Clinical performance of cervical restorations—A meta-analysis

doi:10.1016/j.dental.2010.06.003

Dental Materials

Volume 26, Issue 10, October 2010, Pages 993-1000

https://doi.org/10.1016/j.dental.2010.06.003 Get rights and content

Abstract

Objectives

To carry out a meta-analysis in order to assess the influencing factors on retention loss and marginal discoloration of cervical restorations made of composites and glass ionomer (derivates).

Methods

The literature was searched for prospective clinical studies on cervical restorations with an observation period of at least 18 months.

Results

Fifty clinical studies involving 40 adhesive systems matched the inclusion criteria. On average, 10% of the cervical fillings were lost and 24% exhibited marginal discoloration after 3 years. The variability ranged from 0% to 50% for retention loss and from 0% to 74% for marginal discoloration. Hardly any secondary caries was detected. When linear mixed models with a study and experiment effect were used, the analysis revealed that the adhesive/restorative class had the most significant influence, with 2-step self-etching adhesive systems performing best and 1-step self-etching adhesive systems performing worst; 3-step etch-and-rinse systems, glass ionomers/resin-modified glass ionomers, 2-step etch-and-rinse systems and polyacid-modified resin composites were ranked in between. Restorations placed in teeth whose dentin/enamel had been prepared/roughened showed a statistically significant higher retention rate than those placed in teeth with unprepared dentin (p < 0.05). Beveling of the enamel and the type of isolation used (rubberdam/cotton rolls) had no significant influence.

Significance

The clinical performance of cervical restorations is significantly influenced by the type of adhesive system used and/or the adhesive class to which the system belonged and whether the dentin/enamel is prepared or not. 2-Step self-etching- and 3-step etch&rinse systems shall be chosen over 1-step self-etching systems and glass ionomer derivates. The dentin (and enamel) surface shall be roughened before placement of the restoration.

Introduction

About a quarter of the population do have non-carious cervical lesions, and the lesions are significantly more prevalent at older ages (<50%), with premolars being the most affected teeth [1]. There is consensus that the etiology is multifactorial with mechanical-abrasive (toothbrush/toothpaste) and erosive (acids from food and beverages) processes. Occlusal overloading and/or eccentric movements may be found as co-factors because of some confounding effects, but are unlikely causal factors [2]. There is no biological reason to restore non-carious lesions other than esthetics. Under some circumstances, when the lesion has significantly compromised tooth structure or is progressing at a fast rate, can restoring the lesion prevent further tooth damage. A questionnaire conducted among US general practitioners in the 90s revealed that more than half of the dentists interviewed did not restore non-carious cervical lesions [3].

Loss of retention and marginal discoloration are still the main shortcomings of cervical restorations (Class V) placed with adhesive technology [1], [4]. Both clinical incidents compromise the esthetic appearance, especially if they occur in anterior teeth. The prevalence of retention loss rises sharply with increasing observation periods [5]. On the other hand, Class V non-carious non-retentive lesions are frequently used to clinically evaluate the effectiveness of adhesive systems.

In non-carious cervical lesions, restoratives are placed with either preparation of dentin and/or enamel. In contrast to intact or caries-affected dentin, non-carious cervical lesions exhibit a high degree of sclerosis and have a high amount of minerals, which renders the establishment of a hybrid layer more difficult [6]. Some clinicians roughen the dentin and enamel with a diamond bur and/or bevel the enamel margin to improve the bond to the hard tissues. The results of some clinical studies on the topic of preparation are inconclusive [7]. The influence of absolute versus relative isolation of the treatment field is another topic that is subject to controversy. A meta-analysis revealed no influence of the type of isolation on the survival rate in posterior composite restorations [8]. A systematic analysis of clinical studies on cervical restorations has, to date, not been carried to investigate these operative aspects.

The type of adhesive system and/or the belonging to a specific class of adhesives as proposed by Van Meerbeek [6] may play an important role on the longevity of the restoration. A review of clinical trials on the effectiveness of adhesive systems in non-carious cervical lesions measured as retention loss arrived at the conclusion that glass ionomer cements had the lowest rate of retention loss and 1-step self-etching adhesives the highest [4].

The American Dental Association (ADA) previously defined an adhesive system to be adequate and acceptable for clinical use (“full acceptance”) if the retention rate of restorations placed in non-carious lesions is higher than 90% after an observation period of 1.5 years [9]. Many of the newer adhesive systems, especially the 1-step self-etching systems, would not have received ADA acceptance. The ADA acceptance program was abandoned by the end of 2008 [10].

The goal of the present study was to assess the influence of the following factors on the clinical outcome:

-
operative technique: beveling of enamel, preparation/roughening of dentin/enamel, absolute versus relative isolation;
-
the type of adhesive system and/or restorative material;
-
observation period.

The following hypotheses were examined:

1.
Beveling of enamel and/or preparation/roughening of dentin/enamel results in less retention loss and marginal discoloration.
2.
The type of isolation does not influence the clinical outcome.
3.
The type of adhesive system or restorative material has an influence on the performance of cervical restorations.

Section snippets

Selection of clinical trials on Class V restorations

Prospective clinical studies on Class V restorations were searched in MEDLINE (search period 12/2008) and IADR abstracts (1994–2008). The search words were “Class V” or “cervical” or “abfraction lesion” and “clinical”. The inclusion criteria were as follows:

1.
Prospective clinical trial involving at least one adhesive system in Class V cavities.
2.
Minimal duration of 18 months.
3.
The study had to report about the following outcome variables: retention, marginal discoloration, marginal integrity,

Results

Clinical data from 50 studies have been included in the systematic review (see Appendix A) containing 105 in vivo experiments with 40 different adhesives, 39 different composites, and 63 different combinations adhesives/composites. The type of adhesive and composite/restorative material is listed in the table of the Appendix A. The clinical index could be calculated for 67 experiments at 12 months, 25 at 18 months, 76 at 24 months and 35 at 36 months. Overall, only 14/203 = 7% of the values were

Discussion

The rationale for creating a clinical index is that a better statistical analysis can be carried out. The same index has been used in another study when in vitro and in vivo data on adhesive systems had been compared [11]. The weighing of the three outcome variables was based on the following considerations: (1) Retention loss is the most obvious sign of failure of a cervical restoration and is the most reliable diagnostic evaluation criterion with little variability between different

References (20)

I. Wood et al.
Non-carious cervical tooth surface loss: a literature review
J Dent
(2008)
J.D. Bader et al.
How dentists classified and treated non-carious cervical lesions
J Am Dent Assoc
(1993)
M. Peumans et al.
Clinical effectiveness of contemporary adhesives: a systematic review of current clinical trials
Dent Mater
(2005)
J.W.V. van Dijken
Clinical evaluation of three adhesive systems in class V non-carious lesions
Dent Mater
(2000)
S.D. Heintze et al.
Marginal adaptation in vitro and clinical outcome of Class V restorations
Dent Mater
(2009)
J.W. van Dijken
Clinical evaluation of four dentin bonding agents in Class V abrasion lesions: a four-year follow-up
Dent Mater
(1994)
J.A. Michael et al.
Abfraction: separating fact from fiction
Aust Dent J
(2009)
J.W.V. van Dijken et al.
Clinical long-term retention of etch-and-rinse and self-etch adhesive systems in non-carious cervical lesions. A 13 years evaluation
Dent Mater
(2007)
B. Van Meerbeek et al.
Buonocore memorial lecture. Adhesion to enamel and dentin: current status and future challenges
Oper Dent
(2003)
A. Brunthaler et al.
Longevity of direct resin composite restorations in posterior teeth
Clin Oral Investig
(2003)

There are more references available in the full text version of this article.

Cited by (129)

A qualitative analysis of dentists’ understanding and management of non-carious cervical lesions (NCCL)
2023, Journal of Dentistry
Non-carious cervical lesions (NCCLs) are considered to have a multi-factorial aetiology and their management is affected by a range of variables perhaps most importantly clinical judgement. The aim of this study was to elicit information from practicing dentists, using interviews, to explore their understanding of NCCL aetiology, the decision-making criteria of when to restore, and the restorative techniques used to restore NCCLs. This may help identify gaps or anomalies in our understanding to inform future research and clinical practice for the management of NCCLs.
An interview guide was developed from a literature search which formed 2 domains framed around understanding and management of NCCLs based on: understanding of diagnosis and aetiology, and factors affecting decision making for management. Practicing dentists with more than 10 years of experience were purposively recruited to conduct in-depth, semi-structured interviews. Fifteen interviews were audio recorded and transcribed verbatim. A thematic content analysis was conducted and the results analysed.
From the thematic analysis, 2 domains were identified. In the domain of “diagnosis and aetiology”, while participants have similar understanding and methods of diagnosing NCCL, most stated NCCLs in a patient were caused by a “main aetiology” such as “abrasion”, “abfraction” while few described the inter-relationship of these aetiological factors.
In the domain of “factors affecting decision making”. “Patient reported symptoms” and “lesion dimension” were the main factors that affected participants’ decision to provide restorative or non-restorative management. However, a “restorative threshold” was not able to be identified.
There was notable variety in participants’ understanding of the aetiology, management, and treatment of NCCLs, particularly the restorative threshold of when to treat.
The variability demonstrates the need to have a clearer understanding of the key elements that affect the management of NCCLs and better information to support the decision of when to treat.
Five-year clinical evaluation of universal adhesive applied following different bonding techniques: A randomized multicenter clinical trial
2023, Dental Materials
To evaluate the clinical performance of a universal adhesive system (Futurabond U, Voco) when applied following different adhesive strategies in non-carious cervical lesions (NCCLs) after 5 years.
Fifty participants were included. Futurabond U (Voco) was applied in NCCLs using four adhesive strategies (n = 50 each): only self-etch (SE); selective enamel etching + self-etch (SET + SE); etch-and-rinse with dry dentin (ERD); and etch-and-rinse with wet dentin (ERW). All cavities were restored with Admira Fusion composite resin (Voco). Restorations were evaluated after 1, 3, and 5 years using the World Federation criteria (FDI) and the modified United States Public Health Service (USPHS) criteria.
After 5 years, retention rates were 81 % (65.8–90.5) for SE, 87 % (73.2–94.4) for SET + SE, 84 % (69.6–92.6) for ERD, and 78 % (63.6–88.9) for ERW (p > 0.05). Thirty-five restorations were considered to have minor discrepancies in marginal adaptation at the 5-year recall (14 for SE, 9 for SET + SE, 6 for ERD, and 6 for ERW; p > 0.05). Sixteen restorations were detected as a minor marginal discoloration (6 for SE, 4 for SET + SE, 1 for ERD, and 5 for ERW; p > 0.05) and one restoration showed a recurrence of caries (1 for ERW; p > 0.05) at the 5-year recall. No restorations showed postoperative sensitivity after 5 years.
NCCLs restorations using a universal adhesive showed satisfactory clinical performance after 5 years, regardless of the adhesive strategy.
Comparison of the shear bond strength in Giomer and resin-modified glass ionomer in class V lesions
2023, Heliyon
There are several cosmetic, restorative materials to restore non-carious Cervical Lesions (NCCLs). The aim of this study was to specify and compare the shear bond strength of Giomer and resin-modified glass ionomer in Class V lesions so that whether Giomer showed a better shear bond strength, it could be used instead of RMGI to restore NCCLs because of its better esthetic.
ology: 20 maxillary and 20 mandibular intact premolars were collected. Each group of 20 samples was divided into two 10-tooth subgroups of A and B. A class V preparation was made on the buccal surface of the samples with 2*2*3 mm dimensions using a diamond bur. Also, the crossing path of the universal machine chisel was prepped with 2 mm depth up to incisal edge. For group A, after applying BeautiBond and curing it, Beautifil II Giomer was placed in nylon cylinders and the cylinders were placed in the middle cervical region and cured for 20 s. For group B, 1 spoon powder of Fuji II RMGI was mixed with two drops of its liquid and transported to nylon cylinders and placed in the middle cervical region, then cured for 20 s. The nylon cylinders were removed from all 40 samples. Then, all teeth were thermocycled and then tested using a universal machine with the force of 20 MPa and the speed of 1 mm/min until they fractured to assess their shear bond strength. The obtained data was analyzed using SPSS v.26. The significance level was considered 0.05.
There was no significant difference between Giomer (4.97 ± 2.36) and the resin-modified glass ionomer (3.41 ± 2.71) groups as regards their shear strength (p = 0.059). Likewise, there was no significant difference in shear bond strength between Giomer and RMGI groups as regards jaw type (P = 0.326).
The paper suggests that Giomer and resin-modified glass ionomer groups did not differ significantly in terms of their shear bond strength and that both can be utilized to treat Class V lesions. Furthermore, there was no significant difference between the shear bond strength in terms of jaw type.
A randomized clinical study of the performance of self-etching adhesives containing HEMA and 10-MDP on non-carious cervical lesions: A 2-year follow-up study
2023, Journal of Dentistry
To evaluate the association of HEMA and 10-MDP in the clinical performance of self-etching adhesives in the restoration of NCCLs during 2-years.
60 restorations were performed in 17 volunteers and randomized into three groups: G1 (n = 20) - Prime and Bond Universal (10-MDP); G2 (n = 20) - Optibond All-in-One (HEMA); and G3 (n = 20) - Clearfil SE (10-MDP and HEMA). No cavity preparation was performed. After 2 years, the restorations were evaluated using the modified USPHS criteria for retention, marginal adaptation/ staining, postoperative sensitivity and secondary caries. The results were analyzed using Fisher's exact test and Kruskal–Wallis test.
All groups showed 100% retention rate, except G1, who lost two restorations (p > 0.05). Regarding marginal adaptation, G1 showed greater deficiency, as only eight restorations (40%) remained intact (p < 0.05). Regarding marginal staining, G1 and G2 showed higher rate, as only 12 restorations (65%) in each one were free of staining (p < 0.05). All groups showed similar results for postoperative sensitivity and secondary caries (p > 0.05).
The association of HEMA and 10-MDP monomers in the self-etching adhesives did not influence the clinical performance of the NCCL restorations with respect to retention, postoperative sensitivity, and incidence of secondary caries. However, positively influenced the marginal adaptation and marginal staining at the 2-year follow-up.
The association of HEMA and 10-MDP monomers in the self-etching adhesives positively influence the clinical performance of the NCCL restorations with respect to marginal adaptation and marginal staining.
Clinical efficacy of resin-based direct posterior restorations and glass-ionomer restorations – An updated meta-analysis of clinical outcome parameters
2022, Dental Materials
The present review is an update of a systematic review that has been published in 2012. Meanwhile, many new clinical trials on resin composites had been published. New materials such as bulk fill resin composites and new glass-ionomer (GIC) based materials had been introduced. The focus of this review was to evaluate the longevity in relation to the material class and adhesive class, while adjusting for a possible study bias effect.
The database PUBMED/SCOPUS were searched for clinical trials on posterior resin composites. The inclusion criteria were: (1) studies published between 2000 and 2019, (2) prospective clinical trial with at least 2 years of observation; (2) minimal number of restorations at last recall = 20; (3) report on drop-out rate; (4) report of operative technique and used materials; (5) utilisation of Ryge, modified Ryge or FDI evaluation criteria. The bias of each study was assessed by two independent reviewers using Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. For the statistical analysis, linear mixed models fitted on the individual data recorded along time have been used with random effects to account for study, patients and experiment effects. P-values smaller than 0.05 were considered significant.
Of the 423 clinical trials, 62 studies (including 110 experiments) met the inclusion criteria. Material class was divided according to the composite filler in microhybrid (39 experiments/2807 restorations), nanohybrid (24 experiments/1254 restorations), and hybrid (22 experiments/1255 restorations). So-called bulk fill materials were treated as a separate category (9 experiments/506 restorations) as were the GIC (11 experiments/2121 restorations) and the compomer materials (5 experiments/238 restorations). Only one study (1.6%) had low risk of bias, 42 (67.7%) were assessed to have unclear risk of bias and 19 (30.6%) had a high risk of bias. In 52.3% of the studies Class II and Class I restorations had been placed. After 10 years, the survival rate for resin composite restorations dropped to about 85–90% with no significant difference between hybrid, microhybrid and nao-hybrid resin materials. The main reasons for restoration replacement were bulk fractures and wear, which accounted for a about 70% of replacements. Caries at the restorative margins accounted for about 20% of the replacements, and retention loss, inacceptable colour match or marginal integrity, endodontic treatment or cusp fracture for about 10% of the replacements of the resin composite restorations. For compomer and GIC restorations the mean overall survival rate was about 80% after 6 years. For GIC, the main reasons for failure were substantial loss of anatomical contour along with loss of proximal contacts and retention loss. Mainly fractures reduced the longevity of compomers restorations. Also, there was no statistically significant difference between hybrid, micro-hybrid, nano-hybrid and bulk fill resin composites with regard to colour match, surface texture, material fractures, and anatomical form.
Posterior resin composite restorations that were placed with the enamel etch technique showed the best overall performance; the longevity was not significantly influenced by the filler type or viscosity of resin composite material. With regard to colour match, surface texture and anatomical form, nanohybrid resins were not significantly superior to hybrid or microhybrid resin composites. Compomer and GIC restorations demonstrated considerable shortcomings and had a significant shorter longevity.
Clinical and OCT assessment of application modes of a universal adhesive in a 12-month RCT
2022, Journal of Dentistry
To evaluate a universal adhesive clinically using FDI criteria and by optical coherence tomography (OCT).
In 50 patients, three or four non-carious cervical lesions (NCCL) were restored with composite (Venus® Diamond Flow, Kulzer) using iBond® Universal (iBU, Kulzer) applied in self-etch (iBU-SE, n = 50), selective-enamel-etch (iBU-SEE, n = 29) or etch-and-rinse mode (iBU-ER, n = 50) and the reference OptiBond™ FL (OFL, Kerr, n = 50). Restorations were imaged by SD-OCT. The weighted mean length of interfacial adhesive defects (AD, %) was quantified per restoration immediately after placement (t₀), simultaneously with clinical assessment (FDI criteria) after 14 days (t₁), 6 (t₂) and 12 months (t₃). Data were statistically analyzed (McNemar-/Wilcoxon-/Mann-Whitney-U test (α = 0.05), Kaplan-Meier survival curves).
After 12 months, cumulative failure rates were lower with iBU-SE (0.0%; p = 0.016), iBU-SEE (0.0%; p = 0.125), and iBU-ER (2.1%; p = 0.070; loss t₃) compared to OFL (16.7%; losses t₂, t₃). Generally, marginal adaptation decreased (p_i < 0.001) and marginal staining increased (p_i ≤ 0.031), without significant group differences (p_i > 0.064). AD increased in all groups (p_i < 0.001). At enamel, AD appeared more extended with iBU-SE vs. iBU-SEE (t₂-t₃; p_i ≤ 0.005), iBU-ER (t₁-t₃; p_i ≤ 0.051) and OFL (t₀-t₃; p_i ≤ 0.018). At dentin/cement iBU generally caused fewer defects than OFL (t₁-t₃; p_i ≤ 0.010) and with SE vs. ER (t₂-t₃; p_i = 0.010).
In NCCLs, iBU generally provides a more durable bond than OFL. Recommended mode is SEE. Clinic and OCT provided comparable results. OCT has higher statistical power, shows group differences earlier and specifically for the different hard tooth tissues.
The universal adhesive iBU was superior against the reference OFL in NCCLs. It can be recommended with SEE. Evaluation of interfacial adhesive defects by OCT seems to allow early prediction of adhesives' clinical performance.

View all citing articles on Scopus

View full text

ReviewClinical performance of cervical restorations—A meta-analysis

Abstract

Objectives

Methods

Results

Significance

Introduction

Section snippets

Selection of clinical trials on Class V restorations

Results

Discussion

J Dent

J Am Dent Assoc

Dent Mater

Dent Mater

Dent Mater

Dent Mater

Abfraction: separating fact from fiction

Aust Dent J

Clinical long-term retention of etch-and-rinse and self-etch adhesive systems in non-carious cervical lesions. A 13 years evaluation

Dent Mater

Buonocore memorial lecture. Adhesion to enamel and dentin: current status and future challenges

Oper Dent

Longevity of direct resin composite restorations in posterior teeth

Clin Oral Investig

Review
Clinical performance of cervical restorations—A meta-analysis