Report Peer-reviewed paper.
Submitted February 2013; accepted April 2013
How long will it last? The expected longevity of
prosthodontic and restorative treatment
Donald R. Schwass, Karl M. Lyons, David G. Purton
abstract
With the Internet facilitating access to vast amounts of
free information, dental practitioners face providing
treatment for an increasingly informed public. However,
the available content is not filtered, and it can be difficult
for patients to discriminate between research-informed
evidence and “glamorised” material of dubious origin.
Patients reasonably expect a return for their investment
and want to know how long their treatment will last.
Clinicians have an obligation to inform their patients so
that they can make reasoned decisions about treatment
options. Longevity data are also informative for health
agencies setting service schedules for publicly funded
treatment, and for determining settlements by insurers
such as ACC. Historically, much of the prosthodontic
treatment performed in practice has relied heavily on
dogma, low-level anecdotal evidence, and clinical case
reports. This paper considers the literature on fixed and
removable prosthodontic restorations and provides a
critical review which can be used practically as the basis
for informing patients, and to assist decision-makers in
making fair and appropriate judgements.
INTRODUCTION
Despite continuing significant technical advances in dental
materials, there are relatively few longitudinal studies involving
fixed prosthodontic restorations (Maryniuk and Kaplan, 1986;
Karlsson, 1989; Glantz et al., 2002). Most of the studies have
involved samples of patients attending institutional facilities,
such as dental schools (Schwartz et al.,1970; Sundh and Odman,
1997; Napankangas et al., 2002), or specialist prosthodontic
clinics (Walton et al., 1986; Foster, 1990; Walton, 1997; Walton,
1999; Walton, 2002; Walton, 2003). A considerable proportion
involves Scandinavian samples. Relatively less information is
available on fixed prosthodontic restorations placed in private
general dental practice settings, globally, and there has been
none from New Zealand.
Furthermore, inconsistencies in study design make
meaningful interpretation difficult. Some studies have measured
prosthesis survival whereas others have determined success rates,
with various definitions of what constitutes success or failure
(Creugers et al., 1994; Minguez and Lyons, 2007). For example,
“failure” could be interpreted as total loss of the prosthesis (Owen,
1986), or could include situations where repair of the prosthesis
is required yet total loss is avoided (Schwartz et al., 1970; Walton
et al., 1986; Libby et al., 1997); this makes direct comparisons
of study findings difficult. It may be that only a part of a fixed
partial denture [FPD] may fail, with that section removed and the
remaining portion surviving. In such a situation, the FPD would
98 Expected longevity of prosthodontic treatment
be deemed to have survived because it was still functional. If the
survival estimate was based on prostheses remaining in function,
that survival rate would be 100% despite the FPD having been
modified (Tan et al., 2004).
Notwithstanding such limitations, valuable insights can
be gained from the literature, and generalisations made about
how long restorations might reasonably be expected to last.
Accordingly the aim of this review was to provide a critical
review which can be used to assist dentists and decision-makers
in making fair and appropriate judgements.
METHOD
Using MEDLINE/PubMed and Google Scholar, a literature
search was undertaken for articles published up to and including
2012. The search strategy used the following terms in different
combinations: prosthodontics, longevity, lifespan, survival,
success, failure, fixed partial dentures, bridgework, crowns,
inlays, all-ceramic, ceramic, provisional, direct restorations,
amalgam, composite, glass ionomer cement, complete dentures,
removable partial dentures, reline, and repair.
FIXED PROSTHODONTIC OPTIONS
Bridgework (Fixed Partial Dentures, or “FPDs”)
A meta-analysis involving seven studies by Creugers et al. (1994)
gave a 74% 15-year survival rate for FPDs. Another meta-analysis
reported 92% 10-year and 75% 15-year survival rates for them
(Scurria et al., 1998). The sharp decrease in survival observed
after 10 years has been attributed to material fatigue involving
the ceramic, metal alloy and cements used (Creugers et al., 1994).
Recurrent caries and loss of retention also contribute to the decline
(Scurria et al., 1998). More recently, several systematic reviews
have provided evidence indicating 89% 10-year survival rates for
conventional FPDs (Tan et al., 2004), 82% 10-year survival rates
for cantilever FPDs (Pjetursson et al., 2004a), 94% 5-year survival
rates, 78% 10-year survival rates for combined tooth-implant
FPDs (Lang et al., 2004), and 95% 5-year and 87% 10-year survival
rates for implant FPDs (Pjetursson et al., 2004b). It is noteworthy
that the 94% 5-year survival rate for metal-ceramic FPDs was
significantly higher than that for all-ceramic FPDs (89%; Sailer
et al., 2007). To show just how long FPDs can potentially last,
Holm et al. (2003) reported 53% of FPDs made by undergraduate
dentists at a Swedish Dental School surviving 30 years.
Gold inlays and crowns
Gold restorations are still the “gold standard” against which other
restorations are measured in terms of longevity. Ten-year survival
rates for gold restorations placed at a German university were 76%
for occlusal inlays, 88% for MO inlays, 83% for DO inlays, 88%
for MOD inlays, and 86% for partial crowns (Stoll et al., 1999). A
Swiss study estimated 96% 10-year, 87% 20-year, and 74% 30-year
New Zealand Dental Journal – September 2013
Kaplan-Meier survival rates for cast gold restorations, showing
just how long such restorations can last. Secondary caries was
the most common biological reason for failure, and retentive
loss the most common technical reason (Studer et al., 2000).
Ceramic or gold inlays have been collectively reported to have
90% 4-year, and 68% 7-year survival rates (Chadwick et al., 1999;
Chadwick et al., 2002).
Porcelain-fused-to-metal (PFM) crowns
Perhaps surprisingly, given their popularity, very few studies have
reported survival rates for PFM crowns alone, with most studies
reporting combined crown and bridgework data (Schwartz et al.,
1970; Coornaert et al., 1984; Leempoel et al., 1985; Walton et al.,
1986; Valderhaug, 1991; Palmqvist and Swartz, 1993). One study
of PFM crowns in patients treated by a specialist prosthodontist
gave them a 97% 10-year survival rate when repairs or failure were
accounted for (Walton, 1997). The same author claimed 96% 5 to
10-year and 85% 15-year survival rates for his bridgework (Walton,
2002). Whether such data can be generalised to treatment by the
average dental practitioner in New Zealand is debatable, but they
do show how well PFM crowns may last.
All-ceramic crowns
There are many options available for all-ceramic restorations, and
different ceramic materials can be selected based on the properties
required (such as the aesthetic need for translucency). Arranged
in order of relative translucency (from most to least) ceramic
options are Feldspathic, Empress I, Inceram Spinell, Empress II,
Procera, In-Ceram alumina, In-Ceram and Zirconia, with the
latter the most opaque (Heffernan et al., 2002a; Heffernan et al.,
2002b). Feldspathic materials have relatively low strength and
fracture toughness, but they perform acceptably if well supported
(such as in PFM applications).
Glass ceramics—such as leucite-reinforced IPS-Empress I and
lithium-disilicate-based IPS Empress II—have better fracture
toughness and flexural strength (as determined by three-point
bending test) than feldspathics. However, glass-infiltrated
ceramic materials (such as In-Ceram Alumina and In-Ceram
Zirconia0 are considerably stronger. The recent development
of yttrium-stabilised zirconia and densely sintered aluminous
ceramics has led to materials that now have very high bend-
strength and toughness characteristics which mean that they
can be considered for use in FPDs.
Longevity of all-ceramic crowns
The substantial differences in material properties among different
ceramic materials mean that it is important to consider them
separately.
Heat-pressed, reinforced ceramics
In a clinical trial involving two private dental practices, leucite-
reinforced IPS-Empress I was reported as having 99% survival
after 3.5 years, and 95% survival after 11 years, with better success
when used in anterior applications (Fradeani and Redemagni,
2002). A literature review of research involving this material
reported 92 to 99% 3-3.5-year survival (El-Mowafy and Brochu,
2002). IPS-Empress I offers excellent aesthetics and good
outcomes when used for restoring anterior teeth.
Lithium-disilicate-reinforced IPS-Empress II offers higher
flexural strength than leucite-reinforced material, with encouraging
New Zealand Dental Journal – September 2013
survival figures (Chadwick et al., 2002; Marquardt and Strub,
2006) when used for crowns. Short-term data from a small clinical
trial involving IPS-Empress II found it to be quite satisfactory for
crown fabrication but to have a high failure rate when used for
FPDs (with 50% failing catastrophically; Taskonak and Sertgoz,
2006). This finding was supported by those of Marquardt
and Strub (2006).
Slip-cast glass-infiltrated ceramics
Glass-infiltrated ceramics include magnesia- (Spinell), alumina-
and zirconia-infiltrated variants. There have been reports of 92-
100% 5-year survival rates for In-Ceram Alumina and In-Ceram
Spinell crowns (Wassermann et al., 2006), with another study
which investigated only In-Ceram Alumina crowns showing
slightly higher 3-year survival rates for anterior restorations
(98%) than posteriors (94%), and 96% when anterior and
posterior sites were combined (McLaren and White, 2000). A
further study of alumina-reinforced crowns reported 99%
success for In-Ceram up to 6 years (Segal, 2001), whereas the
5-year success rate for Spinell crowns has been reported to be 98%
(Fradeani et al., 2002).
Metal oxide ceramics
Undoubtedly, metal oxide ceramics containing alumina or
zirconia offer superior fracture toughness and bend strength, but
this comes at the price of inferior aesthetics owing to the inherent
opacity of the high-density metal oxide crystals. A multi-centre
prospective clinical trial of Procera Alumina conducted in
private practice reported 98% 5-year and 94% 10-year survival
rates (Odman and Andersson, 2001). Procera Alumina crowns
are regarded as being as strong as PFM crowns (Potiket et al.,
2004). Zirconia has been described as “ceramic steel’ because
of its superior material properties (Garvie et al., 1975). Yttria-
stabilised zirconia ceramics feature a phenomenon known
as phase transformation toughening, whereby the zirconia is
maintained in the metastable tetragonal crystal state, so that
stress concentrations from crack formation cause conversion
to the monoclinic crystal state. This results in volumtric
expansion which compresses the crack to prevent propagation,
thus enhancing fracture toughness. Zirconia crowns may be
fabricated by milling either in a soft “green”, partially-sintered
state, or in a very hard, fully-sintered state requiring industrial-
strength processing (Denry and Kelly, 2008). The use of zirconia
for 3-unit FPDs has given encouraging findings (Raigrodski,
2004), but caution is warranted when using it for longer spans,
with evidence lacking for full-arch milled ceramic restorations
despite heavy marketing of it by dental laboratories. Cracking and
crazing of feldspathic veneer porcelain on zirconia restorations
have been reported as being significant problems, with one
study reporting an incidence of 50% after only one to two years
(Denry and Kelly, 2008). Indeed, chipping has been extensively
reported, such as in a study of 3-unit FPDs made with zirconia
(Raigrodski et al., 2006). This phenomenon has been attributed
to rapid cooling during fabrication when the final restoration is
removed from the furnace; this can be avoided by making use of
slow cooling protocols when the feldspathic porcelain veneering
layer is fired onto the zirconia coping (Swain, 2009; Tan et al.,
2012). With this problem solved, the longevity of zirconia crowns
is optimistically projected to be good, but long-term data are still
lacking to date.
Expected longevity of prosthodontic treatment 99
Ceramic inlays/onlays
There is reasonable evidence to support the use of all-ceramic
materials for inlay and onlay restorations. IPS-Empress inlays
and onlays have been shown to offer a 96% survival rate after
4.5 years, and 91% after 7 years (El-Mowafy and Brochu, 2002).
Indirect ceramic inlays appear to perform similarly to other cast
posterior restorations (Hayashi et al., 2003).
Recently, directly fabricated CAD/CAM ceramic restorations
have become popular, with CEREC restorations enjoying good
survival rates in the medium term (97% 5-year and 90% 10-
year rates; Fasbinder, 2006). Even the early intra-coronal CEREC
restorations using machinable industrially-produced blocks of
feldspathic porcelain performed well, with 97% surviving after an
average of just over four years (Martin and Jedynakiewicz, 1999).
Repairs to ceramic restorations
Where ceramic is used, damage can occur, with commonly
reported complications being chipping and fracture. These lead
to the dilemma of whether to attempt repair or contemplate
expensive replacement. The repair of fractured ceramic on
crown and bridgework by etching, silane coupling, and resin
bonding has a success rate of up to 89% after 3 years (Ozcan
and Niedermeier, 2002). This suggests that repair may be a
worthwhile option to consider, but with careful case selection,
because failure of repairs can occur rapidly and repeatedly in
some instances.
Preparation-induced devitalisation of teeth
When any tooth is prepared for complex restoration, there is
always the possibility that root canal therapy may be required.
Such a risk is due, in part, to the cumulative lifetime insult
caused by multiple surgical interventions affecting pulp health,
and to the extent of tissue removal. A systematic review by Tan
et al. (2004) reported a 10% risk of previously vital crowned
teeth devitalising over the subsequent 10 years. Another study
reported that 92% of previously vital teeth showed no signs of
pulp symptoms or deterioration after 10 years; it was 87% after
20 years, and 83% after 25 years (Valderhaug et al., 1997).
Maryland bridges (resin-bonded FPDs)
Reported longevity rates for resin-bonded FPDs vary widely.
A meta-analysis evaluating 16 clinical studies reported 1-year
longevity of 89% for resin-bonded FPDs, with 84% after 2 years,
80% after 3 years, and 74% after 4 years (Creugers and Van’t Hof,
1991). Similar findings were reported in another study (Boyer et
al., 1993). Early studies reported substantial failure rates after
short periods, such as 10% after 2.5 years (Clyde and Boyd, 1988),
with an average length of service of 47 months (Chang et al.,
1991); however, advances in the science of dental bonding agents
have reduced the rate of complications.
A more recent meta-analysis involving 17 studies found
a 88% 5-year survival rate (Pjetursson et al., 2008). The same
paper reported lower rates for posterior resin-bonded bridges,
with 75% of resin-bonded anterior bridges and 44% of posterior
resin-bonded bridges surviving 7.5 years. More bond failures
were observed in posterior applications (more than 5% annually)
than anterior ones (3%), but this difference was not statistically
significant (Pjetursson et al., 2008). Resin-bonded FPDs in
posterior maxillary sites appear to survive better than those in
posterior mandibular sites (Verzijden et al., 1994). Resin-bonded
100 Expected longevity of prosthodontic treatment
bridges retained by two abutments last better than those for which
more retainers are used (Chang et al., 1991). Moreover, cantilever
resin-bonded FPDs supported by only one retainer have proven to
last well, with the advantage that they fail by dislodgement; when
multiple retainers are used, failure of individual bonded retainers
may go unnoticed, with subsequent development of caries under
loose retainers (Himmel et al., 1992). For example, one study
found that 88% of cantilever resin-bonded FPDs remained
bonded after 3 years, with the rebonding of some producing
a 94% success overall (Hussey and Linden, 1996). De-bonding
of resin-bonded FPDs has been found to occur in about one in
five cases over a 5-year period (Pjetursson et al., 2008). Greater
failure rates occur when resin-bonded FPDs are re-bonded, with
40% failing after the first re-bonding and 60% after the second
re-bonding (Marinello et al., 1990). The impact of inappropriate
case selection or design flaws inherent in the original restorations
is not likely to be corrected by re-bonding, so it is not surprising
that some restorations repeatedly fail. Moreover, cohesive failures
affecting tooth tissue subjacent to the resin bond interface may
alter the tooth surface morphology, causing margin discrepancies
which can ultimately affect re-bonding success.
Other authors have suggested a 50% lower bond strength
when re-bonding (Naifeh et al., 1988). Thus, clinicians might
be wise to review treatment options rather than make repeated
attempts at reattaching failing resin-bonded FPDs.
Provisional crowns
That there is little information on the longevity of provisional
materials reflects the reality that these materials are not designed
(or expected) to last long in function. Properly executed
provisional restorative treatment rarely fails, and dislodgment
or fracture usually indicates that their form is unacceptable or
that a tooth preparation is inadequate (Burns et al., 2003).
Direct restorations fabricated at the chairside from BIS-
acryl composites (such as Protemp Garant III or Luxatemp),
and urethane dimethacrylate composites (such as Triad), are
commonly used to make good short-term provisional crowns.
These generally offer up to 3 months of service. They lack the
durability to resist breakage under sustained or excessive occlusal
load. They usually have excellent aesthetics and polishability,
with reasonable wear resistance. However, indirect provisional
materials (such as heat-processed PMMA materials) are required
for long-span RPD provisional applications and for long-term
provisionals. Heat-processed PMMA has high flexural strength,
good colour stability and polishability, and acceptable marginal
fit, and is a cost-effective material. Anecdotally, indirectly
fabricated, heat-processed provisionals can last up to 1 year
(which is sometimes required for full-mouth rehabilitation when
reorganising an occlusion is involved). Heat-processed PMMA
provisional crowns can be relined with PEMA materials such
as Trim. Indirect provisional materials can be reinforced with
frameworks of metal, glass, graphite, sapphire, Kevlar, polyester
or rigid polyethylene fibres.
Direct placement restorations
One study found that the median age of failed direct restorations
was 15 years for amalgam, 6 years for composite resins and 7 years
for glass ionomer cements (Forss and Widstrom, 2004). However,
measuring the age of failed restorations alone fails to capture how
long successful restorations last; thus, if interpreted incorrectly,
New Zealand Dental Journal – September 2013
these data might significantly underestimate actual restoration
longevity. This contrasts with other studies, where composites are
seen in a better light, and it is fair to say that, more recently, the
longevity of composite resin restorations reported has improved,
reflecting significant developments in materials science.
A recent life table analysis of survival for Class I and II cavity
preparations gave 92% 5-year and 82% 10-year survival rates for
posterior composites. By contrast, there were 90% 5-year and
79% 10-year survival rates for amalgam (Opdam et al., 2007).
The authors used Cox regression analysis to correct for the effect
of restoration size as a potential confounder because composite
was used (instead of amalgam) to restore smaller cavities during
the first five years of the study; during the later five years, greater
confidence in composite material saw it used more extensively
in preference to amalgam. No statistically-significant differences
between composite resin and amalgam were found, and the
annual failure rates for both materials were similar. This is a
surprising finding, given that other studies have generally found
in favour of amalgam over composite, but it may be explained by
the fact that the two clinicians involved in restoration placement
for the study were experienced in both adhesive techniques and
amalgam placement. Older practitioners may not have had the
same formal training in placement of composite resins that
younger practitioners would have had.
Amalgam
Amalgam is still an excellent choice as a direct restorative
material. The median survival time for amalgam has been
estimated to be 22.5 years (Kolker et al., 2005). Whether or not
it performs this well, several studies certainly testify to it having
good longevity when appropriately used. An older study found
that 50% of all amalgams exceeded 8 to 10 years in lifespan (Mjor
et al., 1990). Smales (1991) reported 72% 15-year survival rates for
Class II and restorations involving cusps. When cost-effectiveness
is considered, composites have been found to be 1.7 to 3.5 times
more expensive to place than amalgams (Chadwick et al., 1999).
A comprehensive review of 62 papers involving amalgam found
that, for seven out of eight studies reporting 10-year survival
rates on permanent teeth, amalgam performed better than 90%;
for two out of three studies reporting 3-year survival rates on
decidiuous teeth, amalgam also performed better than 90%, with
one study indicating no failures at all (Chadwick et al., 2002).
A subsequent commentary on this work identified a need for
further research with a rigorous study design in a general practice
setting and extending beyond 10 years (Jokstad, 2002).
Composite resin
Studies of early posterior composites estimated up to 50% failure
by 10 years (Raskin et al., 1999), but contemporary materials and
methods now yield much more encouraging outcomes (Raj et al.,
2007). Survival rates from studies vary from 55% to 95% over 5
years (Brunthaler et al., 2003), with the longevity of amalgam
usually exceeding that of posterior and anterior resin composites
for most intervals beyond 3 to 5 years (Hondrum, 2000).
Historically, it has been reported that multi-surface
composites lasted a shorter time than amalgam (Mjor et al., 1990).
Meta-analysis of 16 long-term studies found 86% of restorations
were clinically acceptable after 5 years (el-Mowafy et al., 1994).
Chadwick et al. reported 90% survival of composite after 3 years,
and 59% after 8 years (Chadwick et al., 1999; Chadwick et al.,
New Zealand Dental Journal – September 2013
2002). Outcomes have continued to improve, with advancements
in material technology and the recent advent of nanotechnology.
This is reflected by more favourable survival rates for composite
being recently reported (Opdam et al., 2007).
Glass ionomer cement (GIC)
GIC makes an excellent dentine replacement as a lining or base
when managing dental caries, but it should be considered only as
a provisional material when restoring tooth structure because it
generally lacks the physical properties needed for large posterior
restorations (Mjor et al., 1990). This is reflected in the relatively
low survival rates reported, such as 65% by 5 years (Chadwick
et al., 1999; Chadwick et al., 2002); this compares poorly with
other direct placement materials. GIC should not be considered
suitable as a material for core build-ups prior to crown placement.
REMOVABLE PROSTHODONTIC OPTIONS
Plastic removable partial dentures (RPDs)–
interim option
Plastic RPDs are relatively inexpensive to fabricate and involve
few clinical steps, but they can have detrimental effects on the
supporting tissues. They are unable to transmit occlusal forces
optimally because they lack occlusal rests.
Evidence on the lifespan of immediate or interim plastic
partial dentures is lacking. It has been suggested that they
have an anticipated life span of 6-12 months (Walmsley, 2003).
Anecdotally, they seldom seem to function optimally beyond
5 years, and are prone to tooth fracture where isthmus areas
are thin. This is particularly the case when replacing narrow
maxillary teeth such as lateral incisors,.
Valplast RPDs
Thermoplastic resin partial dentures have been popularly
promoted for their reputedly superior aesthetics and comfortable,
secure fit. However, there is a lack of guidelines for the correct
application of thermoplastic resins such as Valplast (a polyamide
resin) for RPDs. There has been little systematic appraisal
(Takabayashi, 2010) despite their being available in various forms
for many years. What we do know is that Valplast is stable and
hygienic with regards to water sorption, has sufficient tensile
strength to cope with repeated insertion or withdrawal, and
offers toughness and resistance to fracture (Takabayashi, 2010;
Hamanaka et al., 2011). Valplast is, however, prone to staining
from highly coloured foods, such as those containing turmeric
(Takabayashi, 2010), and it has been shown to perform more
poorly than other flexible polymer materials (Goiato et al., 2010).
It is vulnerable to hardening with some denture cleaners. The
flexibility of materials such as Valplast means that significant
soft tissue displacement is risked, with potential for traumatic
stripping and recession of gingivae. Considering the current lack
of evidence, they should not be regarded as suitable for long-term
application, but they may be useful for situations where patients
have an allergy to acrylic or metals.
Metal-framed RPDs
Despite a long history of use—and the publication of numerous
textbooks describing the design and use of metal-framed RPD—
there is relatively little published evidence for their longevity.
Anecdotally, it appears that metal-framed RPDs can last over 10
Expected longevity of prosthodontic treatment 101
years in well-maintained mouths and optimal situations. Indeed,
one study found that 65% of original metal-framed RPDs were
still in function after 25 years in well-cared-for mouths (Bergman
et al., 1995). In one study, in which not wearing was categorised as
failure, metal-framed RPDs enjoyed 75% 5-year and 50% 10-year
survival. However, when abutment problems were also taken into
account, only 40% survived 5 years, and 20% survived 10 years
without the need to re-treat abutments (Vermeulen et al., 1996).
In other words, it is to be expected that the maintenance of the
abutments for metal-framed RPDs is relatively high. Extension-
base RPDs appear to need more denture base adjustments than
do tooth-supported RPDs (relative to the tissue displacement
involved). A study of mandibular RPDs found that one-third
of patients believed their prosthesis to require adjustment or
replacement, and one-quarter reported that their RPD had caused
a problem with their natural teeth. Most of those treated with
a mandibular RPD in private dental practice were satisfied with
their prosthesis, but a substantial amount of dissatisfaction
existed nevertheless, with systematic differences by age, general
health, prior prosthesis experience, and the type of opposing
dentition (Frank et al., 1998).
Complete dentures
Evidence on the longevity of complete plastic dentures is lacking,
and many of the techniques used for impression making and
denture fabrication rely purely on anecdotal reports in the
literature describing personal preferences and recommendations.
However, it is generally accepted that complete dentures can
be expected to last between 5 and 10 years (Zarb et al., 1997),
although, in reality, many appliances are used for longer than
this. Occlusion, adaptation of fitting surface and the condition
of denture-bearing tissues should be evaluated at least once a
year to ensure that dentures remain optimal.
Relines
Hard linings are indicated for treatment of unstable, ill-fitting
dentures, but there is a lack of information on how long they can
prolong denture life. Common sense is needed when determining
whether the quality of the existing denture warrants an attempt
to preserve it. For a hard reline to be successful, an adequate
residual ridge, resilient mucosa, and mature, healthy supporting
structures are required. No published guidelines are available on
how frequently dentures should be relined or rebased. Rebasing
has the advantage over relining of being able to markedly change
the architecture of the denture surfaces, affecting vertical
dimension, phonetics and function.
Careful occlusal adjustment is required after relining or
rebasing because these procedures may accentuate stresses on
the residual bony ridge (Maeda and Wood, 1989). Information
is lacking on how long first and subsequent relines should
last. Special consideration is needed to account for individual
variability in the need for them in the first place. Individuals
vulnerable to extensive residual ridge resorption need more
frequent relines to optimise fit. The principle of adequate
extension and support for complete dentures is imperative to
minimise denture displacement stimulating resorption. It is,
however, of value to note that 40% of post-extraction changes
occur by the end of the first month; 65% occur by 3 months,
and 80% by 6 months (Watt and Likeman, 1974). Consequently,
relines are frequently indicated 3-6 months following insertion
102 Expected longevity of prosthodontic treatment
of immediate complete dentures. Relines are often beneficial
when adaptation of the denture base to the tissues of the denture-
bearing area is poor. They may be indicated where, for medical
or psychosocial reasons, the patient is unable to attend the visits
for making replacement dentures, or where the patient is unable
to afford replacement complete dentures. They are inappropriate
in cases where: the underlying tissues are inflamed and/or
hypertrophic or hyperplastic; the patient has TMJ symptoms;
the patient has speech problems; when the appearance of the
dentures is unsatisfactory; or where intermaxillary relationships
are unsatisfactory.
As many as one-quarter of all denture patients are dissatisfied
with their dentures (van Waas, 1990; Lechner and Roessler,
2001), and it has been proposed that soft relining with tissue
conditioners offers a way of converting at least some of these
failures to successes (Chase, 1961). Indirect laboratory relines
offer better mechanical properties and longevity than direct
chair-side intra-oral relines (Parr and Rueggeberg, 1999).
Soft relines (tissue conditioners and soft liners)
Soft linings are indicated for patients with atrophic ridges,
significant bony undercuts, poor mucosal thickness and
viscoelasticity, or pain from mucosal irritation. They are useful
for situations where a denture is opposed by natural teeth,
theoretically reducing the impact of the heavier bite forces
possible with natural teeth. Soft relines can have a role in the
management of maxillofacial defects, or in instances where there
has been traumatic or pathological tissue loss.
True tissue conditioners have a short-term life span (3-4 days).
Soft liners deteriorate with time, losing their elasticity; thus,
3-monthly reviews of patients with soft liners are recommended
(Means et al., 1971). It is important to select soft liners with
features compatible with the presenting clinical situation, and
bearing in mind the setting characteristics, viscoelasticity and
durability of different materials (Murata et al., 1998). Placing a
soft reline 2-3 weeks prior to impression taking when making
replacement complete dentures can be useful to condition
tissue surfaces that have been adversely affected by ill-fitting
old dentures.
Anecdotally, modern silicone soft lining materials can offer
up to 2 years of service, but these are prone to peeling away from
the hard acrylic base. Viscogel is a popular and commonly used
tissue conditioner/soft liner, but it loses its resilience after 2-3
months. One semi-permanent soft lining material worthy of
special note (Molloplast B) offers excellent longevity, with reports
of 100% being in service after over 4 years, and 83% after 6-9
years (Wright, 1984).
Denture adhesives
Denture adhesives provide an acceptable short-term solution for
improving retention and stability for both ill-fitting and well-
fitting dentures, although they should be completely removed
daily (Felton et al., 2011). However, evidence on their use beyond
6 months duration is lacking, and more permanent solutions
such as relines, rebases or remakes might better be considered.
If increasing amounts of adhesive are being used over time, a
reline or rebase should be considered. Denture adhesives offer
a relatively inexpensive adjunct to denture care, delaying the
need for soft or hard relines. They offer many patients a sense of
New Zealand Dental Journal – September 2013
security and confidence, thus converting what would otherwise
be potential failures into successes.
CONCLUSIONS
When faced with a patient who asks how long a restoration or
prosthesis will last, perhaps the most honest answer would be
“I don’t know” ; however, this might not be the best way to
build patient confidence. Familiarity with data on restoration
longevity, and appreciating the applicability (or otherwise) of
studies of other groups to our own patients, at least allows us to
convey an informed message to patients. Nevertheless, we cannot
predict how long a given prosthesis will last for a given patient.
From the patient’s point of view, this approach is much more
likely to seem honest and intelligent. When practising low-risk
dentistry, it is effective communication which helps to engender
reasonable expectations in patients. We should guide patients to
make informed choices for themselves.
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Donald R Schwass BSc, BDS, DclinDent, FPFA
Karl M Lyons MDS, CertMaxillofacPros, PhD, FRACDS
David G Purton MDS, FRACDS
Sir John Walsh Research Institute
Department of Oral Rehabilitation
The University of Otago
Corresponding author
Donald Schwass
e-mail: donald.schwass@otago.ac.nz
Expected longevity of prosthodontic treatment 105