Frankenberger).
0109-5641/$ see front matter 2009 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.dental.2008.12.003

751

d e n t a l m a t e r i a l s 2 5 ( 2 0 0 9 ) 750759

potentially negative effect on clinical success of restorations

[1013].
Bonding to phosphoric acid etched enamel is clinically
durable [1,6,12,1416], dentin still remains the weaker adhesion substrate due to intrinsic wetness [8,9,13,1720], but
clinically acceptable sealing of dentin in order to reduce postoperative hypersensitivities is achievable [4,6,7,11,12,21,22].
Although dentin adhesives are able to durably seal dentin,
especially with multi-step adhesives [14,17,19,2325], it has
not been fully evaluated whether the adhesives are able to
retain marginal seal in Class II cavities with proximal margins
below the cementoenamel junction. Several in vitro studies report varying outcomes after thermomechanical loading
and long-term storage with advantages for conventional
two- or three-step adhesives compared to simplied adhesive systems of recent generations [23,24,2628]. However, a
prospective clinical trial remains the ultimate instrument to
clarify these major questions. Nevertheless, preclinical in vitro
investigations are still needed, especially when experimental questions or a potential for optimizing procedures arise
[17,26,29].
The main problem with clinical trials, although they give
valuable results after many years of clinical service, is that
the adhesive and/or resin composite studied may not be in
the market anymore, like in this study for the case of Tetric Ceram which is replaced by Tetric EvoCeram since several
years [1,11,12,15,16,30,31]. On the other hand, clinical reports
have revealed catastrophic outcomes when adhesive performance per se is neglected [15]. Furthermore it was shown
that, e.g. amalgam may be superior to resin composites for
restoration of extended defects [21].
Beside conventional hybrid resin composites, also ne
hybrid composites or even nanohybrid resin composites
entered the market claiming less polymerization shrinkage
and higher wear resistance [3237]. In most of the cases, a
truly better clinical outcome is not proven.
Therefore, the aim of this clinical trial was to investigate
two different restorative material systems (i.e. adhesive and
resin composite) in extended Class II cavities over time in
order to observe differences between conventional and partially nanolled resin composites. The null-hypothesis tested
was that there would be no difference between the different
resin composites with their respective adhesives under investigation.

bonded with Solobond M (Voco, Cuxhaven, Germany) and 32

Tetric Ceram restorations were bonded with Syntac (Ivoclar
Vivadent, Schaan, Liechtenstein). All llings (only Class II, 52
MO/OD, 16 MOD or more surfaces, no cusp replacements) were
re-restorations made by one dentist in a private practice (31
upper bicuspids, 12 upper molars, 14 lower bicuspids, and 11
lower molars). Reasons for replacement were caries (n = 19),
insufcient esthetics (n = 2), and secondary caries (n = 47). For
all teeth receiving restorations, current X-rays (within six
months of the procedure) were present. After evaluating the
radiographs, 53 cavities (78%) were treated as caries profunda.
Twenty-four cavities (35%) revealed no enamel at the oor of
the proximal box, while 33 cavities (49%) exhibited a proximal
enamel width of <0.5 mm.
All llings were inserted in permanent vital teeth without
pain symptoms. An extension for prevention was disregarded
for maximal substance protection; however, the majority of
restorations were previously prepared with undercuts for
amalgam retention. The cavities were cut using coarse diamond burs under profuse water cooling (80 m diamond,
Komet, Lemgo, Germany), and nished with a 25-m nishing diamond. Inner angles of the cavities were rounded
and the margins were not beveled. After cleaning and drying
under rubber dam isolation (Coltene/Whaledent Inc., Altsttten, Switzerland), adhesive procedures were performed
with Solobond M (two-step etch-and-rinse adhesive) and Syntac (four-step etch-and-rinse adhesive). The resin composite
materials were applied into the cavity in layers of approximately 2-mm thickness and adapted to the cavity walls with
a plugger. Each layer was light cured for 40 s (Elipar Trilight, 3M
Espe, Seefeld, Germany). The occlusal region was modeled as
exactly as possible under intraoral conditions, avoiding visible
overhangs. The light-emission window was placed as close as
possible to the cavity margins. The intensity of the light was
checked periodically with a radiometer (Demetron Research
Corp., Danburg, CT, USA) and was found to be constantly above
650 mW/cm2 .
As soon as polymerization was completed, the surface of
the restoration was controlled for defects and corrected when
necessary. Visible overhangs were removed with a scaler and
the rubber dam was removed. Contacts in centric and eccen-

Table 1 Evaluated clinical codes and criteria.

Modied criteria

2.

Description

Analogous
USPHS

Perfect
Slight deviations from ideal
performance, correction
possible without damage to
tooth or restoration
Few defects, correction
impossible without damage
to tooth or restoration. No
negative effects expected
Severe defects, prophylactic
removal for prevention of
severe failures
Immediate replacement
necessary

Alpha

Methods and materials

Patients selected for this study met the following criteria: (1)
absence of pain from the tooth to be restored; (2) possible
application of rubber dam during luting of restoration; (3) no
further restorations planned in other posterior teeth; (4) high
level of oral hygiene; (5) absence of any active periodontal and
pulpal disease; (6) restorations required in two different quadrants (split-mouth design).
Thirty patients (23 females and 7 males, mean age 32.9
(2459) years) with a minimum of two llings to be replaced
in different quadrants received at least two different restorations in a random decision according to recommendations of
the CONSORT statement [38]. Thirty-six Grandio llings were

Excellent
Good

Sufcient

Insufcient

Poor

Bravo

Charlie

Delta

752

Table 2 Descriptive statistics for all assessed restorations.

Baseline (n = 68)
Alpha I
(%)
Date of investigation

Bravo
(%)

Alpha I
(%)

1.2 months

100
94
44
91
93
94
97
91
91

Alpha
II (%)

24 months (n = 68)
Bravo
(%)

Alpha I
(%)

13.1 months

6
54
9
4
4

2
3
2
3
2
5

7
4

100
97
9
73
53
96
100
97

3
75
25
21
4

Alpha
II (%)

48 months (n = 68)
Bravo
(%)

Alpha I
(%)

24.4 months

99
93
16
2
26

1
7
60
47
41
16

40
9
82
100
100

Alpha
II (%)

Bravo
(%)

49.2 months

93
84
40
13
50
2

29
1
91
100
100
96

7
13
34
56
25
7

3
66
15
74
1

Table 3 Descriptive statistics for all Grandio restorations.

Criterion

Baseline (n = 36)
Alpha I
(%)

Surface roughness
Color match
Marginal integrity
Integrity tooth
Integrity lling
Proximal contact
Change of sensitivity
Hyper-sensitivity
Radiographic assessment

100
92
50
86
100
94
100
97
89

Alpha
II (%)
8
47
14

12 months (n = 36)
Bravo
(%)

3
3

Alpha I
(%)
100
94
8
75
55
97
100
97

Alpha
II (%)
6
75
25
17
3
3

24 months (n = 36)
Bravo
(%)

Alpha I
(%)

Alpha
II (%)

97
92

3
8
53
42
45
11

17
28

47
11
89
100
100

48 months (n = 36)
Bravo
(%)

47
11
44

Alpha I
(%)

Alpha
II (%)

Bravo
(%)

92
81

8
14
36
58
28
6

5
64
11
69

31
3
94
100
100
97

d e n t a l m a t e r i a l s 2 5 ( 2 0 0 9 ) 750759

Criterion
Surface roughness
Color match
Marginal integrity
Integrity tooth
Integrity lling
Proximal contact
Change of sensitivity
Hyper-sensitivity
Radiographic assessment

Alpha
II (%)

12 months (n = 68)

88
100
100
94

31
6
75
100
100
13
6

3
63
3
9
3

6
3
6
3

75
25
25
6

100
100
9
72
50
94
100
97

16
3
25

100
94

6
69
53
38
22

31
16
56
3

28

94
88

6
13
31
53
22
9

69
19
78
3

Bravo
Alpha
II (%)
Alpha
II (%)
Alpha I
(%)
Alpha
II (%)
Alpha I
(%)
Bravo
Alpha
II (%)

100
97
37
97
85
94
94
84
94
Surface roughness
Color match
Marginal integrity
Integrity tooth
Integrity lling
Proximal contact
Change of sensitivity
Hyper-sensitivity
Radiographic assessment

753

tric occlusion were controlled with foils (Roeko, Langenau,

Germany) and adjusted with nishing diamonds (Komet Dental, Lemgo, Germany), shaped with exible discs (3M Dental,
St. Paul, USA), super-ne discs (3M Dental, St. Paul, USA) and
polishing brushes (Hawe-Neos Dental, Bioggio, Switzerland).
A uoride varnish (Elmex Fluid, GABA, Lrrach, Germany) was
used to complete the treatment.
At the initial recall (baseline, i.e. within two weeks),
and after six months, one, and two years, all restorations
were assessed according to the modied United States Public Health Service (USPHS) criteria (Tables 1 and 2) by two
independent investigators using mirrors, probes, bitewing
radiographs, impressions (Dimension Penta and Garant, 3M
ESPE, Seefeld, Germany), and intraoral photographs. Recall
assessments were not performed by the clinician who initially
placed the restorations. Impressions were used to manufacture epoxy replicas (Alpha Die, Schtz Dental, Germany).
Forty-four replicas were selected (22 of each group) for stereo
light microscopic (SLM) analysis, 22 of these 44 replicas (11 of
each group) were subjected to scanning electron microscopic
(SEM) analysis. The replicas with the longest evaluable margins were selected randomly.
SLM replicas were assessed at 130-fold magnication under
a stereo light microscope (SV 11, Zeiss, Germany) in combination with a 3 CCD color camera (Sony, Cologne, Germany)
and a frame grabber (Matrox Meteor RGB, AVT Horn, Aalen,
Germany). The KS 100 software (Jenoptik, Jena, Germany) was
used for digitization and WinMes 2.0 was used for the margin
analysis.
For SEM evaluation, replicas were mounted on aluminum
stubs, sputter-coated with gold and examined with a SEM
(Leitz ISI 50, Akashi, Tokyo, Japan) at 200 magnication. SEM
examination was performed by one operator who had experience with quantitative margin analysis and was blinded to
the restorative procedures. The accessible marginal integrity
between the resin composite and enamel was expressed as a
percentage of the entire margin length that was available for
evaluating. Marginal qualities were classied according to the
same criteria as in the SLM.
Statistical appraisal was computed with SPSS for Windows XP 14.0 (SPSS Inc., Chicago, IL, USA). Statistical unit
was one tooth, differences between groups were evaluated
using MannWhitney U-test, changes over time were calculated with the Friedman test (p = 0.05).

3.
Alpha I
(%)

Baseline (n = 32)
Criterion

Table 4 Descriptive statistics for all Tetric Ceram restorations.

12 months (n = 32)

Bravo

24 months (n = 32)

Bravo

Alpha I
(%)

48 months (n = 32)

d e n t a l m a t e r i a l s 2 5 ( 2 0 0 9 ) 750759

Results

Success rate was 100% after four years of clinical service, while
the drop out of patients was 0%. The results of the clinical
investigation sessions are displayed in Tables 27. The restorative materials did not reveal any signicant differences after
four years in any criterion (p > 0.05; MannWhitney U-test).
Irrespective of the resin composite used, signicant
changes over time were found for all criteria (Friedman test;
p < 0.05) except the criterion radiographic assessment (Friedman test; p > 0.05). Marginal integrity started out with a major
portion of overhangs in all marginal areas detected at the
one-year recall (baseline 44%; six months: 65%; one year: 47%;
two years: 6%; four years: 4%), probably not seen at baseline

754

d e n t a l m a t e r i a l s 2 5 ( 2 0 0 9 ) 750759

Table 5a Descriptive statistics regarding marginal integrity (all restorations).

Criterion

Baseline
(n = 68)

12 months
(n = 68)

24 months
(n = 68)

48 months
(n = 68)

44.1%

8.8%

0.0%

0.0%

Negative step
Overhang
Stained overhang

8.8%
44.1%
1.5%

22.1%
47.1%
5.9%

44.1%
5.9%
10.3%

29.4%
4.4%
0.0%

Gap/negative step
Staining

1.5%
0.0%

8.8%
7.4%

16.2%
23.5%

23.5%
42.6%

Alpha I
Excellent
Alpha II
Slight defects, easily
correctable

Bravo
Slight defects, not
correctable without damage

Table 5b Descriptive statistics regarding marginal integrity (Grandio restorations).

Criterion

Baseline
(n = 36)

12 months
(n = 36)

24 months
(n = 36)

48 months
(n = 36)

50.0%

8.3%

0.0%

0.0%

Negative step
Overhang
Stained overhang

5.6%
38.9%
2.8%

22.2%
47.2%
5.6%

38.9%
2.8%
11.1%

27.8%
8.3%
0.0%

Gap/negative step
Staining

2.8%
0.0%

5.6%
11.1%

19.4%
27.8%

25.0%
38.9%

Alpha I
Excellent
Alpha II
Slight defects, easily
correctable

Bravo
Slight defects, not
correctable without damage

Table 5c Descriptive statistics regarding marginal integrity (Tetric Ceram restorations).

Criterion

Baseline
(n = 32)

12 months
(n = 32)

24 months
(n = 32)

48 months
(n = 32)

37.5%

9.4%

0.0%

0.0%

Negative step
Overhang
Stained overhang

12.5%
50.0%

21.9%
46.9%
6.3%

50.0%
9.4%
9.4%

31.3%
0.0%
0.0%

Gap/negative step
Staining

0.0%
0.0%

12.5%
3.1%

12.5%
18.8%

21.9%
46.9%

Baseline
(n = 68)

12 months
(n = 68)

24 months
(n = 68)

48 months
(n = 68)

91.2%

73.5%

39.7%

29.4%

Alpha I
Excellent
Alpha II
Slight defects, easily
correctable

Bravo
Slight defects, not
correctable without damage

Table 6a Descriptive statistics regarding integrity tooth (all restorations).

Criterion
Alpha I
Excellent
Alpha II
Slight defects, easily
correctable

Enamel chipping
Enamel crack

1.5%
7.4%

0.0%
25.0%

4.4%
42.6%

0.0%
55.9%

Bravo
Slight defects, not
correctable without damage

Enamel chipping
Enamel crack

0.0%
0.0%

1.5%
0.0%

10.3%
2.9%

14.7%
0.0%

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Table 6b Descriptive statistics regarding integrity tooth (Grandio restorations).

Criterion
Alpha I
Excellent

Baseline
(n = 36)

12 months
(n = 36)

24 months
(n = 36)

48 months
(n = 36)

86.1%

75.0%

47.2%

30.6%

Alpha II
Slight defects, easily
correctable

Enamel chipping
Enamel crack

2.8%
11.1%

0.0%
25.0%

2.8%
38.9%

0.0%
58.3%

Bravo
Slight defects, not
correctable without damage

Enamel chipping
Enamel crack

0.0%
0.0%

0.0%
0.0%

8.3%
2.8%

11.1%
0.0%

Table 6c Descriptive statistics regarding integrity tooth (Tetric Ceram restorations).

Criterion
Alpha I
Excellent

Baseline
(n = 32)

12 months
(n = 32)

24 months
(n = 32)

48 months
(n = 32)

96.9%

71.9%

31.3%

28.1%

Alpha II
Slight defects, easily
correctable

Enamel chipping
Enamel crack

0.0%
3.1%

0.0%
25.0%

6.3%
46.9%

0.0%
53.1%

Bravo
Slight defects, not
correctable without damage

Enamel chipping
Enamel crack

0.0%
0.0%

3.1%
0.0%

12.5%
3.1%

18.8%
0.0%

Table 7a Descriptive statistics regarding integrity lling (all restorations).

Criterion

Baseline
(n = 68)

12 months
(n = 68)

24 months
(n = 68)

48 months
(n = 68)

92.6%

52.9%

8.8%

1.5%

Chipping
Crack
Roughness/abrasion

2.9%
0.0%
1.5%

2.9%
0.0%
17.6%

0.0%
1.5%
39.7%

0.0%
0.0%
25.0%

Chipping
Crack probing
Abrasion
Roughness
Void

0.0%
2.9%
0.0%
0.0%
0.0%

8.8%
2.9%
10.3%
0.0%
4.4%

2.9%
0.0%
30.9%
4.4%
11.8%

7.4%
4.4%
51.5%
7.4%
2.9%

12 months
(n = 36)

24 months
(n = 36)

48 months
(n = 36)

100.0%

55.6%

11.1%

2.8%

Chipping
Crack
Roughness/abrasion

0.0%
0.0%
0.0%

2.8%
0.0%
13.9%

0.0%
0.0%
44.4%

0.0%
0.0%
27.8%

Chipping
Crack probing
Abrasion
Roughness
Void

0.0%
0.0%
0.0%
0.0%
0.0%

8.3%
2.8%
11.1%
0.0%
5.6%

5.6%
0.0%
16.7%
5.6%
16.7%

8.3%
2.8%
50.0%
8.3%
0.0%

Alpha I
Excellent
Alpha II
Slight defects, easily
correctable

Bravo
Slight defects, not
correctable without damage

Table 7b Descriptive statistics regarding integrity lling (Grandio restorations).

Criterion

Baseline
(n = 36)

Alpha I
Excellent
Alpha II
Slight defects, easily
correctable

Bravo
Slight defects, not
correctable without damage

756

d e n t a l m a t e r i a l s 2 5 ( 2 0 0 9 ) 750759

Table 7c Descriptive statistics regarding integrity lling (Tetric ceram restorations).

Criterion

Baseline
(n = 32)

12 months
(n = 32)

24 months
(n = 32)

48 months
(n = 32)

84.4%

50.0%

6.3%

0.0%

Chipping
Crack
Roughness/abrasion

6.3%
0.0%
3.1%

3.1%
0.0%
21.9%

0.0%
3.1%
34.4%

0.0%
0.0%
21.9%

Chipping
Crack probing
Abrasion
Roughness
Void

0.0%
6.3%
0.0%
0.0%
0.0%

9.4%
3.1%
9.4%
0.0%
3.1%

0.0%
0.0%
46.9%
3.1%
6.3

6.3%
6.3%
53.1%
6.3%
6.3%

Alpha I
Excellent
Alpha II
Slight defects, easily
correctable

Bravo
Slight defects, not
correctable without damage

Table 8 Margin analysis (percentages and S.D. in parentheses) SEM, all selected restorations.
Baseline
(n = 39)

48 months
(n = 39)

Judged length (in mm)

13.8 (5.8)

14.2 (6.6)

Criterion (in %)
Perfect margin
Negative step formation
Gap formation
Overhang
Positive step formation
Marginal fracture
Artifact

55.4 (14.4)
11.3 (10.8)
0.5 (2.2)
13.4 (12.4)
8.5 (8.0)
0.2 (0.7)
10.6 (12.3)

28.8 (13.8)
49.7 (18.6)
1.0 (2.6)
8.0 (9.1)
3.3 (5.3)
2.7 (4.0)
6.5 (6.7)

Table 9 Margin analysis (percentages and S.D. in parentheses) SEM, all selected Grandio and Tetric Ceram restorations.
Criterion (in %)

Baseline

48 months
Material

Grandio (n = 19)
Perfect margin
Negative step formation
Gap formation
Overhang
Positive step formation
Marginal fracture
Artifact

54.9 (15.0)
13.7 (12.7)
0.1 (0.6)
14.0 (10.9)
8.1 (7.0)
0.3 (0.9)
8.8 (11.0)

due to a good color match. Beyond the one-year recall, more

and more negative step formations due to wear and marginal
staining were detected (Table 2).
Tooth integrity signicantly deteriorated due to enamel
cracks, which increased over time (p < 0.05; Table 2). The main
reasons for a decreasing number of teeth with good restoration integrity were visible signs of surface roughness and
wear facets (28% after one year, 75% after two years, 84% after
four years; Table 2).
The outcome of the margin analysis is displayed in
Tables 8 and 9. The results of the SEM margin analysis revealed no signicant differences among the materials
(MannWhitney U-test; p > 0.05), except for the criteria perfect

Tetric Ceram
(n = 20)
55.9 (14.3)
9.0 (8.4)
0.9 (3.0)
12.9 (13.8)
8.9 (9.0)
0.2 (0.6)
12.2 (13.53)

Grandio
(n = 19)

Tetric Ceram
(n = 20)

22.8 (9.2)
55.7 (17.3)
1.0 (3.2)
8.0 (10.3)
4.4 (5.6)
3.4 (4.7)
4.7 (4.4)

34.8 (15.3)
43.8 (18.3)
0.9 (2.0)
8.0 (8.1)
2.2 (4.7)
1.9 (3.1)
8.3 (8.1)

margin (Grandio: 22.8%; Tetric Ceram: 34.8%) and for positive

step formation after four years (Grandio: 4.4%; Tetric Ceram:
2.2%). Concerning all criteria, changes were signicant over
time (Friedman test; p < 0.05) except for gap formation and
artifact (Friedman test, p > 0.05).

4.

Discussion

Resin composites are suitable materials for posterior cavities

when a meticulous adhesive and layering technique is used
clinically [1012,18,30,39]. It is unclear up to now, where the
limitations of directly applied resin composites are when it

d e n t a l m a t e r i a l s 2 5 ( 2 0 0 9 ) 750759

comes to cavity extension. It is not a single opinion that very

large cavities should be restored with other materials and
techniques [21]. The major concerns with resin composites in
large cavities are both the increased danger of recurrent caries
formation as well as considerably higher wear rates [40].
From clinical trials dealing with ceramic inlays and onlays
it is well known that margins extending below the cementoenamel junction can be safely restored [6,16,25,40]. The same
is true for Class V restorations in which, by nature, approximately 50% of margin length is located in dentin [4,19,20,22].
However, for extended Class II direct resin composite
restorations, the information in the literature is scarce [21].
Therefore, this study was designed to exclude minimally invasive cavities and to limit the clinical procedures mainly to
amalgam replacement restorations. The fact that 35% of the
cavities exhibited no proximal enamel and 49% presented less
than 0.5 mm of enamel was very challenging for the materials
under investigation. Nevertheless, after four years of clinical
service, these unfavorable circumstances had no detrimental
effect on clinical outcome of both material combinations.
A recent publication with recommendations regarding
clinical studies with restorative materials has been published recently [31], however, considerably after this study
was started and evaluation criteria were determined. Therefore, it was not possible to include additional aspects
beside well-suited protocols such as the CONSORT statement
[15,16,38,40].
Resin composites have to be adhesively bonded to guarantee an acceptable clinical performance [5,10,11,14,30].
Etch-and-rinse and self-etch adhesives are the main systems
suggested for use [17,24,26,27,29]. However, the main problem
for clinicians is that they have to deal with two completely different substrates in the vast majority of cavities needing to be
adhesively restored [6,13,18,19]. The selection of materials for
this study was previously accomplished thorough in vitro testing, which showed promising results for both materials used,
in terms of good marginal adaptation and long-term stability
[24,27,28,41]. Nevertheless, one problem with any preclinical
prediction of adhesive performance remains: when an adhesive restoration like a resin composite restoration achieves a
good marginal quality values in vitro, it is seems to be assumed
that its clinical behavior regarding marginal quality will be
similar. On the other hand, it is nearly impossible for the lab
to exactly dene the critical level of marginal quality that is
required to predict acceptable clinical behavior.
Although the preparations in this study required different
bonding protocols, i.e. with considerably more attention to wet
bonding with the acetone-based Solobond M, this obviously
did not affect the clinical results in terms of postoperative hypersensitivities (Tables 3 and 4). Initially, restorations
bonded with Syntac exhibited slightly more hypersensitivities (baseline to six months) (3% vs. 0% bravo scores), but
this played no role past the one-year recall. Therefore, both
the internal sealing of dentin and tight dentin margins were
possible with both adhesives under investigation. However,
evaluating the outcome of restorative systems (i.e. adhesive
and resin composite of two different manufacturers) always
lets some room for speculations. Would the results have been
different when only one adhesive or only one resin composite
would have been used? The present study is not able to com-

757

pletely answer this question, but facing the promising results

over the four-year period we assume that both systems per se
are clinically acceptable.
The prex nano is very fashionable in recent adhesive
dentistry. The benets from incorporating only nanollers,
like in Filtek Supreme (3M ESPE, Seefeld, Germany), are predominantly related to translucency effects and polishability
[12,42,43]. However, irrespective of the fact that, whether
nanollers have been totally partially incorporated into nanooptimized materials, clinical reports dealing with this class
of materials exhibited no signicant advantages in vivo [12].
In terms of classication, Tetric Ceram was used as ne
hybrid resin composite (without nanollers), and Grandio was
used as one of the rst resin composites with incorporated
nanollers beside conventional hybrid type llers, being called
nanohybrid resin composites [12,32,37].
In the course of the present clinical trial we furthermore
included microscopical analyzes using both SLM and SEM
in order to evaluate margin analysis. However, it has to be
stated that in vivo margin analyses always suffer several shortcomings compared to in vitro research related to marginal
adaptation which is routinely performed using thermomechanical loading and SEM analysis of epoxy replicas [2426].
Although a high percentage of proximal margins were located
in dentin, these areas are almost impossible to record by
impressions in a full arch. So the important question whether
proximal margins extending into dentin cannot be answered
by this kind of marginal analysis, only clinical observations
such as gaps or secondary caries can be considered. The
present observations on the microscopical level have mainly
illustrating character and support the clinical observations of
the occlusal surface like wear and consecutive negative step
formations.
Altogether, the null-hypothesis of the present investigation
was conrmed because there was no difference in the clinical
behavior between Grandio and Tetric Ceram used for extended
Class II posterior restorations.

5.

Conclusion

Grandio and Tetric Ceram performed satisfactorily in

extended Class II cavities. After four years, bonding to deep
proximal cavities extending below the CEJ was possible.

Acknowledgement
This work was supported by Voco, Cuxhaven, Germany.

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