Clinical Oral Investigations (2019) 23:2795–2803

https://doi.org/10.1007/s00784-018-2722-5

ORIGINAL ARTICLE

Is composite repair suitable for anterior restorations? A long-term

practice-based clinical study
Françoise H. van de Sande 1 & Rafael R. Moraes 1 & Raquel V. Elias 1 & Anelise F. Montagner
Paulo A. Rodolpho 3 & Flávio F. Demarco 1,4 & Maximiliano S. Cenci 1

Received: 7 August 2018 / Accepted: 17 October 2018 / Published online: 27 October 2018
# Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Objectives This study investigated the impact in survival, when repair is seen as failure or not, in anterior composite restorations
with a retrospective 15-year follow-up study.
Materials and methods Data was collected from patients’ files of a private dental practice, including patients with direct
composite restorations placed in anterior teeth (class III, class IV, or veneer) between January 1994 and December 2009. Data
were analyzed considering or not repair as failure. Statistical analysis was performed with log rank test, Kaplan–Meier, and Cox
regression (p < .05).
Results One hundred forty-four patients’ files were included, with 634 restorations. At 15 years, Class III / IV restorations
showed 69% survival and 2.4% annual failure rate (AFR) when repair was not considered as failure, and 64% and 2.9% AFR,
respectively, when repair was seen as failure. For direct veneers, at 5 and 10 years of follow-up, survival dropped from 85% to
74% and from 52% to 38% respectively, when repair was considered as failure. In general, restorations placed in the upper jaw
showed increased risk for failure compared to the lower jaw (p < .01), and restorations in central incisors presented a higher risk
for failure compared to canines (p < .01).
Conclusion Composite repair seems a suitable alternative for class III, class IV, and veneer restorations since it was able to
increase the survival of restorations performed in anterior teeth.
Clinical relevance Composite repair for anterior restorations is a suitable restorative treatment option and presents benefits over
replacement, including the preservation of sound tooth structures, reduced clinical chair time, and patient anxiety.

Keywords Retrospective study . Composite resins . Dental restoration . Repair . Risk factors . Survival

Introduction as in anterior esthetic restorations [1], with the advantage of

allowing minimally invasive procedures [2, 3]. Despite im-
Composite resin has been considered a universal restorative provements and advances in materials and procedures in the
material used in stress-bearing areas in posterior teeth as well last decades [4], the tooth-restoration set presents a limited
total success rate and is likely to require further interventions
during clinical service. Restoration replacement is one of
* Anelise F. Montagner the most common procedures in clinical practice, with
[email protected]
significant economic impact for the individual and for
health systems [5–7].
1
Programa de Pós-graduação em Odontologia, Universidade Federal A recent systematic review [8] on anterior composite res-
de Pelotas, Gonçalves Chaves, 457, Pelotas, RS 96015-560, Brazil torations showed annual failure rates (AFRs) ranging from 0
2
Programa de Pós-graduação em Odontologia, Universidade Federal to 4.1% and survival rates of 53.4% up to 100%, including
de Santa Maria, Rua Marechal Floriano Peixoto, 1184, Santa studies with a minimum 3-year follow-up. From the 17 clini-
Maria, RS 97015-372, Brazil
3
cal studies included, only 6 studies had follow-up times longer
Clínica Odontológica, Av. Duque de Castilhos, 1348, s. 203, Caxias than 10 years and 3 investigated veneer restorations. Main
do Sul, RS 95010-000, Brazil
4
reasons for failure in anterior restorations have been related
Programa de Pós-graduação em Epidemiologia, Universidade to fracture and esthetics (e.g., color, anatomical form, surface
Federal de Pelotas, Rua Marechal Deodoro, 1160,
Pelotas, RS 96020-220, Brazil staining) [8, 9], likely because in anterior teeth even minor
2796 Clin Oral Invest (2019) 23:2795–2803

imperfections may compromise the esthetic appearance and Clinical procedures

further interventions are required.
Although the replacement of restorations has been the first The same clinician, an experienced dentist (PARR) special-
treatment choice of many clinicians [10, 11], in the context of ized in esthetic dentistry, performed all restorations, clinical
minimally invasive dentistry, there is a current shift favoring evaluations, and re-interventions. Restorations were placed by
more conservative alternatives, such as repairing restorations several reasons, i.e., failed restorations, caries lesions, tooth
with localized Bdefects^ [12–14]. Potential benefits of resto- fracture, corrections in form/size/color of teeth, among others.
ration repair over replacement include the preservation of The type of field isolation varied and was not described in the
sound tooth structures [15], improved cost-effectiveness [6], file. Before the adhesive procedures, the composite shade was
and reduced clinical chair time and patient anxiety [11]. chosen and whenever required, local anesthesia was used.
For restorations placed in posterior teeth, the effect of in- Tooth surfaces were etched with 37% phosphoric acid (enam-
cluding repair as failure or survival was recently shown to el 30 s, dentin 15 s) and a conventional three-step or a two-step
have a great impact in the AFR, which was reduced from adhesive system was applied. Several brands and types of
4.1 to 2.9% at 10 years of follow-up [16]. Since a conservative composite resins were used (Table 1). Immediate surface
approach should be advocated [17, 18] and repair was found finishing and polishing was performed by means of fine dia-
to be less consistently considered for restorations in anterior monds burs (KG Sorensen, Barueri, SP, Brazil) and rubber
teeth [12], the aim of this retrospective study was to investi- cups (Flexicups; Cosmedent, Chicago, IL, USA) with alumi-
gate the influence of considering repair as failure or survival num oxide paste (Enamelize; Cosmedent). At proximal sites,
on the survival of anterior composite restorations and factors aluminum oxide discs and abrasive strips were used (3M
related to failure in a clinical follow-up up to 15 years. ESPE, St. Paul, MN, USA).
Although repair in posterior teeth is well documented, this During the checkup visits, the same clinician identified the
study is endeavored to respond whether composite repair is need for re-intervention through clinical and/or radiographic
a suitable alternative for anterior restorations. examinations and made the choice for restoration’s replace-
ment or repair, according to the type and extent of the defect.
Mostly, the complaints of the patients were the determinants
Material and methods for re-intervention. Fracture, secondary caries, and little color
mismatch or anatomic deficiencies were treated by repair,
Study characteristics and inclusion criteria whereas severe pigmentation or discoloration and significant
volume or shape losses were treated with restoration replace-
This is a long-term retrospective study with data collected ment. In case of repair, localized removal of part of the restor-
from patient files of a private dental practice in Southern ative material with high-speed hand piece and diamond burs
Brazil (Caxias do Sul, RS, Brazil). The survival of restorations and/or caries lesion removal with low-speed hand piece and
with up to 15 years follow-up was determined, and factors carbide burs were performed. Before repair, the composite
potentially associated with failure were investigated. The surface was cleaned with sodium bicarbonate jet and air-
study was approved by the local ethical research committee abraded using 50 μm aluminum oxide particles (ERC
( p r o t o c ol 02 2 / 2 0 08 ) a nd f o l l o w e d t h e S T R O B E Microetcher; Danville Engineering, San Ramon, CA, USA).
(Strengthening the Reporting of Observational studies in Tooth and composite surfaces were etched with 37% phos-
Epidemiology) guideline [19]. phoric acid and a conventional three-step or two-step adhesive
For inclusion (Fig. 1), patients should have had at least one system was applied. Replacements were performed using the
newly placed restoration due to replacement or first-time same protocol of initial placements, with complete removal of
restoration by the operating dentist, in anterior teeth, the restoration. Each material was used according to manufac-
composite resin restoration with direct technique, be- turers’ instructions.
tween January 1994 and December 2009 (for a mini-
mum 4-year follow-up), presenting opposing and adja- Data collection
cent teeth, and presenting posterior occlusion as con-
firmed by radiographic examination. The restoration The following data were collected from the dental records:
type should be class III, class IV, or direct veneer. gender and birth date of the patients; date of restoration place-
After restoration placement, patients should have had ment; restoration type (class III, IV, or veneer); tooth (central
regular appointments (at least once a year) with the incisor, lateral incisor, canine); jaw (upper, lower); composite
same dentist. Restorations with incomplete information resin and adhesive system type; re-interventions (repair or
in the clinical files regarding the type of composite res- replacement); date of each re-intervention; date of the last
in used, restored tooth, restored surfaces, and/or cavity follow-up. Data were organized according to the intervention
class type were excluded. type. Thus, restorations were categorized into the following
Clin Oral Invest (2019) 23:2795–2803 2797

Fig. 1 Flowchart with inclusion

criteria, excluded and included
clinical files. *Type of composite
resin used, restored tooth, restored
surfaces, and/or cavity class type

status at the last recall: 1, clinically acceptable with no re- In the second analysis, repair was considered as failure (event:
intervention; 2, clinically acceptable repaired restoration; 3, repair and replacement). The hazard ratios and respective 95%
repaired and replaced restoration (when the repaired restora- confidence intervals were calculated.
tion failed and was completely replaced, the date of the new
intervention was recorded and considered as the failure time);
and 4, replaced, restoration without previous repair (the re- Results
placement date was considered as the failure time).
From the 366 clinical records with restorations in anterior
Statistical analysis teeth, 144 patients’ clinical files were included for data extrac-
tion. During inclusion, the reason for the initial restoration
The statistical analysis was performed with the software pack- placement was only available in 23% (n = 145) of the cases,
ages SPSS v.23.0 (IBM Corp., Armonk, NY, USA) and R v. and therefore, these data were not considered for analysis.
3.2.2 (RStudio version 1.0.143, The R Foundation for From the available data, most restorations were performed
Statistical Computing). Fisher’s exact test was used to assess due to esthetic reasons (73%), caries (22%), or due to failures
differences within each category level (α = 0.05). Regarding in previous restorations (5%). Excluded from the studies (Fig.
restoration type, preliminary data analysis indicated no signif- 1) were restorations with follow-up times shorter than 4 years
icant differences on survival (log rank test, p = 0.914) and (n = 133), other cavity types (n = 73), no patient follow-up
variables influencing the survival between class III and class (n = 10), and missing information (n = 6). In total, 634 direct
IV restorations, which were then combined for the analysis. composite resin restorations were included, comprising 408
The follow-up times and effect of variables influencing sur- veneers and 226 class III/IV, of which 29% were repaired
vival were different for class III/IV and veneers; thus, the (139 veneers and 48 class III/IV). Regarding only the repaired
analysis was conducted separately. restorations, 59.7% (83 out of 139) veneers and 64.6% (31 out
Life tables were generated for survival and AFRs at differ- of 48) class III/IV restorations were considered clinically ac-
ent time intervals. The Kaplan–Meier method was used to ceptable at the last recall (Table 1).
generate survival curves up to 15 years (class III/IV) and Composite resins included were microhybrids or an associ-
10 years (veneers). The effect of the variables of interest (gen- ation of microhybrids with a top layer of microfilled compos-
der, tooth, jaw, composite resin, adhesive) in restoration sur- ites, which are presented in Table 1 along with the frequency
vival was assessed with multivariate Cox regression analysis distribution according to the collected variables. A two-step
with frailty term (patients) according to the restoration type. In etch-and-rinse adhesive system was applied (67%) mainly,
addition, two separate analyses according to the event were and this information was missing in 15% of the cases. Most
carried. In the first analysis, clinically acceptable repaired res- patients were women (n = 102; 71%), presenting 76% of the
torations were not considered as failure (event: replacement). restorations. The mean age of patients at the time that
2798 Clin Oral Invest (2019) 23:2795–2803

Table 1 Frequency distribution of restorations according to the Table 2 Cumulative survival and annual failure rate (AFR) at different
investigated variables time-periods for anterior restorations considering repair as failure or not

N (%) Class III / IV 5 years 10 years 15 years

restorations
Sex Female 479 (75.6) Survival AFR Survival AFR Survival AFR
Male 155 (24.4) Repair is not failure 93% 1.4% 77% 2.6% 69% 2.4%
Tooth Central incisor 259 (40.9) Repair is failure 86% 3.0% 73% 3.1% 64% 2.9%
Lateral incisor 217 (34.2)
Canine 158 (24.9) Veneer restorations 2 years 5 years 10 years
Jaw Upper 505 (79.7) Survival AFR Survival AFR Survival AFR
Lower 129 (20.3) Repair is not failure 97% 1.5% 85% 3.2% 52% 6.3%
Composite Microfilled a
309 (48.7) Repair is failure 88% 6.2% 74% 5.8% 38% 9.2%
type Microhybridb 325 (51.3)
Adhesive 2-step etch-and-rinsec 426 (67.2)
system
placed in the upper jaw showed increased risk for failure com-
3-step etch-and-rinsed 109 (17.2)
pared to the lower jaw in both analyses. The influence of tooth
Unknown 99 (15.6)
type was only present when repair was considered as failure,
Cavity type Veneer 408 (64.3)
showing higher risk for failure in central incisors than lateral
Class III 161 (25.4)
incisors and canines. No significant differences were found for
Class IV 65 (10.3) lateral incisors when compared to canines. Figure 2 presents
Status Veneer Class Kaplan–Meier survival curves for class III/IV restorations ac-
III/IV
cording to the tooth type and jaw. Regarding veneer restora-
1. Clinically acceptable 153 146 (64.6)
with no re-intervention (37.5) tions, a higher risk of failure was observed for the upper jaw and
2. Clinically acceptable 83 (20.3) 31 (13.7) central incisors compared to canines when repair was consid-
repaired restoration ered as failure. When repair was not seen as failure, the higher
3. Repaired and replaced 56 (13.7) 17 (7.5) failure risk for central incisors compared to canines was main-
restoration
4. Replaced without 116 32 (14.2) tained and the type of composite also influenced the survival
previous repair (28.4) rates, favoring restorations with a top layer of microfilled com-
posite over the other composite types. Figure 3 shows Kaplan–
a
Renamel Microfill (Cosmedent) n = 231 (74.7%), Durafill VS (Heraeus Meier survival curves for veneer restorations according to the
Kulzer, Hanau, Germany) n = 75 (24.3%) and less than 1% from other
brands
variables that significantly affected the survival. The other in-
b
Four Seasons (Ivoclar Vivadent, Schaan, Liechtenstein) n = 204
vestigated variables including gender of the patient and adhe-
(62.8%), Tetric Ceram (Ivoclar-Vivadent) n = 42 (12.9%), Z100 (3M sive system did not significantly influence the survival.
ESPE) n = 40 (12.3%), and Charisma (Heraeus Kulzer) n = 39 (12.0%)
c
Single Bond (3 M ESPE) n = 247 (58.0%), Single Bond 2 (3M ESPE)
n = 179 (42.0%)
d
Adper Scotchbond Multi-Purpose (3M ESPE) n = 85 (78.0%); Discussion
OptiBond FL (Kerr Corporation, Orange, CA, USA) n = 24 (22.0%)
To the authors’ best knowledge, this is the first study investi-
restorations were placed was 41 ± 11 years, ranging from 16 to gating the influence of repair in composite resin restoration
83 years. survival in anterior teeth. The present results indicate that
Life tables with cumulative survival and AFRs are present- when repaired restorations were not considered as failures,
ed in Table 2. At the 15-year follow-up period, class III/IV survival rates increased up to 14% and AFR decreased up to
restorations showed 69% survival and 2.4% AFR when repair 4.7%, including all follow-up times. Considering that in gen-
was not considered as failure. When repair was seen as failure, eral approximately 60% of the repaired restorations were clin-
the survival was 64% and the AFR was 2.9%. For veneers, the ically acceptable at the last recall, the repair seems as suitable
5-year survival rate dropped from 85 to 74% and the 10-year treatment for composite resin restorations in areas at high es-
survival rate dropped from 52 to 38% when repair was con- thetic demands.
sidered as failure. When repaired restorations were not con- For class III/IV restorations, when repair was not consid-
sidered failures, they had an increase in survival rates, ranging ered as failure, AFR were 1.4% (5 years) and 2.4% (15 years),
from 4 to 15% considering all follow-up times. which were increased to 3.0% (5 years) and 2.9% (15 years)
Data from the Cox regression analysis are presented in including repair as failure. Baldissera et al. [1] evaluated class
Table 3. Significant differences were observed when repair III/IV restorations up to 20 years and found considerably low-
was considered or not as failure. Class III/IV restorations er AFR (0.5–1.8%) compared to the present study. Other long-
Clin Oral Invest (2019) 23:2795–2803 2799

Table 3 Results for the Cox regression analysis (HR, hazard Ratios; CI, confidence intervals) for class III/IV and direct veneer restorations with repair
as a failure or not

Class III/IV Direct veneers

HR p 95% CI HR p 95% CI

Repair is not failure

Gender (female)
Male 1.007 0.990 0.373–2.717 0.674 0.550 0.184–2.478
Jaw (lower)
Upper 6.147 0.001 2.058–18.360 0.949 0.910 0.441–2.041
Tooth (canine)
Central incisor 1.644 0.230 0.735–3.681 2.288 0.010 1.214–4.311
Lateral incisor 0.688 0.390 0.292–1.624 2.019 0.033 1.057–3.854
RC (Microfill+Mh)
Microhybrid 0.754 0.500 0.333–1.705 2.395 0.004 1.324–4.334
Adhesive (2-step)
3-step 0.398 0.086 0.139–1.140 0.416 0.080 0.156–1.111

Repair is failure
Gender (female)
Male 0.695 0.260 0.368–1.311 1.205 0.560 0.642–2.263
Jaw (lower)
Upper 2.442 0.011 1.222–4.878 2.509 < 0.001 1.463–4.304
Tooth (canine)
Central incisor 2.136 0.011 1.194–3.822 3.260 < 0.001 2.041–5.206
Lateral incisor 1.179 0.610 0.621–2.240 1.490 0.096 0.932–2.385
CR (Microfill+Mh)
Microhybrid 0.623 0.094 0.357–1.085 1.037 0.860 0.703–1.529
Adhesive (2-step)
3-step 0.724 0.350 0.366–1.433 0.659 0.220 0.337–1.291

CR composite resin, Microfill+Mh Microfilled composite as top layer with microhybrid composite underneath

term studies reported AFR ranging from 2.0 to 4.1% [20–22], in survival was found for the veneers. Even then, 52% survival
whereas in medium- and short-term follow-up studies, the was found when functional repaired restorations were not in-
AFR varied between 0.8 and 8.0% [23, 24]. Taking into ac- cluded as failure. Still, direct veneers restorations seem to
count that esthetic judgment is subjective and replacements of require more repairs than other anterior restorations, and have
anterior restorations may not always be related to Breal^ fail- a greater chance of replacement at 10 years. In corroboration,
ures, differences between studies could be partially explained Demarco et al. in their systematic review observed usually
by the degree of requirement from patients and dentists. lower failure rates for class III when compared to veneers
Noteworthy, an increasing concern regarding esthetic appear- [8]. In the context of the practice where this study was carried
ance is present in many societies, including the desire of well- out, ceramic veneers were also indicated for high esthetic de-
aligned and whiter teeth [25, 26]. The combination of these manding patients, and this can also explain the drop in the
factors may affect the replacement rate of restorations. composite veneer survival at 10 years. What usually happens
Regarding composite veneer restorations, at 5 years of fol- in practice is that after a few repair sessions over successive
low-up, the survival rates were 85% and 74% (3.2% and 5.8% years, some patients demand new restorations, and ceramic
AFR), including functional repaired restorations as success or veneers become a viable option.
failure, respectively. Gresnigt et al. [27] reported 87.5% sur- In the present study, restorations in the lower jaw generally
vival and 3.2% AFR at 4 years follow-up for the same type of showed a greater survival than in the upper jaw. It is possible
restorations. In addition, Coelho-de-Souza et al. [28] found an that patients may have more easily perceived imperfections in
overall survival rate of 80.1%, and AFR of 4.9% for vital teeth the upper teeth, resulting in more interventions. In addition,
and 9.8% for non-vital teeth, at 3.5 years follow-up period. In restorations performed in the upper jaw are subject to different
the present study, at 10 years of follow-up, a substantial drop masticatory forces and increased incisal stress in relation to the
2800 Clin Oral Invest (2019) 23:2795–2803

Fig. 2 Kaplan–Meier survival curves for class III/IV restorations according to the tooth type and jaw. Time 1 is when clinically acceptable repair is
survival and time 2 when repair is failure

lower jaw, which could have also influenced the results. performed with universal or microfilled composites.
Ideally, patient-related variables such as Angles’ incisal rela- However, they reported better esthetic properties for
tionship [29], bruxism [30, 31] and dietary habits [31] should microfilled composites [28]. In a survey with general dental
be assessed. The tooth type also showed to influence the sur- practitioners about their preferences to perform anterior com-
vival of veneers restorations, with the central incisor being the posite restorations, it was detected that more than half of them
most susceptible tooth to failure, regardless of whether repair preferred microhybrids, followed by microfilled (26%) and
was considered or not as failure. For class III and IV, the nanofilled composites (16%) [32]. In the present study, several
influence of tooth type was only seen when repair was includ- composite brands were used, and therefore, they were ana-
ed as failure, indicating that central incisors were more fre- lyzed under categories due to the reduced sample size for
quently repaired than lateral incisors and canines. Again, the some composites. Baldissera et al. [1] found significant differ-
position of the central incisor, especially in the upper jaw, ences between composites after 10 years of follow-up, with
requires higher esthetics and receives the load on incisal the heavier filler-loaded composite presenting better results.
edges, which could predispose to esthetical failure or fracture, One could also argue that nanofilled composites might present
respectively. However, we were not able to assess the reason better clinical behavior for esthetic restorations. However, a
for the interventions; distinguishing fractures from other fail- systematic review on in vitro studies did not find superior
ure reasons could aid in interpreting these findings. performance regarding smoothness or gloss for nanofilled
The effect of resin composite type on survival was only composites [33], and thus, it does not seem likely that this
significant for veneer restorations when repair was not includ- material would present clinically perceptible differences com-
ed as failure, reducing the failure risk of veneers presenting a pared to microhybrid composites. Lempel et al. evaluated two
surface layer of microfilled composites. In total, 45% of composite brands placed in anterior teeth, including one
microfilled veneers were repaired (data not shown), of which microhybrid and one nanofilled, and they did not find signif-
55% were still in function, increasing their survival. Coelho- icant differences in survival between those composites after
de-Souza et al. found no differences in survival of veneers 7 years of evaluation [31]. However, the authors observed
Clin Oral Invest (2019) 23:2795–2803 2801

Fig. 3 Kaplan–Meier survival curves for direct veneer restorations according to the variables that significantly affected the survival. Time 1 is when
clinically acceptable repair is considered as survival and time 2 when repair is considered as failure

significant differences regarding failure types, with higher composite. This is in line with the findings of another system-
failure rates due to color mismatch for the nanofilled compos- atic review [35], which indicated that the retention of glass-
ite and due to fracture for the microhybrid composite [31]. fiber posts into root canals was improved only when physical
Thus, a deeper analysis into the influence of composite mate- treatments were applied to the posts before chemical treat-
rial may be better assessed for each brand separately. ments (i.e., silane coupling agent). Considering the clinical
Investigations on the in vitro repair potential of composite scenario, the present results can be considered positive since
resins is vast in the literature and usually include testing pre- application of adhesive alone is less time-consuming and sim-
treatment procedures able to improve the surface reactivity of pler than combining silane and adhesive.
the Bold^ aged composite before repair. According to a recent Anatomical form, color mismatch, and surface staining,
systematic review [34], the physical method most commonly among others, are frequently reported as reason for failure in
tested for improving the repair ability is air-abrasion with alu- anterior restorations [8]. Clinically, imperfections in restora-
mina particles, whereas the most common chemical treat- tions may not be judged as at need of repair/replacement in
ments are silane coupling agents and adhesive resins. In that posterior teeth [36], yet these aspects are likely to Brequire^
study [34], the meta-analysis showed no significant effect for an intervention if high esthetics demands are considered, as
application of silane alone on the repair ability, whereas the surface alterations become more perceptible to patients in an-
use of adhesive or silane + adhesive significantly improved terior teeth [37]. In this sense, electing conservative interven-
the repair bond strengths. Findings of the present study indi- tions should be preferred, since the repair of restorations seems
cating good clinical behavior for repaired composites where capable of increasing tooth and restoration longevity [6, 7]. In
only a layer of adhesive (either two- or three-step) was applied the 5-year follow-up study of Frese et al. [3], all repaired ante-
seem to corroborate with those results. However, it should be rior restorations remained acceptable, showing a functional sur-
considered that the surfaces were previously air-abraded with vival of 100% or 84.6% overall survival when repair was seen
alumina particles; thus, the good repair was likely an effect of as failure. Even though a repaired restoration is still function-
both the physical and chemical treatments applied to the aged ing, it has been considered as failed in several studies [1, 28,
2802 Clin Oral Invest (2019) 23:2795–2803

31], leading to a significant impact on the survival rates. In Funding This study was financed in part by Coordenação de
Aperfeiçoamento de Pessoal de Nível Superior – Brazil (CAPES) –
order to encourage dentists to perform repair instead of
Finance code 001.
replacement, it seems suitable to critically review the
evaluation criteria used in clinical follow-up studies in
Compliance with ethical standards
which repairs are considered unsuccessful and discrimi-
nate true failures from repairable defects. Oral health Conflict of interest The authors declare that they have no conflict of
problems are still highly prevalent worldwide [38], and interest.
around 5% of the global health expenditure may be
required to treat oral health problems [39]. In that sce- Ethical approval The study was approved by the local ethical research
committee (protocol 022/2008) and followed the STROBE guideline. All
nario, the election of more conservative approaches
procedures performed in studies involving human participants were in
when dealing with Bfailed^ restorations, favoring repair accordance with the ethical standards of the institutional and/or national
over replacement, could save more time for dentists to research committee and with the 1964 Helsinki declaration and its later
treat dental diseases and save money for the individual amendments or comparable ethical standards.
and health systems.
Informed consent Informed consent was obtained from all individual
This study was based on data from a private dental
participants included in the study.
practice of one experienced dentist, specialized in es-
thetic dentistry. An advantage of this sort of study setup
is that the technical procedures and clinical judgments
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