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CLINICAL RESEARCH

Clinical Performance of Direct Composite Restorations in

Patients with Amelogenesis Imperfecta – Anterior Restorations
Neslihan Tekçea / Mustafa Demircib / Safa Tuncerc / Gizem Güderd / Elif Ilgi Sancake

Purpose: To evaluate the clinical performance of direct composite restorations using nanohybrid and nanofill com-
posite materials in anterior teeth in patients with amelogenesis imperfecta (AI).
Materials and Methods: The study included 15 patients with AI aged 14–30 years. During the study, the patients
received anterior direct composite laminate veneer restorations using either a nanohybrid (Clearfil Majesty ES-2
and Clearfil Universal Bond, Kuraray Noritake) or a nanofill resin composite (Filtek Ultimate Universal Restorative
and Single Bond Universal Adhesive, 3M Oral Care). The restorations were evaluated according to the modified
USPHS criteria at baseline and at 1-, 2-, 3- and 4-year follow-up periods.
Results: The cumulative success rate of anterior restorations was 80.5% for nanohybrid and 92.5% for nanofill
composite after 4 years. Eight restorations with nanohybrid and three restorations with nanofill resin composites
failed. Ten restorations failed due to fracture; the fracture rate was 12.3%. Statistically significant differences were
found between nanohybrid and nanofill composites regarding marginal discoloration and surface texture after
3 years. Furthermore, statistically significant differences were observed with respect to color match after 4 years.
Conclusion: The use of a nanohybrid or nanofill composite for anterior direct restorations in patients with AI was
observed to be satisfactory, based on the rate of ideal and clinically acceptable restorations. The primary reason
for restoration failure was fracture. The failure rate of nanohybrid composite restorations was higher than with
nanofill composite restorations with respect to survival and marginal adaptation criteria.
Keywords: amelogenesis imperfecta, dental enamel, composite resin, dental restoration, prospective study.

J Adhes Dent 2022; 24: 77–86. Submitted for publication: 26.08.20; accepted for publication: 14.01.22
doi: 10.3290/j.jad.b2838105

A melogenesis imperfecta (AI) is a rare, inherited, and

congenital disorder that primarily affects only enamel
formation, without any associated morphological or meta-
scription, AI is classified into four types consisting of
14 subdivisions: hypoplastic AI, hypomaturation AI, hypocal-
cified AI, and hypomaturation-hypoplastic AI with taur-
bolic defects. AI is predominantly classified based on clin- odontism.46 The prevalence of AI varies from 1:700 to
ical and radiographic evaluations of enamel defects as well 1:14,000, according to the populations studied.5
as by the mode of its inheritance. Based on the clinical de- Restorative treatment in patients with AI can be con-
ducted through both direct and indirect treatment op-
tions.29,37,41 Direct restorations with resin-based compos-
ites are commonly preferred in young patients to avoid
extensive preparation of teeth during adolescence.41 Also,
a Associate Professor, Department of Restorative Dentistry, Faculty of Dentistry,
University of Kocaeli, Kocaeli, Turkey. Idea, placed the restorations, co-wrote
they can be used in mild cases to veneer the surface of the
the manuscript. teeth, or they can be utilized for more extensive buildups in
b Professor, Department of Restorative Dentistry, Faculty of Dentistry, University of more advanced cases.37,41 Indirect restorations can be
Istanbul, Istanbul, Turkey. Hypothesis, experimental design, wrote the manuscript. used to restore teeth where extensive tooth tissue loss has
c Associate Professor, Department of Restorative Dentistry, Faculty of Dentistry, occurred, and where moisture control is difficult to achieve
University of Istanbul, Istanbul, Turkey. Hypothesis, contributed substantially to for the direct buildup of teeth with a composite.29 Indirect
discussion, proofread the manuscript.
d
treatment options include indirect composite restoration,
Dentist in Private Practice, Dent Design Dental Clinic, Sisli, Istanbul. Co-wrote
the manuscript. post-and-core restorations, ceramic crowns, CAD-CAM res-
e Research Assistant, Department of Restorative Dentistry, Faculty of Dentistry, torations, porcelain veneers, and metal-ceramic fixed dental
University of Kocaeli, Kocaeli, Turkey. Evaluated the restorations at recalls. prostheses.2,24,30,38,39,48 Direct resin composites offer al-
ternative treatment choices. Moreover, they provide excel-
Correspondence: NeslihanTekçe, Department of Restorative Dentistry, Faculty
of Dentistry, University of Kocaeli, Basiskele, Kocaeli, Turkey. lent esthetics and a cost-effective restoration from both
Tel: +90-0-262-344-2222; e-mail: neslihan_arslann@hotmail.com biological and economic points of view compared to other

doi: 10.3290/j.jad.b2838105 77
Tekçe et al

Table 1 Materials used in this study

Material
Manufacturer Ingredients Application Lot number
Clearfil Majesty ES-2 Organic content: bis-GMA, hydrophobic aromatic Place the chosen shade of the paste 00020A
Nano-hybrid composite dimethacrylate, hydrophobic aliphatic dimethacrylate, into the cavity and light cure with a 00006A
dl-camphorquinone, accelerators, initiators dental curing unit. Considering the
(Kuraray Noritake; Tokyo, Inorganic content: silanated barium glass filler, pre- depth of cure, incremental curing may
Japan) polymerized organic filler. Inorganic filler: 78 wt%, 66 vol%, be required.
0.37–1.5 μm

Filtek Ultimate Universal Organic content: bis-GMA, UDMA, TEG-DMA, bis-EMA, Place and light cure restorative in N438989
Restorative (Body) PEG-DMA increments for 10 s with Elipar S10. N441522
Nano-fill composite Inorganic content: a combination of non-agglomerated/
non-aggregated 20-nm silica filler, non-agglomerated/
(3M Oral Care; St Paul, non-aggregated 4- to 11-nm zirconia filler, and aggregated
MN, USA) zirconia/silica, cluster filler (comprised of 20-nm silica and
4- to 11-nm zirconia particles). Inorganic filler: 72.5 wt%,
55.6 vol%, 0.6 μm–10 μm

Clearfil Universal Bond Bis-GMA, HEMA, 10-MDP, hydrophilic aliphatic Apply bond and rub it in for 10 s. Dry 2B0005
(Kuraray Noritake) dimethacrylate, colloidal silica, ethanol, dl- all cavity walls sufficiently with a mild
camphorquinone, silane, accelerators, initiators, water air stream for more than 5 s. Light
cure bonding agent with a light-curing
unit.

Single Bond Universal 10-MDP phosphate monomer, dimethacrylate resins, Following selective enamel etching, 494756
Adhesive HEMA, Vitrebond copolymer, filler, ethanol, water, initiator, apply the adhesive to the prepared
(3M Oral Care) silane tooth and rub it in for 20 s. Direct a
gentle stream of air over the liquid for
about 5 s. Light cure for 10 s.

10-MDP: 10-methacryloyloxydecyl dihydrogen phosphate; bis-GMA: bisphenol A diglycidylmethacrylate; HEMA: 2-hydroxyethyl methacrylate.

more invasive and expensive restorations.29,37 In addition, ical performance of direct composite restorations in pa-
they ensure the preservation of tooth structure, given that tients with AI using nanohybrid and nanofill composite ma-
the preparation is strictly limited to the areas of affected terials. The null hypothesis tested in this study was that
unsupported enamel.37 Therefore, composite resins should there would be no significant difference between the clinical
be considered before more invasive treatment options.29 performance of the nanohybrid and nanofill composite re-
Many case reports have addressed dental treatment of AI storative systems in anterior direct restorations of patients
using direct composite restorations, revealing that direct with AI after 4 years.
composite restorations provide satisfactory esthetics and
function in AI-affected teeth.1,14,37,48,49
Universal dental adhesives and nanohybrid and nanofill MATERIALS AND METHODS
composites (nanocomposites) have been developed within
the last few decades. They were designed for direct and indi- Study Design
rect restorative approaches. Nanohybrid and nanofill compos- In this split-mouth, single-center, prospective clinical trial,
ites show high translucency and high polishing properties, patients received two different restorations with the two dif-
f
and their physical properties and wear resistance are equiva- ferent composite materials under evaluation.8 The indepen-
lent to several hybrid and microhybrid composites.7,25,42 Fur-
r dent variables were the restorative material and time. Ap-
thermore, universal adhesives were designed under the all-in- proval for the study was provided by the Ethics Committee
one concept of existing one-step self-etch adhesives, but can of Kocaeli University, Faculty of Dentistry (KOU KAEK
also be used in different etch-and-rinse modes, such as etch- 2014/247). The patients were informed about the purpose
and-rinse and selective enamel etching.19,31,43,45 The addi- of the study, treatment protocol, and study-related risks be-
tion of acidic functional monomers, such as 10-MDP, to uni- fore beginning the study, and informed consent forms were
versal adhesives, distinguishes them from the classic signed by all patients or their guardians at the start of the
one-step self-etch adhesives.31 However, lack of data, par- study. The materials used are given in Table 1. This study
ticularly on the long-term clinical performance of universal included patients with AI who were enrolled for restorations
adhesives, further complicates clinical decision-making.27 between December 2014 and December 2016, in the de-
Our review of the current literature revealed no published partments of Restorative Dentistry, Faculty of Dentistry at
studies that evaluated the clinical performance of anterior Kocaeli University. Patients with AI who had been referred to
direct composite restorations in patients with AI. Therefore, the Department of Restorative Dentistry for treatment were
the aim of this study was to evaluate and compare the clin- examined by a practitioner (NT) who had experience with AI

78 The Journal of Adhesive Dentistry

 Tekçe et al

Table 2 Clinical and radiographic characteristics of phenotypes of AI13,29,36,46

Phenotypes of AI Clinical characteristics of AI Radiographic characteristics of AI

Hypoplastic AI Reduced enamel thickness The enamel contrasts normally from dentin.
Pitting and grooves in the enamel
Hard and translucent enamel

Hypocalcified AI Defects in enamel calcification Enamel is less radio-opaque than dentin.

Normal thickness enamel
Weak structure of enamel
Opaque or chalky enamel
Teeth become stained and rapidly wear down

Hypomaturation AI Enamel of normal thickness but with a mottled Enamel has approximately the same
appearance with opaque white to yellow-brown radiodensity as dentin.
or red-brown discolouration.
Enamel is slightly softer than normal and
vulnerable to tooth wear, but not as severe as
the hypocalcified type.

Hypomaturation-hypoplasia with taurodontism Enamel is a mottled white-yellow-brown with Enamel has approximately the same or slightly
pits most frequently on the labial surface or is greater radiodensity than dentin.
thin with areas of hypomaturation. Body and pulp chamber of molars enlarged,
and the floor of pulp chamber and furcation is
shifted apically down the root.

Table 3 Distribution of composite restorations according to composite material and tooth number

n Tooth number

11 12 13 21 22 23 31 32 33 41 42 43
Nanohybrid composite 46 11 12 8 0 0 0 0 0 0 5 5 5

Nanofill composite 45 0 0 0 11 11 8 5 5 5 0 0 0

patients. In total, 15 patients (5 males and 10 females), further evaluation or intervention with soft scaling of teeth
with an age range of 14–30 years (mean: 19 years) were for calculus, food impaction, or plaque.26 In the presence of
included in this study. The inclusion criteria were: clinically scores of 2 and 3 at baseline, if a subsequent follow-up 2
verified AI diagnosis, confirmed by anamnestic family his- weeks later indicated a successful intervention and excel-
tory or clinical examination using Witkop’s classification, lent patient report, these patients were included in the
and treatment was necessary.34,46 The exclusion criteria study.26 Radiographs and photographs were taken of all the
were as follows: patients with developmental enamel de- patients for diagnosis and treatment processing. The type
fects of other origins – eg, fluorosis, molar incisor hypomin- of AI was diagnosed according to Witkop’s classification
eralization – and patients in whom AI was associated with using photographs and radiographs to support clinical find-
systemic disorders and dental abnormalities such as open ings. Two other examiners (MD and ST) were subsequently
bite, deep bite, and cross bite.23,34 Oral hygiene and gingi- included to evaluate the findings, and both examiners were
val health factors were recorded using Oral Health Progress given high-resolution images as reference instruments to
Scoring (OHPR).26 Systemic diseases, allergies, pulpal dis- confirm the initial diagnosis. Conflicts in diagnosis were re-
eases, and dietary habits were also taken into consider- solved through consensus between the examiners. Follow-
ation. Each patient received two oral hygiene examinations ing Witkop’s classification,46 of the 15 patients, 10 patients
per year using OHPR. This evaluation uses a simple crite- were diagnosed as having hypoplastic AI, four patients had
rion-based scoring for plaque, stain/calculus, gingival tissue hypomature AI, and one patient had snowcapped teeth of
(bleeding), and program acceptance. According to OHPR, hypomature-type AI. The AI phenotype was determined
“0” or “1” indicates excellent to good oral health, a score based on the clinical presentation of the patient and radio-
of “2” indicates borderline problems, and a score of “3” or graphs.13,29,36,46 The clinical and radiographic characteris-
higher signifies a definite problem in that area, requiring tics of phenotypes of AI are shown in Table 2.

doi: 10.3290/j.jad.b2838105 79
Tekçe et al

Table 4 Direct clinical evaluation criteria (modified USPH criteria)

Rating Aspect Method

Color match
Alpha (A) No mismatch in color, shade and/or translucency between the restoration and the Visual inspection
adjacent tooth structure.
Bravo (B) Mismatch in color, shade and/or translucency between restoration and adjacent Visual inspection
tooth structure, but the mismatch is within the normal range of tooth color, shade
and/or tranclucency.
Charlie (C) The mismatch is between restoration and adjacent tooth structure outside the Visual inspection
normal range of tooth color, shade and/or translucency.
Cavosurface marginal discoloration
Alpha (A) There is no discoloration anywhere on the margin between the restoration and the Visual inspection
tooth structure.
Bravo (B) Discoloration anywhere on the margin between the restoration and the tooth Visual inspection
structure, but the discoloration has not penetrated along the margin of the
restorative material into enamel and can be polished away.
Charlie (C) The discoloration has penetrated along the margin of the restorative material into Visual inspection
enamel.
Wear/anatomic form
Alpha (A) The restoration is not undercontoured, that is, the restorative material is not Visual inspection
discontinuous with existing anatomic form. and explorer
Bravo (B) The restoration is under-contoured, that is, the restorative material is Visual inspection
discontinuous with existing anatomic form, but not enough restorative material is and explorer
missing so as to expose the enamel or base.
Charlie (C) Enough restorative material is missing to expose the enamel or base. Visual inspection
Caries
Alpha (A) There is no evidence of caries contiguous with the margin of the restoration. Visual inspection
Bravo (B) There is evidence of caries contiguous with the margin of the restoration. Visual inspection
Marginal adaptation
Alpha (A) There is no visible evidence of a crevice along the margin into which the explorer Visual inspection
will penetrate. and explorer
Bravo (B) There is visible evidence of a crevice along the margin into which the explorer will Visual inspection
penetrate. The enamel or base is not exposed. and explorer
Charlie (C) There is visible evidence of a crevice along the margin into which the explorer will Visual inspection
penetrate. The enamel or base is exposed. and explorer
Delta (D) The restoration is fractured or missing in part or in toto. Visual inspection
and explorer
Surface texture
Alpha (A) Surface of restoration is smooth. Explorer
Bravo (B) Surface of restoration is slightly rough or pitted, can be refinished. Explorer
Charlie (C) Surface deeply pitted, irregular grooves (not related to anatomy), cannot be Explorer
refinished.
Delta (D) Surface is fractured or flaking. Explorer

Treatment Protocol sive (Single Bond Universal, 3M Oral Care) in selective etch
In the 15 patients, 46 direct laminate restorations were per-
r mode (15 s etching time). The present split-mouth study
formed with a nanohybrid composite (Clearfil Majesty ES-2, design compared the clinical performance of two different
Kuraray Noritake; Tokyo, Japan), and 45 laminate restor- restorations using two different resin restorative systems by
ations were performed with a nanofill composite (Filtek Ulti- randomly allocating the restorations to half of each pa-
mate Universal Restorative, 3M Oral Care; St Paul, MN, tient’s dentition, divided by the mid-sagittal plane, between
USA). The nanohybrid composite was used with the propri- the central incisors, as left and right sides of the denti-
etary universal adhesive (Clearfil Universal Bond, Kuraray tion.32,35 Thus, restorations were started from the upper
Noritake) in selective etch mode (10 s etching time). The right, followed by the upper left, then the lower left and
nanofill composite was also applied with a universal adhe- lower right quadrants of the mouth. The anterior teeth of

80 The Journal of Adhesive Dentistry

 Tekçe et al

Table 5 Results of clinical evaluation of direct composite restorations using modified USPHS criteria
Recall
rate
(number
of restor-
r Marginal Wear/anatomic Marginal
interval ations) Retention Color match discoloration form Caries adaptation Surface texture

A C A B C A B C A B C A B A B C D A B C D
Baseline
Nanohybrid 100 100 100 100 97.8 2.2 100 100 100
composite (46) (46) (46) (46) (45) (1) (46) (46) (46)
Aa Aa Aa Aa Aa Aa A
Nanofill 100 100 100 100 100 100 100 97.8 2.2
composite (45) (45) (45) (45) (45) (45) (45) (44) (1)
Aa Aa Aa Aa Aa Aa Aa
1 year
Nanohybrid 100 (46) 100 100 100 97.8 2.2 100 100 100
composite (46) (46) (46) (45) (1) (46) (46) (46)
Aa Aa Aa Aa Aa Aa A
Nanofill 100 (45) 97.8 2.2 100 100 100 100 97.8 2.2 95.5 4.5
composite (44) (1) (44) (44) (44) (44) (44) (1) (42) (2)
Aa Aa Aa Aa Aa Aa Aac
2 years
Nanohybrid 93.3 (44) 100 100 97.7 2.3 97.7 2.3 100 93.2 6.8 100
composite (44) (44) (43) (1) (43) (1) (44) (41) (3) (44)
Aa Aa Aab Aa Aa Aab A
Nanofill 93.3 (42) 97.7 2.3 100 100 97.6 2.4 100 92.9 7.1 92.9 7.1
composite (42) (1) (42) (42) (41) (1) (42) (39) (3) (39) (3)
Aa Aa Aa Aa Aa Aab Aac
3 years
Nanohybrid 93.3 (44) 95.5 4.5 100 90.5 9.5 97.6 2.4 100 86.4 9.1 4.5 100
composite (42) (2) (42) (38) (4) (41) (1) (42) (38) (4) (2) (42)
Aa Aa Ab Aa Aa Ab A
Nanofill 93.3 (42) 95.3 4.7 92.7 7.3 100 97.6 2.4 100 85.7 11.9 2.4 87.8 12.2
composite (41) (2) (38) (3) (41) (40) (1) (41) (36) (5) (1) (36) (5)
Aa Aa Ba Aa Aa Ab Bbc
4 years
Nanohybrid 86.7 (39) 80.5 19.5 97 3 64.7 32.4 2.9 100 100 65.8 21.1 13.2 97 3
composite (33) (8) (32) (1) (22) (11) (1) (33) (33) (25) (8) (5) (32) (1 )
Ab Aa Ac Aa Aa Ac A
Nanofill 86.7 (38) 92.5 7.5 70.3 29.7 56.8 43.2 94.6 5.4 100 76.3 21.1 2.6 83.8 16.2
composite (37) (3) (26) (11) (21) (16) (35) (2) (37) (29) (8) (1) (31) (6)
Aa Bb Ab Aa Aa Ac Ab

Observations are shown in % (cumulative number of restorations). A: Alpha; B: Bravo, C: Charlie; D: Delta. Different capital letters indicate significant difference between materials
at recall time interval for each evaluation criterion. Different lowercase letters show statistically significant difference between each recall time interval for nanohybrid and nanofill
composite for each evaluation criterion.

the same-side quadrants received the same composite, cre-

S i l ffunctions
Survival i
ating a “split-mouth design.” A coin was flipped to deter- r
1,00
00
mine which restoration would be made. Each restoration Clearfil
Cl f l Majesty
M ES-2
ES 2
Filtek Ultimate Universal
was made from the same materials. Thus, different restor- r Restorative
Clearfil Majesty ES-2
censored
ations on the right and left sides of the mouth were sym- Filtek Ultimate Universal
0,95 Restorative-censored
i l
l i survival

metrically paired, except for one restoration pair. Table 3

shows the distribution of the restorations according to com-
posite material and tooth number.
Cumulative

0,90

Restorative Procedure
For operator calibration, direct laminate restorations were
C

0,85
prepared on extracted anterior teeth using the materials
tested in the study. Then, five direct laminate restorations
per material were performed in patients without AI due to 0,80
0,80
the very limited number of patients with AI. These restor- r
0,00 1,00 2,00 3,00 4,00
ations were not included in the study. First, the teeth under-
r Time
went a cleaning process using a specially prepared pumice-
water slurry, and then a rubber cup was used to remove the Fig 1 Kaplan-Meier survival analysis.

doi: 10.3290/j.jad.b2838105 81
Tekçe et al

Fig 2 Flow diagram describing the history

of the restorations.
Patients with AI assessed for
eligibility, n = 91

Randomized 15 patients with AI

91 restorations

Clearfil Majesty ES-2/ Filtek Ultimate/ Single

Clearfil Universal Bond Baseline Bond Universal
n = 46 restorations n = 45 restorations

1 patient dropped out: 2 restorations lost to analysis

Clearfil Majesty ES-2/ 1 year of Filtek Ultimate/ Single

Clearfil Universal Bond follow-up Bond Universal
n = 44 restorations n = 43 restorations
1 restoration failed

Clearfil Majesty ES-2/ 2 years of Filtek Ultimate/ Single

Clearfil Universal Bond follow-up Bond Universal
n = 44 restorations n = 42 restorations

Clearfil Majesty ES-2/ 3 years of Filtek Ultimate/ Single

Clearfil Universal Bond follow-up Bond Universal
n = 44 restorations n = 42 restorations
2 restorations failed 1 restoration failed

2 patients dropped out: 5 restorations lost to analysis

Clearfil Majesty ES-2/ 4 years of Filtek Ultimate/ Single

Clearfil Universal Bond follow-up Bond Universal
n = 39 restorations n = 38 restorations
6 restorations failed 1 restoration failed

pellicle, as well as to remove any surface stains and any who had experience with the materials used in the study.
remaining residual dental plaque. After the teeth were The operator was blinded to the test materials. An Elipar
cleaned, the shade was selected using the respective com- S10 light-curing unit (3M Oral Care) was used for polymer- r
posite guide. The preparted cavities were moisture isolated ization at an irradiance of 1200 mW/cm2. Then, the com-
using rubber-dam. The preparation also involved smoothing posite was placed in a single increment and light cured for
of surface irregularities and the removal of weakened, un- 20 s. Finishing and polishing were performed during the
supported enamel, which in some cases contained little same appointment. Subsequently, finishing was performed
dentin. During the process, just the porous and colored using micro-fine finishing diamonds. Finally, the restorations
enamel layer was removed. The average preparation depth were polished using Sof-Lex abrasive disks (3M Oral Care).
was 0.5 mm, which remained within the enamel. The mar-
gins were not extended subgingivally. The preparation was Evaluation
extended just facial to the proximal contact point.17 Two calibrated examiners with professional experience as-
Once the cavity preparation was complete, cavities were sessed the restorations under dental-unit lights using a den-
treated and the restorations placed strictly following the tal explorer and a mirror, as per the modified United States
manufacturers’ instructions (Table 1). Cavity treatment, ma- Public Health Service (USPHS) criteria (Table 4).3,10,15,22 The
terial application, and polymerization of dentin adhesives examiners were not involved in the operation or the insertion
were conducted by the same experienced practitioner (N.T.), of the restorations; thus, they were fully blinded to the ex-

82 The Journal of Adhesive Dentistry

 Tekçe et al

perimental protocol. For training purposes, the examiners

were provided with a set of pictures as a reference or as
baseline instruments with which to compare each score for
each criterion. Then, after leaving 2 days between each
examination, the examiners clinically assessed 10 direct
laminate veneers. Inter-examiner and intra-examiner agree-
ment were tested using Cohen’s kappa coefficient. The as-
sessment stage of the study was conducted only when the
minimum threshold of 87% intra-examiner and inter-exam-
iner agreement was attained in the calibration phase.6 Dur- r
ing the baseline period, and subsequently at 1-, 2-, 3- and
4-year recalls, the properties of color match, wear and loss
of anatomic form, marginal discoloration, caries, marginal
adaptation, and surface texture were evaluated and scored Fig 3 Clinical appearance after 3 years with failure (fracture).
(Table 5). During the scoring process, the following criteria
were used: Alpha (A): ideal clinical findings; Bravo (B): clini-
cally acceptable; Charlie (C); and Delta (D): clinically unac-
ceptable, requires restoration replacement. Any conflicts dur-r
ing the scoring process were resolved through consensus.

Statistical Analysis one nanofill composite restoration (2.4%) had failed due to
The SPSSWIN 20.0 (SPSS; Chicago, IL, USA) software was a fracture (Fig 3). At 4 years, five anterior nanohybrid com-
used for statistical analyses. Data related to the two resin posite restorations (12.8%) and one anterior nanofill com-
composite restorative materials were analyzed statistically posite restoration (2.6%) fill had failed due to a fracture,
using the Friedman test for changes that happened through- and one nanohybrid composite restoration (2.6%) had failed
out the 4-year evaluation period. The Mann-Whitney U-test due to unacceptable marginal discoloration. Thus, the cu-
was used to compare the materials at each time point for mulative success rate was 80.5% for nanohybrid composite
each evaluated criterion. When a statistically significant dif-
f restorations, and 92.5% for nanofill composite restorations
ference was identified for any criterion, Dunn’s post-hoc test at the end of the 4 years (Fig 4).
was used for conducting multiple comparisons between Statistically, a significant difference was found between
each recall time interval for each composite resin material. the nanohybrid and nanofill composite restorations with re-
Kaplan-Meier survival analysis was used to determine the spect to marginal discoloration (90.5% and 100%)
probability of clinical survival of nanohybrid and nanofill (p = 0.044) and surface texture (100% and 87.8%)
composite resin (Fig 1). p-values <0.05 were considered (p = 0.020) after 3 years, and color match (97% and 70.3%,
statistically significant. respectively) (p = 0.003) after 4 years (Table 5).

RESULTS DISCUSSION

During the four years of the study, two patients with 10 an- The retention rate of restorations is the principal criterion
terior restorations (5 nanohybrid composite restorations for assessing the clinical effectiveness of adhesives, be-
and 5 nanofill composite restorations) ceased participation cause, before a restoration is lost, its margins may have
in the study (Fig 2). This was because one patient replaced leaked extensively, undermining the restoration’s integrity
her/her restoration with prosthetic crowns after 1 year, and without complete debonding. Although retention is the most
one patient moved to another city after 4 years. Therefore, objective criterion, ie, the restoration is still in place or
the cumulative recall rate for the patients was 86.7% at the debonded, clinical microleakage is far more difficult to eval-
end of 4 years. After 4 years, 13 patients with 77 anterior uate objectively.44 The nanohybrid and nanofill composite
teeth were left in the study. The cumulative recall rates at restorations in this study showed acceptable clinical perfor-
r
baseline and after 1, 2, 3, and 4 years are highlighted in mance with 19.5% and 7.5% failure rates, respectively, for
Table 5. Cohen’s kappa coefficient (0.88) showed strong direct restorations in AI patients. Moreover, there was no
agreement between the examiners, with no statistically sig- significant difference between the success rates of nanohy- y
nificant difference between them (p > 0.05). brid and nanofill composite restorative systems based on
The cumulative failure and success rates, according to retention rates. The hypothesis that there would be no sig-
Kaplan-Meier survival analysis, are shown in Fig 1 and nificant difference between the clinical performance of
Table 5 for anterior restorations. After 1 year, one nanofill nanohybrid and nanofill composite materials in anterior di-
composite restoration (2.2%) failed due to a fracture. There rect restorations of AI patients was also accepted. In this
were no restoration failures at 2 years. At the end of the 3 study, the 4-year retention rate of restorations for the nano-
years, two nanohybrid composite restorations (4.5%) and hybrid composite was 80.5%, and for the nanofill composite

doi: 10.3290/j.jad.b2838105 83
Tekçe et al

a d

b e

c f
Fig 4 Intraoral view of composite laminate veneers on anterior teeth. a: baseline; b: 24 h; c: 1 year; d: 2 years; e: 3 years; f: 4 years.

92.5%. The primary reason for restoration failure was due posite restorations were performed only in permanent
to restoration fracture. As opposed to our study, Chen et al4 teeth; also, most of the patients (10 patients) had hypo-
found that 12 out of 23 direct anterior composite restor- plastic type AI. The bond strength between enamel and ad-
ations had failed, and the failure rate of direct restorations hesive restorative materials is highly dependent on the
was approximately 52% in the mixed dentition of 8 patients enamel surface modification.4 The structural alterations of
with AI. In a cross-sectional, retrospective study,33 it was AI-affected teeth may pose challenges to the bonding of
found that the composite resin restorations had signifi- adhesive restorations in clinical conditions.12 It has been
cantly shorter longevity in the AI group as compared with shown that the enamel mineral content was reduced for all
the control group. The present study did not include a “pos- hypomaturation and hypocalcified AI teeth, and hypoplastic
itive” control group regarding sound teeth with normal AI enamel varied from a normal to reduced state as com-
enamel. Therefore, it is very difficult to draw any conclusion pared with normal enamel.46,47
about the extent to which enamel with AI affects clinical After 4 years, a statistically significant difference was
success compared with normal enamel. In our study, com- found between restorations with nanohybrid and nanofill

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 Tekçe et al

composites concerning their color match. Nanohybrid com- After 4 years, 100% of nanohybrid composite restorations
posite restorations more often had Alpha scores than did and 94.6% of nanofill composite restorations had clinically
nanofill composite restorations in anterior teeth. In accor- r ideal properties regarding their level of wear and their ana-
dance with our findings, a 7-year retrospective analysis fo- tomic form. A 5-year follow-up AI case report revealed that
cusing on fractured maxillary teeth and diastema closure composite restorations aged without macroscopic signs of
revealed that nanofill restorations had a higher rate of discol- excessive wear, except for the loss of glossy surfaces, as
oration than did microhybrid restorations.21 Furthermore, an was routinely observed in cases of extensive composite res-
in vitro study showed that a microhybrid composite exhibited torations.14 Only after 3 years was a statistically significant
the least color change during the consumption of beverages, difference found between restorations with nanohybrid and
including a carbonated drink, tea, and distilled water, after 7 nanofill composite in terms of surface texture; 97% of nano-
and 30 days; it also had a more stable color when compared hybrid composite restorations and 83.8% of nanofill com-
with a nanofill composite.28 In contrast to our results, one posite restorations were found to be clinically ideal in terms
study found no significant difference between nanohybrid of surface texture. In agreement with our findings, there
and nanofill composites with respect to color match in the was no significant difference between microhybrid, nanohy- y
direct composite buildup restorations after 4 years.9 brid, or nanohybrid composites for direct composite buildup
In the present study, seven nanohybrid composite restor- r restorations.9,21 In agreement with the results of Lempel et
ations and three nanofill composite restorations failed due al,21 the nanofill composite restorations in this study re-
to a fracture after 1, 3, and 4 years. Also, two nanofill com- ceived a lower rate of Alpha scores for color stability and
posite restorations failed because of marginal discoloration. surface texture than did the nanohybrid composite restor-
The restoration margins were in enamel, and bonding to AI- ations. Nanofill composites are used to ensure high polish-
affected enamel is more difficult than to normal enamel.11 ing with superior gloss and smoothness.20 A systematic
Marginal discoloration and detectable margins are the only review reported no in vitro evidence to support the selec-
clinically measurable signs of the marginal seal of direct tion of nanocomposites over the microhybrid composites,
restorations.16 Furthermore, no typical etching patterns based on their superior surface gloss or smoothness.20
were detected in five clinical types of AI, namely, pitted hy-y In the present study, no composite restoration exhibited
poplastic, smooth hypoplastic, X-linked (male and female), caries adjacent to the margins in anterior teeth. In agree-
and hypomineralized AI. The reason for this is described as ment with our findings, a 15-year case study reported that
the result of the abnormal prism/enamel structure, etching 18 months after the last treatment in permanent dentition,
time, or acid concentration.40 In a cross-sectional retrospec- all restorations were intact, with no recurrent caries.11 Also,
tive study, among the causes of restoration failure, the rate studies that had cases with a 4-year follow-up demon-
of loss or fracture of a tooth was 60% for hypoplastic AI and strated that the restorations were still in favorable clinical
69% for hypomaturation/hypomineralized AI.33 Another condition without caries.48 In contrast to our results, in a
study revealed that four out of 23 (17%) direct restorations cross-sectional retrospective study, recurrent caries ac-
showed unacceptable margins in regard to marginal integrity counted for 11% of the failures in hypoplastic AI and 21% in
in the mixed dentition of AI patients.4 The difference be- hypomaturation/hypomineralized AI.33 In a study that evalu-
tween these and our studies may have been caused by dif- f ated restorative treatment outcomes in the mixed dentition
ferences in the patient’s age, restoration numbers, restor- r of AI patients, one out of 23 (4%) restorations in incisors
ation materials, restoration types, and the type of AI. showed unacceptable results regarding caries.4
The enamel of hypomineralized-type AI may have normal
thickness, but the enamel is rough and soft, and it wears
rapidly. In hypomature AI, the enamel is of normal size, and CONCLUSION
it contacts the adjacent teeth, but has a mottled, brownish-
yellow, soft appearance.18,33,46 The prism structure shows In the current study, the clinical performance of a nanohy-
abnormalities, and the bonding pattern is inadequate.18,33 brid and a nanofill composite used for direct restorations in
In contrast, the enamel of hypoplastic AI has normal qual- patients with AI was found to be satisfactory, based on the
ity, but differs in its thickness.18,33,46 Therefore, in our rate of ideal and clinically acceptable restorations. Nanohy-
y
study, the high rate of hypoplastic AI may have contributed brid composite restorations performed better than nanofill
to a higher rate of ideal restorations (Alpha) regarding mar- composite restorations in terms of marginal discoloration,
ginal adaptation and marginal discoloration compared to color match, and surface texture. The primary reason for
the studies mentioned above. In agreement with our find- the failure of the restorations was fracture.
ings, a study with 4-year follow-up of AI cases using a one-
bottle etch-and-rinse adhesive in direct labial veneers
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86 The Journal of Adhesive Dentistry