Ken Tan
Bjarni E. Pjetursson
Niklaus P. Lang
Edwin S. Y. Chan
A systematic review of the survival and
complication rates of fixed partial
dentures (FPDs) after an observation
period of at least 5 years
III. Conventional FPDs
Authors’ affiliations:
Ken Tan, National Dental Center, Singapore,
Singapore
Bjarni E. Pjetursson, Niklaus P. Lang, School of
Dental Medicine, University of Berne, Berne,
Switzerland
Edwin S. Y. Chan, Clinical Trials and Epidemiology
Research Unit, Singapore, Singapore
Correspondence to:
Dr Ken Tan,
Department of Restorative Dentistry
National Dental Center Singapore
5 Second Hospital Avenue
Singapore 168938
Singapore
Tel.: (65)-63248947
Fax: (65)-63248900
e-mail: [email protected]
Key words: abutment fractures, biological, caries, fixed partial dentures, loss of retention,
loss of vitality, material fractures, periodontitis, success, survival, systematic review, technical complications
Abstract: The present study was done to determine the long-term success and survival of
fixed partial dentures (FPDs) and to evaluate the risks for failures due to specific biological
and technical complications. A MEDLINE search (PubMed) from 1966 up to March 2004 was
conducted, as well as hand searching of bibliographies from relevant articles. Nineteen
studies from an initial yield of 3658 titles were finally selected and data were extracted
independently by three reviewers. Prospective and retrospective cohort studies with a mean
follow-up time of at least 5 years in which patients had been examined clinically at the
follow-up visits were included in the meta-analysis. Publications only based on patients
records, questionnaires or interviews were excluded. Survival of the FPDs was analyzed
according to in situ and intact failure risks. Specific biological and technical complications
such as caries, loss of vitality and periodontal disease recurrence as well as loss of retention,
loss of vitality, tooth and material fractures were also analyzed. The 10-year probability of
survival for fixed partial dentures was 89.1% (95% confidence interval (CI): 81–93.8%) while
the probability of success was 71.1% (95% CI: 47.7–85.2%). The 10-year risk for caries and
periodontitis leading to FPD loss was 2.6% and 0.7%, respectively. The 10-year risk for loss
of retention was 6.4%, for abutment fracture 2.1% and for material fractures 3.2%.
Date:
Accepted 30 June 2004
To cite this article:
Tan K, Pjetursson BE, Lang NP, Chan ESY. A
systematic review of the survival and complication rates
of fixed partial dentures (FPDs) after an observation
period of at least 5 years. III. Conventional FPDs.
Clin. Oral Impl. Res. 15, 2004; 654–666
doi: 10.1111/j.1600-0501.2004.01119.x
Copyright r Blackwell Munksgaard 2004
654
Fixed partial denture (FPD) replacements
for teeth have taken a variety of designs
throughout the years. Many principles involved in the preparation and construction
of fixed prostheses are still dominating,
although more compatible and resilient
materials have been introduced in recent
years. Owing to the variety of techniques
employed and materials used, failing reconstructions may be attributed to several
causes. While some studies based only on
surveys, attribute over 50% of failures to
the dentists and materials used (Maryniuk
& Kaplan 1986), other self-reported failures
were attributed to biological and technical
failures including secondary caries, loss of
retention and marginal defects (Swartz
et al. 1996).
Biological and technical complications
have been reported in a variety of studies.
However, most of the reports deal with
retrospective cohort studies after a defined
period of observation. Prospective controlled trials are almost non-existent as
there may be ethical problems with randomizing treatment procedures, while retrospective studies or studies with historical
controls have compared treatment outcomes over time. It has to be realized,
however, that retrospective studies may
be biased towards the selection of the
treatment deemed to be optimal at that
Tan et al . Systematic review of FPDs
time over other treatments. (Shugars et al.
1998; Aquilino et al. 2001).
Another difficulty in comparing failure
rates between studies arises from the fact
that the definition of failure used by the
different authors may be highly variable.
While some authors define a failure when
the entire fixed prostheses is no longer in situ
or requires immediate replacement (Leempoel et al. 1985; Karlsson 1989) other authors
report on ‘functional’ survival (Izikowitz
1985) or the occurrence of biological and
technical failures (Hämmerle et al. 2000).
The lifespan of fixed partial dentures is
usually in excess of 10 years. Longer observation periods, however, have rarely
been reported (Palmqvist & Swartz 1993;
Valderhaug et al. 1997) owing to patient
attrition. Some studies used telephone interviews and questionnaires (Randow et al.
1986; Glantz et al. 1993) while others
studies recalled patients for clinical examination. Consequently, these studies will
show a disparity in number of clinical cases
actually examined.
Many studies on failures used databases
from insurance claims (Rene et al. 1991;
Öwall et al. 1992) and others incorporated
patients who complained of problems at
dental institutions (Schwartz et al. 1970;
Foster 1990a, 1990b). Due to the nature of
self-reporting, the length of service of restorations is usually approximated, and the
total number of a particular prostheses type
is unknown. In such instances, failure rates
are impossible to calculate. The progression of periodontal disease, loss of retention
of one or several retainers without the
entire bridge being detached (Ödman &
Karlsson 1988; Djemal et al. 1999), minor
ceramic fractures and other events may go
unnoticed by the patient.
The longevity and complication rate of
FPDs will be influenced by the level of
skills and academic knowledge of the clinician. Reports from academic institutions
presented reports on FPDs incorporated by
either undergraduate students under supervision, graduate students, junior and senior
faculty members, while patient cohorts
from private practice may also reflect a
variety of operator expertise, but conditions
clearly differ from the academic institutions. Hence, failure and complication
rates will always relate only to the patient
cohort treated and examined under the
circumstances specified.
Obviously, results from studies of patient cohorts should never be used to generalize the conditions encountered under
circumstances not fulfilling the criteria
pursued in the given patient cohort. In
particular, patients treated in institutions
may differ from those from private practice
as they may present with higher oral hygiene standards and be part of a strict
maintenance care program (Nyman &
Ericsson 1982).
This present study is aimed at
The determination of the long-term
success/survival of FPDs.
The evaluation of the failure rates of
FPDs due to specific biological and
technical complications.
Search Strategy
First electronic search
3658 Titles
Independently selected by 2 screeners
291 Titles
Kappa score 0.43
Discussion
Discarded
80 Titles
Agreed by both
211 Titles
Abstracts obtained
Discussion
Agreed on 73 abstracts
Full text obtained
Further handsearching
8 Studies
Total full text articles
81
Final number of studies included
19
Material and methods
Fig. 1. Search strategy.
Search strategy and study selection
Search strategy
A MEDLINE search (PubMed) 1966 up to
April 2004 was conducted for articles published in Dental Journals in the English
language searching for ‘fixed partial dentures OR bridges’, and ‘partial edentulism’.
Manual searching of (i) bibliographies of
previous reviews and (ii) bibliographies of
all publications complemented this review.
Since following a screening literature
search there were no randomized controlled trials available on the subject, only
prospective or retrospective cohort studies
with a mean follow-up time of at least 5
years were considered. This was to eliminate obvious iatrogenic reasons for failure
and faulty cementation techniques. Furthermore, only publications in English
and in which patients had been examined
clinically at the follow-up visits were included. Publications based on patients records, questionnaires or interviews were
excluded. Publications that combined findings of both FPDs and single crowns were
included only if at least two-thirds were
FPDs.
Figure 1 describes the process of identifying the 19 included studies from an initial
yield of 3,658 titles. This was independently done by two examiners (K. T. and
B. E. P.). The k statistics revealed a score of
0.43 indicating modest agreement. Consequently disagreements were resolved by
discussion. Data were then extracted
independently by three reviewers (K. T.,
B. E. P. and E. S. Y. C.) using a data
extraction form. Results of cantilever
FPDs have been reported elsewhere (Pjetursson et al. 2004a, 2004b).
Data extraction
The following parameters were analyzed.
Survival of FPDs
Survival was defined as an FPD that was in
situ at the examination visit irrespective of
its condition.
Success of FPD
Success was defined as an FPD that
remained unchanged and did not require
any intervention over the observation
period.
Biological complications
Caries.
Loss of pulp vitality.
Periodontal disease progression.
Technical complications
Loss of retention.
Abutment tooth fractures.
Material fractures (fractures of veneer or
framework).
655 |
Clin. Oral Impl. Res. 15, 2004 / 654–666
Tan et al . Systematic review of FPDs
Statistical analysis
The majority of the studies were characterized by an open cohort follow-up. Cohorts
with open follow-up have varying followup times and censoring progressively depletes the number of persons at risk. For
example, the loss of a FPD due to caries
would compete for the loss of the same
FPD due to abutment fracture if the former
occurred first.
In contrast, a closed cohort follow-up
of N-years is characterized by only the
event of interest (e.g. failure due to caries)
or survivors all with the same follow-up
time (N-years).
For cohorts with open follow-up, only
complication rates (not risks) are directly
calculable. Complication rates incorporate
total exposure time (FPD time and in some
instances abutment time) in the denominator. Total FPD exposure times were extracted and calculated by different means:
1.
2.
3.
4.
5.
Summation of individual observation
times for FPDs surviving and for FPDs
presenting with complications (Ericsson & Marken 1968; Libby et al. 1997;
Reichen-Graden & Lang 1989; Jokstad
& Mjör 1996; Hochman et al. 2003;
Walton 2003).
From the average observation time of
failed and surviving FPDs (Roberts
1970a, 1970b; Fayyad & al-Rafee
1996a, 1996b; Yi et al. 1996).
Using acturial approximation and information given at fixed observation
intervals (Valderhaug 1991; Sundh &
Ödman 1997).
Using the mean of the minimum and
maximum FPD follow-up times (Gustavsen & Silness 1986; Karlsson 1986).
From the standard exponential formula
linking N-year risk and the assumption of a constant complication rate.
(Gustavsen & Silness 1986; Karlsson
1986; Kelsey et al. 1996).
For the remaining studies, one study
reported a mean patient follow-up time
instead of a mean follow-up time to the
first complication (Napankangas et al.
2002), while another study did not report
the times to any specific complications at
all (Palmqvist & Swartz 1993). In two
reports, the number of FPDs lost to follow-up (Jokstad & Mjör 1996) and actual
number of FPDs (Glantz et al. 2002) was
not available. Finally for two studies
656 |
Clin. Oral Impl. Res. 15, 2004 / 654–666
(Reichen-Graden & Lang 1989; Walton
2003), information was obtained from personal communication with the authors to
facilitate exposure time calculations. In several studies, there was insufficient individual or average follow-up information about
particular complications. Consequently, total exposure time was not calculable and
hence, no failure rates were reported.
As the number of events was often too
small for the normal approximation formulas to be valid, 95% confidence intervals
for the rates were computed by exact
methods by assuming that the number of
events follow a Poisson distribution. Studies deemed similar enough by design were
pooled using negative binomial regression
with robust standard errors. This is equivalent to the random-effects Poisson regression models as described elsewhere
(Pjetursson et al. 2004a, 2004b) with the
added conservatism from estimating robust
standard errors. Ten-year survival risks were
calculated using the formula exp(-10x failure rate) which assumes constant event
rates. Ten-year failure risks were calculated
using 1-S(10).
Results
A total of 19 studies on conventional FPDs
met the inclusion criteria and were analyzed (Table 1). Seventeen were retrospective (Table 1a) and two were prospective
cohort studies (Table 1b). All these studies
incorporated 1764 patients with an age
range of 13–90 years. The sampling nonresponse rate for the group ranged from 3%
to 75% in the studies in which the information was available. Many studies
exceeded 10 years of follow-up and
consequently, many patients were unable
to return for follow-up examinations due to
physical and health limitations and death.
In the 19 studies selected, a variety of
different types of FPD were represented.
Despite this heterogeneity in FPD design,
patient selection and clinical setups, 3548
FPDs met the inclusion criteria and formed
the basis for the analysis. However, cantilever FPDs were not included and the
results of such reconstructions are reported
elsewhere (Pjetursson et al. 2004a, 2004b) .
A total of 3548 FPDs were analyzed over
a period 1–25 years (Table 2). Of the seven
studies that reported on FPD design (ac-
counting for 2094/3548 FPDs), 11.6%
were metal-ceramic while the others were
of gold–acrylic design. This distribution in
part reflects that there are few studies with
long follow-up of recent FPD design.
The follow-up time was reported in various ways: in some studies a range was
indicated (Ericsson & Marken 1968; Nyman & Lindhe 1979; Hochman et al. 1992;
Palmqvist & Swartz 1993; Yi et al. 1996;
Walton 2002; Hochman et al. 2003). In
others, the maximum observation times
(Gustavsen & Silness 1986; Karlsson
1986; Valderhaug 1991; Jokstad & Mjör
1996; Sundh & Ödman 1997; Glantz
et al. 2002), averages (Libby et al. 1997;
Nyman & Lindhe 1979; Bergenholtz &
Nyman 1984; Fayyad & al-Rafee 1996a,
1996b; Napankangas et al. 2002) or medians (Reichen-Graden & Lang 1989) were
reported.
Only six studies (Nyman & Lindhe
1979; Karlsson 1986; Sundh & Ödman
1997; Glantz et al. 2002; Napankangas
et al. 2002; Hochman et al. 2003) reported
on the sampling procedures. Four of these
also reported the non-response rate (Karlsson 1986; Yi et al. 1996; Sundh & Ödman
1997; Napankangas et al. 2002). The remainder did not provide adequate information to determine the quality of sampling.
Non-responders included patients who
died, changed their address, refused to be
re-examined, refused to fill in questionnaires or missed appointments due to
chronic illness and work commitments.
All studies represented open cohorts.
Therefore it was important to extract information on the total FPD exposure time
in order for the event rates to be calculated.
This required mean follow-up times to
specific complications including censoring
events (dropout, end of the study, competing events). However, most studies
reported complication risks as simple
proportions associated with the mean patient follow-up time instead of the mean
complication follow-up time.
Survival
Thirteen studies provided data for FPD
survival (Table 3). A total of 2881 FPDs
were observed for 6–23 years, and 374 of
these had been lost. Nine studies permitted
the calculation of FPD exposure times
using methods outlined. In two studies,
the data set was made available by the
657 |
Institutional patients. Selection data
unknown
Private patients by 3 dentists.
Selection data unknown
Institutional patients
Dental insurance plans, random
selection
Institutional periodontal patients.
Number not stated
Institutional periodontal patients
with 50% tissue support loss 251
patients, every consecutive fifth
patient
Institutional patients from register.
Number not stated
Private patients of one dentist.
Selection data unknown
43000 patients from a general dental
practitioners (GDP) requiring
extensive restoration. Random
selection
414 institutional patients random
selection
265 institutional patients consecutive
selection
Institutional patients. Number not
stated.
Institutional and private patients.
Number not stated
4200 institutional patients
Institutional patients from register.
Number not stated
Institutional and private patients.
Number not stated
Institutional patients for board exams
Institutional patients, random
selection, no periodontal involvement
Private specialist practice
Sampling frame and sampling
method
61
102
98
Data not available
50
Data not available
140w
642
88
68
50
122
Data not available
1764
40
102
72
Data not available
50
52
108
164
58
66
34
66
132
50
101
101n
Data not available
132
150
150
159
357
30
Actual no. of
patients in study
Data not available
Data not available
Planned no. of
patients in study
The 30 non-responders were replaced by re-sampling.
wRecalculated to be 140 instead of 143.
zStudy number indicative of studies with at least one follow up observation (prospective study).
n
Total
Jokstad & Mjör (1996)
(b) Prospective studies
Valderhaug (1991) 15 years
Ericsson & Markén (1968)
Roberts (1970a, 1970b)
Bergenholtz & Nyman
(1983)
Nyman & Lindhe (1979)
Reichen-Graden & Lang
(1989)
Gustavsen & Silness (1986)
Karlsson (1986)
Hochman et al. (1992)
Fayyad & al-Rafee (1996a,
1996b)
Yi et al. (1996)
Palmqvist & Swartz (1993)
Libby et al. (1997)
Sundh & Ödman (1997)
Napankangas et al. (2002)
Walton (1997), (2002),
(2003)
Glantz et al. (2002)
(a) Retrospective studies
Hochman et al. (2003)
Study (year)
Table 1. Study and patient characteristics
Mean age
25–69
23–72
21–68
34–78
26–72
33–45
50–81
21–90
39–82
48
29
48.7
47.1
50
58
67
63
52.9
56.8
48.2 males and
4748.9 females
13–74
Age range
Private dentist
Dental students
One private dentist
Specialist and postgraduates
Specialist clinic
Six specialists
Dental students
Private dentists
Dental students
Private dentist
Specialist clinic
Specialist clinic
University and private
Two specialists
Dental students
Dental students
Private dentists
Single specialist
Dental students
Operator
35
z
27 (28)
32 (23)
478 (75)
30 (34)
2 (3)
16 (32)
56 (46)
30 (30)
27 (17)
Non-response (%)
Tan et al . Systematic review of FPDs
Clin. Oral Impl. Res. 15, 2004 / 654–666
Tan et al . Systematic review of FPDs
Table 2. Information on FPDs in the included studies
Study (year)
Hochman et al. (2003)
Walton (1997), (2002), (2003)
Glantz et al. (2002)
Napankangas et al. (2002)
Sundh & Ödman (1997)
Libby et al. (1997)
Yi et al. (1996)
Fayyad & al-Rafee (1996a, 1996b)
Jokstad & Mjör (1996)
Palmqvist & Swartz (1993)
Hochman et al. (1992)
Valderhaug (1991)
Reichen-Graden & Lang (1989)
Karlsson (1986)
Gustavsen & Silness (1986)
Bergenholtz & Nyman (1984)
Nyman & Lindhe (1979)
Roberts (1970a, 1970b)
Ericsson & Markén (1968)
Original no. Total FPDs
of FPDs
515
49
515
n
n
540
163
81
103
108
Ceramic Gold/resin Total
Total
Mean FPD Follow-up Mean
abutments pontics length
range
follow-up
1209
204
138
21
89
43
156
100
59
103
34
138
108
0
73
238
60
114
82
332
0
1046 (1045)
88
3548w
885
117
4.3
238
256
146
224
11.5
1–25
1–15
6.3
2–15
18
1–25
14–15
7.6
18
8.4
14.5
5.1
10
18–23
4–17
15
6.4
10
6
8.7
56
69
108
178
88
487
569
343
182
944
259
150
662
5.6
3.5
6.8
260
164
4.8
5þ
332
1046
1–10
18–23
4–17
15
4–8
10
6
4–13
5–8
5–17
1–16
6.4
n
Total number of FPDs studied not stated.
w3548 does not include an indeterminate number of FPD from Glantz et al. (2002) and discrepancy of 1 FPD between Roberts (1970a, 1970b).
FPDs, fixed partial dentures.
Table 3. Survival of conventional FPDs
Study (year)
Total no.
of FPDs
Hochman et al. (2003)
Walton (2002)
Napankangas et al. (2002)n
Sundh & Ödman (1997)
Yi et al. (1996)
Palmqvist & Swartz (1993)
Hochman et al. (1992)
Valderhaug (1991)
Reichen-Graden & Lang (1989)
Gustavsen & Silness (1986)
Karlsson (1986)
Roberts (1970b)
Ericsson & Markén (1968)
Total
Pooled rates
49
515
204
163
43
103
138
108
73
114
238
1045
88y
2881
Mean
follow-up time
6.3
No. of FPDs
in situ (%)
43
478
197
103
43
79
129
59
71
111
231
828
87
No. of
failures
Total FPDs
exposure time
(87.8)
(92.8)
(96.6)
(76.8)
(100)
(77)
(93.5)
(54.6)
(97.3)
(97.4)w
(97.1)z
(79.2)
(98.8)
6
324
37
3363
7.6
7
1478
16–18
35
2532
14.7
0
632
18–23
24
Data not available
4–17
9
Data not available
15
26
1263
6.4
2
465
6
3
676
10
7
2348
5.1
217
5132
6.4
1
560
374
18,773
Estimated FPD failure rate (95% CI)
Estimated 10-year FPD survival (95% CI)
FPD failure
rate (95% CI)
0.019 (0.006, 0.04)
0.011 (0.008, 0.015)
0.005 (0.002, 0.01)
0.014 (0.01, 0.019)
0 (0, 0.006)
0.021
0.004
0.004
0.003
0.042
0.002
(0.013, 0.03)
(0.001, 0.016)
(0.001, 0.013)
(0.001, 0.006)
(0.04, 0.05)
(0.00004, 0.01)
0.0116 (0.0061, 0.022)
89.1 (81–93.8)
n
10-year FPD in situ survival risk is 84% (Fig. 1) (Napankangas et al. 2002).
wThe 6-year in situ failure risk for Gustavsen & Silness (1986) was 2.6%.
zKarlsson (1986) has different definition of FPD in function. He deemed those totally and partially removed as ‘no longer in function’.
yEricsson & Markén (1968) – one failure was added to the total of 87 observed FPDs as reported and given a follow-up time of 6 years (average follow-up
time).
FPDs, fixed partial dentures; CI, confidence interval.
authors (Reichen-Graden & Lang 1989;
Walton 2002), while for the other two,
the data provided were inadequate (Hochman et al. 1992; Palmqvist & Swartz
1993).
The pooled rate for FPD loss was 11.6
(95% CI: 6.1–22%)/1000 FPD-years.
Hence, the 10-year FPD survival was
89.1% (95% CI: 81–93.8%).
658 |
Clin. Oral Impl. Res. 15, 2004 / 654–666
Figure 2 presents the Forrest plot of the
meta-analysis performed for all the studies
with adequate information for FPD survival. It is evident that one study (Roberts
1970a, 1970b) represents an outlier with a
substantial higher rate of FPD loss than the
other studies. A sensitivity analysis excluding this study (Roberts 1970a, 1970b)
gives a pooled loss rate of 8.3 (95% CI:
4.9–14%)/1000 FPD-years and a 10-year
risk of survival of 92%.
FPD success
Four studies provided information on FPDs
that remained intact over the observation period (Fig. 3, Table 4). The pooled
FPD complication rate was 34.1 (95% CI:
16–74%)/1000 FPD years. Hence, the
Tan et al . Systematic review of FPDs
10-year risk of success of FPD was 71.1%
(95% CI: 47.7–85.2%). It is evident that
one study (Fayyad & al-Rafee 1996a,
1996b) represents an outlier with a substantial higher FPD complication rate than
the other studies. When excluded, the FPD
loss rate was 21 (95% CI: 9.8–43)/loss
FPD-years and the 10-year risk of success
was 81.1%. The study with the lowest
failure rate (Walton 2002) contributed
63% of the total FPD exposure.
Hochman
Walton
Napankangas
Sundh
Yi
Valderhaug
Reichen-Graden
Gustavsen
Karlsson
Biological complications
Roberts
Dental caries
Ericsson
11.6 (95% CI: 6.1 - 22.0)
0
10
20
30
40
50
60
70
80
Failures per 1000 FPD-years
Fig. 2. Failure rates (per 100 years) of conventional fixed partial dentures (FPDs). CI, confidence interval.
Walton
Caries was reported on the surface, abutment and the FPD levels:
Only one study (Karlsson 1986) addressed dental decay on a surface level
and found 8.1% of all surfaces being decayed within 10 years.
Studies that reported the development of
caries of abutments were divided into those
reporting on caries of abutments
(1)
(2)
Libby
Fayyad
Reichen-Graden
34 (95% CI: 16 - 74)
0
10
20
30
40
50
60
70
80
90
100 110
Complications per 1000 FPD-years
Fig. 3. Complication rates (per 100 years) of conventional fixed partial dentures (FPDs). CI, confidence
interval.
not leading to the loss of the abutment
or FPD and
those that resulted in the loss of the
abutment.
Six studies gave information on caries
occurring on abutments. In two studies
with a 10-year follow-up (Karlsson 1986;
Jokstad & Mjör 1996), high caries occurrence was reported (16–23%), while the
other 4 studies revealed a substantially
lower occurrence of caries ranging from
1% to 7% over the observation period.
Three studies reporting on caries resulting
in loss of abutments were excluded from
Table 5a (Hochman et al. 1992; Palmqvist
& Swartz 1993; Yi et al. 1996) as minor
caries was not included in their reports.
The pooled rate of caries on the abutment level was 9.9/1000 abutment years.
Hence, the 10-year risk for caries on
Table 4. Success rate of FPDs in situ (without any complication)
Study (year)
Total no.
of FPDs
Walton (2002)
Libby et al. (1997)
Fayyad & al-Rafee (1996a, 1996b)
Reichen-Graden & Lang (1989)
Total
Pooled rates
515
89
156
73
833
Mean
follow-up
time
8.4
5.1
6.4
Intact
FPDs (%)
470
76
100
56
(91.3)
(85.4)
(63.8)
(76.7)
No. of
complications
45
13
56
17
131
Estimated FPD complication rate (95% CI)
Estimated 10-year FPD success (95% CI)
Total FPDs
exposure time
3363
759
792
465
5379
FPD complication
rate (95% CI)
0.013
0.017
0.071
0.037
(0.01, 0.018)
(0.01, 0.03)
(0.05, 0.09)
(0.021, 0.059)
0.034 (0.016, 0.074)
71.1 (47.7, 85.2)
FPDs, fixed partial dentures; CI, confidence interval.
659 |
Clin. Oral Impl. Res. 15, 2004 / 654–666
Tan et al . Systematic review of FPDs
Table 5a. Caries rate of abutment teeth (caries as a complication)
Study (year)
Walton (2002)
Libby et al. (1997)
Jokstad & Mjör (1996)
Reichen-Graden & Lang (1989)
Karlsson (1986)
Gustavsen & Silness (1986)
Total
Pooled rates
Total no.
of FPDs
Total no. of
abutments
515
89
1209
238
135
z
944
210
73
238
114
1029
Mean
follow-up
time
8.4n
10
6.4 median
10
6
No. of carious
abutments (%)
Total abutment
exposure
time
Abutment
caries rate
(95% CI)
8 (0.7)
15w (6.3)
21
5
212 (22.5)y
4 (1.9)
7894
2030
1078
901
9314
1260
22,477
0.001
0.007
0.019
0.006
0.025
0.003
Estimated abutment complication rate (95% CI)
Estimated 10-year risk for caries at abutments (95% CI)
(0.0004, 0.002)
(0.004, 0.012)
(0.12, 0.03)
(0.002, 0.013)
(0.02, 0.023)
(0.001, 0.008)
0.010 (0.0047, 0.021)
9.5 (4.6–18.9)
n
Follow-up time is calculated from survival curve (Fig. 1) for FPDs.
wFifteen abutments were computed from 238 retainers/89 FPDs approximated to three retainers/FPD. Multiplied by 5 FPDs affected by caries ¼ 15 retainers.
Total abutment time is upper limit.
zAbutments for conventional and cantilever FPDs not differentiated. Approximated that 182 abutments for 94 FPDs in total ¼ 1.94 abutments/FPD.
1.94 464.6 (total FPD time for conventional FPD) ¼ total exposure time for abutments carrying conventional FPD.
yDental caries on tooth surfaces as reported in Karlsson (1986) was omitted as the numbers were indeterminate.
FPDs, fixed partial dentures; CI, confidence interval.
Table 5b. FPDs lost due to caries
Study (year)
Total no.
of FPDs
Mean
follow-up
Hochman et al. (2003)
Napankangas et al. (2002)
Sundh & Ödman (1997)
Reichen-Graden & Lang (1989)
Palmqvist & Swartz (1993)
Valderhaug (1991)
Total
Pooled rates
49
204
138
73
103
108
675
6.3
7.6
18n
6.4
18–23
15n
FPDs lost
due to
caries (%)
Total FPDs
exposure
time
3 (6.1)
324
2 (1)
1478
6 (4.3)
2532
0
465
1 (1)
Data not available
5 (6.2)
1263
17
6062
Estimated FPD failure rate (95% CI)
Estimated 10-year risk of FPD loss due to caries (95% CI)
Failure rate
(95% CI)
0.009 (0.002, 0.01)
0.001 (0.0002, 0.005)
0.002 (0.0009, 0.005)
0 (0, 0.008)
0.004 (0.001, 0.01)
0.0026 (0.0016, 0.0043)
2.6 (1.6–4.2)
n
Follow-up time represented in these studies are the maximum follow-up time.
FPDs, fixed partial dentures; CI, confidence interval.
Table 6. Loss of abutment tooth vitality
Study (year)
Total no. of
abutments
No. of
vitality
Jokstad & Mjör (1996)
Palmqvist & Swartz (1993)
Reichen-Graden & Lang (1989)
Karlsson (1986)
Bergenholtz & Nyman (1984)
Total
Pooled rates
Data not available
487
–
944
Data not available
86n
327
Mean
follow-up
time
No. of abutments
that lost
vitality (%)
10
18–23
6.4
10z
8.7
Total abutment
exposure time
5 (5.8)
686
49 (15)
Data not available
–
3 (3.7)
901
650w
73 (11.2)
6135
255
38 (14.9)
2219
1318
168
9941
Estimated abutment complication rate (95% CI)
Estimated 10-year risk for loss of abutment vitality (95% CI)
Complication rate
(95% CI)
0.007 (0.002, 0.017)
0.003 (0.001, 0.01)
0.012 (0.009, 0.015)
0.017 (0.012, 0.024)
0.011 (0.0059, 0.019)
10.0 (5.7–17.3)
n
Not inclusive of dropouts.
wNine abutments with root fill through the retainer were presumed vital at time of cementation.
zFollow-up time represented in these studies are the maximum follow-up time.
CI, confidence interval.
the abutment level was 9.5% (95% CI:
4.6–18.9%).
Caries reported on the FPD level leading
to the loss of the FPD was addressed in 6
studies (Table 5b). Seventeen out of 675
FPDs were lost as a result of caries. One
study (Palmqvist & Swartz 1993) did not
660 |
Clin. Oral Impl. Res. 15, 2004 / 654–666
contain sufficient information for the calculation of a caries rate at the FPD level.
The pooled rate for caries resulting
in loss of FPD was 2.6/1000 FPD
years. Hence, the 10-year risk for loss of
FPD due to caries is 2.6% (95% CI:
1.6–4.2%).
Loss of abutment vitality
Loss of abutment vitality was reported in
five studies with a 6–23 years of follow-up
time (Table 6). One study (Bergenholtz &
Nyman 1984), specifically addressing loss
of vitality in patients reconstructed after
successful therapy for advanced perio-
Tan et al . Systematic review of FPDs
dontitis, reported the highest loss rate of
17/1000 abutment years. Significantly
higher loss of vitality was observed in
abutments when compared with nonprepared control teeth. Several authors
reported ‘endodontic complications’, without mentioning the baseline vitality status
(Libby et al. 1997; Fayyad and al-Rafee
1996a, 1996b; Sundh & Ödman 1997;
Napankangas et al. 2002). Consequently
these studies were excluded.
The loss of vitality rates was not calculable for one of the five studies (Palmqvist
& Swartz 1993), as total abutment time
was unavailable.
The pooled rate for loss of abutment
vitality was 11/1000 abutment years.
Hence, the 10-year risk for loss of abutment vitality is 10% (95% CI: 5.7–17.3%).
7). Of the 1080 bridges followed for periods
ranging from 4 to 18 years, only seven were
lost due to recurrent periodontitis. One
study (Fayyad & al-Rafee 1996a, 1996b),
however, reported recurrent periodontitis
to affect abutments of 12.8% of the FPDs
after only 5.1 years. Since the information
provided did not differentiate between
periodontitis reported as a complication or
periodontitis leading to the loss of the FPD,
it was excluded from the analysis. Furthermore, one study did not provide sufficient
information for the calculation of total
exposure time (Hochman et al. 1992).
The pooled rate for recurrent periodontitis leading to FPD loss was 0.5/1000
FPD years. Hence, the 10-year recurrent
periodontitis risk was 0.5% (95% CI:
0.1–2.2%).
Technical complications
Recurrent periodontitis
Nine studies provided information on
periodontal disease progression resulting
in loss of abutment teeth or FPDs (Table
Loss of retention (fracture of the luting cement)
Nine studies addressed loss of retention of
the reconstruction (Table 8). Loss of reten-
tion affected 75 out of 1307 FPDs observed
over a period of 5–23 years. Two studies
(Gustavsen & Silness 1986; Karlsson 1986)
reported high occurrences of loss of retention. This correlated to the increased occurrence of caries reported in one of them
(Karlsson 1986).
The pooled rate for loss of retention was
6.6/1000 FPD-years. Hence, the 10-year
risk for loss of retention is 6.4% (95% CI:
3.9–10.4%).
Fracture of the abutment teeth
leading to FPD loss
The occurrence of fracture of abutments
leading to the loss of FPDs was reported
in seven studies (Table 9). Over a period
of 6–18 years, 16 of a total of 749 FPD
were lost due to abutment fracture. In
one study, it was specifically stated that
no FPDs had been lost as a result of
abutment fracture (Ericsson & Marken
1968).
The pooled rate of abutment fracture
leading to FPD loss was 2.2/1000 FPD
Table 7. Loss of FPDs due to periodontal disease
Study (year)
Total
FPDs
Mean
follow-up time
Napankangas et al. (2002)
Sundh & Ödman (1997)
Libby et al. (1997)
Yi et al. (1996)
Hochman et al. (1992)
Valderhaug (1991)
Reichen-Graden & Lang (1989)
Gustavsen & Silness (1986)
Nyman & Lindhe (1979)
Total
Pooled rates
204
138
89
43
138
108
73
114
173
1080
7.6
18n
8.4
14.7
4–17
15n
6.4
6n
6.2
FPDs lost due
to periodontitis (%)
Total FPDs
exposure time
0 (0)
1478
4 (2.9)
2532
0 (0)
759
0 (0)
632
1 (0.7)
Data not available
2 (2.5)
1263
0 (0)
465
0 (0)
676
0 (0)
1073
7
8878
Estimated FPD failure rate (95% CI)
Estimated 10-year risk of FPD loss due to periodontitis (95% CI)
Failure rate (95% CI)
0 (0, 0.003)
0.002 (0.0004, 0.004)
0 (0, 0.005)
0 (0, 0.006)
0.002 (0.00002, 0.006)
0 (0, 0.008)
0 (0, 0.005)
0 (0, 0.003)
0.0005 (0.0001, 0.0022)
0.5 (0.1–2.2)
n
Follow-up time represented in these studies are the maximum follow-up time.
FPDs, fixed partial dentures; CI, confidence interval.
Table 8. Loss of retention
Study (year)
Total no.
of FPDs
Mean
follow-up time
Napankangas et al. (2002)
Sundh & Ödman (1997)
Fayyad & al-Rafee (1996a, 1996b)
Palmqvist & Swartz (1993)
Valderhaug (1991) 15 years
Reichen-Graden & Lang (1989)
Karlsson (1986)
Gustavsen & Silness (1986)
Nyman & Lindhe (1979)
Total
Pooled rates
204
138
156
103
108
73
238
114
173
1307
7.6
18
5.1
18–23
15
6.4
10
6
6.2
FPDs that lost
retention (%)
Total FPD
exposure time
Complication rates (95% CI)
3 (1.5)
1478
3 (2.2)
2532
7 (4.5)
792
8 (7.8)
Data not available
7 (3.7)
1263
3 (4.1)
465
30 (12.6)
2348
8 (7)
676
6 (3.5)
1073
75
10,627
Estimate FPD complication rate (95% CI)
Estimated 10-year risk for loss of retention (95% CI)
0.002 (0, 0.006)
0.001 (0.0002, 0.003)
0.009 (0.004, 0.02)
0.006
0.007
0.013
0.012
0.006
(0.002,
(0.001,
(0.009,
(0.005,
(0.002,
0.01)
0.018)
0.018)
0.023)
0.012)
0.0066 (0.004, 0.011)
6.4 (3.9–10.4%)
FPDs, fixed partial dentures; CI, confidence interval.
661 |
Clin. Oral Impl. Res. 15, 2004 / 654–666
Tan et al . Systematic review of FPDs
Table 9. Loss of FPDs due to abutment tooth fracture
Study (year)
Total no.
of FPDs
Hochman et al. (2003)
Napankangas et al. (2002)
Sundh & Ödman (1997)
Libby et al. (1997)
Valderhaug (1991)
Reichen-Graden & Lang (1989)
Ericsson & Markén (1968)
Total
Pooled rates
49
204
138
89
108
73
88
749
Total no.
of abutments
238
343
260
Estimated
Mean
follow-up time
FPDs lost due to
tooth fracture (%)
6.3
7.6
18
8.4
15
6.4
2 (4.1)
5 (2.45)
4 (2.9)
1n (1.12)
3 (3.7)
1 (1)
0 (0)
16
Estimated FPD failure rate (95% CI)
10-year risk of FPD loss due to abutment fracture
Total FPD
exposure time
Failure rate (95% CI)
324
1478
2532
759
1263
465
560
7381
0.006 (0.0007. 0.01)
0.003 (0.001, 0.008)
0.002 (0.0004, 0.004)
0.001 (0.00003, 0.007)
0.002 (0.0005, 0.007)
0.002 (0, 0.012)
0 (0, 0.007)
(95% CI)
0.0022 (0.0015, 0.0032)
2.1 (1.4–3.2)
n
Assumed fracture led to loss of FPD.
FPDs, fixed partial dentures; CI, confidence interval.
Table 10. Fractures of material: framework, post and core and porcelain veneers
Study (year)
Total no. Mean
Material
Metal
of FPDs
follow-up fracture (%)
time
Hochman et al. (2003)
Walton (2002)
Napankangas et al. (2002)
Sundh & Ödman (1997)
Libby et al. (1997)
Fayyad & al-Rafee
(1996a, 1996b)
Palmqvist & Swartz (1993)
49
515
204
138
89
156
7.6
18
8.4
5.1
103
18–23
3 (2.9)
Hochman et al. (1992)
138
4–17
4 (2.9)
Valderhaug (1991)
108
Reichen-Graden & Lang (1989)
73
Karlsson (1986)
238
Nyman & Lindhe (1979)
173
Total
1984
Pooled rates
6.3
1
4
16
3
2
2
15
6.4
10
6.2
1
4
2
3
45
(2)
(0.8)
(6.9)
(2.2)
(2.2)
(1.3)
(1.2)
(5.5)
(0.8)
(1.7)
1
2
2
2
Ceramic Veneers Core Total FPD Complication
exposure rate (95% CI)
time
2
14
1
1
1
Some data
repeated
3
1
2
3
324
3363
1478
2532
759
792
Data not
available
Data not
available
1263
465
2348
1073
14,397
Estimate FPD complication rate (95% CI)
Estimated 10-year risk of material fractures (95% CI)
0.003
0.001
0.011
0.001
0.003
0.003
(0.00008, 0.01)
(0.0003, 0.003)
(0.006, 0.018)
(0.0002, 0.0003)
(0.0003, 0.01)
(0.003, 0.01)
0.001
0.008
0.001
0.003
(0.0002, 0.004)
(0, 0.012)
(0, 0.003)
(0.001, 0.008)
0.0032 (0.0015, 0.0068)
3.2 (1.5–6.5)
FPDs, fixed partial dentures; CI, confidence interval.
Table 11. Comparison of previous meta-analyses and present review
Review
Creugers et al. (1994)
Scurria et al. (1998)
Present review
Search dates
Language of paper
Number of studies
1970–1992
Dutch, English, German
7
Minimum follow-up
Definition of failure
5
In situ loss or in need of repair
Risk duration
Survival
Success
5 and 10 years
90%
1966–1996
English
4
9
3
In situ loss
In situ loss or in need of repair
10 and (15) years
92% (75%)
87% (69%)
1966–2004
English
13
4
5
Survival
Success
10 years
89.1%
71.1%
years. Hence, the 10-year risk for abutment fracture leading to FPD loss was
2.1% (95% CI: 1.4–3.2%).
Material complications: framework,
veneer and core fractures
Twelve studies reported on the occurrence
of material complications over an observa-
662 |
Clin. Oral Impl. Res. 15, 2004 / 654–666
tion period between 4 and 23 years (Table
10). These included fractures of the framework, the veneers or the core build-ups.
Where information was available, the fractures were recorded as separate categories.
Forty-five out of 1984 FPDs were affected
by material complications. The pooled rate
of material complications was 3.2/1000
FPD years. Hence, the 10-year risk for
material complications was 3.2% (95%
CI: 1.5–6.5%).
Discussion
Long term prospective cohort studies are
the gold standard for determining the sur-
Tan et al . Systematic review of FPDs
vival experience of FPDs. Out of the original yield of 3658 titles, only 19 studies
qualified for the inclusion into the review
and yet, for some aspects of analysis, the
number of studies with valid information
was reduced to a few studies only. Survival
and success rates of the FPDs could be
calculated for most of the studies included.
However, the results of the analysis for the
occurrence of biological and technical complications was drastically affected by the
incompleteness of reported data in the
majority of the studies. Furthermore, it is
evident from the present analysis that most
of the studies on the longevity of FPDs date
back to the 1980s and 1990s, and there is a
paucity of studies performed in the new
century. Consequently, caution must be
exercised to the interpretation of technical
complications such as veneer fractures,
since most of the studies available for
analysis would have reported on gold-acrylic FPDs.
The focus of the present analysis was on
a comprehensive evaluation of survival and
success rates of FPDs. This, in turn, required a calculation of the exposure times
of FPDs. In the present review, all the
studies represented open cohorts that required various methods to calculate FPD
exposure times.
A direct comparison on simple proportions would seriously mislead due to the
differing follow-up times. For the complications of loss of vitality of abutments and
loss of retention of FPDs the rate may be
underestimated due to a larger denominator (loss of retention may have occurred
earlier, but the FPD remained in situ and
thus, accounted for a longer exposure
time). To compare the risk of survival and
success as well as the various complications risks, 10-year risks were estimated
from the event rates.
Survival and success
As a result of the meta-analysis of the
present systematic review, the 10-year
risk of survival of FPDs was 89.1%. This
is similar to the 10-year survival risk of
FPDs reported in previous meta-analyses
(90% and 92%, respectively) (Creugers
et al. 1994; Scurria et al. 1998). The latest
search date for the two analyses were 1992
and 1996, respectively. In the present review, 10 additional studies have been included since 1992 and 6 studies since
1996. In one previous review, studies reported in German and Dutch were included (Creugers et al. 1994) while the
second review (Scurria et al. 1998) was
limited, like the present, to studies reported in English only.
Several papers that were incorporated in
the previous reviews had to be excluded
from the present analysis as they did not
meet the inclusion criteria. In three of the
excluded studies, the mean follow-up time
was less than 5 years (Reuter & Brose
1984; Cheung et al. 1990), while in another two studies (Randow et al. 1986;
Leempoel et al. 1995) data on survival
and complication of the FPDs were obtained from questionnaires without patient
contact. In addition, the previous analyses
required data to be reformulated from life
table analyses that led to the calculation of
N-year risks. In the present review, however, the failure rate was directly estimated
from the exposure times and the 10-year
survival from the relationship between
event rate and survival function. The present 10-year survival rate is affected by one
large study with over 1000 FPDs and a low
10-year survival (Roberts 1970a, 1970b). If
this particular study is excluded from the
analysis, the 10-year survival rate of FPDs
rises to 92.1%.
From the Forrest plot of study-specific
failure rates, it is evident that these vary
widely among the various studies. This
may be attributable to the patient cohort
observed, the design and extent of the FPD,
the maintenance care provided and the
experience and clinical setup of the clinicians. Furthermore, in one study (Yi et al.
1996), some of the FPDs remained in
function, but 30% had portions sectioned,
or abutments removed. Within the definitions of survival, those prostheses remained in function, thus leading to 100%
survival despite the complications encountered. Yet, the effect of the vigorous maintenance regimen and regular follow-up for
this group of patients cannot be overlooked
as being contributory to the high survival.
The 10-year success risk of FPDs was
71.1%. This pooled rate was calculated
from only 4 studies. One of these had
yielded a very low success due to a high
rate of 71 complications/1000 FPD years
(Fayyad & al-Rafee 1996a, 1996b). If this
particular study is excluded from the analysis, the 10-year success risk of FPDs rises
to 81%. The reason for the low risk of
success in this study was the unusually
high occurrence of periodontal disease
(36.6%) and secondary caries (23.2%) leading to failure.
Biological complications
There were a limited number of studies
available that provided sufficient relevant
information to calculate the occurrence
of biological complications such as caries,
loss of abutment vitality and recurrent
periodontitis.
Information on caries was divided into
that which led to repair and that which led
to the loss of the FPD. The 10-year risk for
caries on abutments was 9.5%, but only
2.6% of FPDs were lost as a result of caries.
Only one study (Karlsson 1986) classified
marginal discrepancies and found a correlation between the worst marginal discrepancy (open margins) and the presence of
caries. Two studies reporting on a high
occurrence of caries also reported high
occurrence of loss of retention of FPDs
(Karlsson 1986; Jokstad & Mjör 1996).
However, no clear information on this
association can be determined.
Prosthodontic treatment is known to
cause pulp trauma by mechanical preparation and the contact of various substances
to opened dentinal tubules that may have
precipitated an early response of pulpal
necrosis. (Langeland & Langeland 1968;
Bergenholtz & Nyman 1984; Hume &
Massey 1990). However, from this metaanalysis on 5 studies, it was clear that loss
of vitality of abutment teeth occurred at a
later date than what could be attributed to
the trauma from the preparation of the
teeth. This may either indicate a slow
progressive tissue degeneration induced by
the procedure or reflect the increased susceptibility of pulpal infection by dentinal
tubules in advanced periodontitis (Bergenholtz & Nyman 1984). Pulpal necrosis was
diagnosed primarily on the basis of the
presence of periapical radiolucency (Bergenholtz & Nyman 1984; Gustavsen &
Silness 1986; Karlsson 1986; Reichen-Graden & Lang 1989; Palmqvist & Swartz
1993; Jokstad & Mjör 1996). One study
(Bergenholtz & Nyman 1984) compared
255 abutment teeth with 417 non-abutment teeth and found a higher incidence of
pulpal necrosis in abutment teeth (15% vs.
3%).
663 |
Clin. Oral Impl. Res. 15, 2004 / 654–666
Tan et al . Systematic review of FPDs
The pooled 10-year risk for loss of abutment vitality in the present review was
10%. In agreement with Bergenholtz &
Nyman (1984), it may, therefore, be recommended that patients treated with extensive FPDs should be closely monitored
for the loss of vitality of abutments.
The presence of cast post and dowels and
non-vital abutments especially in distal
abutments has been shown to be associated
with increased retention loss and fracture
of teeth and cores. This cautions against
over dependence on non-vital teeth as strategic abutments.
Based on nine studies, the 10-year risk of
loss of FPDs due to recurrent periodontitis
was only 0.5%. One study (Nyman &
Lindhe 1979) found that patients placed
on a rigorous maintenance programme
maintained gingival indices, probing depths
and alveolar bone heights for all 332 FPDs
throughout the entire observation period of
8–11 years. Another study (Reichen-Graden & Lang 1989) reported increased gingival indices in abutment teeth compared
with control teeth with increased plaque,
bleeding on probing on abutment teeth,
especially at sites where restoration margins had been placed subgingivally compared with control teeth and restorations
with supragingival margins. One study
(Ericsson & Marken 1968) found no significant differences in probing pocket
depths between abutments and control
teeth. Overall, there seemed to be no adverse changes in FPDs incorporated into
periodontally well-maintained patients
even if they presented with a history of
advanced periodontal disease. Where the
recall or maintenance was less stringent,
periodontal breakdown may occur, and
may be more pronounced when margins
were subgingivally located (Valderhaug &
Karlsen 1976). Secondary use of the bridge
for removable appliances also seemed to
have a detrimental effect on the gingiva
(Libby et al. 1997).
Technical complications
The 10-year risk for technical complications such as loss of retention, loss of FPD
due to abutment fracture and the occurrence of material complications were calculated. For any given cause, all other
causes of failure represent competing
events that reduce the precision of the
estimate of that given cause-specific failure
664 |
Clin. Oral Impl. Res. 15, 2004 / 654–666
rate, since the number of admissible events
is concomitantly reduced. Not all studies
reported the cause of FPD failures. Due
to the approximations used, the risks and
rates should be cautiously interpreted.
The highest 10-year risk was for loss of
retention amounting to 6.4%. In one longterm study (Ödman & Karlsson 1988) it
was found that patients were often unaware of loose retainers or even abutment
fractures. This questions the validity and
accuracy of survival figures from patient
surveys and questionnaires.
Far lower was the 10-year risk for the
loss of FPD due to abutment tooth fracture.
Based on seven studies, the 10-year risk
was 2.1%. One study (Nyman & Lindhe
1979) reported that 8/332 FPDs experienced an abutment fracture. Five out of
these eight occurred in distal extension
FPD abutments and six out of eight were
on non-vital and root-treated abutments.
Of particular interest, one study of 121
bridges (Reuter & Brose 1984) found a
higher incidence of abutment failure if
root canal treatment had been performed
after bridge cementation compared with
vital abutments and those that had been
root treated before construction of the
bridge.
Similar relatively low 10-year risks
were obtained for material complications.
These included fractures of the framework,
veneers and/or cores and amounted to a
10-year risk of 3.2%.
In one study (Libby et al. 1997) wear
through the occlusal surface occurred in
two out of 89 FPDs while one out of 89
FPDs showed a porcelain fracture. In a
study (Karlsson 1986) of both acrylic-veneered FPDs and porcelain bonded to gold
FPDs, tootbrush wear on acrylic-veneered
FPDs occurred in 78 out of 1207 units or
6.4%, and porcelain fracture in 14 out of
331 units corresponding to 4.2% of porcelain fused to gold units. A comparison of
the difference in survival between FPDs
with acrylic facings and metal ceramic
FPDs showed that over an 18-year period,
38% of FPDs with acrylic facings and 4%
with metal ceramic FPDs were replaced
(Sundh & Ödman 1997). Reasons cited
for the increase in failures were the greater
incidence of discoloration and fracture after
extensive wear of acrylics.
In conclusion, from the studies included,
the pooled failure rates of fixed partial
dentures requiring intervention but leaving
the FPD in situ were lower than that of
FPDs remaining totally intact during the
observation period. Caries and loss of abutment vitality were the most common
biological complications, while loss of retention of the FPD was the most common
technical complication. Fracture of abutment teeth and material complications
occurred less frequently.
In comparison with the two previous
meta-analyses of 1994 (Creugers et al.
1994) and 1998 (Scurria et al. 1998) (Table
11), the present systematic review by and
large confirmed the survival and success
rates published. On the other hand, complication rates for both biological and technical complications have hitherto not been
reported in a systematic way.
This analysis has revealed that within a
10-year time frame, FPD loss due to biological complications amounted to 2.6% and
0.5% for caries and recurrence of periodontitis, respectively, while technical complications within the same time frame
had much higher risks of FPD loss. The
highest biological complication rate was
loss of abutment vitality, which later on
may lead to technical complications. On
the other hand, loss of retainer retention
may result in unrestorable abutment caries.
Conflicts of interest: None declared.
Résumé
L’étude présente a été effectuée pour déterminer le
succès à long terme et la survie des prothèses fixées
et d’évaluer les risques d’échecs dü à des complications biologiques et techniques. Une recherche
Medline de 1966 à mars 2004 a été effectuée ainsi
que manuelle pour les bibliographies des articles
pouvant répondre à cette question. Dix-neuf études
ont été tirées à partir de 3 658 titres et les données
ont été extraites indépendamment par deux personnes. Les études prospectives et rétrospectives
avec un temps de suivi de minimum cinq années
dans lesquelles les patients avaient été examinés
cliniquement lors du suivi ont été incluses dans
cette méta-analyse. Les publications uniquement
basées sur les dossiers des patients, les questionnaires et les interviews ont été exclues. La survie des
prothèses a été analysée suivant les risques d’échec
et de succès in situ. Des complications techniques et
biologiques spécifiques telle que les caries, la perte
de vitalité et la réapparition de la maladie parodontale ainsi que la perte de rétention, la perte de
vitalité, les fractures dentaires et de matériaux ont
également été analysées. La survie à 10 ans pour les
prothèses fixées était de 89,1% (intervalle de confiance de 95% : 81,0 à 93,8%) tandis que le succès
Tan et al . Systematic review of FPDs
était de 71,1% (52,2 à 83,6%). Le risque à dix ans
pour des caries ou de la parodontite entraı̂nant la
perte de la prothèse était respectivement de 2,6 et
0,7%. Le risque à dix années pour la perte de
rétention était de 6,4%, de fracture du pilier de
2,1% et de fracture de matériaux de 3,2%.
Zusammenfassung
Eine systematische Uebersicht der Ueberlebensund Komplikationsraten bei festsitzenden Brückenrekonstruktionen (FPDs) über eine Beobachtungszeit von mindestens 5 Jahren III. Konventionelle
FPDs
Die vorliegende Studie wurde unternommen, um
die Langzeiterfolgs- und Ueberlebensraten von festsitzenden Brückenrekonstruktionen (FPDs) zu bestimmen und die Risiken für Misserfolge aufgrund
spezifischer biologischer und technischer Komplikationen auszuwerten.
Es wurde eine Medline Suche (PubMed) über einen
Zeitraum von 1966 bis März 2004 durchgeführt und
die Bibliographien von relevanten Artikeln wurden
manuell durchsucht. Von einer anfänglichen Auswahl von 3658 Artikeln wurden schlussendlich 19
ausgewählt und die Daten wurden von drei Rezensenten unabhängig herausgelesen. Es wurden prospektive und retrospektive Kohorten-Studien mit
einer mittleren Beobachtungszeit von mindestens 5
Jahren, in welchen Patienten klinisch nachuntersucht worden waren, in die Meta-Analyse einbezogen. Publikationen, welche nur auf Einträgen in
Krankengeschichten, Fragebogen oder Interviews
basierten, wurden ausgeschlossen. Das Ueberleben
der FPDs wurde entsprechend des in situ und intakten Misserfolgsrisikos analysiert. Spezifische
biologische und technische Komplikationen wie
Karies, Vitalitätsverlust und das Auftreten von Parodontalproblemen sowie Retentionsverlust, Zahnund Materialfrakturen wurden ebenfalls analysiert.
Die Ueberlebensrate von festsitzenden Brückenrekonstruktionen über 10 Jahre betrug 89.1% (95%
Vertrauensintervall (CI): 81–93.8%), während die
Erfolgsrate 71.1% betrug (95% CI: 52.2–83.6%).
Das 10-Jahres Risiko für Karies und Parodontitis,
welche zum Verlust der FPD führen, betrug 2.6%
bzw. 0.7%. Das 10-Jahres Risiko für Retentionsverlust betrug 6.4%, für die Pfeilerfrakturen 2.1% und
für Materialfrakturen 3.2%.
pérdida de vitalidad, fracturas dentales y del
material.
La supervivencia a los diez años para las dentaduras
parciales fijas fue del 89.1% (95% intervalo de
confianza (CI): 81–93.8%) mientras que el éxito
fue del 71.1% (95% CI: 52.2–83.6%). El riesgo de
caries a los 10 años y periodontitis que condujo a la
pérdida del FPD fue del 2.6% y del 0.7% respectivamente. El riesgo de pérdida de retención a los 10
años fue del 6.4%, para la fractura del pilar del 2.1%
y para la fractura del material del 3.2%.
Resumen
El presente estudio se llevó a cabo para determinar el
éxito y supervivencia a largo plazo de dentaduras
fijas parciales (FPDs) y evaluar los riesgos de fracasos
debido a complicaciones biológicas y técnicas especı́ficas.
Se llevó a cabo una búsqueda por Medline (PubMed)
desde 1996 hasta Marzo de 2004 al igual que una
búsqueda a mano de bibliografı́as de artı́culos relevantes. Finalmente se seleccionaron diecinueve artı́culos de una cantidad inicial de 3,658 tı́tulos y se
extrajeron los datos independientemente por tres
revisores. Se incluyeron en este meta-análisis estudios cohorte prospectivos y retrospectivos con un
tiempo de seguimiento medio de 5 años en los que
los pacientes se examinaron clı́nicamente en las
visitas de mantenimiento. Se excluyeron publicaciones basadas solamente en las fichas de los pacientes, cuestionarios o entrevistas. Se analizó la
supervivencia de los FPDs de acuerdo con los riesgos
de fracaso in situ e intacto. También se analizaron las
complicaciones biológicas especı́ficas tales como
caries, pérdida de vitalidad y recurrencia de enfermedad periodontal al igual que la pérdida de retención,
References
Aquilino, S.A., Shugars, D.A., Bader, J.D. & White,
B.A. (2001) Ten-year survival rates of teeth adjacent to treated and untreated posterior bounded
edentulous spaces. Journal of Prosthetic Dentistry
85: 455–460.
Bergenholtz, G. & Nyman, S. (1984) Endodontic
complications following periodontal and prosthetic treatment of patients with advanced periodontal disease. Journal of Periodontology 55:
63–68.
Cheung, G.S., Dimmer, A., Mellor, R. & Gale, M.
(1990) A clinical evaluation of conventional
bridgework. Journal of Oral Rehabilitation 17:
131–136.
Creugers, N.H., Kayser, A.F. & van’t Hof, M.A.
(1994) A meta-analysis of durability data on conventional fixed bridges. Community Dentistry
and Oral Epidemiology 22: 448–452.
Djemal, S., Setchell, D., King, P. & Wickens, J.
(1999) Long-term survival characteristics of 832
resin-retained bridges and splints provided in a
post-graduate teaching hospital between 1978 and
1993. Journal of Oral Rehabilitation 26: 302–320.
Ericsson, S.G. & Marken, K.E. (1968) Effect of fixed
partial dentures on surrounding tissues. Journal of
Prosthetic Dentistry 20: 517–525.
Fayyad, M.A. & al-Rafee, M.A. (1996a) Failure of
dental bridges. II. Prevalence of failure and its
relation to place of construction. Journal of Oral
Rehabilitation 23: 438–440.
Fayyad, M.A. & al-Rafee, M.A. (1996b) Failure of
dental bridges: III – effect of some technical
factors. Journal of Oral Rehabilitation 23:
675–678.
Foster, L.V. (1990) Failed conventional bridge work
from general dental practice: clinical aspects and
treatment needs of 142 cases. British Dental
Journal 168: 199–201.
Glantz, P.O., Nilner, K., Jendresen, M.D. & Sundberg, H. (1993) Quality of fixed prosthodontics
after 15 years. Acta Odontologica Scandinavica
51: 247–252.
Glantz, P.O., Nilner, K., Jendresen, M.D. & Sundberg, H. (2002) Quality of fixed prosthodontics
after twenty-two years. Acta Odontologica Scandinavica 60: 213–218.
Gustavsen, F. & Silness, J. (1986) Clinical and
radiographic observations after 6 years on bridge
abutment teeth carrying pinledge retainers. Journal of Oral Rehabilitation 13: 295–298.
Hämmerle, C.H., Ungerer, M.C., Fantoni, P.C.,
Brägger, U., Bürgin, W. & Lang, N.P. (2000)
Long-term analysis of biologic and technical aspects of fixed partial dentures with cantilevers.
International Journal of Prosthodontics 13:
409–415.
Hochman, N., Mitelman, L., Hadani, P.E. &
Zalkind, M. (2003) A clinical and radiographic
evaluation of fixed partial dentures (FPDs) prepared by dental school students: a retrospective
study. Journal of Oral Rehabilitation 30:
165–170.
Hochman, N., Yaffe, A. & Ehrlich, J. (1992) Splinting: a retrospective 17-year follow-up study. Journal of Prosthetic Dentistry 67: 600–602.
Hume, W.R. & Massey, W.L. (1990) Keeping the
pulp alive: the pharmacology and toxicology of
agents applied to dentine. Australian Dental Journal 35: 32–37.
665 |
Clin. Oral Impl. Res. 15, 2004 / 654–666
Tan et al . Systematic review of FPDs
Izikowitz, L. (1985) A long-term prognosis for the
free-end saddle-bridge. Journal of Oral Rehabilitation 12: 247–262.
Jokstad, A. & Mjör, I.A. (1996) Ten years’ clinical
evaluation of three luting cements. Journal of
Dentistry 24: 309–315.
Karlsson, S. (1986) A clinical evaluation of fixed
bridges, 10 years following insertion. Journal of
Oral Rehabilitation 13: 423–432.
Karlsson, S. (1989) Failures and length of service in
fixed prosthodontics after long-term function. A
longitudinal clinical study. Swedish Dental Journal 13: 185–192.
Kelsey, J. L., Whiltemore, A. S., Evans, A. S. &
Douglas Thompson, W. (1996) Methods in Observational Epidemiology, 2nd ed. NY: Oxford
University Press.
Langeland, K. & Langeland, L.K. (1968) Cutting
procedures with minimized trauma. Journal of the
American Dental Association 76: 991–1005.
Leempoel, P.J., Eschen, S., De Haan, A.F. & Van’t
Hof, M.A. (1985) An evaluation of crowns and
bridges in a general dental practice. Journal of
Oral Rehabilitation 12: 515–528.
Leempoel, P.J., Kayser, A.F., Van Rossum, G.M. &
De Haan, A.F. (1995) The survival rate of bridges.
A study of 1674 bridges in 40 Dutch general
practices. Journal of Oral Rehabilitation 22:
327–330.
Libby, G., Arcuri, M.R., LaVelle, W.E. & Hebl, L.
(1997) Longevity of fixed partial dentures. Journal
of Prosthetic Dentistry 78: 127–131.
Maryniuk, G.A. & Kaplan, S.H. (1986) Longevity of
restorations: survey results of dentists’ estimates
and attitudes. Journal of the American Dental
Association 112: 39–45.
Napankangas, R., Salonen-Kemppi, M.A. & Raustia, A.M. (2002) Longevity of fixed metal ceramic
bridge prostheses: a clinical follow-up study. Journal of Oral Rehabilitation 29: 140–145.
Nyman, S. & Ericsson, I. (1982) The capacity of
reduced periodontal tissues to support fixed
bridgework. Journal of Clinical Periodontology
9: 409–414.
Nyman, S. & Lindhe, J. (1979) A longitudinal study
of combined periodontal and prosthetic treatment
of patients with advanced periodontal disease.
Journal of Periodontology 50: 163–169.
Ödman, P.A. & Karlsson, S. (1988) Follow-up study
of patients with bridge constructions performed by
private dental surgeons and at a university clinic,
666 |
Clin. Oral Impl. Res. 15, 2004 / 654–666
8 years following insertion. Journal of Oral Rehabilitation 15: 55–63.
Öwall, B., Cronstrom, R. & Rene, N. (1992)
Prosthodontic claims in the Swedish Patient Insurance Scheme. Acta Odontologica Scandinavica 50: 365–374.
Palmqvist, S. & Swartz, B. (1993) Artificial crowns
and fixed partial dentures 18 to 23 years after
placement. International Journal of Prosthodontics 6: 279–285.
Pjetursson, B.E., Tan, K., Lang, N.P., Brägger, U.,
Egger, M. & Zwahlen, M. (2004a) A systematic
review of the survival and complication rates
of fixed partial dentures (FPDs) after an observation period of at least 5 years – I. Implant supported FPDs. Clinical Oral Implants Research
doi:10.1111/j.1600-0501.2004.01117.x
Pjetursson, B.E., Tan, K., Lang, N.P., Brägger, U.,
Egger, M. & Zwahlen, M. (2004b) A systematic
review of the survival and complication rates of
fixed partial dentures (FPDs) after an observation
period of at least 5 years – IV. Cantilever or
extensions FPDs. Clinical Oral Implants Research doi:10.1111/j.1600-0501.2004.01120.x
Randow, K., Glantz, P.O. & Zoger, B. (1986) Technical failures and some related clinical complications in extensive fixed prosthodontics. An
epidemiological study of long-term clinical
quality. Acta Odontologica Scandinavica 44:
241–255.
Reichen-Graden, S. & Lang, N.P. (1989)
Periodontal and pulpal conditions of abutment
teeth. Status after four to eight years following
the incorporation of fixed reconstructions.
Schweizer Monatsschrift für Zahnmedizin 99:
1381–1385.
Rene, N., Owall, B. & Cronstrom, R. (1991) Dental
claims in the Swedish Patient Insurance Scheme.
International Dental Journal 41: 157–163.
Reuter, J.E. & Brose, M.O. (1984) Failures in full
crown retained dental bridges. British Dental
Journal 157: 61–63.
Roberts, D.H. (1970a) The failure of retainers in
bridge prostheses. An analysis of 2,000 retainers.
British Dental Journal 128: 117–124.
Roberts, D.H. (1970b) The relationship between age
and the failure rate of bridge prostheses. British
Dental Journal 128: 175–177.
Schwartz, N.L, Whitsett, L.D., Berry, T.G. & Stewart, J.L. (1970) Unserviceable crowns and fixed
partial dentures: life-span and causes for loss of
serviceability. Journal of the American Dental
Association 81: 1395–1401.
Scurria, M.S., Bader, J.D. & Shugars, D.A. (1998)
Meta-analysis of fixed partial denture survival:
prostheses and abutments. Journal of Prosthetic
Dentistry 79: 459–464.
Shugars, D.A., Bader, J.D., White, B.A., Scurria,
M.S., Hayden, W.J. Jr & Garcia, R.I. (1998)
Survival rates of teeth adjacent to treated and
untreated posterior bounded edentulous spaces.
Journal of the American Dental Association
129: 1089–1095.
Sundh, B. & Ödman, P. (1997) A study of fixed
prosthodontics performed at a university clinic 18
years after insertion. International Journal of
Prosthodontics 10: 513–519.
Swartz, B., Svenson, B. & Palmqvist, S. (1996)
Long-term changes in marginal and periapical
periodontal conditions in patients with fixed
prostheses: a radiographic study. Journal of Oral
Rehabilitation 23: 101–107.
Valderhaug, J. (1991) A 15-year clinical evaluation of
fixed prosthodontics. Acta Odontologica Scandinavica 49: 35–40.
Valderhaug, J., Jokstad, A., Ambjornsen, E. & Norheim, P.W. (1997) Assessment of the periapical
and clinical status of crowned teeth over 25 years.
Journal of Dentistry 25: 97–105.
Valderhaug, J. & Karlsen, K. (1976) Frequency and
location of artificial crowns and fixed partial
dentures constructed at a dental school. Journal
of Oral Rehabilitation 3: 75–81.
Walton, T.R. (1997) A 10-year longitudinal study of
fixed prosthodontics: 1 Protocol and patient profile. International Journal of Prosthodontics 10:
325–331.
Walton, T.R. (2002) An up to 15-year longitudinal
study of 515 metal-ceramic FPDs: Part 1. Outcome. International Journal of Prosthodontics 15:
439–445.
Walton, T.R. (2003) An up to 15-year longitudinal
study of 515 metal–ceramic FPDs: Part 2. Modes
of failure and influence of various clinical characteristics. International Journal of Prosthodontics 16: 177–182.
Yi, S.W., Carlsson, G.E., Ericsson, I. & Wennstrom,
J.L. (1996) Long-term follow-up of cross-arch
fixed partial dentures in patients with advanced
periodontal destruction: evaluation of occlusion
and subjective function. Journal of Oral Rehabilitation 23: 186–196.