In this chapter:
■ Tooth-supported veneers
■ Tooth-supported inlays and onlays
■ Tooth-supported SCs
■ Endocrowns
■ Tooth-supported conventional FDPs
■ Tooth-supported cantilever FDPs
■ Resin-bonded fixed dental prostheses (RBFDPs)
■ Implant-supported SCs
■ Implant-supported FDPs
■ Implant-supported cantilever FDPs
■ Combined tooth-implant-supported FDPs
A group of researchers from the Universities of Iceland, Bern, Geneva, and Zurich in Switzerland, and from the National Dental Center in Singapore have published a broad series of systematic reviews in recent years (see Table 3-11 at the end of Part III)1–20. These are based on consistent inclusion and exclusion criteria, methodologies, and a statistical approach summarizing the available information on survival rates of different types of tooth- and implant-supported single crowns (SCs) and fixed dental prostheses (FDPs).
A systematic review21, aiming to evaluate the 5- and 10-year survival rates of ceramic veneers fabricated of non-feldspathic porcelain, reported an estimated 5-year survival rate of 92.4% based on four studies evaluating the outcomes of approximately 400 veneers. Two studies with a follow-up time exceeding 10 years could be included in the systematic review. The reported 10-year survival rates for these studies were 66% and 94%, respectively22,23. A more recent systematic review24 analyzing the survival of both glass-ceramic and feldspathic porcelain laminate veneers reported survival rates of 94% for the glass-ceramic veneers, based on 676 veneers with a mean follow-up time of 7 years, and of 87% for feldspathic porcelain veneers based on 1283 veneers with a mean follow-up time of 8 years24. The difference in survival rates between glass-ceramic and feldspathic porcelain laminate veneers did, however, not reach statistical difference. The most frequent complications were: fracture or chipping (4%); debonding (2%); severe marginal discoloration (2%); endodontic complications (2%); and secondary caries (1%). The authors could not draw any concrete conclusion regarding the influence of preparation depth (limited to enamel or dentin) on the failure rates24.
3.3 Tooth-supported inlays and onlays
Systematic review and meta-analyses aiming to evaluate the survival rates of both ceramic and resin inlays, onlays, and overlays reported an overall estimated 5-year survival rate of 95% for ceramic inlays and onlays based on the observations of 5811 reconstructions and an estimated 10-year survival rate of 91% based on a sample of 2154 reconstructions25. For glass-ceramic inlays and onlays, the 5-year survival rate was reported to be 96% (n = 1579) and the 10-year survival rate was 93% (n = 605). For feldspathic porcelain inlays and onlays the respective survival rates were 92% (n = 661) and 91% (n = 538)25. The systematic review indicated that the type of ceramic material (feldspathic porcelain vs glass-ceramic), the follow-up time (5 years vs 10 years), and the study setting (university vs private clinic) did not significantly affect the survival rates. The most frequently observed complications were related to ceramic fractures or chippings (4%), followed by endodontic complications (3%), secondary caries (1%), and debonding (1%). Severe marginal staining was not reported. No studies were available that reported on resin-based inlays, onlays, and overlays, and fulfilled the inclusion criteria of a mean follow-up time of at least 5 years25.
Recently, Sailer and co-workers15,16 published a systematic review analyzing the survival and complication rates of all-ceramic and metal-ceramic tooth-supported SCs. The meta-analysis included 17 studies reporting on 4663 metal-ceramic crowns and 55 studies reporting on 9493 all-ceramic crowns (different types of ceramic used). For metal-ceramic SCs the estimated 5-year survival rate was 95.7% (Table 3-1)26–58 compared with an overall 5-year survival rate of 94.5% for all-ceramic crowns. The survival rates of all-ceramic crowns differed for various ceramic types. The 5-year survival rates were 96.6% for leucite or lithium-disilicate reinforced glass-ceramic SCs (12 studies with 2689 SCs) (Table 3-1), 96.0% for densely sintered alumina SCs (8 studies with 1099 SCs), 94.6% for glass-infiltrated SCs (15 studies with 2389 SCs), 93.8% for densely sintered zirconia SCs (8 studies with 926 SCs) (Table 3-1), 90.7% for feldspathic or silica-based ceramic SCs (10 studies with 2208 SCs), and 83.4% for composite crowns (1 study with 59 SCs)15,16. Compared with metal-ceramic crowns, feldspathic or silica-based ceramic SCs and composite crowns had significantly lower 5-year survival rates. When the outcomes of anterior and posterior SCs were compared, no significant differences in the survival rates were found for metal-ceramic crowns, for leucite or lithium-disilicate reinforced glass-ceramic crowns, and alumina and zirconia-based crowns. Crowns made out of feldspathic or silicabased ceramics, however, exhibited significantly lower survival rates in the posterior region compared with the anterior region15,16.
Table 3-1 Estimated annual failure rate and 5-year survival rate of tooth-supported metal-ceramic, reinforced glass-ceramic, and densely sintered zirconia-ceramic single crowns (SCs)
Limited data are available on the long-term outcome of endocrowns. A systematic review conducted to evaluate clinical (survival) and in vitro (fracture strength) outcomes of endocrowns compared to conventional crowns was able to include three clinical studies, one prospective and two retrospective. The included studies reported on a total of 55 endocrowns inserted in the posterior area. The survival rates ranged between 94% and 100% at a rather short follow-up time of 6–36 months59. A recent retrospective analysis of 235 molar endocrowns made with a chairside CAD/CAM method reported a very positive outcome with only one crown failure, representing a survival rate of 99.8% at a mean follow-up of 55 months60. The failure was due to ceramic fracture. The authors concluded that endocrowns in the molar area showed even more favorable survival rates compared with conventional CAD/CAM full ceramic crowns60. It must, however, be kept in mind that the studies evaluating the outcomes of endocrowns concentrate on crowns inserted in the posterior area and limited evidenced is available regarding the use of endocrowns in the anterior area.
3.6 Tooth-supported conventional multiple-unit FDPs
Tan and co-workers3 published a systematic review analyzing the survival rates of conventional tooth-supported FDPs. The meta-analysis included 21 studies that incorporated around 2800 patients, receiving approximately 4000 FDPs. The majority of the included studies were retrospective in design and half of the included FDPs were metal-acrylic FDPs. Based on the included material, the estimated 5-year survival rate of FDPs was 93.8% and the 10-year survival rate was 89.2% (Table 3-2)3,4,61–75.
Table 3-2 Annual failure rate and estimated 5- and 10-year survival rate of conventional tooth-supported multiple-unit FDPs with end abutments
n.a., not applicable.
Recently, Pjetursson and co-workers14,17 published a systematic review analyzing the survival rates of all-ceramic and metal-ceramic multiple-unit FDPs. A total of 28 studies that reported on all-ceramic FDPs and 15 studies that reported on metal-ceramic FDPs were included in this review. For all-ceramic FDPs, most of the studies were prospective in design, but for metal-ceramic FDPs two-thirds of the included studies were retrospective. The majority of the included studies were conducted in university settings. For metal-ceramic FDPs, the estimated 5-year survival rate was 94.4% (15 studies with 1796 FDPs) (Table 3-3)11,30,39,61,63,64,76–84. The results for all-ceramic FDPs were divided into reconstructions based on different ceramic materials such as reinforced glass-ceramic, glass-infiltrated alumina (InCeram Alumina and Inceram Zirconia), and densely sintered zirconia. The estimated 5-year survival rates were 90.1% for densely sintered zirconia FDPs (15 studies with 574 FDPs) (Table 3-3)11,29,57,77,80,81,85–94, 86.2% for glass-infiltrated alumina FDPs (6 studies with 229 FDPs), and 85.9% for reinforced glass-ceramic FDPs (5 studies with 136 FDPs). Compared with metal-ceramic FDPs, the 5-year survival rates of both glass-infiltrated alumina and reinforced glass-ceramic FDPs were significantly lower. No conclusion could be made regarding the 10-year survival of metal-ceramic or all-ceramic FDPs11,14,17,30,76–94.
Table 3-3 Estimated 5-year survival rate of tooth-supported metal-ceramic and veneered zirconia-ceramic multiple-unit FDPs
3.7 Tooth-supported cantilever FDPs
Pjetursson and co-workers2 published a systematic review and meta-analysis analyzing the survival rate of tooth-supported FDPs with cantilever units. The 13 included studies reported on approximately 700 patients receiving a total of 816 cantilever FDPs. The studies were mainly conducted in an institutional environment, such as a university or a specialized clinic. The operators were dental students, postgraduate students, private dentists, and specialists. Twelve of the thirteen included studies provided data on survival. The estimated 5-year survival rate of cantilever FDPs was 91.4% and the 10-year survival rate was 80.3% (Table 3-4)2,4,64,66,70,72,95–102.
Table 3-4 Annual failure rate and estimated 5- and 10-year survival rate of cantilever tooth-supported FDPs
n.a., not applicable.
The studies were also divided according to the veneer material used. In a group with ceramic FDPs there was no significant difference regarding survival rates between the two veneer materials2.
3.8 Resin-bonded fixed dental prostheses (RBFDPs)
Recently, Thoma and co-workers18 published a systematic review with meta-analysis analyzing the survival rate of RBFDPs. A total of 29 retro- and prospective studies reporting on 2300 reconstructions were included in the analysis. The studies were conducted under different environmental settings: 22 in a university setting, two in private practices, and four in specialist clinics. The preparation designs ranged from no preparation or conservative preparations to extensive preparations with grooves, guide planes, and wrap-around design to improve the RBFDPs’ mechanical retention. The materials used for the fabrication of the RBFDPs consisted of veneered and non-veneered metal and all-ceramic frameworks or composite frameworks veneered with composite. Different surface treatments of the bonding area of the RBFDPs were performed prior to cementation with various resin cements18.
The reported 5-year survival rate for RBFDPs was 91.4% and the 10-year survival rate was estimated to be 82.9% (Table 3-5)103–125. The studies were also divided according to the material utilized. The estimated 5-year survival rate was 100% for RBFDPs with zirconia as framework material (3 studies with 68 RBFDPs), 95.3% for RBFDPs with reinforced glass-ceramic framework (1 study with 49 RBFDPs), 93.4% for RBFDPs with glass-infiltrated ceramic as framework material (1 study with 38 RBFDPs), 92.8% for RBFDPs with fiber-reinforced composite as framework (3 studies with 267 RBFDPs), 91.3% for metal-ceramic RBFDPs (8 studies with 977 RBFDPs), and 88.9% for metal-resin RBFDPs (1 study with 267 RBBs)18. Statistical analysis of different material types showed that RBFDPs with zirconia frameworks had a significantly higher survival rate than metal-ceramic RBFDPs. Furthermore, the survival rate of RBFDPs was significantly higher when one retainer was utilized compared with RBFDPs retained with two or more retainers. Moreover, the survival rate of RBFDPs inserted in the anterior area was significantly higher than the survival rate of RBFDPs inserted in the posterior area. In addition, the survival rate was higher for reconstructions inserted in the maxilla compared with RBFDPs inserted in the mandible18. Hence, to obtain the best outcomes for RBFDPs, zirconia should be used as framework material, and the RBFDPs should be inserted in the maxillary anterior area and be attached by one retainer only.
Table 3-5 Annual failure rate and estimated 5- and 10-year survival rate of resin-bonded fixed dental prostheses (RBFDPs)
Jung and co-workers12 published a systematic review with meta-analysis analyzing the survival rates of implant-supported SCs. A total of 46 retro- and prospective studies reporting on 3223 inserted implants and 3199 SCs were included in the analysis. Seventy percent (70%) of the crowns were cemented and 30% were screw-retained. During the healing period, 1.3% of the implants were lost and after implant loading the estimated annual implant failure rate was 0.3%. This represents a 5-year survival rate of 97.2% for implants supporting SCs and a 10-year implant survival rate of 95.2%. Twenty-seven of the included studies provided data on the survival of the SCs. The estimated 5-year survival rate of implant-supported SCs was 96.3% and the estimated 10-year survival rate for SCs was 89.4% (Table 3-6). Approximately half of the crown failures were due to implant loss12,36,126–150.
Table 3-6 Annual failure rate and estimated 5- and 10-year survival rate of implant-supported SCs
Recently, Pjetursson and co-workers19 published a systematic review analyzing the survival rates of metal-ceramic and zirconia-ceramic implant-supported SCs. A total of 30 studies reporting on 4363 metal-ceramic SCs and 8 studies reporting on 912 zirconia-ceramic SCs were included in the meta-analysis. All the included zirconia-based SCs consisted of a zirconia core with veneering ceramic and no monolithic crowns were evaluated. The majority of the metal-ceramic SCs were cement-retained, but for the zirconia-based crowns approximately half of the crowns were cemented, and the other half was screw-retained. The studies were conducted both in an institutional environment, such as university or specialized implant clinics and in private practice setting. For implant-supported metal-ceramic SCs the estimated 5-year survival rate was 98.3% and for implant-supported zirconia-ceramic SCs the respective survival rate was 97.6% (Table 3-7)128,133,139,141,144,145,148,151–177. The difference in survival rates between metal-ceramic and zirconia-ceramic SCs was not significant. Moreover, the survival rate of implant-supported SCs was analyzed regarding the location in the dental arch; both metal-ceramic and zirconia-ceramic SCs showed slightly higher survival rates in the posterior compared with the anterior area19.
Table 3-7 Estimated 5-year survival rate of implant-supported metal-ceramic and zirconia-ceramic SCs. There was no significant difference in the survival rates of zirconia-ceramic and metal-ceramic SCs (P = 0.514)
Pjetursson and co-workers13 published a systematic review with meta-analysis analyzing the survival rate of implant-supported FDPs. A total of 32 retro- and prospective studies reporting on 1881 implant-supported FDPs supported by approximately 5200 implants were included in the analysis. The studies were mainly conducted in an institutional environment, such as university or specialized implant clinics. Five of the included studies were conducted in private practice settings. Two-thirds of the FDPs were metal-ceramic and one-third had metal frameworks with acrylic veneering material. The majority of the FDPs were screw-retained. During the healing period 2.4% of the implants were lost. The estimated 5-year survival rate for implants supporting FDPs was 95.6% and the estimated 10-year implant survival rate was 93.1%. The included studies were also analyzed separately according to the implant surface geometry. Machined surface implants were reported to have significantly lower survival rates than rough surface implants13.
Twenty-seven of the included studies provided data on the survival of FDPs. The estimated 5-year survival rate of FDPs was 95.4% and the estimated 10-year survival rate of FDPs was 80.1% (Table 3-8)127,149,169,178–201. The studies were also divided according to the veneer material utilized. The metal-ceramic FDPs showed a significantly higher 10-year survival rate of 93.9% than metal-acrylic FDPs with a survival rate of only 77.4%13.
Table 3-8 Annual failure rate and estimated 5- and 10-year survival rate of implant-supported FDPs
Recently, Sailer and co-workers20 published a systematic review analyzing the survival and complication rates of metal-ceramic and zirconia-ceramic implant-supported FDPs. A total of 16 studies reporting on 993 metal-ceramic FDPs and 3 studies reporting on 175 FDPs with zirconia framework, were included in this review. The majority of the metal-ceramic FDPs were cement-retained, but the zirconia-based reconstructions were mainly screw-retained. The studies were conducted both in an institutional environment, such as university or specialized implant clinics, and in private practice settings. For implant-supported metal-ceramic FDPs, the estimated 5-year survival was 98.7% and for implant-supported zirconia-ceramic FDPs, the estimated 5-year survival was 93.0% (Table 3-9)20,156,158,160–162,165,167,169,174,175,178,187,202–206. Hence, zirconiabased implant-supported FDPs showed significantly lower survival rates compared with metal-ceramic FDPs. However, it must be kept in mind that all included zirconia-based FDPs consisted of a zirconia framework with veneering ceramic and no monolithic zirconia FDPs were evaluated in this material20.
Table 3-9 Estimated 5-year survival rate of implant-supported metal-ceramic and zirconia-ceramic FDPs There was a significant difference in the survival rates of zirconia-ceramic and metal-ceramic FDPs (P <0.001)
3.11 Implant-supported cantilever FDPs
Storelli and co-workers207 recently published a systematic review analyzing the survival rate of implant-supported FDPs with cantilever units. A total of 9 studies reporting on 376 implant-supported cantilever FDPs supported by 739 implants were included in the analysis. The studies were mainly conducted in an institutional environment. The 5-year survival rate for implants supporting cantilever implant-supported FDPs was estimated to be 98.9%. The estimated 5-year survival rate of cantilever implant-supported FDPs was 98.2%. No clear information was available regarding the 10-year survival of implant-supported cantilever FDPs as the included studies were not divided according to the follow-up period. The 5-year survival of implant-supported cantilever FDPs was comparable with the respective survival rate of implant-supported FDPs without cantilever units. However, it must be kept in mind that through the cantilever unit additional load is applied to the supporting implants and the implant-abutment connections. An observational period of 5 years might be too short to experience fatigue failures and complications such as implant or abutment fractures.
3.12 Combined tooth-implant-supported FDPs
Lang and co-workers1,4 published a systematic review with meta-analysis analyzing the survival rate of tooth-implant-supported FDPs. A total of 14 studies reporting on 622 tooth-implant-supported FDPs supported by 1144 implants were included in the analysis. The studies were mainly conducted in an institutional environment, such as university or specialized implant clinics. The majority of the tooth-implant-supported FDPs were screw-retained on the implants. Implant loss prior to functional loading was detected for 2.7% of all implants. The estimated annual implant failure rate after loading amounted to 1.3%, representing an estimated 5-year implant survival rate of 90.1% (95% CI: 82.4–94.5%) and 82.1% (95% CI: 55.8–93.6%) at 10 years. The annual failure rate after loading was significantly higher for implants supporting combined tooth-implant-supported FDPs compared with implants supporting SCs or solely implant-supported FDPs1,4.
Ten of the included studies provided data on the survival of tooth-implant-supported FDPs. The estimated 5-year survival rate of tooth-implant-supported FDPs was 95.5% and the reported 10-year survival rate was 77.8% (Table 3-10; see also summary in Table 3-11)190,193,197,201,208–212. At an observation period of 5 years, 3.2% of the abutment teeth were lost compared to 3.4% of the functionally loaded implants. At 10 years, 10.6% of the abutment teeth were lost compared to 15.6% of the supporting implants149,
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