Optimum Life-Time Management of Coronal Fractures in Anterior Teeth

Optimum life-time management of coronal fractures in anterior teeth:
A review of crowns, veneers, composite resin restorations and intra-coronal bleaching
July 2008
Author: Dr Sarah Clark

Edited by: Jonathan Leichter and Karl Lyons
Optimum life-time management of coronal fractures in anterior teeth
Important Note
This evidence-based review summarises information on treatments utilised for the restoration of fractured anterior teeth: dental crowns, veneers, composite resin restorations and intra-coronal bleach. It is not intended to replace clinical judgement, or be used as a clinical protocol. A reasonable attempt has been made to find and review papers relevant to the focus of this report. It does not claim to be exhaustive. This document has been prepared by staff of the ACC, Evidence Based Healthcare Advisory Group. The content does not necessarily represent the official view of ACC or represent ACC policy.
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Evidence Based Brief Report
Executive Summary
Background: A 2006 review of a sample of ACC crowns for prior approval treatments on anterior teeth revealed that up to 90% of crowns were to be placed inappropriately and unnecessarily, and highlighted a need for improved guidelines for the treatment and restoration of fractured anterior teeth. This evidence based healthcare (EBH) review of crowns, veneers, composite resin restorations and intra-coronal bleaching was undertaken as a first step in the development of new ACC guidelines for the restoration of fractured anterior teeth. Search strategy: A systematic search of major literature databases (Cinahl, Cochrane Central Register of Controlled Trials, Current Contents, Embase, Medline, Index New Zealand, PubMed, and the Science Citation index) was performed using a strategy aimed at sensitivity rather than precision. Key words describing the four interventions (crown, veneer, composite resin restorations, intra-coronal bleaching) were used to create a master database which was then searched for studies of different types and focus as follows: randomised controlled trials (RCTs) and systematic reviews, appropriate or inappropriate utilisation, dental trauma, and safety/adverse effects. identify any further studies of relevance. Selection criteria: Clinical studies about anterior teeth, of any study type except for individual case studies, published from 1987 onwards were considered; but there were unique selection criteria for each intervention. Composite resin studies were limited to traumatised teeth, and bleach studies were limited to discoloured teeth, whereas crown and veneer studies encompassed the general population. Shorter follow-up periods were accepted for composite resin and bleach studies, whereas follow-up periods were limited to 5 and 4 years respectively for crown and veneer literature. Main results: One hundred and forty one references were retrieved, and of these, 92 were selected for critical appraisal. Twenty six studies were included in this review: 10 for crowns, 8 for veneers, and 4 each for composite resin restorations and intra-coronal bleaching. Overall, the quality of the literature was poor by evidence based standards, and none of the studies were directly comparable because of variations in almost every aspect
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The data range was limited to
references from 1987 onwards. Bibliographies of retrieved articles were hand-searched to
of the studies. The most commonly reported main outcome measure for crowns, veneers and composite resin restorations was survival or failure rate over time; the outcome measures for bleach studies were success/failure of the whitening process, patient satisfaction and colour stability. Conclusions: The predominant outcome measure reported in the literature was survival of restorations and the results of this review show that there is a large variation in the survival rate of crowns (43-95%) and veneers (53-96%) over 10-12 years. The survival rate of composite resin restorations is poor, and patients should expect to require retreatment within 2 to 7 years. Intra-coronal bleaching is effective in at least 60% of cases. Some patient factors (e.g. age, oral health) were associated with a higher risk of premature failure of dental crowns, veneers and composite resin restorations. However, there is insufficient evidence to establish guideline-quality patient and tooth selection criteria that relate to specific types of fracture or extent of tooth avulsion. Recommendations: The guideline development panel should consider incorporating the following recommendations into the guidelines. These recommendations arise from a synthesis of all the evidence presented about survival of tooth restorations, and patient risk factors. They also incorporate the philosophies of striving for conservation of tooth tissue, and choosing a treatment plan that maximises the life-time potential of teeth. 1. When the primary indication for restorative treatment of fractured, non-vital anterior teeth is discolouration, intra-coronal bleaching should be the first treatment choice because it is effective in at least 60% of cases, has only one harmful side effect of low incidence, and does not limit subsequent treatment choices. 2. Unless indicated otherwise, patients <30 yrs should be treated conservatively with composite resin build-up, or reattachment of the avulsed fragment if available. This would be done with a clear understanding that these restorations are likely to require replacement within 7 yrs, but that this can be done at least once before the less conservative treatments of veneers and/or crowns need be considered. 3. In cases where either veneer or crowns are indicated, a veneer should be the first treatment choice for the following reasons:
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the survival rate of veneers appears to be better than for crowns. a high percentage of failures are repairable, further extending the life of the restoration. there is greater conservation of tooth tissue, and consequently a retention of some options for future treatments if the veneer fails. 4. Veneers should not be applied to teeth with large amounts of lost tooth tissue. The definition of large amounts remains to be decided. It should also be noted that a relative contraindication for veneers is poor oral health and a high caries rate.
Acknowledgements
The author wishes to acknowledge assistance of Susan Bidwell, Information Specialist, New Zealand Health Technology Assessment (NZHTA) in carrying out the literature search. This evidence based review by peer reviewed by the following people:
Mr Karl Lyons (BDS MDS Cert Maxillofacial Pros FRACDS)

Senior Lecturer/Prosthodontis, Department of Oral Rehabilitation, School of Dentistry, University of Otago, New Zealand
Professor Lindsay Richards (BDS BScDent PhD MRACDS(Prosth) FICD FADI)

Dental School, The University of Adelaide, Australia
Glossary of Terms
CDA/Ryge ANOVA California Dental Association/Ryge criteria for evaluating clinical quality and performance Analysis of Variance
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Table of Contents
Executive Summary ................................................................................................................iii Acknowledgements.................................................................................................................. vi Glossary of Terms ................................................................................................................... vi Table of Contents ................................................................................................................... vii 1 2 3 Background..................................................................................................................... 11 Objectives........................................................................................................................ 12 Methodology ................................................................................................................... 13 3.1 3.2 3.3 3.4 3.5 4 4.1 4.2 Criteria for selecting studies for this review ....................................................... 13 Criteria for excluding studies from this review................................................... 13 Search Strategy and information sources ............................................................ 14 Methods of the review......................................................................................... 15 Description of studies ......................................................................................... 15 Health Technology .............................................................................................. 17 Results ................................................................................................................. 17
Crowns............................................................................................................................. 17
4.2.1 Description of Studies ................................................................................. 17 4.2.2 Clinical Outcomes ....................................................................................... 18 4.2.3 Incidence and cause of crown failure .......................................................... 22 4.2.4 Adverse effects............................................................................................. 24 4.2.5 Patient Selection Criteria: Risk Factors for longevity.................................. 27 4.2.6 Cost ............................................................................................................. 27 4.3 Discussion ........................................................................................................... 27 4.3.1 Methodological Quality ............................................................................... 27 4.3.2 Clinical Outcomes ....................................................................................... 29 4.3.3 Safety and adverse effects ............................................................................ 31 4.4 Summary of Evidence.......................................................................................... 31 4.5 4.6 5 5.1 5.2 Conclusions......................................................................................................... 32 Appendix 1: Evidence Tables for Crowns ........................................................... 33 Health Technology .............................................................................................. 43 Results ................................................................................................................. 43 Description of studies.................................................................................. 43 Clinical Outcomes ....................................................................................... 44 The cause of veneer failure.......................................................................... 46 Adverse effects............................................................................................. 49 Patient Selection Criteria - Risk Factors for longevity................................. 50
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Veneers ............................................................................................................................ 43
5.2.1 5.2.2 5.2.3 5.2.4 5.2.5
5.2.6 Cost of Veneers............................................................................................ 50 5.2.7 Methodological Quality ............................................................................... 50 5.2.8 Clinical Outcomes ....................................................................................... 52 5.2.9 Safety and adverse effects ............................................................................ 53 5.2.10 Implications for outcomes over a lifetime ................................................... 53 5.3 Summary of Evidence.......................................................................................... 54 5.4 5.5 6 6.1 6.2 Conclusions......................................................................................................... 55 Appendix 2: Evidence Tables for Veneers........................................................... 56 Health Technology .............................................................................................. 64 Results ................................................................................................................. 64
Composite resin restorations......................................................................................... 64
6.2.1 Description of studies.................................................................................. 64 6.2.2 Clinical Outcomes ....................................................................................... 65 6.2.3 Adverse effects............................................................................................. 69 6.2.4 Patient Selection Criteria - Risk factors for longevity.................................. 69 6.2.5 Indications for improved longevity ............................................................. 70 6.2.6 Cost of composite resin restorations ........................................................... 70 6.3 Discussion ........................................................................................................... 70 6.3.1 Methodological Quality ............................................................................... 70 6.3.2 Clinical Outcomes ....................................................................................... 71 6.3.3 Safety and adverse effects ............................................................................ 71 6.3.4 Implications for outcomes over a lifetime ................................................... 72 6.4 Summary of Evidence.......................................................................................... 72 6.5 6.6 7 7.1 7.2 Conclusions......................................................................................................... 73 Appendix 3: Evidence Tables for composite resin restorations .......................... 74 Health Technology .............................................................................................. 78 Results ................................................................................................................. 78
Intra-coronal Bleaching................................................................................................. 78
7.2.1 Description of Studies ................................................................................. 78 7.2.2 Clinical Outcomes ....................................................................................... 79 7.2.3 Adverse Effects ............................................................................................ 82 7.2.4 Indications and contra-indications.............................................................. 82 7.2.5 Cost of intra-coronal bleaching ................................................................... 83 7.3 Discussion ........................................................................................................... 83 7.3.1 Methodological Quality ............................................................................... 83 7.3.2 Clinical Outcomes ....................................................................................... 84 7.3.3 Safety and adverse effects ............................................................................ 84 7.3.4 Implications for outcomes over a lifetime ................................................... 84 7.4 Summary of Evidence.......................................................................................... 84 7.5 7.6 8 9 Conclusions......................................................................................................... 85 Appendix 4: Evidence Tables for Intracoronal bleaching ................................... 86
Limitations of the review ............................................................................................... 90 Recommendations .......................................................................................................... 91

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References ................................................................................................................... 93
Appendix 1: Evidence tables for Crowns (go to p 33)......................................................... 97 Appendix 2: Evidence tables for Veneers (go to p 56) ........................................................ 97 Appendix 3: Evidence tables for Composite resin restorations (go to p 74)..................... 97 Appendix 4: Evidence tables for Intracoronal bleaching (go to p 86)............................... 97 Appendix 5. Level of evidence in the SIGN system............................................................. 98 Appendix 6. Studies excluded from this review................................................................... 99
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1 Background
ACC funds the placement of approximately 2,600 crowns per annum for clients who have received an injury to their teeth. Ninety percent of crowns purchased by ACC are on anterior teeth, and 10% are on posterior teeth. Until March 2007, dentists were not required to seek prior approval from ACC before placing these crowns, unless they were for elective treatments. In November 2006 a random sample of elective treatment requests for dental crown restorations in ACC clients was reviewed by an independent dental agency to determine whether crown placement was appropriate and necessary. Of the 59 reviewed, only six, i.e. 10%, were considered necessary and appropriate. The crowns considered inappropriate and unnecessary fell into five groups: Group 1: Group 2: Minimal damage to tooth. Teeth with or needing endodontic treatment, but not indicated for crowns. A significant portion of tooth structure remains and there is minimal risk to form and function. Group 3: Group 4: Group 5: Discoloured tooth; indicated for intra-coronal bleaching Tooth should be extracted Dental work does not fit within ACCs accident/injury legislation, because the tooth needed restorative treatment before the injury. i.e the dental complaint was not attributable to the injury. ACC was alarmed and concerned at finding that 90% of the crowns requested for elective treatment were inappropriate and unnecessary. While these analyses may be biased because they were of elective cases, it was an indication that ACC may be funding a percentage of crowns that should not have been placed in clients teeth. Consequently, in March 2007 ACC implemented a nationwide interim policy change which required dentists to seek prior approval from ACC for all crowns before they could be placed on a clients tooth. Since that time, ACC has seen a sustained 20% reduction in the number of crowns purchased per annum. ACCs primary concern is that clients teeth appear not to be treated conservatively. The placement of a crown is not considered to be a conservative treatment because it involves
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the irreversible removal of tooth structure which commits the tooth to a path of treatment that compromises the integrity and life-long health of the tooth. The choice to crown also eliminates the option to use a range of more conservative dental treatments in the future. These are all issues of concern because crowns are known to have a limited life, and once they fail the choices available for re-intervention are very limited. Alternative and variably more conservative treatments for the restoration of fractured anterior teeth are veneers and composite resin restoration. For those which are discoloured, intracoronal bleaching can be used to restore aesthetics. An evidence based healthcare (EBH) review of crowns, veneers, composite resin restorations, and intracoronal bleaching was requested to determine what evidence was present in the dental literature to guide treatment choices. This EBH review is a first step in the development of ACC guidelines for the restoration of fractured anterior teeth. The guidelines will be underpinned by this EBH review, but will be developed by a panel of dentists with a range of clinical experience and expertise. The purpose of the guidelines is to assist dentists to identify what is the best life-time management of coronal fractures of anterior teeth; i.e. when a crown should be placed, or when an alternative treatment would be more appropriate.
2 Objectives
To evaluate the clinical outcomes of anterior teeth restored with crowns, veneers, bleach or composite restorations. To report any indications/contraindications of crowns, veneers, bleach or composite restorations with relation to how much tooth structure is remaining after the fracture injury. To report any adverse effects associated with crowns, veneers, bleach or composite restorations. To provide an EBH report that will inform an expert panel of dentists who will be tasked with developing guidelines for case selection for crowns, veneers, bleach or composite restorations which consider the life-time management of injured anterior teeth.
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3 Methodology
3.1 Criteria for selecting studies for this review
Clinical studies about anterior teeth, of any study type except for individual case studies, published from 1987 onwards were considered; but there were unique selection criteria for each intervention. Composite resin studies were limited to traumatised teeth, and bleach studies were limited to discoloured teeth, whereas crown and veneer studies encompassed the general population. Shorter follow-up periods were accepted for composite resin and bleach studies, whereas follow-up periods were limited to 5 and 4 years respectively for crown and veneer literature. The inclusion criteria for each intervention are detailed and compared in Table 1. Individual case series were only considered when finding evidence of adverse effects. The type of participants included in the review of intra-coronal bleaching requires further explanation; patients with teeth stained due to fluorosis or tetracycline were excluded. However, patients with other discolouration, whether caused by trauma or as a result of endodontic treatment, were included because the aetiology of discolouration can be the same.
3.2 Criteria for excluding studies from this review

Reports about primary teeth, or posterior teeth were excluded from this study. Crown studies which did not differentiate data on single anterior crowns were excluded. Some reports did not cite a mean follow-up period; in these cases if the mean was likely to be less than the inclusion criteria in Table 1, the study was excluded.
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Table 1: Summary of Inclusion Criteria for four treatment interventions

Types of Study Crown RCT comparing crowns to other interventions Comparative studies Case series
General population with anterior crowns; not limited to trauma population. Single crowns of any type
Veneer RCT comparing veneers to other interventions Comparative studies Case series
General population with veneers; not limited to trauma population Porcelain laminate veneers, or direct composite veneers.
Types of Participant
Composite Resin RCT comparing composite resin restoration to other interventions Comparative studies Case series Limited to traumatised teeth
Bleach RCT comparing bleach to other interventions Comparative studies Case series
Patients with discoloured anterior tooth as a result of injury, or endodontic treatment Intra-coronal bleaching
Intervention
Outcome measure
Survival rate Failure rate Aesthetics (including gingival margin integrity) Patient satisfaction Adverse effects Implications of a repair/recurrent treatment Dental health outcomes over a lifetime > 5 years From 1987
Survival rate Failure rate Aesthetics (including gingival margin integrity) Patient satisfaction Adverse effects Implications of a repair/recurrent treatment Dental health outcomes over a lifetime > 4 years From 1987
Build-up of tooth structure with composite resin, or reattachment of avulsed tooth fragment with composite resin Survival rate Failure rate Aesthetics (including gingival margin integrity) Patient satisfaction Adverse effects Implications of a repair/recurrent treatment Dental health outcomes over a lifetime > 6 months From 1987
Tooth colour change Colour stability Failure rate Patient satisfaction Adverse effects Implications of a repair/recurrent treatment Dental health outcomes over a lifetime
Follow-up period Publication date
> 6 months From 1987
3.3 Search Strategy and information sources

A search of the following literature databases was performed: Cinahl, Cochrane Central Register of Controlled Trials, Current Contents, embase, Medline, Index New Zealand, PubMed (RCT/systematic review search only), and the Science Citation index. The search strategy was aimed at sensitivity rather than precision. The data range was limited to references in English from 1987 to December 2007 [2008 publications will be searched/reviewed before publication of final report]. where possible. A range of keywords, which described the four interventions, were used to create a master database of relevant dental literature. The master database was then searched across four Animal studies were excluded
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areas to capture studies of different types and focus as follows: RCTs and systematic reviews; appropriate or inappropriate utilisation; dental trauma; and safety/adverse effects. Medline was the major database for dental literature. All other databases yielded much fewer results and had poor or no indexing for dental information. Review databases and guidelines compilations were also searched: Cochrane Database of Systematic reviews, Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database, Health Technology Assessment Database, TRIP database, NLH Guidelines Finder (UK), Scottish Intercollegiate Guidelines Network, National Guideline Clearing House (US), Guidelines International Network, and the Canadian Medical Association Infobase. Other sources searched were websites for professional associations, clinical trials, and international health systems.
3.4 Methods of the review

The relevant studies were critically appraised by considering experimental design, population studied, interventions and outcomes reported. The quality of evidence in each study included in the review was graded according to the SIGN criteria, summarised in Appendix 5. The details of included studies were summarised in evidence tables which are supplied at the end of each intervention section.
3.5 Description of studies

The literature search yielded almost 1800 abstracts which were screened for relevant inclusion criteria. This was reduced to 141 references after the first screen, and full articles were retrieved. Hand searching of the bibliographies of the retrieved articles identified additional relevant literature which was also retrieved. Many of the retrieved articles were commentary style reviews, and after these were excluded 92 references were selected for critical appraisal for this review. Following critical appraisal, 26 studies were Most studies were of finally included in this EBH review: 10 about crowns, 8 about veneers, and 4 each about composite resin restorations and intra-coronal bleaching. consecutive series of patients, which were usually selected retrospectively. Further detail about the characteristics of the included studies is provided in the results section for each intervention review.
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Comments from Referee 1: The methodology of the review appears to have been appropriate. While a large number of publications were excluded because they did not meet the inclusion criteria, the findings of this review are unlikely to have been much different if the excluded publications had been included.
Comments from Referee 2: The report provides a clear description of the background to the project, the objectives and the methodology which conforms to contemporary best practice in its approach to systematically identifying and reviewing the relevant, valid literature in each of the four areas being considered. The process of identifying reviewing and including information appears to have been carefully applied and to the best of my knowledge, and in the areas where I have taken the time to independently review references, the information that has been presented is an accurate summary of the current literature. The breadth and depth of the review and the process involved makes it unlikely that significant information has remained un-discovered. The fact that the project has focused on English-language literature is unlikely to be significant as most information relevant to practise in New Zealand will either appear directly or indirectly in English. There is no evidence of bias in the report. Significantly: The background to the report, that could be interpreted as being critical of local practitioners, has been sensitively worded The generally low standard of the available evidence has been appropriately identified The transparent application of inclusion criteria has helped exclude bias
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4 Crowns
4.1 Health Technology
An artificial crown is a restoration covering the whole tooth and is intended to repair damage to individual teeth. Crowns replace tooth structure lost by decay or injury, protect the part of the tooth that remains, and restore the tooths shape and function. Preparation of a tooth for a crown involves the irreversible removal of a significant amount of tooth structure. The amount removed is dependent on the type of crown used. For instance a full gold crown requires a minimum of only 0.5 mm tooth reduction, whereas a porcelain fused to metal crown requires a minimum of 1.5mm buccal tooth reduction. There are four classes of crown, classified according to the material they are made of: Porcelain fused to metal (PFM), all ceramic/porcelain, full gold, and polymer resin crowns (without metal substructure). This review is primarily concerned with porcelain fused to metal (PFM) and all ceramic/porcelain crowns.
4.2 Results
4.2.1 Description of Studies There were no RCTs or comparative studies identified. Forty papers were selected for critical appraisal, after which 10 studies were included and 30 excluded. All included studies were case series, having follow-up periods ranging from 5 to 18 years. One study had an impressive sample size of 19,659, and the other studies had sample sizes ranging from 17 to 353. [Note that three of the included studies have limited relevance to crowning practice today because they report on Dicor all-ceramic crowns which have not been manufactured since 1994]. A further nine studies were included in the adverse effects section. The primary outcomes reported were survival rate and failure rate. In addition, the cause and/or incidence of failure is reported in nine papers. None of the studies reported indications or contraindications with regard to how much tooth structure is remaining after the fracture injury. However, one study discussed indications relating to age, and two studies discussed indications relating to root-filled teeth. The characteristics of the excluded papers are presented in Appendix 6.
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4.2.2 Clinical Outcomes The results of 10 studies about single anterior crowns are presented here, and they are grouped together according to the type of material used in the crown. For a summary of results refer to Table 2. Many of these studies reported the cause and incidence of crown failure and this information is also presented below, and summarised in Table 3. Further details of each study can be found in evidence tables in Appendix 1. All categories: Burke et al (2007)1 did a retrospective analysis of a longitudinal sample of dental records of 47,474 crowns placed in England and Wales over an 11 year period from 1990 to 20021 2. The life of 19,659 anterior crowns was calculated according to the probability of patients returning for a re-treatment other than maintenance. These calculations were based on observed times to re-intervention, and re-intervention was assumed to be associated with the crown restoration. The survival rate of anterior teeth, without root fillings, was 59% at 10 yrs. If a root filling was placed in the same tooth in the same course of treatment as a crown the survival rate was reduced to 43%. This study also showed, from whole-ofmouth data, that all-ceramic crowns showed the least time to re-intervention when compared with other crown types [note there could be a bias due to tooth position influencing the types of crown used]; and that patients in the 20 to 29 age band had the least good outcome in terms of re-intervention. The authors concluded that crowns should be avoided in younger patients if at all possible, and as resin composite restorations may be reliably bonded to tooth substance using the acid etch technique there would appear to be merit in maintaining anterior teeth with such restorations for as long as possible rather than crowns. Metal-Ceramic crowns: Walton (1999)3 4 reported results of a 10 yr longitudinal study, in which 353 crowns were placed on anterior teeth in a private specialist clinic. The retreatment rate (repair or failure) was 5.1% and all occurred within the first 5.5 yrs after cementation. The author reported that non-vital teeth had significantly higher failure and re-treatment rates than vital teeth, and that crowns on anterior teeth had a significantly greater re-treatment rate than crowns on posterior teeth.
5 De Backer et al (2006) did a retrospective survival study of 1037 full crowns over 18 years,
76% of which were porcelain fused to gold. The majority of restorations (79.2%) were
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post and core crowns and the work was carried out in a University undergraduate clinic. The number of anterior crowns, and the proportion which were post and core crowns in the anterior was not stated but the Kaplan Meier survival rate for anterior teeth was calculated as: 76.1% after 18 years, 83.1% after 12 years and 93.9% after 6 years. The reasons for failure of anterior teeth were not differentiated from the whole group of teeth. Porcelain veneer crowns: Etemadi & Smales (2006)6 did a retrospective case study of 134 anterior teeth treated with porcelain full veneer crowns, luted with resin cement systems. The failure rate was 12.6% after 5 years. The reasons for failure were presented, but anterior data could not differentiated from posterior teeth, see Table 4 for more detail. All-ceramic crowns: Alumina category Walter et al (2006)7 did a prospective case series of 61 all-ceramic crowns (Procera AllCeram). At the 6 year follow up the survival rate was 96.7%. The authors concluded that the prognosis is very good for Procera AllCeram in anterior restorations provided that clinical and laboratory instructions are followed. Odn et al (1998)8 did a prospective study to evaluate the clinical performance of Procera AllCeram after 5 years. None of the 17 anterior teeth in this study failed due to fracture, but one tooth required endodontic treatment. The authors concluded that the Procera All Ceram crown is the all-ceramic restoration of choice for anterior teeth needing a single crown restoration. All-ceramic crowns: Glass category
9 Fradeani & Redemagni (2002) did a retrospective analysis of 93 leucite-reinforced glass
ceramic crowns (IPS Empress). At follow-up averaging 7.4 yrs the survival rate was 98.9%. The authors concluded that leucite-reinforced glass-ceramic crowns showed a low clinical failure rate and excellent esthetics after up to 11 years. Erpenstein et al (2000)10 report results from a longitudinal study of 95 Dicor glassceramic crowns placed from 1987 until 1994, when manufacture of Dicor ended. The survival rate at 7 years was 82.7%. The authors concluded that conventionally cemented Dicor crowns are contra-indicated as a long-term restoration because of high risk of fracture.
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Sjgren et al (1999)11 did a retrospective study of 35 Dicor all-ceramic crowns placed on anterior teeth between 1987 and 1997. The mean age of incisor crowns was 6.3 yrs, and for canines it was 7.2 yrs. The failure rate due to fracture was 12%, although half of these were minor fractures and the crowns were still functioning. The authors concluded that fracture rates of the Dicor crowns placed on anterior teeth were relatively high and should be used with caution when the restoration is likely to be subjected to high stress. Malament & Sokransky (1999)12 did a 14 year prospective study of 422 anterior teeth restored with Dicor crowns. Ceramic failure was the only factor considered when reporting outcomes. This study found the following survival rates for acid-etched crowns: lateral incisors on both arches, 100%; mandibular canine, 84.8%; mandibular central incisor, 90%; maxillary canine, 91.4%; maxillary central incisor 80.6%. They also showed that the long-term survival improved significantly when restorations were acid-etched before luting, and the authors concluded that Dicor restorations present an acceptable risk when placed in incisor and premolar regions.
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Table 2. Summary of crown studies Shaded cells represent studies about Dicor crowns which have not been manufactured since 1994.
Reference
Burke et al 20081
anterior teeth
Crown type
All types
Follow- Effectiveness (survival/failure) up

11 years 10 yr survival = 59% without root filling 10 yr survival = 43% with root filling All-ceramic crowns show least time to re-intervention Patients in 20 29 age band have least good outcome 10 yr repair/failure = 5.1% Non-vital teeth had significantly higher failure and repair rate than vital teeth Survival rates for anterior teeth: 6 yr survival = 93.9% 12 yr survival = 83.1% 18 yr survival = 76.1% 5 yr failure = 12.6% 6 yr survival = 96.7% No failures due to fracture 1 tooth required endodontic treatment 7.4 yr survival = 98.9%
Comments
Survival = no re-intervention, other than maintenance, required. Represents on the street outcomes. Survival = no repair or replacement Private specialist practise. Survival = no repair or replacement University undergraduate clinic. 79% of teeth endodontically treated, & received post and core crowns. Survival = no repair or replacement Specialist prosthodontists Survival = no replacement needed Specialists at University clinic Periodontal disease excluded. Survival = no replacement needed Dentists expertise level not stated Author developed ProceraAllCeram. Survival = no replacement needed Private dental offices Only those with good oral health included (selection bias). Survival = no replacement needed Dentists expertise level not stated Periodontal disease excluded. Survival = no intervention A general dental practise; Dentists expertise level not stated Survival = no replacement needed One experienced prosthodontist Only those with good oral health included (selection bias).
19,659
Walton 1997 & 19993

4
353 (1037 all teeth)
PFM PFM
10 years 18 years
De Backer et al 20065
Etemadi 20066 Walter et al 20067 Odn et al 19988 Fradeani & Redemagni 20029 Erpenstein et al 200010 Sjgren et al 199911 Malament & Socransky 199912
N of anterior teeth not stated
134
61 17 93
Porcelain veneer crown All ceramic (alumina) (Procera AllCeram) All ceramic (alumina) (Procera AllCeram) All ceramic (glass) (IPS Empress) All ceramic (glass) (Dicor) All ceramic (glass) (Dicor) All ceramic (glass) (Dicor)
5 years 6 years 5 years 7.4 years
95 35 422
7 years 6.3 7.2 years 14 years
7 yr survival = 82.7% Dicor crowns contraindicated as a long-term restoration. Failure due to fracture = 12% Survival of lateral incisors = 100% Survival of mand and max canine = 84.8% & 91.4% Survival of mand and max c incisor = 90% & 80.6%
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4.2.3 Incidence and cause of crown failure Seven of the studies discussed above, reported in variable degrees of detail the incidence and cause of crown failure. Refer to Table 3 for a summary of this data. Causes of failure were either technical or had a biological origin, and are listed here: Crown fracture (also chipping and cracking) Debonding of crown Caries Aesthetics (including colour mismatch and margin exposure) Tooth fracture Pulpitis/endodontic reasons Periodontal reasons Post fracture With the exception of the study by de Backer et al (2006)5, all studies that reported incidence figures state that the most common reason for failure of crowns was crown fracture (responsible for 27 to 40% of failures). Debonding of the crown caused 6 to 15% of failures; caries caused ~ 24% of failures; aesthetics caused 4-5% of failures. De Backer et al (2006)5 reported that caries were the major cause of failure (24.3% of failures).
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Table 3. Summary of data about the incidence and cause of crown failure. Incidence and Author Cause of crown failure
Failure due to Crown fracture Failure due to Crown fracture Failure due to Crown fracture Failure due to Crown fracture Incidence and cause of crown failure
N
61 anterior teeth Follow-up 6 yrs 93 anterior crowns Average age 7.4 yrs 76 anterior teeth Average age 7.4 yrs 35 anterior teeth Average age 6-7yrs 353 anterior crowns. 5.1% retreated Age of crown 5-10yrs
Result/Conclusion
3.3% failed due to crown fracture 1.1% failed due to crown fracture 25% failed due to crown fracture 12% failed due to fracture Of the retreatments: 50% due to crown or root fracture 25% due to periodontal and caries 15% due to lost retention 4% due to esthetics (margin exposure) Of the irreversible complications: 66.4% due to biologic factors (24.3% caries, 17.2% periodontal, 12.9% fractured tooth, 12% endodontic problems) 39.1% due to technical and patient-related factors (8.7% fracture of porcelain, 6% loss of retention, 4.3% fracture of post, 11.2% needed as abutment for FPD, 1.7% trauma) Of reversible complications: 83% due to technical problems (69% loss of retention, 14% porcelain fracture 77.5% of failures occurred in porcelain veneers without metal reinforcement. Of the failures: 40% due to crown fracture 12.5% due to chip 2.5% due to crack 15% due to debonding 5% due to colour mismatch 20% due to pulpitis
Comment
Walter et al 20067 Procera All Ceram Fradeani & Redemagni 20029 glass-ceramic crown Erpenstein et al 200010 Glass-ceramic (Dicor) crown Sjogren et al 199911 Glass-ceramic (Dicor) crown Walton 19993 4. Metal-ceramic
Incidence and cause of crown failure
De Backer et al 20065 Metal-ceramic (79% were post and core crowns)
1037 crowned teeth 116 crowns failed 1.8% of the patients accounted for 23.3% of failed crowns; most (74%) of which failed due to biologic reasons. Age of crown up to 18 yrs 229 crowns 40 failures (17.5%) Age of crown >5 yrs
Anterior and posterior data can not be differentiated.
Incidence and cause of crown failure
Etmadi & Smales 20066 Resin-bonded porcelain veneer crowns
Can not differentiate the anterior and posterior data, but 42.5% of failures were in anterior teeth.
23
4.2.4 Adverse effects Fourteen studies reporting adverse effects of crowns are included in this section, but only three of these were discussed in the main section of this report. Ten adverse effects were reported. A limitation of most of these studies is that data for anterior and posterior teeth was not differentiated and so the statistics presented here do not necessarily portray the adverse effects (and incidence thereof) for anterior crowns. Furthermore, only three studies provided a comparison with uncrowned teeth in the same mouth13-15. The 10 adverse effects reported are: Altered colour of gingival tissue at the margin of the crown Gingival recession Gingival bleeding Foreign body gingivitis Peri-radicular periodontitis Secondary caries Nickel hypersensitivity related periodontitis Endodontic failure Root fracture Coronal fracture Refer to Table 4 for further details of the adverse effects and the studies reporting them.
24
Table 4. Summary of Adverse effects of crowns Adverse effect

Gingival colour
Author
[*= full appraisal in text]
N
8 teeth 15 central incisors, plus controls 44 teeth (63% anterior) plus controls
Sakai et al 198816 (gold crown) Takeda et al 199613 (metal ceramic and resinveneered)
Age of crown
Not stated 1-5 yrs
Result/Conclusion
Discolouration limited to marginal gingival. Colour varied from bluish purple to dark brown or dark gray. Gingivae around many artificial crowns showed a hue shift toward red-purple. Gingival colour differences (b/w crowned & not crowned teeth) were greater in the marginal and papillary areas. Gingivae tended to recede at crowned teeth during 12 month observation period; Crowned teeth had attachment loss. Originally intra-crevicularly placed crown margins were more or less visible after 12 months. 4% of retreatments due to margin exposure. Bleeding on probing was recorded for 39% of surfaces around crowned teeth, compared to 27% for control contralateral teeth. Persistent gingival inflammation associated with porcelain fused to metal crown was diagnosed as foreignbody gingivitis. Analysis of fragments of crystalline foreign material revealed statistically significant quantities of aluminium, silicon, magnesium, manganese and zirconium. 19% of vital preparations had signs of periradicular disease. 58% of teeth with endodontic treatment had signs of peri radicular radiolucency. 25% of retreatments were due to periodontal problems and caries.
Limitation of study
Only 1/8 of the sample teeth were anterior. Small sample size.
Gingival Recession
Koke et al 200314 (Porcelain fused to metal)
12 months
Anterior teeth not differentiated.
Walton 19993 4* (Metal-ceramic) Gingival Bleeding dman & Andersson 200115 (Procera AllCeram) Gordon 200017 (porcelain fused to metal)
353 anterior teeth 5.1% retreated 87 teeth, 22 anterior; plus controls 1 tooth
5-10 yrs 5-10.5 yrs
Small numbers; can not differentiate anterior teeth.
Foreign Body Gingivitis
2 yrs
A case study, briefly reported.
Periodontal problems and caries
Saunders & Saunders 199818 (Type of crown unknown) Walton 19993 4* (Metal-ceramic)
802 crowns 57% vital 43% endodontic 353 anterior teeth 5.1% retreated
unknown
Anterior teeth not differentiated.
5-10 yrs
25
Adverse effect
Periodontal problems and caries
Author
[*= full appraisal in text]
N
1037 crowns 116 failures 365 teeth
Age of crown
Up to 18 yrs unknown
Result/Conclusion
24.3% failures due to caries. 17.2% failures due to periodontal problems. 9.3% of single crowns failed due to secondary caries.
Limitation of study
Anterior and posterior data cannot be differentiated. There was an inclusion bias for patients with obvious past and/or present secondary caries lesion. Anterior and posterior data cant be separated. Anterior and posterior data cant be separated. However 72% crown replacements were on anterior teeth. One case study.
De Backer et al 2006*5 (Metal-ceramic) Zoellner et al 200219 (Crown material unknown) Wilson et al 200320 (72% porcelain fused to metal)
712 crown replacements 1 case
not stated
15% of the crown replacements were due to caries.
Nickel hypersensitivi ty related periodontitis Endodontic failure
Bruce & Hall 199521 (Porcelain fused to metal) Jackson et al 199222 (Crown material not stated) Cheung 199123 (Porcelain crown) Wilson et al 200320 (72% porcelain fused to metal) De Backer et al 2006*5 (Metal-ceramic) Etmadi & Smales 2006*6 (Porcelain veneer crowns)
unknown
Periodontitis correlated with location of new crowns containing nickel. 1.8% of vital anterior teeth subsequently had or now needed root canal therapy. 3% of crowns had endodontic failure. 3% of the crown replacements were due to endodontic failure. 12% of failures due to endodontic problems. 20% of failures due to pulpitis. 50% of retreatments due to crown or root fracture. 12.9% failures due to fractured tooth.
437 vital teeth with fixed prostheses 34 anterior crowns 712 crown replacements 1037 crowns 116 failures 229 crowns 40 failures 353 anterior teeth 5.1% retreated 1037 crowns 116 failures
2-6 yrs
Only 11% response to recall request; Cant differentiate the single crown and fixed partial denture data in the anterior teeth data. Small sample size. Selection bias: only 38% of selected patients followed through. Anterior and posterior data cant be separated. However 72% crown replacements were on anterior teeth. Anterior and posterior data cannot be differentiated. Cant differentiate the anterior and posterior data; but 42.5% of failures were in anterior teeth.
2.8 yrs not stated Up to 18 yrs >5 yrs 5-10 yrs Up to 18 yrs
Tooth and Root fracture
Walton 19993 4* (Metal-ceramic) De Backer et al 2006*5 (Metal-ceramic)
Anterior and posterior data cannot be differentiated.
26
4.2.5 Patient Selection Criteria: Risk Factors for longevity Only two risk factors for longevity were identified in the included studies. However, it should be noted that both of these findings applied to whole of mouth data, rather than anterior teeth only: Patients in the 20-29 yr age bracket: Burke et al (2008)1 showed that crowns placed in 20-29 yr olds had a poorer outcome (p<0.0001) than patients in the 3039 yr and 40-49 yr age brackets1. Patients in the 70-79 yr age bracket had the poorest outcomes of all. Non-vital teeth: Both Burke et al (2008)1 and Walton (1999)4 showed that non-vital teeth had poorer outcomes than vital teeth. The study of the England and Wales general dental service showed that when a root filling was placed in the same course of treatment as a crown, the survival rate was reduced from 59% to 43% at 10 yrs (p<0.0001)1. In Waltons (1999) 10 yr longitudinal study of 688 crowns, non-vital teeth had a significantly poorer failure outcome (5%) compared to vital teeth (1%) (p<0.05)4. There were no studies that reported indications or contraindications for crowns in relation to how much tooth structure is remaining.
4.2.6 Cost The median price in New Zealand of an all-ceramic crown is $1019, and for a porcelain fused to metal crown it is $973. ACCs contribution to the cost of a crown is $800 (plus $90 for a temporary crown) for an all-ceramic crown and $771 (plus $90 for a temporary crown) for a porcelain fused to metal crown.
4.3 Discussion
4.3.1 Methodological Quality Study design: The methodological quality of the crown studies is low by evidence based healthcare standards because they were all case series, and only 3 of the 10 studies were designed prospectively. None of the studies is directly comparable because of variations in almost every aspect of the studies: patient selection criteria, number of patients, follow-up period, crown type, clinical setting, measurement and reporting of outcomes.
27
Sample size and statistical analysis: Other than the large sample size of the English and Wales general dental service (19,659 patients)1 the sample size for studies of anterior crowns ranged from 17 to 422. Five studies had <100 participants and consequently have less statistical power. The Burke et al (2008)1 study utilised sophisticated statistics in the analysis of data and had strong statistical power due to the large sample size, reporting p values of 0.00011. All studies except for one8 calculated survival rate using Kaplan-Meier statistics (or similar). However, three of the studies reported survival rate for the whole mouth, and so survival statistics for anterior teeth were not available from these studies4 6 11. Some studies also used other statistical tests such as the chi squared test and the Fisher test. The study by Odn et al (1998)8 did not apply any statistical test or analysis other than calculating percentages. Intervention: The exact crown intervention was variable between studies due to different choices of materials, luting agents or different methods of tooth preparation. One study included crowns of all types1, two studies used porcelain fused to metal crowns4 5, six studies used all-ceramic crowns7-12, and one study used porcelain veneer crowns6. The clinical setting in which the interventions were placed varied from general dental practise, to private specialist practise, and university dental clinics. The clinical setting is a relevant consideration when interpreting study outcomes, because confounding factors may include different technical skills of the practitioners, and some self-selection of patients. These variations limit the ability to compare studies directly. Study population, inclusion and exclusion criteria: The study population for crown studies was not restricted to patients with fractured teeth; it was not possible to isolate trauma-only patients from the study statistics, and indeed none of the studies reported solely on a trauma population. The reasons for study participants receiving crowns varied from study to study. Common reasons were trauma, aesthetic considerations (including discolouration), to restore structural integrity (including those that had extensive loss of crown substance due to caries), or to replace a failed crown or other restoration. All ten studies included both anterior and posterior crowns, however only the data for anterior crowns was presented in this EBH report. The endodontic status of participants teeth was mentioned in only two papers5 9 and the statistics related to the whole mouth, rather than anterior teeth only. Patient selection criteria, and inclusion and exclusion criteria were not fully reported in some studies. With the exception of a randomly selected participant sample in the Burke
28
et al (2008)1 study, most studies selected consecutive patients treated between particular dates. Three studies set no particular exclusion criteria1 4 10, however 3 studies excluded patients with poor oral health7 9 12, and so these studies may have lower external validity due to this selection bias. Three studies excluded patients who dropped out during the follow-up period5 8 11. Follow-up and study period: Included studies had mean follow-up periods of at least 5 years. In studies where the Kaplan-Meier survival rate is calculated, the follow-up period reported is the maximum follow-up period calculated for that particular study; it is not the mean. Six studies had short to medium term follow-up periods (5-7 yrs), and three had medium to long term follow-up periods (7-15yrs). Only one study had follow-up data beyond 15 yrs5. Given that crowns are commonly perceived to be permanent long-term restorations, ideally one would like to see follow-up periods of >20 yrs. One of the main reasons for excluding crown studies from this report was short follow-up periods. Outcome measures: The primary outcome measure for crowns was survival/failure rate over a certain period. However, there was variability in the way survival or failure was defined (e.g. whether failure includes repairable failures or not), and which criteria were assessed when determining failure or survival. This variation limits the ability to compare studies directly. Only two studies analysed patient factors which may influence the survival of crowns1 4. 4.3.2 Clinical Outcomes The primary clinical outcome reported for crowns was survival/failure rate. The survival rate of crowns in England and Wales over 10 years ranged from 43% to 59% depending on
1 whether the tooth had a root filling . Of the crown studies included in this report, this
study has the highest external validity because data was obtained from the General Dental Service, and furthermore the sample size was 19,659 anterior teeth, giving the study exceptional statistical power. It is unknown whether these on the street figures would be mirrored in New Zealand, but it is not unreasonable to expect that this would be the case.
Comment from Referee 1 I would suggest caution in comparing dental treatment decisions in the NHS in the UK with what occurs in New Zealand because the NHS has provided publicly funded dentistry whereas NZ dentistry is largely privately funded. Publicly funded dentistry can sometimes impose treatment guidelines and funding on dentists that effect some treatment decisions that may not occur in privately funded dentistry. Comment from Referee 2
29
The statement (pg 28) that the UK study .. has the highest external validity because the data was obtained from the General Dental Service .. (and that) it is unknown whether these on the street figures would be mirrored in New Zealand, but it is not unreasonable to expect that they this would be the case is probably appropriate. In the end the relative success of different treatment strategies is probably more important than the absolute success rate and these are appropriately derived from studies with very large sample sizes.
The other studies have less external validity, but nevertheless they provide useful data on specific types of crowns, placed within specific clinical settings. The failure rates reported in these studies are considerably lower than the failure rate reported for the England and Wales dental service. The failure rate for PFM crowns varied between the two PFM studies included in this report. The 10 year repair/failure rate at a private specialist practise was 5.1%4, whereas the 12 year failure rate at a university undergraduate clinic was more than three times greater at 16.9%5. The failure rate had increased to 23.9% by 18 years follow-up . A possible confounding factor in this study by De Backer et al (2006) is that 79% of the teeth were endodontically treated, and received post and core crowns. Note that the definition of failure in the studies by Burke et al (2008)1, Walton (1999)4 and De Backer et al (2006)5 is a crown needing replacement or repair. The three reports about Dicor all-ceramic crowns, and the outcome data held therein have limited relevance to considerations of modern dentistry in New Zealand because they have not been manufactured since 1994. However, the relatively high number of failures reported in these studies could provide a benchmark when deciding whether a rate of failure is unacceptable or not. Overall, the high failure rates led most authors to conclude that Dicor crowns are contra-indicated as a long-term restoration on anterior teeth. Failure of Dicor all-ceramic crowns ranged from 12 - 17% at around 7 years follow-up 10 11 but were better in Malaments study which reported 14 year failure data for mandibular canines and maxillary central incisors of 15.2% and 19.4% respectively12. There did seem to be a tooth position effect on survival outcomes because there were no failures on lateral canines of either arch after 14 years12. Other brands of all-ceramic crowns (Procera AllCeram, IPS Empress) had lower failure rates (1-6%), as reported at 5-7 years follow-up7-9. However, the definition of failure in these studies was less stringent than the Burke et al (2008), Walton (1999) and De Backer (2006) studies because it only included crowns requiring replacement. A study of a porcelain veneer crown reported a comparatively high failure rate of 12.6% after 5 years6. The main causes of crown failure are crown fracture, debonding of the crown, and caries.
5 5
4.3.3 Safety and adverse effects In general, the adverse effects were reported in studies of both anterior and posterior teeth. However, it is assumed that anterior teeth are as susceptible to these adverse effects as posterior teeth. Whilst gingival colouration and gingival recession seemed to impact mostly on aesthetics, the other reported adverse effects (periodontal problems, caries, endodontic failure, and tooth and root fracture) are somewhat more serious because they cause crown failures.
4.4 Summary of Evidence

Evidence from the three best studies1 4 5 shows that there is a large variation in the survival rate of crowns (43-95%) over 10-12 yrs. The study with the highest external validity (i.e. most relevant to New Zealands dental service) reported survival rates of 43-59%1. Survival in these three studies was defined as a crown that does not require either replacement or repair. It is not possible to conclude with confidence why there is such large variation because there are confounding factors in all three studies. However one can speculate based on the study information provided: Walton (1999)4 provided reasonable evidence to suggest that the survival of PFM crowns in the medium term (10 yrs) is very good (95% survival). This outcome may be comparatively better because the crowns were placed in a private specialist practise (95%)4. De Backer et al (2006)5 provided reasonable evidence that the medium term (12 yr)
4 survival rate of PFM crowns is 83% and lower than Walton (1999) would suggest.
This poorer outcome may be because the crowns were placed in a university undergraduate clinic, or it may be due to patient risk-factors, such as 79% of the teeth being non-vital and endodontically treated. Burke et al (2008)1 provided good, externally valid evidence, supported with strong statistical power, that the medium term (11 yr) survival rate of crowns in a general population is poor (43-59% survival) when crowns are placed in a general dental
1 service . Whether this is a truly accurate representation of on the street outcomes
depends on the validity of the researchers assumption that re-interventions were associated with the crown restoration.
31
Comments from Referee 2: The report appropriately recognizes the complexities of comparing outcomes between general practice, specialist practice and university clinics. Comparing data from Burke (2008) and Walton (1999) is difficult (page 18). The Burke data is for publicly-funded services provide by general practitioners. In comparison Dr Walton is a former president of the International College of Prosthdontists with an international reputation for excellence in fixed prosthodontics.
There is evidence from three lesser quality studies7 8 24 that the short term (5-7 yrs) failure rate (i.e. replacement) of ceramic crowns is very low (1-4%). These studies are of lesser quality because of low participant numbers, a selection bias towards patients with good oral health, or a commercial-interest bias. These studies have low external validity. There is reasonable evidence from a single study that the short term (5 yr) survival rate of porcelain veneer crowns is comparatively poor (12.6% repaired or replaced)6. There is reasonable evidence from two studies that a risk factor for the longevity of crowns is placement on non-vital teeth1 4; and reasonable evidence from one study that being in the age bracket 20-29 yrs is a risk factor for longevity of crowns1. There is reasonable evidence from 7 studies that failure of crowns is caused either by a technical failure of the crown itself (fracture or debonding) or by adverse effects on oral biology such as periodontal problems, secondary caries, endodontic failure, and tooth and root fracture.
4.5 Conclusions
The outcome measures are dominated by survival/failure rates, and these data indicate that crowns applied by appropriate specialists can be highly successful in the medium term (10yrs)4. However, in a general practise setting the survival rates appear to be poor in the medium term (43-59%)1. There is insufficient evidence to establish guideline-quality patient selection criteria for placement of crowns on anterior teeth. However, the data did identify two risk factors: 1. Non-vital teeth are a risk factor for reduced longevity of crowns 2. People in the 20-29 yr age bracket are at risk of reduced longevity of crowns.
32
4.6 Appendix 1: Evidence Tables for Crowns

Reference: Burke & Lucarotti 2008
Evidence Based Healthcare Table 1

Design Description
A retrospective analysis of a longitudinal sample of dental records of 47,474 crowns placed in England and Wales over an 11 year period from 1990 to 2002. Dates of treatment for each tooth and date of next intervention for that tooth were consulted to calculate the time to re-intervention of teeth. The whole set of analyses was repeated on a second and non-overlapping random sample selected in the same way. Analysis was done using right-censored data. i.e. the end time of a restoration is not exactly known but is placed after a specified time, but without further limit. The method involved first estimating the probability that a patient will eventually return for re-treatment by analysing the observed patterns of re-attendance. This estimated probability of reattendance can then be used to modify the standard Kaplan-Meier procedure to produce realistic estimates of the hazard of re-intervention.
Dental Crowns
Bibliographic Number:
Participants
Description: The data set included patients: a) whose date of acceptance was after Sept 1990 and before January 2002, (i.e. Oct 1991 to Dec 2001). b) Whose birthdays were included within a set of randomly selected dates, one of which was chosen in each year. th c) Whose treatment was on or after their 18 birthday
Intervention
Placement of crowns on anterior teeth. 80% of crowns were Metal-ceramic bonded crowns. Maintenance is not considered to be a reintervention.
Outcomes
Outcome Measures: Life of a restoration = interval between successive interventions. This interval was calculated using 2 probabilities, as described in . Survival rate = % expected to survive after a given period, according to Kaplan-Meier method using life of a restoration data.
Definition of Re-intervention: the treatment, other than maintenance, that took place at the next intervention recorded for the crowned tooth. The re-intervention is considered to be associated with the original restoration, because crowns generally cover most of the surface of the tooth; so likelihood of there being no causal connection between original restoration and the re-intervention is low.
No. in Group: 19,659 anterior teeth Age: most frequently in 30 to 49 age group. Inclusions: Patients >18 yrs at time of crown treatment
Results: Canine teeth have the poorest survival rate to next intervention (48% at 10 yrs), followed by incisor teeth (55% for lateral incisor and 61% for central incisor) (p<0.0001). Survival rate of anterior teeth is reduced from 59% to 43% at 10 years if a root filling is placed in the same tooth in the same course of treatment as a crown (p<0.0001). All-ceramic crowns show the least time to reintervention when compared with other crown types (p<0.0001). Patients in the 20 to 29 age band have the poorest outcome in terms of time to re-intervention (p<0.0001), (other than the 70-79 age grouo).
Exclusions:
Selection Notes: See paper for more details of methodological theory.
Methodological Score:
33
Reference: Walton 1999
Evidence Based 4Healthcare Table 3

Design Description
A 10 yr longitudinal study of single-unit metal-ceramic crowns. Not stated whether the study was designed prospectively or retrospectively.
Dental Crowns
Participants
Description: Documented reasons for seeking crowns were aesthetic considerations, structural integrity and previous crown failure. 688 crowns in the whole study
Intervention
Metal-ceramic crowns placed on anterior teeth between Jan 1983 and Dec 1992, in a private specialist practise. Procedures were standardised as much as possible.
Outcomes
Outcome Measures: Retreatment = repair and/or failure. (where failure is when the crown is lost, or the crown had been recemented more than twice) Success = no evidence of retreatment other than maintenance procedures. Follow-up period was from 5 to 10 yrs Results: Retreatment = 5.1%. Occurred within the first 5.5 yrs after cementation (range 0.9 5.5 yrs). Mean service age was 3.3 yrs Major cause of retreatment: approx 50% were coronoradicular and root fractures Other biologic causes were periodontal and caries (approx 25%). Mechanical lost retention (approx 15%) Esthetic margin exposure (approx 4%) Anterior non-vital teeth had significantly higher failure and retreatment rates than anterior vital teeth (p<0.05). Crowns on anterior teeth had significantly greater retreatment rate than crowns on posterior teeth. Methodological Score: 3
No. in Group: 353 anterior crowns Age: 81% of patients were aged 30 to 59 yrs Inclusions: Patients who were treated with crowns from Jan 1983 to Dec 1992.
Exclusions: Patients whose crowns were only 1 5 yrs old; these patients were not included in the statistical analysis.
Selection Notes: Only data for anterior teeth was included in this EBH table. Data posterior teeth were excluded.
34
Reference: De Backer et al 2006

Design Description
Retrospective survival study of full crowns with or without posts
Dental Crowns
Participants
Description: 1312 full crowns placed over 18 yrs from 1974 to 1992. Records available for 456 patients, 1037 crowns. Root canal-treated teeth with a post and core crown represented 79.2% of the study group. Patients invited to have regular maintenance program every 6 months. Reasons for full crown prep were: Extensive loss of crown substance because of caries (66%) Replacement of existing restoration (12.2%) Trauma (7.7%) Endodontic problems (6.3%) Esthetic reasons (5.4%). No. in Group: not differentiated for anterior teeth Mean Age: Inclusions: Those patients which full records available
Intervention
Crowns were placed in undergraduate university clinic, Belgium. Patients were invited to participate in a regular supportive maintenance programme every 6 months. Crowns either cast gold (24%) or porcelain fused to gold (76%).
Outcomes
Outcome Measures: Failures: Irreversible complication: loss of full crown and/or tooth Reversible complication: full crown intact after conservative treatment Biologic or technical failures differentiated. Biologic failure = caries, periodontal problems, fracture of the abutment tooth, endodontic problems. Kaplan Meier survival rate calculated Results: The Kaplan-Meier survival rate for anterior teeth was calculated at 18, 12 and 6 yrs as follows: 18 yrs: 76.1% 12 yrs: 83.1% 6 yrs: 93.9%
Exclusions: Patients who dropped out. Reasons for drop out were: patients chose a private practitioner for maintenance, moved to another city, could not be traced, or died during follow-up period.
Selection Notes:
Methodological Score: 3
35
Reference: Etemadi & Smalesl 2006

Design Description
A retrospective case study of dental records to compare long-term failure rates and modes for all-ceramic veneer crowns (resin-bonded sintered feldspathic porcelain veneer crowns, RBPVCs) either with or without metal reinforcement (i.e. porcelain fused to metal).
Dental Crowns
Participants
Description: Older adolescent and adult patients who had RBPVCs placed during 19881995 on anterior and posterior teeth. Restorations placed due to discoloured, fractured or worn teeth/restorations, and for altering form of tooth as part of orthodontic therapy.
Intervention
Placement of porcelain veneer crowns using dualcured resin cement systems 17 crowns had metal reinforcement
Outcomes
Outcome Measures: Failure of crown: defined by authors as crowns requiring repair, monitoring or replacement. Follow-up: at least 5 years
No. in Group: 134 anterior teeth Mean Age: not stated Inclusions: Older adolescent and adult patients who had RBPVCs placed during 19881995 on anterior and posterior teeth
117crowns had no metal reinforcement Restorations done by two specialist prosthodontists.
Results: 17/134 anterior crowns failed = 12.6% failure Failure-mode data was not differentiated for anterior and posterior teeth. For the whole group of 229 restorations, failure modes were: Bulk fracture of porcelain Chip fracture of porcelain Crack fracture of porcelain Debonding Colour mismatch Pulpitis (tooth sensitivity)
Exclusions: Restorations without opposing occlusal tooth contacts
Selection Notes: Data on posterior teeth were excluded for this EBH summary wherever possible.
36
Reference: Walter et al 2006

Design Description
A prospective case study of patients treated with Procera Alumina AllCeram crowns, followed for 6 years.
Dental Crowns
Participants
Description: Patients who had all-ceramic crowns with alumina cores (Procera Alumina AllCeram crowns) placed on anterior or posterior teeth in 1997 and 1998.
Intervention
Placement of Procera Alumina AllCeram crowns on anterior teeth Restorations done by 3 specially trained clinicians at a Dental school
Outcomes
Outcome Measures: Failure = replacement of crown Survival = no removal Follow-up period was 6 years.
No. in Group: 61 anterior teeth Mean Age: not stated
Results: 2/61 crown fractures; had to be removed. Survival rate = 96.7% +/- 2.3%
Inclusions: Patients in need of crown treatment and demanding superior aesthetics.
Minor fractures within dental porcelain were found in 4 additional cases (anterior vs posterior location not differentiated). These defects were smoothened and polished.
Exclusions: Active periodontitis, current use of removable dentures, and ongoing orthodontic treatment.
Selection Notes: Data for posterior teeth not included in this EBH table where ever possible.
37
Reference: Odn et al 1998

Design Description
A prospective study to evaluate clinical performance of Procera AllCeram crowns after 5 yrs of service. Patients were selected until 100 crowns (posterior or anterior) were placed.
Dental Crowns
Participants
Description: The experimental population consisted of 58 patients who need crown therapy for a variety of reasons. They were selected from consecutive patients of 4 general practitioners.
Intervention
Placement of Procera AllCeram crowns. Preparation was 0.6mm deep.
Outcomes
Outcome Measures: Failure = fracture of crown Follow-up period > 5 yrs No statistical tests were applied in analysis of outcomes. Results: 0% failure Complication: 1 incisor showed clinical sign of pulpal inflammation and was endodontically treated through the crown 14 days after cementation
No. in Group: 17 anterior teeth (out of group of 97 crowns) Mean Age: Inclusions: Patients who needed crown therapy for a variety of reasons.
Most crowns of whole group (97) were luted with conventional luting agents (zinc phosphate cement, or glass ionomer cement). Only 4/97 luted with dual-cure resin cement.
Exclusions: Two patients, (3 crowns) lost to recall.
Selection Notes:
Methodological Score: 3 Bias risk: contributing author was a Manager at Procera
38
Reference: Fradeani & Redemagni 2002

Design Description
A retrospective evaluation of leucitereinforced glassceramic crowns placed on anterior and posterior teeth.
Dental Crowns
Participants
Description: Patients needed crown therapy for a variety of reasons. The study population was selected from consecutive patients at the authors offices. A total of 125 crowns were included in the study; 70 were placed on endodontically treated, 55 were placed on vital teeth. Only data for anterior teeth is considered in this EBH table No. in Group: 93 anterior crowns in 54 patients Mean Age: 41 yrs female, 40 yrs male Inclusions: Patients who received all-ceramic IPS Empress crowns between May 1990 and December 1996, a 6 year period. Only those with good oral health were included in the analysis. Exclusions: 45/170 (26%) crowns excluded from study due to patients lost to follow-up or who died. Patients with severe parafunction, periodontitis, serious gingival inflammation, poor oral hygiene or high caries rates. Selection Notes:
Intervention
Crown placement on anterior teeth. 1.2-1.5 mm preparations done. Dual-polymerizing resin composite cement was used to lute most restorations. Gingival margins located either at gingival crest, or slightly in the sulcus. Work performed by two clinicians.
Outcomes
Outcome Measures: Failure = crown needed replacement Average follow-up = 7.4 yrs; ranged from 4 to 11 years. Kaplan Meier statistics were used.
Results: Failure rate of 1.1%. (one crown failed due to fracture 6 yrs after placement) Survival probability at 11 years is 98.9%
Methodological Score: 3 Bias risk: Study may not reflect a true general population because only those with good oral health were included for analysis.
39
Reference: Erpenstein et al 2000

Design Description
A longitudinal clinical study of performance of two types of crowns, on anterior or posterior teeth. Types of crown studied were glassceramic (Dicor) and galvano-ceramic (Auvo Galvano). Not stated whether prospective or retrospective study design.
Dental Crowns
Participants
Description: Patients were periodontally healthy.
Intervention
Placement of Glass-ceramic crowns (Dicor) on anterior teeth from April 1987 August 1994. (NOTE: Dicor manufacture ended in 1994 due to large number of failures). Conventional cement was used (zinc phosphate). Most treatments (until year 10 of study) were done by one dentist.
Outcomes
Outcome Measures: Failure = fracture of crown (loss of the fractured segment) Survival rate = not fractured; Calculated by KaplanMeier method. Incomplete fracture = a crack in the cement. Follow-up was up to 11 years. Mean years at risk was 7.4 yrs. Results: 19/95 (20%) anterior crowns failed due to crown fracture Survival rate at 7 years = 82.7% (+/- 8.1)
No. in Group: 95 anterior crowns Mean Age: 40.8 yrs (+/- 9.8 yrs) Inclusions: Periodontally healthy patients wanting anterior teeth crowned
Exclusions: For EBH Table: Anterior crowns using galvano-ceramics excluded because follow-up less than 5 yrs. Posterior teeth excluded.
Selection Notes: For this EBH table, only anterior teeth treated with glass ceramic crowns were selected for inclusion.
40
Reference: Sjgren et al 1999

Design Description
A retrospective study of patients treated with Dicor all-ceramic crowns between 1987 and 1997.
Dental Crowns
Participants
Description: 63 Patients treated with Dicor all-ceramic crowns between 1987 and 1997 were invited to participate in the study, and were given an appointment to have their crowns independently examined. Both posterior and anterior crowns were examined, but only anterior teeth considered in this EBH table.
Intervention
Anterior teeth treated with Dicor all-ceramic crowns Most crowns placed at level of gingival margin All work done by one dentist from a general practise.
Outcomes
Outcome Measures: Failure: not defined Mean age of incisor crowns was 6.3 +/- 1.8 yrs; range 1.6 9.2 years. Mean age of canine crowns was 7.2 +/- 2.2;range 5.68.8 Results: 4/35 (12%) anterior crowns failed due to fracture. Two of these were minor fractures and were crowns still functioning.
No. in Group: 35 anterior crowns (98 crowns in total group) Mean Age: women 56.5 yrs, men 52.4 yrs for whole group Inclusions: Not stated
Two evaluators examined the crowns Luting method: not defined specifically for anterior teeth, but of whole group of 98 crowns, 54 glass ionomer cement, 30 with zinc phosphate, 14 with composite cement.
Exclusions: Those who didnt keep their assessment appointment; those who were ill.
Selection Notes: Data for posterior teeth was ignored for purposes of this EBH table.
41
Reference: Malament & Socransky 1999

Design Description
A prospective study of Dicor glass-ceramic crown survival
Dental Crowns
Participants
Description: Patients aged from 17 to 91 yrs, recruited in a clinical private practice. Patients offered choice of 3 materials, but told that Dicor offered potentially improved esthetic results, and had some fracture potential compared with feldspathic ceramic.
Intervention
Placement of Dicor glass ceramic single unit crowns on teeth. Followup period was for 14 yrs
Outcomes
Outcome Measures: Measured failure of ceramic only; not reporting on other causes of crown failure, such as caries, endodontic failure etc. Failure = the crown has a fractured ceramic piece that necessitated a replacement crown. [chips <1mm were reshaped and polished]. Probability of survival was calculated using Kaplan Meier method. Results: The probability of survival of acid-etched crowns at 14 yrs of a: Mandibular canine = 84.8% Mandibular lateral incisor = 100% Mandibular central incisor = 90% Maxillary canine = 91.4% Maxillary lateral incisor = 100% Maxillary central incisor = 80.6% Concluded that Dicor restorations present an acceptable risk when placed in incisor and premolar regions [These rates are better than for molars; max 1st molar nd st was 48.3%; mandibular 2 molar was 48.8%; mand 1 molar 74.1%] Long term survival improved significantly when restorations were acid-etched before luting. Methodological Score: 3 Bias risk: study may not reflect a true general population because only those with good oral health were included in study
No. in Group: 1444 crowns total; 422 anterior teeth crowned Mean Age: not stated Inclusions: Patients had excellent oral hygiene, minimal periodontal inflammation. Tooth preparation length was adequate; teeth exhibited minimal mobility.
Exclusions: Patients with poor oral hygiene, uncontrolled periodontal inflammation or if they preferred gold or metal-ceramic restorations.
Selection Notes:
42
5 Veneers
Veneers are restorations that cover the labial surface of a tooth and are used to improve the colour, form and/or position of anterior teeth. Veneers are comprised of either a thin porcelain laminate or of composite resin. The popularity of using porcelain veneers to restore the aesthetics of anterior teeth increased in the early 1980s when an acid-etching procedure was introduced that substantially improved the long-term retention of this type of veneer25 26. Retention is achieved by micromechanical retention of the porcelain to the tooth via a resin composite luting material. Irreversible enamel reduction of at least 0.5 mm is required to accommodate the minimal 0.5mm thickness of porcelain, and in order to improve the bonding of the porcelain to the tooth.
5.2 Results
5.2.1 Description of studies There were no RCTs or comparative studies identified. Of the 20 studies selected for critical appraisal, eight studies were included and 12 were excluded. All included studies were case series, having follow-up periods ranging from 5 to 12 years. One study had a substantial sample size of 2,562, whilst the other studies had small sample sizes ranging from 36 to 191. One additional study is cited in the adverse effects section. The quality of reporting varied substantially. The primary outcomes reported were survival/failure rate, or clinical acceptability/ unacceptability, although the definition of failure was not consistent across the studies. Marginal adaptation, marginal discolouration, caries recurrence and patient satisfaction were criteria commonly assessed when determining whether a veneer failed. Only one study reported a contraindication with regard to how much tooth structure is remaining after a fracture injury. One study reported the consequence of retreatment, and of high caries activity, and also presented age contraindications. Two studies reported contraindications related to the presence of composite restorations at the veneer margin. The characteristics of the excluded papers are presented in Appendix 6.
43
5.2.2 Clinical Outcomes The results of 8 studies about veneers are presented here. For a summary of results refer to Table 5. Further details of each study can be found in evidence tables in Appendix 2. Burke and Lucarotti (2008)27 did a retrospective analysis of a longitudinal sample of dental records of 2,562 porcelain veneers placed on anterior maxilla teeth in England and Wales over an 11 year period from 1991 to 2002. The life of these veneers was calculated according to the probability of patients returning for a re-intervention, based on observed times to re-intervention. Modified Kaplan-Meier statistics were used to determine a survival rate of 53% at 10 years, i.e. 53% of the porcelain veneers were present without reintervention. An analysis of the treatments provided at re-intervention of a veneered tooth illustrated that in the first year ~10% were recemented, ~40% were replaced with another veneer, ~10-20% were replaced with a crown, and ~20-30% received direct placement restoration. About 2% were extracted. Changes in re-treatment patterns were observed as time since placement of the original veneer progressed; the types and frequencies of retreatments were observed as follows: proportion treated with a replacement veneer decreased to ~20%, and the proportion of crown treatments became more variable (~1050%), extractions became more predominant (~10%), as did the proportion of teeth treated via direct placement restoration (>40%). When patient factors were considered it was found that older patients (>60 years) and younger patients (<30 years) demonstrated poorer survival of porcelain veneers (p=0.003), as did those with high caries activity (as evidenced by high annual treatment costs and/or frequent attendances) (p<0.001). When dentist factors were analysed the results demonstrated that the age, year of training and experience of a dentist had no influence on the survival of porcelain veneers. Fradeani et al (2005)28 did a retrospective study of 182 anterior teeth restored, for various reasons, with porcelain laminate veneers fabricated by both a pressed ceramic technique (IPS Empress) and a refractory die technique (feldspathic porcelain, Vitadur Alpha, Vita). The work was done by two dentists between 1991 and 2002. The clinical failure rate was 5.6%, and the 12 yr survival rate was 94.4%. Aesthetics, assessed according to CDA/Ryge criteria, were satisfactory. Whilst marginal discolouration was considered acceptable it recorded the lowest proportion of A ratings.
44
Smales & Etemadi (2004)29 did a retrospective study of porcelain veneer restorations of 110 anterior teeth with various indications for treatment. The work was done by two specialist prosthodontists between 1989 and 1993. Forty two percent of veneers had incisal coverage. The cumulative survival rate over 7 years was 95.8% in veneers with incisal coverage and 85.5% in veneers without incisal coverage. This difference was not statistically different. Peumans et al (2004)30 did a prospective clinical trial of 87 porcelain veneers in anterior teeth, plus first premolars, and reported a 5 and 10 yr follow-up. The work was done by one dentist in 1990 and 1991. The overall clinical acceptance decreased substantially between the 5 and 10 yrs follow-up from 92% to 64%. Patient satisfaction decreased between the 5 and 10 yr follow-up (from 80% to 59%), as did marginal integrity. Large marginal defects were found in 20% of restorations and were especially noticed at locations where the veneer ended in an existing composite filling. After 5 yrs 14% of veneers had excellent marginal adaptation, and by 10 yrs this reduced to just 4%. Increases were observed in the fracture rate (from 4% at 5 yr to 34% at 10yr), caries rate (2 at 5yr to 8 at 10 yr), and in clinical micro-leakage (from 26% at 5 yr to 65% at 10 yr). In 19% of the restorations, a clinically unacceptable marginal discolouration was observed at the 10 yr recall. The primary reasons for clinical failure were fractures of the porcelain and large marginal defects. However, most restorations were repairable, and only 4% needed to be replaced. These total failures were present in veneered teeth with a large amount of lost tooth tissue. The author concluded that porcelain veneers are not indicated in such teeth. Aristidis and Dimitra (2002)31 reported on a case series of 186 porcelain veneers, 94% of which were on anterior teeth. Veneers were assessed for marginal adaptation, marginal discolouration, fracture rate, caries recurrence, and patient satisfaction. After a five year follow up, 98.4% were clinically acceptable. Sieweke et al (2000)32 did a retrospective study of 36 porcelain (IPS Empress ceramic) veneer restorations of patients who had lost canine guidance. The mean age of patients was 45.2 years. The dental work was done by six dentists at a dental school, and preparation involved enamel reduction of 1 mm, and working an oval groove into the dentin. The Kaplan-Meier survival rate at 6.5 yrs was 75.8%. The main causes of failure were ceramic fracture and fracture of the adhesive bond.
45
Dumfahrt & Schffer (1999)33 reported on the clinical performance of 191 veneers after 1 to 10 yrs in service (average service time of 4.6 yrs). The cumulative survival rate over 5 yrs was 97%, and after 10.5 yrs was 91%. There were seven failures, due to fracture or multiple cracks. Worth noting is that when a failure occurred, parts of the preparation surface were situated within dentin, although this finding was not statistically significant (p=0.058). A finding that was significant was that the failure rate increased when the finish line crossed an existing filling (p<0.01). Marginal defects were slightly detectable or visible in 36% of cases, marginal discolouration occurred in 18% of restorations, and slight gingival recession (0.1 to 0.5 mm) was observed in 31% of restorations, particularly when the margins were equigingival or subgingival. Despite these defects at the margins, patient satisfaction was high with 99% of patients rating aesthetics as excellent.
34 Walls (1995) reported the failure rate in a case series of 43 veneers (36 on anterior teeth,
7 on premolars) after follow-up of up to 5.4 yrs. The total failure rate was 14% and was comprised of two complete failures, and four partial failures. The partial failures involved loss of material from gingival extensions or from the incisal edge. There was little evidence of marginal discolouration up to 3 years, however between 3 and 5 yrs, 28% of veneers developed marginal discolouration which appeared to occur due to marginal leakage at the luting agent to tooth interface.
5.2.3 The cause of veneer failure Refer to Table 6 for a summary of the cause of veneer failure. The most commonly reported cause of failure was veneer fracture, and the incidence of irrepairable fracture ranged from 0.5 5.5%, with the exception of one study reporting 11% failure32. In comparison the incidence of repairable fractures was greater, ranging from 1.6% to 30%. The next most commonly reported reason for failure of veneers was debonding, the incidence of which ranged from 1.8 to 5.6%.
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Table 5. Summary of Veneer studies.

Reference N
Burke and Lucarotti 200727 Fradeani et al 200528 Smales & Etemadi 200429 Peumans et al 200430
anterior teeth
Veneer type
Porcelain
Follow- Effectiveness (survival/failure) up

11 years 10 yr survival = 53% Patients <30 yrs and >60 yrs had poorest survival of veneers. 12 yr survival = 94.4% 7 yr survival = 95.8% (with incisal coverage) 7 yr survival = 85.5% (without incisal coverage)* *Difference not statistically significant 5 yr clinical acceptance = 92% 10 yr clinical acceptance = 64% *Survival rate when repaired = 96%
Definition of failure & clinical unacceptability

Repairable failure (implied) Re-intervention required.
Irrepairable failure (stated) fracture, partial debonding, impaired esthetics, impaired function Irrepairable failure (implied) fracture, debonding, colour mismatch
Comments
Represents on the street outcomes. Survival = no re-intervention required. Private practise. Marginal discolouration rated lowest Specialist prosthodontists
2,562
182 110
Porcelain Porcelain
12 years 7 years
87 teeth (95% anterior, rest premolar) 186 teeth (94% anterior, rest premolar) 36 canines
Porcelain
5 & 10 years
Repairable failure (stated) Clinically unacceptable Seven criteria were assessed.
Aristidis & Dimitra 200231 Sieweke et al 200032
Porcelain
5 years
5 yr clinical acceptance = 98.4%
Irrepairable failure (implied) Clinically unacceptable Seven criteria were assessed. Irrepairable failure (implied) Fracture, debonding, loss of function
A controlled university based clinical study. Primary reasons for clinical failure were fractures of porcelain and large marginal defects. Most restorations were repairable. Only 4% replaced. Dentists expertise level not stated. Reporting is brief.
Porcelain
6.5 years
6.5 yr survival = 75.8%
Dumfahrt & Schffer 200033 Walls 199534
191
Porcelain
1 - 10 years 5.4 years
43 (84% anterior, rest premolar)
Porcelain
5 yr survival = 97% 10.5 yr survival = 91% Marginal defects detectable/visible in 36% of cases 5.4 yr survival = 86%
Irrepairable failure (stated) fracture, partial debonding, impaired esthetics or function
Six dentists at a dental school; restoration of lost canine guidance. Failures were ceramic fracture and fracture of adhesive bond. Two dentists at a university clinic. Failures due to fracture or multiple cracks. University dental clinic.
Repairable failure (implied) total loss of veneer or fracture requiring replacement.. plus partial failures where veneers retained
47
Table 6. Cause of irrepairable veneer failure Type of failure

Veneer fracture (Irrepairable)
Study
Fradeani et al 2005 Smales & Etemadi 2004 Peumans et al 2004 Aristidis & Dimitra 2002 Sieweke et al 2000 Dumfahrt & Schaffer 2000 Walls 1995 Fradeani et al 2005 Peumans et al 2004 Walls et al Dumfahrt & Schaffer 2000 Smales & Etemadi 2004 Sieweke et al 2000 Walls 1995 Smales & Etemadi 2004 Aristidis & Dimitra 2002 Sieweke et al 2000 Peumans et al 2004 Sieweke et al 2000 Peumans et al 2004
Incidence N
1.1% 5.5% 2.3% 0.5% 11% 2.6% 2.3% 1.6% 30% 9.3% 1% 1.8% 5.6% 2.3% 0.9% 0.5% 2.8% 1.2% 2.8% 1.2% 182 110 87 186 36 191 43 182 87 43 191 110 36 43 110 186 36 87 36 87
Follow-up
12 yrs 7 yrs 10 yrs 5 yrs 6.5 yrs 10.5 yrs 5.4 yrs 12 yrs 10 yrs 5.4 yrs 10.5 yrs 7 yrs 6.5 yrs 5.4 yrs 7 yrs 5 yrs 6.5 yrs 10 yrs 6.5 yrs 10 yrs
Comment
Veneers replaced Four of the 6 fractures occurred in 1 patient Replaced with crown.
Veneer fracture (Repairable)
Limited fracture extension; these were rebonded Repairable fracture lines, and small bulk fractures. Fractures were repaired
Multiple cracks Debonding
Colour mismatch Marginal Adaptation Loss of function Retreatment complication Undocumented failure
Restored with a crown after tooth fractured during endodontic treatment
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5.2.4 Adverse effects There were no serious adverse effects of veneer placement, other than the irreversible loss of surface enamel during tooth preparation. Burke & Lucarotti (2008)27 do however demonstrate the consequences of retreatment; approximately 20% of teeth with failed veneers are retreated with crowns, which is a more invasive restoration presenting with a new set of potential adverse effects and no guarantee of life-time success. One other study
30 also mentioned that three of the four failures were retreated with crowns . The only other
adverse effects mentioned were: Gingival recession Caries at the veneer margin Margin discolouration Gingival recession: Two studies with 10 year follow-up periods reported that gingival recession occurs on veneered teeth30 33. Peumans et al (2004)30 reported that an increased tendency for gingival recession at the veneered tooth was already noticed after 5 yrs and became more obvious at the 10yr recall. Similarly, Dumfarht and Schffer (2000)33 described slight gingival recession in 31% of restored teeth. However, neither study compared gingival recession of unrestored teeth in the same mouth, so it is not possible to conclude a causal link between veneers and gingival recession. Nevertheless, that gingival recession occurs is a consideration for the aesthetics of veneers in the long term. Caries: Peumans et al (2004)30 reported a relatively low incidence of caries (2.3%) at 5 years, but this increased to 9.2% over 10 years. These caries were more prevalent where veneers crossed an existing composite restoration. One other study of 186 veneers assessed
31 the caries rate and found no carious lesions . One study excluded from this review
reported one carious lesion case out of 43 veneer restorations; it was repaired without detriment to the veneer35. Marginal Discolouration: Four studies reported that some veneers develop staining at the margins. The incidence figures reported were: 28% at 5.4 yrs34, 17% at 4.6 yrs33 and 19% at 10 yrs30.
49
5.2.5 Patient Selection Criteria - Risk Factors for longevity Four risk factors for longevity of veneers were identified in the included studies. One of these related to the amount of tooth structure remaining. Patients >60 yrs and <30 yrs: Burke & Lucarotti (2008)27 showed that veneers placed in people aged over 60 or under 30 had the poorest survival rates (p=0.003). High caries rate: Burke & Lucarotti (2008)27 showed that veneers had the poorest outcome in patients who have high caries activity (as evidenced by high annual treatment costs and/or frequent attendances) (p<0.001). Fillings at margins: Peumans et al (2004)30 reported that large marginal defects were especially noticed at locations where the veneer ended in an existing composite filling; and Dumfarht & Schaffer (2000)33 reported that the failure rate increased when the veneer finish line crossed an existing filling (p<0.01). Large amounts of lost tooth tissue: Peumans et al (2004)30 reported that all veneer failures involved teeth with large amounts of lost tooth tissue. There was some evidence, albeit statistically insignificant, that the survival rate of veneers may be diminished when: There is no incisal coverage29 There is dentin exposure33
5.2.6 Cost of Veneers The median cost of a porcelain laminate veneer in New Zealand is $844. ACCs contribution to the cost of Porcelain veneers is $675.80. 5.2.7 Methodological Quality Study Design: The methodological design quality of the veneer studies is low by evidence based healthcare standards because the relevant studies were all case series, and only one of the 8 studies was designed prospectively30. None of the studies is directly comparable because of variations in almost every aspect of the studies: patient selection criteria, number of patients, follow-up period, clinical setting and measurement and reporting of outcomes. Sample size and statistical analysis: Other than the large sample size of the English and Wales general dental service (2,562 patients)27, the sample size for studies of porcelain
50
veneers ranged from 36 to 186. The Burke et al (2007)27 study utilised sophisticated statistics in the analysis of data and had far greater statistical power due to the large sample size, reporting p values between 0.001 and 0.003. Five studies27-29 32 33 calculated survival rate using Kaplan-Meier statistics (or similar), and the other three studies30 31 34 calculated percentages. Intervention: All studies except one27 either described how the teeth and veneers were prepared and luted, or stated that manufacturers instructions were adhered to. private specialist practise, and university dental clinics. Study population, inclusion and exclusion criteria: As with the review of crowns, the study population for veneers was not restricted to patients with fractured teeth because it was not possible to isolate trauma-only patients from the study statistics, and none of the studies reported solely on a trauma population. Not all studies stated the reasons for study participants receiving veneers, but in those that did, the range of reasons included: tooth defects, diastema, malalignment, discolourations, fractures, wear, minor malocclusions, replacement of composite restorations and veneers. The veneered teeth were predominantly anterior, however 4 studies also included a small proportion (5-16%) of premolars30 31 34 36. Patient selection criteria, and inclusion and exclusion criteria was not fully reported in some studies. The method of patient selection was primarily by selecting consecutive patients treated between particular dates, except for the study by Burke &
27 Lucarotti (2008) which randomly selected the participant sample. Two studies did not
The
clinical setting in which the veneers were placed ranged from general dental practise, to
state how selection occurred34 36. Reasons for patient exclusion were not consistent across the studies but the range of reasons included: patient drop-out32 34 36, poor oral health or hygiene
28 30
, severe discolouration and evidence of marked or severe bruxism29, inadequate
remaining sound enamel29 30 36, and unfavourable occlusion30. Follow-up and study period: Included studies had a mean follow-up period of at least 4 yrs, and the maximum reported follow-up was 12 yrs28. Two studies reported survival rates at both short (5 yrs) and medium/long term (10 yrs) follow-up periods30 33. In studies where the Kaplan-Meier survival rate was calculated, the follow-up period was the maximum follow-up period calculated for that particular study, rather than the mean. One of the main reasons for excluding veneer studies from this report was short follow-up periods.
51
Outcome measures: The primary outcome measure for veneers was the survival/failure rate. However, as with the crowns studies, there was variability in the way this was defined (i.e. whether failure includes repairable failures or not), and variation regarding which criteria were used to assess a survival or failure. Other outcome measures widely reported were aesthetics, and adverse effects; and one study discussed the implications of a repair and the possible dental health outcomes over a lifetime27. 5.2.8 Clinical Outcomes The primary effectiveness outcome for veneers was the survival/failure rate, although there was not a commonly used definition across all studies. Three studies defined failure as repairable failure27 30 34, whereas the other five studies defined failure more narrowly as irrepairable failure. When only irrepairable failures were considered, (aside from Siewekes study32 confounded by patients with lost canine guidance and reporting a low survival rate (75.8%)), the survival rate was > 90% in four studies over a range of follow-up periods (5 to 12 years)28 29
31 33
When repairable failures were included in the failure definition, the survival rate for porcelain veneers was lower. Walls (1995)34 and Peumans et al (2004)30 reported survival rates of 86% and 92% respectively at 5 years; but at 10 years Peumans et al (2004)30 reported a substantially lower survival rate of 64%, illustrating that veneers deteriorate with time in service. However, it should be noted that most of the failed veneers in the Peumans et al (2004) study were repaired and when this was taken into account, the survival rate was 96% at 10 yrs. The figure of 64% survival in the study by Peumans et al (2004) is not inconsistent with the 53% survival rate for porcelain veneers in England and Wales general dental service over 10 years27. This study of veneers in a General Dental Service has the highest external validity of all the veneer studies included in this review because the results are representative of an entire service across a large sample size of 2,562 veneers. It is unknown whether these figures would be mirrored in New Zealands on the street situation, but it is not unreasonable to expect that this would be the case.
Comment from Referee 1 I would suggest caution in comparing dental treatment decisions in the NHS in the UK with what occurs in New Zealand because the NHS has provided publicly funded dentistry whereas NZ dentistry is largely privately funded. Publicly funded dentistry can sometimes impose treatment guidelines and funding on dentists that effect some treatment decisions that may not occur in privately funded dentistry.
52
The effectiveness (survival rate) of veneers was diminished when: the finish line of the veneer crossed an existing composite filling30 33 patients were aged less than 30 years or older than 60 years27 there is a high caries rate27 there are large amounts of lost tooth tissue30
The main causes of failure were fracture of the veneer, or debonding of the veneer.
Comments from Referee 2: The reference to debonding of veneers as major cause of failure (page 52) highlights one area of concern that could receive some additional attention but is difficult to investigate. Over time cement systems and bonding technology have changed significantly (this is also referred to in Section 6). Many studies neglect to mention how restorations were cemented but there are likely to be significant difference between traditional zinc phosphate cements, glass-ionomer cements and resin cements and also between how these cements perform in cementing different metals or ceramics to either enamel or dentine. The last paragraph in Section 8 which refers to this matter could perhaps be expanded to include some indication that this is a whole additional area of investigation, but that the quality of the clinical evidence is likely to be very poor as the materials are often very recently introduced and most studies have been conducted in vitro and their validity is difficult to assess.
5.2.9 Safety and adverse effects The most prevalent adverse effects of veneers are gingival recession and margin discolouration. Whilst these effects are not considered unsafe, they do have a negative impact on the aesthetics of the restoration, which may become a reason for either the dentist or patient requesting additional restorations. 5.2.10 Implications for outcomes over a lifetime The life-time outcomes of restoring a tooth with a veneer could be deduced from only one study27. The findings in the study of veneers in the England and Wales general dental service demonstrated that approximately 10% of teeth with failed veneers were extracted, and 20% were restored with crowns. The review of crowns in this EBH report has already demonstrated that the survival rate of crowns is variable, and likely to be poor in the general population, when placed by a general dental service.
53

All relevant studies about veneers were case series, hence the quality of evidence by EBH standards is low. The survival rate of veneers after 10 years of service varies greatly: at worst, survival rate is 53% - 64% if replacements and repairs are considered; and at best it is 96% if only replacements are considered (i.e. repair rates are ignored). There is evidence from multiple studies demonstrating that the short-term (~5 yrs) survival rate of veneers ranges from 86% - 98%; (excluding the study by Sieweke (2000) which had confounding patient factors). There is evidence from three studies27 30 33 that the risk factors for the longevity of veneers are patients aged <30 yrs or >60 yrs, a high caries rate, fillings at margins, and large amounts of lost tooth tissue. There is evidence from 7 studies indicating that the failure of veneers is caused primarily by fracture of the veneer and debonding of the veneer. There is evidence from numerous studies indicating that the main adverse effects of veneers are gingival recession, margin discolouration, and caries at the veneer margin. There is evidence from one study indicating that approximately 20% of failed veneers will be retreated with crowns.
54
5.4 Conclusions
The outcome measures in veneer studies are dominated by survival/failure rates, and the results are conflicting. Data from studies using small sample sizes show that veneers appear to be highly successful, but do deteriorate over time and large percentages of aging veneers require repair28-31 33. Data from a large sample size in a general dental practise indicate that a proportion of teeth (20% or more) in which veneers fail receive more invasive restorations (crowns or extraction)27. The adverse effects of veneers (gingival recession, margin discolouration) impact negatively on the aesthetic quality of veneers and it is conceivable that these factors may have influenced the removal of veneers in the Burke and Lucarotti (2008)27 study.
There is insufficient evidence to establish guideline-quality patient selection criteria for placement of veneers on anterior teeth. However, the data did identify four risk factors: 1. Veneers that cross an existing composite filling are at higher risk of failure. 2. Veneers placed in mouths with a high caries rate are at higher risk of failure. 3. Veneers placed in patients aged less than 30 yrs or older than 60 yrs have a higher risk of failure. 4. Veneers are contraindicated for teeth with large amounts of tooth tissue have been lost; [large amounts was not defined].
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5.5 Appendix 2: Evidence Tables for Veneers

Reference: Burke & Lucarotti 2008

Design Description
A retrospective analysis of a longitudinal sample of dental records of 2,562 porcelain veneer restorations placed in England and Wales over an 11 year period from 1990 to 2002. Dates of treatment for each tooth and date of next intervention for that tooth were consulted to calculate the time to re-intervention of teeth. The whole set of analyses was repeated on a second and nonoverlapping random sample selected in the same way. Analysis was done using rightcensored data. i.e. the end time of a restoration is not exactly known but is placed after a specified time, but without further limit. The method involved first estimating the probability that a patient will eventually return for re-treatment by analysing the observed patterns of reattendance. This estimated probability of re-attendance can then be used to modify the standard Kaplan-Meier procedure to produce realistic estimates of the hazard of reintervention.
Veneers
Participants
Description: The data set included patients: whose date of acceptance was from January 1991 to March 2002. Whose birthdays were included within a set of randomly selected dates, one of which was chosen in each year. th Whose treatment was on or after their 18 birthday. No. in Group: 2,562 anterior teeth in the maxilla. Age: most frequently in 30 to 49 age group. Inclusions: Patients >18 yrs at time of crown treatment
Intervention
Placement of porcelain veneers on anterior maxilla teeth.
Outcomes
Outcome Measures: Life of a restoration = interval between successive interventions. This 2 interval was calculated using probabilities, as described in . Survival rate = % expected to survive after a given period, according to Kaplan-Meier method using life of a restoration data. Definition of Re-intervention: the treatment that took place at the next intervention recorded for the veneered tooth. The re-intervention on a previously restored tooth may be associated with the original restoration, but it is nevertheless possible that there is no causal connection. Results: 10 yrs: 53% of porcelain veneers survived without re-intervention Older patients (>60 yrs) and younger patients (<30 yrs) demonstrated poorer survival of porcelain veneers (p=0.003). Patients with high caries activity (high annual treatment costs/frequent attendance) (p<0.001). The treatments required at re-intervention are: ~10% recementation ~40% replacement by another veneer ~20% replacement with a crown ~20% replacement by a direct placement restoration (may or may not be associated with original veneer) As time since placement of original veneer progresses, the proportion of replacement veneers decreases, and the proportion of other restorations, including crowns, increases. Dentist factors (training year, experience) do not influence survival of porcelain veneers to re-intervention. Methodological Score: 3
Exclusions:
Selection Notes: See paper for more details of methodological theory.
56
Reference: Fradeani et al 2005

Design Description
Retrospective case series
Veneers
Participants
Description: Sample collected from consecutive patients at the authors offices. Treatment was for a variety of reasons. All restorations, except for one, were placed on vital teeth.
Intervention
Restoration of anterior teeth with porcelain laminate veneers (Empress, and Vitadur Alpha). Work done between June 1991 and Dec 2002. Tooth prep ranged from 0.3 to 0.6mm in cervical third, to 0.8 to 1.0mm in the incisal third. The incisal reduction was up to 2 mm. Detailed methodology reported Follow-up occurred every 3 to 12 months.
Outcomes
Outcome Measures: Mean follow-up 5.69 yrs Esthetics (colour match, marginal discolouration, marginal integrity; assessed according to CDA/Ryge criteria) Survival rate: Survival time being time from cementation to irreparable failure. (Kaplan Meier statistics). Irreparable failure included porcelain fracture and/or partial debonding that exposed the tooth structure and/or impaired aesthetic quality or function. Results: 5 restorations failed, 5.6%. (2 were replaced, 3 were rebonded). Survival probability (Kaplan Meier) 12 yr: 94.4%. 95% confidence interval from 100% to 89.4% Aesthetics were satisfactory. Marginal discoloration recorded the lowest proportion of A ratings, but can be considered acceptable.
Group 1 No. in Group: 182 Mean Age: men 36.8 yr Women 38.3 yr Inclusions:
Exclusions: Patients with uncontrolled parafunction, periodontitis, severe gingival inflammation, poor oral hygiene, or high caries rates.
Selection Notes:
Methodological Score: 3 Bias risk: study may not reflect a true general population because only those with good oral health were included for analysis.
57
Reference: Smales & Etemadi 2004

Design Description
A retrospective study of anterior porcelain laminate veneers placed with and without incisal coverage
Veneers
Participants
Description: Patients had tooth defects and discolourations, fractures, wear or minor malocclusions. In some instances, incisal wear had led to exposure of dentin.
Intervention
Restoration of anterior teeth with porcelain laminate veneers. Some had incisal coverge, others did not. Work done by 2 prosthodontists at a specialist dental practice between 1989 and 1993. Where possible all preparations confined within enamel, but exposure of some dentin often occurred, especially in cervical tooth region.
Outcomes
Outcome Measures: Cumulative survival over 7 years (using life table method and SPSS stats software). Mean follow-up was 4 yrs. Failure = fracture, debonding, colour mismatch
No. in Group: 110 anterior teeth Age: older adolescent and adults Inclusions: Randomly selected dental records from among those of the longest attending patients
Results: Veneers with incisal coverage 7 yrs cumulative survival was 95.8%. Veneers without incisal coverage 7 yr cumulative survival was 85.5% Difference not statistically different. 6/9 failures occurred from porcelain fracture in veneers without incisal coverage. 4/6 fractures occurred in the one patient, who had worn incisal edges. All failures occurred within first 4 years.
Exclusions: Severe tooth discolouration, inadequate remaining sound enamel, evidence of marked or severe bruxism.
Selection Notes:
58
Reference: Peumans et al 2004

Design Description
A prospective clinical trial, set in a university dental school.
Veneers
Participants
Description: Veneers were placed to improve aesthetics by replacing worn and discoloured composite restorations and veneers, or to correct discoloured, malformed and/or malaligned anterior teeth. There was a 93% recall rate at the 10 yr follow-up No. in Group: 87 anterior teeth (includes first premolars) Age: 19 to 69 yrs Inclusions: See description above. Patients treated with veneers in 1990 and 1991.
Intervention
Restoration of anterior teeth and first premolars with porcelain veneers. Work done by one dentist in 1990 and 1991, following a meticulous clinical procedure. Feldspathic porcelain used. Labial enamel reduction was from 0.3 to 0.7 mm. incisal edge shortened and shoulder prepared on palatal side. Equigingival cervical margin.
Outcomes
Outcome Measures: Clinical acceptability Failure = clinically unacceptable but repairable; or clinically unacceptable with replacement needed. Esthetics, marginal integrity, retention, clinical microleakage, caries recurrence, fracture, vitality, patient satisfaction Follow-up at 5 year and 10 yrs. Results: Overall Clinically acceptable: 5 yrs: 92% (95 CI: 90 %to 94%) 10 yrs: 64% (95 CI: 51% to 77%). No veneers were lost. 4% needed to be replaced. Most restorations were repairable. Patient satisfaction: 59% patients very satisfied with esthetic result at 10 yr, compared with 80% at 5 yrs. Fracture rate: 4% at 5 yr, 34% at 10 yr Marginal integrity; large marginal defects in 20% (cause for failure). Especially noticed at locations where veneer ended in an existing composite filling. 14% excellent margin adaptation at 5 yr; 4% excellent margin adaptation at 10 yr. Clinical microleakage: 26% at 5 yr, 65% at 10 yr. 19% had clinically unacceptable marginal discolouration. Caries at veneer margin: 2 at 5 yr, 8 at 10 yr. Most caries (7/8) were observed where veneers crossed an existing composite restoration. Tooth vitality: 3 teeth needed endodontic treatment. They all had deep or large composite fillings. Methodological Score: 3 Prospective, university based study, thorough reporting.
Exclusions: When less than 50% of the enamel remained for bonding or in patients with poor oral hygiene or unfavourable occlusion.
Selection Notes:
59
Reference: Aristidis & Dimitra 2002

Design Description
A case series. Presumed to be restrospective.
Veneers
Participants
Description:
Intervention
Placement of porcelain veneers between Feb 1993 to Dec 1994. Work done by one dentist. Facial enamel reduced 0.3 to 0.5 mm, and incisal reduction was 0.5mm. Tooth preparation did not expose dentin.
Outcomes
Outcome Measures: Teeth were assessed across 7 categories which dealt with aesthetics, marginal integrity, marginal discolouration, fracture rate, patient satisfaction. Ratings were perfect, clinically acceptable, or clinically unacceptable, but these terms were not further defined. 5 year follow up Results: Overall, 98.4% clinically acceptable. Marginal adaptation: 1/186 unacceptable Fracture: 3/186 fractured, 2 were acceptable, 1 was unacceptable. Patient satisfaction: 5/186 were not completely satisfied Marginal discolouration: 2/186 cases, but clinically acceptable. There was no caries recurrence.
No. in Group: 186 veneers. 94% st anterior teeth, rest were 1 premolar Age range: 18 to 70 Inclusions: Not described
Exclusions: Not described
Selection Notes:
Methodological Score: 3 Poorly reported
60
Reference: Sieweke et al 2000

Design Description
Retrospective case series
Veneers
Participants
Description: Patients had a healthy periodontum and dentition free of caries and/or restored. The patients had lost canine guidance.
Intervention
Restoration of canine guidance using oroincisal IPS Empress ceramic veneers. Minimal thickness of enamel reduction was 1 mm. Oval groove also made into the dentin. Patients were recalled 6 monthly. Work done at a dental school by 6 dentists, between 1992 to Jan 2000.
Outcomes
Outcome Measures: Survival rate using Kaplan-Meier method. Average follow-up period was 6.74 yrs. Failure = fracture, debonding, loss of function. It is implied that only irrepairable failures are reported in statistics. Results: Survival rate: 6.5 yrs: 75.78% 95% confidence intervals were 58% to 88% 8 veneers failed. Cause of failure: 4/8 ceramic fracture 2/8 fracture of adhesive bond 1/8 loss of function 1/8 not documented
No. in Group: 36 canines (in 17 patients) Mean Age: 45.2 yrs Inclusions: The patients had lost canine guidance.
Exclusions: Patients who did not participate in or dropped out of the recall program
Selection Notes:
61
Evidence Based Healthcare Table

Reference: Dumfahrt & Schaffer 2000; and Dumfahrt 1999
33 36
Veneers
Case Number: Bibliographic Number:
Design Description
A retrospective case series
Participants
Description: Reasons for treatment were: worn anterior teeth (80) surface enamel defects(34), intrinsic discolouration (30), hypoplasia (22), occlusal correction (13), diastema (13), fractured teeth (9), and mild malalignment (4).
Intervention
Restoration of anterior teeth with porcelain laminate veneers. Two dentists did the restorations and examinations at a university dental clinic. Consensus was reached when disagreements over scoring occurred.
Outcomes
Outcome Measures: Average observation period was 4.6 yrs. Survival time = time from placement to irrepairable failure. Veneers assessed following a modified California Dental Association/Ryge criteria. Kaplan Meier survival statistics applied. Results: Failures: 5 fractures, 2 multiple cracks Kaplan Meier Survival estimation 5 yrs: 97% 10.5 yrs: 91% Failure rate significantly increased when the finish line crossed an existing filling (p<0.01). When a failure occurred, parts of the preparation surface were situated within dentin. Findings not significant (p=0.058). Marginal integrity: 99% acceptable; 36% showed slight detectable and/or visible marginal defect. Facial marginal integrity was worse when the prepared gingival margin located within dentin. Marginal disintegration: significantly increased for longer wearing time (p<0.05). Superficial marginal discolouration: in 17% of veneers. Significantly increased when gingival preparation was located within dentin (p<0.001). Gingival recession: increased recession in 31% of veneers; 88% of these were in teeth with equigingival or subgingival margins Patient satisfaction: 99% excellent aesthetics Methodological Score: 3
No. in Group: 191 teeth (94% anterior) Age: 13-63 yrs; largest number in 31-40 age group. Inclusions: Non-carious surface defects, discolourations, and minor to moderate structural defects.
Exclusions: 7 patients who were unavailable for final evaluation between Sept and Dec 1997. Teeth with structural enamel defects that would leave insufficient enamel and tooth structure, such as amelogenesis and dentinogenesis imperfecta. Cases where less than 50% of the potential bonding area was within the enamel as a result of large areas of exposed dentin or large restorations.
Selection Notes:
62
Reference: Walls 1995

Design Description
A case series. Presumed to be retrospective.
Veneers
Case Number: Bibliographic Number:
Participants
Description: Patients had worn or fractured teeth
Intervention
Outcomes
Outcome Measures: Failure = total loss of the veneer or such severe fracture that the restoration had to be replaced. Follow-up: the minimum time was 50 months (4.16 yrs), the max was 65 months (5.4 yrs)
Restoration of teeth with porcelain veneers. Acid etch technique used along with dentine-bonding system. No. in Group: 43 veneers (36 on anterior teeth, 7 on premolars) University dental clinic. Patients were reviewed at 6 month intervals.
Mean Age: not stated Inclusions: Twelve patients presented to a dental hospital with problems involving toothwear and/or localised tooth fracture.
Results: 2 complete failures (one after 2 days; poor prep blamed) (4.7%) 4 partial failures (loss of material from gingival extensions or from the incisal edge) (9.3%) Total failure=14% Marginal stain 0-3 yrs: little evidence 3-5 yrs: 12/43 (28%) veneers developed marginal discolouration
Exclusions: 9 restorations lost to follow-up.
Selection Notes:
63
6 Composite resin restorations

Composite resins used in dentistry to restore carious, worn or fractured teeth are composed of an organic resin-based matrix and an inorganic filler. In the restoration of fractured teeth, they are used in both the build-up of the remaining crown tissue, and in the reattachment of avulsed fragments. The methods of both of these treatment approaches have evolved over the last 30 years as successive generations of composite resins and adhesive products that can form strong bonds with enamel, and latterly dentine, have been developed. The earliest method for reattachment of avulsed fragments, reported in 197837 38, involved preparation of the tooth and fragment by an enamel acid-etch technique followed by adhesion of fragments using composite resin. Acid etching produces micro-porosities in the enamel surface into which low viscosity adhesives can penetrate resulting in a mechanical bond with the tooth. The method was further advanced in the mid 1980s when dentine bonding agents were developed to increase the bond strength of composite resins to dentine, and since then there have been several generations of development. Various additional techniques have been employed to enhance dental fragment retention after reattachment and these include enamel bevels, internal enamel or dentine grooves,
39 chamfers and over-contouring .
6.2 Results
6.2.1 Description of studies The majority of composite resin literature is about fillings. Seventeen papers were selected for critical appraisal; none of these were RCTs or studies which compared composite resin methods with crowns, veneers or bleaching. After a critical appraisal of the studies, 13 were excluded and 4 included. All 4 included papers were case series with a sample size ranging from 18 to 334, and a follow-up period ranging from 2 to 7.5 years. These studies reported the use of both fragment reattachment and composite build-up. The primary outcome measure reported by all four of the included studies was retention rate or survival of the restoration and two studies reported
64
on pulpal health and aesthetics. Composite resin restoration was the only intervention for which indications/contrindications were presented regarding the type of fracture, and the extent of fracture. The characteristics of the excluded studies are presented in Appendix 6.
6.2.2 Clinical Outcomes The results of 4 studies about composite resin restorations of fractured teeth are presented here. For a summary of results refer to Table 7. Further details of each study can be found in evidence tables in Appendix 3. Spinas (2004)40 did a seven year follow-up study of 90 injured teeth in children and adolescents. Seventy teeth received a composite resin build-up, and the remaining 20 received fragment reattachment treatment. The acid-etch conditioning technique was used, along with 3rd or 4th generation adhesive systems. Ten parameters of effectiveness were evaluated before each restoration was assigned a final overall evaluation. Of the composite resin build-up restorations, 47% needed a complete replacement after 3 years, and 100% needed complete replacement after 7 years. The study showed that composite build-up was more reliable for injuries of class C: involving the incisal edge and at least a third of the crown, when compared to injuries of class B: involving a mesial or distal coronal angle and/or incisal edge. A difference in treatment reliability was also observed when fragments were reattached, except that the situation was reversed: class B injuries were more durable than class C with this treatment. After 3 years there were no replacements of reattachments required for class B injuries, whereas 61% of class C injuries required complete replacement. By 7 years after reattachment, 100% of both class B and C injuries needed a complete replacement. The authors were of the opinion that a tooth can probably undergo 3 or 4 composite restoration replacements before it shows a severe reduction of its adhesive properties; although they did not provide clinical evidence to support that particular opinion. The most frequent events that led to a replacement restoration were loss of the restoration, loss of marginal integrity, and unacceptable pigmentation/discolouration caused by pulp necrosis secondary to initial injury. The authors opinion was that the greatest limitation of composites is poor quality of the marginal seal. Interestingly, a great number of restoration losses were due to 2nd or 3rd successive injuries. Consequently a risk factor
for longevity of composite resin restorations is teeth with anatomical factors predisposing to further traumatic injury (overjet, overbite, Angles Class II malocclusion). Garcia-Ballesta et al (2001)41 reported clinical outcomes for a group of 18 children who had avulsed coronal fragments reattached. In addition to the standard acid-etching, use of a bonding agent and light-curable composite resin, a notch was also made in the enamel in an effort to improve bonding strength. The retention rate after 2 years was 39%. The mean retention period was 19.5 months, but varied depending on the amount of dentin exposure. Where there was little to moderate dentin exposure (n=10), the mean retention period was 22.1 months, whereas where there was wide dentin exposure (n=8) the mean retention period was shorter, being 15.1 months.
42 Cavalleri & Zerman (1995) reported the 5 year outcomes of 84 fractured incisors in
children aged from 6 to 12 years. Teeth were restored either with reattachment of avulsed fragment or with composite resin build-up. Pulpal exposure occurred in 16% of injuries; fractures involving fracture of enamel and dentine occurred in 80% of injuries. Of those without pulp involvement, 6% developed pulp necrosis. This was a significantly different result (p<0.01) compared to injuries that exposed the pulp, of which 57% developed pulp necrosis. The restorations were aesthetically satisfactory in 43% of teeth. A high proportion (40%) of teeth were retreated because of a new trauma, and 17% of restorations were unsatisfactory due to wear of the composite. Andreasen et al (1995)43 reported the results of a multi-center case series study of 334 fractured anterior teeth restored by reattachment of the avulsed fragment. The study compared the effectiveness of two bonding methods: acid etching of enamel alone (AE) and a combination of enamel etching and dentinal bonding (DBA). The extent of fracture had no influence on loss or retention of fragments, but the treatment method did. The final retention rate at 7.5 years was similar for each group: 15% for AE and 25% for DBA. However, it took three times longer to reach 50% retention in the dentinal bonding group (2.5 years compared to 1 year). The aesthetics, as judged by colour harmony between the tooth, the fragment and the composite at the fracture line, was acceptable in 55% of DBA cases, and in 45% of AE cases. Fragment loss was predominantly caused by new trauma (~50%), non-physiologic use of the bonded tooth (~12%), and horizontal traction (i.e. biting into chewy or tough foods). About 25% were lost spontaneously or during physiological use. Although there was pulpal involvement in 39.5% of injuries, this was
66
not an indicator of subsequent pulpal necrosis. Pulp canal obliteration and pulpal necrosis occurred in 6.6% of cases and was apparently related to a concomitant luxation injury, not to a complicated crown injury exposing pulp.
67
Table 7. Summary of composite resin studies Reference

Spinas 200440
N
teeth 90
Composite Usage
Composite build up Reattachment (acid etch + 3rd or 4th generation adhesive systems used)
Followup (yrs)
7
Effectiveness
(retention rate/ survival of restoration, pulpal health, esthetics) Build-up 3 yr: 47% needed complete replacement 7 yr: 100% needed complete replacement Reattachment 3 yrs: B grade injuries 0% needed replacement C grade injuries 61% needed replacement 7 yrs: 100% needed complete replacement A great number of restoration losses due to a new trauma 2 yr: 39% retention rate mean retention period little/moderate dentin exposure: 22.1 months wide dentin exposure: 15.1 months 5 yr: 43% intact and esthetically satisfactory 17% unsatisfactory 40% retreated due to a new trauma Pulp necrosis was most prevalent in injuries which exposed the pulp. 7.5 yr: 15% retention for acid etch group 25% retention for acid etch + dentin bonding group 50% loss of retention took longer to reach in the dentin bonding group 50% fragment loss due to a new trauma. Pulp necrosis (6.6%) not associated with pulp exposure (39.5%), but rather to a concomitant luxation injury.
Comments
Patients were children & adolescents. Detailed analysis; many subgroups considered. C type injuries involve loss of more coronal structure (at least a third). Patients were children. The less dentin exposed, the longer the tooth fragment remained attached. Patients were children.
Garcia-Ballesta et al 200141
18
Reattachment (acid etch + dentin bonding) Composite build up Reattachment (acid-etch) Reattachment; (study compares acid etch with acid etch + dentin bonding agent)
Cavalleri & Zerman 199542
84
Andreasen et al 199543
334
7.5
Mean patient age ranged from 10.5 yrs to 14.5 yrs.
68
6.2.3 Adverse effects No adverse effects were reported for the use of composite resin. Any negative outcomes with this treatment were related to effectiveness.
6.2.4 Patient Selection Criteria - Risk factors for longevity Three possible risk factors for longevity of reattachment of avulsed fragments using composite resin were identified or discussed. Fractures involving the incisal edge and at least a third of the crown fail quicker than fractures involving a mesial or distal coronal angle and/or incisal edge40. Anatomical factors predisposing to further traumatic injury (overjet, overbite, Angles class II malocclusion). Three of the four studies reported that 40-50% of fragment loss occurred due to a new trauma40 42 43. Wide exposure of dentin: There is conflicting evidence regarding the influence of dentin exposure. One study reported that restorations failed quicker (mean life was 15 months) when there was wide dentine exposure; as compared to restorations with little/moderate dentin exposure (mean life was 22 months)41. However, this study had only 18 participants and it is unknown whether this is a statistically significant finding. In contrast, a study with 334 participants showed
43 that the extent of fracture had no influence on loss or retention of fragments .
In addition, there was conflicting evidence from two studies about the influence of pulp
exposure on pulp survival in teeth restored with composite resin42 43. Cavalleri & Zerman
42 (1995) reported up to 57% pulp necrosis when pulp was exposed, and that injuries with
pulp involvement had a significantly higher chance of pulp necrosis (p<0.01). In contrast, Andreasen et al (1995)43 reported that pulpal necrosis occurred in only 6.6% of cases and was apparently related to a concomitant luxation injury, not to a complicated crown injury involving pulp exposure. This difference in the outcome for teeth with pulp involvement is possibly also due to a robust treatment of exposed pulp by Andreasen et al (1995)43.
69
6.2.5 Indications for improved longevity Composite resin build-up Fractures involving the incisal edge and at least a third of the crown: composite resin build-ups were more reliable for injuries of this class compared to fractures involving a mesial or distal coronal angle and/or incisal edge. Composite resin reattachment Fractures involving a mesial or distal coronal angle and/or incisal edge: reattachment of tooth fragments more durable for injuries of this class compared to fractures involving the incisal edge and at least a third of the crown. 6.2.6 Cost of composite resin restorations Composite restorations for 50% or more of the tooth costs $295. [Awaiting further price
data for this section].
6.3 Discussion
6.3.1 Methodological Quality Study Design: The methodological design quality of the composite resin studies is low by evidence based healthcare standards because the four relevant studies were all case series. None were designed prospectively. None of the studies is directly comparable because of variations in almost every aspect of the studies: patient selection criteria, number of patients, follow-up period, and type of intervention. There were a number of individual case studies (8) excluded from this review because of their comparatively low quality of evidence. Sample size and statistical analysis: The sample size in the four studies of composite resin restorations ranged from 18 to 334. Two studies did no statistical analysis except for calculating percentages40 41. One study applied the chi-squared test to analyse pulp survival in two subgroups of participants42; and one study applied the Students t-test and chisquared test, employing 95% confidence intervals, to analyse fragment retention times43. Intervention: Two studies reported using composite resin both to reattach avulsed tooth fragments, and to rebuild tooth structure where fragments were lost40 42, whereas two studies reported using composite resin to only reattach avulsed tooth fragments
41 43
. All
70
studies employed the acid-etch technique and mentioned whether or not dentin bonding agents were used. Only one study stated the generation of adhesive system that was used40. The descriptions of the intervention were generally quite broad; only one study described the intervention in sufficient detail that the treatment could be replicated41. Study population, inclusion and exclusion criteria: The study populations were young people aged from 6 to 18 yrs, and limited to patients with fractured anterior teeth. One study classified the study participants according to the type of injury sustained, using a more precise method than the Andreasen system40. Two studies excluded crown fractures associated with other complications such as root fracture or luxation41 42. The other two studies did not describe exclusion criteria40 43. Follow-up and study period: By comparison with the other interventions already described in this review, the follow-up period for composite resin restorations is shortterm, ranging from 2 to 7.5 yrs. Outcome measures: The main outcome measure for composite resin restorations was the survival of the restoration. This was presented in various ways: either as retention time; or the percentage retained or successful at certain follow-up periods; or time taken to reach 50% retention. Two studies also reported on pulp survival, the aesthetics of the restorations, and reasons for failure of composite resin restorations 42 43. 6.3.2 Clinical Outcomes Overall, the retention/survival rate of either composite resin build-up restorations, or reattachment of tooth fragments is poor, indicating that these treatments can not be considered as long-term restorations. Spinas (2004)40 reported that 100% of restorations
43 needed complete replacement after 7 yrs, Andreasen et al (1995) reported that between
75 and 85% of restorations had been lost after 7.5 years, and Cavalleri & Zerman (1995)42 reported that 57% of restorations were either unsatisfactory or were replaced after 5 yrs. Garcia-Ballesta et al (2001)41 reported only a 2 yr follow-up period, and by then the retention rate was only 39%. 6.3.3 Safety and adverse effects There were no safety concerns raised or adverse effects reported.
71
6.3.4 Implications for outcomes over a lifetime Fractured teeth treated with composite resin restorations will require retreatment. Although the timing of retreatment will be uncertain for each case, the evidence presented above suggests that retreatment would be required for most teeth within 7 years (at best), and within 2 years at worst. The author of one study believes that a tooth can probably undergo 3 or 4 composite resin replacements before it shows a severe reduction of its adhesive properties; however they did not provide clinical evidence to support that opinion40. Restoration of teeth with composite resin would appear not to place limitations on future retreatment options.

There is low quality evidence from case series to suggest that the survival of composite resin restorations is poor, either by reattachment of avulsed fragments or by building up the tooth structure; and patients should expect to require retreatment within 2 to 7 years. Composite resin restorations of fractured teeth appear to be safe, and patients suffered from no adverse effects. Despite the short-term survival of composite resin restorations, there is evidence from one case series that fractures involving the incisal edge and greater than a third of the crown, have a better treatment outcome when built-up with composite resin. Whereas, fractures involving a mesial or distal coronal angle and/or incisal edge have a better treatment outcome when tooth fragments are reattached. There is evidence from three studies40 42 43 showing that 40-50% of reattachment failures are due to a new trauma (severity of new trauma not described), indicating that this treatment is not durable or strong enough to withstand trauma. Teeth with anatomy predisposing them to further trauma were identified as a risk factor for longevity of fragment reattachment. There is equivocal evidence about the influence that dentin exposure has on the longevity of fragment reattachment.
72
6.5 Conclusions
Composite resin restorations appear to have limited longevity and are not suitable as permanent restorations. However, they are not associated with adverse effects and can be readily replaced without negatively reducing the options for future retreatment the tooth. There is insufficient evidence to establish guideline-quality patient selection criteria for placement of composite resin on fractured anterior teeth.
73
6.6 Appendix 3: Evidence Tables for composite resin restorations

Reference: Spinas 2004

Design Description
Composite resin
Participants
Description: 90 injured teeth, all with crown fractures of varying severity. Injuries were classified using a more precise method than the Andreasen 44 system .
Class A: injury limited to only enamel which includes a mesial or distal coronal angle, or only the incisal edge Class B: involving the enamel-dentin which involves a mesial or distal coronal angle and incisal edge. When pulp exposed defined as subclass B1. Class C: involving enamel-dentin with incisal edge and at least a third of the crown. When pulp exposed defined as subclass C1. Class D: involves enamel-dentin with a mesial or distal coronal angle and the incisal or lingual surface, with root involvement. When pulp exposed defined as subclass D1.
Intervention
Resin-based composite restorations, or, reattachment of original fragment. Used total-etch conditioning technique and rd th 3 or 4 generation adhesive systems.
Outcomes
Outcome Measures: 7 year follow up. Ten parameters were evaluated before restoration was assigned one of 4 evaluations: Optimal: no complications or functional or aesthetic problems Good: minor changes occurred, eliminated with simple polishing. Acceptable: slight discomfort or dissatisfaction or colour alterations or ditching between enamel and composite. May need a partial replacement Not acceptable: major discomfort, or poor marginal integrity, poor aesthetic qualities, or loss of restoration, or need for endodontic treatment. Needs an immediate and complete replacement.
Whenever fractured tooth presents a necrotic pulp, defined with addition of h. Class B and C were most frequent injuries Group 1 - composite build-up No. in Group: 70 Position in mouth not stated, presumably anterior. Age: 8-18 yrs Group 2 - fragment reattachment No. in Group: 20 Position in mouth not stated, presumably anterior Age: 8-18 yrs
Inclusions: Complete clinical diary, from moment of injury to last check-up. Initial photographic and radiographic images All treatments made by same dentist Patients signed an informed consent for future treatments Exclusions:
Results: Composite restorations C class more reliable than B class 3 yr: 47% needed a complete replacement 7 yrs: 100% needed complete replacement Of those with replacements, at 6 yrs, 48% needed further complete replacement. Reattachments B class more durable than C class. 5 yrs: About 70% needed complete replacement. 7 yrs: 100% needed complete replacement; 45% replaced for a second time. (some replaced with composite resin rather than fragment). Of those replaced, by 7 years about 50% needed further complete replacement. Class B and C tend to get worse while undergoing repairs: each time tooth is treated, is an inevitable loss of dental tissues; may have tendency to become subclass 1 or h. A tooth can probably undergo 3 or 4 composite restoration replacements before it shows severe reduction of its adhesive properties. Methodological Score: 3
Selection Notes:
74
Reference: Garcia-Ballesta 2001

Design Description
A case series. Presumed to be retrospective.
Composite resin
Participants
Description: Children with fractured teeth. Varying degrees of dentin exposure. In all cases apices were immature to some degree.
Intervention
Reattachment of avulsed fragment. A notch was made in the enamel at an angle of 45 degrees; the tooth and fragment were then prepared with acid-etching, and bonded using a dental adhesive, and light-curable composite resin.
Outcomes
Outcome Measures: Retention over time
No. in Group: 18 anterior teeth Mean Age: 8.6 yrs Inclusions: Uncomplicated crown fractures.
Results: 1 month: 94% retention 2 yrs: 39% retention Mean retention period was 19.5 months, but varied depending on amount of dentin exposure: little/moderate dentin exposure (n=10) = 22.1 months wide dentin exposure (n=8) = 15.1 months
Exclusions: Two teeth with comminuted fractures were unsuitable for restoration. Cases presenting with other associated lesions (root fracture, luxation) in addition to crown fracture. Cases seeking treatment more than 5-6 hours post accident because the coronal fragment could have become dehydrated. Selection Notes: Methodological Score: 3
75
Reference: Cavalleri & Zerman 1995

Design Description
A restrospective case series.
Composite resin
Participants
Description: 95% of injured teeth were maxillary central incisors; most injuries were in 8 year olds; sex ratio was 3.6:1 for boys and girls. 80% injuries were fracture of enamel and dentine without pulpal exposure 16% injuries were fracture of enamel and dentine with pulpal exposure 4% injuries were fracture of enamel 40% of injuries occurred in patients with maxillary overjets more than 3mm. No. in Group: 84 incisors Age range: 6-12 years Inclusions:
Intervention
Outcomes
Outcome Measures: 5 year follow-up Pulpal health Esthetics Survival of restoration
12% of cases had fragment reattached 46% of cases had acid-etch composite resin build-up 38% of cases had composite restorations subsequent to dentin coverage, pulp capping, or coronal pulpotomy 3.6% of cases received enamel grinding
Results: Survival of restoration: 40% of teeth were retreated because of a new trauma. 43% of restored teeth were deemed esthetically satisfactory 17% were unsatisfactory due to wear of the composite Only 1 case required rebonding of a fragment Pulp survival: Injuries without pulp involvement: 6% had pulp necrosis Injuries with pulp involvement : 57% had pulp necrosis (The difference between these results is statistically significant according to chi-squared test, p<0.01.)
Exclusions: Crown-fractured incisors associated with subluxation, luxation, root and/or crown-root fractures
Selection Notes:
76
Reference: Andreasen et al 1995

Design Description
A multicenter clinical study (case series). Presumed to be retrospective.
Composite resin
Participants
Description: Permanent incisors with fractures of the crown or crown and root. (3.8% had root fractures). There was pulpal involvement in 39.5% of injuries. Age ranged from 6.5 yrs to 43.4 yrs. Mean age in dentinal bonding group was 14.5 years. Mean age of acidetching group was 10.5 years. No. in Group: 334 teeth Mean Age: 14.5 yrs in dentinal bonding group; 10.5-10.6yrs in acid-etch group. Inclusions: Not stated
Intervention
Reattachment of dental fragments. 44% had acid etching of enamel alone for fragment bonding (the AE group). Work performed in one of two clinics. 56% had a combination of enamel etching and dentinal bonding (the DBA group). Work performed in a third clinic. In cases where multiple tooth fractures occurred (6%), one tooth received reattachment, the other received composite build-up. For fractures approaching pulpal exposure, or actually exposing pulp, the tooth fragment was wet-stored for up to 3 months before reattachment.
Outcomes
Outcome Measures: Retention rate Esthetics (fracture line visibility; colour harmony between fragment and tooth) Pulp status
Exclusions: Not stated
Results: The extent of fracture had no influence on loss or retention of fragments in either treatment group. Retention Rate: Final retention rate was similar for each group (15% in AE, 25% in DBA at 7.5 years). 50% retention rate took 3 times longer to occur in the dentinal bonding group. (2.5 yrs compared to 1 yr). Esthetics DBA: acceptable in 55% AE: acceptable in 45% Cause of fragment loss: Predominantly caused by new trauma, non-physiologic use of the bonded tooth, and horizontal traction (biting into chewy/tough foods). 25% lost spontaneously or during physiological use. Pulp status: Pulp canal obliteration and pulpal necrosis occurred in 6.6% of cases and was apparently related to a concomitant luxation injury, not to a complicated crown injury involving pulp exposure. Methodological Score: 3
Selection Notes:
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7 Intra-coronal Bleaching
The active agent in tooth bleaching is hydrogen peroxide and its use in tooth bleaching was first reported in 188445. Hydrogen peroxide is an oxidising agent that releases free radicals that can break unsaturated double bonds of long, coloured molecules, or reduce the coloured metallic oxides like Fe2O3(Fe3+) to colourless FeO(Fe2+) (reviewed by Attin et al, 200346). Hydrogen peroxide is either applied directly or is produced in a chemical reaction from sodium perborate or carbamide peroxide. Intra-coronal bleaching, also know as non-vital bleaching, is the process whereby discoloured non-vital teeth are bleached internally. There are three general approaches to achieve intra-coronal bleaching: 1) via the walking bleach technique; or 2) via a quicker in-office technique, or 3) via a combination of both these techniques. The walking bleach technique is performed by sealing bleach (typically sodium perborate in either its monohydrate or tetrahydrate form), and either water or 3% hydrogen peroxide) inside the pulp chamber for several days, whereas in-office bleaching involves filling the pulp chamber with cotton soaked in 30% hydrogen peroxide. The practise of using heat to activate bleach during the in-office treatment (thermo-catalytic bleaching) is no longer advocated by some authorities due to safety concerns over the use of high concentrations of bleach in combination with heat46 47.
7.2 Results
7.2.1 Description of Studies The majority of tooth bleaching literature pertains to the bleaching of vital teeth, and covers the use of gels, pastes, strips and night-guards. There are fewer studies about the bleaching of non-vital teeth, and they can generally be categorised into those about teeth either discoloured with tetracycline staining or discoloured as a result of trauma and/or root-canal treatment. There were no RCTs or comparative studies identified. Fifteen papers were selected for critical appraisal, after which 4 case series studies were retained for inclusion in the main review. Additionally one other paper was included in the adverse effects section; the remaining 10 studies were excluded. The number of participants ranged from 21 to 86 Interestingly, although the current and the follow-up period ranged from 1 to 8 years.
recommended internal bleach method typically utilises sodium perborate-(tetrahydrate) mixed with either water or 3% hydrogen peroxide46 47, none of the included studies used
this mixture; they used 30 or 35% hydrogen peroxide either alone or mixed with sodium perborate. The primary outcome measures reported were tooth colour change, success/failure and patient satisfaction. However, the definition of these outcome measures was not always well defined and there was little consistency of the definitions between studies, with the exception being failure. When failure was reported it was broadly defined as being teeth that demonstrated little or no change in colour. The reporting of patient selection and bleaching methods was not of a consistently high standard. The characteristics of the excluded papers are presented in Appendix 6.
7.2.2 Clinical Outcomes The results of 4 studies about intra-coronal bleaching are presented here, and they are grouped according to the bleach technique used. For a summary of results refer to Table 8. Further details of each study can be found in evidence tables in Appendix 4. Walking Bleach Glockner et al (1999)48 reported successful results 4.8 years after 86 patients with discoloured anterior teeth were treated by the walking bleach technique (using sodium perborate/30% hydrogen peroxide). treatments were successful. Waterhouse & Nunn (1996)49 performed the walking bleach technique (using sodium perborate/30% hydrogen peroxide) on 21 endodontically treated discoloured central incisors in children and adolescents. After 18 months follow-up 62% of patients were satisfied and the number of gray reddish gray or off-guide teeth had decreased from 97% to 57%. Stability of shade was displayed in 83% of teeth, and 17% showed some rediscoloration. Failure occurred in 29% of cases. One tooth had minor and stable apical resorption prior to bleaching, which remained non-progressive 18 months after bleaching. Walking bleach and thermocatalytic bleaching combination Friedman et al (1988)50 reported a 79% success rate 1-8 yrs following internal bleaching of 58 non-vital anterior teeth using 30% hydrogen peroxide. Thirty five percent received Using subjective observations, overall, 66.2% of treatments were successful according to dentists, whereas patients judged that 91.9% of
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walking bleach treatment, 22% received thermocatalytic treatment and 43% received both treatments. A successful treatment included teeth which matched the colour of the adjacent teeth, and those that had some discolouration but were acceptable to the patient. There was a 6.9% incidence (4 teeth) of external tooth resorption. Thermocatalytic bleaching Deliperi & Bardwell (2005)51 bleached 25 anterior teeth (having shades of A3 or darker according to a Vita shade guide) using a combination of thermocatalytic bleaching with 35% hydrogen peroxide and at-home custom tray bleaching with 10% carbamide peroxide. Two weeks after the treatment 100% of teeth improved by at least 8 Vita shades. Colour stability was assessed 2 years later. The mean shade values at baseline, 2 week follow-up and 2 year follow-up were 14.4 (1.9), 1.6 ( 0.7) and 2.8 ( 1.7) respectively. At the two year recall a shade rebound to a darker shade of up to 4 shades was evident in 13/25 teeth. Tooth colour was stable in 12/25 teeth.
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Table 8. Summary of intra-coronal bleach studies Reference N Method/Agent

teeth Deliperi & Bardwell 200551 25 Thermocatalytic: 35% H2O2, Followed by at home custom tray: 10% carbamide peroxide Walking bleach: sodium perborate + 30% H2O2 Walking bleach: sodium perborate + 30% H2O2 25%: Walking bleach: 30% H2O2 22%: Thermocatalytic: 30% H2O2 + heat 43%: Walking bleach + thermocatalytic
Follow-up Effectiveness
(yrs) 2 (success/failure, patient satisfaction, colour stability) 100% of teeth improved by at least 8 Vita shade values 48% of teeth retained their new shade 91.9% success judged by patient 66.2% success judged by dentist Failure=little or no colour change 62% patient satisfaction 29% failure Failure=no colour change, or veneered 83% displayed stability of shade 79% success 21% failure Failure=discoloration, requiring further treatment
Adverse events
Not reported
Glockner et al 199948 Waterhouse & Nunn 199649 Friedman et al 198850
86 * 21
4.8 1.5
Not reported No evidence of cervical or progressive apical resorption 6.9% external tooth resorption
58
1-8
* this paper reported N as patient number, not tooth number
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7.2.3 Adverse Effects The most serious adverse effect of internal bleaching is external tooth resorption. Friedman et al (1988)50 reported an incidence of 6.9%. An article by Heithersay (1994)52 which was not included in this review because it did not report success/failure outcomes, reported an external tooth resorption incidence of 2.5%. The association of external tooth resorption with bleaching has been reviewed extensively46 53-56, and is also reported in a number of studies published in the early 1980s. Because the latter were published prior to 1987, they are not included in this review. The consensus view is that the risk of tooth resorption is higher if hydrogen peroxide at high concentrations (30%) is used, and the risk further increases when 30% hydrogen peroxide is combined with heat46 53-56. It has been suggested that tooth resorption may be caused by diffusion of the bleaching chemicals through dentinal tubules to the periodontal ligament. Whether a trauma history increases the risk of tooth resorption is debated in the literature. Root resorption may be halted if detected early57, but if left unnoticed or untreated it can lead to loss of the tooth. Therefore, it is recommended that a close radiographic and clinical follow-up of internally bleached teeth takes place to enable early detection of resorption49 57. A possible adverse effect of bleaching is a negative influence on restorative materials and restorations, although this has not been clinically substantiated.
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A recent systematic
review concluded that there is a body of evidence from in vitro studies demonstrating that bleaching therapies may have a negative effect on physical properties, marginal integrity, enamel and dentin bond strength, and colour of restorative materials. However, in the absence of clinical in vivo reports describing this adverse effect, the clinical relevance of in
vitro observations is unknown.
7.2.4 Indications and contra-indications There were no indications or contra-indications for non-vital bleaching identified in the reviewed studies, despite the fact that some teeth did not respond to intra-coronal bleaching. Similarly, there was no evidence to indicate which teeth are more or less likely to have a stable bleached colour.
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7.2.5 Cost of intra-coronal bleaching The cost of one bleaching treatment ranges from $150 to $200. ACCs contribution to the cost of a single intra-coronal bleaching treatment is $150.
7.3 Discussion
7.3.1 Methodological Quality Study Design: The methodological design quality of the non-vital bleach studies is low by evidence based healthcare standards because the four relevant studies were all case series. One was designed prospectively51. None of the studies are directly comparable because of variations in almost every aspect of the studies: patient selection criteria, number of patients, follow-up period, and type of intervention. Sample size and statistical analysis: Sample sizes were quite small, ranging from 21 to 86 teeth. Only one study applied statistical analysis to the results51. Although p values of 0.0001, and 0.008 were reported for ANOVA and post-hoc comparison tests (respectively) of tooth colour change, it should be noted that the sample size was only 25. The other studies calculated percentages. Intervention: A range of intra-coronal bleaching techniques were used in the four studies. None of the studies used the current recommended bleach recipe of sodium perborate mixed with either water or low concentration hydrogen peroxide. Two studies employed only the walking bleach technique using sodium perborate and 30% hydrogen peroxide. One study employed thermocatalytic bleaching using 35% hydrogen peroxide, and one study used 30% hydrogen peroxide in three methods: walking bleach, thermocatalytic, and a combination of those methods.
Comment from Referee 1: The use of 3% hydrogen peroxide is a relatively recent recommendation. As you noted, for this reason the most commonly used concentration of hydrogen peroxide for non-vital bleaching is 30 to 35% as reported in the literature.
Study population, inclusion and exclusion criteria: All study participants had endodontically treated, discoloured anterior teeth. The trauma history of study participants was stated in two studies, including one whose entire patient sample had lost tooth vitality due to trauma49. The age of study participants was not well described; one study did not state age50, the study consisting of all trauma cases described patients as
49 51 being children and adolescents , one study included patients aged >18 yrs , and one
reported a range of 15-57 yrs48. The exclusion of teeth with severe internal and external
discolouration due to tetracycline stains, or fluorosis was explicitly stated in only one study. Follow-up and study period: The follow-up period of bleach studies was relatively short, ranging from 1 to 8 years. Outcome measures: Three outcomes related to the effectiveness of tooth bleaching were reported; these were patient satisfaction, success/failure and colour stability. 7.3.2 Clinical Outcomes Intra-coronal bleaching of discoloured non-vital teeth is effective in at least 60% of teeth, as measured over the short-term. Success in three studies, as judged by dentists, ranged from 66.2 79%48-50. One study showed that the dentist judged far more critically than the patient, with success according to the patient being 91.9%, compared with 66.2% success according to the dentist48. Another study reported a patient satisfaction of just 62%49. The colour change is not stable in all teeth; Deliperi & Bardwell (2005)51 and Waterhouse & Nunn (1996)49 demonstrated a stable colour change in 48% and 83% of teeth respectively. The majority of cases of re-discolouration involved minor colour changes of 1 or 2 shades51, and none of the re-discoloured teeth returned to their original shade49 51. The long-term stability of the bleach induced colour change is unknown. 7.3.3 Safety and adverse effects Intracoronal bleaching is associated with external tooth resorption. One of the four studies reported a 6.9% incidence of external tooth resorption50. The consensus opinion in review literature is that high concentrations of hydrogen peroxide should be avoided, particularly in combination with heat. 7.3.4 Implications for outcomes over a lifetime Teeth with unstable bleached tooth colour may need retreatment to restore acceptable aesthetics to the tooth. Intra-coronal bleaching of non-vital teeth would appear not to place limitations on future retreatment options

There is low quality evidence from case series to suggest that discoloured non-vital teeth can be whitened satisfactorily in at least 60% of cases, using high percentage hydrogen
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peroxide in intra-coronal bleaching techniques. There is currently no evidence base that describes the effectiveness of the currently recommended method that uses low concentrations of hydrogen peroxide. There was evidence from one of the studies that the use of high concentrations of hydrogen peroxide is associated with external tooth resorption. The review literature supports the use of low concentrations of hydrogen peroxide, and avoidance of heat if high concentrations are used.
7.5 Conclusions
Intra-coronal bleaching appears to be effective in the short term for a significant proportion of discoloured non-vital teeth; but not all teeth are aesthetically restored by this method. There is sufficient evidence to suggest that patients of any age with discoloured non-vital secondary teeth are good candidates for receiving this treatment. However, there is insufficient evidence to enable a description of contraindications for this treatment.
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7.6 Appendix 4: Evidence Tables for Intracoronal bleaching

Reference: Glockner et al 1999

Design Description
Intracoronal bleaching
Participants
Description: Patients who had received walking internal bleaching were invited to have a follow-up examination. Patients were classified according to the indication: ideal = an anterior tooth with only one palatal endodontic opening borderline = included teeth with extensive proximal composite restorations that involved a large part of the tooth structure that are difficult to bleach.
Intervention
Walking internal bleaching using a mixture of sodium perborate (tetrahydrate) and 30% hydrogen peroxide. Treatments lasted one week, and were terminated with neutralizing calcium hydroxide for at least 7 days. Some patients received multiple treatments, until desired results were achieved. Average follow-up was 57.9 months (4.8 yrs).
Outcomes
Outcome Measures: Subjective observations of a) the patient and b) the dentist. Successful grades: 1=optimal 2=very good 3=good Failure grades: 4=better than before treatment 5=identical to before treatment Results: Overall: 66.2% success rate according to dentists 91.9% according to patients Combining scores from patients and dentists 55.2% success rate for borderline cases 91.3% success rate for ideal cases Conclusions: 1. The dentist judges far more critically than the patient 2. A high percentage of success was possible after 5 yrs when only ideal clinical indications were treated.
No. in Group: 86 patients. Number of teeth not stated, but all were anterior Age: 15-57 yrs Inclusions: Pre-requisites for treatment were 1) careful root canal treatment 2) a radiograph to ensure no cervical defect 3) coronal sealing of root canal 4) for those with silver point root canal treatments, the silver was removed and replaced with gutta percha. Exclusions: Not stated
Selection Notes:
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Reference: Waterhouse & Nunn 1996

Design Description
A case series, presumed to be retrospective.
Intracoronal Bleaching
Participants
Description: Children and adolescents with endodontically treated discoloured permanent anterior teeth. All patients had lost tooth vitality due to an earlier traumatic episode 97% of teeth were classified as gray, reddish gray or off-guide.
Intervention
Walking bleach technique; a thick crystalline paste made with sodium perborate granules/30% hydrogen peroxide solution was sealed within the tooth. The chamber was sealed with glass-ionomer cement material. Patient was asked to return 1 to 2 weeks later. The bleaching procedure was repeated up to 10 times if improvement in colour was visible. After bleaching the tooth was restored with white gutta percha and resin composite filling.
Outcomes
Outcome Measures: Follow-up occurred at 6 month intervals for 18 months Colour change according to a Vita porcelain shade guide. Rediscolouration = if shade has changed by more than one unit Root resorption assessed by periapical radiograph Results: The number of gray, reddish gray or off-guide teeth had decreased from 97% to 57% 62% of patients satisfied 83% displayed stability of shade; 17% showed some re-discoloration, but never matched original discolouration 29% failed (were veneered, or colour unchanged) No evidence of cervical or progressive apical resorption
No. in Group: 21 central incisor teeth Mean Age: children and adolescents Inclusions: Teeth that exhibited well-condensed gutta-percha restorations and were clinically and radiographically healthy
Selection Notes:
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Reference: Friedman et al 1988

Design Description
A retrospective case series.
Participants
Description: The records of 64 pulpless teeth which had been bleached were pooled and the patients were recalled for follow-up examination. 38% had suffered a trauma at some time.
Intervention
Intracoronal bleaching with 30% hydrogen peroxide (Superoxol) via walking bleach method. Thermocatalytic bleaching was performed on some teeth. 35% had walking bleach 22% had thermocatalytic 43% had both 74% had one treatment 9% had 2 treatments 17% had 3 treatments All teeth were restored after bleaching with composite filling materials
Outcomes
Outcome Measures: Follow up occurred 1-8 yrs after bleaching occured Color assessment: A) Absolutely satisfactory = matching the adjacent teeth B) Clinically acceptable = some discoloration but acceptable to the patient C) Failed = discoloration, requiring further treatment Radiographic assessment of roots to assess external tooth resorption Results: Colour 50% were absolutely satisfactory 29% were clinically acceptable 21% failed Root resorption 6.9% (4 teeth) had external root resorption
No. in Group: 58 pulpless anterior teeth Mean Age: not stated Inclusions: Patients who had received intracoronal bleaching of their pulpless teeth.
Selection Notes:
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Reference: Deliperi & Bardwell 2005

Design Description
A prospective case series
Participants
Description: Patients were 18 yrs or over
Intervention
In-office bleaching 35% hydrogen peroxide gel inside the pulp chamber and on the facial enamel for 30 minutes; followed with at-home bleaching using custom tray and 10% carbamide peroxide according to the inside/outside bleaching technique. At-home bleaching treatment period not stated.
Outcomes
Outcome Measures: 1. Tooth colour stability during follow-up period(number of shade changes): Alpha = no change Bravo = change of colour up to 4 shades Charlie = change of colour up to 8 shades Delta = change of colour >8 shades. Tooth shades were assigned according to a Vita shade guide. 2. Shade values (1 to 16) and percentage change from baseline. Follow-up periods: 14 days after at-home bleaching was completed, then at 6 month recalls for 2 years. Results: Colour change: all teeth improved by at least 8 vita shade values. Colour stability (2 yrs): scored Bravo. 12/25 teeth had no shade rebound 13/25 teeth had a shade rebound to a darker shade of up to 4 shades. 9 of these 13 had a shade rebound of only 1 or 2 shades. Shade values: Baseline mean = 14.4 (+/- 1.9) 2 wk follow up = 1.6 (+/- 0.7) 2 yr follow up = 2.8 (+/- 1.7) [2 weeks after treatment 89% change from baseline 2 yrs after treatment: 81% change from baseline There was a significant shade change between 2 wk and 2 yr follow-up, p=0.008. It is not clear what these are %s of] Methodological Score: 3 Well reported.
No. in Group: 25 anterior teeth Mean Age: not stated Inclusions: Pulpless anterior teeth endodontically treated at least 2 yrs prior, with A3 or darker shades. Only teeth having a combination of endodontic access and Class III/IV cavities were included in the study. Exclusions: Severe internal and external discoloration (tetracycline stains, fluorosis), smokers & pregnant & nursing women. Teeth having previous bleach treatments, and with a complete loss of clinical crown; teeth having endodontic access opening only to be restored.
Selection Notes:
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8 Limitations of the review

The findings of this evidence based review are considerably limited by the paucity of good quality, long-term clinical studies, and a lack of indications and contraindications for treatments. As a result this review was not able to establish comprehensive patient selection criteria for each of the four treatments reviewed. The development of such criteria will rely heavily on the consensus opinion of dental experts who convene during the guideline development process. The review excluded in vitro studies, and so has not accessed a source of information that contributes to the development to current best practise in dentistry. Similarly, the review included studies published in English only; it is known that there are some studies published in German that may have met other inclusion criteria for this review. A considerable limitation of this review is that many of the studies report technology and techniques that are out of date, e.g. all the bleaching studies used bleach solutions that are no longer considered best practise; most of the composite resin studies used early generation dentine bonding agents which are now obsolete; and with the release of late generation dentine bonding agents, presumably advancements have been made in the bonding of porcelain veneers and crowns.
Comment from Referee 1: While there have been various generations of resin bonding systems, currently the 4th generation is still considered the gold standard which has been available since the 1980s.
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9 Recommendations
There is insufficient evidence to make recommendations about which treatments are the most appropriate for specific types of fracture and extent of tooth avulsion. However, the guideline development panel should consider incorporating the following recommendations into the guidelines. These recommendations arise from a synthesis of all the evidence presented about survival of tooth restorations, and patient risk factors. They also incorporate the philosophies of striving for conservation of tooth tissue, and choosing a treatment plan that maximises the life-time potential of teeth. 1. When the primary indication for restorative treatment of fractured, non-vital anterior teeth is discolouration, intra-coronal bleaching should be the first treatment choice because it is effective in at least 60% of cases, has only one harmful side effect of low incidence, and does not limit subsequent treatment choices. 2. Unless indicated otherwise, patients <30 yrs should be treated conservatively with composite resin build-up, or reattachment of the avulsed fragment if available. This would be done with a clear understanding that these restorations are likely to require replacement within 7 yrs, but that this can be done at least once before the less conservative treatments of veneers and/or crowns need be considered. 3. In cases where either veneer or crowns are indicated, a veneer should be the first treatment choice for the following reasons: the survival rate of veneers appears to be better than for crowns. a high percentage of failures are repairable, further extending the life of the restoration. there is greater conservation of tooth tissue, and consequently a retention of some options for future treatments if the veneer fails. 4. Veneers should not be applied to teeth with large amounts of lost tooth tissue. The definition of large amounts remains to be decided. 5. A relative contraindication for veneers is poor oral health and a high caries rate.
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Comments from Referee 1: The review was accurate. This review appears to be completely based on the papers that satisfied the inclusion criteria. I consider that the report was balanced and fair and correctly interpreted the literature reviewed. Based on the evidence provided, the conclusions in this report appear to be appropriate. I appreciate your concern that there is relatively little high quality evidence on which to make recommendations about which treatments are most appropriate for certain types of tooth fracture. This particularly relates to sample size in the publication included in this review. This also makes it difficult to establish guidelines for patient and/or tooth selection criteria for each of the four treatments reviewed, however the literature for these four treatments across the range of the evidence hierarchy do report relatively similar findings. For this reason, I believe that this evidence review will be a valuable document that will be of great assistance in supporting the guideline development panel to establish restoration guidelines for fractured anterior teeth for ACC.
Comments from Referee 2: Because of the low quality of the available research, making evidenced-based recommendations is difficult. This has been clearly identified in Section 8. The conclusions outlined in Section 9 represent a conservative approach to both the interpretation of the evidence and patient management. They are in my view consistent with what we know from the literature and what many experts would regard as best practise. The report is likely to be of significant assistance to an expert panel developing practise guidelines. The panel should be in a position to make progress with the development of a consensus-based expert opinion confident that there is no significant information of which they are not aware, avoiding the need to spent time identifying and debating the value of individual studies.
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10 References
1. Burke FJ, Lucarotti PSK. Ten year outcome of crowns placed within the general dental services in England and Wales. Journal of Dentistry 2008;doi:101.1016/j.jdent.2008.03.017. 2. Lucarotti PSK, Holder RL, Burke FJ. Analysis of an administrative database of half a million restorations over 11 years. Journal of Dentistry 2005;33:791-803. 3. Walton TR. A ten-year longitudinal study of fixed prosthodontics: 1. Protocol and patient profile. International Journal of Prosthodontics 1997;10(4):325-31. 4. Walton TR. A 10-year longitudinal study of fixed prosthodontics: clinical characteristics and outcome of single-unit metal-ceramic crowns. International Journal of Prosthodontics 1999;12(6):519-26. 5. De Backer H, Van Maele G, De Moor N, Van den Berghe L, De Boever J. An 18-year retrospective survival study of full crowns with or without posts. International Journal of Prosthodontics 2006;19(2):136-42. 6. Etemadi S, Smales RJ. Survival of resin-bonded porcelain veneer crowns placed with and without metal reinforcement. Journal of Dentistry 2006;34(2):139-45. 7. Walter MH, Wolf BH, Wolf AE, Boening KW. Six-year clinical performance of allceramic crowns with alumina cores. International Journal of Prosthodontics 2006;19(2):162-3. 8. Oden A, Andersson M, Krystek-Ondracek I, Magnusson D. Five-year clinical evaluation of Procera AllCeram crowns. Journal of Prosthetic Dentistry 1998;80(4):450-6. 9. Fradeani M, Redemagni M. An 11-year clinical evaluation of leucite-reinforced glassceramic crowns: a retrospective study. Quintessence International 2002;33(7):503-10. 10. Erpenstein H, Borchard R, Kerschbaum T. Long-term clinical results of galvanoceramic and glass-ceramic individual crowns. Journal of Prosthetic Dentistry 2000;83(5):530-4. 11. Sjogren G, Lantto R, Tillberg A. Clinical evaluation of all-ceramic crowns (Dicor) in general practice. Journal of Prosthetic Dentistry 1999;81(3):277-84. 12. Malament KA, Socransky SS. Survival of Dicor glass-ceramic dental restorations over 14 years: Part I. Survival of Dicor complete coverage restorations and effect of internal surface acid etching, tooth position, gender, and age. Journal of Prosthetic Dentistry. 1999;81(1):23-32. 13. Takeda T, Ishigami K, Shimada A, Ohki K. A study of discoloration of the gingiva by artificial crowns. International Journal of Prosthodontics 1996;9(2):197-202. 14. Koke U, Sander C, Heinecke A, Muller H. A possible influence of gingival dimensions on attachment loss and gingival recession following placement of artificial crowns. International Journal of Periodontics & Restorative Dentistry 2003;23(5):438-45. 15. Odman P, Andersson B. Procera AllCeram crowns followed for 5 to 10.5 years: a prospective clinical study. International Journal of Prosthodontics. 2001;14(6):504-9. 16. Sakai T, Sakai H, Hashimoto N, Hirayasu R. Gingival pigmentation beneath a metallic crown: light and electron microscopic observations and energy dispersive X-ray analysis. Journal of Oral Pathology 1988;17(8):409-15. 17. Gordon S. Foreign body gingivitis associated with a new crown: EDX analysis and review of the literature.[erratum appears in Oper Dent 2000 Sep-Oct;25(5):455]. Operative Dentistry 2000;25(4):344-8. 18. Saunders WP, Saunders EM. Prevalence of periradicular periodontitis associated with crowned teeth in an adult Scottish subpopulation.[see comment]. British Dental Journal 1998;185(3):137-40.
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19. Zoellner A, Heuermann M, Weber HP, Gaengler P. Secondary caries in crowned teeth: correlation of clinical and radiographic findings. Journal of Prosthetic Dentistry 2002;88(3):314-9. 20. Wilson NA, Whitehead SA, Mjor IA, Wilson NH. Reasons for the placement and replacement of crowns in general dental practice. Primary Dental Care 2003;10(2):53-9. 21. Bruce GJ, Hall WB. Nickel hypersensitivity-related periodontitis. Compendium of Continuing Education in Dentistry 1995;16(2):178, quiz 186. 22. Jackson CR, Skidmore AE, Rice RT. Pulpal evaluation of teeth restored with fixed prostheses. Journal of Prosthetic Dentistry 1992;67(3):323-5. 23. Cheung GS. A preliminary investigation into the longevity and causes of failure of single unit extracoronal restorations. Journal of Dentistry 1991;19(3):160-3. 24. Fradeani M, D'Amelio M, Redemagni M, Corrado M. Five-year follow-up with Procera all-ceramic crowns. Quintessence International. 2005;36(2):105-13. 25. Horn HR. Porcelain laminate veneers bonded to etched enamel. Dent Clin North Am 1983;27:671-684. 26. Calamia JR. Etched porcelain veneers: the current state of the art. Quintessence International. 1985;16(1):5-12. 27. Burke FJ, Lucarotti PSK. Ten year outcome of porcelain laminate veneers placed within the genral dental services in England and Wales. Journal of Dentistry 2008;doi:10.1016/j.jdent.2008.03.016. 28. Fradeani M, Redemagni M, Corrado M. Porcelain laminate veneers: 6- to 12-year clinical evaluation--a retrospective study. International Journal of Periodontics & Restorative Dentistry 2005;25(1):9-17. 29. Smales RJ, Etemadi S. Long-term survival of porcelain laminate veneers using two preparation designs: a retrospective study. International Journal of Prosthodontics 2004;17(3):323-6. 30. Peumans M, De Munck J, Fieuws S, Lambrechts P, Vanherle G, Van Meerbeek B. A prospective ten-year clinical trial of porcelain veneers. Journal of Adhesive Dentistry 2004;6(1):65-76. 31. Aristidis GA, Dimitra B. Five-year clinical performance of porcelain laminate veneers. Quintessence International 2002;33(3):185-9. 32. Sieweke M, Salomon-Sieweke U, Zofel P, Stachniss V. Longevity of oroincisal ceramic veneers on canines--a retrospective study. Journal of Adhesive Dentistry 2000;2(3):229-34. 33. Dumfahrt H, Schaffer H. Porcelain laminate veneers. A retrospective evaluation after 1 to 10 years of service: Part II--Clinical results. International Journal of Prosthodontics. 2000;13(1):9-18. 34. Walls AW. The use of adhesively retained all-porcelain veneers during the management of fractured and worn anterior teeth: Part 2. Clinical results after 5 years of follow-up. British Dental Journal 1995;178(9):337-40. 35. Calamia JR. Clinical evaluation of etched porcelain veneers. American Journal of Dentistry 1989;2(1):9-15. 36. Dumfahrt H. Porcelain laminate veneers. A retrospective evaluation after 1 to 10 years of service: Part I--Clinical procedure. International Journal of Prosthodontics. 1999;12(6):505-13. 37. Mader C. Restoration of a fractured anterior tooth. Journal of the American Dental Association 1978;96(1):113-115. 38. Tennery TN. The fractured tooth reunited using the acid-etch bonding technique. Texas Dental Journal 1978;96(8):16-17. 39. Reis A, Loguercio AD. Tooth fragment reattachment: current treatment concepts. Practical Procedures & Aesthetic Dentistry: Ppad 2004;16(10):739-40.
40. Spinas E. Longevity of composite restorations of traumatically injured teeth. American Journal of Dentistry 2004;17(6):407-11. 41. Garcia-Ballesta C, Perez-Lajarin L, Cortes-Lillo O, Chiva-Garcia F. Clinical evaluation of bonding techniques in crown fractures. Journal of Clinical Pediatric Dentistry 2001;25(3):195-7. 42. Cavalleri G, Zerman N. Traumatic crown fractures in permanent incisors with immature roots: A follow-up study. Endodontics & Dental Traumatology 1995;11(6):294-296. 43. Andreasen FM, Noren JG, Andreasen JO, Engelhardtsen S, Lindh-Stromberg U. Longterm survival of fragment bonding in the treatment of fractured crowns: a multicenter clinical study. Quintessence International 1995;26(10):669-81. 44. Andreasen JO, Andreasen FM, editors. Textbook and color atlas of traumatic injuries to the teeth. 3rd ed. Copenhagen: Munksgaard, 1994. 45. Harlan AW. The removal of stains caused by administration of medicinal agents and the bleaching of pulpless teeth. American Dental Science 1884;18:521. 46. Attin T, Paque F, Ajam F, Lennon AM. Review of the current status of tooth whitening with the walking bleach technique. International Endodontic Journal 2003;36(5):313-29. 47. Dahl JE, Pallesen U. Bleaching of the Discolored Traumatized Tooth, Chapter 33. In: Andreasen J, Andreasen F, Andersson L, editors. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4th ed: Blackwell Munksgaard, 2007:852-860. 48. Glockner K, Hulla H, Ebeleseder K, Stadtler P. Five-year follow-up of internal bleaching. Brazilian Dental Journal 1999;10(2):105-110. 49. Waterhouse PJ, Nunn JH. Intracoronal bleaching of nonvital teeth in children and adolescents: interim results. Quintessence International 1996;27(7):447-53. 50. Friedman S, Rotstein I, Libfeld H, Stabholz A, Heling I. Incidence of external root resorption and esthetic results in 58 bleached pulpless teeth. Endodontics & Dental Traumatology 1988;4(1):23-6. 51. Deliperi S, Bardwell DN. Two-year clinical evaluation of nonvital tooth whitening and resin composite restorations. Journal of Esthetic & Restorative Dentistry: Official Publication of the American Academy of Esthetic Dentistry 2005;17(6):369-78; discussion 379. 52. Heithersay GS, Dahlstrom SW, Marin PD. Incidence of invasive cervical resorption in bleached root-filled teeth. Australian Dental Journal 1994;39(2):82-7. 53. Haywood VB. History, safety, and effectiveness of current bleaching techniques and applications of the nightguard vital bleaching technique. Quintessence International 1992;23(7):471-88. 54. MacIsaac AM, Hoen CM. Intracoronal bleaching: concerns and considerations. Journal (Canadian Dental Association) 1994;60(1):57-64. 55. Dahl JE, Pallesen U. Tooth bleaching--a critical review of the biological aspects. Critical Reviews in Oral Biology & Medicine 2003;14(4):292-304. 56. Tredwin CJ, Naik S, Lewis NJ, Scully C. Hydrogen peroxide tooth-whitening (bleaching) products: review of adverse effects and safety issues. British Dental Journal 2006;200(7):371-6. 57. Friedman S. Internal bleaching: long-term outcomes and complications. Journal of the American Dental Association 1997;128 Suppl:51S-55S. 58. Attin T, Hannig C, Wiegand A, Attin R. Effect of bleaching on restorative materials and restorations--a systematic review. Dental Materials 2004;20(9):852-61.
95
96
Appendix 1: Evidence tables for Crowns (go to p 33)
Appendix 2: Evidence tables for Veneers (go to p 56)
Appendix 3: Evidence tables for Composite resin restorations (go to p 74)
Appendix 4: Evidence tables for Intracoronal bleaching (go to p 86)
97
Appendix 5. Level of evidence in the SIGN system

1++ 1+ 12++ High quality meta analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias Well conducted meta analyses, systematic reviews, or RCTs with a low risk of bias Meta analyses, systematic reviews, or RCTs with a high risk of bias High quality systematic reviews of case-control or cohort studies High quality case-control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal 2+ 23 4 Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal Non-analytic studies, e.g. case reports, case series Expert opinion
98
Appendix 6. Studies excluded from this review

Study Title Reasons for excluding
Crown Studies
Akkayan & Caniklioglu 1998 Aquilino & Caplan 2002 Ellner et al 2003
Resistance to fracture of crowned teeth restored with different post systems. European Journal of Prosthodontics & Restorative Dentistry 1998;6(1):13-8. Relationship between crown placement and the survival of endodontically treated teeth. Journal of Prosthetic Dentistry 2002;87(3):256-63. Four post-and-core combinations as abutments for fixed single crowns: a prospective up to 10-year study. International Journal of Prosthodontics 2003;16(3):249-54. Retrospective clinical investigation and survival analysis on ceramic inlays and partial ceramic crowns: results up to 7 years. Clinical Oral Investigations 1998;2(4):161-7. Tooth preparations for complete crowns: an art form based on scientific principles. Journal of Prosthetic Dentistry 2001;85(4):363-76. Factors affecting treatment outcomes following complicated crown fractures managed in primary and secondary care. Dental Traumatology 2006;22(4):179185. Plaque retention on Dicor crowns and gingival health evaluated over a 4-year period. International Journal of Periodontics & Restorative Dentistry. 1990;10(6):454-63. A clinical evaluation of ceramic laminate veneers. International Journal of Prosthodontics. 1992;5(5):447-51. A clinical survey of failed post retained crowns. British Dental Journal. 1988;165(3):95-7.
An in vitro study Can not differentiate data for anterior teeth Can not differentiate data for anterior teeth
Felden et al 1998
Posterior teeth
Goodacre et al 2001 Jackson et al 2006
Does not report outcomes Outside scope. About pulp treatment, not restorative treatment Posterior teeth
Jensen et al 1990
Karlsson et al 1992 Lewis & Smith 1988
Follow-up less than 5 years Tooth position not stated
99
Kelly & Smales 2004 Malament & Socransky 1999 Malament & Socransky 2001 Miyamoto et al 2007 Moopnar & Faulkner 1991 Ozcan & Niedermeier 2002 Palmqvist & Swartz 1993 Pippin et al 1995 Reitemeier et al 2006 Scherrer et al 2001 Segal 2001 Sjogren et al 1999
Long-term cost-effectiveness of single indirect restorations in selected dental practices. British Dental Journal. 2004;196(10):639-43; discussion 627. Survival of Dicor glass-ceramic dental restorations over 14 years. Part II: effect of thickness of Dicor material and design of tooth preparation. Journal of Prosthetic Dentistry. 1999;81(6):662-7. Survival of Dicor glass-ceramic dental restorations over 16 years. Part III: effect of luting agent and tooth or tooth-substitute core structure. Journal of Prosthetic Dentistry. 2001;86(5):511-9. Treatment history of teeth in relation to the longevity of the teeth and their restorations: outcomes of teeth treated and maintained for 15 years. Journal of Prosthetic Dentistry 2007;97(3):150-6. Accidental damage to teeth adjacent to crown-prepared abutment teeth. Australian Dental Journal 1991;36(2):136-40. Clinical study on the reasons for and location of failures of metal-ceramic restorations and survival of repairs. International Journal of Prosthodontics 2002;15(3):299-302. Artificial crowns and fixed partial dentures 18 to 23 years after placement. International Journal of Prosthodontics. 1993;6(3):279-85. Clinical evaluation of restored maxillary incisors: veneers vs. PFM crowns. Journal of the American Dental Association 1995;126(11):1523-9. Metal-ceramic failure in noble metal crowns: 7-year results of a prospective clinical trial in private practices. International Journal of Prosthodontics 2006;19(4):397-9. Incidence of fractures and lifetime predictions of all-ceramic crown systems using censored data. American Journal of Dentistry. 2001;14(2):72-80. Retrospective assessment of 546 all-ceramic anterior and posterior crowns in a general practice. Journal of Prosthetic Dentistry 2001;85(6):544-50. Clinical examination of leucite-reinforced glass-ceramic crowns (Empress) in general practice: a retrospective study. International Journal of Prosthodontics
Cannot differentiate data for anterior teeth Outside scope; Not relevant to EBH question
Outside scope; Not relevant to EBH question
Can not differentiate data for anterior teeth
Adverse effect not relevant to the EBH question Can not differentiate between crown data and fixed partial denture data Can not differentiate between fixed partial dentures and crowns Follow-up less than 5 years No anterior teeth data
Can not differentiate data for anterior teeth Can not differentiate follow-up period for anterior teeth Follow-up less than 5 years
100
1999;12(2):122-8. Spiechowicz et al 1999 Thayer et al 1993 Tiwarri et al 1992 Valderhaug et al 1997 Wagenberg et al 1989 Wagner et al 2003 Wasserman et al 2006 Wolfart et al 2004 A long-term follow-up of allergy to nickel among fixed prostheses wearers. European Journal of Prosthodontics & Restorative Dentistry 1999;7(2):41-4. Acid-etched, resin bonded cast metal prostheses: a retrospective study of 5- to 15-year-old restorations. International Journal of Prosthodontics 1993;6(3):264-9. Effects of restorations and carious lesions on the periodontium in humans. Annals of Dentistry 1992;51(2):22-5. Assessment of the periapical and clinical status of crowned teeth over 25 years. Journal of Dentistry. 1997;25(2):97-105. Exposing adequate tooth structure for restorative dentistry. International Journal of Periodontics & Restorative Dentistry 1989;9(5):322-31. Long-term clinical performance and longevity of gold alloy vs ceramic partial crowns. Clinical Oral Investigations 2003;7(2):80-5. Clinical long-term results of VITA In-Ceram Classic crowns and fixed partial dentures: A systematic literature review. International Journal of Prosthodontics 2006;19(4):355-63. Comparison of using calcium hydroxide or a dentine primer for reducing dentinal pain following crown preparation: a randomized clinical trial with an observation time up to 30 months. Journal of Oral Rehabilitation 2004;31(4):34450. Clinical evaluation of Procera AllCeram crowns in the anterior and posterior regions. International Journal of Prosthodontics 2007;20(3):239-41. Esthetic restoration of traumatized permanent teeth in children using composite vestibular veneers (preliminary communication). Folia Medica (Plovdiv) 2001;43(1-2):9-11. The effect of porcelain laminate veneers on gingival health and bacterial plaque characteristics. Journal of Clinical Periodontology 1994;21(9):638-40. Can not differentiate the crown data Not about single crowns; Fixed Partial Denture Does not report N for crown group. Can not differentiate data for anterior teeth Not relevant. Related to tooth lengthening procedure Posterior teeth No anterior tooth data
Adverse effect not relevant to the EBH question
Zitzmann et al 2007
Follow-up less than 5 years
Veneer studies
Belcheva 2001
Reason for exclusion

Follow-up less than 4 years
Kourkouta et al 1994
Follow-up period not cited; small sample size
101
Reid et al 1991 Friedman 1998 Meijering et al 1997 Meijering et al 1997 Kreulen et al 1998 Calamia 1989 Shaini et al 1997 Coyne & Wilson 1994 Wakiaga et al 2004 Dunne & Millar 1993
Gingival health associated with porcelain veneers on maxillary incisors. International Journal of Paediatric Dentistry 1991;1(3):137-41. A 15-year review of porcelain veneer failure--a clinician's observations. Compendium of Continuing Education in Dentistry. 1998;19(6):625-8. Patients' satisfaction with different types of veneer restorations. Journal of Dentistry 1997;25(6):493-7. Recognition of veneer restorations by dentists and beautician students. Journal of Oral Rehabilitation 1997;24(7):506-511. Meta-analysis of anterior veneer restorations in clinical studies. Journal of Dentistry 1998;26(4):345-53. Clinical evaluation of etched porcelain veneers. American Journal of Dentistry 1989;2(1):9-15. Clinical performance of porcelain laminate veneers. A retrospective evaluation over a period of 6.5 years. Journal of Oral Rehabilitation. 1997;24(8):553-9. A clinical evaluation of the marginal adaptation of porcelain laminate veneers. European Journal of Prosthodontics & Restorative Dentistry. 1994;3(2):87-90. Direct versus indirect veneer restorations for intrinsic dental stains. Cochrane Database of Systematic Reviews John Wiley & Sons, Ltd Chichester, UK 2004. A longitudinal study of the clinical performance of porcelain veneers. British Medical Journal 1993;175:317-21. External Root Resorption after Bleaching - a Case-Report. Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics 1991;72(5):607-609. Bleaching teeth treated endodontically: Long-term evaluation of a case series. Journal of Endodontics 2006;32(4):376-378. Carbamide peroxide whitening of nonvital single discolored teeth: case reports. Quintessence International 1999;30(3):155-61, 213-4.
Follow-up period less than 4 years A commentary; Inadequate reporting of methods, inclusion, and outcome data. Follow-up period less than 4 years Follow-up period less than 4 years Follow-up period less than 4 years Follow-up period less than 4 years Mean follow-up period not cited Follow-up period less than 4 years Follow-up period less than 4 years Follow-up period less than 4 years
Bleach Studies
Alnazhan 1991 Amato et al 2006 Caughman et al 1999

The adverse effect being reported had signs of being present prior to bleach treatment Analysis is flawed. Reported n of those followed up is incorrect. No follow-up Outcome measures not clearly defined
102
Dahlstrom et al 1997 Feiglin 1987 Frazier 1998 Haywood et al 1994 McCaslin et al 1999 Poyser et al 2004 Turkun & Turkun 2004
Hydroxyl radical activity in thermo-catalytically bleached root-filled teeth. Endodontics & Dental Traumatology 1997;13(3):119-25. A 6-year recall study of clinically chemically bleached teeth. Oral Surgery, Oral Medicine, Oral Pathology 1987;63:610-3. Nightguard bleaching to lighten a restored, nonvital discoloured tooth. Compendium 1998;19(8):810-813. Effectiveness, side effects and long-term status of nightguard vital bleaching. Journal of the American Dental Association 1994;125(9):1219-26. Assessing dentin color changes from nightguard vital bleaching. Journal of the American Dental Association 1999;130(10):1485-90. Managing discoloured non-vital teeth: the inside/outside bleaching technique. Dental Update 2004;31(4):204-10. Effect of nonvital bleaching with 10% carbamide peroxide on sealing ability of resin composite restorations. International Endodontic Journal 2004;37(1):52-60.
An in vitro study Position of teeth not stated Outcome measure not adequate No follow-up Position of teeth not stated Outcome measure not adequate An in vitro study Not relevant; about methodology/technique An in vitro study
Composite Resin Studies

Redman et al 2003 Salvi et al 2007

The survival and clinical performance of resin-based composite restorations used to treat localised anterior tooth wear. British Dental Journal 2003;194:566-572. Clinical evaluation of root filled teeth restored with or without post-and-core systems in a specialist practice setting. International Endodontic Journal 2007;40(3):209-15. 5-year follow-up of a prospective clinical study on various types of core restorations. International Journal of Prosthodontics 2005;18(1):34-9. A 5-year prospective clinical study on core restorations without covering crowns. International Journal of Prosthodontics 2005;18(1):40-1. Reattachment of the original fragment after vertical crown. The Journal of Pedodontics 1988;13:53-62. Not fractured teeth Outside scope of EBH Question. Not fractured teeth, a study of root-filled teeth. Outside scope of EBH Question. Not fractured teeth, a study of root-filled teeth. An expanded abstract. Outside scope of EBH Question. Not fractured teeth, a study of root-filled teeth. No follow-up described.
Creugars et al 2005 Creugars et al 2005 Martens et al 1988
103
Smales 1991 Peumans et al 1998 Ehrmann 1989
Effects of enamel-bonding, type of restoration, patient age and operator on the longevity of an anterior composite resin. Am J Dent 4(3):130-3 1991;4(3):130-3. The influence of direct composite additions for the correction of tooth form and/or position on periodontal health. A retrospective study. Journal of Periodontology 1998;69(4):422-7. Restoration of a fractured incisor with exposed pulp using original tooth fragment: report of case. Journal of the American Dental Association. 1989;118(2):183-5. Tooth fracture reattachment: case reports. Quintessence International 1990;21:261-70. Replacement of a fractured incisor fragment over pulpal exposure: a long-term case report. Quintessence International 1996;27:829-32. Direct pulp capping with a dentin adhesive resin system in children's permanent teeth after traumatic injuries: case reports. Quintessence International 2000;31(4):241-8. Tooth fragment reattachment: Fundamentals of the technique and two case reports. Quintessence International 2003;34(2):99-107. Tooth fragment reattachment after retrieval from the lower lip - a case report. Dental Traumatology 2007;23(3):177-80. Partial pulpotomy and tooth reconstruction of a crown-fractured permanent incisor: A case report. Quintessence International 2003;34(10):740-747. 1. Shah P. direct restoration of a discoloured single anterior tooth - A multi-layer approach. Oral Health 2007;97(4):61-64.
Not trauma population Not trauma population
Case study
Baratieri et al 1990 Kanca 1996 Gorecka et al 2000
Case study Case study Case study
Vilela Maia et al 2003 Basuttil Naudi & Fung 2007 Svizero et al 2003 Shah 2007
Case study Case study Case study Case study
104
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Optimum Life-Time Management of Coronal Fractures in Anterior Teeth

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Optimum life-time management of coronal fractures in anterior teeth:

A review of crowns, veneers, composite resin restorations and intra-coronal bleaching

Author: Dr Sarah Clark

Optimum life-time management of coronal fractures in anterior teeth

Accident Compensation Corporation

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

The data range was limited to

references from 1987 onwards. Bibliographies of retrieved articles were hand-searched to

Optimum life-time management of coronal fractures in anterior teeth

Optimum life-time management of coronal fractures in anterior teeth

Accident Compensation Corporation

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

Mr Karl Lyons (BDS MDS Cert Maxillofacial Pros FRACDS)

Professor Lindsay Richards (BDS BScDent PhD MRACDS(Prosth) FICD FADI)

Accident Compensation Corporation

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

5.2.1 5.2.2 5.2.3 5.2.4 5.2.5

Accident Compensation Corporation

Optimum life-time management of coronal fractures in anterior teeth

Composite resin restorations......................................................................................... 64

Limitations of the review ............................................................................................... 90 Recommendations .......................................................................................................... 91

Accident Compensation Corporation

Optimum life-time management of coronal fractures in anterior teeth

Accident Compensation Corporation

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

Accident Compensation Corporation

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

Optimum life-time management of coronal fractures in anterior teeth

Accident Compensation Corporation

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

3.2 Criteria for excluding studies from this review

Accident Compensation Corporation

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

Table 1: Summary of Inclusion Criteria for four treatment interventions

Follow-up period Publication date

> 6 months From 1987

3.3 Search Strategy and information sources

Accident Compensation Corporation

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

3.4 Methods of the review

3.5 Description of studies

Accident Compensation Corporation

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

Accident Compensation Corporation

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

Accident Compensation Corporation

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

Accident Compensation Corporation

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

Accident Compensation Corporation