Accepted Manuscript

Title: Longevity of direct and indirect resin composite

restorations in permanent posterior teeth: A systematic review
and meta-analysis

Author: Ana Maria Antonelli da Veiga Amanda Carneiro

Cunha Daniele Masterson Tavares Pereira Ferreira Tatiana
Kelly da Silva Fidalgo Thomaz Kauark Chianca Kátia
Rodrigues Reis Lucianne Cople Maia

PII: S0300-5712(16)30160-9
DOI: http://dx.doi.org/doi:10.1016/j.jdent.2016.08.003
Reference: JJOD 2655

To appear in: Journal of Dentistry

Received date: 9-2-2016

Revised date: 13-5-2016
Accepted date: 10-8-2016

Please cite this article as: {http://dx.doi.org/

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Title of paper: Longevity of direct and indirect resin composite restorations in
permanent posterior teeth: a systematic review and meta-analysis

Short title: Longevity of direct and indirect resin restorations: systematic review

Name of authors: Ana Maria Antonelli da Veigaa, Amanda Carneiro Cunhab,

Daniele Masterson Tavares Pereira Ferreirac, Tatiana Kelly da Silva Fidalgob,
Thomaz Kauark Chiancab, Kátia Rodrigues Reisa, Lucianne Cople Maiab

Job titles and adresses:

a
Department of Prosthodontics and Dental Materials, Federal University of Rio
de Janeiro, Av. Carlos Chagas Filho, 373, Prédio do CCS, Bloco K, Ilha da
Cidade Universitária, Rio de Janeiro, Brazil.

b
Department of Pediatric Dentistry and Orthodontics, Federal University of Rio
de Janeiro, Av. Carlos Chagas Filho, 373, Prédio do CCS, Bloco K, Ilha da
Cidade Universitária, Rio de Janeiro, Brazil.

c
Center of Health Science, Federal University of Rio de Janeiro, Av. Carlos
Chagas Filho, 373, Prédio do CCS, Bloco I, Ilha da Cidade Universitária, Rio de
Janeiro, Brazil

Corresponding Authors:

Dr Lucianne Cople Maia

Disciplina de Odontopediatria da FO-UFRJ, caixa postal 68066 – CEP: 21941-

971- Cidade Universitária – Rio de Janeiro – RJ – BRAZIL.

Tel +55 21 39382098

Endereço eletrônico: rorefa@terra.com.br (Cople Maia, L)

Keywords: resin composite restoration, inlay, direct composite, longevity,
systematic review, meta-analysis.
 ABSTRACT

Longevity of direct and indirect resin composite restorations in

permanent posterior teeth: a systematic review and meta-analysis

Objectives: The aim of this systematic review and meta-analysis was to assess
the differences in clinical performance in direct and indirect resin composite
restorations in permanent posterior teeth.

Sources: PubMed, the Cochrane Library, Web of Science, Scopus, LILACS,

BBO, ClinicalTrials.gov and SiGLE were searched without restrictions.

Study selection: We included randomized clinical trials (RCTs) that compared

the clinical performance of direct and indirect resin composite restorations in
Class I and Class II cavities in permanent teeth, with at least two years of
follow-up. The risk of bias tool suggested by Cochrane Collaboration was used
for quality assessment.

Data: After duplicate removal, 912 studies were identified. Twenty fulfilled the
inclusion criteria after the abstract screening. Two articles were added after a
hand search of the reference list of included studies. After examination, nine
RCTs were included in the qualitative analysis and five were considered to have
a ‘low’ risk of bias. The overall risk difference in longevity between direct and
indirect resin composite restorations in permanent posterior teeth (p > 0.05) at
five-year follow-up was 1.494 [0.893–2.500], and regardless of the type of tooth
restored, that of molar and premolars was 0.716 [0.177–2.888] at three-year
follow-up.

Conclusions: Based on the findings, there was no difference in longevity of

direct and indirect resin composite restorations regardless of the type of
material and the restored tooth.

Clinical significance: Contemporary dentistry is based on minimally invasive

restorations. Any indication of a less conservative technique must have
unquestionable advantages. In vitro and in vivo studies reveal contradictory
evidence of the clinical performance of direct and indirect resin composite
restorations in posterior teeth. Thus this study clarified this doubt.

Keywords: resin composite restoration, inlay, direct composite, longevity,

systematic review, meta-analysis.

1. Introduction

Direct and indirect resin composite restorations are widely used in

contemporary dentistry to restore posterior teeth.1-3 Traditionally, the choice
between the use of direct and indirect techniques for resin composites in
posterior teeth is based on the size of the cavity to be restored. Small and
medium cavities are usually restored with direct composite resin restorations.
On the other hand, in large cavities, where the width of the isthmus exceeds
two-thirds of the distance between facial and lingual cusp tips, indirect
restorations become indicated.3-6 However, because of the evidence that direct
resin composite restorations have properties suitable for use in posterior teeth,7-
11
do not require invasive preparation and12 are made in only one session at low
cost, many dentists are also using them in large cavities, making the clinical
decision challenging.14
Bis-GMA-based resin composites could have considerable
polymerization linear shrinkage around 0.36–0.88 %15 and volumetric shrinkage
of about 1.5 to 3.4 %.16 This phenomenon is a consequence of the reduction of
intermolecular distances by creation of single covalent bonds between resin
monomers during the formation of the polymer network. These volumetric
changes may lead to the formation of local interfacial gaps and consequent
microleakage.17,18 However, it is still not clear whether these gaps could exceed
the clinically relevant width of around 60µm at the outer margin of the
restoration.17 The magnitude of this contraction depends on factors like resin
matrix formulation, amount of filler used in the resin composite, degree of
conversion19 and incremental filling technique.20 The stress generated by this
polymerization shrinkage in direct resin composites is much higher than in
indirect ones (13 times).21 For indirect resin composite restorations, postcure
using light, heat, pressure or atmosphere of nitrogen5 and the thin layer of
adhesive cement help to relax the stress of the contraction of polymerization.22
The only shrinkage which may influence interfacial adaptation occurs in the
cement layer.19 Thus, it is expected theoretically that the mechanical and
physical properties23-25 and consequently the clinical performance of indirect
resin composite restorations should be improved.21, 25-27

However, when both techniques are compared, in vitro21, 26-28 and in vivo
studies2, 29
seem not to be unanimous regarding the best results of one
technique over the other, including when it is used to restore large cavities in
posterior teeth.1, 2, 4, 30 Thus, the aim of the present systematic review (SR) and
meta-analysis was to answer the following question focus: is there a difference
in the clinical longevity of restorations performed of direct and indirect resin
composite restorations in permanent posterior teeth?

2. Materials and methods

2.1 Protocol and registration

The study protocol was registered on the PROSPERO database

(http://www.crd.york.ac.uk) under number CDR42015020210 on 05/06/2015
and we followed as closely as possible the preferred reporting items of
systematic review and meta-analysis protocols (PRISMA-P) 2015.31

2.2 Eligibility criteria

The controlled vocabulary (MeSH terms) and free terms were used to define the
search strategy (Table 1) based on the elements of PICOS questions (S –
study design)32 as follows:
1. Population (P): permanent posterior teeth of humans, with Class I or Class II
cavities, with or without cusp involvement, from decay, exchange of pre-existing
dental material or dental erosion.
2. Intervention (I): indirect resin composite restorations.
3. Comparison (C): direct resin composite restorations.
4. Outcome (O): longevity of the direct and indirect resin composite restorations.
5. Study design (S): randomized clinical trial (RCTs) with at least two years of
follow-up.
Only RCTs that compared the longevity of direct and indirect resin
composite restorations in Class I or Class II cavities with or without cusp
involvement and with at least two years of follow-up were selected and
included. There were no restrictions regarding setting, language or year of
publication.
The failure rate of direct and indirect resin composite restorations in
posterior teeth was the primary outcome. Secondly, the failure rate in a
subgroup that compared direct resin composite (DRC) with indirect resin
composite (IRC) and direct composite resins (DRC) and direct inlay/onlay
restorations (DIO) was evaluated, along with whether the type of teeth, bruxism
and risk of caries have some effect of clinical longevity of the resin composite
restorations.

2.3 Exclusion criteria

Non-controlled clinical trials, case reports, series of cases, reviews, abstracts, in

vitro studies, observational studies, discussions, interviews, editorial and expert
opinion were excluded. Additionally, studies that do not relate to the issue
because they were conducted in relation to another type of cavity, cavities
extending to the root surface, restorations of anterior teeth, deciduous teeth, not
vital tooth and tooth without antagonist were also excluded.

2.4 Information sources and search

The literature search strategy was developed using a combination of MeSH

terms with free terms most frequently cited in published literature related to
direct and indirect resin composite restorations in posterior teeth. The search
process was performed by two independent researchers (A.M.A.V and A.C.C)
under the guidance of an expert librarian (D.T.P.F). The search strategies were
adapted according to the requirement of the base researched and are described
individually (Table 1). The terms were searched in the fields Title and Abstract
without application of any filter or limit regards to the idiom. For manuscripts in
idioms other than English (such as Spanish, French and Portuguese), there was
at least one researcher in the team to translate them. The last update was
performed on August 18, 2015 and the following electronic databases were
searched: MEDLINE via PubMed, Cochrane Library, Web of Science, Scopus,
Latin American and Caribbean Health Sciences (LILACS) and the Brazilian
Library of Dentistry (BBO). To locate unpublished and ongoing clinical trials
related to the review question we follow the website ClinicalTrials.gov
(www.clinicaltrial.gov), and the grey literature was explored using the database
System for Information on Grey Literature in Europe (SIGLE) (Table 1).

2.5 Study collection and data collection process

All references were collected in web software (www.myendnoteweb.com) during

the selection process. Articles were selected by title and abstract and when
appearing in more than one database they were considered only once. When
there was insufficient information in the title and abstract, full-text articles were
obtained to make a clear decision. Two of the reviewers (A.M.A.V and A.C.C)
classified those who met the inclusion criteria. If multiple reports of the same
study were identified but with, for example, a different follow-up, only the report
with the longer follow-up was considered to avoid overlapping data. However, in
the case of doubts regarding methodology, the article that gave rise to the study
series was accessed or its authors were consulted. We hand-searched the
reference lists of the selected articles in order to find any studies that had not
been identified by the electronic search strategy. Selected articles about which
the two authors did not agree were included or excluded in a consensus
meeting with a third author (L.C.M), following the predefined eligibility criteria.
Each study was identified by ID, combining the first author and year of
publication. A pilot test was conducted using a sample of study reports to verify
that the eligibility criteria were consistent with the research question. The
following details were extracted by customized forms based on
recommendations by Cochrane Handbook 5.0.2 (www.handbook.cochrane.org):
  Details of the sources including first researcher, year of publication
and reviewer’s identification.
 Details of eligibility including study design, population, intervention,
control and follow-up.
 Details of participants including number of restorations per group,
age and gender.
 Details of intervention and control including type of intervention,
material and technique used and time spent until the outcome.
 Details of outcomes including success and failure rates, and number
of and reasons for dropouts.

In addition, information was extracted about source of funding and

number of attempts to contact the authors, if necessary (up to three attempts in
over a period of two months through the electronic means available). When the
corresponding authors did not answer the researchers, the same number of
attempts were made to contact other co-authors.

2.6 Risk of bias in individual studies

Qualitative analysis of the studies was carried out using the Collaboration’s tool
for assessing risk of bias in RCTs. Due to the methodological characteristics of
the studies, only four domains were considered key domains for the
assessment of the risk of bias: sequence generation, allocation concealment,
incomplete outcome data and selective outcome reporting. Blinding of
participants, personnel and outcome assessors was not considered key due to
the specific characteristics of the studies that compare direct and indirect
restorations.

The risk of bias for each entry recording was judged as ‘no’ to indicate
high risk of bias, ‘yes’ to indicate low risk bias and ‘unclear’ to indicate either
lack of information or uncertainty over the potential risk of bias. When a study
was judged as ‘unclear’ in any of fields, contact with the authors by electronic
message was made in order to obtain more information and to enable the
judgment of low or high risk of bias. During the extraction of the data, in the
case of disagreements between reviewers, these were resolved through
discussion with an experienced researcher (L.C.M).
2.7 Summary measures and synthesis of the results

A meta-analysis was performed using the Comprehensive Meta-Analysis

software (version 3.2, Biostat, Englewood, USA) to assess differences in the
clinical longevity of direct and indirect resin composite restorations. The studies
showed that failure rates for each group and the total number of teeth were
included in the meta-analysis. Since the studies had the same follow-up, failure
rates were obtained and pooled in the meta-analysis according to the follow-up.
The overall failure rate was only computed for studies that had a follow-up of
five years. In addition to the general rate, two subgroups were created for
comparing analysis: (i) direct resin composite (DRC) against indirect resin
composite (IRC) and (ii) DRC against direct inlay/onlay (DIO) based on five
years of follow-up. A final analysis was performed comparing the clinical
performance of the DRC against the IRC in molars and premolars at three-year
follow-up.

A fixed effects model was employed. Heterogeneity was assessed using

the Inconsistency Index (I2) and the relative risk was also calculated (p < 0.05).
The I2 describes the percentages of total variation across studies that are due to
heterogeneity rather than chance.33 When necessary, sensitivity analysis and
subgroup analysis were used.

3. Results

3.1 Characteristics of included articles

After the database screening and removal of duplicates, 912 studies were
identified (Fig. 1). After title and abstract screening, 20 studies were selected by
eligibility. Two more studies were added following a manual search of the
references of these 20 studies. Among them, 13 were excluded due to the
following reasons: (1) no access to article,-34-36 (2) overlapping data,37-41 (3) no
relation to the topic, 41, 42 (4) no RCTs,43-45 (5) no comparison direct with indirect
46
resin composite restorations. There was only one paper in an idiom we did
not have anyone to translate (Chinese). However, the paper’s abstract was in
English, with enough information for us to identify that it did not fit the eligibility
criteria to be included in the systematic review.
 The characteristics of the nine studies selected for the qualitative data
analysis are listed in Table 2. All studies were developed at universities with
follow-ups ranging from two to 11 years. The minimum number of enrolled
patients was 28 and the maximum 157. The ages were quite heterogeneous.
Four studies used a paired-tooth design, in one study the subjects received only
one type of restoration (intervention or control) and in another one patients
received five restorations. However, in three studies it was unclear how the
study was conducted. The United States Public Health Service (USPHS) and
the United States Public Health Service – Modified (USPHS-M) indexes were
employed for almost all of the studies. Only one used a qualitative analysis
itself.

Six studies compared the performance of DRC restorations with IRC and
three compared the performance of DRC with DIO. All cavities were Class I or
Class II, and in six studies cavities were medium-to-large-size Class II
restorations, and may have had three or more surfaces involved, including one
or more cusps. With regard to tooth type (molars and premolars), in studies in
which there was a comparison of DRC with IRC restorations, only two studies
used both teeth. When the intervention was DIO restorations, only one of them
described the number of teeth used for each group and the type of restoration
they received. Despite the large variety of composite brands used, we had
difficulty describing them. Resin composites were divided into high filler load
(>60% vol.) and filler load (<60% vol.)6, 10
In studies that compared DRC
restorations with IRC, resin composites with high filler load were employed for
IRC and filler load <60% vol. for DRC. In three studies in which the intervention
was DIO, both groups, control and intervention, used resin composite with filler
load <60% vol.

With regard to patient-related variables such as caries risk and bruxism,

only three studies reported such analysis.1, 13, 52
The most common general
failures reported were (i) DRC: fracture of restoration, anatomical form, tooth
fracture and marginal adaptation; (ii) IRC: marginal discolouration and marginal
adaptation, fractures and debonding of restoration; and (iii) DIO: secondary
caries.
3.2 Assessment of the risk of bias

An assessment of the risk of bias of the studies selected is presented in Fig. 2.

According to the predetermined key domains, three studies were considered
‘high’ risk of bias,4, 5, 51
five were classified as ‘low’1, 13, 48, 52, 54
and one as
‘unclear’3 risk of bias. All studies with ‘low’ risk of bias were considered for the
meta-analysis, and after susceptibility testing was conducted and there were no
significantly different results with or without the inclusion of the ‘unclear’ risk of
bias, this was also included in the meta-analysis. In summary, six studies met
the best requirement features for quantitative analysis.

3.3 Synthesis of the results: meta-analysis

Following the guidance of Cochrane Handbook 5.0.2, after conducting a general

meta-analysis, there was no statistically significant difference for the outcomes
studied, regardless of the inclusion of ‘unclear’ risk of bias (p> 0.05). Fig. 3 is
the meta-analysis for the overall failure rate of all studies with five-year follow
up.1, 3, 13, 47, 48
These studies showed low heterogeneity (I2 = 4.09%) and a
relative risk of 1.494 [0.893 – 2.500] for indirect restorations. However, the
pooled meta-analysis showed no statistically significant difference in clinical
longevity for direct and indirect resin composite restorations (p = 0.126).

Fig. 4A shows the subgroup analysis comparing (i) DRC against IRC at
five-year follow-up. The relative risk was 1.278 [0.663–2.465] in relation to IRC,
with no statistically significant difference between the two groups (p = 0.464)
and low heterogeneity (I2 = 35.44%). Fig. 4B shows the subgroup analysis
comparing (ii) DRC with DIO with five-year follow-up. There was no statistical
difference between the groups, with a relative risk of 1.915 [0.837–4.385] (p =
0.124) in relation to DIO and without heterogeneity between groups (I2 =
0.00%).

A pooled meta-analysis is presented in Fig. 5, which compares molars

and premolars restored with DRC and IRC with three-year follow-up. The
heterogeneity was low for both molars (I2 = 25.03%) and premolars (I2 =
0.00%). The overall relative risk was 0.716 [0.177–2.888], without statistical
difference (p = 0.638).
4. Discussion

Systematic review and meta-analysis studies are complementary to RCTs,

since they help summarize the current knowledge available in health with the
common goal of seeking solid scientific evidence for use in clinical practice.46,47
To reduce the individual risk of bias of RCTs included in an SR it is necessary
for them to be evaluated for their methodological quality. The current
recommendation of Cochrane Handbook 5.0.2 (www.handbook.cochrane.org)
for assessing the risk of bias in clinical trials is the use of a domain-based tool,
i.e. a critical assessment is made separately for different aspects of the risk of
bias.38 However, the assessment of the overall risk of bias involves the
consideration of the relative importance of the different areas according to the
peculiarities of each SR, thereby helping the authors decide on which domains
they consider to be key.36 This tool recommends that only studies with ‘low’ risk
of bias in all key domains must be considered in meta-analysis, because they
synthesize the best evidence for clinical practice. Although including only RCTs
is an important inclusion criterion, this decision usually results in a limited
number of studies and, consequently, of restorations that can be included in a
study, posing the possibility of underpowering the study’s outcomes. Despite
the fact that, over the time, this study showed that there were no statistical
differences in clinical longevity between direct and indirect resin composite
restorations, it is important to highlight that all nine studies included in this meta-
analysis performed sample size calculation. Therefore, they had sufficient
power to detect significant differences between groups if those differences were
present. In addition, the effect sizes of all individual studies were analyzed in a
pooled meta-analysis, showing no statistically significant difference in clinical
longevity for direct and indirect resin composite restorations. For this reason,
the authors believe that the number of studies (n = 9) and restorations (n = 899)
included did not underpower the study’s results and conclusions. The
randomization is important in clinical studies to allow an unpredictable result
and prevent selection bias, which can lead to overestimation of the effect of
intervention according to Cochrane Handbook 5.0.2. Unfortunately, a recurring
problem encountered in the RCTs included in this SR was the lack of clarity in
describing the sequence generation. Another difficulty was in relation to the
allocation concealment. Authors rarely described the method used to conceal
the allocation sequence in sufficient detail to determine whether intervention
allocations could have been foreseen in advance of, or during, enrolment. To
clarify these two key domains, it was necessary to contact, through e-mail, the
majority of the authors,1, 4, 5, 13, 48, 51
showing that this information is rarely
described in the methodology of the RCTs.

Although blinding of participants, operators and outcome assessors is

very important to avoid bias of performance and detection, there are intrinsic
technical differences between direct, direct inlay/only and indirect resin
composite restorations that make it impossible to blind operators and patients
(Fennis et al.48). Assessor blinding is also a major challenge in such studies.
Only three studies included in our systematic review (SR) indicated they blinded
the assessors. They asserted the assessors did not have previous knowledge
about the type of restoration or the materials used in the restorations they were
about to assess. Even though not explicitly mentioned in their papers, it is fair to
assume the other six studies included in our SR also did not provide assessors
with up-front information about the type of the restorations they were about to
assess. However, not knowing in advance which type of restorations they were
going to assess does not prevent assessors from knowing immediately, by
looking at the restorations, which type they are. In the case of indirect
restorations (made through a laboratory), only professionals with limited training
or experience are unable to distinct them from a direct resin composite
restoration when they evaluate one; there are clear differences in clinical
appearance, for instance, in terms of morphology, polishing, and
presence/absence of line of cementation. The differences between direct resin
composite and direct inlay/onlay restorations, however, are more subtle,
especially when they have been in the mouth for some time; for inlay/onlay the
cement line is not the same as for ceramic restorations and their anatomic form
is rather similar to direct restorations. Given assessor blinding is a source of
bias almost impossible to be completely eliminated in any study of this kind, we
have not considered it as a key domain (point) of bias in our selection criteria.
The report of incomplete outcome data is important because it describes
the number of participants lost in each intervention group compared with the
total number of randomized participants. If caution isn’t taken with regard to the
report of incomplete outcome data, there may be the risk of creating
attrition/exclusion bias due to the disproportion of participants in one group
compared to another. Fortunately, in our SR only one study did not report how
many participants were lost.51 Loss of participants can be due to patients
moving out of the area or a loss of interest in returning for recall appointments.
This can be justified because clinical trials take a lot of time to be concluded
and specifically in dental trials the benefits are more for researchers than for
patients.47

Selective outcome reporting was a key domain because through this

domain we can examine whether the reports were free of suggestion of
selective outcome reporting and the outcomes were according to the pre-
existing protocol. In this SR the majority of studies were free of such bias (Fig.
2).

With regard to the restorative technique employed in the intervention

groups of RCTs included in our SR, indirect composite resin restorations were
named in different ways as ‘inlays’13 or ‘indirect resins’3, 4, 5, 48, 52 when they were
made in a dental lab and ‘direct inlay/onlay’1, 47 or only as ‘indirect restorations’51
when they were made using conventional direct resin composite placed into the
tooth cavity previously isolated and posteriorly placed for secondary curing. To
avoid confounding variables, the authors subdivided indirect resin composite
restorations into two subgroups called ‘Indirect resin composite’ and ‘Direct
inlay/onlay’ to analyse these subgroups individually and when pooled in a single
group in the meta-analysis. As there was no statistically significant difference in
clinical performance between them (Figs. 3, 4A and 4B) and there is no
unanimity among the classifications, we suggest considering terms such as
‘Indirect resin composite restorations’ or just ‘Resin composite inlay/onlay’ and
the technique could be better described in the material and method section.
Moreover, the resin composites employed in indirect techniques of these RCTs
have not always been indicated exclusively for dental laboratories;13 all received
secondary curing and were cemented with an adhesive cement agent.
Unification of this terminology could make access to the literature available
easier for researchers, clinicians and students.
 In In vitro studies,23-25 secondary curing is seen as one of the advantages
of indirect resin composite restorations; however, it does not seem clinically
applicable for improving the longevity of these materials. This can be justified
because clinically patient-related variables such as bruxism and caries risk8, 10,
17, 19, , 55
can significantly impact on the long-term success of restorations.
Unfortunately, in our SR it was not possible to perform meta-analysis for these
factors because it was considered in three of the RCTs1, 13, 40 and in only one of
them52 were the failures associated with individual patient risk.

In addition to the factors described above, other factors such as

material and tooth-related variables have also been identified as key factors for
the clinical success of resin composite restorations.10, 11, 17, 53, 54 With regard to
resin composite materials, due to the variety among them, we could not perform
a meta-analysis but did conduct a descriptive analysis in which it was shown
that both high filler load (>60% vol) and filler load (<60% vol.) resin composites
were used regardless of technique. One limitation of this systematic review is
that some of the materials used in the studies that fulfilled the eligibility criteria
are not on the market anymore. However, independently of the materials and
techniques employed, it did not influence the longevity of restorations, once
they were considered clinically acceptable, and the number of failures was
considered low. On the other hand, considering the improvements on the more
recent restorative materials, it is suggested that new longitudinal studies
comparing direct and indirect resin composite restorations using materials
currently in the market should be implemented.
The tooth-related variable, only two trials with 'low' risk of bias employed both
types of teeth, molars and premolars, and a meta-analysis was possible only
with three-year follow-up. Overall, there was no statistically significant difference
(p = 0.638) between them. Although this meta-analysis only included two trials
with a short follow-up, these results are in accordance with Pallesen and Van
Dijken,56 who also found no difference in longevity between molars and
premolars restored with DRC over a 30-year follow-up. Failures were
analysed descriptively and do not appear in the meta-analysis due to variable
factors reported in each of the three groups of restorations. For DRC
restorations, fracture of the restoration and changes in anatomical form were
most frequently reported, followed by failures in marginal adaptation of
restorations. In longitudinal studies that evaluated the performance of DRC,8, 10,
11, 56
these results were also found to be the most prevalent failures followed by
dental caries. However, in our SR, no study has reported decay as the most
prevalent factor of failure in DRC restorations, and only two trials1, 47
reported
failures in DIO due to dental caries. For IRC, marginal adaptation was the most
frequently reported factor of failures. Both in vivo6, 57
and in vitro 26
studies,
crevices at the margins and marginal discolouration were prevalent factors of
failures.

Making clinical decisions about indirect resin composite restorations is

not always easy, especially when the professional is faced with issues related to
increased wear of the remaining tooth structure, time and cost without having
the clear advantage of longevity compared to direct resin composite
restorations. One example is the research by Laegreid et. al.,14 in which, in a
questionnaire answered by 270 dentists from Bergen, Norway, when asked
about which type of restorative material they preferred to employ in largely
destroyed posterior teeth, with losses of up to two cusps, 65.1% answered that
they rarely or never employed indirect resin composite restoration while 83.5%
often used direct resin composite for such clinical situations. Perhaps the
predilection for direct composite resin restorations is due to very favourable
results regarding the clinical performance of these restorations in posterior teeth
shown by clinical trials.7, 11, 56, 58 These findings are consistent with those found
in our meta-analysis, which showed no statistically significant difference in the
clinical performance of the DRC when compared to IRC at five-year follow-up (p
= 0.126).

5. Conclusion

Based on the results of this systematic review and meta-analysis, there is

evidence of no difference in terms of clinical longevity between direct and
indirect resin composite restorations. This conclusion remains valid even when
the type of restored tooth is taken into account. Therefore, it seems more
reasonable to suggest that direct restorations should be given preference to
indirect restorations in many situations, since the former require less effort and
cost. 6. Conflict of interest

None.

Acknowledgments

This study was conducted as part of the master degree of Ana Maria Antonelli da Veiga
under the supervision of Professor Lucianne Cople Maia. The authors of this study
would like to thank the following authors who kindly provided information not available
in their full texts: Jan Van Djiken, Ulla Pallesen, David Bartlett and Willem Fennis.
REFERENCES

1. Van Dijken JW. Direct resin composite inlays/onlays: an 11 year follow-up.

Journal of Dentistry 2000;28:299-306.
2. Spreafico RC, Krejci N, Dietschi D. Clinical performance and marginal
adaptation of class II direct and semidirect composite restorations over 3.5
years in vivo. Journal of Dentistry 2005;33:499-507.
3. Cetin AR, Unlu N, Cobanoglu N. A Five-Year Clinical Evaluation of Direct
Nanofilled and Indirect Composite Resin Restorations in Posterior Teeth.
Operative Dentistry 2013;38:E31-E41.
4. Manhart J, Neuerer P, Scheibenbogen-Fuchsbrunner A, Hickel R. Three-year
clinical evaluation of direct and indirect composite restorations in posterior
teeth. Journal of Prosthetic Dentistry [Internet] 2000;84:[289-96 pp.]. Available
from: http://onlinelibrary.wiley.com/o/cochrane/clcentral/articles/054/CN-
00326054/frame.html.
5. Ozakar-Ilday N, Zorba YO, Yildiz M, Erdem V, Seven N, Demirbuga S.
Three-year clinical performance of two indirect composite inlays compared to
direct composite restorations. Medicina oral, patología oral y cirugía bucal
2013;18:e521-8.
6. Huth KC, Chen HY, Mehl A, Hickel R, Manhart J. Clinical study of indirect
composite resin inlays in posterior stress-bearing cavities placed by dental
students: results after 4 years. Journal of Dentistry 2011;39:478-88.
7. Manhart J, Chen HY, Hickel R. Three-year results of a randomized controlled
clinical trial of the posterior composite QuiXfil in class I and II cavities. Clinical
Oral Investigations 2009;13:301-7.
8. Da Rosa Rodolpho PA, Donassollo TA, Cenci MS, Loguercio AD, Moraes
RR, Bronkhorst EM, et al. 22-Year clinical evaluation of the performance of two
posterior composites with different filler characteristics. Dental Materials
2011;27:955-63.
9. Demarco FF, Correa MB, Cenci MS, Moraes RR, Opdam NJ. Longevity of
posterior composite restorations: not only a matter of materials. Dental
Materials 2012;28:87-101.
10. Opdam NJ, van de Sande FH, Bronkhorst E, Cenci MS, Bottenberg P,
Pallesen U, et al. Longevity of posterior composite restorations: a systematic
review and meta-analysis. Journal of Dental Research. 2014;93:943-9.
11. Frankenberger R, Reinelt C, Kraemer N. Nanohybrid vs. fine hybrid
composite in extended class II cavities: 8-year results. Clinical Oral
Investigations 2014;18:125-37.
12. Magne P. Conservative restoration of compromised posterior teeth with
direct composites: a 7-year report. Practical Periodontics and Aesthetic
Dentistry 2000;12:747-9.
13. Pallesen U, Qvist V. Composite resin fillings and inlays. An 11-year
evaluation. Clinical Oral Investigations 2003;7:71-9.
14. Laegreid T, Gjerdet NR, Johansson A, Johansson AK. Clinical decision
making on extensive molar restorations. Operative Dentistry 2014;39:E231-40.
15. Kweon HJ, Ferracane J, Kang K, Dhont J, Lee IB. Spatio-temporal analysis
of shrinkage vectors during photo-polymerization of composite. Dental Materials
2013;29:1236-43.
16. Boaro LC, Goncalves F, Guimaraes TC, Ferracane JL, Pfeifer CS, Braga
RR. Sorption, solubility, shrinkage and mechanical properties of "low-shrinkage"
commercial resin composites. Dental Materials 2013;29:398-404.
17. Nedeljkovic I, Teughels W, De Munck J, Van Meerbeek B, Van Landuyt KL.
Is secondary caries with composites a material-based problem? Dental
Materials 2015;31(11):e247-77.
18. Schneider LF, Cavalcante LM, Silikas N. Shrinkage Stresses Generated
during Resin-Composite Applications: A Review. Journal of Dental
Biomechanics 2010;2010.
19. van Dijken JW, Lindberg A. A 15-year randomized controlled study of a
reduced shrinkage stress resin composite. Dental Materials 2015;31(9):1150-8.
20. Van Ende A, Mine A, De Munck J, Poitevin A, Van Meerbeek B. Bonding of
low-shrinking composites in high C-factor cavities. Journal of Dentistry
2012;40(4):295-303.
21. Dejak B, Młotkowski A. A comparison of stresses in molar teeth restored
with inlays and direct restorations, including polymerization shrinkage of
composite resin and tooth loading during mastication. Dental Materials
2015;31:e77-e87.
22. Bagis YH, Rueggeberg FA. Effect of post-cure temperature and heat
duration on monomer conversion of photo-activated dental resin composite.
Dental Materials 1997;13:228-32.
23. Asmussen E, Peutzfeldt A. Mechanical properties of heat treated restorative
resins for use in the inlay/onlay technique. Scandinavian Journal of Dental
Research 1990;98(6):564-7.
24. Khan AM, Satou N, Shintani H, Taira M, Wakasa K, Yamaki M. Effects of
post-curing by heat on the mechanical properties of visible-light cured inlay
composites. Journal of Oral Rehabilitation 1993;20:605-14.
25. Coelho-de-Souza FH, Camacho GB, Demarco FF, Powers JM. Fracture
resistance and gap formation of MOD restorations: Influence of restorative
technique, bevel preparation and water storage. Operative Dentistry
2008;33:37-43.
26. Aggarwal V, Logani A, Jain V, Shah N. Effect of cyclic loading on marginal
adaptation and bond strength in direct vs indirect Class II MO composite
restorations. Operative Dentistry 2008;33:587-92.
27. Duquia RCS, Osinaga PWR, Demarco FF, Habekost LV, Conceicao EN.
Cervical microleakage in MOD restorations: In vitro comparison of indirect and
direct composite. Operative Dentistry 2006;31:682-7.
28. de Paula AB, Duque C, Correr-Sobrinho L, Puppin-Rontani RM. Effect of
restorative technique and thermal/mechanical treatment on marginal adaptation
and compressive strength of esthetic restorations. Operative Dentistry
2008;33:434-40.
29. Kuijs RH, Fennis WMM, Kreulen CM, Roeters FJM, Verdonschot N,
Creugers NHJ. A comparison of fatigue resistance of three materials for cusp-
replacing adhesive restorations. Journal of Dentistry 2006;34:19-25.
30. Thordrup M, Isidor F, Horsted-Bindslev P. A 5-year clinical study of indirect
and direct resin composite and ceramic inlays. Quintessence International
2001;32:199-205.
31. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al.
Preferred reporting items for systematic review and meta-analysis protocols
(PRISMA-P) 2015 statement. Systematic Review 2015;4:1.
32. Maia LC, Antonio AG. Systematic reviews in dental research. A guideline.
The Journal of Clinical Pediatric Dentistry 2012;37:117-24.
33. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency
in meta-analyses. British Medical Journal 2003;327(7414):557-60.
34.Conti GF, Ragni G, Foglio Bonda PL, Centini S, Micheletti P, Sapelli PL.
Direct inlays and onlays in composite material. Dental Cadmos 1987;55:83-8.
Lowe E. Restoring form, function, and aesthetics in Class II direct composite
restorations. Dentistry Today 1998;17:72-4.
36. Trushkowsky R. Direct and indirect composites for the restoration of
decimated dentition in elderly patients. Dentistry Today 2000;19:92-9.
37. Cetin AR, Unlu N. Clinical wear rate of direct and indirect posterior
composite resin restorations. International Journal of Periodontics Restorative
Dentistry 2012;32:e87-94.
38. Scheibenbogen-Fuchsbrunner A, Manhart J, Kremers L, Kunzelmann KH,
Hickel R. Two-year clinical evaluation of direct and indirect composite
restorations in posterior teeth. Journal of Prosthetic Dentistry 1999;82:391-7.
39. Wassell RW, Walls AW, McCabe JF. Direct composite inlays versus
conventional composite restorations: three-year clinical results. British Dental
Journal 1995;179:343-9.
40. Pallesen U, Qvist V. Clinical evaluation of resin fillings and inlays: 8-year
report. Journal of Dental Research 1998;77:914(Abstract nº 2254).
41. Freilich MA, Goldberg AJ, Gilpatrick RO, Simonsen RJ. Direct and indirect
evaluation of posterior composite restorations at three years. Dental Materials
1992;8:60-4.
42. Kreulen CM, van Amerongen WE, Gruythuysen RJ, Akerboom HB,
Borgmeijer PJ. Evaluation of treatment times for Class II resin composite inlays.
Journal of Dentistry for Children 1992;59:333-7.
43. Spreafico RC, Krejci N, Dietschi D. Clinical performance and marginal
adaptation of class II direct and semidirect composite restorations over 3.5
years in vivo. Journal of Dentistry 2005;33:499-507.
44. Zhang LL, Liu TJ, Fang MX, Li W. Clinical evaluation of composite inlays in
defective molars. Zhonghua Kou Qiang Yi Xue Za Zhi 2008;43:44-7.
45. Harb-Kadiri J, Khairallah W. [Restoration of cusped teeth using composite
resins: direct or indirect method?]. Le-Chirurgien-dentiste de France
1986;56:43-7.
46. Thordrup M, Isidor F, Horsted-Bindslev P. A 5-year clinical study of indirect
and direct resin composite and ceramic inlays. Quintessence International
2001;32:199-205.

47. Wassell RW, Walls AW, McCabe JF. Direct composite inlays versus
conventional composite restorations: 5-year follow-up. Journal of Dentistry
2000;28:375-82.
48. Fennis WM, Kuijs RH, Roeters FJ, Creugers NH, Kreulen CM. Randomized
Control Trial of Composite Cuspal Restorations: Five-year Results. Journal of
Dental Research 2014;93:36-41.
49. Berwanger O, Suzumura EA, Buehler AM, Oliveira JB. How to Critically
Assess Systematic Reviews and Meta-Analyses? Revista Brasileira de Terapia
Intensiva 2007;19:475-480.
50. Carvalho APV, SilvaI V, GrandeIl AJ. Avaliação do risco de viés de ensaios
clínicos randomizados pela ferramenta da colaboração Cochrane. Diagnóstico
e Tratamento 2013;18:38-44.
51. Wendt Jr SL, Ziemiecki TL, Leinfelder KF. Proximal wear rates by tooth
position of resin composite restorations. Journal of Dentistry 1996;24:33-9.
52. Bartlett D, Sundaram G. An up to 3-year randomized clinical study
comparing indirect and direct resin composites used to restore worn posterior
teeth. International Journal Prosthodontic 2006;19:613-7.
53. Signore A, Benedicenti S, Covani U, Ravera G. A 4- to 6-year retrospective
clinical study of cracked teeth restored with bonded indirect resin composite
onlays. International Journal Prosthodontic 2007;20:609-16.
54. Van Dijken JW. Durability of resin composite restorations in high C-factor
cavities: a 12-year follow-up. Journal of Dentistry 2010;38:469-74.
55. Van de Sande FH, Opdam NJ, Rodolpho PA, Correa MB, Demarco FF,
Cenci MS. Patient risk factors' influence on survival of posterior composites.
Journal of Dental Research 2013;92:78s-83s.
56. Pallesen U, van Dijken JW. A randomized controlled 30 years follow up of
three conventional resin composites in Class II restorations. Dental Materials
2015;31:1232-44.
57. Dukic W, Dukic OL, Milardovic S, Delija B. Clinical evaluation of indirect
composite restorations at baseline and 36 months after placement. Operative
Dentistry 2010;35:156-64.
58. Opdam NJ, Bronkhorst EM, Loomans BA, Huysmans MC. 12-year survival
of composite vs. amalgam restorations. Journal of Dental Research
2010;89:1063-7.
FIGURE CAPTIONS

Fig. 1: Flow diagram of literature search.

Fig. 2: Summary of the risk of bias assessment according to the Cochrane

Collaboration tool. The underlined authors provided extra information by e-mail
to enable assessment of the risk of bias.

Fig. 3: Forest plot of the risk of failures in permanent posterior restorations

performed with direct vs. indirect resin composite restorations with five-year
follow-up (p = 0.126).

Fig. 4A: Forest plot of the risk of failures in permanent posterior restorations
performed with subgroup analysis comparing DRC vs. IRC at five-year follow-
up, showing no differences between the two groups (p = 0.464).

Fig. 4B: Forest plot of the risk of failures in permanent posterior restorations
performed with subgroup analysis comparing DRC vs. DIO at five-year follow-
up, showing no differences between the two groups (p = 0.124).

Fig. 5: Forest plot of the risk of failures in permanent posterior restorations

performed comparing DRC vs. IRC in molars and premolars with three-year
follow-up. There was no statistical difference in a global analysis between the
groups (p = 0.638).
Table 1 - Eletronic databases and research strategies (18/ AUG/ 2015)
PUBMED
#1Molar [MH] OR Molar [TIAB] OR Molars [TIAB] OR Bicuspid [MH] OR Bicuspid [TIAB]
OR Premolar* [TIAB] OR Dentition, Permanent [MH] OR Permanent Dentition [TIAB] OR
Tooth erosion [MH] OR Tooth erosion [TIAB] OR Erosive tooth wear [TIAB] OR Posterior
teeth [TIAB] OR Posterior tooth [TIAB] OR Dental caries [MH] OR Dental caries [TIAB]
OR Dental decay [TIAB] OR Class I [TIAB] OR Class II [TIAB] #2 Indirect composite
resin* [TIAB] OR Indirect resin* [TIAB] OR Indirect posterior composite [TIAB] OR
Indirect restoration* [TIAB] OR Indirect resin composite [TIAB] OR Indirect composite
[TIAB] OR Indirect [TIAB] OR Inlays [MH] OR Inlays [TIAB] OR Inlay [TIAB] OR Overlay*
[TIAB] OR Onlay* [TIAB] #3 (Composite resins [MH] OR Composite resins [TIAB] OR
Composite resin [TIAB] OR Composite restorative materials [TIAB] OR Resin composit*
[TIAB] OR Resin composite restoration* [TIAB] OR Posterior composite
restoration*[TIAB] OR Resin-based composite*[TIAB] OR Tooth-colored restorat* [TIAB]
OR Dental composite* [TIAB] OR Composite restoration* [TIAB]) Direct composite resin*
[TIAB] OR Direct resin composite restoration* [TIAB] OR Direct composite restorations
[TIAB] OR Direct posterior composite* [TIAB] OR Direct restoration* [TIAB] OR Direct
resin composite [TIAB] OR Direct composite [TIAB] OR Direct [TIAB])
#1 AND #2 AND #3
SCOPUS
#1 TITLE-ABS-KEY (“Molar” OR “Molars” OR “Bicuspid” OR “Premolar” OR
“Premolars” OR “Permanent Dentition” OR “Tooth erosion” OR “Erosive tooth wear”
OR “Posterior teeth” OR “Posterior tooth” OR “Dental caries” OR “Dental decay” OR
“Class I” OR “Class II”) #2 TITLE-ABS-KEY (“Indirect composite resin” OR “Indirect
composite resins” OR “Indirect resin” OR “Indirect resins” OR “Indirect posterior
composite” OR “Indirect restoration” OR “Indirect restorations” OR “Indirect resin
composite” OR “Indirect composite” OR “Indirect” OR “Inlay” OR “Inlays” OR
“Overlay” OR “Overlays” OR “Onlay” OR “Onlays”) #3 TITLE-ABS-KEY (“Composite
resins” OR “Composite resin” OR “Composite restorative materials” OR “Resin
composite” OR “Resin composites” OR “Resin composite restoration” OR “Resin
composite restorations” OR “Posterior composite restoration” OR “Posterior
composite restorations” OR “Resin-based composite” OR “Resin-based composites”
OR “Tooth-colored restoration” OR “Tooth-colored restorations” OR “Dental
composite” OR “Dental composites” OR “Composite restoration” OR “Composite
restorations”) AND (“Direct composite resin” OR “Direct composite resins” OR “Direct
resin composite restoration” OR “Direct resin composite restorations” OR “Direct
composite restorations” OR “Direct posterior composite” OR “Direct posterior
composites” OR “Direct restoration” OR “Direct restorations” OR “Direct resin
composite” OR “Direct composite” OR “Direct”)
#1 AND #2 AND #3
WEB OF SCIENCE
#1 Topic : (“Molar” OR “Molars” OR “Bicuspid” OR “Premolar” OR “Premolars” OR
“Permanent Dentition” OR “Tooth erosion” OR “Erosive tooth wear” OR “Posterior
teeth” OR “Posterior tooth” OR “Dental caries” OR “Dental decay” OR “Class I” OR
“Class II”) #2 Topic: (“Indirect composite resin” OR “Indirect composite resins” OR
“Indirect resin” OR “Indirect resins” OR “Indirect posterior composite” OR “Indirect
restoration” OR “Indirect restorations” OR “Indirect resin composite” OR “Indirect
composite” OR “Indirect” OR “Inlay” OR “Inlays” OR “Overlay” OR “Overlays” OR
“Onlay” OR “Onlays”) #3 Topic: (“Composite resins” OR “Composite resin” OR
“Composite restorative materials” OR “Resin composite” OR “Resin composites” OR
“Resin composite restoration” OR “Resin composite restorations” OR “Posterior
composite restoration” OR “Posterior composite restorations” OR “Resin-based
composite” OR “Resin-based composites” OR “Tooth-colored restoration” OR “Tooth-
colored restorations” OR “Dental composite” OR “Dental composites” OR “Composite
restoration” OR “Composite restorations”) AND (“Direct composite resin” OR “Direct
composite resins” OR “Direct resin composite restoration” OR “Direct resin composite
restorations” OR “Direct composite restorations” OR “Direct posterior composite” OR
“Direct posterior composites” OR “Direct restoration” OR “Direct restorations” OR
“Direct resin composite” OR “Direct composite” OR “Direct”)
COCHRANE LIBRARY
ID Search Hits
#1 MeSH descriptor: [Molar] explode all trees
#2 molar
#3 molars
#4 #1 or #2 or #3
#5 MeSH descriptor: [Bicuspid] explode all trees
#6 bicuspid
#7 premolar*
#8 #5 or #6 or #7
#9 MeSH descriptor: [Dentition, Permanent] explode all trees
#10 dentition, permanent
#11 permanent dentition
#12 #9 or #10 or #11
#13 MeSH descriptor: [Tooth Erosion] explode all trees
#14 tooth erosion
#15 erosive tooth wear
#16 #13 or #14 or #15
#17 posterior tooth or posterior teeth
#18 MeSH descriptor: [Dental Caries] explode all trees
#19 dental caries
#20 dental decay
#21 #18 or #19 or #20
#22 "class I" or "class II"
#23 #4 or #8 or #12 or #16 or #17 or #21 or #22
#24 Indirect composite resin* or Indirect resin* or Indirect restoration* or Indirect
resin composite or Indirect composite or Indirect
#25 Indirect posterior composite
#26 #24 or #25
#27 MeSH descriptor: [Inlays] explode all trees
#28 inlays
#29 inlay
#30 overlay or overlays or onlay*
#31 #27 or #28 or #29 or #30
#32 #26 or #31
#33 MeSH descriptor: [Composite Resins] explode all trees
#34 composite resins
#35 composite resin or Resin composit* or Resin composite restoration* or Resin-
based composite* or Tooth-colored restorat* or Dental composite* or Composite
restoration*
#36 Composite restorative materials
#37 #33 or #34 or #35 or #36
#38 Direct composite resin* or Direct resin composite restoration* or Direct
composite restorations or Direct posterior composite* or Direct composite or Direct
#39 #37 and #38
#40 #23 and #32 and #39
LILACS and BBO
#1 TW:(MH:molar OR diente molar OR dente molar OR molars OR dientes molares OR
dentes molares OR MH:bicuspid OR diente premolar OR dente pré-molar OR dentición
permanente OR dentição permanente OR MH: dentition, permanente OR MH:tooth
erosion OR erosión de los dientes OR erosão dentária OR MH:dental caries OR cáries
dental OR cárie dentária OR caries decay OR posterior tooth OR diente posterior OR
dente posterior OR posterior teeth OR dientes posteriores OR dentes posteriores OR
class I OR clase I OR classe I OR class II OR clase II OR classe II) #2
TW:(MH:Composite resins OR Resinas compuestas OR Resinas compostas OR
Composite resin OR Composite resins OR Composite restorative materials OR Resin
composit$ OR Resina composta$ OR Resin composite restoration$ OR Posterior
composite restoration$ OR Resin-based composite$ OR Tooth-colored restorat$ OR
Dental composite$ OR Compuesto dental$ OR Compósito dental$ OR Composite
restoration$ OR Restauración de compusto$ OR Restauração de compósito$ OR Direct
composite resin$ OR Direct resin composite restoration$ OR Direct composite
restorations OR Direct restoration$ OR Restaración directa$ OR Restauração direta$
OR Direct composite OR Compuesto directo OR Compósito direto OR Direct OR Directa
OR Direta)
#1 AND #2
CLINICAL TRIALS.GOV
Posterior teeth and Inlay and Direct composite resin
SIGLE
(Molar OR Molars OR Bicuspid OR Premolar OR Premolars OR “Class I” OR “Class II”)
AND (“Indirect composite resin*” OR “Indirect resin*” OR “Indirect restoration*” OR
Indirect OR Inlay OR Inlays OR Overlay OR Overlays OR Onlay OR Onlays) AND
(“Composite resin*” OR “Resin composite*” OR “Resin composite restoration*” OR
“Tooth-colored restoration*” OR “Dental composite*” OR “Composite restoration*”)
Table 2: Study and patients characteristics for qualitative analysis.

o o o
Study/ Folow- Study Criteria N Mean age/ N Tooth Cavity N Manufacturing Results Conclusions
Setting up design of range restorat restorat procedure
(years) pati ions ions/
ents (DRC drop-
PM M
(% /IRC or out
(DRC (DRC
men DIO*)
/IRC or /IRC or
)
DIO) DIO)
Bartlett 3 Split- USPHS 29 TW: 16 (16) 11 (11) 5 (7) TW: multiple 29 (2) IRC: TW: Lost: IRC 5 PM and TW: high
&Sundara mouth (n.r.) 43 (25-62) worn A developmental, DRC 3PM + 1M; fracture rate
m, 2006 light/heat-cured, Fractured: IRC 3PM + 1M for direct and
microfilled resin and DRC 2PM + 1M indirect resin
Control: 13 (13) 6 (6) 7 (7) Control:
University composite material Control: Lost: IRC 2 PM; composite
39 (28-65) Extensive
DRC: Fractured: IRC 1 M Control: both
caries
Heliomolar HB, Ivoclar performed
lesions at
Vivadent satisfactorily
least 1 cusp
missing

Cetin et al. 5 Split- USPHS- 22 23(20-28) 67 (41) _ 67 (41) Class I and 54 (0) IRC: Alfa score: Annual failure
2013 mouth M (32) II cavities Estenia [E]; Tescera Gingival adaptation and rates: DRC:
(small to [TATL] Retention: 100%; Color 1.6% IRC:
University medium) DRC: match: 100% FS XT, 2.5%.
Filtek Supreme XT [FS TEC, E; 95% AA, TATL; All
XT]; Tetric EvoCeram Marginal Integraty: 100% acceptable.
[TEC]; AELITE Aesthetic FS XT, 95% TEC,
[AA] 90%TATL, 84% E, 82%
AA; Surface texture: 95%
E, TEC, TATL, 82% FS,
AA; Marginal
dislocoloration: 95% TEC,
87%FS XT, 73%E,
70%TALT, 64% AA.

Fennis et 5 19 Clinical 77 54,9 (35- 92 (84) 92 (84) _ Class II 157(18) IRC: Failure rate: Overall
al. 2014 (1/patient) examina (80) 81) (Fracture of Estenia, Kuraray DRC: Fracture remaining survival:
138 (2/ tion palatal or DRC: cusp (37.5%) and DRC: 91.2%
University patient) buccal cusp AP-X, Kuraray. cohesive failure e IRC:83.2%.
of upper restoration (25%). No significant
PM) RCI: Dislodged restoration difference
 (26.7%) and dilodged & between the
cohesive restoration techniques.
(20%).

Manhart et 3 n.r. USPHS- n.r n.r. 43 (45) 17 (20) 13 (10) Large 88 (28) RCI: Alfa score: Overall
al. 2000 M Classe I, II rest. Tetric [T], Vivadent; Surface texture: IRC 67% survival:
cavities Blend-a-lux, Procter & and DRC 33%; Marginal IRC: 93% and
University Gamble [BL] e Pertac- integrity: IRC 57% and DRC: 87%.
hibrid Unifil, ESPE [PHU] DRC 40%; Integrity of the No significant
RCD: Tetric [T], Vivadent; restoration: DRC 97% and difference
Blend-a-lux, Procter & IRC 77%, RCD (p=.023). between the
Gamble [BL] e Pertac- . techniques.
hibrid Unifil, ESPE [PHU]

Ozakar- 3 n.r. USPHS- 28 32 20 (40) 20 (40) _ IRC: Large 49 (0) IRC: Annual overall survival: IRC [T]
Ilday et al. M (21) class II Brilliant DI, Coltene [DI]; 93% [T], 86% [DI] and Best result.
2013 DRC: Small Tescera ATL, Bisco [T]. 67% RCD.
to médium DRC:
University Class II Valux Plus, 3M ESPE.
cavities

Pallesen & 11 Split- USPHS- 8 35(19-64) 54 (81) n.r n.r Large class 27(1) IRC: Failure rate: DRC 16% No significant
Qvist, mouth M (20) II cavities Brilliant Dentin, Coltene and IRC 17% (p>0.05). M: difference in
2003 [BD]; Estilux Posteirior, DRC 14% and IRC 20%; the long-term
Kulzer [EP]; SR-Isosit PM: DRC 5% e IRC 8%. survival
University [ISO]. Most common failures: Additional
DRC: DRC: Color match and oven curing
BD e EP. minor fractures; IRC: wear had only a
of luting composite, minor
marginal discoloration and influence on
match color. the fracture
resistance
and did not
improve the
wear
resistance in
IRC.

Van 11 n.r USPHS- 24 48(27-70) 34 (100) 20 (84) 14 (16) Large class 96 (33) IOD: Failure rate: DIO 17.7% The
Dijken, M (16) II restorati Briliant DI, Coltene. and DRC 27.3%. Main mechanical
2000 ons RCD: reasons for fail: fracture properties of
Fulfil, DeTray, Dentsply. DIO 8.3% and DRC the material
University 12.1%, occlusal wear in apparently
contact áreas DIO 4.2% were not
and DRC 6.1% abd improved by
secondary caries: DIO secondary
 4.2% and DRC 9.1%. cure.
Higher mechanical failures
in M than PM.

Wassell et 5 Split- USPHS 19 29,6 (+- 50 (20) n.r n.r Class II 100 (35) IOD: Failure rate: DIO 17.4% Direct inlays
al. 2000 mouth (54) 10 years) restorati Briliant, Coltene. and DRC 7.5%. Main show no
ons reasons for fail: pressure advantage
University RCD: sensitivity: 4 DIO, 1 DRC; over the direct
Briliant, Coltene. periapical abscess 2 DIO, placement
2 DRC, fracture restorations
restoration 2 DIO, 1 DRC; and have a
fracture tooth 3 DIO, 1 trend to a
DRC and secondary higher failure
caries 1 DIO. rate.

Wendt et 2 1/ patient USPHS n.r n.r 50 (20) n.r n.r Class II n.r DIO e DRC: DIO P-50 < proximal wear. There were
al.1996 P-30, P-50, (3M), no
Heliomolar differences
University (Vivadent),Clearfil in the
(Kuraray) e Brilliant amount of
DI(Coltene). proximal
wear with
regard to
tooth
position.

DRC: Direct resin composite, DIO: Direct Inlay/Onlay and IRC: Indirect resin composite; USPHS: United States Public Health Service; USPHS-M: United States Public Health Service modified; PM: Premolars; M:
Molars; RC: resin composite; TW: Tooth wear.
Fig 1

PubMed Scopus Web of Cochrane Lilacs e Clinical SIGLE

Identification

(n=825) (n=247) Science Library BBO Trials.gov

(n=132) (n=89) (n=4) (n=1) (n=1)

Records identified through database searching

(n=1300)

Records excluded after title

Screening

Records after duplicates removed and abstract screen

(n=912) (n=892)

Full-text articles assessed by

database searching
(n=20)

Hand searching
(n=2)
Elegibility

Full-text articles assessed for

elegibility
(n=22)
Articles excluded, with reasons (n=13)
No access of article (n=3)34-36
Overlapping data (n=4)37-40
No related to the topic (n=2)41,42
No RCTs (n=3)43-45
No compared direct with indirect composite
resin restorations (n=1)46
Studies included in qualitative
synthesis
Included

(n=9)

Studies included in quantitative

synthesis (meta-analysis)
(n=6)
Figure
Figure
Figure
Figure
Figure