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.

Accident Compensation Corporation

ii

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

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
Accident Compensation Corporation iii Evidence Based Brief Report

The data range was limited to

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

This would be done with a clear understanding that these restorations are likely to require replacement within 7 yrs. veneers and composite resin restorations was survival or failure rate over time. and choosing a treatment plan that maximises the life-time potential of teeth.Optimum life-time management of coronal fractures in anterior teeth of the studies. the outcome measures for bleach studies were success/failure of the whitening process. but that this can be done at least once before the less conservative treatments of veneers and/or crowns need be considered. 3. age. The survival rate of composite resin restorations is poor. 2. 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. Intra-coronal bleaching is effective in at least 60% of cases. In cases where either veneer or crowns are indicated. veneers and composite resin restorations.g. and patient risk factors. non-vital anterior teeth is discolouration. Unless indicated otherwise. 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. They also incorporate the philosophies of striving for conservation of tooth tissue. or reattachment of the avulsed fragment if available. intra-coronal bleaching should be the first treatment choice because it is effective in at least 60% of cases. These recommendations arise from a synthesis of all the evidence presented about survival of tooth restorations. and does not limit subsequent treatment choices. oral health) were associated with a higher risk of premature failure of dental crowns. patient satisfaction and colour stability. 1. patients <30 yrs should be treated conservatively with composite resin build-up. a veneer should be the first treatment choice for the following reasons: Accident Compensation Corporation iv Evidence Based Brief Report . Recommendations: The guideline development panel should consider incorporating the following recommendations into the guidelines. When the primary indication for restorative treatment of fractured. Some patient factors (e. The most commonly reported main outcome measure for crowns. However. has only one harmful side effect of low incidence. and patients should expect to require retreatment within 2 to 7 years.

Veneers should not be applied to teeth with large amounts of lost tooth tissue. 4.Optimum life-time management of coronal fractures in anterior teeth the survival rate of veneers appears to be better than for crowns. further extending the life of the restoration. there is greater conservation of tooth tissue. The definition of ‘large amounts’ remains to be decided. Accident Compensation Corporation v Evidence Based Brief Report . a high percentage of failures are repairable. It should also be noted that a relative contraindication for veneers is poor oral health and a high caries rate. and consequently a retention of some options for future treatments if the veneer fails.

Information Specialist. New Zealand Professor Lindsay Richards (BDS BScDent PhD MRACDS(Prosth) FICD FADI) Dental School. This evidence based review by peer reviewed by the following people: Mr Karl Lyons (BDS MDS Cert Maxillofacial Pros FRACDS) Senior Lecturer/Prosthodontis. School of Dentistry. New Zealand Health Technology Assessment (NZHTA) in carrying out the literature search. University of Otago.Optimum life-time management of coronal fractures in anterior teeth Acknowledgements The author wishes to acknowledge assistance of Susan Bidwell. Australia Glossary of Terms CDA/Ryge ANOVA California Dental Association/Ryge criteria for evaluating clinical quality and performance Analysis of Variance Accident Compensation Corporation vi Evidence Based Brief Report . The University of Adelaide. Department of Oral Rehabilitation.

.................................................. 17 Crowns.............. 12 Methodology ..3 Safety and adverse effects ....................6 Cost ...................................5 Accident Compensation Corporation .......................................Optimum life-time management of coronal fractures in anterior teeth Table of Contents Executive Summary ............................................................2............................................................ 17 Results ........................................................................................................................................................................................................................................ 46 Adverse effects.......................... 43 5....... 31 4.............................................................. 11 Objectives.........2 Criteria for selecting studies for this review ......................1 3.....................................................................................................................2........1 4.....2.............................................5 4..... 22 4............................................................................... 43 Results ............. 29 4....................................... 15 Health Technology ..........3.......................................1 Methodological Quality ....................... 17 4.....................................4 Adverse effects.....................3 5.................................................2............................................................................................... 32 Appendix 1: Evidence Tables for Crowns ......5 Patient Selection Criteria: Risk Factors for longevity.......2 Clinical Outcomes ............................ 15 Description of studies ...... 13 Criteria for excluding studies from this review......... 27 4..............................................3 Discussion ...........................3 Incidence and cause of crown failure ............................................................................................................1 5..............................................................................1 5.............................................................................................................................................................................................................. 31 4.... 18 4...............................................................................2...iii Acknowledgements....2 3............................................................................................................................................2.................................3.......................................................2 5.............. 24 4..............2.................................2 Conclusions.................5 4 4..................................................................................6 5 5........Risk Factors for longevity......1 Description of Studies ....................................................4 Summary of Evidence....2 Clinical Outcomes ................................................................................. 17 4.. vii 1 2 3 Background.................................................. 27 4...............................................................................................................4 3.................................. vi Table of Contents ........................ 49 Patient Selection Criteria ................................................... 33 Health Technology .....2.. vi Glossary of Terms .... 13 3......................................................................................................2........................................................................................... 13 Search Strategy and information sources ...............................................3...... 44 The cause of veneer failure..................................... 27 4....2.....................................2............................4 5................................................3 3.................................... 50 vii Evidence Based Brief Report Veneers ......... 43 Clinical Outcomes ............................................................ 14 Methods of the review.................................................... 43 Description of studies............................................................... 27 4................

...........5 7........................2 Clinical Outcomes ........... 79 7...................................................................3 Safety and adverse effects ................5 Cost of intra-coronal bleaching ............... 78 Intra-coronal Bleaching...... 82 7.................................. 86 Limitations of the review .............................................................4 Implications for outcomes over a lifetime ..................................................................... 69 6..................... 56 Health Technology ........ 70 6..................3........ 91 viii Evidence Based Brief Report Accident Compensation Corporation ...................3...........................2....... 84 7..............................................2 Conclusions..................................4 5...............3........................................................................................ 71 6......................... 78 7.....4 Summary of Evidence.... 84 7............ 71 6.....1 6......6 8 9 Conclusions............................................................................................................... 53 5.. 83 7............................ 65 6.................................................................................................................6 Cost of composite resin restorations ..............5 6.......... 90 Recommendations ... 55 Appendix 2: Evidence Tables for Veneers...............................................................5 6 6...............7 Methodological Quality .................................. 70 6....................2................................................................................................... 50 5............................. 52 5..1 7.............................................................................................3 Discussion ........................................3..............................................................3................................................................6 7 7....................................................................2.........................................................4 Indications and contra-indications.....................8 Clinical Outcomes ....................................... 83 7... 84 7......2............................................. 64 Results ........................................2........................... 82 7............... 72 6.......... 73 Appendix 3: Evidence Tables for composite resin restorations .................................................10 Implications for outcomes over a lifetime ....................................................................... 83 7..............................................2...2...............2 Clinical Outcomes ..........................1 Methodological Quality ................. 78 Results ...................... 78 7.............................................................3 Discussion ...................4 Patient Selection Criteria ........................ 70 6.........3 Adverse effects.................................................................6 Cost of Veneers................................................................................................. 54 5................2 Conclusions..............................................2......2.........................................................................3 Summary of Evidence..........................................1 Description of studies...............................................4 Implications for outcomes over a lifetime ..............................2.....1 Methodological Quality ...Optimum life-time management of coronal fractures in anterior teeth 5.........2............................................................................3................... 50 5.................... 69 6............................................................................... 72 6.....3.......2... 64 6....... 85 Appendix 4: Evidence Tables for Intracoronal bleaching ..................................................3 Safety and adverse effects .................2..Risk factors for longevity............................................................2............................2.......... 53 5................................................................. 74 Health Technology ...........................5 Indications for improved longevity ............................................................................................................................. 64 Composite resin restorations....................4 Summary of Evidence.. 64 6.........................................................................................2............. 84 7.............................................................................................. 70 6....3 Adverse Effects ................................2 Clinical Outcomes .........................................2 Clinical Outcomes .............9 Safety and adverse effects .............3.........................................1 Description of Studies ...

...... 97 Appendix 3: Evidence tables for Composite resin restorations (go to p 74)..................... Studies excluded from this review....................... 97 Appendix 4: Evidence tables for Intracoronal bleaching (go to p 86)................................................... Level of evidence in the SIGN system........................................................ 98 Appendix 6.......................................................................................................... 93 Appendix 1: Evidence tables for Crowns (go to p 33)..................... 97 Appendix 5......................................................................... 97 Appendix 2: Evidence tables for Veneers (go to p 56) ...........................Optimum life-time management of coronal fractures in anterior teeth 10 References ........... 99 Accident Compensation Corporation ix Evidence Based Brief Report ................

Optimum life-time management of coronal fractures in anterior teeth Accident Compensation Corporation x Evidence Based Brief Report .

Ninety percent of crowns purchased by ACC are on anterior teeth. indicated for intra-coronal bleaching Tooth should be extracted Dental work does not fit within ACC’s accident/injury legislation. ACC has seen a sustained 20% reduction in the number of crowns purchased per annum. Until March 2007. Group 3: Group 4: Group 5: Discoloured tooth. unless they were for elective treatments. were considered necessary and appropriate. ACC was alarmed and concerned at finding that 90% of the crowns requested for elective treatment were inappropriate and unnecessary. 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.Optimum life-time management of coronal fractures in anterior teeth 1 Background ACC funds the placement of approximately 2. Since that time. 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. A significant portion of tooth structure remains and there is minimal risk to form and function. i. because the tooth needed restorative treatment before the injury.600 crowns per annum for clients who have received an injury to their teeth. but not indicated for crowns. only six. it was an indication that ACC may be funding a percentage of crowns that should not have been placed in clients teeth. and 10% are on posterior teeth.e. The placement of a crown is not considered to be a conservative treatment because it involves Accident Compensation Corporation 11 Evidence Based Brief Report . i. The crowns considered inappropriate and unnecessary fell into five groups: Group 1: Group 2: Minimal damage to tooth. Of the 59 reviewed. Teeth with or needing endodontic treatment. dentists were not required to seek prior approval from ACC before placing these crowns. 10%. Consequently.e the dental complaint was not attributable to the injury. While these analyses may be biased because they were of elective cases. ACC’s primary concern is that clients teeth appear not to be treated conservatively.

e. These are all issues of concern because crowns are known to have a limited life. 2 Objectives To evaluate the clinical outcomes of anterior teeth restored with crowns. composite resin restorations. Accident Compensation Corporation 12 Evidence Based Brief Report . veneers. bleach or composite restorations.Optimum life-time management of coronal fractures in anterior teeth 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. or when an alternative treatment would be more appropriate. The guidelines will be underpinned by this EBH review. i. For those which are discoloured. The choice to crown also eliminates the option to use a range of more conservative dental treatments in the future. and intracoronal bleaching was requested to determine what evidence was present in the dental literature to guide treatment choices. bleach or composite restorations. veneers. when a crown should be placed. The purpose of the guidelines is to assist dentists to identify what is the best life-time management of coronal fractures of anterior teeth. 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. Alternative and variably more conservative treatments for the restoration of fractured anterior teeth are veneers and composite resin restoration. An evidence based healthcare (EBH) review of crowns. veneers. intracoronal bleaching can be used to restore aesthetics. veneers. bleach or composite restorations which consider the life-time management of injured anterior teeth. and once they fail the choices available for re-intervention are very limited. This EBH review is a first step in the development of ACC guidelines for the restoration of fractured anterior teeth. 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. but will be developed by a panel of dentists with a range of clinical experience and expertise. To report any indications/contraindications of crowns.

of any study type except for individual case studies. in these cases if the mean was likely to be less than the inclusion criteria in Table 1. The type of participants included in the review of intra-coronal bleaching requires further explanation. Composite resin studies were limited to traumatised teeth. whereas crown and veneer studies encompassed the general population. However. Individual case series were only considered when finding evidence of adverse effects. patients with teeth stained due to fluorosis or tetracycline were excluded. whether caused by trauma or as a result of endodontic treatment. Some reports did not cite a mean follow-up period. Accident Compensation Corporation 13 Evidence Based Brief Report . and bleach studies were limited to discoloured teeth. the study was excluded. Crown studies which did not differentiate data on single anterior crowns were excluded. The inclusion criteria for each intervention are detailed and compared in Table 1. Shorter follow-up periods were accepted for composite resin and bleach studies. were included because the aetiology of discolouration can be the same. published from 1987 onwards were considered. but there were unique selection criteria for each intervention. patients with other discolouration. 3.2 Criteria for excluding studies from this review Reports about primary teeth. or posterior teeth were excluded from this study.Optimum life-time management of coronal fractures in anterior teeth 3 Methodology 3. whereas follow-up periods were limited to 5 and 4 years respectively for crown and veneer literature.1 Criteria for selecting studies for this review Clinical studies about anterior teeth.

Single crowns of any type Veneer RCT comparing veneers to other interventions Comparative studies Case series General population with veneers. The search strategy was aimed at sensitivity rather than precision.3 Search Strategy and information sources A search of the following literature databases was performed: Cinahl. where possible. and the Science Citation index. 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. were used to create a master database of relevant dental literature. The master database was then searched across four Animal studies were excluded Accident Compensation Corporation 14 Evidence Based Brief Report . or direct composite veneers. PubMed (RCT/systematic review search only). Index New Zealand. 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. Medline. which described the four interventions. 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. not limited to trauma population Porcelain laminate veneers. Cochrane Central Register of Controlled Trials. 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]. Current Contents. A range of keywords.Optimum life-time management of coronal fractures in anterior teeth 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. embase.

8 about veneers. and 4 each about composite resin restorations and intra-coronal bleaching. The quality of evidence in each study included in the review was graded according to the SIGN criteria. Other sources searched were websites for professional associations. Health Technology Assessment Database. and after these were excluded 92 references were selected for critical appraisal for this review. National Guideline Clearing House (US). and safety/adverse effects.4 Methods of the review The relevant studies were critically appraised by considering experimental design. The details of included studies were summarised in evidence tables which are supplied at the end of each intervention section. Medline was the major database for dental literature. Database of Abstracts of Reviews of Effects. TRIP database. population studied. Following critical appraisal. summarised in Appendix 5. Further detail about the characteristics of the included studies is provided in the results section for each intervention review. This was reduced to 141 references after the first screen. NLH Guidelines Finder (UK). and the Canadian Medical Association Infobase. and international health systems. and full articles were retrieved.Optimum life-time management of coronal fractures in anterior teeth areas to capture studies of different types and focus as follows: RCT’s and systematic reviews. consecutive series of patients. interventions and outcomes reported. Review databases and guidelines compilations were also searched: Cochrane Database of Systematic reviews. NHS Economic Evaluation Database. appropriate or inappropriate utilisation. Hand searching of the bibliographies of the retrieved articles identified additional relevant literature which was also retrieved. Guidelines International Network. Scottish Intercollegiate Guidelines Network. Many of the retrieved articles were commentary style reviews.5 Description of studies The literature search yielded almost 1800 abstracts which were screened for relevant inclusion criteria. Accident Compensation Corporation 15 Evidence Based Brief Report . dental trauma. 3. 3. which were usually selected retrospectively. All other databases yielded much fewer results and had poor or no indexing for dental information. 26 studies were Most studies were of finally included in this EBH review: 10 about crowns. clinical trials.

The process of identifying reviewing and including information appears to have been carefully applied and to the best of my knowledge.Optimum life-time management of coronal fractures in anterior teeth Comments from Referee 1: The methodology of the review appears to have been appropriate. There is no evidence of bias in the report. 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 Accident Compensation Corporation 16 Evidence Based Brief Report . valid literature in each of the four areas being considered. that could be interpreted as being critical of local practitioners. 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. While a large number of publications were excluded because they did not meet the inclusion criteria. the objectives and the methodology which conforms to contemporary best practice in its approach to systematically identifying and reviewing the relevant. Significantly: The background to the report. the findings of this review are unlikely to have been much different if the excluded publications had been included. the information that has been presented is an accurate summary of the current literature. Comments from Referee 2: The report provides a clear description of the background to the project. and in the areas where I have taken the time to independently review references.

one study discussed indications relating to age. having follow-up periods ranging from 5 to 18 years.1 Description of Studies There were no RCT’s or comparative studies identified. This review is primarily concerned with porcelain fused to metal (PFM) and all ceramic/porcelain crowns. One study had an impressive sample size of 19. and restore the tooth’s shape and function. All included studies were case series. and polymer resin crowns (without metal substructure). The amount removed is dependent on the type of crown used. For instance a full gold crown requires a minimum of only 0.1 Health Technology An artificial crown is a restoration covering the whole tooth and is intended to repair damage to individual teeth. However. Forty papers were selected for critical appraisal. A further nine studies were included in the adverse effects section. Crowns replace tooth structure lost by decay or injury. and the other studies had sample sizes ranging from 17 to 353.5 mm tooth reduction. all ceramic/porcelain. Accident Compensation Corporation 17 Evidence Based Brief Report . There are four classes of crown. None of the studies reported indications or contraindications with regard to how much tooth structure is remaining after the fracture injury.5mm buccal tooth reduction. 4. after which 10 studies were included and 30 excluded. [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]. whereas a porcelain fused to metal crown requires a minimum of 1. Preparation of a tooth for a crown involves the irreversible removal of a significant amount of tooth structure.2. and two studies discussed indications relating to root-filled teeth.2 Results 4. In addition. protect the part of the tooth that remains. classified according to the material they are made of: Porcelain fused to metal (PFM). the cause and/or incidence of failure is reported in nine papers.659.Optimum life-time management of coronal fractures in anterior teeth 4 Crowns 4. full gold. The characteristics of the excluded papers are presented in Appendix 6. The primary outcomes reported were survival rate and failure rate.

All categories: Burke et al (2007)1 did a retrospective analysis of a longitudinal sample of dental records of 47. without root fillings. This study also showed. The survival rate of anterior teeth.5 yrs after cementation. These calculations were based on observed times to re-intervention.659 anterior crowns was calculated according to the probability of patients returning for a re-treatment other than maintenance. and re-intervention was assumed to be associated with the crown restoration.474 crowns placed in England and Wales over an 11 year period from 1990 to 20021 2. Further details of each study can be found in evidence tables in Appendix 1.2%) were Accident Compensation Corporation 18 Evidence Based Brief Report . The author reported that non-vital teeth had significantly higher failure and re-treatment rates than vital teeth. The authors concluded that crowns should be avoided in younger patients if at all possible. The retreatment rate (repair or failure) was 5. in which 353 crowns were placed on anterior teeth in a private specialist clinic. The majority of restorations (79. from whole-ofmouth data. Metal-Ceramic crowns: Walton (1999)3 4 reported results of a 10 yr longitudinal study. and that crowns on anterior teeth had a significantly greater re-treatment rate than crowns on posterior teeth. 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]. 5 De Backer et al (2006) did a retrospective survival study of 1037 full crowns over 18 years.2. 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. 76% of which were porcelain fused to gold. and they are grouped together according to the type of material used in the crown. and summarised in Table 3. and that patients in the 20 to 29 age band had the least good outcome in terms of re-intervention. was 59% at 10 yrs. The life of 19. 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%.Optimum life-time management of coronal fractures in anterior teeth 4. Many of these studies reported the cause and incidence of crown failure and this information is also presented below. For a summary of results refer to Table 2.1% and all occurred within the first 5.2 Clinical Outcomes The results of 10 studies about single anterior crowns are presented here.

4 yrs the survival rate was 98. The reasons for failure were presented. 83.9% after 6 years. Accident Compensation Corporation 19 Evidence Based Brief Report . The authors concluded that conventionally cemented Dicor crowns are contra-indicated as a long-term restoration because of high risk of fracture. The authors concluded that the prognosis is very good for Procera AllCeram in anterior restorations provided that clinical and laboratory instructions are followed. 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. Erpenstein et al (2000)10 report results from a longitudinal study of 95 ‘Dicor’ glassceramic crowns placed from 1987 until 1994. but anterior data could not differentiated from posterior teeth. All-ceramic crowns: Alumina category Walter et al (2006)7 did a prospective case series of 61 all-ceramic crowns (Procera AllCeram).1% after 12 years and 93. At the 6 year follow up the survival rate was 96. see Table 4 for more detail. when manufacture of Dicor ended. 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: 76.7%. The failure rate was 12. The authors concluded that leucite-reinforced glass-ceramic crowns showed a low clinical failure rate and excellent esthetics after up to 11 years.Optimum life-time management of coronal fractures in anterior teeth post and core crowns and the work was carried out in a University undergraduate clinic. luted with resin cement systems. The authors concluded that the Procera All Ceram crown is the all-ceramic restoration of choice for anterior teeth needing a single crown restoration.1% after 18 years. The survival rate at 7 years was 82. The reasons for failure of anterior teeth were not differentiated from the whole group of teeth.6% after 5 years. None of the 17 anterior teeth in this study failed due to fracture.9%. Porcelain veneer crowns: Etemadi & Smales (2006)6 did a retrospective case study of 134 anterior teeth treated with porcelain full veneer crowns.7%. Odén et al (1998)8 did a prospective study to evaluate the clinical performance of Procera AllCeram after 5 years. but one tooth required endodontic treatment. The number of anterior crowns.

Optimum life-time management of coronal fractures in anterior teeth Sjögren et al (1999)11 did a retrospective study of 35 Dicor all-ceramic crowns placed on anterior teeth between 1987 and 1997.2 yrs. and the authors concluded that Dicor restorations present an acceptable risk when placed in incisor and premolar regions.8%. 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. mandibular canine. 100%. The failure rate due to fracture was 12%.4%. Accident Compensation Corporation 20 Evidence Based Brief Report . maxillary canine. 84. 90%. The mean age of incisor crowns was 6. 91.6%. although half of these were minor fractures and the crowns were still functioning. They also showed that the long-term survival improved significantly when restorations were acid-etched before luting. mandibular central incisor. Malament & Sokransky (1999)12 did a 14 year prospective study of 422 anterior teeth restored with Dicor crowns. This study found the following survival rates for acid-etched crowns: lateral incisors on both arches. maxillary central incisor 80. and for canines it was 7. Ceramic failure was the only factor considered when reporting outcomes.3 yrs.

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. other than maintenance. Survival = no replacement needed Dentist’s expertise level not stated Author developed ProceraAllCeram.6% Accident Compensation Corporation 21 Evidence Based Brief Report .7% No failures due to fracture 1 tooth required endodontic treatment 7. required. Survival = no replacement needed Dentist’s expertise level not stated Periodontal disease excluded.4% Survival of mand and max c incisor = 90% & 80.659 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 Odén et al 19988 Fradeani & Redemagni 20029 Erpenstein et al 200010 Sjögren 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. Survival = no repair or replacement Specialist prosthodontists Survival = no replacement needed Specialists at University clinic Periodontal disease excluded. Reference Burke et al 20081 N anterior teeth Crown type All types Follow. & received post and core crowns.1% 5 yr failure = 12.3 – 7. Dentist’s expertise level not stated Survival = no replacement needed One experienced prosthodontist Only those with good oral health included (selection bias).6% 6 yr survival = 96. 79% of teeth endodontically treated.9% Comments Survival = no re-intervention.2 years 14 years 7 yr survival = 82.1% Non-vital teeth had significantly higher failure and repair rate than vital teeth Survival rates for anterior teeth: 6 yr survival = 93.4 yr survival = 98.4 years 95 35 422 7 years 6. 19. Failure due to fracture = 12% Survival of lateral incisors = 100% Survival of mand and max canine = 84. Survival = no replacement needed Private dental offices Only those with good oral health included (selection bias).1% 18 yr survival = 76.7% Dicor crowns contraindicated as a long-term restoration.Optimum life-time management of coronal fractures in anterior teeth Table 2.9% 12 yr survival = 83. Represents ‘on the street’ outcomes. Survival = no intervention A general dental practise. Survival = no repair or replacement Private specialist practise. Survival = no repair or replacement University undergraduate clinic.8% & 91. Summary of crown studies Shaded cells represent studies about Dicor crowns which have not been manufactured since 1994.

3% of failures).2.3 Incidence and cause of crown failure Seven of the studies discussed above. aesthetics caused 4-5% of failures. 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). Refer to Table 3 for a summary of this data. Accident Compensation Corporation 22 Evidence Based Brief Report . Debonding of the crown caused 6 to 15% of failures. 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. De Backer et al (2006)5 reported that caries were the major cause of failure (24. Causes of failure were either technical or had a biological origin. reported in variable degrees of detail the incidence and cause of crown failure.Optimum life-time management of coronal fractures in anterior teeth 4. caries caused ~ 24% of failures.

Age of crown up to 18 yrs 229 crowns 40 failures (17. 14% porcelain fracture 77. Accident Compensation Corporation 23 Evidence Based Brief Report . 12% endodontic problems) 39.5% due to chip 2. 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. Incidence and cause of crown failure Etmadi & Smales 20066 Resin-bonded porcelain veneer crowns Can not differentiate the anterior and posterior data. Summary of data about the incidence and cause of crown failure. 12.3% of failed crowns.1% due to technical and patient-related factors (8. 11.9% fractured tooth. 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.Optimum life-time management of coronal fractures in anterior teeth Table 3.8% of the patients accounted for 23.5% of failures were in anterior teeth.5% of failures occurred in porcelain veneers without metal reinforcement.4% due to biologic factors (24. 6% loss of retention.7% trauma) Of reversible complications: 83% due to technical problems (69% loss of retention.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. 5.5% 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 4.3% failed due to crown fracture 1.7% fracture of porcelain. 1. most (74%) of which failed due to biologic reasons.1% retreated Age of crown 5-10yrs Result/Conclusion 3.5%) Age of crown >5 yrs Anterior and posterior data can not be differentiated.4 yrs 76 anterior teeth Average age 7. Of the failures: 40% due to crown fracture 12.3% fracture of post.2% periodontal.4 yrs 35 anterior teeth Average age 6-7yrs 353 anterior crowns. 17.3% caries. but 42.2% needed as abutment for FPD. 4.

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.2. but only three of these were discussed in the main section of this report. Accident Compensation Corporation 24 Evidence Based Brief Report . Furthermore.4 Adverse effects Fourteen studies reporting adverse effects of crowns are included in this section. 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. Ten adverse effects were reported.Optimum life-time management of coronal fractures in anterior teeth 4. only three studies provided a comparison with uncrowned teeth in the same mouth13-15.

Crowned teeth had attachment loss.1% retreated unknown Anterior teeth not differentiated. 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. 4% of retreatments due to margin exposure. Originally intra-crevicularly placed crown margins were more or less visible after 12 months. Colour varied from bluish purple to dark brown or dark gray. plus controls 1 tooth 5-10 yrs 5-10. 25% of retreatments were due to periodontal problems and caries. Gingival Recession Koke et al 200314 (Porcelain fused to metal) 12 months Anterior teeth not differentiated. 58% of teeth with endodontic treatment had signs of peri radicular radiolucency. Small sample size. silicon. manganese and zirconium. Walton 19993 4* (Metal-ceramic) Gingival Bleeding Ödman & Andersson 200115 (Procera AllCeram) Gordon 200017 (porcelain fused to metal) 353 anterior teeth 5. magnesium.5 yrs Small numbers. 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. Bleeding on probing was recorded for 39% of surfaces around crowned teeth.Optimum life-time management of coronal fractures in anterior teeth Table 4. 22 anterior. compared to 27% for control contralateral teeth. can not differentiate anterior teeth. Limitation of study Only 1/8 of the sample teeth were anterior. Gingival colour differences (b/w crowned & not crowned teeth) were greater in the marginal and papillary areas. 19% of vital preparations had signs of periradicular disease. Gingivae tended to recede at crowned teeth during 12 month observation period.1% retreated 87 teeth. briefly reported. 5-10 yrs Accident Compensation Corporation 25 Evidence Based Brief Report . Summary of Adverse effects of crowns Adverse effect Gingival colour Author [*= full appraisal in text] N 8 teeth 15 central incisors. Foreign Body Gingivitis 2 yrs A case study. 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. Gingivae around many artificial crowns showed a hue shift toward red-purple.

Optimum life-time management of coronal fractures in anterior teeth

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 can’t be separated. Anterior and posterior data can’t 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; Can’t 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 can’t be separated. However 72% crown replacements were on anterior teeth. Anterior and posterior data cannot be differentiated. Can’t 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.

Accident Compensation Corporation

26

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

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 Walton’s (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. ACC’s 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.

Accident Compensation Corporation

27

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

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 Odén 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

Accident Compensation Corporation

28

Evidence Based Brief Report

This variation limits the ability to compare studies directly. it is not the mean. Comment from Referee 2 Accident Compensation Corporation 29 Evidence Based Brief Report . this study has the highest external validity because data was obtained from the General Dental Service. 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. and so these studies may have lower external validity due to this selection bias. 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 . giving the study exceptional statistical power. and which criteria were assessed when determining failure or survival. Of the crown studies included in this report. Six studies had short to medium term follow-up periods (5-7 yrs). Outcome measures: The primary outcome measure for crowns was survival/failure rate over a certain period. 4. Three studies set no particular exclusion criteria1 4 10. Only one study had follow-up data beyond 15 yrs5. the follow-up period reported is the maximum follow-up period calculated for that particular study. It is unknown whether these ‘on the street’ figures would be mirrored in New Zealand.659 anterior teeth. One of the main reasons for excluding crown studies from this report was short follow-up periods.Optimum life-time management of coronal fractures in anterior teeth et al (2008)1 study. however 3 studies excluded patients with poor oral health7 9 12. there was variability in the way survival or failure was defined (e. Follow-up and study period: Included studies had mean follow-up periods of at least 5 years.g.2 Clinical Outcomes The primary clinical outcome reported for crowns was survival/failure rate.3. 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. Given that crowns are commonly perceived to be permanent long-term restorations. In studies where the Kaplan-Meier survival rate is calculated. Three studies excluded patients who dropped out during the follow-up period5 8 11. Only two studies analysed patient factors which may influence the survival of crowns1 4. and furthermore the sample size was 19. ideally one would like to see follow-up periods of >20 yrs. However. most studies selected consecutive patients treated between particular dates. and three had medium to long term follow-up periods (7-15yrs). whether ‘failure’ includes repairable failures or not). but it is not unreasonable to expect that this would be the case.

and caries. However.. Overall. 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.Optimum life-time management of coronal fractures in anterior teeth The statement (pg 28) that the UK study “. A possible confounding factor in this study by De Backer et al (2006) is that 79% of the teeth were endodontically treated. The failure rates reported in these studies are considerably lower than the failure rate reported for the England and Wales dental service. placed within specific clinical settings. However. whereas the 12 year failure rate at a university undergraduate clinic was more than three times greater at 16. The failure rate for PFM crowns varied between the two PFM studies included in this report.4% respectively12. as reported at 5-7 years follow-up7-9. The failure rate had increased to 23. 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. the definition of failure in these studies was less stringent than the Burke et al (2008). The 10 year repair/failure rate at a private specialist practise was 5. the high failure rates led most authors to conclude that Dicor crowns are contra-indicated as a long-term restoration on anterior teeth. A study of a porcelain veneer crown reported a comparatively high failure rate of 12.2% and 19. The other studies have less external validity.1%4. 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. (and that) … it is unknown whether these “on the street” figures would be mirrored in New Zealand. Other brands of all-ceramic crowns (Procera AllCeram. IPS Empress) had lower failure rates (1-6%). has the highest external validity because the data was obtained from the General Dental Service . The three reports about Dicor™ all-ceramic crowns. Walton (1999) and De Backer (2006) studies because it only included crowns requiring replacement. 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.. The main causes of crown failure are crown fracture.9%5. Walton (1999)4 and De Backer et al (2006)5 is a crown needing replacement or repair. Note that the definition of failure in the studies by Burke et al (2008)1.6% after 5 years6. but nevertheless they provide useful data on specific types of crowns. debonding of the crown. and received post and core crowns. Accident Compensation Corporation 30 Evidence Based Brief Report 5 5 . but it is not unreasonable to expect that they this would be the case” is probably appropriate.9% by 18 years follow-up . Failure of Dicor all-ceramic crowns ranged from 12 .17% at around 7 years follow-up 10 11 but were better in Malament’s study which reported 14 year failure data for mandibular canines and maxillary central incisors of 15.

3. 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). most relevant to New Zealand’s dental service) reported survival rates of 43-59%1. This outcome may be comparatively better because the crowns were placed in a private specialist practise (95%)4. Survival in these three studies was defined as a crown that does not require either replacement or repair. supported with strong statistical power. externally valid evidence. or it may be due to patient risk-factors. Burke et al (2008)1 provided good. the adverse effects were reported in studies of both anterior and posterior teeth. endodontic failure. 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. the other reported adverse effects (periodontal problems. Accident Compensation Corporation 31 Evidence Based Brief Report .e. This poorer outcome may be because the crowns were placed in a university undergraduate clinic. The study with the highest external validity (i. it is assumed that anterior teeth are as susceptible to these adverse effects as posterior teeth. It is not possible to conclude with confidence why there is such large variation because there are confounding factors in all three studies. caries. Whilst gingival colouration and gingival recession seemed to impact mostly on aesthetics.Optimum life-time management of coronal fractures in anterior teeth 4. and tooth and root fracture) are somewhat more serious because they cause crown failures.3 Safety and adverse effects In general. 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. 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 . such as 79% of the teeth being non-vital and endodontically treated. However.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. 4.

and these data indicate that crowns applied by appropriate specialists can be highly successful in the medium term (10yrs)4.6% repaired or replaced)6. In comparison Dr Walton is a former president of the International College of Prosthdontists with an international reputation for excellence in fixed prosthodontics. Non-vital teeth are a risk factor for reduced longevity of crowns 2. endodontic failure. Comparing data from Burke (2008) and Walton (1999) is difficult (page 18). or a commercial-interest bias. secondary caries. However. There is reasonable evidence from a single study that the short term (5 yr) survival rate of porcelain veneer crowns is comparatively poor (12.Optimum life-time management of coronal fractures in anterior teeth Comments from Referee 2: The report appropriately recognizes the complexities of comparing outcomes between general practice. Accident Compensation Corporation 32 Evidence Based Brief Report . There is evidence from three lesser quality studies7 8 24 that the short term (5-7 yrs) failure rate (i. 4. 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. The Burke data is for publicly-funded services provide by general practitioners. the data did identify two risk factors: 1. and tooth and root fracture. There is reasonable evidence from two studies that a risk factor for the longevity of crowns is placement on non-vital teeth1 4.e. These studies are of lesser quality because of low participant numbers. People in the 20-29 yr age bracket are at risk of reduced longevity of crowns. However. and reasonable evidence from one study that being in the age bracket 20-29 yrs is a risk factor for longevity of crowns1. in a general practise setting the survival rates appear to be poor in the medium term (43-59%)1. These studies have low external validity. replacement) of ceramic crowns is very low (1-4%). specialist practice and university clinics.5 Conclusions The outcome measures are dominated by survival/failure rates. a selection bias towards patients with good oral health. There is insufficient evidence to establish guideline-quality patient selection criteria for placement of crowns on anterior teeth.

one of which was chosen in each year. Oct 1991 to Dec 2001). 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. 80% of crowns were Metal-ceramic bonded crowns. (i. Dental Crowns Bibliographic Number: Participants Description: The data set included patients: a) whose date of acceptance was after Sept 1990 and before January 2002. the end time of a restoration is not exactly known but is placed after a specified time. Survival rate = % expected to survive after a given period. Exclusions: Selection Notes: See paper for more details of methodological theory. other than maintenance. because crowns generally cover most of the surface of the tooth.e. 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.474 crowns placed in England and Wales over an 11 year period from 1990 to 2002. Analysis was done using right-censored data. Maintenance is not considered to be a reintervention. in Group: 19. 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. i.0001).0001).659 anterior teeth Age: most frequently in 30 to 49 age group.Optimum life-time management of coronal fractures in anterior teeth 4.e. Outcomes Outcome Measures: Life of a restoration = interval between successive interventions. The whole set of analyses was repeated on a second and non-overlapping random sample selected in the same way. The re-intervention is considered to be associated with the original restoration. All-ceramic crowns show the least time to reintervention when compared with other crown types (p<0. Patients in the 20 to 29 age band have the poorest outcome in terms of time to re-intervention (p<0. This interval was calculated using 2 probabilities.0001). No. (other than the 70-79 age grouo). Methodological Score: 3 Accident Compensation Corporation 33 Evidence Based Brief Report . The method involved first estimating the probability that a patient will eventually return for re-treatment by analysing the observed patterns of re-attendance. th c) Whose treatment was on or after their 18 birthday Intervention Placement of crowns on anterior teeth. but without further limit. Inclusions: Patients >18 yrs at time of crown treatment Results: Canine teeth have the poorest survival rate to next intervention (48% at 10 yrs). b) Whose birthdays were included within a set of randomly selected dates. so likelihood of there being no causal connection between original restoration and the re-intervention is low.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. that took place at the next intervention recorded for the crowned tooth. according to Kaplan-Meier method using ‘life of a restoration’ data.0001). followed by incisor teeth (55% for lateral incisor and 61% for central incisor) (p<0. as described in . Definition of Re-intervention: the treatment.

Accident Compensation Corporation 34 Evidence Based Brief Report .Optimum life-time management of coronal fractures in anterior teeth Reference: Walton 1999 Evidence Based 4Healthcare Table 3 Design Description A 10 yr longitudinal study of single-unit metal-ceramic crowns. Data posterior teeth were excluded. Occurred within the first 5. Dental Crowns Bibliographic Number: Participants Description: Documented reasons for seeking crowns were aesthetic considerations. structural integrity and previous crown failure. Procedures were standardised as much as possible.1%. Mean service age was 3. Exclusions: Patients whose crowns were only 1 – 5 yrs old. (where failure is when the crown is lost. in a private specialist practise. Outcomes Outcome Measures: Retreatment = repair and/or failure. 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. or the crown had been recemented more than twice) Success = no evidence of retreatment other than maintenance procedures.5 yrs after cementation (range 0. these patients were not included in the statistical analysis. Selection Notes: Only data for anterior teeth was included in this EBH table.3 yrs Major cause of retreatment: approx 50% were coronoradicular and root fractures Other biologic causes were periodontal and caries (approx 25%).5 yrs). 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. Methodological Score: 3 No.05). Crowns on anterior teeth had significantly greater retreatment rate than crowns on posterior teeth. Not stated whether the study was designed prospectively or retrospectively. 688 crowns in the whole study Intervention Metal-ceramic crowns placed on anterior teeth between Jan 1983 and Dec 1992.9 – 5. Follow-up period was from 5 to 10 yrs Results: Retreatment = 5.

Crowns either cast gold (24%) or porcelain fused to gold (76%).2%) Trauma (7.1% 12 yrs: 83.1% 6 yrs: 93. Records available for 456 patients. Reasons for drop out were: patients chose a private practitioner for maintenance. could not be traced. fracture of the abutment tooth. 1037 crowns. Belgium. in Group: not differentiated for anterior teeth Mean Age: Inclusions: Those patients which full records available Intervention Crowns were placed in undergraduate university clinic.4%). Biologic failure = caries. periodontal problems. Root canal-treated teeth with a post and core crown represented 79.7%) Endodontic problems (6. No. or died during follow-up period.Optimum life-time management of coronal fractures in anterior teeth Reference: De Backer et al 2006 Evidence Based Healthcare Table 5 Design Description Retrospective survival study of full crowns with or without posts Dental Crowns Bibliographic Number: Participants Description: 1312 full crowns placed over 18 yrs from 1974 to 1992. Patients invited to have regular maintenance program every 6 months. 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. 12 and 6 yrs as follows: 18 yrs: 76. Selection Notes: Methodological Score: 3 Accident Compensation Corporation 35 Evidence Based Brief Report . endodontic problems. Reasons for full crown prep were: Extensive loss of crown substance because of caries (66%) Replacement of existing restoration (12. moved to another city.9% Exclusions: Patients who dropped out.2% of the study group. Patients were invited to participate in a regular supportive maintenance programme every 6 months.3%) Esthetic reasons (5. Kaplan Meier survival rate calculated Results: The Kaplan-Meier survival rate for anterior teeth was calculated at 18.

RBPVCs) either with or without metal reinforcement (i.e.6% failure Failure-mode data was not differentiated for anterior and posterior teeth. Restorations placed due to discoloured. 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. fractured or worn teeth/restorations. For the whole group of 229 restorations. Methodological Score: 3 Accident Compensation Corporation 36 Evidence Based Brief Report . and for altering form of tooth as part of orthodontic therapy. 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. monitoring or replacement. Follow-up: at least 5 years No. Results: 17/134 anterior crowns failed = 12. 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. Dental Crowns Bibliographic Number: Participants Description: Older adolescent and adult patients who had RBPVCs placed during 19881995 on anterior and posterior teeth.Optimum life-time management of coronal fractures in anterior teeth Reference: Etemadi & Smalesl 2006 Evidence Based Healthcare Table 6 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. porcelain fused to metal).

Selection Notes: Data for posterior teeth not included in this EBH table where ever possible.2. current use of removable dentures. Survival rate = 96.7% +/. and ongoing orthodontic treatment. 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. Exclusions: Active periodontitis. followed for 6 years. in Group: 61 anterior teeth Mean Age: not stated Results: 2/61 crown fractures. Methodological Score: 3 Accident Compensation Corporation 37 Evidence Based Brief Report . These defects were smoothened and polished. had to be removed. Minor fractures within dental porcelain were found in 4 additional cases (anterior v’s posterior location not differentiated).Optimum life-time management of coronal fractures in anterior teeth Reference: Walter et al 2006 Evidence Based Healthcare Table 7 Design Description A prospective case study of patients treated with Procera Alumina AllCeram crowns. No. Dental Crowns Bibliographic Number: Participants Description: Patients who had all-ceramic crowns with alumina cores (Procera Alumina AllCeram crowns) placed on anterior or posterior teeth in 1997 and 1998.3% Inclusions: Patients in need of crown treatment and demanding superior aesthetics.

Dental Crowns Bibliographic Number: 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. Preparation was 0. (3 crowns) lost to recall.Optimum life-time management of coronal fractures in anterior teeth Reference: Odén et al 1998 Evidence Based Healthcare Table 8 Design Description A prospective study to evaluate clinical performance of Procera AllCeram crowns after 5 yrs of service. in Group: 17 anterior teeth (out of group of 97 crowns) Mean Age: Inclusions: Patients who needed crown therapy for a variety of reasons. Outcomes Outcome Measures: Failure = fracture of crown Follow-up period > 5 yrs No statistical tests were applied in analysis of outcomes. Selection Notes: Methodological Score: 3 Bias risk: contributing author was a Manager at Procera Accident Compensation Corporation 38 Evidence Based Brief Report . Patients were selected until 100 crowns (posterior or anterior) were placed. Exclusions: Two patients. Intervention Placement of Procera AllCeram crowns.6mm deep. or glass ionomer cement). Most crowns of whole group (97) were luted with conventional luting agents (zinc phosphate cement. Only 4/97 luted with dual-cure resin cement. Results: 0% failure Complication: 1 incisor showed clinical sign of pulpal inflammation and was endodontically treated through the crown 14 days after cementation No.

2-1. Dual-polymerizing resin composite cement was used to lute most restorations. Work performed by two clinicians. serious gingival inflammation. The study population was selected from consecutive patients at the authors’ offices. ranged from 4 to 11 years. Gingival margins located either at gingival crest. poor oral hygiene or high caries rates. Exclusions: 45/170 (26%) crowns excluded from study due to patients lost to follow-up or who died. Patients with severe parafunction. Kaplan Meier statistics were used. Accident Compensation Corporation 39 Evidence Based Brief Report .5 mm preparations done. Outcomes Outcome Measures: Failure = crown needed replacement Average follow-up = 7. Selection Notes: Intervention Crown placement on anterior teeth.4 yrs.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.1%. periodontitis. Only data for anterior teeth is considered in this EBH table No. 55 were placed on vital teeth. 1. (one crown failed due to fracture 6 yrs after placement) Survival probability at 11 years is 98. Only those with good oral health were included in the analysis. in Group: 93 anterior crowns in 54 patients Mean Age: 41 yrs female. or slightly in the sulcus. Results: Failure rate of 1.Optimum life-time management of coronal fractures in anterior teeth Reference: Fradeani & Redemagni 2002 Evidence Based Healthcare Table 9 Design Description A retrospective evaluation of leucitereinforced glassceramic crowns placed on anterior and posterior teeth. Dental Crowns Bibliographic Number: Participants Description: Patients needed crown therapy for a variety of reasons. a 6 year period. 70 were placed on endodontically treated. A total of 125 crowns were included in the study. 40 yrs male Inclusions: Patients who received all-ceramic IPS Empress crowns between May 1990 and December 1996.

7% (+/. Conventional cement was used (zinc phosphate).4 yrs.1) No. Most treatments (until year 10 of study) were done by one dentist. Results: 19/95 (20%) anterior crowns failed due to crown fracture Survival rate at 7 years = 82. only anterior teeth treated with glass ceramic crowns were selected for inclusion.8 yrs (+/. (NOTE: Dicor manufacture ended in 1994 due to large number of failures). Posterior teeth excluded. Intervention Placement of Glass-ceramic crowns (Dicor) on anterior teeth from April 1987 – August 1994. Dental Crowns Bibliographic Number: Participants Description: Patients were periodontally healthy. Mean years at risk was 7.Optimum life-time management of coronal fractures in anterior teeth Reference: Erpenstein et al 2000 Evidence Based Healthcare Table 10 Design Description A longitudinal clinical study of performance of two types of crowns.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. Not stated whether prospective or retrospective study design. in Group: 95 anterior crowns Mean Age: 40. Outcomes Outcome Measures: Failure = fracture of crown (loss of the fractured segment) Survival rate = not fractured. Types of crown studied were glassceramic (Dicor) and galvano-ceramic (Auvo Galvano). Methodological Score: 3 Accident Compensation Corporation 40 Evidence Based Brief Report .8.9. on anterior or posterior teeth. Follow-up was up to 11 years. Selection Notes: For this EBH table. Incomplete fracture = a crack in the cement. Calculated by KaplanMeier method.

Two of these were minor fractures and were crowns still functioning.2.1.6 – 9. 54 glass ionomer cement. 30 with zinc phosphate.3 +/.4 yrs for whole group Inclusions: Not stated Two evaluators examined the crowns Luting method: not defined specifically for anterior teeth. Mean age of canine crowns was 7.68. but only anterior teeth considered in this EBH table.2 years. and were given an appointment to have their crowns independently examined.Optimum life-time management of coronal fractures in anterior teeth Reference: Sjögren et al 1999 Evidence Based Healthcare Table 11 Design Description A retrospective study of patients treated with Dicor all-ceramic crowns between 1987 and 1997. Exclusions: Those who didn’t keep their assessment appointment. Outcomes Outcome Measures: Failure: not defined Mean age of incisor crowns was 6. men 52.2 +/. in Group: 35 anterior crowns (98 crowns in total group) Mean Age: women 56.5 yrs. 14 with composite cement.8 Results: 4/35 (12%) anterior crowns failed due to fracture.2. Both posterior and anterior crowns were examined. range 1. Selection Notes: Data for posterior teeth was ignored for purposes of 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. Dental Crowns Bibliographic Number: Participants Description: 63 Patients treated with Dicor all-ceramic crowns between 1987 and 1997 were invited to participate in the study.8 yrs. but of whole group of 98 crowns. those who were ill.range 5. No. Methodological Score: 3 Accident Compensation Corporation 41 Evidence Based Brief Report .

Optimum life-time management of coronal fractures in anterior teeth Reference: Malament & Socransky 1999 Evidence Based Healthcare Table 12 Design Description A prospective study of Dicor glass-ceramic crown survival Dental Crowns Bibliographic Number: Participants Description: Patients aged from 17 to 91 yrs. Tooth preparation length was adequate. Patients offered choice of 3 materials. Probability of survival was calculated using Kaplan Meier method. [chips <1mm were reshaped and polished]. 422 anterior teeth crowned Mean Age: not stated Inclusions: Patients had excellent oral hygiene.6% Concluded that Dicor restorations present an acceptable risk when placed in incisor and premolar regions [These rates are better than for molars. Intervention Placement of Dicor glass ceramic single unit crowns on teeth. Failure = the crown has a fractured ceramic piece that necessitated a replacement crown. recruited in a clinical private practice. 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. Followup period was for 14 yrs Outcomes Outcome Measures: Measured failure of ceramic only.3%.8%. not reporting on other causes of crown failure.1%] Long term survival improved significantly when restorations were acid-etched before luting. in Group: 1444 crowns total. mand 1 molar 74. mandibular 2 molar was 48. endodontic failure etc. such as caries. Results: The probability of survival of acid-etched crowns at 14 yrs of a: Mandibular canine = 84. teeth exhibited minimal mobility.8% Mandibular lateral incisor = 100% Mandibular central incisor = 90% Maxillary canine = 91. Exclusions: Patients with poor oral hygiene. max 1st molar nd st was 48. and had some fracture potential compared with feldspathic ceramic. but told that Dicor offered potentially improved esthetic results. uncontrolled periodontal inflammation or if they preferred gold or metal-ceramic restorations. minimal periodontal inflammation.4% Maxillary lateral incisor = 100% Maxillary central incisor = 80. Selection Notes: Accident Compensation Corporation 42 Evidence Based Brief Report .

Accident Compensation Corporation 43 Evidence Based Brief Report . having follow-up periods ranging from 5 to 12 years.Optimum life-time management of coronal fractures in anterior teeth 5 Veneers 5. marginal discolouration. and also presented age contraindications. The quality of reporting varied substantially. Irreversible enamel reduction of at least 0. or clinical acceptability/ unacceptability. 5. Two studies reported contraindications related to the presence of composite restorations at the veneer margin. Marginal adaptation. Veneers are comprised of either a thin porcelain laminate or of composite resin. All included studies were case series.5mm thickness of porcelain. One study had a substantial sample size of 2. The primary outcomes reported were survival/failure rate. One additional study is cited in the adverse effects section. Of the 20 studies selected for critical appraisal. eight studies were included and 12 were excluded. One study reported the consequence of retreatment. 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. Only one study reported a contraindication with regard to how much tooth structure is remaining after a fracture injury. The characteristics of the excluded papers are presented in Appendix 6. form and/or position of anterior teeth. Retention is achieved by micromechanical retention of the porcelain to the tooth via a resin composite luting material.5 mm is required to accommodate the minimal 0. whilst the other studies had small sample sizes ranging from 36 to 191.1 Health Technology Veneers are restorations that cover the labial surface of a tooth and are used to improve the colour. although the definition of failure was not consistent across the studies.1 Description of studies There were no RCT’s or comparative studies identified.2.562. and of high caries activity.2 Results 5. and in order to improve the bonding of the porcelain to the tooth. caries recurrence and patient satisfaction were criteria commonly assessed when determining whether a veneer failed.

based on observed times to re-intervention.2 Clinical Outcomes The results of 8 studies about veneers are presented here. extractions became more predominant (~10%). 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=0.2.Optimum life-time management of coronal fractures in anterior teeth 5. The work was done by two dentists between 1991 and 2002. Aesthetics. The life of these veneers was calculated according to the probability of patients returning for a re-intervention. Changes in re-treatment patterns were observed as time since placement of the original veneer progressed. i. were satisfactory. the types and frequencies of retreatments were observed as follows: proportion treated with a replacement veneer decreased to ~20%. Whilst marginal discolouration was considered acceptable it recorded the lowest proportion of ‘A’ ratings. Further details of each study can be found in evidence tables in Appendix 2. When dentist factors were analysed the results demonstrated that the age.003).562 porcelain veneers placed on anterior maxilla teeth in England and Wales over an 11 year period from 1991 to 2002. Burke and Lucarotti (2008)27 did a retrospective analysis of a longitudinal sample of dental records of 2. For a summary of results refer to Table 5. The clinical failure rate was 5. and the proportion of crown treatments became more variable (~1050%). for various reasons.e. Vita). Accident Compensation Corporation 44 Evidence Based Brief Report . and the 12 yr survival rate was 94. with porcelain laminate veneers fabricated by both a pressed ceramic technique (IPS Empress) and a refractory die technique (feldspathic porcelain. ~10-20% were replaced with a crown. An analysis of the treatments provided at re-intervention of a veneered tooth illustrated that in the first year ~10% were recemented. Modified Kaplan-Meier statistics were used to determine a survival rate of 53% at 10 years. About 2% were extracted.6%. year of training and experience of a dentist had no influence on the survival of porcelain veneers.4%. Fradeani et al (2005)28 did a retrospective study of 182 anterior teeth restored. ~40% were replaced with another veneer.001). 53% of the porcelain veneers were present without reintervention. assessed according to CDA/Ryge criteria. as did the proportion of teeth treated via direct placement restoration (>40%). as did those with high caries activity (as evidenced by high annual treatment costs and/or frequent attendances) (p<0. Vitadur Alpha. and ~20-30% received direct placement restoration.

94% of which were on anterior teeth. In 19% of the restorations. and reported a 5 and 10 yr follow-up.8%. The primary reasons for clinical failure were fractures of the porcelain and large marginal defects. The author concluded that porcelain veneers are not indicated in such teeth. Large marginal defects were found in 20% of restorations and were especially noticed at locations where the veneer ended in an existing composite filling. The Kaplan-Meier survival rate at 6.2 years. This difference was not statistically different. Increases were observed in the fracture rate (from 4% at 5 yr to 34% at 10yr). The work was done by one dentist in 1990 and 1991. and only 4% needed to be replaced. and preparation involved enamel reduction of 1 mm. The mean age of patients was 45. Accident Compensation Corporation 45 Evidence Based Brief Report . caries recurrence. and patient satisfaction. The dental work was done by six dentists at a dental school. Veneers were assessed for marginal adaptation. marginal discolouration. The cumulative survival rate over 7 years was 95.Optimum life-time management of coronal fractures in anterior teeth Smales & Etemadi (2004)29 did a retrospective study of porcelain veneer restorations of 110 anterior teeth with various indications for treatment.5 yrs was 75. fracture rate. and in clinical micro-leakage (from 26% at 5 yr to 65% at 10 yr). 98. After 5 yrs 14% of veneers had excellent marginal adaptation. a clinically unacceptable marginal discolouration was observed at the 10 yr recall. Sieweke et al (2000)32 did a retrospective study of 36 porcelain (IPS Empress ceramic) veneer restorations of patients who had lost canine guidance. Peumans et al (2004)30 did a prospective clinical trial of 87 porcelain veneers in anterior teeth. plus first premolars. as did marginal integrity.5% in veneers without incisal coverage. Patient satisfaction decreased between the 5 and 10 yr follow-up (from 80% to 59%). Forty two percent of veneers had incisal coverage. and by 10 yrs this reduced to just 4%. After a five year follow up. Aristidis and Dimitra (2002)31 reported on a case series of 186 porcelain veneers. The overall clinical acceptance decreased substantially between the 5 and 10 yrs follow-up from 92% to 64%. The work was done by two specialist prosthodontists between 1989 and 1993. and working an oval groove into the dentin.8% in veneers with incisal coverage and 85. These total failures were present in veneered teeth with a large amount of lost tooth tissue.4% were clinically acceptable. The main causes of failure were ceramic fracture and fracture of the adhesive bond. caries rate (2 at 5yr to 8 at 10 yr). most restorations were repairable. However.

with the exception of one study reporting 11% failure32. parts of the preparation surface were situated within dentin.5 mm) was observed in 31% of restorations. There were seven failures.3 The cause of veneer failure Refer to Table 6 for a summary of the cause of veneer failure. the incidence of which ranged from 1.058). Accident Compensation Corporation 46 Evidence Based Brief Report . due to fracture or multiple cracks.5 yrs was 91%. although this finding was not statistically significant (p=0. The partial failures involved loss of material from gingival extensions or from the incisal edge.5%. marginal discolouration occurred in 18% of restorations. The total failure rate was 14% and was comprised of two complete failures. and four partial failures. ranging from 1.8 to 5. particularly when the margins were equigingival or subgingival. and slight gingival recession (0. A finding that was significant was that the failure rate increased when the finish line crossed an existing filling (p<0. 28% of veneers developed marginal discolouration which appeared to occur due to marginal leakage at the luting agent to tooth interface.5 – 5. In comparison the incidence of repairable fractures was greater.01). 7 on premolars) after follow-up of up to 5. 5.1 to 0. patient satisfaction was high with 99% of patients rating aesthetics as excellent.6 yrs).Optimum life-time management of coronal fractures in anterior teeth Dumfahrt & Schäffer (1999)33 reported on the clinical performance of 191 veneers after 1 to 10 yrs in service (average service time of 4. however between 3 and 5 yrs. and the incidence of irrepairable fracture ranged from 0.2.6%. and after 10. Despite these defects at the margins. The most commonly reported cause of failure was veneer fracture.4 yrs. Marginal defects were slightly detectable or visible in 36% of cases. The cumulative survival rate over 5 yrs was 97%. Worth noting is that when a failure occurred. 34 Walls (1995) reported the failure rate in a case series of 43 veneers (36 on anterior teeth. There was little evidence of marginal discolouration up to 3 years.6% to 30%. The next most commonly reported reason for failure of veneers was debonding.

Reference N Burke and Lucarotti 200727 Fradeani et al 200528 Smales & Etemadi 200429 Peumans et al 200430 anterior teeth Veneer type Porcelain Follow. rest premolar) 36 canines Porcelain 5 & 10 years Repairable failure (stated) ‘Clinically unacceptable’ Seven criteria were assessed.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’. restoration of lost canine guidance. partial debonding. 12 yr survival = 94. Reporting is brief. impaired function’ Irrepairable failure (implied) ‘fracture.4% Irrepairable failure (implied) ‘Clinically unacceptable’ Seven criteria were assessed. Porcelain 6. partial debonding..4 yr survival = 86% Irrepairable failure (stated) ‘fracture.4 years 43 (84% anterior.10 years 5. Dentist’s expertise level not stated. loss of function’ A controlled university based clinical study. Most restorations were repairable.Effectiveness (survival/failure) up 11 years 10 yr survival = 53% Patients <30 yrs and >60 yrs had poorest survival of veneers. Survival = no re-intervention required.5 yr survival = 75. Private practise.5 years 6. Only 4% replaced. Failures were ceramic fracture and fracture of adhesive bond. rest premolar) 186 teeth (94% anterior. Summary of Veneer studies. debonding. Aristidis & Dimitra 200231 Sieweke et al 200032 Porcelain 5 years 5 yr clinical acceptance = 98. Irrepairable failure (stated) ‘fracture.5 yr survival = 91% Marginal defects detectable/visible in 36% of cases 5.562 182 110 Porcelain Porcelain 12 years 7 years 87 teeth (95% anterior. impaired esthetics. Marginal discolouration rated lowest Specialist prosthodontists 2. impaired esthetics or function’ Six dentists at a dental school. Two dentists at a university clinic.4% 7 yr survival = 95. rest premolar) Porcelain 5 yr survival = 97% 10. colour mismatch’ Comments Represents ‘on the street’ outcomes. debonding. Failures due to fracture or multiple cracks.Optimum life-time management of coronal fractures in anterior teeth Table 5.8% (with incisal coverage) 7 yr survival = 85. Irrepairable failure (implied) ‘Fracture. University dental clinic.8% Dumfahrt & Schäffer 200033 Walls 199534 191 Porcelain 1 . Primary reasons for clinical failure were fractures of porcelain and large marginal defects. Repairable failure (implied) ‘total loss of veneer or fracture requiring replacement…. plus partial failures where veneers retained’ Accident Compensation Corporation 47 Evidence Based Brief Report .

4 yrs 12 yrs 10 yrs 5.3% 1.2% 2.5 yrs 10.Optimum life-time management of coronal fractures in anterior teeth Table 6.4 yrs 10.3% 1% 1.1% 5.3% 0.8% 1.5% 2.8% 5. 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 1.8% 1.6% 30% 9. these were rebonded Repairable fracture lines.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 6.4 yrs 7 yrs 5 yrs 6.5 yrs 10 yrs 6.5% 2. Veneer fracture (Repairable) Limited fracture extension.5 yrs 5.5 yrs 10 yrs Comment Veneers replaced Four of the 6 fractures occurred in 1 patient Replaced with crown.5% 11% 2. 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 Accident Compensation Corporation 48 Evidence Based Brief Report .3% 0.9% 0.5 yrs 7 yrs 6.6% 2.5 yrs 5.6% 2.

Accident Compensation Corporation 49 Evidence Based Brief Report . it was repaired without detriment to the veneer35. other than the irreversible loss of surface enamel during tooth preparation.Optimum life-time management of coronal fractures in anterior teeth 5. Dumfarht and Schäffer (2000)33 described slight gingival recession in 31% of restored teeth.3%) at 5 years. The incidence figures reported were: 28% at 5.4 Adverse effects There were no serious adverse effects of veneer placement. which is a more invasive restoration presenting with a new set of potential adverse effects and no guarantee of life-time success.2. One other study 30 also mentioned that three of the four failures were retreated with crowns . One other study of 186 veneers assessed 31 the caries rate and found no carious lesions . that gingival recession occurs is a consideration for the aesthetics of veneers in the long term.4 yrs34. Caries: Peumans et al (2004)30 reported a relatively low incidence of caries (2. Nevertheless. One study excluded from this review reported one carious lesion case out of 43 veneer restorations. approximately 20% of teeth with failed veneers are retreated with crowns. Burke & Lucarotti (2008)27 do however demonstrate the consequences of retreatment. Similarly. However. neither study compared gingival recession of unrestored teeth in the same mouth. 17% at 4. 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.6 yrs33 and 19% at 10 yrs30. so it is not possible to conclude a causal link between veneers and gingival recession. Marginal Discolouration: Four studies reported that some veneers develop staining at the margins. but this increased to 9. These caries were more prevalent where veneers crossed an existing composite restoration. 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 33.2% over 10 years.

ACC’s contribution to the cost of Porcelain veneers is $675. 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. One of these related to the amount of tooth structure remaining. and Dumfarht & Schaffer (2000)33 reported that the failure rate increased when the veneer finish line crossed an existing filling (p<0.80.2.562 patients)27.Optimum life-time management of coronal fractures in anterior teeth 5.003). albeit statistically insignificant. 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. 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. Sample size and statistical analysis: Other than the large sample size of the English and Wales general dental service (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. follow-up period.5 Patient Selection Criteria .6 Cost of Veneers The median cost of a porcelain laminate veneer in New Zealand is $844. There was some evidence. the sample size for studies of porcelain Accident Compensation Corporation 50 Evidence Based Brief Report . that the survival rate of veneers may be diminished when: There is no incisal coverage29 There is dentin exposure33 5.Risk Factors for longevity Four risk factors for longevity of veneers were identified in the included studies. 5.001).2. None of the studies is directly comparable because of variations in almost every aspect of the studies: patient selection criteria.01).2. 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. clinical setting and measurement and reporting of outcomes. number of patients. and only one of the 8 studies was designed prospectively30.

001 and 0. Intervention: All studies except one27 either described how the teeth and veneers were prepared and luted. 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. wear. Two studies reported survival rates at both short (5 yrs) and medium/long term (10 yrs) follow-up periods30 33. replacement of composite restorations and veneers. and unfavourable occlusion30. and the maximum reported follow-up was 12 yrs28. One of the main reasons for excluding veneer studies from this report was short follow-up periods. or stated that manufacturers instructions were adhered to. 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. inadequate remaining sound enamel29 30 36. except for the study by Burke & 27 Lucarotti (2008) which randomly selected the participant sample. but in those that did. The veneered teeth were predominantly anterior. and the other three studies30 31 34 calculated percentages. reporting p values between 0. The method of patient selection was primarily by selecting consecutive patients treated between particular dates. In studies where the Kaplan-Meier survival rate was calculated. severe discolouration and evidence of marked or severe bruxism29. and inclusion and exclusion criteria was not fully reported in some studies.Optimum life-time management of coronal fractures in anterior teeth veneers ranged from 36 to 186. Two studies did not The clinical setting in which the veneers were placed ranged from general dental practise. private specialist practise. malalignment. and none of the studies reported solely on a trauma population. minor malocclusions. Study population. Follow-up and study period: Included studies had a mean follow-up period of at least 4 yrs. Patient selection criteria. and university dental clinics. Accident Compensation Corporation 51 Evidence Based Brief Report . fractures. the follow-up period was the maximum follow-up period calculated for that particular study.003. Five studies27-29 32 33 calculated survival rate using Kaplan-Meier statistics (or similar). however 4 studies also included a small proportion (5-16%) of premolars30 31 34 36. Reasons for patient exclusion were not consistent across the studies but the range of reasons included: patient drop-out32 34 36. inclusion and exclusion criteria: As with the review of crowns. rather than the mean. diastema. poor oral health or hygiene 28 30 . Not all studies stated the reasons for study participants receiving veneers. the range of reasons included: tooth defects. to state how selection occurred34 36. discolourations.

562 veneers. It is unknown whether these figures would be mirrored in New Zealand’s ‘on the street’ situation. there was variability in the way this was defined (i.2. but at 10 years Peumans et al (2004)30 reported a substantially lower survival rate of 64%.8 Clinical Outcomes The primary effectiveness outcome for veneers was the survival/failure rate. When repairable failures were included in the failure definition. Three studies defined failure as repairable failure27 30 34.Optimum life-time management of coronal fractures in anterior teeth Outcome measures: The primary outcome measure for veneers was the survival/failure rate. When only irrepairable failures were considered. whether ‘failure’ includes repairable failures or not). 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. 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. However. However. although there was not a commonly used definition across all studies. Walls (1995)34 and Peumans et al (2004)30 reported survival rates of 86% and 92% respectively at 5 years. the survival rate was > 90% in four studies over a range of follow-up periods (5 to 12 years)28 29 31 33 . 5. and one study discussed the implications of a repair and the possible dental health outcomes over a lifetime27. illustrating that veneers deteriorate with time in service. the survival rate for porcelain veneers was lower. and adverse effects. 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. (aside from Sieweke’s study32 confounded by patients with lost canine guidance and reporting a low survival rate (75. but it is not unreasonable to expect that this would be the case. Accident Compensation Corporation 52 Evidence Based Brief Report . the survival rate was 96% at 10 yrs. as with the crowns studies.8%)). 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. Other outcome measures widely reported were aesthetics. and variation regarding which criteria were used to assess a survival or failure. whereas the other five studies defined failure more narrowly as irrepairable failure.e.

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. and likely to be poor in the general population. or debonding of the veneer. Accident Compensation Corporation 53 Evidence Based Brief Report . 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. Whilst these effects are not considered unsafe. and 20% were restored with crowns. they do have a negative impact on the aesthetics of the restoration.9 Safety and adverse effects The most prevalent adverse effects of veneers are gingival recession and margin discolouration. when placed by a general dental service.2. Many studies neglect to mention how restorations were cemented but there are likely to be significant difference between traditional zinc phosphate cements. 5. Over time cement systems and bonding technology have changed significantly (this is also referred to in Section 6). which may become a reason for either the dentist or patient requesting additional restorations. 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.Optimum life-time management of coronal fractures in anterior teeth 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. The review of crowns in this EBH report has already demonstrated that the survival rate of crowns is variable.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. 5. glass-ionomer cements and resin cements and also between how these cements perform in cementing different metals or ceramics to either enamel or dentine. 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.

64% if replacements and repairs are considered. Accident Compensation Corporation 54 Evidence Based Brief Report . fillings at margins. and at best it is 96% if only replacements are considered (i.e. hence the quality of evidence by EBH standards is low. repair rates are ignored). 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. and caries at the veneer margin. There is evidence from numerous studies indicating that the main adverse effects of veneers are gingival recession. There is evidence from multiple studies demonstrating that the short-term (~5 yrs) survival rate of veneers ranges from 86% . The survival rate of veneers after 10 years of service varies greatly: at worst. margin discolouration.98%.Optimum life-time management of coronal fractures in anterior teeth 5. (excluding the study by Sieweke (2000) which had confounding patient factors). 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. survival rate is 53% .3 Summary of Evidence All relevant studies about veneers were case series. There is evidence from one study indicating that approximately 20% of failed veneers will be retreated with crowns. a high caries rate.

and the results are conflicting. However. Data from studies using small sample sizes show that veneers appear to be highly successful. The adverse effects of veneers (gingival recession.Optimum life-time management of coronal fractures in anterior teeth 5. Veneers are contraindicated for teeth with large amounts of tooth tissue have been lost. Veneers placed in patients aged less than 30 yrs or older than 60 yrs have a higher risk of failure. but do deteriorate over time and large percentages of aging veneers require repair28-31 33. 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. the data did identify four risk factors: 1. 4.4 Conclusions The outcome measures in veneer studies are dominated by survival/failure rates. Veneers that cross an existing composite filling are at higher risk of failure. There is insufficient evidence to establish guideline-quality patient selection criteria for placement of veneers on anterior teeth. 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. Veneers placed in mouths with a high caries rate are at higher risk of failure. [‘large amounts’ was not defined]. 2. Accident Compensation Corporation 55 Evidence Based Brief Report . 3.

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. 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.562 porcelain veneer restorations placed in England and Wales over an 11 year period from 1990 to 2002.001). experience) do not influence survival of porcelain veneers to re-intervention. Whose birthdays were included within a set of randomly selected dates. th Whose treatment was on or after their 18 birthday. Analysis was done using rightcensored data. as described in . The method involved first estimating the probability that a patient will eventually return for re-treatment by analysing the observed patterns of reattendance. including crowns. Veneers Bibliographic Number: Participants Description: The data set included patients: whose date of acceptance was from January 1991 to March 2002. Accident Compensation Corporation 56 Evidence Based Brief Report . 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. Survival rate = % expected to survive after a given period.Optimum life-time management of coronal fractures in anterior teeth 5.003). the proportion of replacement veneers decreases.e. Dentist factors (training year. according to Kaplan-Meier method using ‘life of a restoration’ data. 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 re-intervention on a previously restored tooth may be associated with the original restoration. and the proportion of other restorations. one of which was chosen in each year. The whole set of analyses was repeated on a second and nonoverlapping random sample selected in the same way. the end time of a restoration is not exactly known but is placed after a specified time. Patients with high caries activity (high annual treatment costs/frequent attendance) (p<0. but it is nevertheless possible that there is no causal connection. Methodological Score: 3 Exclusions: Selection Notes: See paper for more details of methodological theory.5 Appendix 2: Evidence Tables for Veneers Reference: Burke & Lucarotti 2008 Evidence Based Healthcare Table 27 Design Description A retrospective analysis of a longitudinal sample of dental records of 2. i. No. Definition of Re-intervention: the treatment that took place at the next intervention recorded for the veneered tooth. but without further limit. 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. in Group: 2. Outcomes Outcome Measures: Life of a restoration = interval between successive interventions. increases.562 anterior teeth in the maxilla. This 2 interval was calculated using probabilities.

periodontitis. except for one. Treatment was for a variety of reasons. marginal discolouration.8 yr Women 38. marginal integrity. Survival probability (Kaplan Meier) 12 yr: 94. Group 1 No. were placed on vital teeth. (Kaplan Meier statistics). Irreparable failure included porcelain fracture and/or partial debonding that exposed the tooth structure and/or impaired aesthetic quality or function. and Vitadur Alpha). Marginal discoloration recorded the lowest proportion of ‘A’ ratings.6mm in cervical third. severe gingival inflammation. poor oral hygiene. Outcomes Outcome Measures: Mean follow-up 5. Tooth prep ranged from 0.8 to 1. Intervention Restoration of anterior teeth with porcelain laminate veneers (Empress. to 0. but can be considered acceptable.0mm in the incisal third. (2 were replaced.Optimum life-time management of coronal fractures in anterior teeth Reference: Fradeani et al 2005 Evidence Based Healthcare Table 28 Design Description Retrospective case series Veneers Bibliographic Number: Participants Description: Sample collected from consecutive patients at the authors’ offices. Detailed methodology reported Follow-up occurred every 3 to 12 months. 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. 5. Work done between June 1991 and Dec 2002. or high caries rates. All restorations.3 yr Inclusions: Exclusions: Patients with uncontrolled parafunction.4%.6%. Accident Compensation Corporation 57 Evidence Based Brief Report .4% Aesthetics were ‘satisfactory’.3 to 0. in Group: 182 Mean Age: men 36. The incisal reduction was up to 2 mm.69 yrs Esthetics (colour match. 95% confidence interval from 100% to 89. 3 were rebonded). assessed according to CDA/Ryge criteria) Survival rate: Survival time being time from cementation to irreparable failure. Results: 5 restorations failed.

Exclusions: Severe tooth discolouration. but exposure of some dentin often occurred. Veneers without incisal coverage 7 yr cumulative survival was 85. inadequate remaining sound enamel. Mean follow-up was 4 yrs. 6/9 failures occurred from porcelain fracture in veneers without incisal coverage. incisal wear had led to exposure of dentin. evidence of marked or severe bruxism. Intervention Restoration of anterior teeth with porcelain laminate veneers. Work done by 2 prosthodontists at a specialist dental practice between 1989 and 1993. others did not. Some had incisal coverge. 4/6 fractures occurred in the one patient. debonding. wear or minor malocclusions. especially in cervical tooth region. Failure = fracture. fractures. 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.Optimum life-time management of coronal fractures in anterior teeth Reference: Smales & Etemadi 2004 Evidence Based Healthcare Table 29 Design Description A retrospective study of anterior porcelain laminate veneers placed with and without incisal coverage Veneers Bibliographic Number: Participants Description: Patients had tooth defects and discolourations. who had worn incisal edges. Selection Notes: Methodological Score: 3 Accident Compensation Corporation 58 Evidence Based Brief Report .8%. All failures occurred within first 4 years.5% Difference not statistically different. colour mismatch No. Outcomes Outcome Measures: Cumulative survival over 7 years (using life table method and SPSS stats software). In some instances. Where possible all preparations confined within enamel.

They all had deep or large composite fillings. fracture. clinical microleakage. No veneers were lost. 14% excellent margin adaptation at 5 yr. Patients treated with veneers in 1990 and 1991. There was a 93% recall rate at the 10 yr follow-up No. 4% excellent margin adaptation at 10 yr. 4% needed to be replaced. set in a university dental school. Work done by one dentist in 1990 and 1991. compared with 80% at 5 yrs. Equigingival cervical margin. retention. Most restorations were repairable. Labial enamel reduction was from 0. 19% had clinically unacceptable marginal discolouration. Exclusions: When less than 50% of the enamel remained for bonding or in patients with poor oral hygiene or unfavourable occlusion.7 mm. patient satisfaction Follow-up at 5 year and 10 yrs. Fracture rate: 4% at 5 yr. Clinical microleakage: 26% at 5 yr. in Group: 87 anterior teeth (includes first premolars) Age: 19 to 69 yrs Inclusions: See description above.3 to 0. Veneers Bibliographic Number: Participants Description: Veneers were placed to improve aesthetics by replacing worn and discoloured composite restorations and veneers. Feldspathic porcelain used. following a meticulous clinical procedure. or to correct discoloured. marginal integrity. Results: Overall Clinically acceptable: 5 yrs: 92% (95 CI: 90 %to 94%) 10 yrs: 64% (95 CI: 51% to 77%). Patient satisfaction: 59% patients very satisfied with esthetic result at 10 yr. Caries at veneer margin: 2 at 5 yr. 8 at 10 yr. thorough reporting. 65% at 10 yr. Outcomes Outcome Measures: Clinical acceptability Failure = clinically unacceptable but repairable. Esthetics. Intervention Restoration of anterior teeth and first premolars with porcelain veneers. Especially noticed at locations where veneer ended in an existing composite filling.Optimum life-time management of coronal fractures in anterior teeth Reference: Peumans et al 2004 Evidence Based Healthcare Table 30 Design Description A prospective clinical trial. large marginal defects in 20% (cause for failure). Most caries (7/8) were observed where veneers crossed an existing composite restoration. caries recurrence. vitality. malformed and/or malaligned anterior teeth. Selection Notes: Accident Compensation Corporation 59 Evidence Based Brief Report . Methodological Score: 3 Prospective. or clinically unacceptable with replacement needed. Tooth vitality: 3 teeth needed endodontic treatment. 34% at 10 yr Marginal integrity. incisal edge shortened and shoulder prepared on palatal side. university based study.

marginal integrity. Tooth preparation did not expose dentin. No. Outcomes Outcome Measures: Teeth were assessed across 7 categories which dealt with aesthetics. Ratings were perfect. 98. patient satisfaction. and incisal reduction was 0. Patient satisfaction: 5/186 were not completely satisfied Marginal discolouration: 2/186 cases.4% clinically acceptable. 5 year follow up Results: Overall. 94% st anterior teeth. but these terms were not further defined. Presumed to be restrospective. 1 was unacceptable. in Group: 186 veneers. rest were 1 premolar Age range: 18 to 70 Inclusions: Not described Exclusions: Not described Selection Notes: Methodological Score: 3 Poorly reported Accident Compensation Corporation 60 Evidence Based Brief Report . or clinically unacceptable. marginal discolouration. Facial enamel reduced 0. but clinically acceptable.5 mm. Veneers Bibliographic Number: Participants Description: Intervention Placement of porcelain veneers between Feb 1993 to Dec 1994.5mm.Optimum life-time management of coronal fractures in anterior teeth Reference: Aristidis & Dimitra 2002 Evidence Based Healthcare Table 31 Design Description A case series. Marginal adaptation: 1/186 unacceptable Fracture: 3/186 fractured. fracture rate. Work done by one dentist. 2 were acceptable.3 to 0. clinically acceptable. There was no caries recurrence.

It is implied that only irrepairable failures are reported in statistics.74 yrs. between 1992 to Jan 2000.78% 95% confidence intervals were 58% to 88% 8 veneers failed.2 yrs Inclusions: The patients had lost canine guidance. Outcomes Outcome Measures: Survival rate using Kaplan-Meier method. Intervention Restoration of canine guidance using oroincisal IPS Empress ceramic veneers. Results: Survival rate: 6. Exclusions: Patients who did not participate in or dropped out of the recall program Selection Notes: Methodological Score: 3 Accident Compensation Corporation 61 Evidence Based Brief Report . Work done at a dental school by 6 dentists. Oval groove also made into the dentin. Patients were recalled 6 monthly.5 yrs: 75. Average follow-up period was 6.Optimum life-time management of coronal fractures in anterior teeth Reference: Sieweke et al 2000 Evidence Based Healthcare Table 32 Design Description Retrospective case series Veneers Bibliographic Number: Participants Description: Patients had a healthy periodontum and dentition free of caries and/or restored. loss of function. The patients had lost canine guidance. Minimal thickness of enamel reduction was 1 mm. debonding. Failure = fracture. in Group: 36 canines (in 17 patients) Mean Age: 45. Cause of failure: 4/8 ceramic fracture 2/8 fracture of adhesive bond 1/8 loss of function 1/8 not documented No.

such as amelogenesis and dentinogenesis imperfecta. Veneers assessed following a modified California Dental Association/Ryge criteria. diastema (13). and mild malalignment (4).01). fractured teeth (9). Teeth with structural enamel defects that would leave insufficient enamel and tooth structure. parts of the preparation surface were situated within dentin. Exclusions: 7 patients who were unavailable for final evaluation between Sept and Dec 1997. occlusal correction (13).058). Significantly increased when gingival preparation was located within dentin (p<0. and minor to moderate structural defects. Superficial marginal discolouration: in 17% of veneers. discolourations. Inclusions: Non-carious surface defects. When a failure occurred. Consensus was reached when disagreements over scoring occurred. Two dentists did the restorations and examinations at a university dental clinic. Kaplan Meier survival statistics applied. 88% of these were in teeth with equigingival or subgingival margins Patient satisfaction: 99% excellent aesthetics Methodological Score: 3 No. 2 multiple cracks Kaplan Meier Survival estimation 5 yrs: 97% 10. hypoplasia (22). Marginal disintegration: significantly increased for longer wearing time (p<0. intrinsic discolouration (30). Marginal integrity: 99% acceptable. 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: Accident Compensation Corporation 62 Evidence Based Brief Report .05).6 yrs. Outcomes Outcome Measures: Average observation period was 4.001). Gingival recession: increased recession in 31% of veneers. 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). Facial marginal integrity was worse when the prepared gingival margin located within dentin.5 yrs: 91% Failure rate significantly increased when the finish line crossed an existing filling (p<0. in Group: 191 teeth (94% anterior) Age: 13-63 yrs. Survival time = time from placement to irrepairable failure. 36% showed slight detectable and/or visible marginal defect. largest number in 31-40 age group. Results: Failures: 5 fractures. Intervention Restoration of anterior teeth with porcelain laminate veneers. Findings not significant (p=0.Optimum life-time management of coronal fractures in anterior teeth Evidence Based Healthcare Table Reference: Dumfahrt & Schaffer 2000.

in Group: 43 veneers (36 on anterior teeth. 7 on premolars) University dental clinic. Mean Age: not stated Inclusions: Twelve patients presented to a dental hospital with problems involving toothwear and/or localised tooth fracture. poor prep blamed) (4. Results: 2 complete failures (one after 2 days. Selection Notes: Methodological Score: 3 Accident Compensation Corporation 63 Evidence Based Brief Report . Presumed to be retrospective. Patients were reviewed at 6 month intervals.7%) 4 partial failures (loss of material from gingival extensions or from the incisal edge) (9. Acid etch technique used along with dentine-bonding system. No.4 yrs) Restoration of teeth with porcelain veneers. 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.Optimum life-time management of coronal fractures in anterior teeth Reference: Walls 1995 Evidence Based Healthcare Table 34 Design Description A case series. the max was 65 months (5.3%) 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. Follow-up: the minimum time was 50 months (4.16 yrs).

39 chamfers and over-contouring . Various additional techniques have been employed to enhance dental fragment retention after reattachment and these include enamel bevels. and a follow-up period ranging from 2 to 7. and latterly dentine. In the restoration of fractured teeth.1 Health Technology Composite resins used in dentistry to restore carious.2 Results 6. veneers or bleaching. The primary outcome measure reported by all four of the included studies was retention rate or survival of the restoration and two studies reported Accident Compensation Corporation 64 Evidence Based Brief Report . worn or fractured teeth are composed of an organic resin-based matrix and an inorganic filler. These studies reported the use of both fragment reattachment and composite build-up. All 4 included papers were case series with a sample size ranging from 18 to 334. internal enamel or dentine grooves. and since then there have been several generations of development. 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. reported in 197837 38. 13 were excluded and 4 included. Seventeen papers were selected for critical appraisal.1 Description of studies The majority of composite resin literature is about fillings.2. involved preparation of the tooth and fragment by an enamel acid-etch technique followed by adhesion of fragments using composite resin.5 years. The earliest method for reattachment of avulsed fragments.Optimum life-time management of coronal fractures in anterior teeth 6 Composite resin restorations 6. The method was further advanced in the mid 1980’s when dentine bonding agents were developed to increase the bond strength of composite resins to dentine. have been developed. Acid etching produces micro-porosities in the enamel surface into which low viscosity adhesives can penetrate resulting in a mechanical bond with the tooth. 6. they are used in both the build-up of the remaining crown tissue. After a critical appraisal of the studies. and in the reattachment of avulsed fragments. none of these were RCT’s or studies which compared composite resin methods with crowns.

Interestingly. and the remaining 20 received fragment reattachment treatment. The characteristics of the excluded studies are presented in Appendix 6. 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. The acid-etch conditioning technique was used. except that the situation was reversed: class B injuries were more durable than class C with this treatment. a great number of restoration losses were due to 2nd or 3rd successive injuries. The authors opinion was that the greatest limitation of composites is poor quality of the marginal seal. Ten parameters of effectiveness were evaluated before each restoration was assigned a final overall evaluation. By 7 years after reattachment.Optimum life-time management of coronal fractures in anterior teeth on pulpal health and aesthetics. A difference in treatment reliability was also observed when fragments were reattached. For a summary of results refer to Table 7. Seventy teeth received a composite resin build-up. 100% of both class B and C injuries needed a complete replacement. Composite resin restoration was the only intervention for which indications/contrindications were presented regarding the type of fracture. Spinas (2004)40 did a seven year follow-up study of 90 injured teeth in children and adolescents. along with 3rd or 4th generation adhesive systems. when compared to injuries of class B: involving a mesial or distal coronal angle and/or incisal edge. and 100% needed complete replacement after 7 years. and the extent of fracture. The most frequent events that led to a replacement restoration were loss of the restoration. After 3 years there were no replacements of reattachments required for class B injuries. loss of marginal integrity. 47% needed a complete replacement after 3 years.2.2 Clinical Outcomes The results of 4 studies about composite resin restorations of fractured teeth are presented here. and unacceptable pigmentation/discolouration caused by pulp necrosis secondary to initial injury. Further details of each study can be found in evidence tables in Appendix 3. whereas 61% of class C injuries required complete replacement. 6. Of the composite resin build-up restorations. 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. although they did not provide clinical evidence to support that particular opinion. Consequently a risk factor Accident Compensation Corporation 65 Evidence Based Brief Report .

the fragment and the composite at the fracture line. and in 45% of AE cases. The aesthetics.e. and 17% of restorations were unsatisfactory due to wear of the composite. The mean retention period was 19. as judged by colour harmony between the tooth. Where there was little to moderate dentin exposure (n=10). However. and horizontal traction (i. was acceptable in 55% of DBA cases. overbite. In addition to the standard acid-etching. 42 Cavalleri & Zerman (1995) reported the 5 year outcomes of 84 fractured incisors in children aged from 6 to 12 years. but varied depending on the amount of dentin exposure. the mean retention period was 22.1 months. being 15. About 25% were lost spontaneously or during physiological use. Pulpal exposure occurred in 16% of injuries.5 months. The retention rate after 2 years was 39%. The restorations were aesthetically satisfactory in 43% of teeth. non-physiologic use of the bonded tooth (~12%). The final retention rate at 7. Angle’s Class II malocclusion). Although there was pulpal involvement in 39. 6% developed pulp necrosis. use of a bonding agent and light-curable composite resin. it took three times longer to reach 50% retention in the dentinal bonding group (2.Optimum life-time management of coronal fractures in anterior teeth for longevity of composite resin restorations is teeth with anatomical factors predisposing to further traumatic injury (overjet. Garcia-Ballesta et al (2001)41 reported clinical outcomes for a group of 18 children who had avulsed coronal fragments reattached. Fragment loss was predominantly caused by new trauma (~50%). Teeth were restored either with reattachment of avulsed fragment or with composite resin build-up. 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.5% of injuries.5 years compared to 1 year).1 months. The extent of fracture had no influence on loss or retention of fragments. This was a significantly different result (p<0.5 years was similar for each group: 15% for AE and 25% for DBA. but the treatment method did. fractures involving fracture of enamel and dentine occurred in 80% of injuries. whereas where there was wide dentin exposure (n=8) the mean retention period was shorter. A high proportion (40%) of teeth were retreated because of a new trauma. of which 57% developed pulp necrosis. Of those without pulp involvement. biting into chewy or tough foods).01) compared to injuries that exposed the pulp. this was Accident Compensation Corporation 66 Evidence Based Brief Report . a notch was also made in the enamel in an effort to improve bonding strength. 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).

6% of cases and was apparently related to a concomitant luxation injury. not to a complicated crown injury exposing pulp. Accident Compensation Corporation 67 Evidence Based Brief Report . Pulp canal obliteration and pulpal necrosis occurred in 6.Optimum life-time management of coronal fractures in anterior teeth not an indicator of subsequent pulpal necrosis.

Optimum life-time management of coronal fractures in anterior teeth

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)

2

Cavalleri & Zerman 199542

84

5

Andreasen et al 199543

334

7.5

Mean patient age ranged from 10.5 yrs to 14.5 yrs.

Accident Compensation Corporation

68

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

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.

Accident Compensation Corporation

69

Evidence Based Brief Report

Optimum life-time management of coronal fractures in anterior teeth

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 Student’s 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

Accident Compensation Corporation

70

Evidence Based Brief Report

only one study described the intervention in sufficient detail that the treatment could be replicated41.Optimum life-time management of coronal fractures in anterior teeth studies employed the ‘acid-etch technique’ and mentioned whether or not dentin bonding agents were used. and limited to patients with fractured anterior teeth. 6. Garcia-Ballesta et al (2001)41 reported only a 2 yr follow-up period. and reasons for failure of composite resin restorations 42 43.5 yrs. The descriptions of the intervention were generally quite broad. Andreasen et al (1995) reported that between 75 and 85% of restorations had been lost after 7. 6. Spinas (2004)40 reported that 100% of restorations 43 needed complete replacement after 7 yrs. Study population. using a more precise method than the Andreasen system40. and Cavalleri & Zerman (1995)42 reported that 57% of restorations were either unsatisfactory or were replaced after 5 yrs. Follow-up and study period: By comparison with the other interventions already described in this review.5 years. One study classified the study participants according to the type of injury sustained. Accident Compensation Corporation 71 Evidence Based Brief Report .3. Only one study stated the ‘generation’ of adhesive system that was used40. or time taken to reach 50% retention. the aesthetics of the restorations. inclusion and exclusion criteria: The study populations were young people aged from 6 to 18 yrs. or reattachment of tooth fragments is poor. The other two studies did not describe exclusion criteria40 43. and by then the retention rate was only 39%. Outcome measures: The main outcome measure for composite resin restorations was the survival of the restoration. the follow-up period for composite resin restorations is shortterm.3. This was presented in various ways: either as retention time. Two studies excluded crown fractures associated with other complications such as root fracture or luxation41 42.3 Safety and adverse effects There were no safety concerns raised or adverse effects reported.2 Clinical Outcomes Overall. Two studies also reported on pulp survival. indicating that these treatments can not be considered as long-term restorations. or the percentage retained or successful at certain follow-up periods. the retention/survival rate of either composite resin build-up restorations. ranging from 2 to 7.

however they did not provide clinical evidence to support that opinion40. the evidence presented above suggests that retreatment would be required for most teeth within 7 years (at best). indicating that this treatment is not durable or strong enough to withstand trauma. Despite the short-term survival of composite resin restorations.3. there is evidence from one case series that fractures involving the incisal edge and greater than a third of the crown. Whereas. Teeth with anatomy predisposing them to further trauma were identified as a risk factor for longevity of fragment reattachment.4 Implications for outcomes over a lifetime Fractured teeth treated with composite resin restorations will require retreatment. and within 2 years at worst. 6. Accident Compensation Corporation 72 Evidence Based Brief Report .4 Summary of Evidence There is low quality evidence from case series to suggest that the survival of composite resin restorations is poor.Optimum life-time management of coronal fractures in anterior teeth 6. and patients should expect to require retreatment within 2 to 7 years. and patients suffered from no adverse effects. have a better treatment outcome when built-up with composite resin. 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). 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. There is equivocal evidence about the influence that dentin exposure has on the longevity of fragment reattachment. Restoration of teeth with composite resin would appear not to place limitations on future retreatment options. Composite resin restorations of fractured teeth appear to be safe. Although the timing of retreatment will be uncertain for each case. fractures involving a mesial or distal coronal angle and/or incisal edge have a better treatment outcome when tooth fragments are reattached. either by reattachment of avulsed fragments or by building up the tooth structure.

Accident Compensation Corporation 73 Evidence Based Brief Report . However. There is insufficient evidence to establish guideline-quality patient selection criteria for placement of composite resin on fractured anterior teeth.Optimum life-time management of coronal fractures in anterior teeth 6.5 Conclusions Composite resin restorations appear to have limited longevity and are not suitable as permanent restorations. they are not associated with adverse effects and can be readily replaced without negatively reducing the options for future retreatment the tooth.

presumably anterior Age: 8-18 yrs Inclusions: Complete clinical diary. reattachment of original fragment. When pulp exposed defined as subclass D1. or only the incisal edge Class B: involving the enamel-dentin which involves a mesial or distal coronal angle and incisal edge.Optimum life-time management of coronal fractures in anterior teeth 6. Class B and C were most frequent injuries Group 1 . Of those replaced. from moment of injury to last check-up. Used total-etch conditioning technique and rd th 3 or 4 generation adhesive systems. in Group: 20 Position in mouth not stated.6 Appendix 3: Evidence Tables for composite resin restorations Reference: Spinas 2004 Evidence Based Healthcare Table 40 Design Description A retrospective case series Composite resin Bibliographic Number: Participants Description: 90 injured teeth. is an inevitable loss of dental tissues. Intervention Resin-based composite restorations. or loss of restoration. Reattachments B class more durable than C class. all with crown fractures of varying severity. Whenever fractured tooth presents a necrotic pulp. or. in Group: 70 Position in mouth not stated. with root involvement. 45% replaced for a second time. or poor marginal integrity. at 6 yrs. Class B and C tend to get worse while undergoing repairs: each time tooth is treated. poor aesthetic qualities. A tooth can probably undergo 3 or 4 composite restoration replacements before it shows severe reduction of its adhesive properties. 48% needed further complete replacement. or need for endodontic treatment. defined with addition of ‘h’. 5 yrs: About 70% needed complete replacement. Methodological Score: 3 Selection Notes: Accident Compensation Corporation 74 Evidence Based Brief Report . 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. Class D: involves enamel-dentin with a mesial or distal coronal angle and the incisal or lingual surface. 7 yrs: 100% needed complete replacement. Class C: involving enamel-dentin with incisal edge and at least a third of the crown. (some replaced with composite resin rather than fragment). 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. When pulp exposed defined as subclass B1. Ten parameters were evaluated before restoration was assigned one of 4 evaluations: Optimal: no complications or functional or aesthetic problems Good: minor changes occurred. Outcomes Outcome Measures: 7 year follow up. eliminated with simple polishing. presumably anterior. Needs an immediate and complete replacement. May need a partial replacement Not acceptable: major discomfort. by 7 years about 50% needed further complete replacement. Age: 8-18 yrs Group 2 .fragment reattachment No. may have tendency to become subclass ‘1’ or ‘h’. When pulp exposed defined as subclass C1. Acceptable: slight discomfort or dissatisfaction or colour alterations or ditching between enamel and composite.composite build-up No.

Composite resin Bibliographic Number: Participants Description: Children with fractured teeth. Presumed to be retrospective. Cases seeking treatment more than 5-6 hours post accident because the coronal fragment could have become dehydrated.1 months wide dentin exposure (n=8) = 15. in Group: 18 anterior teeth Mean Age: 8.5 months. Cases presenting with other associated lesions (root fracture. In all cases apices were immature to some degree. but varied depending on amount of dentin exposure: little/moderate dentin exposure (n=10) = 22.Optimum life-time management of coronal fractures in anterior teeth Reference: Garcia-Ballesta 2001 Evidence Based Healthcare Table 41 Design Description A case series.1 months Exclusions: Two teeth with comminuted fractures were unsuitable for restoration. Results: 1 month: 94% retention 2 yrs: 39% retention Mean retention period was 19. Outcomes Outcome Measures: Retention over time No. Intervention Reattachment of avulsed fragment. and light-curable composite resin. A notch was made in the enamel at an angle of 45 degrees. luxation) in addition to crown fracture. Varying degrees of dentin exposure. Selection Notes: Methodological Score: 3 Accident Compensation Corporation 75 Evidence Based Brief Report .6 yrs Inclusions: Uncomplicated crown fractures. and bonded using a dental adhesive. the tooth and fragment were then prepared with acid-etching.

01. sex ratio was 3.6:1 for boys and girls. or coronal pulpotomy 3. pulp capping. luxation. 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. 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.6% of cases received enamel grinding Results: Survival of restoration: 40% of teeth were retreated because of a new trauma. p<0. most injuries were in 8 year olds. No.Optimum life-time management of coronal fractures in anterior teeth Reference: Cavalleri & Zerman 1995 Evidence Based Healthcare Table 42 Design Description A restrospective case series.) Exclusions: Crown-fractured incisors associated with subluxation. Composite resin Bibliographic Number: Participants Description: 95% of injured teeth were maxillary central incisors. 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. root and/or crown-root fractures Selection Notes: Methodological Score: 3 Accident Compensation Corporation 76 Evidence Based Brief Report .

Retention Rate: Final retention rate was similar for each group (15% in AE. No. 25% lost spontaneously or during physiological use. 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. 44% had acid etching of enamel alone for fragment bonding (the AE group). For fractures approaching pulpal exposure. 50% retention rate took 3 times longer to occur in the dentinal bonding group. Presumed to be retrospective. Esthetics DBA: acceptable in 55% AE: acceptable in 45% Cause of fragment loss: Predominantly caused by new trauma.Optimum life-time management of coronal fractures in anterior teeth Reference: Andreasen et al 1995 Evidence Based Healthcare Table 43 Design Description A multicenter clinical study (case series). the other received composite build-up.5 years. the tooth fragment was wet-stored for up to 3 months before reattachment.5 yrs compared to 1 yr). (2. non-physiologic use of the bonded tooth.6yrs in acid-etch group.5-10. not to a complicated crown injury involving pulp exposure.6% of cases and was apparently related to a concomitant luxation injury.5% of injuries. 25% in DBA at 7.5 years). In cases where multiple tooth fractures occurred (6%).5 yrs in dentinal bonding group. Work performed in a third clinic.5 years. 10. There was pulpal involvement in 39. Mean age of acidetching group was 10.5 yrs to 43. one tooth received reattachment. Mean age in dentinal bonding group was 14. in Group: 334 teeth Mean Age: 14.4 yrs. Pulp status: Pulp canal obliteration and pulpal necrosis occurred in 6. or actually exposing pulp. Age ranged from 6.8% had root fractures). Composite resin Bibliographic Number: Participants Description: Permanent incisors with fractures of the crown or crown and root. Inclusions: Not stated Intervention Reattachment of dental fragments. 56% had a combination of enamel etching and dentinal bonding (the DBA group). and horizontal traction (biting into chewy/tough foods). Outcomes Outcome Measures: Retention rate Esthetics (fracture line visibility. Work performed in one of two clinics. (3. Methodological Score: 3 Selection Notes: Accident Compensation Corporation 77 Evidence Based Brief Report .

Optimum life-time management of coronal fractures in anterior teeth 7 Intra-coronal Bleaching 7. or 3) via a combination of both these techniques. also know as non-vital bleaching. The ‘walking bleach’ technique is performed by sealing bleach (typically sodium perborate in either its monohydrate or tetrahydrate form).2. Intra-coronal bleaching. the remaining 10 studies were excluded. There were no RCT’s or comparative studies identified.2 Results 7. whereas in-office bleaching involves filling the pulp chamber with cotton soaked in 30% hydrogen peroxide. 200346). The number of participants ranged from 21 to 86 Interestingly. and covers the use of gels. 7.1 Health Technology The active agent in tooth bleaching is hydrogen peroxide and its use in tooth bleaching was first reported in 188445. and either water or 3% hydrogen peroxide) inside the pulp chamber for several days. is the process whereby discoloured non-vital teeth are bleached internally. recommended internal bleach method typically utilises sodium perborate-(tetrahydrate) mixed with either water or 3% hydrogen peroxide46 47. There are three general approaches to achieve intra-coronal bleaching: 1) via the ‘walking bleach’ technique. strips and night-guards. 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. Hydrogen peroxide is either applied directly or is produced in a chemical reaction from sodium perborate or carbamide peroxide. coloured molecules. 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. pastes. none of the included studies used Accident Compensation Corporation 78 Evidence Based Brief Report . or 2) via a quicker in-office technique. Fifteen papers were selected for critical appraisal. after which 4 case series studies were retained for inclusion in the main review. There are fewer studies about the bleaching of non-vital teeth. Hydrogen peroxide is an oxidising agent that releases free radicals that can break unsaturated double bonds of long. Additionally one other paper was included in the adverse effects section. or reduce the coloured metallic oxides like Fe2O3(Fe3+) to colourless FeO(Fe2+) (reviewed by Attin et al. although the current and the follow-up period ranged from 1 to 8 years.1 Description of Studies The majority of tooth bleaching literature pertains to the bleaching of vital teeth.

success/failure and patient satisfaction. Failure occurred in 29% of cases. the definition of these outcome measures was not always well defined and there was little consistency of the definitions between studies. 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%. One tooth had minor and stable apical resorption prior to bleaching.2. with the exception being ‘failure’. When failure was reported it was broadly defined as being teeth that demonstrated little or no change in colour. treatments were successful. However. 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. 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. Further details of each study can be found in evidence tables in Appendix 4. overall. and they are grouped according to the bleach technique used. which remained non-progressive 18 months after bleaching. 7.2% of treatments were successful according to dentists.2 Clinical Outcomes The results of 4 studies about intra-coronal bleaching are presented here. they used 30 or 35% hydrogen peroxide either alone or mixed with sodium perborate. 66. Walking Bleach Glockner et al (1999)48 reported successful results 4.Optimum life-time management of coronal fractures in anterior teeth this mixture. The primary outcome measures reported were tooth colour change. whereas patients judged that 91. For a summary of results refer to Table 8. Thirty five percent received Using subjective observations. Stability of shade was displayed in 83% of teeth.8 years after 86 patients with discoloured anterior teeth were treated by the walking bleach technique (using sodium perborate/30% hydrogen peroxide). and 17% showed some rediscoloration.9% of Accident Compensation Corporation 79 Evidence Based Brief Report . The characteristics of the excluded papers are presented in Appendix 6. The reporting of patient selection and bleaching methods was not of a consistently high standard.

9).7) and 2.9% incidence (4 teeth) of external tooth resorption.4 (±1.Optimum life-time management of coronal fractures in anterior teeth walking bleach treatment. Two weeks after the treatment 100% of teeth improved by at least 8 Vita shades. There was a 6. 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.7) respectively. The mean shade values at baseline. 2 week follow-up and 2 year follow-up were 14. Tooth colour was stable in 12/25 teeth. Accident Compensation Corporation 80 Evidence Based Brief Report . Colour stability was assessed 2 years later. 22% received thermocatalytic treatment and 43% received both treatments. At the two year recall a shade rebound to a darker shade of up to 4 shades was evident in 13/25 teeth. and those that had some discolouration but were acceptable to the patient. 1.6 (± 0.8 (± 1. A successful treatment included teeth which matched the colour of the adjacent teeth.

not tooth number Accident Compensation Corporation 81 Evidence Based Brief Report .9% external tooth resorption 58 1-8 * this paper reported N as patient number. or veneered 83% displayed stability of shade 79% success 21% failure Failure=discoloration. 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.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. colour stability) 100% of teeth improved by at least 8 Vita shade values 48% of teeth retained their new shade 91. requiring further treatment Adverse events Not reported Glockner et al 199948 Waterhouse & Nunn 199649 Friedman et al 198850 86 * 21 4.8 1.Optimum life-time management of coronal fractures in anterior teeth Table 8.5 Not reported No evidence of cervical or progressive apical resorption 6. patient satisfaction.

Root resorption may be halted if detected early57. 58 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. Whether a trauma history increases the risk of tooth resorption is debated in the literature. it is recommended that a close radiographic and clinical follow-up of internally bleached teeth takes place to enable early detection of resorption49 57. and colour of restorative materials. in the absence of clinical in vivo reports describing this adverse effect. An article by Heithersay (1994)52 which was not included in this review because it did not report success/failure outcomes. However. The consensus view is that the risk of tooth resorption is higher if hydrogen peroxide at high concentrations (30%) is used. the clinical relevance of in vitro observations is unknown.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. and the risk further increases when 30% hydrogen peroxide is combined with heat46 53-56. despite the fact that some teeth did not respond to intra-coronal bleaching. A possible adverse effect of bleaching is a negative influence on restorative materials and restorations. It has been suggested that tooth resorption may be caused by diffusion of the bleaching chemicals through dentinal tubules to the periodontal ligament. Because the latter were published prior to 1987.Optimum life-time management of coronal fractures in anterior teeth 7. there was no evidence to indicate which teeth are more or less likely to have a stable bleached colour. they are not included in this review.9%. and is also reported in a number of studies published in the early 1980s.2.4 Indications and contra-indications There were no indications or contra-indications for non-vital bleaching identified in the reviewed studies.2. but if left unnoticed or untreated it can lead to loss of the tooth. Accident Compensation Corporation 82 Evidence Based Brief Report . 7.5%. Similarly. The association of external tooth resorption with bleaching has been reviewed extensively46 53-56. Therefore. although this has not been clinically substantiated. reported an external tooth resorption incidence of 2. enamel and dentin bond strength.

for this reason the most commonly used concentration of hydrogen peroxide for non-vital bleaching is 30 to 35% as reported in the literature. ACC’s contribution to the cost of a single intra-coronal bleaching treatment is $150. Comment from Referee 1: The use of 3% hydrogen peroxide is a relatively recent recommendation. The age of study participants was not well described. number of patients.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. Study population.3. and one study used 30% hydrogen peroxide in three methods: walking bleach. and one reported a range of 15-57 yrs48. 7. discoloured anterior teeth. Two studies employed only the walking bleach technique using sodium perborate and 30% hydrogen peroxide.0001. The other studies calculated percentages. None of the studies used the current recommended bleach recipe of sodium perborate mixed with either water or low concentration hydrogen peroxide.5 Cost of intra-coronal bleaching The cost of one bleaching treatment ranges from $150 to $200. Only one study applied statistical analysis to the results51. None of the studies are directly comparable because of variations in almost every aspect of the studies: patient selection criteria.2. and type of intervention.008 were reported for ANOVA and post-hoc comparison tests (respectively) of tooth colour change. Although p values of 0. inclusion and exclusion criteria: All study participants had endodontically treated. One study employed thermocatalytic bleaching using 35% hydrogen peroxide. The exclusion of teeth with severe internal and external Accident Compensation Corporation 83 Evidence Based Brief Report . one study did not state age50. The trauma history of study participants was stated in two studies. including one whose entire patient sample had lost tooth vitality due to trauma49. Sample size and statistical analysis: Sample sizes were quite small. one study included patients aged >18 yrs . and 0. One was designed prospectively51. it should be noted that the sample size was only 25.3 Discussion 7. the study consisting of all trauma cases described patients as 49 51 being children and adolescents . ranging from 21 to 86 teeth. Intervention: A range of intra-coronal bleaching techniques were used in the four studies.Optimum life-time management of coronal fractures in anterior teeth 7. thermocatalytic. As you noted. follow-up period. and a combination of those methods.

Intra-coronal bleaching of non-vital teeth would appear not to place limitations on future retreatment options 7. as measured over the short-term. with success according to the patient being 91. Another study reported a patient satisfaction of just 62%49. ranged from 66.3. and none of the re-discoloured teeth returned to their original shade49 51.9%. these were patient satisfaction.3. using high percentage hydrogen Accident Compensation Corporation 84 Evidence Based Brief Report . success/failure and colour stability.2 – 79%48-50. One study showed that the dentist judged far more critically than the patient.2% success according to the dentist48. ranging from 1 to 8 years. or fluorosis was explicitly stated in only one study. The colour change is not stable in all teeth.9% incidence of external tooth resorption50.2 Clinical Outcomes Intra-coronal bleaching of discoloured non-vital teeth is effective in at least 60% of teeth.4 Summary of Evidence 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. The majority of cases of re-discolouration involved minor colour changes of 1 or 2 shades51. 7. Outcome measures: Three outcomes related to the effectiveness of tooth bleaching were reported.4 Implications for outcomes over a lifetime Teeth with unstable bleached tooth colour may need retreatment to restore acceptable aesthetics to the tooth. Success in three studies. One of the four studies reported a 6. 7.3.3 Safety and adverse effects Intracoronal bleaching is associated with external tooth resorption. The consensus opinion in review literature is that high concentrations of hydrogen peroxide should be avoided. Deliperi & Bardwell (2005)51 and Waterhouse & Nunn (1996)49 demonstrated a stable colour change in 48% and 83% of teeth respectively. The long-term stability of the bleach induced colour change is unknown.Optimum life-time management of coronal fractures in anterior teeth discolouration due to tetracycline stains. Follow-up and study period: The follow-up period of bleach studies was relatively short. 7. as judged by dentists. compared with 66. particularly in combination with heat.

However. 7. there is insufficient evidence to enable a description of contraindications for this treatment. There is currently no evidence base that describes the effectiveness of the currently recommended method that uses low concentrations of hydrogen peroxide. The review literature supports the use of low concentrations of hydrogen peroxide. Accident Compensation Corporation 85 Evidence Based Brief Report .Optimum life-time management of coronal fractures in anterior teeth peroxide in intra-coronal bleaching techniques. There is sufficient evidence to suggest that patients of any age with discoloured non-vital secondary teeth are good candidates for receiving this treatment. and avoidance of heat if high concentrations are used.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 was evidence from one of the studies that the use of high concentrations of hydrogen peroxide is associated with external tooth resorption.

Number of teeth not stated. Average follow-up was 57. in Group: 86 patients. the silver was removed and replaced with gutta percha. 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. The dentist judges far more critically than the patient 2.6 Appendix 4: Evidence Tables for Intracoronal bleaching Reference: Glockner et al 1999 Evidence Based Healthcare Table 48 Design Description A retrospective case series Intracoronal bleaching Bibliographic Number: Participants Description: Patients who had received ‘walking internal bleaching’ were invited to have a follow-up examination.2% success rate for borderline cases 91. Outcomes Outcome Measures: Subjective observations of a) the patient and b) the dentist. A high percentage of success was possible after 5 yrs when only ideal clinical indications were treated.Optimum life-time management of coronal fractures in anterior teeth 7. Exclusions: Not stated Selection Notes: Methodological Score: 3 Accident Compensation Corporation 86 Evidence Based Brief Report .2% success rate according to dentists 91. Intervention Walking internal bleaching using a mixture of sodium perborate (tetrahydrate) and 30% hydrogen peroxide. Some patients received multiple treatments. Treatments lasted one week.9% according to patients Combining scores from patients and dentists 55.9 months (4. until desired results were achieved. and were terminated with neutralizing calcium hydroxide for at least 7 days. No.3% success rate for ideal cases Conclusions: 1. Successful grades: 1=optimal 2=very good 3=good Failure grades: 4=better than before treatment 5=identical to before treatment Results: Overall: 66.8 yrs). 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.

After bleaching the tooth was restored with white gutta percha and resin composite filling. reddish gray or off-guide teeth had decreased from 97% to 57% 62% of patients satisfied 83% displayed stability of shade. The chamber was sealed with glass-ionomer cement material. but never matched original discolouration 29% failed (were veneered. The bleaching procedure was repeated up to 10 times if improvement in colour was visible. 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 Exclusions: Not stated Selection Notes: Methodological Score: 3 Accident Compensation Corporation 87 Evidence Based Brief Report . 17% showed some re-discoloration. reddish gray or off-guide. Patient was asked to return 1 to 2 weeks later. Rediscolouration = if shade has changed by more than one unit Root resorption assessed by periapical radiograph Results: The number of gray. All patients had lost tooth vitality due to an earlier traumatic episode 97% of teeth were classified as gray. Intervention Walking bleach technique.Optimum life-time management of coronal fractures in anterior teeth Reference: Waterhouse & Nunn 1996 Evidence Based Healthcare Table 49 Design Description A case series. presumed to be retrospective. a thick crystalline paste made with sodium perborate granules/30% hydrogen peroxide solution was sealed within the tooth. or colour unchanged) No evidence of cervical or progressive apical resorption No. Intracoronal Bleaching Bibliographic Number: Participants Description: Children and adolescents with endodontically treated discoloured permanent anterior teeth. Outcomes Outcome Measures: Follow-up occurred at 6 month intervals for 18 months Colour change according to a Vita porcelain shade guide.

Intervention Intracoronal bleaching with 30% hydrogen peroxide (Superoxol) via walking bleach method. Intracoronal Bleaching Bibliographic Number: 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. Exclusions: Not stated Selection Notes: Methodological Score: 3 Accident Compensation Corporation 88 Evidence Based Brief Report .Optimum life-time management of coronal fractures in anterior teeth Reference: Friedman et al 1988 Evidence Based Healthcare Table 50 Design Description A retrospective case series. 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. Thermocatalytic bleaching was performed on some teeth. 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. in Group: 58 pulpless anterior teeth Mean Age: not stated Inclusions: Patients who had received intracoronal bleaching of their pulpless teeth.9% (4 teeth) had external root resorption No.

7) 2 yr follow up = 2. Teeth having previous bleach treatments. teeth having endodontic access opening only to be restored. smokers & pregnant & nursing women.4 (+/. p=0. It is not clear what these are %’s of] Methodological Score: 3 Well reported. No. fluorosis). Shade values: Baseline mean = 14. Results: Colour change: all teeth improved by at least 8 vita shade values. Tooth shades were assigned according to a Vita shade guide.8 (+/.0. in Group: 25 anterior teeth Mean Age: not stated Inclusions: Pulpless anterior teeth endodontically treated at least 2 yrs prior. Exclusions: Severe internal and external discoloration (tetracycline stains.1. then at 6 month recalls for 2 years.008. 9 of these 13 had a shade rebound of only 1 or 2 shades. Follow-up periods: 14 days after at-home bleaching was completed. 2.9) 2 wk follow up = 1. Outcomes Outcome Measures: 1. Shade values (1 to 16) and percentage change from baseline. Selection Notes: Accident Compensation Corporation 89 Evidence Based Brief Report . followed with at-home bleaching using custom tray and 10% carbamide peroxide according to the inside/outside bleaching technique.Optimum life-time management of coronal fractures in anterior teeth Reference: Deliperi & Bardwell 2005 Evidence Based Healthcare Table 51 Design Description A prospective case series Intracoronal Bleaching Bibliographic Number: 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.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. At-home bleaching treatment period not stated. Only teeth having a combination of endodontic access and Class III/IV cavities were included in the study. and with a complete loss of clinical crown.6 (+/. Colour stability (2 yrs): scored “Bravo”. with A3 or darker shades. 12/25 teeth had no shade rebound 13/25 teeth had a shade rebound to a darker shade of up to 4 shades.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.

Comment from Referee 1: While there have been various generations of resin bonding systems. e. most of the composite resin studies used early generation dentine bonding agents which are now obsolete. Accident Compensation Corporation 90 Evidence Based Brief Report . currently the 4th generation is still considered the gold standard which has been available since the 1980s. Similarly. and with the release of late generation dentine bonding agents. presumably advancements have been made in the bonding of porcelain veneers and crowns. The review excluded in vitro studies. all the bleaching studies used bleach solutions that are no longer considered best practise. A considerable limitation of this review is that many of the studies report technology and techniques that are out of date. and so has not accessed a source of information that contributes to the development to current best practise in dentistry.Optimum life-time management of coronal fractures in anterior teeth 8 Limitations of the review The findings of this evidence based review are considerably limited by the paucity of good quality. 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. long-term clinical studies. 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. and a lack of indications and contraindications for treatments.g.

2. a high percentage of failures are repairable. or reattachment of the avulsed fragment if available. When the primary indication for restorative treatment of fractured. Veneers should not be applied to teeth with large amounts of lost tooth tissue. a veneer should be the first treatment choice for the following reasons: the survival rate of veneers appears to be better than for crowns. and patient risk factors.Optimum life-time management of coronal fractures in anterior teeth 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. has only one harmful side effect of low incidence. This would be done with a clear understanding that these restorations are likely to require replacement within 7 yrs. intra-coronal bleaching should be the first treatment choice because it is effective in at least 60% of cases. non-vital anterior teeth is discolouration. A relative contraindication for veneers is poor oral health and a high caries rate. further extending the life of the restoration. 4. patients <30 yrs should be treated conservatively with composite resin build-up. and does not limit subsequent treatment choices. but that this can be done at least once before the less conservative treatments of veneers and/or crowns need be considered. 1. Accident Compensation Corporation 91 Evidence Based Brief Report . In cases where either veneer or crowns are indicated. there is greater conservation of tooth tissue. 5. the guideline development panel should consider incorporating the following recommendations into the guidelines. They also incorporate the philosophies of striving for conservation of tooth tissue. Unless indicated otherwise. and choosing a treatment plan that maximises the life-time potential of teeth. 3. These recommendations arise from a synthesis of all the evidence presented about survival of tooth restorations. The definition of ‘large amounts’ remains to be decided. However. and consequently a retention of some options for future treatments if the veneer fails.

This also makes it difficult to establish guidelines for patient and/or tooth selection criteria for each of the four treatments reviewed. avoiding the need to spent time identifying and debating the value of individual studies. This has been clearly identified in Section 8. They are in my view consistent with what we know from the literature and what many experts would regard as best practise. I consider that the report was balanced and fair and correctly interpreted the literature reviewed. This review appears to be completely based on the papers that satisfied the inclusion criteria. 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. Accident Compensation Corporation 92 Evidence Based Brief Report . Comments from Referee 2: Because of the low quality of the available research.Optimum life-time management of coronal fractures in anterior teeth Comments from Referee 1: The review was accurate. The conclusions outlined in Section 9 represent a conservative approach to both the interpretation of the evidence and patient management. making evidenced-based recommendations is difficult. Based on the evidence provided. This particularly relates to sample size in the publication included in this review. For this reason. however the literature for these four treatments across the range of the evidence hierarchy do report relatively similar findings. the conclusions in this report appear to be appropriate. 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. 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. The report is likely to be of significant assistance to an expert panel developing practise guidelines.

Clinical evaluation of all-ceramic crowns (Dicor) in general practice. Tillberg A. Burke FJ. Journal of Dentistry 2005. Six-year clinical performance of allceramic crowns with alumina cores. 8. Smales RJ.12(6):519-26. Long-term clinical results of galvanoceramic and glass-ceramic individual crowns.25(5):455]. Holder RL. Protocol and patient profile. Journal of Dentistry 2006.19(2):136-42.017. Redemagni M.03. Walton TR. Socransky SS. Foreign body gingivitis associated with a new crown: EDX analysis and review of the literature. Sander C.19(2):162-3. Accident Compensation Corporation 93 Evidence Based Brief Report . Walter MH.9(2):197-202.33(7):503-10.34(2):139-45. 16. 15. Journal of Prosthetic Dentistry 1999. 9. Odman P. Saunders EM. International Journal of Prosthodontics 2006. Journal of Prosthetic Dentistry 2000. Ten year outcome of crowns placed within the general dental services in England and Wales.80(4):450-6. An 18-year retrospective survival study of full crowns with or without posts.1016/j. Gordon S. 11.[see comment].185(3):137-40. and age. Hashimoto N.2008. Journal of Prosthetic Dentistry 1998. Sakai H. Operative Dentistry 2000. Krystek-Ondracek I. Lantto R. 6. Wolf BH. 13. Etemadi S. Ohki K.23(5):438-45. Andersson B. International Journal of Prosthodontics 2006. Burke FJ. Oden A. Andersson M. Shimada A.jdent. Wolf AE. Saunders WP. British Dental Journal 1998. Journal of Prosthetic Dentistry. Heinecke A. 4. Five-year clinical evaluation of Procera AllCeram crowns. 14. 18.10(4):325-31. Procera AllCeram crowns followed for 5 to 10. Sjogren G.5 years: a prospective clinical study. Gingival pigmentation beneath a metallic crown: light and electron microscopic observations and energy dispersive X-ray analysis. Van Maele G. 2. Fradeani M. International Journal of Prosthodontics 1999.14(6):504-9. 7. Journal of Dentistry 2008. 3. De Backer H. Takeda T. 5. gender. 17. Erpenstein H. 12.doi:101. Van den Berghe L. International Journal of Prosthodontics 1996. Analysis of an administrative database of half a million restorations over 11 years. A possible influence of gingival dimensions on attachment loss and gingival recession following placement of artificial crowns. Ishigami K. Koke U. De Moor N. Survival of Dicor glass-ceramic dental restorations over 14 years: Part I.[erratum appears in Oper Dent 2000 Sep-Oct. 1999. International Journal of Prosthodontics.Optimum life-time management of coronal fractures in anterior teeth 10 References 1. Lucarotti PSK.25(4):344-8. A ten-year longitudinal study of fixed prosthodontics: 1. Walton TR. International Journal of Periodontics & Restorative Dentistry 2003. Malament KA. 10. Muller H. Journal of Oral Pathology 1988. Kerschbaum T. Hirayasu R. Prevalence of periradicular periodontitis associated with crowned teeth in an adult Scottish subpopulation. A study of discoloration of the gingiva by artificial crowns. De Boever J. Sakai T. An 11-year clinical evaluation of leucite-reinforced glassceramic crowns: a retrospective study. 2001.17(8):409-15. Survival of Dicor complete coverage restorations and effect of internal surface acid etching. Magnusson D. Survival of resin-bonded porcelain veneer crowns placed with and without metal reinforcement.33:791-803.81(3):277-84.83(5):530-4. Lucarotti PSK.81(1):23-32. Quintessence International 2002. International Journal of Prosthodontics 1997. A 10-year longitudinal study of fixed prosthodontics: clinical characteristics and outcome of single-unit metal-ceramic crowns. tooth position. Borchard R. Boening KW.

Reasons for the placement and replacement of crowns in general dental practice. Longevity of oroincisal ceramic veneers on canines--a retrospective study. Fieuws S.6(1):65-76.16(1):5-12. Journal of Adhesive Dentistry 2000. Horn HR. Weber HP. Lambrechts P. Zofel P. Whitehead SA. Aristidis GA. Journal of the American Dental Association 1978. Journal of Dentistry 1991. Wilson NA.36(2):105-13.19(3):160-3. Skidmore AE.96(1):113-115. Practical Procedures & Aesthetic Dentistry: Ppad 2004.Optimum life-time management of coronal fractures in anterior teeth 19. Ten year outcome of porcelain laminate veneers placed within the genral dental services in England and Wales. 25. 29. 28. Gaengler P. Quintessence International. 2005.33(3):185-9. Mader C.1016/j. Jackson CR.to 12-year clinical evaluation--a retrospective study.doi:10. Five-year clinical performance of porcelain laminate veneers. The use of adhesively retained all-porcelain veneers during the management of fractured and worn anterior teeth: Part 2. A retrospective evaluation after 1 to 10 years of service: Part I--Clinical procedure. De Munck J. 2000. Stachniss V. A preliminary investigation into the longevity and causes of failure of single unit extracoronal restorations. Secondary caries in crowned teeth: correlation of clinical and radiographic findings. 32. Cheung GS. Dimitra B. Porcelain laminate veneers. 20. 26.178(9):337-40. Long-term survival of porcelain laminate veneers using two preparation designs: a retrospective study. International Journal of Prosthodontics. Porcelain laminate veneers bonded to etched enamel. Porcelain laminate veneers: 6. Zoellner A.2(3):229-34. D'Amelio M. Etched porcelain veneers: the current state of the art. 30.12(6):505-13.17(3):323-6. Tooth fragment reattachment: current treatment concepts.10(2):53-9. Dent Clin North Am 1983.67(3):323-5. Peumans M. Burke FJ.03. Etemadi S. Corrado M. A prospective ten-year clinical trial of porcelain veneers. A retrospective evaluation after 1 to 10 years of service: Part II--Clinical results. Dumfahrt H.16(10):739-40.25(1):9-17. 23.96(8):16-17. Schaffer H. Redemagni M. Smales RJ. Salomon-Sieweke U. Mjor IA. Porcelain laminate veneers. 36. 35. Van Meerbeek B. Calamia JR. 39. Pulpal evaluation of teeth restored with fixed prostheses. Quintessence International. International Journal of Periodontics & Restorative Dentistry 2005. Clinical evaluation of etched porcelain veneers. Vanherle G. Calamia JR. 37.88(3):314-9. 33. International Journal of Prosthodontics. Quintessence International 2002. Heuermann M. 24. Fradeani M. Hall WB. Corrado M.016.jdent. Bruce GJ.27:671-684. 27.16(2):178. Nickel hypersensitivity-related periodontitis. quiz 186. Texas Dental Journal 1978. 22. Fradeani M. 1999. Restoration of a fractured anterior tooth. 34. Five-year follow-up with Procera all-ceramic crowns.13(1):9-18. Redemagni M. Reis A. Journal of Adhesive Dentistry 2004. Clinical results after 5 years of follow-up.2008. British Dental Journal 1995. Journal of Prosthetic Dentistry 2002. 21. Lucarotti PSK. Wilson NH. Sieweke M. Dumfahrt H. 1985. Compendium of Continuing Education in Dentistry 1995. 31. American Journal of Dentistry 1989. International Journal of Prosthodontics 2004. Accident Compensation Corporation 94 Evidence Based Brief Report . 38. Primary Dental Care 2003. Walls AW. Rice RT. The fractured tooth reunited using the acid-etch bonding technique. Journal of Prosthetic Dentistry 1992. Journal of Dentistry 2008. Loguercio AD. Tennery TN.2(1):9-15.

Quintessence International 1996. Attin T. Lindh-Stromberg U. Traumatic crown fractures in permanent incisors with immature roots: A follow-up study.20(9):852-61. Dahl JE. Perez-Lajarin L. Waterhouse PJ. In: Andreasen J. Incidence of invasive cervical resorption in bleached root-filled teeth. Critical Reviews in Oral Biology & Medicine 2003. Internal bleaching: long-term outcomes and complications. Nunn JH. Cavalleri G. safety. Accident Compensation Corporation 95 Evidence Based Brief Report . Heithersay GS.17(6):407-11. Endodontics & Dental Traumatology 1995. Andreasen F. Endodontics & Dental Traumatology 1988. Noren JG. American Dental Science 1884. 2007:852-860. 50. Journal of Clinical Pediatric Dentistry 2001.10(2):105-110. Textbook and color atlas of traumatic injuries to the teeth. Longevity of composite restorations of traumatically injured teeth. 3rd ed. Hulla H. 46. Chiva-Garcia F. Two-year clinical evaluation of nonvital tooth whitening and resin composite restorations.14(4):292-304. Rotstein I. International Endodontic Journal 2003. Review of the current status of tooth whitening with the walking bleach technique. Australian Dental Journal 1994. Dental Materials 2004. Marin PD. editors. Bardwell DN. 55.11(6):294-296. 48. Ajam F. discussion 379. Incidence of external root resorption and esthetic results in 58 bleached pulpless teeth.18:521. Quintessence International 1995. and effectiveness of current bleaching techniques and applications of the nightguard vital bleaching technique. 45. Deliperi S. Intracoronal bleaching of nonvital teeth in children and adolescents: interim results. MacIsaac AM. Paque F. Attin R. 52.25(3):195-7. Dahlstrom SW. Lewis NJ. Chapter 33. Dahl JE. 4th ed: Blackwell Munksgaard.60(1):57-64. Hoen CM. Pallesen U. Haywood VB. 54. Heling I. Friedman S. Harlan AW. Five-year follow-up of internal bleaching. Zerman N. Bleaching of the Discolored Traumatized Tooth. Andreasen FM.39(2):82-7. American Journal of Dentistry 2004. Journal of Esthetic & Restorative Dentistry: Official Publication of the American Academy of Esthetic Dentistry 2005. Andreasen JO. 57. Journal of the American Dental Association 1997. 58. Garcia-Ballesta C. Scully C.26(10):669-81. 49. Stabholz A. Friedman S. Stadtler P. 42. Glockner K. 41. Wiegand A. British Dental Journal 2006. Hydrogen peroxide tooth-whitening (bleaching) products: review of adverse effects and safety issues. Andreasen FM. Spinas E. Copenhagen: Munksgaard. Effect of bleaching on restorative materials and restorations--a systematic review. Journal (Canadian Dental Association) 1994.17(6):369-78. Brazilian Dental Journal 1999. 47. Engelhardtsen S. History. Textbook and Color Atlas of Traumatic Injuries to the Teeth. Cortes-Lillo O. Clinical evaluation of bonding techniques in crown fractures.36(5):313-29.27(7):447-53. Lennon AM.200(7):371-6. 51. Andersson L. Naik S. Pallesen U. Attin T. Ebeleseder K. 53.4(1):23-6. 56.Optimum life-time management of coronal fractures in anterior teeth 40. Quintessence International 1992. 1994. 44. Hannig C. Tredwin CJ. Andreasen JO. Intracoronal bleaching: concerns and considerations. editors. Longterm survival of fragment bonding in the treatment of fractured crowns: a multicenter clinical study.23(7):471-88. Tooth bleaching--a critical review of the biological aspects. 43. The removal of stains caused by administration of medicinal agents and the bleaching of pulpless teeth. Libfeld H.128 Suppl:51S-55S.

Optimum life-time management of coronal fractures in anterior teeth Accident Compensation Corporation 96 Evidence Based Brief Report .

Optimum life-time management of coronal fractures in anterior teeth 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) Accident Compensation Corporation 97 Evidence Based Brief Report .

Level of evidence in the SIGN system 1++ 1+ 12++ High quality meta analyses. systematic reviews of RCTs. 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. case reports. systematic reviews. or RCTs with a low risk of bias Meta analyses. systematic reviews. or RCTs with a very low risk of bias Well conducted meta analyses. case series Expert opinion Accident Compensation Corporation 98 Evidence Based Brief Report .g.Optimum life-time management of coronal fractures in anterior teeth Appendix 5.

International Journal of Prosthodontics 2003. 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. Tooth preparations for complete crowns: an art form based on scientific principles.16(3):249-54. 1990. 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 Accident Compensation Corporation 99 Evidence Based Brief Report . Four post-and-core combinations as abutments for fixed single crowns: a prospective up to 10-year study.22(4):179185. Journal of Prosthetic Dentistry 2002. A clinical survey of failed post retained crowns. A clinical evaluation of ceramic laminate veneers. About pulp treatment. Retrospective clinical investigation and survival analysis on ceramic inlays and partial ceramic crowns: results up to 7 years.85(4):363-76. 1992. Relationship between crown placement and the survival of endodontically treated teeth. International Journal of Periodontics & Restorative Dentistry. Plaque retention on Dicor crowns and gingival health evaluated over a 4-year period. International Journal of Prosthodontics.5(5):447-51. Factors affecting treatment outcomes following complicated crown fractures managed in primary and secondary care. British Dental Journal. Dental Traumatology 2006. 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. 1988.6(1):13-8. Clinical Oral Investigations 1998.87(3):256-63.165(3):95-7. European Journal of Prosthodontics & Restorative Dentistry 1998.2(4):161-7.Optimum life-time management of coronal fractures in anterior teeth Appendix 6.10(6):454-63. Journal of Prosthetic Dentistry 2001.

Not relevant to EBH question Outside scope. 2001. Metal-ceramic failure in noble metal crowns: 7-year results of a prospective clinical trial in private practices. Retrospective assessment of 546 all-ceramic anterior and posterior crowns in a general practice. American Journal of Dentistry.6(3):279-85. 1993. Artificial crowns and fixed partial dentures 18 to 23 years after placement. British Dental Journal. Australian Dental Journal 1991. Incidence of fractures and lifetime predictions of all-ceramic crown systems using censored data. Part III: effect of luting agent and tooth or tooth-substitute core structure. Clinical examination of leucite-reinforced glass-ceramic crowns (Empress) in general practice: a retrospective study. Journal of the American Dental Association 1995. Clinical study on the reasons for and location of failures of metal-ceramic restorations and survival of repairs.Optimum life-time management of coronal fractures in anterior teeth 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. International Journal of Prosthodontics Cannot differentiate data for anterior teeth Outside scope. 2001. Clinical evaluation of restored maxillary incisors: veneers vs. 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 Accident Compensation Corporation 100 Evidence Based Brief Report .19(4):397-9.196(10):639-43.86(5):511-9. Part II: effect of thickness of Dicor material and design of tooth preparation.36(2):136-40. International Journal of Prosthodontics. PFM crowns. Journal of Prosthetic Dentistry. Survival of Dicor glass-ceramic dental restorations over 16 years. Treatment history of teeth in relation to the longevity of the teeth and their restorations: outcomes of teeth treated and maintained for 15 years.97(3):150-6. Journal of Prosthetic Dentistry 2001. Survival of Dicor glass-ceramic dental restorations over 14 years.14(2):72-80. International Journal of Prosthodontics 2002.126(11):1523-9.15(3):299-302. Accidental damage to teeth adjacent to crown-prepared abutment teeth.81(6):662-7. 2004. Journal of Prosthetic Dentistry. 1999. Journal of Prosthetic Dentistry 2007.85(6):544-50. International Journal of Prosthodontics 2006. discussion 627.

6(3):264-9. International Journal of Periodontics & Restorative Dentistry 1989.12(2):122-8. The effect of porcelain laminate veneers on gingival health and bacterial plaque characteristics.7(2):80-5.9(5):322-31. resin bonded cast metal prostheses: a retrospective study of 5. Can not differentiate the crown data Not about single crowns. International Journal of Prosthodontics 2006. Acid-etched.43(1-2):9-11.20(3):239-41. Folia Medica (Plovdiv) 2001. Annals of Dentistry 1992. Esthetic restoration of traumatized permanent teeth in children using composite vestibular veneers (preliminary communication). 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. Assessment of the periapical and clinical status of crowned teeth over 25 years. International Journal of Prosthodontics 1993.7(2):41-4. Effects of restorations and carious lesions on the periodontium in humans. Journal of Clinical Periodontology 1994.51(2):22-5. European Journal of Prosthodontics & Restorative Dentistry 1999. Clinical Oral Investigations 2003. 1997.21(9):638-40.Optimum life-time management of coronal fractures in anterior teeth 1999. Journal of Oral Rehabilitation 2004.19(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. Exposing adequate tooth structure for restorative dentistry. International Journal of Prosthodontics 2007. 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.to 15-year-old restorations. small sample size Accident Compensation Corporation 101 Evidence Based Brief Report . Journal of Dentistry.25(2):97-105. Can not differentiate data for anterior teeth Not relevant.31(4):34450. Clinical long-term results of VITA In-Ceram Classic crowns and fixed partial dentures: A systematic literature review. Clinical evaluation of Procera AllCeram crowns in the anterior and posterior regions. Long-term clinical performance and longevity of gold alloy vs ceramic partial crowns. Fixed Partial Denture Does not report N for crown group.

Clinical performance of porcelain laminate veneers.3(2):87-90.72(5):607-609.32(4):376-378.2(1):9-15. American Journal of Dentistry 1989. Cochrane Database of Systematic Reviews John Wiley & Sons. Journal of Dentistry 1997. 1994. Journal of Endodontics 2006.1(3):137-41. British Medical Journal 1993. Journal of Oral Rehabilitation 1997. inclusion. European Journal of Prosthodontics & Restorative Dentistry. Carbamide peroxide whitening of nonvital single discolored teeth: case reports. Clinical evaluation of etched porcelain veneers. No follow-up Outcome measures not clearly defined Accident Compensation Corporation 102 Evidence Based Brief Report .Optimum life-time management of coronal fractures in anterior teeth 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. 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 Reason for exclusion The adverse effect being reported had signs of being present prior to bleach treatment Analysis is flawed. Direct versus indirect veneer restorations for intrinsic dental stains. Oral Surgery Oral Medicine Oral Pathology Oral Radiology and Endodontics 1991.a Case-Report. A clinical evaluation of the marginal adaptation of porcelain laminate veneers.175:317-21. Compendium of Continuing Education in Dentistry.25(6):493-7. Journal of Oral Rehabilitation.26(4):345-53. Reported ‘n’ of those followed up is incorrect. 213-4. Follow-up period less than 4 years A commentary. International Journal of Paediatric Dentistry 1991.19(6):625-8. Journal of Dentistry 1998. Inadequate reporting of methods.24(7):506-511. Recognition of veneer restorations by dentists and beautician students. Quintessence International 1999. Patients' satisfaction with different types of veneer restorations. and outcome data.30(3):155-61.24(8):553-9.5 years. Bleaching teeth treated endodontically: Long-term evaluation of a case series. 1998. A 15-year review of porcelain veneer failure--a clinician's observations. UK 2004. A retrospective evaluation over a period of 6. A longitudinal study of the clinical performance of porcelain veneers. Meta-analysis of anterior veneer restorations in clinical studies. Ltd Chichester. External Root Resorption after Bleaching . 1997.

Optimum life-time management of coronal fractures in anterior teeth 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. Clinical evaluation of root filled teeth restored with or without post-and-core systems in a specialist practice setting.19(8):810-813. Effectiveness. Outside scope of EBH Question. a study of root-filled teeth. Effect of nonvital bleaching with 10% carbamide peroxide on sealing ability of resin composite restorations.40(3):209-15. Reattachment of the original fragment after vertical crown.18(1):34-9. International Journal of Prosthodontics 2005. Journal of the American Dental Association 1994. Compendium 1998. Creugars et al 2005 Creugars et al 2005 Martens et al 1988 Accident Compensation Corporation 103 Evidence Based Brief Report . A 5-year prospective clinical study on core restorations without covering crowns. nonvital discoloured tooth. Oral Surgery. An expanded abstract. Managing discoloured non-vital teeth: the inside/outside bleaching technique. a study of root-filled teeth. 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. International Journal of Prosthodontics 2005. side effects and long-term status of nightguard vital bleaching.31(4):204-10.63:610-3. Not fractured teeth. The Journal of Pedodontics 1988. about methodology/technique An in vitro study Composite Resin Studies Redman et al 2003 Salvi et al 2007 Reason for exclusion The survival and clinical performance of resin-based composite restorations used to treat localised anterior tooth wear. Journal of the American Dental Association 1999. Oral Medicine. Nightguard bleaching to lighten a restored. No follow-up described. British Dental Journal 2003. International Endodontic Journal 2007. Oral Pathology 1987.13(3):119-25.130(10):1485-90. a study of root-filled teeth. Not fractured teeth. Not fractured teeth Outside scope of EBH Question. Assessing dentin color changes from nightguard vital bleaching.13:53-62.37(1):52-60. Dental Update 2004. International Endodontic Journal 2004. 5-year follow-up of a prospective clinical study on various types of core restorations. Not fractured teeth. Outside scope of EBH Question.125(9):1219-26.194:566-572. A 6-year recall study of clinically chemically bleached teeth. Endodontics & Dental Traumatology 1997.18(1):40-1.

patient age and operator on the longevity of an anterior composite resin.A multi-layer approach. type of restoration. Journal of Periodontology 1998. Journal of the American Dental Association. Quintessence International 2003. Replacement of a fractured incisor fragment over pulpal exposure: a long-term case report. Quintessence International 2003.a case report.23(3):177-80. 1989. Direct pulp capping with a dentin adhesive resin system in children's permanent teeth after traumatic injuries: case reports. The influence of direct composite additions for the correction of tooth form and/or position on periodontal health.97(4):61-64.34(2):99-107.Optimum life-time management of coronal fractures in anterior teeth Smales 1991 Peumans et al 1998 Ehrmann 1989 Effects of enamel-bonding.27:829-32. Dental Traumatology 2007. Shah P. Am J Dent 4(3):130-3 1991. Partial pulpotomy and tooth reconstruction of a crown-fractured permanent incisor: A case report. Quintessence International 1996. Quintessence International 2000. 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 Accident Compensation Corporation 104 Evidence Based Brief Report . Tooth fragment reattachment: Fundamentals of the technique and two case reports.34(10):740-747. Tooth fragment reattachment after retrieval from the lower lip . direct restoration of a discoloured single anterior tooth .4(3):130-3. A retrospective study.118(2):183-5. Restoration of a fractured incisor with exposed pulp using original tooth fragment: report of case.21:261-70. 1. Tooth fracture reattachment: case reports.69(4):422-7.31(4):241-8. Quintessence International 1990. Oral Health 2007.

Optimum life-time management of coronal fractures in anterior teeth Accident Compensation Corporation 105 Evidence Based Brief Report .