Longevity of posterior direct versus indirect composite restorations: A systematic review and meta-analysis

Objectives: The goal of this systemic review and meta-analysis was to compare the longevity of direct and indirect composite restorations in posterior teeth. Data: Randomized controlled trials (RCT) investigating direct and indirect composite restorations in permanent posterior teeth. Sources: Three electronic databases (PubMed, CENTRAL (Cochrane) and Embase) were screened. No language or time restrictions were applied. Study selection, data extraction and quality assessment were done in duplicate. Risk of bias and level of evidence was graded using Risk of Bias 2.0 tool and Grade Profiler 3.6. Results: A total of 3056 articles were found by electronic databases. Finally, five RCTs were selected. Overall, 627 restorations of which 323 were direct and 304 indirect composite restorations have been placed in 279 patients (age: 28-81 years). The highest annual failure rates (AFR) were found for indirect restorations ranging from 0 % to 15.5 %. Lower AFR were found for direct restorations ranging from 0 % to 5.4%. The most frequent failures were found to be chipping and fracture of the restoration followed by caries. Meta-analysis revealed that the failure rate for direct restorations was significantly lower than for indirect restorations (Risk Ratio (RR) [95 %CI] = 0.61 [0.47; 0.79]; very low level of evidence). Furthermore, all studies showed a high risk of bias. Conclusion: Direct and indirect composite restorations can be recommended for large class II cavities including cusp coverage in posterior teeth for single tooth restoration. Meta-analysis revealed significantly lower relative risk to fail for direct composite restorations than for indirect restorations but results are with high risk of basis.