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RESEARCH CRITICAL SUMMARIES

Ante's law is not evidence based

A critical summary of Lulic M, Brägger U, Lang NP, Zwahlen M, Salvi GE. Ante's (1926) law revisited: a
systematic review on survival rates and complications of fixed dental prostheses (FDPs) on severely reduced
periodontal tissue support (published correction appears in Clin Oral Implants Res 2008;19[3]:326-328). Clin
Oral Implants Res 2007;18(suppl 3):63-72.
Ben Balevi, DDS, MSc

Systematic review conclusion. The long-term prognosis of a fixed dental pros thesis
Main results. Six retrospective
studies met the inclusion criteria.
(FDP) with abutments that have severely reduced periodontal support depends on the
maintenance of a healthy periodontium. A meta-analysis incorporating the
Critical summary assessment. Although the results of this review are limited by the results of only two studies (84
quantity and quality of included articles, there appears to be no scientific evidence participants at baseline [with 17
requiring that in fixed dental prosthesis (FDP) design, “the total perio dontal membrane dropouts] and 79 FDPs) yielded an
area of the abutment teeth must equal or exceed that of the teeth to be replaced”1 estimated FDP survival rate of 96.4
(Ante's law). percent (95 percent confidence
Evidence quality rating. Limited. interval [CI], 94.6-97.6 percent)
after five years and 92.9 percent (95
percent CI, 89.5-95.3 percent) after
Clinical question. In adult seven relevant journals. They con
10 years. These results were
patients who have a fixed dental sidered only prospective and
comparable with published survival
prosthesis (FDP) that has healthy retrospective cohort studies published rates of FDPs with abutments that
periodontal tissue support, would in the English language. They included satisfied Ante's law.
abutments that have severely in the review only studies of FDPs
with abutment teeth that did not meet conclusions. The long-term
reduced periodontal tissue support
prognosis of FDPs with abutments
(that is, those not satisfying Ante's the requirements of Ante's law,
that have severely reduced
law1 ), compared with abutments according to clinical and radiographic
periodontal support depends on
that have no or minimally reduced data. The primary outcomes the
reviewers measured and calculated proper control of periodontal disease,
periodontal tissue support (that is, strict adherence to a maintenance
those satisfying Ante's law), lead to were the five- and 10-year survival
lower FDP survival rates? care program and rigid splinting of
rates of these FDPs. They then mobile abutment teeth.
Review methods. The compared the out comes with
reviewers searched one electronic The review described in this critical summary
published survival rates of FDPs that
mary was funded by the Clinical Research
database (PubMed) through Sep had abutment teeth satisfying Ante's Foundation for the Promotion of Oral Health,
tember 2006 and hand searched law. University of Bern, Switzerland.

Dr. Balevi maintains a private practice in general dentistry in Vancouver, British Columbia, Canada, and has an appointment to the faculty of medicine,
University of British Columbia, Vancouver. He is also an evidence reviewer for the American Dental Association. Address reprint requests to Dr. Balevi,
Faculty of Medicine, University of British Columbia, No. 306, 805 W. Broadway, Vancouver, British Columbia, Canada V5Z 1K1, e-mail drben@dentalben.com.

JADA 143(9) http://jada.ada.org September 2012 1011

Copyright © 2012 American Dental Association. All rights reserved.
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RESEARCH CRITICAL SUMMARIES
COMMENTARY
Importance and context. Ante's law states
that “the total periodontal membrane area of the
abutment teeth must equal or exceed that of the
teeth to be replaced.”1 For more than 80 years, this
law has been taught in standard textbooks of
prosthodontics as an important condition influencing
FDP design.2,3 If Ante's law is shown not to be
evidence based, then the option of an FDP
supported by abutments with healthy but
compromised periodontal bone support would be
viable for patients and clinicians to consider.
Strengths and weaknesses of the system
atic review. The authors of this review sought to
answer a well-focused question and provided a
complete description of the criteria used to include
and exclude articles. However, the review is limited
by the authors' decision to search only one
database and to include only English-language
articles. Also, they conducted no assessment of
selection agreement between two independent
reviewers (in other words, they provided no ÿ
statistic). The findings of the six retrospective
studies included are well summed up, but discussion
is lacking regarding the risk of bias or of
heterogeneity among the studies. For example, it
is unclear whether the authors were consistent in
applying to all the included studies the criteria used
to determine whether an FDP satisfied Ante's law.
The lack of consistency between studies allowed
for only two studies to be included in the meta-
analysis. Also, the authors did not assess the
potential risk of publication bias to their review.
Strengths and weaknesses of the
evidence. The six included studies were of
the lower-quality retrospective design. Furthermore,
the authors could not find a single clinical study in
which the investigators compared the survival rates
between FDPs that did not meet the requirements
of Ante's law and those that did.
Hence, this left the authors to make comparisons
between the results of studies of each respective
FDP design. Nevertheless, the results of all
reviewed studies appeared to demonstrate
consistently that FDPs placed on severely with
promised periodontally supported abutments were
serviceable. Only two studies, which included only
79 PDFs and had a high overall participant dropout
rate (20 percent), were eligible for meta-analysis.
Nevertheless, the estimated five- and 10-year
survival rates of 96 and 92 percent, respectively,
are slightly higher than the 10-year survival rate of
89.1 percent (95 per cent CI, 81-93.8 percent)
reported in Tan and
1012 JADA 143(9) http://jada.ada.org September 2012
Copyright © 2012 American Dental Association. All rights reserved.
colleagues'4 systematic review of FDPs that
involved abutments with generally good
periodontal support. Lulic and colleagues
explained the slight difference as possibly being
caused by operator bias because their own review
included FDPs in patients who were treated and
whose FDPs were maintained regularly by clinical
specialists, in contrast to those in the review by Tan
and colleagues,4 which included FDPs completed
by general dentists and dental students. Also, Tan
and colleagues' meta-analysis consisted of 2,881
PDFs, compared with only 79 in this review.
However, investigators in two studies that were
published after this review and that met its inclusion
criteria also confirmed the impressive long-term
prognosis of FDPs that were supported by
periodontally healthy tissue but that had
compromised bone-supported abutments.5,6
Implications for dental practice. With well-
maintained, healthy periodontal tissue sup port,
FDPs not satisfying Ante's law have sur vival rates
comparable with the high rates of FDPs that do
satisfy Ante's law. Therefore, the design of an FDP
does not necessarily have to satisfy Ante's law. ÿ
Disclosure. Dr. Balevi did not report any disclosures.
Critical Summaries is supported by grant G08 LM008956 from the
National Library of Medicine and the National Institute of Dental and
Craniofacial Research, National Institutes of Health, Bethesda, Md.
These summaries, published under the auspices of the American
Dental Association Center for Evidence-Based Dentistry, are pre
pared by practitioners trained in critical appraisal of published system
tematic reviews who work under the mentorship of experts. The sum
maries are not intended to, and do not, express, imply or summarize
standards of care, but rather provide a concise reference for dentists to
aid in understanding and applying evidence from the referenced
systematic review in making clinically sound decisions as guided by their
clinical judgment and by patient needs.
For more information on the evidence quality rating provided above
and additional critical summaries, please visit http://ebd.ada.org.
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Dent Soc Bull 1926;8:14-23.
2. Shillingburg HT. Fundamentals of Fixed Prosthodontics. 3rd ed.
Chicago: Quintessence; 1997:92.
3. Rosenstiel SF, Land MF, Fujimoto J. Contemporary Fixed
Prosthodontics. 4th ed. St Louis: Mosby Elsevier; 2006:95.
4. Tan K, Pjetursson BE, Lang NP, Chan ES. 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 Implants Res 2004;15(6):654-666.
5. Cabanilla LL, Neely AL, Hernandez F. The relationship between
periodontal diagnosis and prognosis and the survival of prosthodontic
abutments: a retrospective study. Quintessence Int 2009;40(10):821-831.
6. Bragger U, Hirt-Steiner S, Schnell N, et al. Complication and
failure rates of fixed dental prostheses in patients treated for
periodontal disease (published online ahead of print Dec. 16, 2010). Clin
Oral Implants Res 2011;22(1):70-77. doi:10.1111/j.1600-0501.2010.02095.x.