Direct Composite Resin for the Management of Tooth Wear: A Systematic Review and Meta-Analysis
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The survival of direct composite resin restorations for the treatment of worn teeth has been reported in several studies. This systematic review aims to integrate studies with outcomes that are comparable and to critically evaluate the literature. A comprehensive electronic search of 4 databases (Medline-PubMed, Cochrane Central, Scopus, Google scholar) was performed on literature published between January 1990 and December 2017. Inclusion criteria were based on the PICO format. Exclusions included studies on children, adults with non-carious cervical lesions, cast and all-ceramic restorations, case reports with ≤4 participants, narrative and systematic reviews, other meta-analyses. The risk of bias was assessed by a funnel plot. Selected data extraction included participant sample size, number of composite restorations, number of operators, type of composite, whether the Occlusal Vertical Dimension (OVD) was increased or not, location (anterior or posterior), mean or total follow-up time and success rate expressed as either percent of successful restorations or Median Survival Time (MST) in years. A total of 1461 studies were identified and 1316 were screened. 61 full text papers were assessed for eligibility resulting in 11 studies that met inclusion criteria for quantitative analysis. These 11 publications assessed 2,733 direct composite restorations placed in 375 subjects with survival ranging from 50% to 96.4%. The funnel plot showed a low risk of publication bias. A meta-analysis of proportions using survival percentage of direct composite restorations gave a pooled effect size estimate of 81.3 % survival, but considerable heterogeneity was evident (I2=96.7). Between studies variance was high. Studies were mainly of a case series type performed in hospital settings. Clinical heterogeneity was a significant factor with different operators, different interventions (composite manufacturer, micro-filled or hybrid) and outcomes expressed in different ways (percentage survival, Median Survival Time, Annual Failure Rate). Furthermore, sample sizes varied from 6 to 164 patients with concomitant wide age range and the number of restorations followed-up varied widely also from 16 to 1,010 composites. Follow-up times were generally short which could have a significant influence on survival outcome. It is reasonable to assume more advanced wear would be seen and treated in a hospital setting but few studies described the severity of the wear which would also affect survival outcome. An inconsistent result between studies implies statistical heterogeneity may also be present. Overall, the estimated survival of direct composite restorations in tooth wear cases was 81.3% although the substantial heterogeneity seriously limits the precision of this estimate.