JJOD-2277; No. of Pages 7 journal of dentistry xxx (2014) xxx–xxx
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Comparison of pattern of failure of resin composite restorations in non-carious cervical lesions with and without occlusal wear facets Adeleke Oke Oginni a,*, Adeyinka Adedayo Adeleke b a b
Department of Restorative Dentistry, Faculty of Dentistry, Obafemi Awolowo University, Ile-Ife, Nigeria Department of Dental Surgery, Ekiti State University Teaching Hospital, PMB 5355, Ado-Ekiti, Nigeria
article info
abstract
Article history:
Objectives: Many studies have reported the clinical problems associated with resin compos-
Received 30 September 2013
ite restorations in NCCLs. None has compared these clinical problems in NCCLs with and
Received in revised form
without occlusal wear facets. The present study sets out to determine the proportion of
2 April 2014
NCCLs that presents occlusal wear facets, and to compare the failure pattern of resin
Accepted 5 April 2014
composite restorations in NCCLs with and without occlusal wear facets.
Available online xxx
Methods: Teeth with NCCLs were classified into two groups, those with and without occlusal
Keywords:
were evaluated at the end of 2 years concerning post-operative sensitivity, retention,
Non-carious cervical lesions
marginal integrity, marginal discolouration, wear, and secondary caries, using the USPHS
wear facets. Both groups were restored using micro hybrid resin composite. The restorations
Wear facets Restoration
criteria. Statistical analysis compared the ratings of each criterion between the two groups using Pearson’s x2 or Fisher’s exact test. Results: About one-third (33.8%) of teeth with NCCLs presented with occlusal wear facets, more NCCLs with occlusal wear facets in mandibular teeth (44.7%) than maxillary teeth (24.5%). Retention rate of composite resin restorations in NCCLs with and without occlusal wear facets was 63.9% and 74.4% respectively at the end of 2 years. More marginal discolouration and defects were observed in restorations in NCCLs with occlusal wear facets, the differences were not statistically significant ( p > 0.05). Conclusions: The decline in ratings of marginal discolouration and defects, and the lower retention rate of restorations in NCCLs with occlusal wear facets may support the role of occlusal stress and tooth flexure as a cause of failure of restorations in NCCLs. Clinical significance: The ability to distinguish between stress induced lesions (with occlusal wear facets) and other cervical lesions will have important ramifications for the success of their restorations because they are not subjected to the same physical forces that are responsible for the deterioration of the restoration. # 2014 Elsevier Ltd. All rights reserved.
* Corresponding author at: Department of Restorative Dentistry, Faculty of Dentistry, Obafemi Awolowo University, Ile-Ife 220005, Nigeria. Tel.: +234 80 64459618. E-mail addresses: [email protected], [email protected] (A.O. Oginni). http://dx.doi.org/10.1016/j.jdent.2014.04.003 0300-5712/# 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Oginni AO, Adeleke AA, Comparison of pattern of failure of resin composite restorations in non-carious cervical lesions with and without occlusal wear facets. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.04.003
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1.
Introduction
Non-carious cervical lesions (NCCLs) may be caused by erosion, abrasion and/or stress induced cervical lesion (‘abfraction’) and occur frequently in clinical practice.1 Its incidence has been increasing. Several studies suggest that NCCLs do have multifactorial aetiology and that multiple causal mechanisms may operate in the initiation and progression of each individual lesion.1,2 These lesions present in a variety of forms; shallow, grooved and wedged shaped lesions,3 depending on the most predominant aetiological factor. Correct diagnosis based on adequate history, clinical examination and investigation is a prerequisite for treatment. Abrasion is the abnormal wearing away of the tooth substance or structure by a mechanical process. Tooth brushing has been implicated as a cause, other factors involved are: improper or incorrect tooth brushing technique, excessive brushing force, bristle stiffness, brushing frequency, and abrasivity of toothpaste. It tends to be more obvious at the necks of teeth where it forms a rounded or v-shaped lesion depending on the predominating causal factor that is, erosion or tooth brushing respectively.4 Acid erosion can be distinguished by its smooth loss of tooth structure and its history of dietary, environmental or gastric acids. Whereas abfraction is the disruption of the enamel crystals at the cervical region, secondary to tooth flexure, resulting from occlusal loading,5 and are typically wedge shaped lesions with sharp line angles.6,7 It has also been reported that the forces from occlusal loading resulting in the development of wedge shaped cervical lesion on a tooth will cause wear facet on the same tooth.8 Therefore, the key diagnostic considerations for stress-induced cervical lesions include the presence of wear facets, and the sharp wedge shape of the lesion. Restorations of NCCLs are done to prevent further loss of tooth structure, to improve aesthetics, and to relieve hypersensitivity. However, the longevity of resin-based composite restorations for NCCLs was previously unsatisfactory compared to that of anterior approximal restorations.9 The main reasons for failures were loss of the restoration, secondary caries, marginal discolouration/marginal defects and postoperative sensitivity.10,11 These failures are probably due to the non retentive cavity shape and margins of NCCLs lying on dentine or cementum which poses a challenge for bonding. Several studies12,13 support the tensile stress aetiology of stress induced cervical lesions. Lambrechets et al. also pointed out that the premature loss of the cervical restoration results because the restoration is subjected to the same tensile force that can cause debonding, leakage, and retention failure.12 Hence, stress concentration at the cervical region is responsible for not only the development of cervical lesions, but for restoration failure as well.12,14 However, Wood et al. in a review of the literature, concluded that there is no evidence that occlusal adjustment is helpful in terms of slowing down lesion formation or improving the retention of restorations when placed to restore NCCLs.15 In a recent systematic review of the association between occlusal factors and NCCLs by Silva et al.16 three studies2,17,18 reported significant associations between NCCL and some variables including occlusal contact area,17 right canine guidance,2 premature contacts in centric relation and working side.18
Currently, the materials of choice indicated for restoring cervical lesions include glass ionomer cement, resin-modified glass ionomer cements (RMGICs), polyacid-modified resin composites (‘Compomers’) and several types of resin composites.19 Many studies have reported the clinical problems associated with resin composites in NCCLs.20,21 However, we are not aware of any study comparing these clinical problems associated with resin composite restorations, in NCCLs with and without occlusal wear facets. It was therefore the aim of the present study to determine the proportion of NCCL that presents occlusal wear facet, and to compare the failure pattern of resin composite restorations in NCCLs with and without occlusal wear facets.
2.
Materials and methods
The study included patients referred to the Department of Restorative Dentistry, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria for the restoration of NCCLs over a period of six months (mid-June 2007–mid-December 2007). Patients were properly informed about the study and informed consent obtained. Ethical approval was given by the Ethical Committee of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife. Clinical data included gender, ages of patients, teeth involved. The teeth with NCCLs were classified into two groups, those with and without occlusal wear facets. Occlusal wear facets were defined as loss of enamel exposing dentine. Both groups were restored using micro hybrid resin composite (Bright light DMP Ltd., Markopoulo, Greece). The restorations were performed by one author, no cavity reparation was carried out, enamel margins were not bevelled, and no mechanical retention was placed, rubber dam was placed and cavities were pumiced with a prophylaxis cup. Enamel and dentine were etched for 30 s with 37% phosphoric acid gel (Prime-dent, USA). The etchant was rinsed off with water spray and gently air dried without desiccation. One coat of adhesive system (Prime-dent, USA) was applied; following evaporation of alcohol solvent, the self-priming adhesive was light-cured for 20 s according to manufacturer’s instructions. The micro hybrid resin composite (Bright light DMP Ltd., Markopoulo, Greece) was placed incrementally (2 mm). Each increment was light cured for 40 s by means of a well controlled visible light cure unit (Gnatus LD Max. RibeiraoPreto-SP-Brasil). The restorations were finished and polished with enhance polishing system (Dentsply) and Sof-Lex polishing discs (3M). The restorations were evaluated at baseline (1 week after restoration), and every 6 months for 2 years concerning postoperative sensitivity, retention, marginal integrity, marginal discolouration, wear, and secondary caries, using the USPHS criteria (Table 1). Dentine hypersensitivity was confirmed by short, sharp pain arising from the exposed dentine in response to a blast of air from a triple syringe or air jet from the dental unit (evaporative stimulus). At recall visits, postoperative sensitivity was registered if there was short sharp pain in response to cold or hot drinks (thermal stimulus) since the previous visit. The evaluations were done by two evaluators, inter- and intra examiner’s agreement for the evaluated
Please cite this article in press as: Oginni AO, Adeleke AA, Comparison of pattern of failure of resin composite restorations in non-carious cervical lesions with and without occlusal wear facets. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.04.003
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Table 1 – The USPHS rating criteria for direct clinical evaluation. Category
Restorative score
Retention
Alpha (A) Bravo (B) Charlie (C)
Restoration is fully intact Partial loss of restoration Total loss of restoration
Marginal discoloration
Alpha (A)
No discoloration anywhere on the margin between the restoration and the tooth margin. The discoloration has not penetrated in a pulpal direction along the margin. The discoloration has penetrated in a pulpal direction along the margin
Criteria used in rating restoration
Bravo (B) Charlie (C)
Marginal adaptation
Alpha (A)
The restoration appears to adapt closely to the tooth along the periphery of the abrasive wear restoration. An explorer does not catch when drawn across the margin, or when it does catch, it will catch only in one direction and no crevice is visible. The explorer catches and there is visible evidence of a crevice into which the explorer will penetrate. However, neither dentine nor base is visible The explorer penetrates into a crevice that is of such depth that dentine or base is exposed
Bravo (B)
Charlie (C)
Abrasive wear resistance
Alpha (A) Bravo (B) Charlie (C)
Completely intact with no loss of contour Slight contour loss, replacement is unnecessary Extensive contour loss requiring replacement
Post operation sensitivity
Alpha (A) Bravo (B)
Post operative sensitivity entirely absent Slight sensitivity to temperature change and/or probe exploration Severe sensitivity to temperature change and/or probe exploration
Charlie (C)
Secondary Caries
Alpha (A) Charlie (C)
criteria were between 88 and 93% at regular calibrated exercises. Statistical analysis compared the ratings of each criterion between the two groups using Pearson’s x2 or Fisher’s exact test at a level of significance of 5% ( p < 0.05). The clinical bonding efficiency was determined by the cumulative retention failure rate
No caries present Caries present
the 287 teeth with NCCLs that were restored, 240 and 189 could be evaluated at the end of 1 and 2 years respectively. At the end of 2 years, 26 composite resin restorations in NCCLs with occlusal wear facets were lost (dislodged), while 30 restorations in NCCLs without occlusal wear facets were lost, indicating
Table 2 – Distribution of NCCLs with and without associated occlusal wear facet by jaw location.
3.
Results
A total of 287 teeth with NCCLs were restored in 89 patients (51 male and 38 female) with a mean age of 46 4.7 years (range 29–76). Two NCCLs were restored in 5 patients, 3 in 69 patients, 4 in 10 patients, and 6 in 5 patients. Of all the teeth with NCCLs that were restored, 97 (33.8%) presented with associated occlusal wear facets, while 190 (66.2%) presented without associated occlusal wear facets. The distribution of NCCLs with and without associated occlusal wear facets by jaw location is shown in Table 2. One hundred and fifty-five NCCLs were in the maxilla, 38 (24.5%) had occlusal wear facets, while 117 (75.5%) had none. One hundred and thirty-two were in the mandible, 59 (44.7%) had occlusal wear facets, while 73 (55.3%) had none. There were more NCCLs with occlusal wear facets in the mandible than in the maxilla; the differences were statistically significant ( p < 0.001). At the end of 1 and 2 years, 15 (16.9%) patients, 47 teeth and 32 (36.0%) patients, 98 teeth were lost to follow-up respectively. Of
NCCLs with occlusal wear facet
NCCLs without occlusal wear facet
No.
(%)
No.
(%)
Maxilla Anterior teeth Premolars Molars
0 25 13
(0) (16.1) (8.4)
5 68 44
(3.2) (43.3) (28.4)
Total
38
(24.5)
117
(75.5)
Mandible Anterior teeth Premolars Molars
0 38 21
(0) (28.8) (15.9)
3 29 41
(2.3) (21.9) (31.1)
Total
59
(44.7)
73
(55.3)
Maxilla, Pearson’s x2 = 1.995, p = 0.37. Mandible Pearson’s x2 = 9.28, p = 0.010. Maxilla vs Mandible Pearson’s x2 = 12.98, p = 0.000.
Please cite this article in press as: Oginni AO, Adeleke AA, Comparison of pattern of failure of resin composite restorations in non-carious cervical lesions with and without occlusal wear facets. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.04.003
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Table 3 – Evaluation of resin composite restorations in NCCLs with and without occlusal wear facet at baseline, 1 year and at the end of 2 years. Baseline (n = 287) n
A
Retention Wear facet No wear facet
97 0 190 0 Exact p = 1.0 Marginal discoloration 97 0 Wear facet 190 0 No wear facet Exact p = 1.0 Marginal adaptation 97 0 Wear facet 190 0 No wear facet Exact p = 1.0 Abrasive wear resistance 97 0 Wear facet 190 0 No wear facet Exact p = 1.0 Post operative sensitivity Wear facet 97 94 190 185 No wear facet Exact p = 1.0 Secondary caries Wear facet 97 0 190 0 No wear facet Exact p = 1.0
1 year (n = 240)
B
C
(A + B)%
n
A
0 0
0 0
100.0 100.0
86 154
69 134
0 0
0 0
100.0 100.0
86 154
0 0
0 0
100.0 100.0
0 0
0 0
3 5
0 0
(A + B)%
n
2 15 0 20 Exact p = 0.09
82.6 87.0
72 117
82 152
4 0 2 0 Exact p = 0.19
100.0 100.0
72 117
86 154
83 149
3 0 5 0 Exact p = 1.0
100.0 100.0
72 117
100.0 100.0
86 154
82 139
4 0 12 3 Exact p = 0.31
100.0 98.1
72 117
67 100
5 0 13 4 Exact p = 0.11
100.0 96.6
0 0
100.0 100.0
86 154
0 0
0 0 0 0 Exact p = 1.0
100.0 100.0
72 117
0 0
0 0 0 0 Exact p = 1.0
100.0 100.0
0 0
100.0 100.0
86 154
86 154
0 0 0 0 Exact p = 1.0
100.0 100.0
72 117
72 117
0 0 0 0 Exact p = 1.0
100.0 100.0
63.9% and 74.4% retention of restorations in NCCLs with and without occlusal wear facets respectively, Table 3. The difference was not statistically significant ( p > 0.05). In respect to marginal discolouration, 5 restorations in NCCLs with occlusal wear facets rated Bravo, 3 restorations rated Charlie at the end of 2 years. While 2 restorations in NCCLs without occlusal wear facets rated Bravo and none
Table 4 – Distribution of retention failure of resin composite restorations in NCCLs with and without occlusal wear facet. Rest. NCCLs with occlusal wear facet
Rest. NCCLs without occlusal wear facet
No.
(%)
No.
(%)
Maxilla Anterior teeth Premolars Molars Total
0 6 3 9
(0) (28.5) (14.3) (42.8)
0 8 4 12
(0) (38.1) (19.1) (57.2)
Mandible Anterior teeth Premolars Molars Total
0 12 5 17
(0) (34.3) (14.3) (48.6)
0 11 7 18
(0) (31.4) (20.0) (51.4)
Cumulative survival (%) First year Second year
(83.6) (46.5)
Maxilla, Pearson’s x2 = 0.13, p = 0.72. Mandible Pearson’s x2 = 0.35, p = 0.56. Maxilla vs mandible Pearson’s x2 = 3.37, p = 0.07.
(88.4) (61.2)
B
C
2 years (n = 189) A
B
C
(A + B)%
41 5 26 63.9 84 3 30 74.4 Pearson’s x2 = 5.16, p = 0.08 64 115
5 3 2 0 Exact p = 0.01
95.8 100.0
62 2 8 93.1 109 3 5 93.2 Pearson’s x2 = 3.28, p = 0.91
rated Charlie. Table 3 shows that at the end of 2 years, the marginal adaptation of 8 restorations in NCCLs with occlusal wear facets and 5 restorations in NCCLs without occlusal wear facets were rated Charlie, with exposure of dentine. The difference was not statistically significant ( p > 0.05). There was extensive contour loss requiring replacement (USPHS, Charlie) in 4 restorations in NCCLs without occlusal wear facets, while there was none in restorations in NCCLs with occlusal wear facets. In patients that presented with dentine hypersensitivity before placement of restorations, postoperative sensitivity was registered during the first to third week after placement. Thereafter no postoperative sensitivity was reported. At the end of the follow-up period, no caries was evident contiguous with the margin of the restorations in NCCLs with and without occlusal wear facets. Table 4 shows the distribution of retention failure of composite resin restoration in NCCLs with and without occlusal wear facet after a 2-year period. There were more retention failures in mandibular teeth than in maxillary teeth. The cumulative survival of restorations in NCCLs with occlusal wear facets at the end of 1 year and 2 years was 83.6% and 46.5% respectively, while the cumulative survival of restorations in NCCLs without occlusal wear facets at the end of 1 year and 2 years was 88.4% and 61.2% respectively. The cumulative survival of restorations during the 2-year followup showed a reduced survival rate of restorations placed in NCCLs with occlusal wear facets.
4.
Discussion
The loss to follow-up (32 patients and 98 teeth) at the end of 2 years was high. This was due to non-availability of patients at
Please cite this article in press as: Oginni AO, Adeleke AA, Comparison of pattern of failure of resin composite restorations in non-carious cervical lesions with and without occlusal wear facets. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.04.003
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Fig. 1 – (a) NCCLs in teeth with generalised occlusal wear. (b) NCCLs in teeth 43 and 44 with occlusal wear facets and tooth 45 without occlusal wear facet. There is also evidence of erosion on teeth 43, 44 and 46.
recall visit attributed to failure to obtain permission from work place, and lack of funds for transportation. The patients did not drop out because they were less likely to experience restorative failure. In fact, it was assumed that the patients lost to follow up have the same prognosis as those that remained in the study.22 It is also generally observed that once the problem is solved or treatment completed, the majority of patients are complacent in attending recall visits. The result of the present study shows that about one-third (33.8%) of teeth with NCCLs presented with occlusal wear facets, this is in agreement with an earlier study.23 Occlusal wear facets was defined as loss of enamel exposing dentine, due to the contact of opposing teeth as a result of vigorous mastication of the typical African fibrous diet (Fig. 1a and b). More NCCLs were reported in the maxillary teeth than in mandibular teeth, this is in contrast to the study of Sognnaes et al. who reported a higher frequency of NCCLs in mandibular teeth.24 However, in the present study, there were more NCCLs with occlusal wear facets in mandibular teeth than in maxillary teeth, the difference was statistically significant ( p < 0.05). Also there were more retention failure of resin composite restoration in NCCLs in mandibular teeth than in maxillary teeth; this is consistent with previous studies that reported higher retention failure for the mandibular arch than the maxillary arch.25,26 These may be due to the lingual orientation of the mandibular teeth which makes them more susceptible to the concentration of tensile stresses at the cervical region.27 The weakness of mandibular teeth to withstand tensile stress may be due to their anatomically smaller cervical cross section, in particular the premolars28. A wide variety of retention rates had been reported for resin composite restorations in NCCLs, van Dijken in his study of 10
Fig. 2 – (a) NCCLs in teeth 24 and 25 (pre-operative). (b) 1 week post-operative restoration of NCCLs in teeth 24 and 25 with resin composite. (c) 2 years post-operative failure of resin composite restorations showing cervical Marginal adaptation failure in tooth 24 with occlusal wear facet.
resin composite systems, showed retention loss rates between 15 and 25% in five systems, while the other five showed loss rates between 40 and 80%.29 Another study reported a retention rate of 65% of resin composite material at 18 months evaluation.26 In the current study, the retention rate for resin composite restoration in NCCLs with and without occlusal wear facets was 63.9% and 74.4% respectively. These compare favourably well with the findings of van Dijken29 and Neo et al.30 However, a lower failure rate of 11–14% had also been reported in 24 months evaluation of resin-based materials.31 van Dijken and Pallesen in another study, reported increasing overall relative cumulative loss rate of 0.8%, 6.9% and 23% at 6
Please cite this article in press as: Oginni AO, Adeleke AA, Comparison of pattern of failure of resin composite restorations in non-carious cervical lesions with and without occlusal wear facets. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.04.003
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and 18 months and 7 years respectively.32 The causes of restoration dislodgement from NCCLs have been variously ascribed to tooth flexure,33 a high viscosity and perhaps a high modulus of elasticity of the restorative material.34 Hence the seemingly high loss rate in the present study in which hybrid resin with a high modulus of elasticity was used. Also the higher loss rate of restorations in NCCLs with occlusal wear facets may support the role of occlusal stress and tooth flexure as a cause of failure of restorations in NCCLs. Factors other than the restorative material and occlusal loading/stress, that may significantly influence the clinical performance of cervical restorations include sclerotic dentine, location of lesion, lesion size and shape, absence of enamel bevel.33,35 Although several adhesives including one-step adhesives,36 self-etch and conventional adhesives (etch and rinse) with multiple application steps have been used for treatment of NCCLs, there is no enough evidence to support one adhesive or bonding strategy over another for treatment of NCCLs.37 Clinical studies have shown that restorations of NCCLs have inadequate retention rates with higher percentages of failure despite the improvement in bond strength of adhesive resins to dentine.38,39 Therefore, to improve the clinical longevity of cervical restorations, modified or unmodified preparations, enamel bevels have been suggested, especially when nonaxial occlusal force cannot be reduced or eliminated.34,40 One of the early clinical signs that resin composite restoration is prone to failure is marginal discolouration. Its incidence has been reported to increase over time.20 In the current study, more marginal discolouration was observed in restorations in NCCLs with occlusal wear facets. Also more of the restorations in NCCLs with occlusal wear facets had marginal defects that exposed the dentine (Charlie) Table 3. Although the differences were not statistically significant, it may be that tooth flexure resulting from occlusal loading have contributed to localised defects in marginal integrity Fig. 2a,b and c. The decline in rating (Alpha to Bravo to Charlie) in respect to marginal discolouration and adaptation is probably due to no marginal bevel, and or to small fracture of the cavosurface margin and material due to stress from polymerization shrinkage. Several studies41 have indicated the relationship between marginal discolouration and marginal adaptation. Marginal stains were always detected in combination with small marginal defects. However, not all marginal defects resulted in marginal discoloration.41 The extensive contour loss in 4 restorations in NCCLs without occlusal wear facets signifies poor wear resistance of resin composite and may be explained by the location of this restorations combined with the effect of tooth brushing.
references
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Please cite this article in press as: Oginni AO, Adeleke AA, Comparison of pattern of failure of resin composite restorations in non-carious cervical lesions with and without occlusal wear facets. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.04.003
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26. Powell LV, Johnson GH, Gordon GE. Factors associated with clinical success of cervical abrasion/erosion restorations. Operative Dentistry 1995;20:7–13. 27. Demster WI, Adams WJ, Duddles RA. Arrangement in the jaws of the roots of the teeth. Journal of American Dental Association 1963;67:779–97. 28. William CL, Eakle WS. Stress-induced cervical lesions: review of advances in the past 10 years. Journal of Prosthetic Dentistry 1996;75:487–94. 29. van Dijken JWV. Clinical effectiveness of 12 adhesive systems in class-V non-retentive lesions. A 5-year evaluation. CED/NOF meeting Warsaw, Poland. Journal of Dental Research 2001;80:1272. [Abstr. no. 42]. 30. Neo J, Chew CL, Yap A, Sidhu S. Clinical evaluation of toothcolored materials in cervical lesions. American Journal of Dentistry 1996;9:15–8. 31. Browning WD, Brackett WW, Gilpatrick RO. Two-year clinical comparison of a microfilled and a hybrid-resinbased composite in non-carious class V lesions. Operative Dentistry 2000;25:46–50. 32. van Dijken JWV, Pallesen U. A 7-year randomized prospective study of a one-step self-etching adhesive in non-carious cervical lesions. The effect of curing modes and restorative material. Journal of Dentistry 2012;40:1060–7. 33. Heymann HO, Sturdevant JR, Bayne SC, Wilder AD, Sluder TB, Brunson WD. Examining tooth flexure effects on cervical restorations. A two-year clinical study. Journal of American Dental Association 1991;122:41–7.
34. Kemp-Schotte CM, Davidson CL. Complete marginal seal of class V resin composite restorations affected by increased flexibility. Journal of Dental Research 1990;69:1240–3. 35. Heymann HO, Studervant JR, Brunson WD, Wilder AD, Sluder TR, Bayne SC. Twelve-month clinical study of dentinal adhesives in class V cervical lesions. Journal of American Dental Association 1988;116:179–83. 36. Moretto SG, Russo EMA, Carvalho RCR, De Munck J, Van Landuyt K, Peumans M, et al. 3-year clinical effectiveness of one-step adhesives in non-carious cervical lesions. Journal of Dentistry 2013;41:675–82. 37. Chee B, Rickman LJ, Satterthwaite JD. Adhesives for the restoration of non-carious cervical lesions: a systemic review. Journal of Dentistry 2012;40:443–52. 38. Matis BA, Cochran MJ, Carlson TJ, Guba C, Eckert GJ. A 3-year clinical evaluation of two dentine bonding agents. Journal of American Dental Association 2004;135:451–7. 39. van Dijken JW. Retention of a resin-modified glass ionomer adhesive in non-carious cervical lesions. A 6-year follow-up. Journal of Dentistry 2005;33:541–7. 40. Brackett MG, Dib A, Bracket WW, Estrada BE, Reyes AA. One-year clinical performance of a resin-modified glass ionomer and a resin composite restorative material in unprepared class V restorations. Operative Dentistry 2002;27:112–6. 41. Kubo S, Yokota H, Kawasaki K, Hayashi Y. Five-year clinical evaluation of two adhesive systems in non-carious cervical lesions. Journal of Dentistry 2006;34:97–105.
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7
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.intl.elsevierhealth.com/journals/jden
Comparison of pattern of failure of resin composite restorations in non-carious cervical lesions with and without occlusal wear facets Adeleke Oke Oginni a,*, Adeyinka Adedayo Adeleke b a b
Department of Restorative Dentistry, Faculty of Dentistry, Obafemi Awolowo University, Ile-Ife, Nigeria Department of Dental Surgery, Ekiti State University Teaching Hospital, PMB 5355, Ado-Ekiti, Nigeria
article info
abstract
Article history:
Objectives: Many studies have reported the clinical problems associated with resin compos-
Received 30 September 2013
ite restorations in NCCLs. None has compared these clinical problems in NCCLs with and
Received in revised form
without occlusal wear facets. The present study sets out to determine the proportion of
2 April 2014
NCCLs that presents occlusal wear facets, and to compare the failure pattern of resin
Accepted 5 April 2014
composite restorations in NCCLs with and without occlusal wear facets.
Available online xxx
Methods: Teeth with NCCLs were classified into two groups, those with and without occlusal
Keywords:
were evaluated at the end of 2 years concerning post-operative sensitivity, retention,
Non-carious cervical lesions
marginal integrity, marginal discolouration, wear, and secondary caries, using the USPHS
wear facets. Both groups were restored using micro hybrid resin composite. The restorations
Wear facets Restoration
criteria. Statistical analysis compared the ratings of each criterion between the two groups using Pearson’s x2 or Fisher’s exact test. Results: About one-third (33.8%) of teeth with NCCLs presented with occlusal wear facets, more NCCLs with occlusal wear facets in mandibular teeth (44.7%) than maxillary teeth (24.5%). Retention rate of composite resin restorations in NCCLs with and without occlusal wear facets was 63.9% and 74.4% respectively at the end of 2 years. More marginal discolouration and defects were observed in restorations in NCCLs with occlusal wear facets, the differences were not statistically significant ( p > 0.05). Conclusions: The decline in ratings of marginal discolouration and defects, and the lower retention rate of restorations in NCCLs with occlusal wear facets may support the role of occlusal stress and tooth flexure as a cause of failure of restorations in NCCLs. Clinical significance: The ability to distinguish between stress induced lesions (with occlusal wear facets) and other cervical lesions will have important ramifications for the success of their restorations because they are not subjected to the same physical forces that are responsible for the deterioration of the restoration. # 2014 Elsevier Ltd. All rights reserved.
* Corresponding author at: Department of Restorative Dentistry, Faculty of Dentistry, Obafemi Awolowo University, Ile-Ife 220005, Nigeria. Tel.: +234 80 64459618. E-mail addresses: [email protected], [email protected] (A.O. Oginni). http://dx.doi.org/10.1016/j.jdent.2014.04.003 0300-5712/# 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Oginni AO, Adeleke AA, Comparison of pattern of failure of resin composite restorations in non-carious cervical lesions with and without occlusal wear facets. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.04.003
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1.
Introduction
Non-carious cervical lesions (NCCLs) may be caused by erosion, abrasion and/or stress induced cervical lesion (‘abfraction’) and occur frequently in clinical practice.1 Its incidence has been increasing. Several studies suggest that NCCLs do have multifactorial aetiology and that multiple causal mechanisms may operate in the initiation and progression of each individual lesion.1,2 These lesions present in a variety of forms; shallow, grooved and wedged shaped lesions,3 depending on the most predominant aetiological factor. Correct diagnosis based on adequate history, clinical examination and investigation is a prerequisite for treatment. Abrasion is the abnormal wearing away of the tooth substance or structure by a mechanical process. Tooth brushing has been implicated as a cause, other factors involved are: improper or incorrect tooth brushing technique, excessive brushing force, bristle stiffness, brushing frequency, and abrasivity of toothpaste. It tends to be more obvious at the necks of teeth where it forms a rounded or v-shaped lesion depending on the predominating causal factor that is, erosion or tooth brushing respectively.4 Acid erosion can be distinguished by its smooth loss of tooth structure and its history of dietary, environmental or gastric acids. Whereas abfraction is the disruption of the enamel crystals at the cervical region, secondary to tooth flexure, resulting from occlusal loading,5 and are typically wedge shaped lesions with sharp line angles.6,7 It has also been reported that the forces from occlusal loading resulting in the development of wedge shaped cervical lesion on a tooth will cause wear facet on the same tooth.8 Therefore, the key diagnostic considerations for stress-induced cervical lesions include the presence of wear facets, and the sharp wedge shape of the lesion. Restorations of NCCLs are done to prevent further loss of tooth structure, to improve aesthetics, and to relieve hypersensitivity. However, the longevity of resin-based composite restorations for NCCLs was previously unsatisfactory compared to that of anterior approximal restorations.9 The main reasons for failures were loss of the restoration, secondary caries, marginal discolouration/marginal defects and postoperative sensitivity.10,11 These failures are probably due to the non retentive cavity shape and margins of NCCLs lying on dentine or cementum which poses a challenge for bonding. Several studies12,13 support the tensile stress aetiology of stress induced cervical lesions. Lambrechets et al. also pointed out that the premature loss of the cervical restoration results because the restoration is subjected to the same tensile force that can cause debonding, leakage, and retention failure.12 Hence, stress concentration at the cervical region is responsible for not only the development of cervical lesions, but for restoration failure as well.12,14 However, Wood et al. in a review of the literature, concluded that there is no evidence that occlusal adjustment is helpful in terms of slowing down lesion formation or improving the retention of restorations when placed to restore NCCLs.15 In a recent systematic review of the association between occlusal factors and NCCLs by Silva et al.16 three studies2,17,18 reported significant associations between NCCL and some variables including occlusal contact area,17 right canine guidance,2 premature contacts in centric relation and working side.18
Currently, the materials of choice indicated for restoring cervical lesions include glass ionomer cement, resin-modified glass ionomer cements (RMGICs), polyacid-modified resin composites (‘Compomers’) and several types of resin composites.19 Many studies have reported the clinical problems associated with resin composites in NCCLs.20,21 However, we are not aware of any study comparing these clinical problems associated with resin composite restorations, in NCCLs with and without occlusal wear facets. It was therefore the aim of the present study to determine the proportion of NCCL that presents occlusal wear facet, and to compare the failure pattern of resin composite restorations in NCCLs with and without occlusal wear facets.
2.
Materials and methods
The study included patients referred to the Department of Restorative Dentistry, Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, Nigeria for the restoration of NCCLs over a period of six months (mid-June 2007–mid-December 2007). Patients were properly informed about the study and informed consent obtained. Ethical approval was given by the Ethical Committee of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife. Clinical data included gender, ages of patients, teeth involved. The teeth with NCCLs were classified into two groups, those with and without occlusal wear facets. Occlusal wear facets were defined as loss of enamel exposing dentine. Both groups were restored using micro hybrid resin composite (Bright light DMP Ltd., Markopoulo, Greece). The restorations were performed by one author, no cavity reparation was carried out, enamel margins were not bevelled, and no mechanical retention was placed, rubber dam was placed and cavities were pumiced with a prophylaxis cup. Enamel and dentine were etched for 30 s with 37% phosphoric acid gel (Prime-dent, USA). The etchant was rinsed off with water spray and gently air dried without desiccation. One coat of adhesive system (Prime-dent, USA) was applied; following evaporation of alcohol solvent, the self-priming adhesive was light-cured for 20 s according to manufacturer’s instructions. The micro hybrid resin composite (Bright light DMP Ltd., Markopoulo, Greece) was placed incrementally (2 mm). Each increment was light cured for 40 s by means of a well controlled visible light cure unit (Gnatus LD Max. RibeiraoPreto-SP-Brasil). The restorations were finished and polished with enhance polishing system (Dentsply) and Sof-Lex polishing discs (3M). The restorations were evaluated at baseline (1 week after restoration), and every 6 months for 2 years concerning postoperative sensitivity, retention, marginal integrity, marginal discolouration, wear, and secondary caries, using the USPHS criteria (Table 1). Dentine hypersensitivity was confirmed by short, sharp pain arising from the exposed dentine in response to a blast of air from a triple syringe or air jet from the dental unit (evaporative stimulus). At recall visits, postoperative sensitivity was registered if there was short sharp pain in response to cold or hot drinks (thermal stimulus) since the previous visit. The evaluations were done by two evaluators, inter- and intra examiner’s agreement for the evaluated
Please cite this article in press as: Oginni AO, Adeleke AA, Comparison of pattern of failure of resin composite restorations in non-carious cervical lesions with and without occlusal wear facets. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.04.003
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Table 1 – The USPHS rating criteria for direct clinical evaluation. Category
Restorative score
Retention
Alpha (A) Bravo (B) Charlie (C)
Restoration is fully intact Partial loss of restoration Total loss of restoration
Marginal discoloration
Alpha (A)
No discoloration anywhere on the margin between the restoration and the tooth margin. The discoloration has not penetrated in a pulpal direction along the margin. The discoloration has penetrated in a pulpal direction along the margin
Criteria used in rating restoration
Bravo (B) Charlie (C)
Marginal adaptation
Alpha (A)
The restoration appears to adapt closely to the tooth along the periphery of the abrasive wear restoration. An explorer does not catch when drawn across the margin, or when it does catch, it will catch only in one direction and no crevice is visible. The explorer catches and there is visible evidence of a crevice into which the explorer will penetrate. However, neither dentine nor base is visible The explorer penetrates into a crevice that is of such depth that dentine or base is exposed
Bravo (B)
Charlie (C)
Abrasive wear resistance
Alpha (A) Bravo (B) Charlie (C)
Completely intact with no loss of contour Slight contour loss, replacement is unnecessary Extensive contour loss requiring replacement
Post operation sensitivity
Alpha (A) Bravo (B)
Post operative sensitivity entirely absent Slight sensitivity to temperature change and/or probe exploration Severe sensitivity to temperature change and/or probe exploration
Charlie (C)
Secondary Caries
Alpha (A) Charlie (C)
criteria were between 88 and 93% at regular calibrated exercises. Statistical analysis compared the ratings of each criterion between the two groups using Pearson’s x2 or Fisher’s exact test at a level of significance of 5% ( p < 0.05). The clinical bonding efficiency was determined by the cumulative retention failure rate
No caries present Caries present
the 287 teeth with NCCLs that were restored, 240 and 189 could be evaluated at the end of 1 and 2 years respectively. At the end of 2 years, 26 composite resin restorations in NCCLs with occlusal wear facets were lost (dislodged), while 30 restorations in NCCLs without occlusal wear facets were lost, indicating
Table 2 – Distribution of NCCLs with and without associated occlusal wear facet by jaw location.
3.
Results
A total of 287 teeth with NCCLs were restored in 89 patients (51 male and 38 female) with a mean age of 46 4.7 years (range 29–76). Two NCCLs were restored in 5 patients, 3 in 69 patients, 4 in 10 patients, and 6 in 5 patients. Of all the teeth with NCCLs that were restored, 97 (33.8%) presented with associated occlusal wear facets, while 190 (66.2%) presented without associated occlusal wear facets. The distribution of NCCLs with and without associated occlusal wear facets by jaw location is shown in Table 2. One hundred and fifty-five NCCLs were in the maxilla, 38 (24.5%) had occlusal wear facets, while 117 (75.5%) had none. One hundred and thirty-two were in the mandible, 59 (44.7%) had occlusal wear facets, while 73 (55.3%) had none. There were more NCCLs with occlusal wear facets in the mandible than in the maxilla; the differences were statistically significant ( p < 0.001). At the end of 1 and 2 years, 15 (16.9%) patients, 47 teeth and 32 (36.0%) patients, 98 teeth were lost to follow-up respectively. Of
NCCLs with occlusal wear facet
NCCLs without occlusal wear facet
No.
(%)
No.
(%)
Maxilla Anterior teeth Premolars Molars
0 25 13
(0) (16.1) (8.4)
5 68 44
(3.2) (43.3) (28.4)
Total
38
(24.5)
117
(75.5)
Mandible Anterior teeth Premolars Molars
0 38 21
(0) (28.8) (15.9)
3 29 41
(2.3) (21.9) (31.1)
Total
59
(44.7)
73
(55.3)
Maxilla, Pearson’s x2 = 1.995, p = 0.37. Mandible Pearson’s x2 = 9.28, p = 0.010. Maxilla vs Mandible Pearson’s x2 = 12.98, p = 0.000.
Please cite this article in press as: Oginni AO, Adeleke AA, Comparison of pattern of failure of resin composite restorations in non-carious cervical lesions with and without occlusal wear facets. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.04.003
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Table 3 – Evaluation of resin composite restorations in NCCLs with and without occlusal wear facet at baseline, 1 year and at the end of 2 years. Baseline (n = 287) n
A
Retention Wear facet No wear facet
97 0 190 0 Exact p = 1.0 Marginal discoloration 97 0 Wear facet 190 0 No wear facet Exact p = 1.0 Marginal adaptation 97 0 Wear facet 190 0 No wear facet Exact p = 1.0 Abrasive wear resistance 97 0 Wear facet 190 0 No wear facet Exact p = 1.0 Post operative sensitivity Wear facet 97 94 190 185 No wear facet Exact p = 1.0 Secondary caries Wear facet 97 0 190 0 No wear facet Exact p = 1.0
1 year (n = 240)
B
C
(A + B)%
n
A
0 0
0 0
100.0 100.0
86 154
69 134
0 0
0 0
100.0 100.0
86 154
0 0
0 0
100.0 100.0
0 0
0 0
3 5
0 0
(A + B)%
n
2 15 0 20 Exact p = 0.09
82.6 87.0
72 117
82 152
4 0 2 0 Exact p = 0.19
100.0 100.0
72 117
86 154
83 149
3 0 5 0 Exact p = 1.0
100.0 100.0
72 117
100.0 100.0
86 154
82 139
4 0 12 3 Exact p = 0.31
100.0 98.1
72 117
67 100
5 0 13 4 Exact p = 0.11
100.0 96.6
0 0
100.0 100.0
86 154
0 0
0 0 0 0 Exact p = 1.0
100.0 100.0
72 117
0 0
0 0 0 0 Exact p = 1.0
100.0 100.0
0 0
100.0 100.0
86 154
86 154
0 0 0 0 Exact p = 1.0
100.0 100.0
72 117
72 117
0 0 0 0 Exact p = 1.0
100.0 100.0
63.9% and 74.4% retention of restorations in NCCLs with and without occlusal wear facets respectively, Table 3. The difference was not statistically significant ( p > 0.05). In respect to marginal discolouration, 5 restorations in NCCLs with occlusal wear facets rated Bravo, 3 restorations rated Charlie at the end of 2 years. While 2 restorations in NCCLs without occlusal wear facets rated Bravo and none
Table 4 – Distribution of retention failure of resin composite restorations in NCCLs with and without occlusal wear facet. Rest. NCCLs with occlusal wear facet
Rest. NCCLs without occlusal wear facet
No.
(%)
No.
(%)
Maxilla Anterior teeth Premolars Molars Total
0 6 3 9
(0) (28.5) (14.3) (42.8)
0 8 4 12
(0) (38.1) (19.1) (57.2)
Mandible Anterior teeth Premolars Molars Total
0 12 5 17
(0) (34.3) (14.3) (48.6)
0 11 7 18
(0) (31.4) (20.0) (51.4)
Cumulative survival (%) First year Second year
(83.6) (46.5)
Maxilla, Pearson’s x2 = 0.13, p = 0.72. Mandible Pearson’s x2 = 0.35, p = 0.56. Maxilla vs mandible Pearson’s x2 = 3.37, p = 0.07.
(88.4) (61.2)
B
C
2 years (n = 189) A
B
C
(A + B)%
41 5 26 63.9 84 3 30 74.4 Pearson’s x2 = 5.16, p = 0.08 64 115
5 3 2 0 Exact p = 0.01
95.8 100.0
62 2 8 93.1 109 3 5 93.2 Pearson’s x2 = 3.28, p = 0.91
rated Charlie. Table 3 shows that at the end of 2 years, the marginal adaptation of 8 restorations in NCCLs with occlusal wear facets and 5 restorations in NCCLs without occlusal wear facets were rated Charlie, with exposure of dentine. The difference was not statistically significant ( p > 0.05). There was extensive contour loss requiring replacement (USPHS, Charlie) in 4 restorations in NCCLs without occlusal wear facets, while there was none in restorations in NCCLs with occlusal wear facets. In patients that presented with dentine hypersensitivity before placement of restorations, postoperative sensitivity was registered during the first to third week after placement. Thereafter no postoperative sensitivity was reported. At the end of the follow-up period, no caries was evident contiguous with the margin of the restorations in NCCLs with and without occlusal wear facets. Table 4 shows the distribution of retention failure of composite resin restoration in NCCLs with and without occlusal wear facet after a 2-year period. There were more retention failures in mandibular teeth than in maxillary teeth. The cumulative survival of restorations in NCCLs with occlusal wear facets at the end of 1 year and 2 years was 83.6% and 46.5% respectively, while the cumulative survival of restorations in NCCLs without occlusal wear facets at the end of 1 year and 2 years was 88.4% and 61.2% respectively. The cumulative survival of restorations during the 2-year followup showed a reduced survival rate of restorations placed in NCCLs with occlusal wear facets.
4.
Discussion
The loss to follow-up (32 patients and 98 teeth) at the end of 2 years was high. This was due to non-availability of patients at
Please cite this article in press as: Oginni AO, Adeleke AA, Comparison of pattern of failure of resin composite restorations in non-carious cervical lesions with and without occlusal wear facets. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.04.003
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Fig. 1 – (a) NCCLs in teeth with generalised occlusal wear. (b) NCCLs in teeth 43 and 44 with occlusal wear facets and tooth 45 without occlusal wear facet. There is also evidence of erosion on teeth 43, 44 and 46.
recall visit attributed to failure to obtain permission from work place, and lack of funds for transportation. The patients did not drop out because they were less likely to experience restorative failure. In fact, it was assumed that the patients lost to follow up have the same prognosis as those that remained in the study.22 It is also generally observed that once the problem is solved or treatment completed, the majority of patients are complacent in attending recall visits. The result of the present study shows that about one-third (33.8%) of teeth with NCCLs presented with occlusal wear facets, this is in agreement with an earlier study.23 Occlusal wear facets was defined as loss of enamel exposing dentine, due to the contact of opposing teeth as a result of vigorous mastication of the typical African fibrous diet (Fig. 1a and b). More NCCLs were reported in the maxillary teeth than in mandibular teeth, this is in contrast to the study of Sognnaes et al. who reported a higher frequency of NCCLs in mandibular teeth.24 However, in the present study, there were more NCCLs with occlusal wear facets in mandibular teeth than in maxillary teeth, the difference was statistically significant ( p < 0.05). Also there were more retention failure of resin composite restoration in NCCLs in mandibular teeth than in maxillary teeth; this is consistent with previous studies that reported higher retention failure for the mandibular arch than the maxillary arch.25,26 These may be due to the lingual orientation of the mandibular teeth which makes them more susceptible to the concentration of tensile stresses at the cervical region.27 The weakness of mandibular teeth to withstand tensile stress may be due to their anatomically smaller cervical cross section, in particular the premolars28. A wide variety of retention rates had been reported for resin composite restorations in NCCLs, van Dijken in his study of 10
Fig. 2 – (a) NCCLs in teeth 24 and 25 (pre-operative). (b) 1 week post-operative restoration of NCCLs in teeth 24 and 25 with resin composite. (c) 2 years post-operative failure of resin composite restorations showing cervical Marginal adaptation failure in tooth 24 with occlusal wear facet.
resin composite systems, showed retention loss rates between 15 and 25% in five systems, while the other five showed loss rates between 40 and 80%.29 Another study reported a retention rate of 65% of resin composite material at 18 months evaluation.26 In the current study, the retention rate for resin composite restoration in NCCLs with and without occlusal wear facets was 63.9% and 74.4% respectively. These compare favourably well with the findings of van Dijken29 and Neo et al.30 However, a lower failure rate of 11–14% had also been reported in 24 months evaluation of resin-based materials.31 van Dijken and Pallesen in another study, reported increasing overall relative cumulative loss rate of 0.8%, 6.9% and 23% at 6
Please cite this article in press as: Oginni AO, Adeleke AA, Comparison of pattern of failure of resin composite restorations in non-carious cervical lesions with and without occlusal wear facets. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.04.003
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and 18 months and 7 years respectively.32 The causes of restoration dislodgement from NCCLs have been variously ascribed to tooth flexure,33 a high viscosity and perhaps a high modulus of elasticity of the restorative material.34 Hence the seemingly high loss rate in the present study in which hybrid resin with a high modulus of elasticity was used. Also the higher loss rate of restorations in NCCLs with occlusal wear facets may support the role of occlusal stress and tooth flexure as a cause of failure of restorations in NCCLs. Factors other than the restorative material and occlusal loading/stress, that may significantly influence the clinical performance of cervical restorations include sclerotic dentine, location of lesion, lesion size and shape, absence of enamel bevel.33,35 Although several adhesives including one-step adhesives,36 self-etch and conventional adhesives (etch and rinse) with multiple application steps have been used for treatment of NCCLs, there is no enough evidence to support one adhesive or bonding strategy over another for treatment of NCCLs.37 Clinical studies have shown that restorations of NCCLs have inadequate retention rates with higher percentages of failure despite the improvement in bond strength of adhesive resins to dentine.38,39 Therefore, to improve the clinical longevity of cervical restorations, modified or unmodified preparations, enamel bevels have been suggested, especially when nonaxial occlusal force cannot be reduced or eliminated.34,40 One of the early clinical signs that resin composite restoration is prone to failure is marginal discolouration. Its incidence has been reported to increase over time.20 In the current study, more marginal discolouration was observed in restorations in NCCLs with occlusal wear facets. Also more of the restorations in NCCLs with occlusal wear facets had marginal defects that exposed the dentine (Charlie) Table 3. Although the differences were not statistically significant, it may be that tooth flexure resulting from occlusal loading have contributed to localised defects in marginal integrity Fig. 2a,b and c. The decline in rating (Alpha to Bravo to Charlie) in respect to marginal discolouration and adaptation is probably due to no marginal bevel, and or to small fracture of the cavosurface margin and material due to stress from polymerization shrinkage. Several studies41 have indicated the relationship between marginal discolouration and marginal adaptation. Marginal stains were always detected in combination with small marginal defects. However, not all marginal defects resulted in marginal discoloration.41 The extensive contour loss in 4 restorations in NCCLs without occlusal wear facets signifies poor wear resistance of resin composite and may be explained by the location of this restorations combined with the effect of tooth brushing.
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Please cite this article in press as: Oginni AO, Adeleke AA, Comparison of pattern of failure of resin composite restorations in non-carious cervical lesions with and without occlusal wear facets. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.04.003
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