Benefits and disadvantages of tooth-coloured alternatives to amalgam

Objectives: To give the practising dentist scientifically based data to assist him/her in the responsible decision-making process necessary to weigh the options available to the patient if she/he prefers not to have an amalgam placed. Data sources: Based on the literature and on the research work, which was done in the authorʹs department, the indications and limitations of the known alternatives of amalgam were formulated. Description of alternatives to amalgam: With the exception of cast gold restorations, all alternatives require the strict use of adhesive techniques. When compared with similar amalgam restorations, placing composite restorations (if they are indicated) takes approximately 2.5 times longer because complex incremental techniques are needed. Despite all the efforts, direct composite restorations placed in large cavities still show unacceptable amounts of marginal openings. Tooth-coloured inlays are a better alternative for large restorations. These restorations must be inserted with adhesive techniques. With composite inlays it is difficult to achieve a composite-composite bond. Ceramic inlays may be micromechanically bonded to the luting composite. They all show clinically a good marginal behaviour and the use of ultrasonic energy may further simplify the application technique of aesthetic inlays. Study selection: Papers describing the different techniques were used as a base for the corresponding chapter. To assess and compare the longevity of the different restoration types, literature data were used. We limited ourselves to papers reporting at least 5-year clinical data. Longitudinal, clinically controlled studies were preferred. However, to be more complete, retrospective, cross sectional studies were also included. Longevity of posterior restorations: Amalgam shows excellent longevity data with studies up to 20 years. The average annual failure rate is 0.3–6.9%. Posterior composites are in the same range (0.5–6.6%), however, the study times are much shorter (max. 10 years). For tooth-coloured inlays much less data are available. Longevity is reported up to 6 years with annual failure rates of 0.6–5%. Conclusions: All aesthetic alternatives to amalgam require more complex procedures and more time. If cost benefit considerations are a concern, amalgam is still the most convenient restorative material for posterior teeth.