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1); 7279
SUMMARY The objective of this report is to summa- bonded bridges 877%. Moreover, after 10 years of
rize the results on survival and complication rates of function the estimated survival decreased to 892%
different designs of fixed dental prostheses (FDP) for conventional FDP, to 803% for cantilever FDP,
published in a series of systematic reviews. More- to 867% for implant-supported FDP, to 778%
over, the various parameters for survival and risk for combined tooth-implant-supported FDP, to
assessment are to be used in attempt to perform 894% for implant-supported SC and to 65% for
treatment planning on the basis of scientific evi- resin-bonded bridges. When planning prosthetic
dence. Three electronic searches complemented by rehabilitations, conventional end-abutment tooth-
manual searching were conducted to identify pro- supported FDP, solely implant-supported FDP or
spective and retrospective cohort studies on FDP implant-supported SC should be the first treatment
and implant-supported single crowns (SC) with a option. Only as a second option, because of reasons
mean follow-up time of at least 5 years. Patients had such as financial aspects patient-centered prefer-
to have been examined clinically at the follow-up ences or anatomical structures cantilever tooth-
visit. Failure and complication rates were analyzed supported FDP, combined tooth-implant-supported
using random-effects Poisson regression models to FDP or resin-bonded bridges should be chosen.
obtain summary estimates of 5- and 10-year survival KEYWORDS: treatment planning, fixed dental pros-
proportions. Meta-analysis of the studies included theses, dental implants, implant dentistry, resin
indicated an estimated 5-year survival of conven- bonded bridges, systematic review, survival, success,
tional tooth-supported FDP of 938%, cantilever FDP longitudinal, failures, complications, technical com-
of 914%, solely implant-supported FDP of 952%, plications, biological complications
combined tooth-implant-supported FDP of 955%
and implant-supported SC of 945% as well as resin- Accepted for publication 4 November 2007
2008 The Authors. Journal compilation 2008 Blackwell Publishing Ltd doi: 10.1111/j.1365-2842.2007.01824.x
TREATMENT PLANNING OF FIXED RECONSTRUCTIONS 73
has to be based on the highest level of evidence review (11). In addition, results from 5-year studies of
available (4, 5). The studies in the dental literature resin-bonded bridges (RBB) (12) were added to the data
reporting on tooth-supported and implant-supported bank of the review mentioned (11). All searches were
FDPs are mostly observational studies and single center complemented by manual searches of the bibliogra-
case cohorts studies, both prospective and retrospective phies of all full text articles and related reviews, selected
in nature. from the electronic search.
Randomized controlled clinical trials (RCT), would
best be conducted in a multicentre setting with long
Inclusion criteria
enough follow-up time and sample sizes that allow
estimating relevant differences between the outcomes In the absence of RCT, this report is based on prospec-
of the treatments. However, it must be kept in mind tive or retrospective cohort studies. The additional
that to detect with an 80% power and at the signifi- inclusion criteria for study selection were that: (i) the
cance level of 5% a clinically relevant difference of an studies had a mean follow-up time of 5 years or more,
annual rate of failures a two-arm study would need to (ii) the included patients had been examined clinically
randomize over 1000 patients and to follow them for at at the follow-up visit, i.e. publications based on patient
least 5 years. It is evident that such studies are difficult records only, on questionnaires or interviews were
to perform, time-consuming and extremely costly. excluded; and (iii) the studies reported details on the
Therefore, it is understandable that the prosthetic characteristics of the suprastructures.
literature is depleted of such studies of high quality
and consequently, the professional must rely on studies
Data extraction
of a lower ranking in evidence level. The analysis in a
systematic review including meta-analysis may result in Survival was defined as the reconstruction remaining
the necessary power of analysis provided the studies are in situ at the follow-up examination visit irrespective of
homogeneous in nature. its condition. Success was defined as the reconstruction
Previously, a series of systematic reviews, based on that remained unchanged and did not require any
consistent inclusion and exclusion criteria, summarized intervention during the entire observation period.
the available information on survival and success rates Biological complications for tooth-supported recon-
and the incidence of biological and technical complica- structions covered dental caries, loss of pulp vitality and
tions of conventional FDP, cantilever FDP, combined periodontal disease progression. Biological complications
tooth-implant-supported FDP and solely implant-sup- for implant and combined tooth-implant-supported
ported FDP as well as implant-supported SC (610). reconstructions were characterized by a biological pro-
These reviews have been updated and completed in a cess affecting the supporting tissues.
recent systematic review (11). For that endeavour, the Technical complications for tooth-supported recon-
relevant literature had been searched up to July 2006. structions encompassed loss of retention, abutment
The aim of the present report is to utilize available tooth fractures and fractures, or deformations of the
evidence on survival and risk assessment to perform framework or veneers. Technical complications for
evidenced-based treatment planning for fixed recon- implant and combined tooth-implant-supported recon-
structions. structions denoted mechanical damage of implants,
implant components and or the suprastructures.
Among these, fractures of the implants, fracture of
Materials and methods
screws or abutments, loss of retention, fractures or
Originally, three MEDLINE (PubMED) searches were deformations of the framework or veneers, loss of the
performed for articles published in the Dental Litera- screw access hole restoration and screw or abutment
ture. The first search, covered the time period from loosening were included.
1966 to April 2004 (69), and the second one the period Survival estimates and complication rates were used
of May 2004 to July 2006 (11). In a supplementary for decision-making. The following clinical situations
search of the dental literature up to August 2007 using will be addressed:
the same search strategy no additional studies were 1 Single tooth gaps in the anterior maxilla.
identified to influence the outcome of the systematic 2 Single tooth gaps in the anterior mandible.
Table 1. Summary of annual failure rates, relative failure rates and 5-year survival estimates
5-year survival
Type of Total number of Total exposure Mean follow-up Estimated annual summary estimate,
reconstructions reconstructions time time failure rate % (95% CI)
Table 2. Summary of annual failure rates, relative failure rates and 10-year survival estimates
10-year survival
Type of Total number of Total exposure Mean follow-up Estimated annual summary estimate,
reconstructions reconstructions time time failure rate % (95% CI)
3 Single tooth gaps in the posterior region. exposure years and Poisson regression with a logarith-
4 Multiple gaps in the anterior maxilla. mic link-function and total exposure time per study as
5 Multiple gaps in the anterior mandible. an offset variable were used (13, 14). All analyses were
6 Multiple gaps in the posterior region. performed using Stata, version 82*.
7 Free-end situation with missing molars.
8 Free-end situation with missing premolars and
Results
molars.
Consideration will be given to the vitality of the Meta-analysis of the included studies indicated an
teeth, the remaining tooth structure, the presence or estimated 5-year survival of conventional tooth-sup-
absence of reconstructions on adjacent teeth and the ported FDP of 938%, cantilever FDP of 914%, solely
morphology of the alveolar bone in edentulous areas. implant-supported FDPl of 952%, combined tooth-
implant-supported FDPl of 955% and implant-sup-
ported SC of 945% as well as resin-bonded bridges
Statistical analysis
877% (Table 1). Moreover, after 10 years of function
Failure and complication rates were calculated by the estimated survival decreased to 892% for conven-
dividing the number of events (failures or complica- tional FDP, to 803% for cantilever FDP, to 867% for
tions) in the numerator by the total exposure time of implant-supported FDP, to 778% for combined tooth-
the reconstruction in the denominator. implant-supported FDP, to 894% for implant-sup-
The event rates for reconstructions were calculated ported SC and to 65% for resin-bonded bridges
by dividing the total number of events by the total (Table 2).
reconstruction exposure time in years. For further
analysis, the total number of events was considered to
be Poisson distributed for a given sum of reconstruction *Stata Corp. College Station, Texas, USA.
although the risks for complications with the incorpo- On the other hand, it has to be considered that the
ration of conventional FDP (Fig. 5) appear to be lower incidence of technical complications such as ceramic
than in the maxilla. Tissue volume and morphology of fractures or chipping is generally higher for implant-
the alveolar bone may, however, dictate the necessity supported (annual complication rate of 184%) than for
of augmentation procedures that are difficult to per- tooth-supported reconstructions (annual complication
form and often result in unpredictable outcomes. rate of 059%) (11).
Therefore, unfavourable morphologic conditions may
preclude the possibility of an otherwise preferred
Free-end situation with missing molars
implant-supported reconstruction. Evidence for the
incorporation of multi-unit RBB in the anterior man- The treatment options available to replace missing
dible is lacking (12). molars with fixed reconstructions are the implant-
supported SC or the tooth-supported cantilever FDP.
The former presented with a very favourable annual
Multiple missing adjacent teeth in the posterior region
failure rate (112%) (11), while the latter yields a
As opposed to the opinion expressed during previous higher annual failure rate of 220% (11). It is evident
decades in which implant-supported reconstructions
were not yet considered a predictable treatment, large
edentulous gaps may, today, be reconstructed prefera-
bly with implant-supported FDP (Fig. 6). The shorter
extension of these usually reduces the biomechanical
risks encountered with long-span conventional FDP.
that the implant-supported SC (Fig. 7) is preferred over tooth-implant-supported FDP may be performed. These
the tooth-supported cantilever FDPs provided the bone yielded an annual failure rate of 220% (11) and 251%
morphology favours implant installation. If the adjacent (7, 11) respectively. It is evident that aspects other that
teeth of the free-end saddle are to be restored, the those of longevity and complication rates may domi-
tooth-supported cantilever FDP may be chosen. How- nate the decision-making process. For example, ana-
ever, it has to be realized that non-vital endodontically tomical situations may dictate choosing the second
treated terminal-abutments present with an increased option treatments.
risk for tooth fractures when compared with vital end-
abutments (16, 17).
Conclusions
Prior to choosing a treatment option for missing
molars an evaluation of the subjective chewing capacity When planning prosthetic rehabilitations, conventional
and the functional needs of the patient regarding molar end-abutment tooth-supported FDP, solely implant-
replacement has to be made. Shortened dental arches supported FDP or implant-supported SC should be
with bilateral premolar occlusion provide a reasonable the first treatment option. Cantilever tooth-supported
and individually optimal, restricted treatment goal in FDP, combined tooth-implant-supported FDP or resin-
many patients (1820), presenting an option where no bonded bridges should only be chosen as a second
prosthetic reconstruction is needed. option.
For conventional tooth-supported FDP, the most
frequent complications were biological complications
Free-end situation with missing premolars and molars
such as caries and loss of pulp vitality. For cantilever
In these situations, increasing subjective chewing com- FDP, the incidence of biological complications was
fort is a desire in most patients. In addition to the similar to that of conventional FDP. Technical compli-
options discussed above for the free-end situation with cations such as loss of retention and material fractures
missing molars, tooth-implant-supported FDP, solely were, however, more frequent.
implant-supported FDP and multiple implant supported For implant-supported reconstructions, the inci-
SC may be considered. From a longevity point of view, dence of biological complications, such as mucositis
the first category of preferred options include solely and peri-implantitis was similar for solely implant-
implant-supported FDP (Fig. 8) and multiple implant- supported, combined implant-tooth-supported FDP
supported SC. These presented with an annual failure and implant-supported SC. Fractures of the veneer
rate of 143% (6, 11) and 112% (11), respectively, material (ceramic fractures), abutment or screw loos-
based on the 10-year data. As a second option, the ening and loss of retention were the most frequently
tooth supported cantilever FDP and the combined encountered technical complications. Fractures of the
veneer material was more frequent in studies report-
ing on gold-acrylic than metal-ceramic reconstruc-
tions.
The incidence of complications is substantially higher
in implant-supported than in tooth-supported recon-
structions. This, however, does not necessarily imply
that the possibilities for corrective measures are more
cumbersome. Although a variety of subjective and
objective aspects heavily influence the choice of treat-
ment modalities, the knowledge of survival and com-
plication rates of various reconstructions based on the
long-term studies certainly help in optimizing the
decision process.
Fig. 8. Several years ago, the patient lost all his premolars and
molars in the maxilla. He had difficulties adjusting to a removable
dental prosthesis. Bilateral sinus floor elevations were performed, Conflicts of interest
and five implants were placed to support one three-unit and one
four-unit FDP. Both authors declare no conflicts of interest.