[version 1; peer review: 1 approved, 1 approved with reservations]
No competing interests were disclosed.
Immediate Dentin Sealing (IDS) is a technique that applies an adhesive layer immediately after tooth preparation, prior to the placement of indirect restorations. This method is gaining attention due to its potential to improve the bond strength and mechanical properties of restorations, particularly in the posterior region where restorations endure significant masticatory forces. The objectif of this systematic review and meta-analysis is to evaluate the effect of IDS on the fracture strength of indirect posterior restorations.
Following PRISMA guidelines, a comprehensive literature search was conducted in four databases: Web of Science, Scopus, Cochrane Library, and PubMed. Inclusion criteria focused on in vitro studies involving human teeth with indirect posterior restorations, published between 2014 and 2023. Studies using IDS were compared to those using conventional methods. The risk of bias was assessed using the Cochrane Collaboration’s tool, and a meta-analysis was performed with a random-effects model. The standard mean difference and 95% confidence intervals were calculated to compare fracture strength, with I 2 statistics assessing heterogeneity. Forest and funnel plots were employed to visualize results and publication bias, respectively.
The results indicate that IDS generally enhances the fracture strength of indirect posterior restorations, particularly with ceramic materials like lithium disilicate. However, the effectiveness of IDS varies depending on the material and restoration type. While some studies demonstrated improved fracture resistance with IDS, others showed minimal benefit, especially with composite restorations. Additionally, IDS improved marginal adaptation and internal fit but increased the risk of severe failures, such as root fractures.
PROSPERO: CRD42024584545 (Registered on 08/09/2024).
Immediate Dentin Sealing (IDS) has emerged as a highly influential technique in the field of restorative dentistry, particularly in the context of indirect posterior restorations.
The technique has gained significant attention for its potential to improve the mechanical properties of partial restorations, particularly those located in the posterior region of the mouth, where restorations are exposed to substantial masticatory forces.
Despite its growing popularity, the effects of IDS on fracture strength remain a topic of debate. While several studies suggest that IDS enhances the fracture resistance of indirect restorations, discrepancies exist depending on factors such as the materials used, the specific restoration type, and the methods employed. Therefore, a systematic review and meta-analysis are necessary to consolidate the existing evidence and provide a clear understanding of IDS’s role in improving fracture strength.
This systematic review and meta-analysis aim to assess the effect of IDS on the fracture strength of indirect posterior restorations, offering a thorough evaluation of current evidence.
This systematic review will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) checklist. It will also comply with the Methodological Expectations of Cochrane Intervention Reviews and the Cochrane Handbook for Systematic Reviews of Interventions. The review protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42024584545, as of September 8, 2024.
Specify the effect of immediate dentin sealing on the fracture strength of indirect posterior restorations.
Describe the benefits of IDS in posterior partial restorations
Present the mechanical properties of these restorations.
Specifying the impact of IDS on their fracture resistance.
The PICOS framework (Participants, Intervention, Comparison, Outcome, Study Design) will be used to organize the eligibility criteria, which is intended to emphasize the key components of the research question.
The PICO question is: What is the effect of immediate dentin sealing (intervention) on the fracture strength (outcome) of indirect posterior restorations (population) compared to delayed dentin sealing (comparison)?
This systematic review will focus on teeth restored with indirect posterior restoration: Endocrown, Overlay, occlusal veneer, Inlay and Onlay.
The intervention of interest is
The primary outcome of interest is the
The main outcome, fracture strength, will be measured using either the
This review will include both
Studies will be excluded if they meet any of the following criteria:
Studies involving indirect anterior restorations.
Studies with animal models.
Interventions on temporary teeth.
Two independent searchers, Y.G. and R.K. will search four different databases: Web of Science, Scopus, Cochrane library and PubMed.
They will perform a manual search and meticulously reviewed the reference lists of the studies included in this review to identify eligible ones. Additionally, electronic searches in databases will conduct using a combination of mesh terms (
| Database | Search strategy |
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((“Fracture Strength” OR “Strength” OR “Force to fracture” OR “Fracture resistance”) AND (“Indirect posterior restorations” OR “Indirect restorations” OR “Endocrown” OR “Denture, Overlay” OR “occlusal veneer” OR “occlusal veneers” OR “Overlay” OR “Overlays” OR “Inlay” OR “Onlay”) AND immediate dentin sealing) |
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(TS=(“Fracture Strength”) OR TS=(“Strength”) OR TS=(“Force to fracture”) OR TS=(“Fracture resistance”)) AND (TS=(“Indirect posterior restorations”) OR TS=(“Indirect restorations”) OR TS=(“Endocrown”) OR TS=(“Denture, Overlay”) OR TS=(“occlusal veneer”) OR TS=(“occlusal veneers”) OR TS=(“Overlay”) OR TS=(“Overlays”) OR TS=(“Inlay”) OR TS=(“Onlay”)) AND TS=(“immediate dentin sealing”) |
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(TITLE-ABS(“Fracture Strength”) OR TITLE-ABS(“Strength”) OR TITLE-ABS(“Force to fracture”) OR TITLE-ABS(“Fracture resistance”)) AND (TITLE-ABS(“Indirect posterior restorations”) OR TITLE-ABS(“Indirect restorations”) OR TITLE-ABS(“Endocrown”) OR TITLE-ABS(“Denture, Overlay”) OR TITLE-ABS(“occlusal veneer”) OR TITLE-ABS(“occlusal veneers”) OR TITLE-ABS(“Overlay”) OR TITLE-ABS(“Overlays”) OR TITLE-ABS(“Inlay”) OR TITLE-ABS(“Onlay”)) AND TITLE-ABS(“immediate dentin sealing”) |
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"Fracture Strength” OR “Strength” OR “Force to Fracture” OR “Fracture Resistance” in Title Abstract Keyword AND ”Indirect posterior restorations” OR “Indirect restorations” OR “Endocrown” OR “Denture, Overlay” OR “occlusal veneer” OR “occlusal veneers” OR “Overlay” OR “Overlays” OR “Inlay” OR “Onlay” in Title Abstract Keyword AND ”immediate dentin sealing” in Title Abstract Keyword - (Word variations have been searched) |
To select studies, duplicates will be removed. Titles and abstracts will be reviewed by the two investigators, and studies that do not meet the inclusion criteria will be excluded.
The methodological quality of the included studies will be assessed using the Cochrane Collaboration’s risk of bias tool, a standard method for evaluating biases in clinical research. This assessment will be done using Review Manager software (RevMan, version 5.4). Each type of bias, such as selection, performance, and detection bias, will be evaluated individually. The risk of bias for each domain will be rated as “low,” “unclear,” or “high” according to Cochrane guidelines. An overall rating will then be assigned to summarize the risk of bias for each study.
Data from the included articles will be collected by one author (Y.G.), while a second researcher (R.K.) will review all the extracted data. The collected data will include: the first author, year, type of study, sample characteristics, IDS technique used in each study, and fracture strength values.
The meta-analysis will evaluate the fracture strength of indirect posterior restorations (inlays, overlays, occlusal veneers) by comparing conventional methods to the immediate dentin sealing (IDS) method. Studies that contrast IDS with conventional methods will be included. Data analysis will be performed using RevMan software (version 5.4). The standard mean difference with a 95% confidence interval will be applied, andthe I 2 statistic will assess heterogeneity by measuring the percentage of variation across studies caused by true differences rather than chance. It helps determine if differences in study populations, methods, or interventions explain the variability. Due to the variability in immediate dentin sealing (IDS) techniques, types of restorations, and methodologies employed across the included studies, a random effects model will be used for the meta-analysis. This model is appropriate in this context as it accounts for the inherent differences among studies, allowing for a more accurate estimate of the overall effect size.
To visually represent the results of the meta-analysis, forest plots will be generated. These plots will display the individual study outcomes along with the overall pooled effect, providing a clear illustration of the results and the degree of consistency among the studies. Additionally, funnel plots will be employed to evaluate the potential for publication bias. By plotting the effect sizes of the studies against their standard errors, funnel plots can help identify any asymmetry that may suggest selective reporting or other biases affecting the literature.
IDS generally enhances the fracture strength of indirect posterior restorations, especially with ceramic materials like lithium disilicate.
This review serves as a valuable resource for clinicians, offering guidance when restoring posterior teeth with indirect restorations.
Ethical approval is not required for this systematic review. The authors plan to present the results at relevant conferences and publish the findings in a peer-reviewed journal, following open science practices.
The protocol of this systematic review was submitted to PROSPERO registry on 08th September, 2024 (CRD42024584545).
No data are associated with this article.
Figshare. PRISMA-P checklist for Effect of immediate dentin sealing on the fracture strength of indirect posterior restorations: Systematic review and meta-analysis Protocol. DOI:
The project contains the following dataset:
PRISMA-P-checklist.docx
Data are available under the terms of the
PICOS criteria needs to be properly defined. Include a table of PICOS framework with specific inclusion and exclusion criteria. The current PICOS is very vague.
Data extraction needs to have details of the agent applied and the restorative material used.
In meta-analysis, specify the effects model and define heterogeneity values for those models - random and fixed.
Include a section of subgroup analysis if the authors are including different restorative materials and adhesive agents, as these may differently influence the bonding process entirely.
Limitations of the protocol need to be acknowledged and wherever possible, addressed.
There are several spelling mistakes and grammatical errors in the manuscript such as 'objectif' or in the sentence stating the aim of the study. Similar errors are present sporadically in the manuscript.
The formatting of the manuscript is poor. The authors are suggested to write it in the form of paragraphs and use bullet points only when necessary for a neatly formatted protocol. The bullet points seem to be missing.
The risk of bias tool mentioned may not be appropriate for in vitro studies. Since the authors are focusing on in vitro studies, they are suggested to use more suitable tools such as the QUIN tool.
Is the study design appropriate for the research question?
Yes
Is the rationale for, and objectives of, the study clearly described?
Partly
Are sufficient details of the methods provided to allow replication by others?
Partly
Are the datasets clearly presented in a useable and accessible format?
Partly
Reviewer Expertise:
Dentistry, Systematic Reviews
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Dear Reviewer,
We would like to thank you sincerely for your constructive feedback on our manuscript. Your comments have greatly contributed to improving the clarity, methodological rigor, and overall quality of our work. Below, we provide a detailed response to each point, along with the corresponding revisions made in the manuscript.
The adhesive/agent applied (etch-and-rinse, self-etch, universal, protective liners, etc.), The restorative material used (lithium disilicate, polymer-infiltrated ceramic, composite resin, glass-ceramic, etc.). Information on the provisional phase, impression method, and storage conditions has also been included. These modifications ensure a comprehensive capture of all relevant variables influencing fracture strength.
Type of restorative material (ceramic, resin composite, polymer-infiltrated ceramic), Type of adhesive agent (etch-and-rinse, self-etch, universal adhesives, protective liners). This will allow us to evaluate whether IDS effectiveness differs across materials and bonding protocols.
Restriction to in vitro studies, limiting direct clinical applicability, Variability in test setups, IDS techniques, and restorative materials, Potential for publication bias, despite efforts to minimize it. We also suggest that future well-designed clinical studies address these gaps.
We are grateful for the reviewer’s constructive insights, which have allowed us to substantially strengthen the manuscript. We believe the revised version now addresses all concerns and meets the methodological standards expected.
Sincerely
This is an interesting article done to evaluate the effect of IDS on the fracture strength of indirect posterior restorations.
Abstract:
The spelling of the Objective is a mistake. Please correct.
The Introduction presents the background and Method explains in detail.
PICOS framework (Participants, Intervention, Comparison, Outcome, Study Design is also clear.
Does the IDS affect the bonding of the ceramic?
More discussion is needed.
Discuss with similar previous studies.
Is the study design appropriate for the research question?
Yes
Is the rationale for, and objectives of, the study clearly described?
Partly
Are sufficient details of the methods provided to allow replication by others?
Yes
Are the datasets clearly presented in a useable and accessible format?
Yes
Reviewer Expertise:
Dental Biomaterials, Prosthetic Dentistry
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.