journal of dentistry 34 (2006) 427–435

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A clinical evaluation of posterior composite restorations:
17-year findings

Paulo Antônio da Rosa Rodolpho a, Maximiliano Sérgio Cenci b, Tiago Aurélio Donassollo c,
Alessandro Dourado Loguércio d, Flávio Fernando Demarco c,*
a
Private Practice, Caxias do Sul, RS, Brazil
b
Graduate Program in Dentistry, Cariology Area, Faculty of Dentistry of Piracicaba, State University of Campinas, Piracicaba, SP, Brazil
c
Department of Operative Dentistry, Dental School, Federal University of Pelotas, Pelotas, RS, Brazil
d
Department of Operative Dentistry, Dental School, University of Oeste of Santa Catarina, Joaçaba, SC, Brazil

article info abstract

Article history: Objective: Since an increasing number of composite restorations in posterior teeth are
Received 28 June 2005 placed as a routine, this study was conducted to evaluate long-term survival of these
Received in revised form restorations placed in general practice.
13 September 2005 Methods: Patients from a private dental office that received restorations in posterior teeth
Accepted 20 September 2005 between 1987 and 1988 with P-50 (3M) or Herculite XR (Kerr) resin composites were selected
and invited to participate. Restorations were placed under rubber dam isolation. Dentine
walls were covered with glass ionomer cement, and composites were placed according to
Keywords: manufacturer’s instructions. Thirty-eight patients agreed to participate and signed an
Clinical trial informed consent prior to the evaluation. Two calibrated operators worked independently
Composite in the evaluation, using modified USPHS criteria. Survival of restorations or subsets of
Survival rates restorations grouped on the basis of variables (material, tooth, cavity type and size) was
Failure causes determined using Kaplan–Meier survival curves.
Posterior restorations Results: Ninety-eight failures were recorded among the 282 restorations providing a crude
estimate of 34.8% failures. The survival rate was not significant for material ( p = 0.92) but
was significant between tooth (lower premolars and lower molars, p < 0.0001), cavity type
( p < 0.001) and size ( p < 0.001). The majority of restorations exhibited A or B scores for the
evaluated criteria. The main failure cause was fracture of both composites.
Conclusions: The clinical performance of posterior resin composite restorations evaluated
was acceptable after 17-year evaluation. However, the probability of failure of resin com-
posite restorations in molars, Class II, and large restorations is higher.
# 2005 Elsevier Ltd. All rights reserved.

1. Introduction In recent years, there has been an emphasis on relatively

Over the past decades, new developments in resin technology,
patient demands for tooth-colored restorations and a need to
find alternatives to amalgam were some reasons for the
increased use of resin composite materials for posterior tooth
restorations.1,2
short-term studies to provide an early prediction of the long-
term clinical performance of posterior composites. However,
long-term studies are needed to identify the modes of failure,3
the possible reasons for these failures, and to compare the
expected life-span of posterior resin restorations. There is
limited information available on performance determinants

* Corresponding author. Present address: Departamento de Odontologia Restauradora, UFPel, rua Gonçalves Chaves, 457, 58 andar, CEP
96015 560, Pelotas, RS, Brazil. Tel.: +55 53 32224439; fax: +55 53 32255581.
E-mail address: fdemarco@ufpel.tche.br (F.F. Demarco).
0300-5712/$ – see front matter # 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2005.09.006
428 journal of dentistry 34 (2006) 427–435
and reasons of failure of composite restorations.4,5 A few studies
on the use of composites in posterior teeth reported findings of
7–10 years6–16 and only one study reported results for more than
10 years.17
Long-term studies have shown controversial results
regarding the same items: tooth, cavity size and cavity type.
There are reports that restorations in Class II cavities, in molar
teeth and with large size have a higher potential of failure.18–20
However, some long-term clinical evaluations reported no
clear difference according to location, Class and size of
restorations after 10 years clinical evaluation.7,10,13,14,16
Most of clinical trials have been carried out in university
clinical settings, where time and costs are usually different
than the ones in general dental practice. These differences
could challenge applying the results to individual patients
who are treated in general dental practice.21 Therefore, clinical
evidence from data generated in clinical practice is needed.
Only one 4-year study was found reporting results from a
general practice setting.22
The aim of the present 17-year study was to evaluate the
clinical performance of two resin composite posterior restora-
tions placed in a private dental practice and compare the
survival rates according tooth, cavity size and cavity type.
2. Materials and methods
2.1. Patients’ selection
For this study, the case reports of 56 adult patients were selected
according to pre-determined inclusion criteria among the
registers of a private practice dental office, from a total of 576
patients who attended the dental office from January 1987 to
December 1988. Patients with complete dentition and normal
occlusion, verified by the clinical and radiographic registers, in
continuous clinical follow-up in the last 17 years (at least one
annual recall), that had received at least two restorations in
posterior teeth between 1987 and 1988 with a compact-filled
ultrafine composite (P-50 APC-3M, St. Paul, MN, USA) or a
midway-filled ultrafine composite (Herculite XR-Kerr, Orange,
CA USA), were selected and invited to evaluation both by phone
calls and letters. A researcher (MSC) with no previous contacts
with the patients carried out all the selection procedures. Of the
56 patients selected, 38 patients (mean age 42.5  6.4) agreed
with the study terms, and signed written informed consent
prior to commencement of the clinical evaluation. Eighteen
patients fulfilled the inclusion criteria but could not be
evaluated (two patients moved to another city, four changed
dentist and decided not to participate, six patients declined the
invitation without further explanations and five patients could
not be found). The present study was approved by the local
Ethics Committee.
2.2. Restorative procedures
One operator (PARR) placed all restorations under rubber-dam
isolation. The patients received restorations with both
materials, randomly. During the referred period (1987–1988),
only the two composites in study were placed in posterior
teeth in the dental office.
Cavities were prepared using low-speed steel burs (#2 and
3, KG Sorensen, Barueri, SP, Brazil) to remove carious tissue,
and carbide burs (#245 and 330, KG Sorensen) to remove old
restorations, and the preparations were restrict to carious
tissue elimination, without bevels on the cavity cavosurface
angles. Deeper cavities were covered with calcium hydroxide
(Dycal, Dentsply, Petrópolis, RJ, Brazil), and dentine in all
cavities was covered with a conventional glass ionomer
cement (Ketac-Fil, 3M ESPE, St. Paul, MN, USA).
All enamel and cavosurface margins were acid-etched and
coated with a bonding agent (Scotchbond 2 for P-50 APC, 3M,
St. Paul, MN, USA; and XR Prime/XR Bond for Herculite XR,
Kerr, Orange, CA, USA). Bonding agents were placed according
to manufacturer’s instructions. For the Scotchbond 2, Scotch
Prep was applied for 45 s with agitation using brush, air-dried
for 10 s, and then the adhesive was applied with a brush. The
adhesive was light cured for 20 s. For XR Prime/XR Bond, XR
Prime was applied for 30 s with agitation using brush, air-dried
for 20 s and light cured for 10 s. The XR Bond was subsequently
applied and light-cured for 20 s. The composites were placed
and light-cured according to an incremental technique,
similar to the oblique technique.23,24 All light curing proce-
dures were made using a Visilux light curing unit (3M ESPE, St.
Paul, MN, USA).
Finishing of the restorations was carried out after 1 week
using fine-grit diamonds (#1190FF, 3168FF and 2135FF, KG
Sorensen) and rubber points (#8001, 8010, 8040 and 8045, KG
Sorensen) with aluminum oxide polishing paste (Micro I and
Luster past, Kerr; Orange, CA, USA). Aluminum oxide discs
were used for proximal finishing. If necessary, abrasive
finishing strips were used in the interproximal surfaces. The
same investigator that placed the restorations carried out
baseline evaluations.
2.3. Evaluation and statistic procedures
The restorations were re-evaluated between January and
March, 2004 by direct evaluation carried out with the modified
USPHS criteria (Table 1).21
Two calibrated examiners other than the operator that
placed the restorations worked independently to perform the
evaluation, and an inter-examiner agreement of 80% or more
was obtained and considered statistically acceptable. Evalua-
tion was blind in relation to the examiners. Radiographic
examination was carried out when necessary to complement
the clinical evaluation. Moreover, most patients had a
complete bi-annual periapical radiographic exam, which
was observed by examiners.
Descriptive statistics were used to describe the frequency
distributions of the evaluated criteria. Differences between
baseline and 17-year evaluations were analyzed with McNe-
mar’s test (a = 0.05).
For each restored tooth, the time of failure of the
restoration was recorded or, if failure did not occur, then
the time of survival in years was recorded at the 17-year
evaluation. The survival of the restorations or subsets of
restorations grouped on the basis of variables (material, tooth,
cavity type and size) were evaluated using Kaplan–Meier
survival curves.25 The significance of differences between
survival curves was determined with the log rank test. The
 journal of dentistry 34 (2006) 427–435 429

Table 1 – Codes and criteria for the direct assessment of the restorations
Criteria Code Definition

Color match A Restoration matches adjacent tooth structure in color and translucency
B Mismatch is within an acceptable range of tooth color and translucency
C Mismatch is outside the acceptable range

Marginal adaptation
A Restoration closely adapted to the tooth. No crevice visible. No explorer catch
at the margins, or there was a catch in one direction
B Explorer catch. No visible evidence of a crevice into which the explorer could
penetrate. No dentin or base visible
C Explorer penetrates into a crevice that is of a depth that exposes dentin or base

Anatomic form A Restorations continuous with existing anatomic form

B Restorations discontinuous with existing anatomic form but missing material
not sufficient to expose dentin base
C Sufficient material lost to expose dentin or base

Surface roughness A Surface of restoration is smooth

B Surface of restoration is slightly rough or pitted, but can be refinished
C Surface deeply pitted, irregular grooves and cannot be refinished
D Surface is fractured or flaking

Marginal staining A No staining along cavosurface margin

B <50% of cavosurface affected by stain
C >50% of cavosurface affected by stain

Oclusal contacts A Normal

B Heavy/light
C Absent

Sensitivity A None
B Mild but bearable
C Uncomfortable, but no replacement is necessary
D Painful. Replacement of restoration is necessary

Secondary caries A Absent

B Present

Based on Wilson et al.21

total time at risk was computed as the sum of the censoring
and survival times for each group.26 Estimated risk was
computed as the number of failures in that group divided by
the corresponding total time at risk.
3. Results
Thirty-eight patients (76.3% female and 23.7% male, mean age
42.5  6.4) agreed to participate in the study. The distribution
rates for both composites in relation to location, cavity type
and complexity are shown in Table 2.
Ninety-eight failures were recorded for the 282 restorations
placed, providing a crude estimate of 34.8% failures. The 98
failures occurred during a cumulative monitoring period of 4102
years, providing an estimated risk of 2.4% per year (Table 3).
Table 4 shows the number of restorations that needed
replacement or repair during the observation period, failure
causes, and time of failure for each composite. The main failure
cause was repair–fracture of restoration (42.9%), and this failure
occurred in most of restorations at the occusal surface. For this
evaluation, repaired restorations were classified as failed
restorations, and also, restorations replaced by endodontic,
prosthetic or periodontal reasons were classified as failures.
The Kaplan–Meier survival probability to each variable
evaluated is displayed in Figs. 1–4, and interpretation is
displayed separately as follows:
Material: Probability of survival of P-50 APC was 28.0% at 17
years and Herculite XRV was 26.6% at 17 years (Table 3; Fig. 1).
The difference between materials was not statistically
significant ( p = 0.92) with log rank test. For both materials, a
sharply decreasing survival was observed from 10 to 15 years
(Table 4). The relative risk of failure was similar between
materials (Table 3).
Tooth: The probability of survival in lower premolars and
upper molars was 43% and 37% at 17 years, respectively
(Table 3; Fig. 2). The probability of survival in upper premolars
and lower molars was 24% and 13% at 17 years, respectively.
The difference between tooth types was significant
( p < 0.0001) only between lower premolars and lower molars.

Table 2 – Number of restorations evaluated for each material according to tooth, class type and size
Molars Pre-molars Class I Class II One surface Two surfaces Multi-surfaces

P-50 APC 74 (62.2%) 45 (37.8%) 35 (29.4%) 84 (70.6%) 29 (24.4%) 43 (36.1%) 47 (39.5%)

Herculite XR 102 (62.6%) 61 (37.4%) 40 (24.5%) 123 (75.5%) 39 (24.0%) 61 (37.4%) 63 (38.6%)
430 journal of dentistry 34 (2006) 427–435

Table 3 – Effect of material, tooth, cavity type and cavity size on estimated risk of failure of all restorations
Restorations Failures Cumulative Estimated annual Relative
monitoring years risk of failure (%) risk

All restorations 282 98 4102 2.4 –

Material P-50 119 47 1660 2.8 1.4

Herculite 163 51 2442 2.1 1.0

Tooth Lower molar 98 40 1390 2.9 1.7

Upper premolar 43 16 630 2.5 1.5
Upper molar 78 25 1140 2.2 1.3
Lower premolar 63 16 942 1.7 1.0

Cavity type Class II 207 75 2912 2.6 2.8

Class I 75 11 1190 0.9 1.0

Cavity size (surfaces) Multi 110 51 1516 3.4 3.3

Two 104 36 1515 2.4 2.3
One 68 11 1071 1.0 1.0

Table 4 – Failed restorations by material during the 17-year monitoring period

Material Time of failure (years)

P-50 Herculite 0–4 5 6 7 8 9 10 11 12 13 14 15 16 17 Total (%)

APC XR

Repair 21 21 2 3 4 7 5 3 3 3 7 3 0 2 0 0 42 (42.86%)
(restoration fracture)
Lost tooth (periodontal 4 7 0 0 0 0 0 2 5 3 0 0 0 1 0 0 11 (11.22%)
or tooth
fracture reasons)
Replacement 9 13 0 1 0 4 2 3 3 3 3 1 0 1 1 0 22 (22.45%)
(secondary caries)
Replacement 4 1 0 0 0 0 0 0 1 2 1 1 0 0 0 0 5 (5.10%)
(tooth fracture)
Replacement 2 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0 2 (2.05%)
(prosthesis pilar)
Replacement 2 3 0 0 0 0 0 0 2 2 0 0 1 0 0 0 5 (5.10%)
(endodontic reasons)
Replacement 5 6 0 1 0 0 1 1 1 2 1 3 0 1 0 0 11 (11.22%)
(restoration fracture)

Total 47 51 2 5 4 11 8 9 15 15 13 9 1 5 1 0 98 (100.0%)

Fig. 1 – Kaplan–Meier survival probability of P50-APC and Herculite XR restorations. Difference between curves was not
significant ( p = 0.92) with log rank test.
 journal of dentistry 34 (2006) 427–435 431

Fig. 2 – Kaplan–Meier survivor probability of type of tooth restorations. Difference between curves was significant as
p < 0.0001 with log rank test.

Fig. 3 – Kaplan–Meier survivor probability of Class I and Class II restorations. Difference between curves was significant as
p < 0.0001 with log rank test.

Fig. 4 – Kaplan–Meier survivor probability of one, two and multi surfaces restorations. Difference between curves was
significant as p < 0.001 with log rank test.
432 journal of dentistry 34 (2006) 427–435

Table 5 – Number of evaluated restorations by direct assessment (modified USPHS criteria, Wilson et al.21) after 17 years
according to material
Criteria Code Restorative material

P-50 Herculite XR
a
Baseline 17-year (N = 72) Baseline 17-yeara (N = 112)

Color match A 119 7 163 22

B 0 63 0 86
C 0 2 0 4

Marginal integrity A 119 48 163 67

B 0 24 0 43
C 0 0 0 2

Anatomic form A 119 57 163 90

B 0 15 0 20
C 0 0 0 2

Surface roughness A 119 67 163 104

B 0 5 0 8
C 0 0 0 0

Marginal staining A 119 18 163 29

B 0 43 0 62
C 0 11 0 21

Occlusal contacts A 119 66 163 99

B 0 2 0 3
C 0 4 0 10

Postoperative sensitivity A 119 72 163 112

B 0 0 0 0
C 0 0 0 0

Secondary caries A 119 72 163 112

B 0 0 0 0
a
Only data from restorations that remained (without repair) in situ at the 17-year evaluation were recorded. The original number of
restorations is showed in the baseline column.

Considering lower premolars as a reference, there was a risk of
failure approximately 1.7 higher for lower molars, 1.5 times
higher for the upper premolars, and 1.3 higher risk for upper
molars (Table 3).
Cavity type: Fig. 3 illustrates survival functions for Class I or
II restorations. Probability of survival for Class I restorations
was 55.0% and for Class II restorations was 20.2% at 17 years.
The difference between cavity types was significant at
p < 0.0001. The relative risk of failure was 2.8 times greater
for Class II cavities in comparison with Class I cavities
(Table 3).
Cavity size: Survival functions for the number of restored
surfaces are shown in Fig. 4. The probabilities of survival for
one-surface, two-surface and multi-surface restorations were
49%, 27% and 18%, respectively, at 17 years. The differences
among curves were significant ( p < 0.001) with log rank test.
Compared to one-surface restorations, there was approxi-
mately 2.3 times greater risk of failure for two-surface
restorations and, 3.3 times greater risk of failure for multi-
surface restorations (Table 3).
The subjects presented no postoperative sensitivity or
secondary caries after 17 years (Table 5). Among all variables,
the materials showed different performances in the baseline
and after 17 years according to the McNemar test ( p < 0.05,
Table 5). A great number of restorations showed evidence of a
slight crevice along the marginal interface (marginal integrity)
associated with marginal staining, as well as a bravo score for
color match.
4. Discussion
Meta-analyses of the clinical performance of different
restorative materials in posterior permanent teeth reported
an annual failure rate of 2.2% (range from 0% to 9%) for resin
composite restorations in stress-bearing posterior cavities.20
Similar annual failure rates were found in the present study
(2.1% for Herculite and 2.8% for P50).
In a similar follow-up (17 years), Wilder et al.17 evaluated
the clinical performance of some composites (including ultra-
violet-activated materials) and observed an annual failure rate
of 1.4%, lower than that observed in our study. Other long-
term clinical studies showed annual failure rates from 0.7 to
1.6 similar to this study.8,9,12,14,15
While the restorations evaluated in our study were placed
in a dental clinic environment, the restorations performed in
those studies8,9,12,14,15 were placed in the academic environ-
ment, and, therefore, the results could not be directly
compared.21 According to Wilder et al.,17 success of the resin
composite in posterior teeth is primarily related to the
operator, and secondarily to the specific commercial product
selected. Future studies could be done to test this hypothesis.
 journal of dentistry 34 (2006) 427–435
According to Willems et al.,27 the compact-filled ultrafine
composite could have superior mechanic properties compared
to a midway-filled composite, since compact-filled composites
have a Young’s modulus of elasticity that is higher than the
dentin, and also display good Vickers hardness and relatively
high compressive strength, compared to dentine. So, these
composites might have a satisfactory clinical performance in
posterior teeth. Moreover, the midway-filled ultrafine compo-
sites could be very satisfactory materials for restorations in
anterior teeth,27 since their Young modulus of elasticity would
be higher enough to resist the functional stresses of relatively
low stress areas.
In the present long-term clinical study, no differences were
observed in the comparison between a midway-filled compo-
site (P-50) and a compact-filled ultrafine composite (Herculite
XR). Data generated in laboratory investigations about the
various composites are very confusing, and ranking the
different materials according to their laboratory results does
not necessarily reflect their clinical performance.27,28 Long-
term clinical studies6,8,9,12–16 usually omit differences between
materials, since the resin composite used is a hybrid one at
least.19 An explanation could be that the high percentage of
wear and failure in posterior restorations occurs in the first 5
years.27
A problem with clinical trials of composites is the frequent
alteration of these materials by manufacturers, and few
materials are still unaltered in the market after 3 years.29–30
Both composites used in the present study were replaced by
materials with improved properties according to their man-
ufacturers. Observing the clinical performance in the present
study, similar or better results could be expected from the new
improved materials. Thus, systematic reviews concerning
composite performance in posterior teeth have demonstrated
the feasible application for this purpose.19,20,31
Regarding tooth location, there was a relative risk of failures
of 1.7 for lower molars (failure rate = 13%) when compared to
lower premolars (failure rate = 43%). In an early study,
Leinfelder et al.18 found that the position of the lower molar
in the dental arch (Spee curve) caused an intense occlusal
loading and this could be the main reason for the increased
wear observed in restorations placed in these teeth. Since
chewing forces are strong in this area and the increased stress
could cause fatigue of the material, the occurrence of fracture
could be more prone to happen in this area. In premolars the
cavity tends to be smaller and, consequently, the chewing
forces are less intense,20 leading these teeth to higher survival
rates than molars in long-term clinical evaluations.6,27
Another significant effect on restoration survival was the
cavity type. After 17 years, the survival probability for Class I
restorations was 55.0%, and for Class II restorations was 20.2%
(relative risk of failure 2.8 times greater). In a 5-years follow-
up, Moffa32 observed a survival rate of 80% for Class I
composite restorations and 55% for Class II. In a longitudinal
study (5 years), Wilson et al.33 found higher failure rates in
Class II than in Class I restorations. Marginal ridges are
reinforcement structures and their removal would cause a
significant reduction in the tooth resistance to fracture.34 The
replacement of the marginal ridge for composite will submit
the material to a daily stress condition, facilitating the fatigue
and composite fracture.
433
Cavity size also exerted a significant effect in composite
restorations survival. When compared to a one-surface
restoration, the relative risk of failure was approximately
2.3 times greater for two-surface restorations and, 3.3 times
greater for multi-surface restorations. As previously stated,
reduction in cavity size will protect the restoration of the
chewing forces.20 Generally, multi-surface restorations will
involve the marginal ridges (Class II), which are areas of
increased loading. In a clinical trial of amalgam restorations,
deterioration was greater in molars and large-sized restora-
tions.35 Another long-term (15 years) longitudinal study of
amalgam restorations corroborates this study, showing that
the replacement risk for MOD restorations was significantly
higher than for MO/OD restorations.36
Additionally, Brunthaler et al.19 in a survey of prospective
studies showed that filling extension also influenced failure
rates (Class II fillings had higher failure rates). Manhart et al.20
showed that a mean failure rate of 1.8 was observed for Class I
direct composite restorations and 2.3 for Class II, in a meta-
analysis review. However, posterior resin composite studies
usually report no clear difference according to location, class
and size of restorations after 10 years of clinical service. A
possible reason is that few restorations failed during the
observation period, which made analysis difficult.7,10,13,16
Several studies have reported secondary caries as the main
reason for restoration failure.20,37,38 A review of literature19
regarding to clinical performance of posterior composite
restorations showed that the main cause of failure in
evaluations up to 5 years was restoration fracture, while the
main reason for failure in studies from 6 to 17 years was
secondary caries, as showed by other long-term clinical
evaluations.7,13 The main reason for failure observed in the
present study was fracture of the restoration and this finding
is corroborated by other long-term clinical studies.8,13,14,16
Although the adhesive systems used for both composites
were third-generation materials with lower bonding capacity
than the adhesives currently available,39 the failure causes
were not mainly related to secondary caries. This finding could
be attributed to the glass ionomer fluoride-releasing capacity
and a potential for fluoride recharge, which could potentially
provide anticariogenic activity.40 Other long-term clinical
studies corroborate this finding.13,14,16
It is important to highlight that the clinical setting where
the restorations were placed had a dental practice focused on
health promotion, with a preventive approach based on the
control of caries. Factors influencing the longevity of dental
restorations are material, dentist and patient related. Patient
factors such as oral hygiene, dietary habits, preventive
measures, fluoride availability, compliance in recall and
cooperation during treatment, and oral environment are
relevant topics when considering the durability of restora-
tions.20 Patients in this study had regularly attended to the
dental office with at least one appointment/year and they have
not changed dentist, which could conduct to a high prevalence
of restoration replacement.41
It would be important to conduct a study on clinical
evaluation of posterior composites considering a multi-center
and multi-operator experimental design, in order to provide
data of stronger power of inference and to determine the
operator influence on clinical performance of posterior
434 journal of dentistry 34 (2006) 427–435
composite, which remains as an unclear factor.42 However, an
experimental design with a single-operator is a commonly
method used in clinical evaluations in dentistry4,9–11,15,43–46
that allows a more-controlled comparison of materials and
techniques. Hence, the present study was designed to reduce
confounding variables as operator and working environment.
5. Conclusions
The results of the present study showed similar clinical
performance between the two composites evaluated. The
clinical performance of posterior composite restorations
evaluated was acceptable after 17-year evaluation, and
composites may be indicated for restorations in posterior
teeth. However, the probability of failure in molars, Class II,
and large restorations was higher than in pre-molars, Class I
and small restorations.
Acknowledgments
The authors thank Mrs. Gleise Cristina Vanz and Mrs. Tatiane
Danaluz for their assistance with the patient’s recall and
processing of the data. The authors would also thank to Dr.
John M. Powers for his revision.
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