Longevity of fiber-reinforced composite fixed partial dentures (FRC FPD)—Systematic review

Abstract

Objectives

to assess FRC FPDs longevity through systematically reviewing contemporary clinical evidence. Population investigated comprised patients requiring replacement of a single missing anterior/posterior tooth. Intervention was FRC FPDs. No control/comparison selected. Outcome was longevity of FRC FPDs. The focus question was: ‘What is the longevity of FRC FPDs used to replace one anterior or posterior tooth in patients?’

Data

Randomised, non-randomised, controlled, prospective and retrospective clinical studies were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were applied. The Overall Strength of Clinical Recommendation (OSCR) was assessed using the Strength of Recommendation Taxonomy system. Survival of FPDs was assessed using the Kaplan-Meier method. Analysis of FPD-survival according to location and occurrence of different failures was performed using Logrank and Chi-square testing.

Sources

PubMed, MEDLINE, and Web of Science databases were searched between January 2007 and December 2015.

Study selection

Nine studies were included, involving placement of 592 FRC FPDs in 463 patients. Follow-up periods ranged between 2 months and 8 years. Kaplan-Meier overall survival probability was 94.5% (95% C.I: 92.5%–96.5%) at 4.8 years. There was no significant difference in survival probability of anterior versus posterior FRC FPDs (P = 0.278). Veneering material fracture/delamination occurred significantly more than other types of failures (Ps < 0.05). A meta-analysis could not be performed. OSCR was moderate.

Conclusions

FRC FPDs demonstrated high overall survival with predictable performance outcomes. However, long-term performance remains unclear.

Clinical significance

FRC FPDs are viable medium-term management alternatives for replacing single anterior or posterior teeth in patients.

Introduction

Fiber-reinforced composites (FRC), consisting of a plastic matrix reinforced by fine thin fibers , have been used for an array of dental applications. These include, but are not limited to, endodontic posts , splints for periodontally compromised teeth , provisional restorations for implants , space maintainers in a children , posterior metal-free crowns and restorative management of localised tooth wear at increased occlusal vertical dimensions (OVD) .

One of the most promising applications of FRCs is their use in the fabrication of fixed partial dentures (FPD). Such restorations are composed of 2 types of composite materials, a fiber reinforced composite substructure and an overlay of resin veneering composite . FRC FPDs can be surface retained and/or inlay retained as they require a minimally invasive preparation. Furthermore, they have improved aesthetics, and can be fabricated either directly or indirectly, and at a lower cost. Therefore, FRC FPDs present a viable treatment alternative to conventional cast metal resin bonded bridges (CM RBB) . However, relatively short-term clinical evidence exists to support the use of FRC FPDs, in contrast to the existing long-term performance data of CM RBBs.

In 2005, the first systematic review on FRC FPDs was published . The review reported a lack of clinical evidence supporting their use, concluding that FRC FPDs should be regarded as experimental. A later systematic review assessing the longevity of FRC FPDs included studies published between 1950 and 2007 . The included studies reported varying follow-up periods, the longest being 5.7 years . The review estimated a survival of 73.4% at 4.5 years for FRC FPDs and identifying that delamination of the veneering composite was the most common reason for failure. Subsequently, there has been a growing number of published studies investigating the survival of FRC FPD with larger sample-sizes, longer follow-up periods, and employing different FRC systems .

The purpose of this systematic review was to assess the longevity of FRC FPDs, used to replace single anterior or posterior teeth in patients, through systematically reviewing and evaluating existing contemporary clinical evidence.

Materials and methods

The review aimed to systematically identify and assess all clinical studies investigating the survival rate of anterior and posterior FRC FPDs replacing a single tooth. The PICO principle was used to formulate the research focus question . Henceforth, the patient population being investigated comprised patients requiring replacement of a single missing anterior or posterior tooth. The intervention was FRC FPDs; no control/comparison was selected. The outcome assessed was the longevity of FRC FPD restorations. As such, the formulated research focus question was: ‘What is the longevity of FRC FPDs used to replace one anterior or posterior tooth in patients?’ The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines where employed in development of the review and applied whenever applicable . Formulation and prospective registration of a research protocol were not performed.

Search strategy

A search was performed using PubMed, MEDLINE, and Web of Science databases to identify suitable studies for inclusion. The last search was performed on 14 January 2016. Two investigators (K.A and C.M) independently searched and screened the results using the agreed search strategy using MeSH terms and text words ( Table 1 ). Blinding of journal names or paper-author/s was not performed. The Peer Review of an Electronic Search (PRESS) process was employed with no major revisions advised .

Table 1
Search strategy used for PubMed.
1 Search ((((composite) AND fiber-reinforced) OR fiber reinforced) OR fiber-reinforced) OR fiber reinforced
2 Search (((fixed partial dentures) OR fixed partial prosthesis) OR fixed partial prostheses) OR FPD) OR bridges
3 Search ((#1 and #2)) Filters: Publication date from 2007/01/01 to 2015/12/31, Humans, English

Study selection

Only clinical studies were included, with all in-vitro studies excluded. Randomised, and non-randomised, controlled, prospective and retrospective studies were included. However, case reports were excluded. Selection was limited to studies involving humans and published in English language between January 2007 and December 2015. Study inclusion was achieved through discussion and agreement between investigators. Selected citations were then independently full-text screened. Citation mining was also performed via cross-referencing and hand searching all reference lists of included articles.

Data extraction and assessment

Once an agreement upon included studies was achieved, data were extracted and assessed from included studies according to the following criteria:

  • Study design (prospective/retrospective)

  • Participants’ details (number and age of participants)

  • Follow-up period

  • FRC FPD features (location, type of fiber-reinforcement, type of resin composite used, fabrication technique, retainer type, number of abutments, luting cement/bonding agent and operator details)

  • Assessment protocol (criteria, assessor details, definition of failure)

  • Longevity/survival rate

  • Performance (technical and biological performance)

  • Funding sources

As far as reported, the survival period for each FPD was extracted and the above characteristics of bridge design were extracted on an individual basis. Data were retrieved from tables, figures, and the main text of the articles. The authors of included studies were not contacted. If reported in the included studies, Kaplan–Meier statistics, number and types of technical complications and the number of failures were also extracted. A risk of bias evaluation, at a study level, using the Newcastle-Ottawa assessment scale was performed . Domains assessed were selection and outcome. The overall strength of the systematic review’s clinical recommendation was also assessed using the Strength of Recommendation Taxonomy (SORT) grading system .

Statistical analysis

To construct a pooled overall survival curve for the total number of FPDs from the selected studies, a database was made in which individual FPDs from each study were regarded as individual cases. If no individual information but Kaplan–Meier statistics were reported, number of the events were calculated by the Kaplan–Meier survival estimate. If neither individual information nor Kaplan-Meier statistics were reported, then final numbers of failure and survival reported after the follow-up period were extracted. Survival of FPDs was assessed using the Kaplan-Meier method. Sensitivity analysis was also performed. Furthermore, for comparison between FPD survivals in different tooth locations, log-rank testing was also performed. The probabilities of having different types of reported unfavourable events/failures were estimated and compared by Chi-square test with a significance level as 0.05. All analyses were performed using SPSS version 23 (SPSS, Chicago, IL, USA). A meta-analysis was planned, if feasible.

Materials and methods

The review aimed to systematically identify and assess all clinical studies investigating the survival rate of anterior and posterior FRC FPDs replacing a single tooth. The PICO principle was used to formulate the research focus question . Henceforth, the patient population being investigated comprised patients requiring replacement of a single missing anterior or posterior tooth. The intervention was FRC FPDs; no control/comparison was selected. The outcome assessed was the longevity of FRC FPD restorations. As such, the formulated research focus question was: ‘What is the longevity of FRC FPDs used to replace one anterior or posterior tooth in patients?’ The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines where employed in development of the review and applied whenever applicable . Formulation and prospective registration of a research protocol were not performed.

Search strategy

A search was performed using PubMed, MEDLINE, and Web of Science databases to identify suitable studies for inclusion. The last search was performed on 14 January 2016. Two investigators (K.A and C.M) independently searched and screened the results using the agreed search strategy using MeSH terms and text words ( Table 1 ). Blinding of journal names or paper-author/s was not performed. The Peer Review of an Electronic Search (PRESS) process was employed with no major revisions advised .

Table 1
Search strategy used for PubMed.
1 Search ((((composite) AND fiber-reinforced) OR fiber reinforced) OR fiber-reinforced) OR fiber reinforced
2 Search (((fixed partial dentures) OR fixed partial prosthesis) OR fixed partial prostheses) OR FPD) OR bridges
3 Search ((#1 and #2)) Filters: Publication date from 2007/01/01 to 2015/12/31, Humans, English

Study selection

Only clinical studies were included, with all in-vitro studies excluded. Randomised, and non-randomised, controlled, prospective and retrospective studies were included. However, case reports were excluded. Selection was limited to studies involving humans and published in English language between January 2007 and December 2015. Study inclusion was achieved through discussion and agreement between investigators. Selected citations were then independently full-text screened. Citation mining was also performed via cross-referencing and hand searching all reference lists of included articles.

Data extraction and assessment

Once an agreement upon included studies was achieved, data were extracted and assessed from included studies according to the following criteria:

  • Study design (prospective/retrospective)

  • Participants’ details (number and age of participants)

  • Follow-up period

  • FRC FPD features (location, type of fiber-reinforcement, type of resin composite used, fabrication technique, retainer type, number of abutments, luting cement/bonding agent and operator details)

  • Assessment protocol (criteria, assessor details, definition of failure)

  • Longevity/survival rate

  • Performance (technical and biological performance)

  • Funding sources

As far as reported, the survival period for each FPD was extracted and the above characteristics of bridge design were extracted on an individual basis. Data were retrieved from tables, figures, and the main text of the articles. The authors of included studies were not contacted. If reported in the included studies, Kaplan–Meier statistics, number and types of technical complications and the number of failures were also extracted. A risk of bias evaluation, at a study level, using the Newcastle-Ottawa assessment scale was performed . Domains assessed were selection and outcome. The overall strength of the systematic review’s clinical recommendation was also assessed using the Strength of Recommendation Taxonomy (SORT) grading system .

Statistical analysis

To construct a pooled overall survival curve for the total number of FPDs from the selected studies, a database was made in which individual FPDs from each study were regarded as individual cases. If no individual information but Kaplan–Meier statistics were reported, number of the events were calculated by the Kaplan–Meier survival estimate. If neither individual information nor Kaplan-Meier statistics were reported, then final numbers of failure and survival reported after the follow-up period were extracted. Survival of FPDs was assessed using the Kaplan-Meier method. Sensitivity analysis was also performed. Furthermore, for comparison between FPD survivals in different tooth locations, log-rank testing was also performed. The probabilities of having different types of reported unfavourable events/failures were estimated and compared by Chi-square test with a significance level as 0.05. All analyses were performed using SPSS version 23 (SPSS, Chicago, IL, USA). A meta-analysis was planned, if feasible.

Results

A total of 9 studies, published between 2009 and 2015, were identified and included for assessment and analysis in this systematic review . Six studies had a retrospective study design while three were prospective . Included studies involved the placement of 592 FRC FPDs in 463 patients (age 12–80) with follow-up periods ranging between 2 months and 8 years ( Table 2 ). The number of FPDs exceeded the number of patients in all studies, bar one , indicating that a number of patients received more than one FPD. However, patient-FPD allocation details were not clearly reported. Two studies reported a drop-out rate of 22% , one study reported 13% , while remaining studies did not report any drop outs.

Table 2
Details of studies included in the systematic review. Fixed Partial Dentures (FPDs). *Seven patients were not clinically examined at recall.
Study Type Patients Follow-up Drop-out (%)
van Heumen Retrospective 52 pts (13–64y/o) 5–9 years 23% (n = 14 FPDs)
Cenci Retrospective 13 pts (39–62 y/o) Upto 8 years 0
van Heumen, Retrospective 77 pts (12–78 y/o) 4.5–8.9years 13% (n = 12 FPDs)
Wolff Retrospective 29 pts (mean age 39.45y/o) 2 months–5.3 years 0
Izgi Prospective Cohort 10 pts (age = unclear) 16 months–3.3 years 0
Spinas Retrospective 30 pts (13–17y/o) 5 years 0
Frese Retrospective 24 pts (15–60y/o) 3.5–6.3 years 0*
Kumbuloglu Prospective
Cohort
134 pts (16–68y/o) Upto 7.5 years 0
Malmstrom Prospective Randomised 94 pts 18–80 y/o) 2 years 22% (n = 30/167 FPDs)

Three studies explicitly stated that patients were excluded if they presented with active or extensive periodontal disease or demonstrated a mobility score of 2 or 3 . Patients with parafunctional habits were also excluded in 2 studies .

Location

The majority of FRC FPDs replaced anterior teeth (64%, n = 378/592), with 4 studies investigating anterior FRC FPDs , 2 studies investigating anterior and posterior FRC FPDs and 3 studies investigating posterior FRC FPDs . Moreover, most FRC FPDs were located in the maxilla at 68% ( n = 387/570) of all delivered FPDs, with one study not reporting the exact location of prostheses .

The reported survival rates of anterior FRC FPDs varied between 85.6% at 4.5 years , 97.7% at 4.8 years and 64% and 94% at 5 years ( Table 3 ). On the other hand, the survival rates of posterior FRC FPDs was 71.4% at 3 years , 78% at 5 years , dropping to 34% at 8 years .

Table 3
Data extracted from studies included in systematic review. Maxilla (Max); mandible (Man); fixed partial denture (FPD); surface retained (SR); inlay retained (IR); hybrid retained (HR); reported Kaplan Meier survival estimate (KM).
Study Location FPDs/Retention Abutments Technique Framework Composite resin Bonding protocol Operator details Assessment criteria Survival rates
van Heumen Anterior (Max = 57, Man = 3) n = 60.
SR (n = 48/60), and HR (n = 12/60)
Two Indirect Stick Flowable resin (unclear). Veneering: Sinfony Artglass Compolute, Twin-look, and Panavia 6 experienced operators Clinical examination of periodontal status, caries, wear, discolouration, fractures and dislodgements KM = 64% at 5 years
Cenci Posterior (Max/Man = unclear) n = 22 IR Two Indirect Ribbond Tertic Ceram Veneering: Durafill; Renamel Rely X ARC 1 experienced operator Modified USPHS KM = 34.2% at 8 years
van Heumen Posterior (Max = 4, Man = 46) n = 96.
SR (n = 31/96), HR (20/96), and IR (45/96)
Two Indirect Stick Flowable resin (unclear). Veneering: Sinfony; Artglass Compolute, Variolink, Twin-look, and Panavia 6 experienced operators Clinical examination of periodontal status, caries, wear, discolouration, fractures and dislodgements KM = 78% at 5 years
Wolff Anterior (Max = 12, Man = 12), and Posterior (Max = 3/Man = 5) n = 32.
SR n = 11. IR, n = 21.
Two (n = 25); One (n = 7) Indirect and Direct everStick C&B Unclear Optibond FL 8 specialist operators Modified USPHS/Ryge KM = 74.4% at 1.5 years
Izgi Posterior (Max = 10, Man = 4) n = 14 IR Two Direct everStick C&B, (n = 7/14) and Ribbond, (n = 7/14) Flowable resin: Ionosit-Baseliner. Vennering: Ecusit-Composite Clearfil SE Bond Unclear Modified USPHS KM = 71.4% at 2.9 years for everStick 3.3 years for Ribbond
Spinas Anterior (Max = 32) n = 32 SR Two Indirect Vectris Veneering: SR Adoro One Coat Bond and Permamix Smartix Dual 1 operator Modified USPHS 94% (n = 30/32) after 5 years
Frese Anterior (Max = 11, Man = 13) n = 24.
SR, n = 13/24. IR, n = 11/24
Two (n = 20); One (n = 4) Indirect and Direct everStick C&B Flowable resin: Tetric Flow. Veneering: Herculite XRV; Enamel HFO plus; Tetric Evo Ceram Optibond FL Unclear Modified USPHS and periodontal evaluation. 7pts not available for clinical examination KM = 85.6% after 4.5 years
Kumbuloglu Anterior (Max = 112, Man = 63) n = 175 SR Two Indirect everStick C&B Flowable resin: Grandio Flow. Veneering: Dialog RelyX ARC, Bifix DC, Variolink II, Multilink 1 operator Technical and biological assessment KM = 97.7% at 4.8 years
Malmstrom Anterior (Max = 51, Man = 12). Posterior (Max = 48, Man = 26) n = 137( at follow-up ).
SR, n = 63. IR, n = 29. HR, n = 45
Two Direct everStick C&B, (n = 66) and Ribbond, (n = 71) Flowable resin: Tetric Flow. Veneering: Tetric Ceram or Esthet.X Optibond solo total-etch 6 postgraduate residents Modified USPHS 93% (n = 127/137) at 2 years
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Jun 19, 2018 | Posted by in General Dentistry | Comments Off on Longevity of fiber-reinforced composite fixed partial dentures (FRC FPD)—Systematic review
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