Keywords dentine adhesives - resin composite - dental restoration - failures - clinical studies
- meta-analysis
Introduction
Dentine adhesives, which have undergone substantial changes over the last 20 years,
are classified into two techniques: self-etch or etch-and-rinse.[1 ] Etch-and-rinse, the first to be introduced, is the technique that results in the
deepest hybrid layer in enamel.[2 ] Because of the higher number of steps and stronger effect of the etching procedure
on dentine substrate, etch-and-rinse technique requires a longer clinical application
time, results in increased postoperative sensitivity, and is the more sensitive to
failure.[2 ]
The shorter application time and decreased postoperative sensitivity favors the choice
for the self-etch,[3 ] but their thinner hybrid layer raises concern on whether the durability of the restoration
is reduced or not.[4 ] At the other hand, the thinner dentine hybrid layer theoretically provides less
substrate to be degraded by chemical (both hydrolysis and enzymatic) and mechanical
factors.
Adhesive composite restorations in posterior teeth are currently the first choice
for direct restorations in posterior teeth,[5 ]
[6 ] and their popularity is expected to increase with current prevailing conservative
philosophy in the restorative treatment where minimal hard dental tissue removal is
recommended. Self-etch technique is in line with such a philosophy, and short duration
clinical studies have reported similarities between self-etch and etch-and-rinse techniques
with respect to clinical outcomes.[7 ]
[8 ]
[9 ] However, relying mostly on statistical analysis restricted to p -values (statistical significance), the individual scientific contribution of those
studies to the choice of the appropriate dentine adhesive technique is questionable.[10 ]
[11 ]
To the best of our knowledge, there are no systematic reviews with meta-analysis comparing
self-etch and etch-and-rinse techniques for dentine adhesives in posterior composite
restorations. Filling the gap in such an important topic in clinical Dentistry could
provide an important contribution to the restorative dental practice with maximum
preservation of tooth structure.
Therefore, the aim of this study was to perform a systematic review with meta-analysis
on the comparison of self-etching adhesives and etch-and-rinse adhesives on the failure
rate of posterior composite resin restorations.
Methods
Focused Question
This systematic review was aimed at answering the following research question: do
composite resin restorations in posterior teeth performed with either self-etch or
etch-and-rinse techniques differ in the clinical failure rate?
This review followed the PRISMA guidelines,[12 ] and its protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the number CRD42017078015.
Search Strategy
The literature search included studies published through July 2021, and it was undertaken
by two independent researchers in the following databases: MEDLINE (PubMed), ISI Web
of Science, LILACS, SCOPUS, and Cochrane Library, in addition to searches in grey
literature (Google Scholar and manual search in the list of references of included
studies).
Search strategies for the literature are based on PICO acronym.[13 ] A combination of MeSH terms, keywords, and related terms was used in the systematic
literature search in conjunction with Boolean operators “AND” and “OR” ([Table 1 ]).
Table 1
Search strategies for the literature based on PICO acronym, with the use of Boolean
operators and adapted to each database
Databases
Search strategies
PubMed
(((((((Self-etching adhesives[Title/Abstract]) OR Self etching adhesive[Title/Abstract])
OR All in one adhesive[Title/Abstract]) OR All in one adhesives[Title/Abstract]) OR
One-step adhesive[Title/Abstract])) AND (((((((((((((Dentin-bonding agents[MeSH Terms])
OR Dentin-bonding agents[Title/Abstract]) OR Agents, Dentin-Bonding[Title/Abstract])
OR Bonding Agents, Dentin[Title/Abstract]) OR Agents, Dentin Bonding[Title/Abstract])
OR Dentin Bonding Agents[Title/Abstract]) OR Etch[Title/Abstract]) OR rinse adhesives[Title/Abstract])
OR Etch-and-rinse[Title/Abstract]) OR Three step adhesive[Title/Abstract]) OR Three
step adhesives[Title/Abstract])))) AND (((((((Dental Restoration Failure[MeSH Terms])
OR Dental Restoration Failure[Title/Abstract]) OR Failure, Dental Restoration[Title/Abstract])
OR Restoration Failure, Dental) OR Restoration Failures, Dental) OR Dental Restoration
Failures) OR Failures, Dental Restoration)
Scopus
(TITLE-ABS-KEY(Self-etching adhesives) OR TITLE-ABS-KEY(Self etching adhesive) OR
TITLE-ABS-KEY(All in one adhesive) OR TITLE-ABS-KEY(All in one adhesives) OR TITLE-ABS-KEY
(One-step adhesive)) AND (TITLE-ABS-KEY(Dentin-bonding agents) OR TITLE-ABS-KEY(Agents,
Dentin-Bonding) OR TITLE-ABS-KEY(Bonding Agents, Dentin) OR TITLE-ABS-KEY(Agents,
Dentin Bonding) OR TITLE-ABS-KEY (Etch) TITLE-ABS-KEY(rinse adhesives) OR TITLE-ABS-KEY(Etch-and-rinse)
OR TITLE-ABS-KEY(Three step adhesive) OR TITLE-ABS-KEY(Three step adhesives)) AND
(TITLE-ABS-KEY(Dental Restoration Failure) OR TITLE-ABS-KEY(Failure, Dental Restoration)
OR TITLE-ABS-KEY(Failure, Dental Restoration) OR TITLE-ABS-KEY(Restoration Failures,
Dental) OR TITLE-ABS-KEY (Dental Restoration Failures) OR TITLE-ABS-KEY (Failures,
Dental Restoration))
Lilacs
((TW:(Self-etching adhesives)) OR (TW:(Self etching adhesive)) OR (TW:(All in one
adhesive)) OR (TW:(All in one adhesives)) OR (TW:(One-step adhesive)) OR (TW:(Adesivo
autocondicionantes)) OR (TW:(Adesivos autocondicionantes)) OR (TW:(Adesivo de passo
único)) OR (TW:(Adesivos de passo único)) OR (TW:(Adesivo de um passo)) OR (TW:(Adhesivo
autocondicionante)) OR (TW:(Adhesivos autocondicionantes)) OR (TW:(adhesivo de paso
único)) OR (TW:(adhesivos de paso único)) OR (TW:(adhesivo de paso))) AND ((MH:(Dentin-bonding
agents)) OR (TW:(Dentin-bonding agents)) OR (TW:(Agents, Dentin-Bonding)) OR (TW:(Bonding
Agents, Dentin)) OR (TW:(Agents, Dentin Bonding)) OR (TW:(Dentin Bonding Agents))
OR (TW:(etch rinse adhesives)) OR (TW:(Etch-and-rinse)) OR (TW:(Three step adhesive))
OR (TW:(Three step adhesives)) OR (MH:(Adesivos dentinários)) OR (TW:(Adesivos dentinários))
OR (TW:(Agente de ligação a dentina)) OR (TW:(Agentes de ligações a dentina)) OR (TW:(Agente
de união a dentina)) OR (TW:(Agentes de união a dentina)) OR (TW:(Adesivo convencional))
OR (TW:(Adesivos convencionais)) OR (TW:(Adesivo de três passos)) OR (TW:(Adesivos
de três passos)) OR (MH:(Recubrimientos dentinarios)) OR (TW:(Recubrimientos dentinarios))
OR (TW:(Agente de unión a la dentina)) OR (TW:(Agentes de unión a la dentina)) OR
(TW: (Agente de unión a dentina)) OR (TW:(Agentes de unión a dentina)) OR (TW:(Adhesivo
convencional)) OR (TW:(adhesivos convencionales)) OR (TW:(Adhesivo de tres pasos))
OR (TW:(Adhesivos de tres pasos))) AND ((MH:(Dental Restoration Failure)) OR (TW:(Dental
Restoration Failure)) OR (TW:(Failure, Dental Restoration)) OR (TW:(Restoration Failure,
Dental)) OR (TW:(Restoration Failures, Dental)) OR (TW:(Dental Restoration Failures))
OR (TW:(Failures, Dental Restoration)) OR (MH:(Falha de restauração dentária)) OR
(TW:(Falha de restauração dentária)) OR (TW:(Falha, Restauração dentária)) OR (TW:(Falha
na restauração, dental)) OR (TW:(Falhas de Restaurações, dental)) OR (TW:(Falhas de
restauração dentária)) OR (TW:(Falhas, Restaurações dentárias)) OR (MH:(Fracaso de
la Restauración Dental)) OR (TW:(Fracaso de la Restauración Dental)) OR (TW:(Fracaso,
Restauración Dental)) OR (TW:(Fracaso de la Restauración, dental)) OR (TW:(Fracasos
de las Restauraciones, dental)) OR (TW:(Falla, restauración dental)) OR (TW:(Fallas,
restauraciones dental)))
Web of Science
TS = (Self-etching adhesives OR Self etching adhesive OR All in one adhesive OR All
in one adhesives OR One-step adhesive) AND TS = (Dentin-bonding agents OR Agents,
Dentin-Bonding OR Bonding Agents, Dentin OR Agents, Dentin Bonding OR Dentin Bonding
Agents OR etch rinse adhesives OR Etch-and-rinse OR Three step adhesive OR Three step
adhesives) AND TS = (Dental Restoration Failure OR Failure, Dental Restoration OR
Restoration Failure, Dental Restoration Failures, Dental OR Dental Restoration Failures
OR Failures, Dental Restoration)
Screening and Study Selection
Duplicate removal was undertaken by two independent examiners (B.R.V. and E.L.A.D.),
using Mendeley software (version 1.5.2 for Windows). Article selection for inclusion
was based on the evaluation of titles, abstracts (step1), and then evaluation of full
texts (step 2). Only randomized clinical trials, controlled clinical trials, and nonrandomized
controlled prospective studies were selected for this systematic review. Observational
studies, case reports, cases series, in vitro studies, literature review, editorials, and letters to the editor were excluded.
Full analysis of selected articles was undertaken based on the following PICO terms[13 ]: Population represented by posterior permanent teeth with Class I or Class II resin
composite restorations due to caries, Intervention represented by self-etch adhesives,
Control represented by etch-and-rinse (conventional) adhesives, and Outcome represented
by failures in restorations that compromise longevity. Disagreements between examiners
were solved by consensus. When disagreement persisted, the opinion of a third examiner
(B.M.S.) was used.
Data Collection
Full texts were accessed for validation of eligibility criteria, and the following
data were collected: study design, population, group sample, adhesive type, outcome,
evaluation criteria, time of follow-up evaluation, statistical analysis, main results,
failure rate (marginal staining, marginal adaptation, secondary caries, fractures
and retention, and postoperative sensitivity), limitations, and conclusions. This
was undertaken independently by two reviewers.
Risk of Bias (Quality Assessment)
Quality assessment of selected studies was performed individually and independently
by two examiners (B.R.V. and E.L.A.D.) using the Cochrane Collaboration Risk of Bias tool ,[14 ] and the following aspects were analyzed: sequence generation, allocation concealment,
blinding of participants and personnel, blinding of outcome assessors, incomplete
outcome data, and other sources of bias. Studies were then classified as low, medium,
or high risk of bias; those with insufficient information were classified as unclear.
Data Analysis
From each study, differences between two groups (etch-and-rinse as control and self-etching
as intervention) were considered. Using data on failure rates (proportions) and sample
size per group for each study, we calculated the effect size of difference between
proportions using Cohen H effect size [difference between arcsine transformation of
proportions: arcsine * sqrt(p1) – arcsine * sqrt(p2)] and statistical power, following
equations described in the literature.[15 ] Only failures related to the adhesive were included, which comprised marginal staining,
marginal adaptation, secondary caries, fractures and retention, and postoperative
sensitivity. The unit restoration with failure was considered as a restoration with
one or more failures, so that computation of more than one failure per restoration
was excluded. The unit restoration with failure was recorded regardless of the need
of restoration replacement. For each group (intervention or control), proportions
of restorations with failures were computed using the number of restorations with
failures divided by the number of restorations.
A two-tailed 5% significance level was used. The 95% confidence interval (CI) for
Cohen H was calculated using formula for sampling variance described elsewhere.[16 ] Considering that some failure rates in controls were lower than 10%, risk ratio
(attributable risk) was not computed because it overestimates the effect size when
the proportion of controls is lower than 10%.[17 ]
Statistical power, whose threshold of 80% is used to determine whether studies were
conclusive (acceptable probability that an effect exists in the population)[15 ] or not, was calculated for all studies selected for meta-analysis.
One meta-analysis was performed. Following published statistical procedures,[15 ]
[16 ]
[18 ] we calculated the effect size (Cohen H; es), standard error, sampling variance,
individual study weights (w ), the weighted effect sizes (w * es), and the corresponding squared values (w 2 and w * es2). Both Cochran Q test and I
2 were computed,[18 ] and the level of heterogeneity was graded as low (25%), moderate (50%), or high
(75%).[19 ] The summary outcome was calculated using the fixed effects model when heterogeneity
was very low, otherwise the random effects model was used.[19 ] The statistical power of the meta-analysis was also computed.[20 ]
[21 ] A forest plot was prepared using calculated parameters. In addition, bias was also
investigated using funnel plots (scatter plots of effect sizes in the X axis against
the effect size's standard error in the Y axis).[22 ]
Certainty of Evidence
The certainty of the evidence was assessed through Grades of Recommendations, Assessment,
Development and Evaluation (GRADE) approach. The initial ratings followed the recommendations
of GRADE group and the certainty of evidenced initiated as high, since this systematic
review was performed with randomized clinical trials. The outcome “failure rate of
resin restorations” was carefully analyzed for each of the five domains that can lower
the certainty: risk of bias, inconsistency, indirectness, imprecision, and publication
bias.[22 ]
Results
The flowchart and reasons for exclusion of articles are shown in [Fig. 1 ]. A total of 823 articles were recovered, of which 459 were duplicates (removed using
the Mendeley software). After careful analysis of titles and abstracts, 15 articles
were selected for full text reading, and five articles[9 ]
[23 ]
[24 ]
[25 ]
[26 ] met the inclusion criteria. One article[16 ] contained three studies, and one study was excluded because the adhesive (iBond)
was not recommended for clinical use by the authors, yielding a total of six studies
(five papers with one study each and one paper with two studies) included in the review.
The characteristics of the included studies are presented in [Table 2 ].
Fig. 1 Flowchart of the steps of the literature search.
Table 2
Summary of data extracted from selected studies
Study (design)
Groups
Evaluation criteria - outcome
Number of failures (%)
Limitations
Conclusion (as reported in the paper)
Van Dijken and Pallesen (2017)[24 ] (Randomized Clinical Trial)
N = 114
C: Two-step etch-and-rise, Optibond
(n = 57)
I: One Step self-etch all bond universal (n = 57)
USPHS Ryge modified
C:6 (10.52%)
I:7 (12.28%)
Moisture control with cotton rolls;
In patients with a single restoration, preference was given to intervention.
No statistically significant differences between groups. Fracture was the most common
failure type.
Van Dijken and Pallesen (2015)[9 ] (Randomized Clinical Trial)
N = 158
C: Two-step etch-and-rise, Excite (n = 69)
I: One Step self-etch Xeno III (n = 89)
USPHS Ryge modified
C: 21 (30.43%)
I:26 (29.21%)
Moisture control with cotton rolls;
In patients with a single restoration, preference was given to intervention.
No statistically significant differences between groups. Fracture was the most common
failure type.
Van Dijken and Pallesen (2017)[25 ] (Randomized Clinical Trial)
N = 139
C: Three step TEGDMA/HEMA free etch-and-rise, CMF-els (n = 70)
I: One step HEMA free self-etch, Adhese One F (n = 65)
USPHS Ryge modified
C:12 (17.14%)
I:24 (36.92%)
Moisture control with cotton rolls; customized/modified adhesive.
The etch-and-rinse adhesive was better than the self-etch adhesive.
Çakir and Demirbuga (2019)[26 ] (Randomized Clinical Trial)
N = 133
C: Gluma Bond Universal, Clearfil Universal, Prime&Bond Elect Universal, All bond
Universal and Single Bond Universal
(n = 99)
I: Five step self-etch (Gluma Bond Universal, Clearfil Universal, Prime&Bond Elect
Universal, All bond Universal and Single Bond Universal)(n = 100).
USPHS Ryge modified
C: 37 (37.38%) I: 29 (29%)
Used the same adhesives in the control and intervention groups, changing only the
acid etching step.
No statistically significant differences between groups.
Perdigão et al (2009)[23 ] (Randomized Clinical Trial)
N = 199
C:Etch-and-rinse adhesive, One step Plus (n = 23)
I: Self-etching adhesives: iBond, (n = 21), Clearfil SE (n = 22) Adper Prompt (n = 25)
USPHS Ryge modified
C:
6 (26.08%)
I(Adper):
16 (64%)
I(Clearfil): 11 (50.0%)
–
Control group resulted in statistically better good marginal
adaptation than intervention groups. One intervention group (iBond) presented unacceptable
outcome.
All studies compared etch-and-rinse (conventional) and self-etch adhesives with respect
to the differences between failure rates of resin composite restorations in posterior
teeth (Class I and II). All studies were randomized clinical trials.[9 ]
[23 ]
[24 ]
[25 ]
[26 ]
A total of 699 resin composite restorations were analyzed during 2[23 ] to 8[9 ] years of follow-up; 342 restorations in the control group (etch-and-rinse adhesive),
and 357 in the intervention group (self-etch). Only two studies[23 ]
[26 ] used rubber dam for moisture control during the restorative procedure.
The following brands of dentine adhesives were reported in the selected studies: Xeno
III (Dentsply, Ballaigues, Suíça), Excite (Ivoclar Vivadent, Schaan, Liechtenstein),
Prime&Bond Elect Universal (Dentsply, Milford, United States), Single Bond Universal
(3M ESPE, Neuss, Germany), Gluma Bond Universal (Heraeus Kulzer, Germany), One Step
Plus (Bisco, Schaumburg, United States), iBond (Heraeus Kulzer, Germany), Clearfil
Universal Bond (Kuraray Noritake, Okayama, Japan), Clearfil SE (Kuraray Noritake,
Okayama, Japan), Adper Prompt (3M ESPE, St Paul, United States), All-bond Universal
(Bisco, Schaumburg, United States), OptiBond XTR (Kerr, Orange, United States) in
addition to adhesives modified by the authors.
Generally, the studies used similar criteria of evaluation for failed dental restoration. The United States Public Health Services (USPHS) system was used, with
some modifications among studies which did not preclude comparisons: USPHS Ryge system
was reported in three articles,[9 ]
[24 ]
[25 ] while another paper[23 ] reported the Modified USPHS direct evaluation criteria. Calibrated examiners were
reported in all papers.[9 ]
[23 ]
[24 ]
[25 ]
[26 ]
From the quality assessment and risk of bias analysis using the Cochrane Collaboration
Risk of Bias tool, two studies presented low risk, and the other three presented high
risk ([Table 3 ]). The main aspects related to high risk were modification of adhesives by authors,[25 ] and lack of use of rubber dam for moisture control.[9 ]
[24 ]
[25 ]
Table 3
Quality assessment and risk of bias according to Cochrane Risk of Bias Tool
[14 ]
Studies
Sequence generation
Allocation Concealment
Blinding of participants and personnel
Blinding of outcome assessors
Incomplete outcome data
Selective outcome reporting
Other sources of bias
Risk of bias
Van Dijken and Pallesen (2017)[24 ]
Yes
No
Yes
Yes
Yes
Yes
No
High risk
Van Dijken and Pallesen (2015)[9 ]
Yes
No
Unclear
Yes
Yes
Yes
No
High risk
Van Dijken and Pallesen (2017)[25 ]
Yes
No
Unclear
Yes
Yes
Yes
No
High risk
Çakir and Demirbuga (2019)[26 ]
Unclear
No
Yes
Yes
No
No
No
Low risk
Perdigão et al (2009)[23 ]
Unclear
Yes
No
Yes
Yes
No
Yes
Low risk
From the statistical analysis of individual studies, low statistical power was computed
for most studies ([Fig. 2 ]). The low power values are accompanied by wide 95% CIs of the effect size ranging
from negative values (favoring the intervention group, self-etch adhesives) to positive
values (favoring the control group, etch-and-rinse adhesives), indicating that sample
sizes were smaller than required for the relatively large variability.
Fig. 2 Results of meta-analyses: Negative Cohen H values favor self-etching adhesives. Positive
Cohen H values favor etch-and-rise adhesives.
For each study, a single failure type accounted for the total number of restorations
with failure: marginal adaptation in five studies[23 ]
[24 ]
[25 ]
[26 ] and marginal staining in one study.[9 ]
Meta-analysis of all selected studies was performed using the random effects model
due to the low heterogeneity (I
2 = 16.59%; Cochrane Q test's p -value of 0.309) computed for this model. The meta-analysis showed a low summary positive
effect size (0.406) with a wide 95% CI (0.100; 0.713; p = 0.0093) and power of 73.91%, favoring etch-and-rinse adhesives ([Fig. 2 ]).
The funnel plot detected the presence of important bias ([Fig. 3 ]).
Fig. 3 Funnel plot (Cohen H effect size against standard errors) of publication bias, for
all studies.
The assessment of the certainty of evidence through GRADE approach revealed a very
low certainty of evidence ([Fig. 4 ]). Although the certainty initiated as high through the five studies included in
this systematic review, which were randomized controlled clinical trial, the process
of detailed ratings across the five domains that can lower the certainty, downgraded
this certainty. The critical domains were: (1) Risk of bias, illustrated in [Table 3 ], that revealed problems related to sequence generation, blinding of participants
and operators, incomplete outcome data and selective reporting outcome in the majority
of studies, leading to downgrading the certainty of evidence in two levels; (2) Imprecision,
observed through the wide CIs. We downgraded the certainty just in one level, since
the number of restorations included in metanalyses was above the rule-of-thumb of
400 (200 per group) and also above the optimal information size calculated (n = 89 after loss of follow-up); (3) Publication bias, which was suspected analyzing
the sample size of each study included, was small, and also confirmed through the
funnel plot.
Fig. 4 Grades of Recommendations, Assessment, Development and Evaluation (GRADE).
Discussion
Our review detected six studies that met the inclusion criteria, and the main research
question was whether the self-etch adhesives differed from etch-and-rinse adhesives
in terms of failure rates of composite resin restoration in posterior permanent teeth.
In addition to considering the statistical significance reported in the papers, we
further computed effect sizes (intensity of the difference between failure rates),
their CIs, and power. The analysis detected that four out of six selected studies
presented individually wide CIs, which means that the sample size was smaller than
required to yield reasonable standard errors.[10 ]
[11 ] When interpreting the high p-value and the wide 95% CI found for the meta-analysis
of all studies (with and without rubber dam), one must consider that the probability
within the CI is maximum at the point estimate (effect size of 0.403, favoring etch-and-rinse
adhesives) and decreases towards both upper (0.703) and lower (0.100) limits. The
words “were included” should be removed.[11 ] More specifically, the wide CI is the result of small sample sizes in the individual
studies and can be improved by further studies with larger sample sizes. The presence
of important publication bias ([Fig. 3 ]) further supports the idea that the pooled studies have high variability.
The failures in marginal adaptation and marginal staining are closely related to the
location of the dentine adhesive in the restoration, supporting the interpretation
that the failure rate was mostly related to the adhesive type used. Self-etching adhesives
face a coupled diffusion challenge: the outward diffusion of dissolved mineral ions
(due to acid etching) and the inward diffusion of both the primer and the bonding
molecules, with embedding of dissolved calcium phosphates within the dentin hybrid
layer would destabilize the adhesive interface with time.[27 ] The lack of intermediate step potentially includes difficulties for establishing
and reasonable hybrid layer, and the current recommendation includes a separate selective
enamel acid conditioning prior to applying self-etching adhesives.[27 ] Such selective enamel conditioning was not used in any of the studies included in
the current meta-analysis.
Our results are consistent with previous meta-analyses indicating higher sensitivity
of self-etching adhesives to long-term water storage in vitro
[28 ] and higher annual failure rates of one step self-etching adhesives in non-cervical
carious lesions compared to both two steps etch-and-rinse and two steps self-etching
adhesives.[29 ]
The thinner hybrid layer obtained with self-etch adhesives[4 ] is another probable explanation for the higher failure rate of resin composite restoration
in posterior teeth using self-etch adhesives.
In order to contribute to the planning of future longitudinal studies on the failure
rates of etch-and-rinse versus one-step adhesives in posterior composite restorations,
the use of rubber dam in paired groups recommended. For sample size calculations,
to the best of available evidence identified in the current meta-analysis, it would
be recommended the use of an effect size Cohen H of 0.406 (close to the cut-off of
5, for medium effect size), a two-tailed 5% significance level, power of 80%, which
would result in a sample size of 48 per group. This estimation does not include any
sample size loss due to the failure in compliance with study recall appointments during
the follow-up period.
Conclusion
In conclusion, current available evidence indicates that etch-and rinse adhesives
performed better than self-etching adhesives in terms of failure rates in posterior
composite restorations. But the certainty of evidence is very low, indicating the
necessity of more well-conducted studies with larger sample sizes and less risk of
bias. Improved ad hoc planning for future studies is required to achieve scientific
evidence with smaller variability.
