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Difficulties Encountered in Materials Placement for Deep Cavity of Posterior Restoration among Dental Practices.











Abdul Azim Asy Abdul Azizi,
Aimi Amalina Ahmadii, Azlan Jaafariii, Aws H Ali
Al-Kadhimiv, Norazlina Mohammadv

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i  Trainee Lecturer , Faculty of Dentistry  USIM. [email protected]

ii Trainee Lecturer, Faculty of
Dentistry USIM. [email protected]

iii Lecturer, Faculty of Dentistry
USIM. [email protected]

iv Lecturer, Faculty of Dentistry
USIM. [email protected]

v  Lecturer, Faculty of Dentistry USIM. [email protected]














Tooth restoration is a common,
routine procedure among dentists but still has its own difficulties especially
for posterior teeth.  As it is a
straightforward procedure, some dentists are not aware of the difficulties that
may contribute in reducing the longevity of the filling. The aim of the study
is to determine the difficulties encountered during and after placement of
restorative materials in deep cavity. Standardized questionnaires were devised
randomly among general private dental practitioners in Kuala Lumpur. The data
was processed and analyzed using SPSS version 21.0 and Chi-square test was used
to determine any significant factors associated with difficulties of material
placement. Results showed that the most frequent difficulties encountered among
practitioners were to obtain good moisture control (39.0%). No significant
association was found between obtaining good moisture control and year of
clinical experience (p= 0.286) and also place of graduation with the
manipulation of the materials (p= 0.542). In conclusion, dental practitioner
claimed that it was difficult to obtain good moisture control in placement of
posterior restoration. Thus, it is an obligation of dental practitioner to


isolation and
good manipulation of materials on posterior restoration.



Keywords: posterior
restoration, difficulties, material manipulation, moisture control 












Deep cavities may be defined by the
likelihood of a pulp exposure. It is agreed by majority of dentists that deep
cavities are demineralization involving ¾ or more of entire dentine thickness
when evaluated on radiograph1. Restorative materials used for
posterior deep cavities are divided into two groups, which are non
tooth-coloured restorations and tooth-coloured restorations.

 Amalgam as non tooth-coloured restoration has
been the goal standard for permanent posterior restorations for many years.  However,
the number of amalgam fillings has been decreased since people are
aware, concern about mercury toxicity and also, it’s aesthetical criteria. Thus,
the demand for tooth-coloured such as composite and glass ionomer cement (GIC)
increased and
slowly replaced the amalgam3, 4.

 Recent trends
demonstrate dentists tend to use composites more because of its superior
aesthetic, less invasive, less setting time and good bonding to tooth structure5
particularly in United States, Ireland, United Kingdom, Japan and Norway2.
It is reported that 78% of amalgam and 84% of composite restorations survived
more than 5 years6.

are few reasons for failure of posterior restorations in deep cavities.
Secondary caries is the most common reason, followed by marginal defect and
discoloration as well as deficient anatomical form and over contouring of a
restoration7, 8. These failures of restoration might be because of
difficulties encountered during and after placement of restorations such as
insufficient moisture control, inadequate tooth preparation and poor proximal
contact6. Therefore, it is crucial to achieve good moisture control
and proper clinical handling of restorative material in order to prolong
longevity of posterior restorations6, 7, 8.

all the difficulties need to be minimised to prevent further destructions such
as removal of unnecessary tooth structure, reinfection and pulp exposure.
Excellent work culture from Islamic perspective stated that in order to get a
good outcome, it should be derived from halal
resources as well as proper methods and techniques. In summary, dentists
with good values should perform proper clinical skills during placement of
restorations to minimise further destructions of the tooth.

Replacement of failed posterior restorations
can be complicated especially in deep cavities as likelihood of a pulp exposure
is increased1. Incompetent dentist with poor handling of the
restorative materials can lead to poor restorations and further complications
such as pain and sensitivity, micro leakage, secondary caries, marginal defect
and discoloration7, 8. Three factors that contribute towards ‘work
attitudes’ by Robert Kreitner are, work involvement, satisfactory and
commitment. Dentist with high commitment only can produce a good restoration, with smooth
interface between tooth and restoration, good anatomical contour and proximal

to Alan et al. (2009), more than 80% of dentists never use rubber dam during
placement of posterior restorations9 which later causing
microleakage especially at the gingival margin followed with secondary caries
formation10. In addition, placement of posterior restoration is more
critical as compared to anterior restoration because of difficulty to maintain
gingival seal10. Even though some patients could not
appreciate the benefits of using good tooth isolation during restoration,
dentist should explain the procedure beforehand and be trustworthy during
placement of restoration. The Prophet said that the one, who does not
possess honesty, does not possess faith, and the one who does not keep his
pledge, is not a Muslim, narrated by Ahmad,al-Tabarani, and al-Bayhaqi.R

Listed above are few difficulties encountered
during placement of posterior restorations. Therefore, the aim of the study to
determine difficulties encountered during and after placement of restorations
as well as to determine the influence of having good isolation with the year of






This is a cross sectional
study that was carried out from February 2017 to July 2017 among private
general dental practitioner in Kuala Lumpur. A simple random sampling method
was used to select the respondents involved in this study from the list in
Dental Practitioners Information Management System (DPIMS). Any part time locum
practitioner from government dental clinics were excluded from this research.
Upon questionnaire completion, an ethical approval was obtained from faculty
research ethical committee.


questionnaire adapted from a similar study (TAREK H.RABI) was used in obtaining the research data and outcome.
Then, it was tested for content validity among dentists in USIM. Some minor modification
then was done for the use in the present survey. This questionnaire consist of
two part; part A on sociodemographic profile and part B with regards of
material selection including its factors, the dentists’ perception as well as
problems encountered during the procedure.


This was self-administered questionnaire completed by the respondent
themselves. The questionnaires were devised by email and letter to the dental
practitioners in Kuala Lumpur. Information related about the survey and written
consent were attached together to be filled by respondents. Then, the complete
form sent back by letter or some of them directly emailed the questionnaire to


The data were processed using
Statistical Package for Social Science (SPSS) version 21.0 and were figured by
evaluating the descriptive data in mean, frequency, percentage and standard
deviation for some particular variables. In order to determine any significant
factors associated with difficulties of material placement, the analysis was done
using Chi-square test.










Of 207 dentits, 77 returned the
questionnaire which represent 38% of response rate. The participants involved
37 (48%) males and 40 (52%) females. Most of the participants were young
dentists (44%) with the mean age of them were 36 years (SD=10.4). Only 24 (31%)
of the respondents graduated oversea. About 60% of them reported that their
clinical experience is less than 10 years. Table 1 shows the summary
characteristics of respondents for this study.


Table 2 shows the response of the
participants on the difficulties faced during and after the placement of
selected materials for posterior tooth. Most of the responses found were rarely
of frequently. However, good moisture control was found to be difficulties
encountered (39 %). Meanwhile, about 19.5% reported to encounter difficulty
during manipulation of posterior tooth restoration.


Table 3 and 4 demonstrated some factors
from sociodemographic of respondents to be associated with two difficulties in
material placement. From the result, there was no significant association found
between obtaining good moisture control and year of practice (p= 0.286). The
analysis also found that place of graduation neither local nor oversea was no
significant relation with the manipulation of the materials (p= 0.542).





Throughout this study, the most three difficulties encountered by the
general private dental practice are good moisture control, tooth sensitivity
and obtaining proximal contact which 
39%, 29% and 27% respectively. However, the result were against to the
findings of Gilmar AS et al in 2007, especially regarding the problem of
isolation, which is 79%. R. But,
in more recent study done by Iftikhar Akbar 2015 in Northern Saudi Arabia, the
number has decreased to 36%.R.
This may be due to contribution of rubber dam application lately.


moisture control will lead to the unacceptable quality of restoration or worst
to produce secondary caries. In previous study done by Mjor et al in 2000, it mentioned
more experienced dentists have lower replacement rates and secondary caries
incidence provided the good isolation done.R Despite, the relation between good isolation and year of
experience is vice versa for this present survey because there is no
significant association between them as in Table 3.


coloured restoration technique have been taught worldwide and actually have
increased markedly to the undergraduate in dental schools. R. But one dental school in
Netherlands has stopped instruction on amalgam (Roeters et al, 2004).R? In Norway and Sweden, the dentists
have been banned amalgam starting from 2009.R? This might cause some of the dental practitioners in Kuala
Lumpur  to have difficulty in
manipulation materials since 31 % of them graduated oversea because in
Malaysia, amalgam filling still being practiced here. Nevertheless, table 4
showed no significant relation between place of graduation with materials
manipulation in this study (p=0.542).


the difficulties will incline the dentist either to do it improperly or to
encounter it accordingly. It is regarding the value of integrity.  The Code of Professional Conduct in Malaysia
Dental Council (MDC) guidelines wrote that, if the practitioner is in doubt
regarding the difficult procedure, he should ask opinion or consultation from
colleagues.R. Otherwise, the
dentist can refer the case to the specialist for further advance treatment.
This has been highlighted in a part of excellent Islamic working culture which
to be judicious and smart in managing job’s obstacles. R.


Professional Development (CPD) is a compulsory task to all dentists registered
under Malaysia Dental Council (MDC). This is important to ensure the
practitioners equipt themselves with updating knowledge and skills to provide
beneficence and non-maleficeince during managing patients as if in Basic
Principle of Medical Ethics.R. In
the hadith, the Prophet (pbuh) outspokenly said, ‘ Neither inflict injury nor
repay one injury with another ) . R.


the difficulties encounter after placement of materials, majority of the
private general dental practices mentioned that they have rarely or never
encountered these problems such as staining and tooth sensitivity (Table 1).
The response given by them were almost same for all options given in Tarek H.
Rabi’s findings. R.








In conclusion, the objective for this study
was achieved. Deep cavity is a big challenge among the dentists especially
fresh graduate. Keep update with the recent findings and always attend courses
related to the difficulties will help to improve and encounter the problems. It
mentions in Holy Quran Surah Ash-Sharh,’ Verily, with the hardship,there is







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