Ó

Operative Dentistry, 2018, 43-4, E191-E209

Do Nanofilled/Nanohybrid
Composites Allow for Better Clinical
Performance of Direct Restorations
Than Traditional Microhybrid
Composites? A Systematic Review
D Angerame  M De Biasi

Clinical Relevance
The effectiveness of direct restorations performed with nanofilled/nanohybrid composites
was similar to that obtainable with traditional microhybrid composites. The weight of the
available evidence supports the free choice in the clinical setting between these two classes
of restorative materials.

SUMMARY and the Cochrane Library. The present review

This systematic review was carried out to selected only randomized controlled trials
assess the clinical effectiveness of nanofilled comparing the clinical performance of a nano-
and nanohybrid composites used for direct filled or nanohybrid composite for direct res-
restorations in comparison with microhybrid torations with that of a microhybrid compos-
composites. The guidelines for the preferred ite. The research found 201 studies. Twenty-
reporting items for systematic reviews and one articles fulfilled the criteria of the present
meta-analyses were followed. A search of arti- review. However, the included studies were
cles published from July 1996 to February 2017 characterized by great methodological diver-
was performed in PubMed, SciVerse Scopus, sities. As a general trend, nanofilled and nano-
Latin American and Caribbean Health Scienc- hybrid composites were found to be capable of
es, the Scientific Electronic Library Online, clinical performance, marginal quality, and
resistance to wear similar to that of traditional
Daniele Angerame, MD, DDS, University Clinical Depart- composites without showing improved surface
ment of Medical, Surgical and Health Sciences, University of
characteristics. The risk of bias of included
Trieste, Trieste, Italy
studies was judged unclear or high. The clin-
*Matteo De Biasi, DDS, MS, PhD, University Clinical
ical performance of nanofilled/nanohybrid
Department of Medical, Surgical and Health Sciences,
University of Trieste, Trieste, Italy composites was found to be comparable to that
of traditional composites in the posterior area.
*Corresponding author: Piazza Ospedale 1, Trieste, I-34125
Italy; e-mail: [email protected]
The data concerning anterior and cervical
restorations were insufficient. With regard to
DOI: 10.2341/17-212-L
the esthetic properties, there is a compelling
E192 Operative Dentistry

need for studies on anterior teeth in which the parisons among materials or findings of different
operators are kept unaware of the restorative studies are frequently impeded by differences in the
material. Nanofilled/nanohybrid composites materials being tested, as well as in the qualitative
seem to be a valid alternative to traditional and quantitative assessment methods of surface
microhybrid composites, and at the moment, characteristics. In light of the aforementioned
there is low-level evidence attesting a lack of drawbacks, the reliability of the clinical implications
their superiority. deriving from the information gathered in in vitro
studies might be questionable.
INTRODUCTION To delineate evidence-based guidelines for the
Among the several resin-based materials used for update and the practice of the clinician involved in
direct dental restorations, manufacturers offer a restorative dentistry,12,13 the aim of this systematic
wide array of composites suitable for anterior and review was to assess the effectiveness of nanofilled
posterior teeth. These materials greatly differ from and nanohybrid composite resins by selecting ran-
each other in terms of characteristics of their domized clinical trials (RCTs) that compare these
inorganic filler, which is known to influence the materials with traditional composite resins in the
viscosity and handling of the material,1 as well as its middle and long term. The primary outcome mea-
physical properties,2,3 hence affecting the clinical sure was the annual failure rate (AFR). The
performance of the restoration.4,5 The composite secondary outcome measures were the United States
strength is maximized when a substantial amount Public Health Service (USPHS) criteria for Clinical
of evenly dispersed filler particles is embedded in the Evaluation of Restorations scores, the marginal
resin matrix.6 Even if in a manner that lacks quality, and the resistance to surface wear.
consistency in the plethora of dental literature, The present review followed the criteria of the
resin-based composites are usually classified accord- Preferred Reporting Items for Systematic Reviews
ing to their filler characteristics, such as chemical and Meta-Analyses, the PRISMA statement (http://
composition, shape, and especially particle size.7 prisma-statement.org/).14
By following the general belief that composites
with smaller filler particles prevent the wear of the METHODS AND MATERIALS
resin matrix and minimize the surface alteration Search Methods for Identification of Studies
deriving from the particles’ detachment,8 several
new filler formulations have been proposed. Specif- Each phase of the review was carried out by two
ically, the evolution of filler has recently turned to calibrated reviewers acting independently, who
the fabrication of nanofilled and nanohybrid com- discussed the cases of disagreement to reach a
posites, which are regarded as the state of the art in consensual decision.
terms of filler formulation.7 The size of the filler is The inclusion criteria chosen to consider the trials
surely one of the main determining factors for the for the present review are RCTs considering patients
most clinically relevant surface properties, such as who received direct tooth restoration with a nano-
smoothness and gloss.9,10 filled/nanohybrid composite compared with a tradi-
Despite the endeavor of the manufacturers that tional one. The following databases were searched for
produce nanofilled and nanohybrid composites to relevant studies: PubMed, SciVerse Scopus, Latin
grant better initial surface smoothness and provide American and Caribbean Health Sciences (LILACS),
superior gloss retention, doubt still remains as to The Scientific Electronic Library Online (SciELO),
whether the clinician should prefer these new- and the Cochrane Library. Records from July 1996 to
generation materials over traditional universal February 2017 were included. There was no restric-
microhybrid composites.11 A systematic review of in tion in terms of language. The details of the database
vitro studies assessing the difference in surface consultation process are reported in Table 1.
characteristics between composites with nano- or Additional manual research of eligible articles was
submicron-sized fillers and conventional composites carried out by searching 1) related citations of
concluded that, currently, there is insufficient selected articles via the PubMed dedicated function,
evidence attesting the superiority of nanofilled or 2) the references of the included articles, and 3) the
submicron materials in terms of surface smoothness articles published during the past 10 years in the
and gloss.11 However, laboratory investigations are following scientific journals, which were regarded
very abundant in the literature, and this inevitably authoritative because of the topics they treat and
implies huge methodological variability. The com- their impact factor: Journal of Dental Research,
Angerame & De Biasi: Clinical Effectiveness of Nanocomposites E193

Table 1: Research Algorithms Used for Each Electronic Database

Database Web Address Algorithm
PubMed http://www.ncbi.nlm.nih.gov ((((nanocomposite) OR nanofilled) OR nanohybrid) OR submicron) AND clinical trial
SciVerse Scopus http://www.scopus.com (TITLE-ABS-KEY(((nanocomposite) OR (nanofilled) OR (nanohybrid) OR (submicron))
AND (clinical trial)))
LILACS http://lilacs.bvsalud.org/en (nanocomposite or nanofilled or nanohybrid or submicron) AND (clinical trial)
SciELO http://www.scielo.org (nanocomposite or nanofilled or nanohybrid or submicron) AND (clinical trial)
Cochrane Library http://www.thecochranelibrary.com (nanocomposite or nanofilled or nanohybrid or submicron) AND (clinical trial)

Dental Materials, Journal of Dentistry, and Clinical and nanofilled/nanohybrid composites, the normal-
Oral Investigations. ized failure index (NFI)15 was calculated according
to the formula
Study Selection Pn
ðAFRi  evaluated restorationsi Þ
The duplicated records were removed. Then, the two NFI ¼ i Pn
reviewers simultaneously and independently read i evaluated restorationsi
the title and abstract of the identified articles to
select the articles meeting all these criteria: where n is the number of included studies. NFI
calculation was performed distinguishing between
 Is it an RCT? the following categories: anterior, posterior, or
 Does it involve the assessment of direct restorations cervical restoration and traditional or nanofilled/
with nanofilled and/or nanohybrid composites? nanohybrid composite. If the same research was
 Are the failure rate, the USPHS criteria, and the identified in distinguished papers, the paper with
marginal quality or the surface wear evaluated and the longest follow-up period was considered for the
reported at the end of the follow-up period? calculation.

A restoration was deemed a failure according to The continuous secondary outcomes were summa-
the criteria adopted in the trials. rized calculating the mean values and 95% confi-
dence intervals.
To proceed to the screening of eligible articles, the
full text was retrieved if all the criteria were met by If the text of the article reported incomplete
the article or if the reviewers could not extrapolate information about the data of interest, the corre-
sufficient information from the title and abstract. sponding author was contacted via e-mail and asked
to provide the missing data, as e-mail has been
Data Extraction described as the written method that requires the
fewer numbers of attempts and the shortest time to
The two reviewers independently filled out a previ-
obtain unpublished content.16 To deal with non-
ously designed spreadsheet to perform data extraction.
replying authors, a reminder was sent after two
From the selected studies, the two reviewers extracted
the following information: study design, length of weeks. In the case of failure to get in touch with the
follow-up, restoration type, outcome of interest, type of corresponding author, the data were considered not
analysis, characteristics of the sample, operator(s) reported.
performing the interventions, field isolation tech-
nique, marginal preparation, lining technique, defini- Quality Assessment
tion of groups and restorative materials, adhesive For the quality assessment of included RCTs, the
strategy, polishing protocol, and final recall rate. two reviewers made use of the Cochrane risk of bias
For each experimental group, the AFR of the tool. The following criteria were taken into consid-
restorations was calculated according to the follow- eration:
ing formula:
1. Random sequence generation (protection against
f ailed restorations selection bias)
AFR ¼
evaluated restorations  years of f ollow  up a. Criterion ‘‘met’’: the method used to generate
the allocation sequence is described in suffi-
Moreover, to combine the data of the included cient detail to allow an assessment of whether
studies and compare the failure rate of traditional it should produce comparable groups.
E194 Operative Dentistry

b. Criterion ‘‘unclear’’: such information is not that are taken into account in the review have
reported. been reported in a prespecified way; if the
c. Criterion ‘‘unmet’’: the method used to gener- study protocol is not available, the published
ate the allocation sequence is not described or reports include all expected outcomes.
inadequate to produce comparable groups. b. Criterion ‘‘unclear’’: such information is not
2. Allocation concealment (protection against selec- reported.
tion bias) c. Criterion ‘‘unmet’’: not all of the prespecified
a. Criterion ‘‘met’’: patients’ recruitment and primary outcomes of the study have been
assignment were randomized, and the re- reported; one or more primary outcomes are
searcher recruiting participants was unaware reported but were not prespecified or are
of the allocation sequence, which was con- reported using measurements, methods, or
cealed before and until assignment. subsets of the data that were not prespecified.
b. Criterion ‘‘unclear’’: such information is not 7. Protection against other bias.
reported. a. Criterion ‘‘met’’: the study appears to be free of
c. Criterion ‘‘unmet’’: the allocation schedule was other sources of bias.
not kept concealed to the researcher recruiting b. Criterion ‘‘unclear’’: insufficient information to
participants. assess whether an identified problem will
3. Blinding of participants and personnel (protec- introduce bias.
tion against performance bias) c. Criterion ‘‘unmet’’: there is a potential source
a. Criterion ‘‘met’’: the participants and the of bias related to the specific study design
personnel involved in the study were kept used, or the study stopped early due to some
blind; alternatively, the impossibility of blind- data-dependent process or has been claimed to
ing was deemed noninfluential to determine have been fraudulent.
bias.
The validity of the studies was established by
b. Criterion ‘‘unclear’’: such information is not
classifying each one as follows:
reported.
c. Criterion ‘‘unmet’’: the participants and the
1. Low risk of bias: all of the criteria met
personnel involved in the study were not kept
2. Moderate risk of bias: one or more criteria
blind.
unclear; the others met
4. Blinding of outcome assessment (protection
3. High risk of bias: one or more criteria unmet
against detection bias)
a. Criterion ‘‘met’’: the researcher assessing the Other methodological aspects were taken into
treatment outcomes was kept blind. consideration and analyzed, namely, the description
b. Criterion ‘‘unclear’’: such information is not of sample size calculation (if present) and the clarity
reported. of inclusion and exclusion criteria.
c. Criterion ‘‘unmet’’: the researcher was not
blind to the outcomes. RESULTS
5. Incomplete outcome data (protection against Literature Search
attrition bias)
a. Criterion ‘‘met’’: no dropouts or withdrawals The search found 201 studies; the review of the title
took place, and all outcome data are reported. and abstract caused the exclusion of 173 of them, as
Alternatively, missing outcome data are even- shown in Figure 1. Full-text articles were obtained
ly distributed among groups and missing for for the remaining 28, which were all in English.
similar reasons. Seven articles were discarded because they did not
b. Criterion ‘‘unclear’’: such information is not fulfil the inclusion criteria of the present review.
reported. Two studies with the same first author17,18 were
c. Criterion ‘‘unmet’’: relevant outcome data are excluded from the review because the authors
not reported and/or missing data are imbal- assessed direct and indirect restorations but did
anced in either number or reasons among not make use of a control group with a direct
groups. traditional restorative material for the comparison
6. Selective reporting (protection against reporting with nanofilled/nanohybrid composites. Two studies
bias) were excluded because they did not consider a
a. Criterion ‘‘met’’: the study protocol is available, control group with a microhybrid composite: in the
and all of the primary and secondary outcomes study of Karaman and others,19 the authors com-
Angerame & De Biasi: Clinical Effectiveness of Nanocomposites E195

Figure 1. Flow diagram of study

inclusion.

pared a nanofilled composite with a flowable nano- are subsequent reports of the same trial. Despite little
filled composite, without further control groups; the differences in the determination of groups, all of the
study of Türkün and Celik20 used a polyacid included articles had a split-mouth design.
modified resin composite (Dyract eXtra, Dentsply,
York, PA, USA) as sole control. Three other studies Evaluation Criteria in the Selected Studies
were not randomized.21-23
RCTs appraising the clinical performance of nano-
As the selected studies were heterogeneous in filled or nanohybrid composite restorations as pri-
terms of several methodological variables and they mary objective were the clear majority of included
considered different clinical criteria for analysis, a studies.24-32 Clinical evaluation of restored teeth was
meta-analysis was not feasible. consistently carried out according to one of the
modified versions of the USPHS criteria. Given the
Study Characteristics intrinsic variation among the different versions and
The data sets arranged in Tables 2, 3, and 4 describe in the interpretability of the scores, the concept of
detail the information obtained from the included failure of a restoration was not uniformly shared
studies regarding the primary and secondary out- among the included articles. The attribution of
comes of the present review on anterior, posterior, and Charlie or Delta scores corresponded to the most
cervical restorations, respectively. The oldest study common and consistent events that caused a resto-
was published in 2006 and the most recent one in ration to be classified as failures, such as lack of
2015. The nationality of the patients involved in the retention, secondary decay, bulk restoration frac-
trials and most of the authors were Brazilian (six ture, restoration fracture with exposed dentin, and
articles, three trials), German (six articles, two trials), pain. Restorations scored as Bravo according to the
Belgian (four articles, two trials), Swedish (two USPHS criteria were considered functional and,
articles, one trial), Chinese (one article, one trial), thus, not failed.
Turkish (one article, one trial), and Iranian (one In other articles, the researchers performed
article, one trial). As expected, there was a remarkable indirect analyses on positive replicas of the restored
variety of materials, techniques, and combination of teeth. Some of them focused on the assessment of
them across studies. Several of the examined articles marginal quality via scanning electron microsco-
E196 Operative Dentistry

Table 2: Characteristics of the Included Study on Anterior Restorations

Author Population and Outcome of Intervention Polishing Comparison Conclusions Quality
and Year Follow-up Interest and Protocol Assessment
Duration Type of
Analysis
Loguercio, 38 Brazilian Clinical Class III Sof-Lex Pop- MH: Filtek Z250 Excellent No detail of the
200729 adult patients, performance restorations On disks (3M (3M ESPE), 38 immediate and randomization
114 maxillary assessed by Two instructed ESPE) restorations 12-mo color procedure. Quote:
anterior teeth clinical experienced NF: Filtek match of the ‘‘The resin
followed up for evaluation and dentists Supreme (3M microhybrid composite used in
one year USPHS criteria Rubber dam ESPE), 38 composite resin, each cavity was
Bevelled buccal restorations which was randomly selected
enamel of the Microfilled: superior to the before the
cavosurface Durafill VS nanofilled and beginning of the
margins (Heraeus microfilled restorative
Lining with Kulzer), 38 composites procedure.’’
calcium restorations tested It is not specified
hydroxide AS: Clearfil SE whether the
(Dycal, Bond (Kuraray) patients were aware
Dentsply) and/or with or without of the materials
glass ionomer enamel etching used for each tooth.
cement in all groups The operators
(Vitrebond, 3M performing the
ESPE, St. Paul, restorations were
MN, USA) not blind.
The outcome data
obtained with the
two different
adhesive protocols
(with or without
enamel etching) is
unclearly and
insufficiently
reported.
Abbreviations: AS, adhesive system; MH, microhybrid; NF, nanofilled; USPHS, United States Public Health Service.

py.33,34 Another research group took into consider- nanohybrid composites was 0.91. With respect to
ation in different articles the evaluation of the cervical restorations of Class V noncarious lesions,
occlusal wear of Class I and II restorations, by only one study was included in the present review30;
three-dimensional laser scanning positive gypsum the NFI for traditional and nanofilled/nanohybrid
replicas and observing them with scanning electron composites was 0 and 2.68, respectively. A summary
microscopy for the analysis of microwear pat- of the most relevant findings of each included study is
terns.35,36 reported below.
The research group of de Andrade and coworkers
Main Findings From the Selected Studies published four articles24,33,37,38 on their 54-month
Table 5 reports the mean AFRs, the failure indices trial, designed to compare the clinical effectiveness
(number of evaluated restorations 3 AFR), and the of Class I restorations made either with a nanofilled
NFI calculated from the included studies. The data for or a nanohybrid composite, using a microhybrid
all the included studies were combined, distinguishing composite control group. Their sample was consti-
between anterior, posterior, and cervical restorations. tuted of 41 adolescent patients in a state of poverty.
There was only one study29 comparing the clinical In synthesis, all of the investigated materials led to
performance on anterior teeth of traditional and acceptable clinical performance, even if the authors
nanofilled/nanohybrid composites over a period of one reported a trend of better surface smoothness
year; the NFI for the former was calculated to be 0, associated with the tested nanofilled composite.
with the corresponding value for the latter being 5.26. The two-year trial by Arhun and others25 was
A larger amount of longer-lasting studies (1 to 10 years designed to compare the clinical performance of
of follow-up)24-28,31,32,35,36 performed the same compar- posterior restorations with a low-shrinkage micro-
ison in the posterior area. The NFI for traditional hybrid composite with a nanohybrid one in 31 adult
composites was equal to 1.20, while that of nanofilled/ patients. The two materials demonstrated similar
Angerame & De Biasi: Clinical Effectiveness of Nanocomposites E197

and acceptable clinical performance. The authors of the present review. These two sets of coupled-
observed increased surface texture deterioration on articles report the findings at subsequent time points
the nanohybrid composite restorations. of two distinct trials with a similar setup. The first
Dresch and coworkers26 published an article on two articles35,42 compared the clinical performance
the comparison among four materials (a nanofilled, a and, more specifically, the surface wear of a micro-
nanohybrid, a packable, and a microhybrid compos- hybrid and a nanofilled composite used for the
ite) used for Class I and II restorations in 37 dental restoration of teeth in the posterior area. Sixteen
students. Presenting recall and success rates of dental students were involved in the study as
100%, the authors found no difference among patients. The researchers carried out the measure-
materials. Several methodological characteristics of ment of surface wear by taking precision impressions
the study raise questions about the reliability of the of the area of interest of the restored teeth and laser
data in the article, since clarity and rigor were often scanning the positive gypsum replicas. The compar-
isons made after three and five years led to the
lacking, especially in the description of the enroll-
conclusion that vertical loss in height and volume
ment phase.
loss on the restoration surface in the nanofilled
In the two-year trial by Ernst and others,27 the group were not significantly different from the
clinical performance of a nanofilled composite was microhybrid group. The latter two publications,36,43
compared with that of a microhybrid composite for which were conducted with similar aim and meth-
the restoration of Class II cavities. By comparing the odology, report the three-year and five-year wear
outcome of 112 restorations placed by six different data registered on restorations performed with other
dentists in 50 adult patients, the authors concluded materials, namely, a microhybrid, a traditional
that both restorative materials showed acceptable hybrid, and a nanohybrid. The authors concluded
clinical performance (98% success rate) without that the wear resistance of the three tested materials
observing differences between them. complies with American Dental Association specifi-
A German research group presented in five cation minimum requirements for posterior compos-
different papers28,34,39-41 the findings of a trial ite restorations (vertical loss ,50 lm/y) and that the
investigating the clinical performance of a micro- nanohybrid composite Tetric EvoCeram showed
hybrid and a nanofilled composite after 2, 4, 6, 8, and significantly lower volume loss than the other two
10 years. A private practitioner placed 68 Class II materials.
composite restorations in 30 adult patients. At each In the study by Qin and others,30 116 cervical
reevaluation time point, including the last 10-year noncarious lesions on anterior and premolar teeth
recall of 29 of the 30 involved patients, there were no belonging to 46 adult patients were restored either
differences in the success rate of all restorations with a microhybrid or a nanofilled composite and
between the two tested materials, with an overall followed up for two years. The authors found that the
success rate equal to 96.9%. The only reported restorations performed with both investigated mate-
differences in clinical performance between the rials demonstrated acceptable clinical effectiveness
control microhybrid composite and the nanofilled in noncarious cervical lesions without significant
composite concerned the worse surface smoothness differences in their clinical performance.
and color match of the latter (Grandio, Voco GmbH,
The 18-month trial by Sadeghi and others31
Indian Land, SC, USA).
compared the clinical performance of Class I resto-
Loguercio and others29 published the only study rations received by 35 dental and oral hygiene
presenting outcomes that are of interest in the students. For each patient, a single operator per-
present review specifically focused on anterior teeth. formed one restoration per material type: micro-
The authors evaluated the clinical performance of a hybrid, packable, and nanofilled composite. All
microhybrid, a nanofilled, and a microfilled compos- materials showed acceptable clinical performance,
ite for the restoration of Class III defects in with 94%-97% success rates; the differences among
maxillary anterior teeth. Even if after one year of materials were not significant.
clinical service high success rates were recorded in In two different publications reporting the findings
all groups (95%-100%), the authors reported better of the same trial enrolling 52 patients,32,44 van Dijken
scores for the item ‘‘color match’’ in the microhybrid and Pallesen tested the clinical performance of a
composite group, compared with the other two. microhybrid and a nanohybrid composite used in Class
The research group of Palaniappan and others II restorations. This 10-year trial reported a remark-
produced four articles that met the inclusion criteria ably high recall rate (93%). With a success rate higher
E198 Operative Dentistry

Table 3: Characteristics of the Included Studies on Posterior Restorations

Author and Population and Outcome of Intervention Polishing Protocol
Year Follow-up Interest and
Duration Type of
Analysis
de Andrade, 41 destitute Clinical Class I restorations Multi-bladed bur
201424 Brazilian performance One operator (FG7714F, KG Sorensen,
adolescent assessed by ‘‘absolute isolation of the Cotia, Brazil), rubber cups
students, 123 clinical operative field’’ and points (FlexiCups and
permanent evaluation and Cavities prepared with FlexiPoints, Cosmedent
molars followed USPHS criteria carbide burs, no details on Inc, Chicago, IL, USA),
up for 4.5 y margin characteristics Enamelize Polishing Paste
Lining with glass ionomer (Cosmedent Inc), diamond
cement (Vitrebond, 3M felt disk (FGM Produtos
ESPE) in deep cavities Odontologicos, Joinville,
Brazil)
Arhun, 31 Turkish Clinical Class I and II restorations Fine and super fine
201025 patients, 82 performance One clinician of the diamond points (KG
posterior teeth assessed by research team Finishing Kit, Karensen
followed up for 2 clinical Cotton rolls and saliva Ltd) and rubber polishing
years evaluation and ejectors kits (Eveflex Polisher, EVE
USPHS criteria No bevelling Ernst Vetter GmbH)
Lining with calcium
hydroxide (Dycal, Dentsply
Caulk) for deep cavities

Dresch, 37 Brazilian Clinical Class I and II restorations Fine-grit diamond burs

200626 dental students performance Two calibrated operators (KG Sorensen) and
(42 according to assessed by Rubber dam aluminium oxide polishing
the abstract), clinical Cavities prepared with paste (Kerr, Orange, CA,
148 permanent evaluation and stainless steel burs, no USA) in rubber cups on
molars followed USPHS criteria details on margin the occlusal surfaces
up for one year characteristics
Lining with calcium
hydroxide (Dycal,
Dentsply) and/or glass
ionomer cement
(Vitrebond, 3M ESPE)

Ernst, 200627 50 German adult Clinical Class II restorations Flexible discs (Soflex, 3M
patients, 112 performance Six experienced dentists ESPE), Enhance polishing
posterior teeth assessed by placing approximately the tips (Dentsply DeTrey),
followed up for clinical same number of and polishing brushes
two years evaluation and restorations (Soflex Brush, 3M ESPE)
USPHS criteria Rubber dam
Margins, quote: ‘‘Occlusal
and lateral enamel
margins and cervical
cementum margins
received no bevel
preparations, except for
cervical enamel margins if
enough enamel was left.’’
No lining
Angerame & De Biasi: Clinical Effectiveness of Nanocomposites E199

Table 3: Extended.
Author and Comparison Conclusions Quality Assessment
Year

de Andrade, MH: Filtek Z250 (3M The three tested materials The methods of the randomization procedure are not described.
201424 ESPE), 41 restorations showed similar and Unclear allocation concealment. Quote: ‘‘To ensure randomness, a
NF: Filtek Z350 (3M acceptable clinical drawing was held using sealed envelopes, to establish in which
ESPE), 41 restorations performance in Class I group a certain tooth would be placed.’’ The details of the draw are
NH: Esthet-X (Dentsply restorations after 12 mo of missing (use of a random sequence, sequential numbered
Caulk), 41 restorations clinical service. envelopes, assignment procedure, etc).
AS: Adper Single Bond 2 The patients were unaware of the restorative material used for
(3M ESPE) in all groups each tooth. The operator performing the restorations was not
blinded.

Arhun, Low-shrinkage MH: Quixfil Nanohybrid and low- Not properly randomized. Quote: ‘‘Interference in the randomization
201025 (Dentsply Caulk), 41 shrinkage posterior procedure within patients was performed to equally distribute
restorations; AS: Xeno III composite restorations materials into some important variables.’’
(Dentsply Caulk) demonstrated similar and Quote: ‘‘The distribution of materials and tooth locations were
NH: Grandio (Voco acceptable clinical randomly determined by tossing a coin.’’ In trials with relatively
GmbH), 41 restorations; performance after two small samples, simple randomization often results in an allocation
AS: Futurabond NR (Voco years. Increased surface sequence leading to groups that differ, by chance, substantially.
GmbH) texture deterioration in The patients were unaware of the restorative material used for
nanohybrid composite each tooth. The operator performing the restorations was not
restorations. blinded.
The authors did not report the reasons for the patients lost to
follow-up.
The statistical unit of the study is unclear, since some patients
participated with more than one couple of restorations.
Dresch, NF: Filtek Supreme (3M Excellent one-year clinical Not properly randomized. Quote: ‘‘Interference in the randomization
200626 ESPE), 37 restorations; performance and no procedure within patients was performed to equally distribute
AS: Single Bond (3M significant difference materials into some important variables.’’ The randomization is not
ESPE) among materials meant to be adjusted by the researchers.
Packable composite: Quote: ‘‘Randomization of the materials was performed on each
Pyramid (Bisco), 37 patient by tossing a coin.’’ In trials with relatively small samples
restorations; AS: One Step and with more than two groups, simple randomization often results
Plus (BISCO) in an allocation sequence leading to groups that differ, by chance,
NH: Esthet-X (Dentsply substantially.
DeTrey), 37 restorations; Not mentioned whether the patients or the operator were aware of
AS: Prime & Bond NT the composite type used for each restoration.
(Dentsply DeTrey) It is not specified in the materials and methods section how many
MH:Tetric Ceram (Ivoclar patients were enrolled, so we have no information on withdrawals/
Vivadent), 37 restorations; dropouts.
AS: Excite (Ivoclar The study design is unclear and contradictory: the study enrolled
Vivadent) patients requiring at least five Class V restorations, but the authors
declare also that 148 restorations were placed in 37 patients (148/
37 = 4).
Ernst, 200627 MH: Tetric Ceram Both restorative materials The allocation sequence was not prepared before the start of the
(Ivoclar), 56 restorations investigated showed trial. The researchers tossed a coin just before performing each
NF: Filtek Supreme (3M acceptable clinical pair of restorations to decide the cavity to start with and then the
ESPE), 56 restorations performance; no significant restorative material.
AS: Scotchbond 1 (3M differences were observed The operators performing the restorations and the patients were
ESPE) in all groups between both types of not blinded.
dental composites.
E200 Operative Dentistry

Table 3: Continued.
Author and Population and Outcome of Intervention Polishing Protocol
Year Follow-up Interest and
Duration Type of
Analysis
Krämer, 30 German adult Clinical Class II restorations Super-fine discs (3M
201528 patients, 68 performance One dentist in a private ESPE), polishing brushes
posterior teeth assessed by practice (Hawe-Neos Dental), and
followed up for clinical Rubber dam a fluoride varnish (Elmex
10 y evaluation and Cavities finished with a 25- Fluid)
USPHS criteria lm diamond bur and not
bevelled
No lining

Palaniappan, 16 Belgian Resistance to Class I and II restorations Diamond composite

201135 dental student wear assessed Two dentists finishing kit (Komet) and
volunteers, 37 by 3D laser Rubber dam Sof-Lex (3M ESPE)
molar teeth scanning and Enamel margins bevelled finishing and polishing set
followed up for scanning with diamond-coated bevel
five years electron tips (Sonic-Sys, KaVo
microscopy Company, Orange, CA,
analysis of USA)
positive replicas Lining with glass ionomer
of restored teeth cement (Vitrebond, 3M
ESPE) to cover
preparations closer than
0.5 mm to the pulp

Palaniappan, 15 Belgian Resistance to Class I and II restorations Sof-Lex discs and strips
201236 dental student wear assessed Two dentists (3M ESPE), polishing kit
volunteers, 49 by 3D laser Rubber dam (Komet, Rock Hill, SC,
molar teeth scanning and Enamel margins bevelled USA), Prisma gloss paste
followed up for scanning with diamond-coated bevel on polishing cup
five years electron tips (Sonic-Sys, KaVo (Dentsply), and Prisma
microscopy Company) gloss extra-fine paste on
analysis of Lining with glass ionomer polishing cup (Dentsply).
positive replicas cement (Vitrebond, 3M
of restored teeth ESPE) to cover
preparations closer than
0.5 mm to the pulp

Sadeghi, 35 Iranian dental Clinical Class I restorations Microfine diamond

201031 and oral hygiene performance One operator finishing burs for
students, 105 assessed by Cotton rolls contouring and removal of
permanent clinical No enamel bevel excess restorative
molars followed evaluation and No lining material, followed by
up for 1.5 y USPHS criteria abrasive aluminium oxide
disks
Angerame & De Biasi: Clinical Effectiveness of Nanocomposites E201

Table 3: Continued. Extended.

Author and Comparison Conclusions Quality Assessment
Year

Krämer, MH: Filtek Z250 (3M After 10 y, Grandio No detail of the randomization procedure is reported. Quote:
201528 ESPE), 32 restorations; showed worse surface ‘‘fillings to be replaced in different quadrants received at least two
AS: Adper Single Bond 2 smoothness and color different restorations in a random decision’’
(3M ESPE) match. Allocation concealment not mentioned. After contacting the
NF: Grandio (Voco authors, they stated that they made used of envelopes without
GmbH), 36 restorations; providing further details.
AS: Solobond M (Voco It is not specified whether the patients were aware of the materials
GmbH) used for each tooth. The operator performing the restorations was
not blind.
Palaniappan, MH: Z100 (3M ESPE), 19 Vertical loss in height and The patients were unaware of the materials used for each tooth.
201135 restorations volume loss on the The operators performing the restorations were not blind.
NF: Filtek Supreme (3M restoration surface in the
ESPE), 18 restorations nanofilled group was not
AS: Scotchbond Adhesive significantly different from
(3M ESPE) in all groups the microhybrid group at
the five-year recall.
Generalized vertical loss
(mean; 95% CI): MH,
0.870 lm/mo [0.830;
0.910]; NF, 0.925 lm/mo
[0.887; 0.963]
Generalized volume loss
(mean; 95% CI): MH,
0.014 mm3/mo [0.014;
0.014]; NF, 0.011 mm3/mo
[0.010; 0.011]
Palaniappan, MH: Gradia Direct The wear resistance of the The filling materials were randomized over cavity groups in an
201236 Posterior (GC), 16 three materials complies unspecified way. After contacting the authors, they stated that they
restorations; AS: UniFil with ADA specification of performed a block randomization.
Bond (GC) minimum requirements for No details on allocation concealment.
Traditional hybrid: Tetric posterior composite The patients were unaware of the materials used for each tooth.
Ceram (Ivoclar), 16 restorations: vertical loss The operators performing the restorations were not blind.
restorations; AS: AdheSe (,50 lm/y). Tetric It is not specified if the personnel involved in the wear analysis is
(Ivoclar) EvoCeram (NH) showed aware of the materials used for each tooth. After contacting the
NH: Tetric EvoCeram significantly lower volume authors, they stated that the evaluator was kept blind.
(Ivoclar), 17 restorations; loss than the other two
AS: AdheSe (Ivoclar) materials.
Generalized vertical loss
(mean; 95% CI): MH,
1.830 lm/mo [1.777;
1.883]; traditional hybrid,
1.411 lm/mo [1.364;
1.458]; NH, 1.401 lm/mo
[1.369; 1.433]
Generalized volume loss
(mean; 95% CI): MH,
0.018 mm3/mo [0.017;
0.019]; traditional hybrid,
0.017 mm3/mo [0.016;
0.017]; NH, 0.011 mm3/mo
[0.010; 0.012]
Sadeghi, MH: Point 4 (Kerr), 35 Acceptable clinical No detail of the randomization procedure is reported. Quote:
201031 restorations performance, no significant ‘‘Three cavities of each patient were randomly restored with three
Packable composite: difference among types of light-cured resin composites.’’
Packable Premise (Kerr), materials No details on allocation concealment.
35 restorations It is not specified whether the operators were aware of the
NF: Nanofilled Premise materials used for each tooth. The patients were kept blind.
(Kerr) All the restorations are performed in a single increment, but this is
AS: OptiBond Solo Plus usually not advisable except in the case of extremely small cavities
(Kerr) in all groups filled with low-shrinkage composites.
E202 Operative Dentistry

Table 3: Continued.
Author and Population and Outcome of Intervention Polishing Protocol
Year Follow-up Interest and
Duration Type of
Analysis
van Dijken, 52 Swedish Clinical Class II restorations Enhance finishing system
201432 adult patients, performance One operator (first author) (Dentsply DeTrey) or
122 posterior assessed by Cotton rolls and suction brownie points (Shofu Co)
teeth followed clinical device and proximal finishing
for 10 y evaluation and No bevels strips
USPHS criteria No lining

Abbreviations: 3D, three dimensional; ADA, American Dental Association; AS, adhesive system; CI, confidence interval; MH, microhybrid; NF, nanofilled; NH,
nanohybrid; USPHS United States Public Health Service.

than 80% in both groups, the authors concluded that DISCUSSION

the two materials did not differ in clinical performance. The present review demonstrated that there is low-
level evidence attesting the absence of differences
Risk of Bias Assessment between the clinical effectiveness of nanofilled/nano-
The item-by-item analysis of the critical points of hybrid composites and traditional microhybrid com-
the quality assessment of included studies accord- posites. Primary and secondary studies that do not
ing to the Cochrane Quality Assessment tool is provide significant differences between the treat-
reported and justified in Tables 2, 3, and 4. All the ments being compared are often labeled as negative,
included studies showed some flaws, as most of but it is known that a systematic review that does
them were judged at high risk of bias and the not find evidence of difference is very different from
remaining four at unclear risk of bias, as synthet- one that finds evidence of no difference.45 Indeed, the
findings of the present review have some clinical
ically depicted in Figures 2 and 3. More specifically,
significance, because until a sufficient number of
only a few articles27,35,36,42,43 properly described an
high-quality RCTs are conducted, filling a cavity
adequate method to generate the allocation se-
either with a traditional microhybrid composite or a
quence, judged capable of producing comparable
nanofilled/nanohybrid composite can still be left to
groups. Further, the issue of allocation concealment
the choice of the operator, who can select the
has been totally ignored by the included studies, material that better matches his or her preferences.
with none of them furnishing information about the
procedure for keeping the researcher recruiting There are, however, some reasons to exercise
participants unaware of the allocation sequence. caution when drawing conclusions from the present
review, both in consideration to its primary outcome
Also, the risk of performance bias appeared to be
(AFR) or its secondary outcomes (USPHS scores,
relevant in the included studies, because even
marginal quality, and surface wear). It is known that
though the participants involved in the trials were
heterogeneity of the data may cause problems when
often blind to the restorative material being used,
combining the results of a number of studies to
the operative personnel other than the evaluators
provide an overview, for example, with a meta-
were never kept blind to the restorative material. analysis.15 Using the NFI is an alternative way to
The included articles generally fulfilled the criteria systematically compare results obtained in hetero-
to ensure blinding of outcome assessment, selective geneous studies, which weights the sample size and
reporting, and completeness of outcome data, with the AFR of the individual studies. Nonetheless, the
the exception of two studies, in which a substantial present review included a reasonable number of
number of dropouts was observed25 or less than one- studies involving posterior restorations but very few
fourth of enrolled patients were subjected to the involving cervical and anterior restorations. In these
analysis.33 Sporadic minor sources of study-specific conditions, the mere comparison of NFI values to
methodological biases were identified and are assess the clinical effectiveness of nanofilled and
reported in the relevant sections of Tables 2, 3, nanohybrid composite resins can only be indicative
and 4. in delineating a general trend, until a larger number
Angerame & De Biasi: Clinical Effectiveness of Nanocomposites E203

Table 3: Continued. Extended.

Author and Comparison Conclusions Quality Assessment
Year

van Dijken, MH: Tetric Ceram No significant difference The restorative material was randomly chosen by casting a coin in
201432 (Ivoclar), 61 restorations between the two tested a split-mouth design. No details on allocation concealment.
NH: Tetric EvoCeram materials The patients were unaware of the restorative material used for
(Ivoclar), 61 restorations each tooth. The operator performing the restorations was not
AS: Excite (Ivoclar) in all blinded.
groups Blinding of outcome is unclear. Quote: ‘‘The restorations were
evaluated direct after placement (baseline), six months, and then
annually during the following six years by the treating dentist. At
different recalls, two calibrated dentists without knowledge of earlier
assessments evaluated part of the restorations.’’

of well-conducted RCTs becomes available and a via coin tossing, but this approach is generally not
meta-analysis feasible. Although all the trials that advisable in trials with fewer than 100 subjects per
fulfilled the inclusion criteria of the present review randomized group.46 The allocation concealment,
reported optimistic findings, with overall success which should prevent selection bias in intervention
rates ranging from 80% to 100% in relation to the assignment by protecting the allocation sequence
length of the follow-up period regardless of the before and until assignment and can always be
experimental group, none of them were judged at implemented regardless of the study,47 was never
low risk of bias. taken into account in the selected articles. In some
As to the risk of bias assessment, there were some articles, a certain tooth is assigned to a designated
criteria that were never met by the included studies. restorative material by means of a draw of enve-
The random sequence generation or the use of a lopes, but the details of the draw organization and
known random sequence is seldom described or management were not described or retrievable.
appropriate. The included studies often describe Moreover, it is known that using envelopes is more
the use of simple randomization procedures achieved susceptible to manipulation than other approach-

Table 4: Characteristics of the Included Study on Cervical Restorations

Author Population and Outcome of Intervention Polishing Comparison Conclusions Quality
and Year Follow-up Interest and Protocol Assessment
Duration Type of
Analysis
Quin, 46 Chinese Clinical Class V Not specified MH: Clearfil AP- Both the Clearfil No detail of the
201330 adult patients, performance restorations extra-fine X (Kuraray), 58 AP-X and Filtek randomization
116 teeth (not assessed by Two diamond point restorations; AS: Z350 procedure is
molars) followed clinical experienced Clearfil SE Bond restorations reported. Quote:
up for two years evaluation and dentists (Kuraray) demonstrated ‘‘Each patient
USPHS criteria Cotton rolls and NF: Filtek Z350 acceptable received at least
retraction cords (3M ESPE), 58 clinical one pair of
Quote: ‘‘The restorations; AS: effectiveness in restorations that
incisal enamel Adper Prompt noncarious were randomly
margins of the (3M ESPE) cervical lesions allocated.’’
cervical lesions without No details on
were bevelled to significant allocation
1-mm area with differences in concealment.
a diamond bur their clinical It is not
at high speed.’’ performance. specified
No lining whether the
patients or the
operators were
aware of the
materials used
for each tooth.
Abbreviations: AS, adhesive system; MH, microhybrid; NF, nanofilled; USPHS, United States Public Health Service.
E204 Operative Dentistry

Table 5: Comparison Between Failure Rate of Restoration With Traditional and Nanofilled/Nanohybrid Composites
Site Composite Study Study No. of No. of Mean Annual Failure Index Normalized
Material Duration, Evaluated Restorations Failure Rate, (No. of Restorations Failure
y Restorations Reported as % 3 Mean Annual Index
Having Failed Failure Rate)
Anterior Traditional Loguercio, 200729 1 38 0 0 0
Total 38 0 0
Nanofilled/ Loguercio, 200729 1 38 2 5.3 200.0
nanohybrid Total 38 200.0 5.26
24
Posterior Traditional de Andrade, 2014 4.5 31 2 1.4 44.4
Arhun, 201025 2 35 2 2.9 100.0
Dresch, 200626 1 37 0 0 0
Ernst, 200627 2 56 1 0.9 50.0
Krämer, 201528 10 32 1 0.3 10.0
Palaniappan, 201135 5 19 0 0 0
Palaniappan, 201236 5 16 0 0 0
Sadeghi, 201031 1.5 35 1 1.9 66.7
van Dijken, 201432 10 57 11 1.9 110.0
Total 318 381.1 1.20
Nanofilled/ de Andrade, 201424 4.5 62 3 1.1 66.7
nanohybrid Arhun, 201025 2 35 1 1.4 50.0
Dresch, 200626 1 74 0 0 0
Ernst, 200627 2 56 1 0.9 50.0
Krämer, 201528 10 36 1 0.3 10.0
Palaniappan, 201135 5 18 0 0 0
Palaniappan, 201236 5 17 0 0 0
Sadeghi, 201031 1.5 35 1 1.9 66.7
van Dijken, 201432 10 57 11 1.9 110
Total 390 353.4 0.91
Cervical Traditional Qin, 201330 2 58 0 0 0
Total 58 0 0
Nanofilled/ Qin, 201330 2 56 3 2.7 150.0
nanohybrid Total 56 150.0 2.68

es.48 The last main flaw that threatens the reliability placing the restorations could have differentiated
of the findings of the included studies is the risk of their behavior when using different materials,
performance bias deriving from defective blinding of especially whether strong beliefs or prejudices exist
participants and personnel. Most studies claimed to among operators. For future investigations, the
be ‘‘double-blind,’’ specifically reporting that the blinding would be feasible with little effort, for
patients were unaware of the restorative materials instance by removing the producers’ labels from the
being used on each tooth. Only a few studies did not bottles and syringes and creating a standard
report this information; however, the blinding of reference color scale for shade choice, by preparing
patients is likely to have an impact only on the dedicated molds of known dimensions.
subjective outcomes (such as postoperative sensitiv- There are numerous other sources of variability
ity) and not on those assessed by the evaluators. capable of affecting the results reported in the
What is really noteworthy is that the operator included studies. In fact, it is known that the
performing the restorations was almost never kept material can be a secondary factor for the determi-
blind to the restorative materials in use; in the other nation of the prognosis of a restoration.5 First, the
cases, these details were not specified at all, despite characteristics of the participants involved in the
the recommendations in the CONSORT Statement study are likely to play a major role in determining
to be explicit.49 The lack of blinding, in this case, the success of an adhesive restoration. In the
would probably introduce bias, as the operators selected studies, the samples varied hugely in terms
Angerame & De Biasi: Clinical Effectiveness of Nanocomposites E205

of age, culture, social status, wealth, dietary habits,

quality of oral hygiene, and so forth; for example, one
trial was conducted on Brazilian adolescents living
in the suburbs (some of whom were without
adequate supply of food),24 another one on German
adult patients of a private practitioner,41 and other
ones on dental students.26,31 This probably reflects
the different aims of the researchers, who wanted to
test the performance of the materials in the most
controlled conditions or, on the contrary, in the worst
possible scenario. It is difficult to comprehend the
complex interaction of the multitude of these
elements and appraise their relevance since the
studies included in the present review involved a
relatively small number of patients.
It can be safely assumed that the USPHS criteria
are the most widespread and used method to score
the performance of tooth-colored restorative materi-
als. One way to deal with ordinal data to produce a
meta-analysis is binarization, meaning that some
scores were to be considered acceptable and, hence, a
clinical success, while the others unacceptable and,
thus, restoration failure. This process can be strong-
ly influenced by the arbitrary decision of both
authors and reviewers and also because several
modifications of the USPHS criteria exist and are
further adapted by the authors of primary research.
Some versions of the USPHS criteria include the
variant of Cvar and Ryge,50 the adaptation of Wilson
and others,51 and the color-match modification of
Reusens and others.52 The use of these multiple
versions of the criteria is undesirable because it
hinders the summary of the findings of different
studies. Even if the evaluators are trained and
calibrated, they always make a subjective estimate
of the parameters of interest, and there is no
guarantee of agreement among evaluators of differ-
ent trials. This is particularly relevant when the
different versions of the scoring system do not share
the same amount of rating steps, with some scales
contemplating four scores (from Alpha to Delta) and
other ones three (from Alpha to Charlie) for the same
parameter. Although, at the moment, no better
evaluation methods have been proposed to overcome
the problems relative to the subjectivity of the
appraisal, the reliability of the rating of some items
of the evaluation can be easily questioned. Specifi-
cally, a substantial difference in opinions is likely to
arise when distinguishing among the scores relative
Figure 2. Risk of bias summary: review authors’ judgments about
to color match and surface roughness; these intrin- each risk of bias item for each included study.
sically subjective parameters were the most relevant
outcomes of interest in the present review. More-
over, there are some methodological details that can
E206 Operative Dentistry

Figure 3. Risk of bias graph: review

authors’ judgments about each risk of
bias item presented as percentages
across all included studies.

alter the scores of the USPHS criteria. Examples the RCTs published on the clinical performance of
that support this statement are reported in Table 6. nanofilled/nanohybrid composites in comparison to
It is hard to delineate robust evidence in favor of or that of microhybrid composites. In fact, it can
against the use of nanofilled/nanohybrid composites, happen that the words nanocomposites, nanofilled,
also because they belong to a class of materials with nanohybrid, or submicron do not appear in the title
numerous commercial products. Furthermore, there or in the abstract of the article. In the case of trials
is still debate and a certain extent of confusion about referring to the materials only with brand names,
the classification of composite resins,7 since the the probability of the trial to be missed is high;
distinction between the different classes of materials hence, the use of descriptive words that attribute the
can be vague and the attribution of a particular material to a specific class should be encouraged.
composite resin to a single class arduous. Because of Even if, nowadays, patients are demanding tooth-
the low quality of the evidence found in the present colored restorations with optimal esthetic properties
review, it was not possible to carry out any meta- in the posterior teeth, the most relevant area of the
analysis. mouth from an esthetic point of view is undoubtedly
the anterior area, especially in the maxilla. It is
One of the limitations of the present review is that
disappointing that a sole trial29 among those that
it might not have been sensitive enough to locate all
fulfilled the inclusion criteria of the present review
was specifically designed to address the issue of the
Table 6: Factors Other Than the Restorative Material That potential benefits of the use of nanofilled composite
Could Affect the Evaluation of the Clinical for Class III restoration of teeth in the esthetic area.
Performance of the Restorations Placed in the The assessment of the hypothetical benefits of
Included Studies
nanofilled/nanohybrid materials (ie, possible im-
Methodological Item USPHS Criteria Being Affected proved surface luster and prolonged gloss retention)
Marginal preparation Marginal adaptation would be particularly useful in this area of the
Marginal discoloration mouth because it is the most esthetically relevant.
Color match Nevertheless, the authors reported that the hybrid
Secondary caries control composite resin showed an immediate and
Field isolation Secondary caries 12-month color match that was superior to the
Postoperative sensitivity nanofilled and microfilled composites tested. On
Lining Postoperative sensitivity the other hand, the nanofilled and microfilled
Adhesive system Marginal discoloration composites obtained the best surface appearance
Color match after six months.
Secondary caries
Postoperative sensitivity CONCLUSIONS
Polishing protocol Anatomic form The present review assessed that there are several
Color match RCTs attesting that in the posterior area, nanofilled
Surface roughness and nanohybrid composites are capable of satisfac-
Secondary caries tory clinical effectiveness, which was similar to that
Abbreviation: USPHS, United States Public Health Service. of microhybrid composites. No substantial trend of
Angerame & De Biasi: Clinical Effectiveness of Nanocomposites E207

improved surface characteristics, marginal quality, 6. Kahler B, Kotousov A, & Swain MV (2008) On the design
or resistance to wear associated with nanofilled or of dental resin-based composites: a micromechanical
approach Acta Biomaterialia 4(1) 165-172, http://dx.doi.
nanohybrid composites emerged. Data concerning org/10.1016/j.actbio.2007.06.011.
cervical and anterior restorations were extremely
7. Ferracane JL (2011) Resin composite—state of the art
scarce.
Dental Materials 27(1) 29-38, http://dx.doi.org/10.1016/j.
Considering that the risk of bias was deemed to be dental.2010.10.020.
unclear or high, the reader should interpret the 8. Scougall-Vilchis RJ, Hotta Y, Hotta M, Idono T, &
findings of the present review with caution. The Yamamoto K (2009) Examination of composite resins
need should be stressed for further well-conducted with electron microscopy, microhardness tester and
long-term RCTs comparing nanofilled/nanohybrid energy dispersive X-ray microanalyzer Dental Materials
Journal 28(1) 102-112.
composite resins with traditional ones, aiming at
decreasing the risk of selection and performance 9. Cavalcante LM, Masouras K, Watts DC, Pimenta LA, &
Silikas N (2009) Effect of nanofillers’ size on surface
bias. properties after toothbrush abrasion American Journal of
At this time, the choice of restorative material Dentistry 22(1) 60-64.
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composite continues to be up to the clinician Surface deterioration of dental materials after simulated
performing the restoration. toothbrushing in relation to brushing time and load
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11. Kaizer MR, de Oliveira-Ogliari A, Cenci MS, Opdam NJ,
This study was conducted in accordance with all the & Moraes RR (2014) Do nanofill or submicron composites
provisions of the local human subjects oversight committee show improved smoothness and gloss? A systematic
guidelines and policies of the University of Trieste, in Trieste, review of in vitro studies Dental Materials 30(4) e41-78,
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Conflict of Interest
guides to the medical literature. I. How to get started. The
The Authors of this article certify that they have no Evidence-Based Medicine Working Group Journal of the
proprietary, financial, or other personal interest of any nature American Association 270(17) 2093-2095.
or kind in any product, service, and/or company that is
presented in this article. 13. Swingler GH, Volmink J, & Ioannidis JP (2003) Number
of published systematic reviews and global burden of
(Accepted 24 October 2017) disease: database analysis British Medical Journal
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