When presenting a treatment plan
to a patient, we have to explain all available options, including why specific restorative
materials are superior or contraindicated in certain situations. The trends are
shifting more towards esthetic dentistry and less consideration is being given
to long-term prognosis. If finances are an issue, patients might compromise and
not choose the “optimal” option. Whichever factors drive the patient, it is up
to us to educate them to the best of our ability to make sure they understand the
implications of choosing a material.
Many choices of restorative
materials exist for patients presenting with cavities, tooth wear, trauma or
cosmetic issues. All materials have different properties and require various techniques
for placement. Ideally, a restorative material should be identical to natural
tooth structure, including physical properties, biocompatibility, esthetics and
application. Some long lasting restorative materials are composite resin,
amalgam and gold.
Direct resin based composite
restorations have increased in popularity because they closely replicate the appearance
of natural teeth. However, are they the most superior material for posterior
restorations? It is important to remember that posterior restorations need to withstand
greater occlusal forces. The current resin-based composite materials have
improved enormously, but research still shows that for posterior restorations,
they are at a disadvantage in comparison to amalgam due to decreased longevity
and bacteriostatic properties. Resin based composite allows for a more
conservative preparation, but is more technique sensitive. Overusing
resin-based composite can be detrimental to the patient’s teeth in the
long-term, due to shorter longevity of the material and decreased strength of
the tooth every time the restoration needs to be replaced.
Amalgam is the most cost
effective of the three materials and has great strength and longevity. Amalgam
is easily placed, can withstand high occlusal forces, and has a marginal seal
that improves over time. However, due to misconceptions about mercury and poor esthetics,
amalgam is not a favorite for many patients and dental professionals. Clinicians
must be aware that it is unethical to replace sound amalgam restorations by
preying on patient’s misinformation or solely to make a profit. Amalgam can
produce staining on the teeth over time or fractured cusps can result due to
the preparation technique and wedging effect. An additional limitation of
amalgam is different expansion and contraction characteristics in comparison to
natural tooth structure. Still, it is a great material to be used on high
caries risk patients.
Gold’s popularity has also
decreased due to esthetics and cost. Gold does not discolor the tooth and, up
until resin based composite increased in popularity, it used to be considered
esthetic for posterior restorations. Some dentists still use gold and have
learned to do exceptional esthetic dentistry through techniques like the
invisible onlay or adequate placement of intracoronal restorations. Gold
restorations have excellent durability, an almost nonexistent marginal gap on
the cavosurface and will not exhibit marginal wear. The coefficient of
expansion is similar to natural tooth structure. Gold is very biocompatible
with gingival and supporting tissues and does not contribute to allergic
responses. Even thought the procedures have become more efficient, gold foil
technique is no longer taught in most dental schools or postgraduate programs.
Adequate informed consent is
imperative before starting any procedure. It is important to stay knowledgeable
about the latest products and to be aware of existing research and the longevity
of the materials. As dental professionals, we should know how to work with all restorative
materials and how to educate the patient to choose the most adequate option for
their treatment goals.