its margins if steps are not taken to reduce the effects of
PRIMARY CARE DENTISTRY polymerisation eon traction.'" Stresses in the restored tooth
Introduction
Dental amalgam, which essentially is a mixture of a silver-tin
alloy and mercury, has been the material of choice for restoration
of posterior teeth for well over a century, but the placement
of restorations of good aesthetics appears increasingly to be
requested by patients.'- Apart from aesthetics, patients may
request tooth-coloured restorations because of concems about
perceived mercury toxicity. while govemment departments and
dental practitioners may seek amalgam altematives beeause of
the environmental concerns associated with mereury. Results
of surveys have shown that almost half of the Class 1 and one
third of Class II restorations placed in the US are now tooth-
coloured and one quarter of class I restorations placed in the
UK are made in resin-bascd composite (RBC) materials.-''
However, despite the increasing importance of good dental
aesthetics, effective patient eare in the form of restorations
of good quality and optimal longevity should be the goal of
the dental practitioner, no matter what material is used in their
placement.
Dental Amalgam
Dental amalgam, when placed in a cavity prepared in a tooth,
sets within 30 to 90 minutes. It is capable of being carved
immediately after placement, but cannot be polished until set.
Principal advantages are its low cost, and ease of use for the
dentist. However, there have been concems related to the use of
amalgam, almost since its introduction a century and a half ago.
Current expert opinion is that there are no concerns for patient
safety but there may be anxieties for the dentists plaeing the
restorations.'^ The CDO of Finland, summarized the situation
regarding regulations on amalgam usage in 1997, stating:
• Expert groups in different countries who have evaluated the
scientific research on the health effects of dental amalgam have
concluded that there is no direct evidence of an adverse effect
of mercury from amalgam restorations on general health.
• Amalgam, when properly handled, has not been shown to be
hazardous to dental personnel.
• Health authorities in some countries have taken a rather
cautious attitude to the use of amalgam in dentistry. Major
amalgam therapy has not been reeommendcd when treating
pregnant women and young ehildren or patients with renal
disease, the rationale being a desire to lower the exposure to
mereury during sensitive periods of life.
• Amalgam separators in the wastelines of dental units are a
legal requirement in some countries and there are pressures to
introduce them in many more countries.
• Approximately 250,000 dentists within the EU treat their
patients using amalgam fillings.
Analysis of worldwide data on amalgam usage, where
available, has indicated few govemmental restrictions in
amalgam use and decreasing use in many countries.''
Resin Composite
Resin-based composite materials essentially eonsist of a resin
matrix, with a glass, quartz or siliea filler up to 85% by weight.
On polymerisation, it contracts by up to 3% volume, with the
attendant problems of stress at restoration margins, potential
for cusp movement, or the restoration to be de-bonded at
•g^H The Royal Colleges of Surgeons of Edinburgh and Ireland
may demonstrate as post-operative pain, usually on biting.
Early composites suffered from poor wear resistance, but this
problem appears largely to have been overcome."
During placement of resin composite restorations, steps
must be taken to counter the effect of polymerisation shrinkage.
These include;
• Incremental placement, with each increment touching only
one wall ofthe eavity at any timc.'-^
" An awareness of the configuration factor, which recognises
that occlusal cavities have the highest potential for stress, given
that the surface area where polymerisation shrinkage can oecur
(the oeclusal surface) is small in comparison with the area of
the surfaces whieh are bonded.''
• So-called "ramped" curing, in which the intensity of the
curing light is increased over a period of 30 seconds, either by
bringing the light towards the tooth from a distance, by curing
through a cusp or by using a euring light designed to increase
in intensity.'"*
• Pulsed activation has been suggested, in which curing for
30 seconds and then leaving the restorations for five minutes
before subjeeting the restorations to a further 30 second cure,
and has been shown to signifieantly reduee microleakage.'^
• The placement of a low-modulus flowable composite layer at
the base ofthe cavity has been demonstrated to reduce in vitro
microleakage at the gingival margin in Class II restorations."'
The above techniques were introduced to reduee the effects
of polymerisation shrinkage, but these add to the technique
sensitivity of composite placement, so another approach, the
development of new resins with polymerisation contraction as
low as 1% would be welcomed by clinicians.''"* Contraction of
this magnitude may be being balanced by a similar uptake of
moisture when the restoration is placed in the mouth. However,
no restorative materials with a polymerisation shrinkage of
this level are commercially available at the time of writing,
although it is likely that sueh a material will be introduced in
the near future.
Resin composite restorations are placed using a dentine
bonding agent, and because this produces adhesion to tooth
substance, eavity preparation may be limited to only the
removal of caries, in contrast to amalgam restorations which
require the cutting of a retentive lock, or key, often with the
attendant removal of sound tooth substanee. Saucer-shaped
cavity preparations may be considered appropriate for small
approximal lesions in posterior teeth.'** An extension to the
minimal intervention technique is the Preventive Resin
Restoration, which incorporates prevention by sealing
remaining fissures, to provide a preventive role to the
restoration.'"
In the past, difficulties were experienced in aehieving
correct interproximal contour for composite restorations.''
Newer "paekable" materials may permit the use of metal matrix
systems which can be "pressed" against the adjacent tooth. One
system (Kerr-Hawe Supermat; Lugano, Switzerland) allows the
use of a thin metal matrix in a retainer-less holder, with the thin
metal being eapable of being "bumished" against the adjacent
tooth. Other "sectional" matrix systems (such as the Palodent
Sectional Matrix system: Dentsply, Weybridge, Surrey, UK)
use a ring that causes slight separation of adjacent teeth, and
©2005 Surgeon 3. 3; 187-196
contoured metal matrices whieh are supplied in a variety of
sizes. Once placed, metal matrices should be bumished against
the adjacent tooth and wedges placed at the gingiva! margin to
ensure that the matrix fits tightly.
Dentine bonding agents have been designed for use
with resin composite materials, since the currently available
composite materials do not possess the ability to bond to
tooth substance. These bonding agents have been refined in
reeent years to reduce their technique sensitivity. The use of
a resin-modified glass ionomer base may also be considered
appropriate, sinee these materials adhere to tooth substance
and have the advantage of fluoride release." In an altemative
technique, known as the "sandwich (or laminate) technique", a
thicker glass ionomer base may be placed.-^
Resin composite has been eonsidered to be suitable for the
following indications:
• Small carious lesions which allow conservative preparation,
ineluding the preventive resin restoration.-"
• Restorations for whieh appearance is important.
• Moderate-sized Class I and II restorations.-'"'
• Restorations in patients allergic to metals.'*

Black versus White: Amalgam versus Composite

Advantages of resin composite over amalgam for restoration of
posterior teeth include:
• Good aesthetics (Figures 2 and 3), while gold and amalgam
restorations may be cosmetically unnattractive (Figures 1 and 4).
• Capable of being bonded to tooth stmeture, so reducing Figures 1 ar\d 2: Good appearance of a resin composite restoration replac-
microleakage and removing the need to remove sound toolh ing a tarnished gold inlay.
structure to achieve retention. The technique of amalgam
bonding has recently been introduced and is recommended for
these reasons.
• Patients appear to respond well to the placement of
restorations in resin composite in their posterior teeth.'

Advantages of amalgam over resin composite for restoration of

posterior teeth include:
• Long track record.
• Low cost.

Disadvantages of resin composite over amalgam include:

More time eonsuming plaeement, so less cost-effective to
patient or third party funder than amalgam restorations.-"^
However, this should be balanced by the lack of a need to
remove sound tooth substance to provide mechanical retention Figure 3; A restoration of dental amalgam.
for the resin composite restorations.

Disadvantages of amalgam over resin composite inelude:

• Unaesthetic appearance.
• Need to cut sound tooth structure to provide retention, unless
bonding techniques used.

Regarding elinical performance, a meta-analysis of

the perfonnance of resin composites in posterior teeth has
concluded that •"considering the limited number of studies of
variable length available, the results indicate generally high
clinical performance of the various posterior composites for
the outcomes analyzed".-'' These workers added that "wilh
the development of more advanced formulations of posterior
composite materials and more advanced technology for Figure 4: A mesio-occlusal-distal composite iniay.
polymerisation and plaeement, the performance of posterior

& 2005 Surgeon 3:3:1B7-m The Royal Colleges of Surgeons of Edinburgh and Ireland
composite restorations will continue to improve". Two
recent literature reviews, eaeh of whieh have included over
50 publications on longevity of composite and amalgam
restorations, have shown that the longevities of both types
of restoration are similar.'--'* Results in other publications on
longevity of posterior composite restorations are promising and
at least one dental school has abandoned teaching of amalgam
in favour of composite.-''-''"
Concluding Remarks
The satisfactory restoration of posterior teeth using tooth-
coloured materials may increasingly become an important
aspect of a successful practice. Early evaluations of restorations
in resin composite in posterior teeth demonstrated poor
performance, but the problems have largely been overcome and
longevity data for amalgam and resin composite restorations
are now similar." However, a principal problem relating to the
perfonnance of composite in posterior teeth is the clinician,
rather than the material, given the many relatively difficult
steps in placement. It can be hoped that the development of low
shrinkage materials and in the longer term, self-etch materials
will improve the technique sensitivity of resin eomposite for
restorations in posterior teeth. The clinician should choose a
material which she/he is eonfident in handling, given thai ease
and confidence in handling are requirements for the routine
achievement of optimum results. The use of magnification aids
by loupes may be of value in such cases (and indeed, in all areas
of adhesive dentistry).
A wide variety of devices and teehniques. designed to
optimise results, are now available lo the clinician, although
these may require a period of leaming. It would seem
appropriate that undergraduate course organisers offer modules
on these treatments to their students, since, as the demand
for tooth-coloured restorations in posterior teeth increases.
practitioners will have to respond by being proficient in
placement techniques that produce restorations with good
longevity in clinical service.
Black or white, amalgam versus composite for restoration
of posterior teeth, is a continuing debate. The balance was.
until recently, heavily weighted in favour of amalgam by way
of its weight of research evidence on longevity. However, as
data on the success rates of posterior eomposite restorations
become increasingly available and positive, the disadvantages
of amalgam, such as poor appearance and the need to cut
tooth substanee to produce a retentive cavity, become more
significant. It may be considered that the development of
low shrink materials will inereasingly make clinicians favour
composite over amalgam, and, if and when a self-adhesive
resin becomes available for restoration of teeth, a tme amalgam
replacement will have arrived. However, in the UK. the
adoption of techniques sueh as posterior composite will remain
dependant on the retiulations set by third party funders such as
the NHS.
T. Burke
The Royal Colleges of Surgeons of Edinburgh and Ireland
REFERENCES
1. Reinhardt JW, Capilouto ML. Composite resin esthetic
dentistry survey in New England. J Am Dent Assoc
1990; 120:541-44.
2. Burke FJ. Patient acceptance of posterior composite
restorations. Dent Update 1989; 16:114-20.
3. Brown LJ, Wall T, Wassenaar JD. Trends in resin
and amalgam usage as recorded on insurance claims
submitted by dentists from the early 1990s and 1998../
Dent Res 2000;79:461; Abstract 2542.
4. Burke FJ, Cheung SW. Mjor IA, Wilson NHF.
Restoration longevity and analysis of reasons for
their placement and replacement. Paper submitted for
editorial consideration.
5. Ekstrand J, Bjorkman L, Ediund C, Sandborgh-Engiund
G. Toxicologieal aspects on the release and systemic
uptake of mercury from dental amalgam. Eur J Oral Sci
1998;106:678-86.
6. US Public Health Service and Department of Health and
Human Services. Dental amalgam: A scientific review
and recommended Public Health Service strategy for
research, education, and regulation. Washington, DC:
USDHHS; 1993.
7. Ritchie KA, Burke FJ, Gilmour WH, Macdonald EB,
Dale IM, Hamilton RM et al. Mercury vapour levels in
dental praetiees and body mercury levels of dentists and
controls. SrDf'/7/./2004;I97:625-32.
8. Widstrom E. Amalgam arouses hot feelings. Community
Dental Health 1997;14:125-26.
9. Burke FJ. Amalgam to tooth coloured materials
- implieations for clinical practice. Governmental
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343-50.
10. CombeEC, Burke FJ, Douglas WH.D^H/a//j/owa/er/a/.y.
London: Kluwer Academic Publishers, 1999.
11. El-Mowafy OM. Wear of posterior composite
restorations. A problem ofthe past. Ont Dent 1991;71:
13-17.
12. Wieczkowski G. Joynt RB, Klockowski R. Davis EL.
Effects of incremental versus bulk fill technique on
resistanee to cuspal fracture of teeth restored with
posterior composites. 7 Prfw^/je/ Dent 1988;60:283-87.
13. Feilzer AJ, DcGee AJ, Davidson CL. Setting stress in
composite resin in relation to the configuration of the
restoration. J Dent Res 1987;66:1636-39.
14. Koran P, Kursehner R. Effect of sequential versus
continuous irradiation of a light-cured resin composite
on shrinkage, viscosity, adhesion and degree of
polymerisation./Jmy Dem l998;IO:17-22.
15. Kanea J. Suh BI. Pulse activation: reducing resin-
based eomposite contraction stresses at the enamel
cavosurface margins, .^m 7 Dew/ 1999:12:107-12.
16. Uctasli S, Shortall AC, Burke FJ. Effect of accelerated
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composites, ^m 7 Dfn/2002:15:153-58.
17. Eick D. Laughlin G, Krenkel D, Rozzi S, Craig B,
Reiman M. A new oxirane/polyol low shrink/low stress
dental eomposite. J Dent Res 2001:80:271.
18. Palin W, Fleming G, Burke F, Marquis P, Randall RC.
Evaluation ofthe volumetric shrinkage of a novel resin-
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 based restorative. J Dent Res 2002:81:A-36.
19. Nordbo H, Leirskar J, van der Fehr FR. Saucer-shaped
cavity preparations for posterior approximal resin
composite restorations: Observations up to 10 years.
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1994;25:155-59.
21. Cunningham J, Mair LH. Foster MA, Ireland RS.
Clinical evaluation ol" three posterior composite and
two amalgam restorative materials: 3-ycar results. Br
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22. Sidhu S, Watson IF. Resin-modificd glass ionomer
materials. A status report for the American Joumal of
Dentistry. Am J Dent l995;8:59-67.
23. McLean JW, Powis DR, Prosscr HJ. Wilson AD. The
use of glass-ionomer cements in bonding composite
resins to dentine. BrDentJ I985;158:4l0-14.
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26. El-Mowafy OM, Lewis DW, Benmergui C, Levinton
C. Meta-analysis on long-term clinical performance
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the clinical survival of direct and indirect restorations
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28. Hiekel R. Manhart J. Longevity of restorations in
posterior teeth and reasons for failure. J Adhes Dent
2001;3:45-64.
29. Mair LH. Ten-year clinical assessment of three posterior
resin composites and two amalgams. Quintessence Int
1998;29:483-90.
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s) 2005 Sofgeon 3. 3, 187-196
TREATMENT OF THE EDENTULOUS PATIENT
One of the best examples of the benefits of dental health
education has been the significant decrease in the percentage
of adults with no remaining natural teeth (edentulousness).
In 1970. in the United Kingdom, this figure was almost 50%
for all adults. In the recent survey of Adult Denial Health,
this figure was 19%.' This is clearly a signincant outcome
of the benefits of dental care as delivered through patient
and media education. Further, the fallacious assumption that
edentulousness is an inevitable consequenee o^anno domini is
now; hopefully, laid to rest.
How then has dental eare advanced to benefit those who are
edentulous and, indeed, those who are at risk of being rendered
edentulous'' These sub-populations will be overviewed via two
discussion topics: firstly, complete denture prosthodonties and
secondly, under preventive prosthodonties.
Complete Denture Prosthodontics
When our College was celebrating its tricentenary, the
prosthodontie techniques required to provide complete
dentures had not undergone mueh of an advancement over the
preceding centuries, impressions or moulds being formed of
the edentulous jaws in beeswax, easts poured in plaster of Paris
and the prostheses carved of ivory. Between the tricentenary
and the quarter-centenary, advances in prosthodontics and
prosthodontie technology included new impression materials
(e.g. impression compounds, steel-pressing of stainless steel
dental bases, the process of vulcanisation and porcelain
denture teeth.- Indeed. Woodforde (1871) details the dentures
worn by George Washington. President ofthe United States
of Ameriea.' They were constructed of (pressed) stainless
steel bases, had "teeth" carved from hippopotamus ivory and
the upper and lower dentures were connected with swivels
and springs, a device considered to help keep the upper
denture up! According to Hillam (1990). these advanees
were predicated by the introduction of general anaesthesia,
whereby teeth could be removed in a painless way.^
Between 1881 and 1981. the science and art of complete
denture prosthodontics experieneed considerable advances
both in the science of dental materials and also in the seience
of dental technology. For example., impression materials were
developed (e.g. hydroeolloid and other elastic impression
materials) which resulted in more accurate moulds of the
edentulous jaws. As polymer chemistry expanded, so did the
materials available to clinicians and (poly) methylmethacrylate
was developed which is still used to make denture bases
(albeit with refinements to give greater strength) and is still
used in orthopaedies. Dental technological methods also
resulted in improved quality of prostheses whieh resulted in
not only in improved "fit" of dentures but also with improved
appearance and stability. In parallel with many other dental,
medieal and surgical disciplines at that time, however, not all
ofthese advanees had an evidence base."^
A good example was the development in the first half of the
twentieth century of dental implants. Many ingenious devices
were used and described; few. however, had any credibility.
In 1981. however, a vanguard article by Adell e? a/ (1981)
heralded the introduction of a clinical technique that was to
ehange the basis of what prosthodontists and their patients
would accept as a gold standard." In the almost quarter
The Royal Colleges of Surgeons of Edinburgh and Ireland