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The International Journal of Oral & Maxillofacial Implants 71
In Patients Requiring Single-Tooth Replacement,
What Are the Outcomes of Implant- as Compared to
Tooth-Supported Restorations?
Thomas J. Salinas, DDS
1
/Steven E. Eckert, DDS, MS
2
Purpose: The study provides a systematic review of the literature to determine the long-term survival
characteristics of single implant-supported crowns and fixed partial dentures. Materials and Methods:
A search of the MEDLINE, EMBASE, and Cochrane Collaboration databases was conducted to identify
articles that compared survival and success of fixed partial dentures and single implant-supported
crowns. In addition to comparative cohort studies, articles that pertained specifically to single implant-
supported crowns or fixed partial dentures were included in this review. Inclusion criteria for implant
and fixed partial denture articles included a minimum 2-year study, primary publication in the English
language, a minimum of 12 implants, implants designed to osseointegrate, and inclusion of data
regarding implant and prosthetic performance. Data were analyzed using cumulative proportions of
survival and success for both prosthetic types and for individual implants. Wilson score method was
used to establish 95% confidence intervals for each population. The chi-square test for homogeneity
was performed. Results: The literature search failed to identify any articles that directly compared sur-
vival or success of single implant-supported restorations with fixed partial dentures. Following the
search criteria, and independent analysis by reviewers, 51 articles were identified in the implant litera-
ture (agreement, 95.42%; kappa coefficient, 0.8976), and 41 were identified in the fixed partial den-
ture literature (agreement, 90.97%; kappa coefficient, 0.7524). Pooled success of single-implant
restorations at 60 months was 95.1% (CI: 92.2%–98.0%), while fixed partial dentures of all designs
exhibited an 84.0% success rate (CI: 79.1%–88.9%). Conclusions: This systematic review of the scien-
tific literature failed to demonstrate any direct comparative studies assessing clinical performance of
single implant-supported crowns and tooth-supported fixed partial dentures. The analysis suggested
differences at 60 months between survival of implant-supported single crowns and natural tooth-sup-
ported fixed prostheses when resin-bonded and conventionally retained fixed prostheses were
grouped. This difference disappeared when implant-supported single crowns were compared with con-
ventionally retained fixed partial dentures at 60 months. For other time periods, direct comparative
data were unavailable. I
NT
J O
RAL
M
AXILLOFAC
I
MPLANTS
2007;22(
SUPPL
):71–95.
Key words: etched bonded dentures, fixed partial dentures, implant-supported restorations, implant-
supported single crowns, implant-supported single-tooth restorations, resin-bonded fixed partial
denture, success, survival
P
atients with missing teeth face the prospect of tooth
replacement either through the use of removable
prostheses, fixed natural tooth–supported prostheses,
or implant-supported prostheses. Each of these
prosthetic designs has inherent risks and benefits.
Although it is possible to replace single teeth using
a removable partial denture, these restorations are
generally considered provisional in nature rather than
definitive. For this reason, removable partial dentures
were not considered in this review. In distinction, fixed
natural tooth–supported prostheses (FPDs) and
implant-supported single crowns (ISCs) may be more
applicable to the restoration of the single missing
tooth. When considering either of these treatment
options, the clinician must weigh the risks and benefits
of either approach. Careful scrutiny of the scientific lit-
1
Associate Professor, Mayo Clinic, Department of Dental Special-
ties, Rochester, Minnesota; Former Assistant Professor, Depart-
ment of Otolaryngology, The University of Nebraska Medical Cen-
ter, Omaha, Nebraska.
2
Associate Professor, Mayo Clinic, Department of Dental Special-
ties, Rochester, Minnesota.
Correspondence to: Dr Thomas J. Salinas, Mayo Clinic, Depart-
ment of Dental Specialties W4, 200 First Street SW, Rochester,
MN 55905.
SECTION 3
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72 Volume 22, Supplement, 2007
Salinas/Eckert
erature may assist the clinician in determining the
treatment when a single-tooth replacement is needed.
Previous systematic reviews of implant-supported
single restorations demonstrated that failure of
osseointegrated implants occurred relatively early in
the period of follow-up.
1,2
The prosthetic complica-
tions of ISCs, however, seemed to be infrequent and
easily correctable in comparison with other types of
implant-supported or retained restorations such as
overdentures or fixed partial dentures.
3
Previous systematic reviews of fixed tooth-sup-
ported partial dentures demonstrated both biologic
and structural complications occurring relatively
long after initial prosthesis insertion.
4–6
In meta-
analyses of resin-bonded FPD (RBFPD) studies, it is
apparent that these restorations have therapeutic
advantages in the short term.
7
It was of interest to
the authors and the sponsorship by the Academy of
Osseointegration to include a representative popula-
tion of RBFPDs and fixed partial dentures and
restorations for survey of survival characteristics.
The purpose of this study was to conduct a system-
atic review of the scientific literature to assess the suc-
cess and/or survival of ISCs in comparison to FPDs.
MATERIALS AND METHODS
The dental literature was searched from 1966 to
August 2004 using MEDLINE, Cochrane Collabora-
tion, and EMBASE to determine a list of scientific arti-
cles pertaining to clinical use of dental implants and
FPDs in humans. The 2 individuals also reviewed a
master list of implant articles supplied by an advisory
group of the Academy of Osseointegration to deter-
mine article applicability to the primary question
using the established inclusion criteria. Each reviewer
searched the references independently. When dis-
agreement was found, the articles were discussed
until agreement was reached. Calculations were
made to determine percentage of reviewer agree-
ment and the kappa coefficient. References from the
identified articles were hand searched.
Inclusion Criteria
The master lists were sorted to determine the pres-
ence of articles pertinent to single implant-sup-
ported restorations, FPDs, and RBFPDs.The list of arti-
cles that related to single implant-supported
restorations was then reviewed through comprehen-
sive assessment of each original article.
Implant-supported Restorations. Articles were
included in the data extraction section of the sys-
tematic review if they demonstrated at least 2 years
of clinical survival, included a minimum of 12 restora-
tions, had been first published in the English lan-
guage, and presented data that could be extracted.
Anticipation of attrition rates of 20% or more
8
resulted the decision to include studies with a mini-
mum of 12 FPDs or single implants with restorations
for review. Only studies that clearly differentiated
ISCs from other prosthetic designs were included.
Only clinical studies of adult subjects could be
included. Animal studies, in vitro studies, technique
articles, and case reports were all excluded from this
review.
FPDs. Articles were included in the data extraction
section of the systematic review if they demon-
strated at least 2 years of clinical survival, included a
minimum of 12 restorations, had been first published
in the English language, and presented data that
could be extracted.
Data Extraction
Data were extracted from the references relative to
implant survival, prosthesis survival, and method of
failure as it applied to ISCs. Similarly, data were
extracted from references relative to tooth survival,
prosthesis survival, and mode of failure as applied to
FPDs. Data were extracted relative to time; when
time-dependent data were unavailable, articles were
rejected from the review.
Data extraction tables were created to determine
time of implant placement, time of prosthesis service,
implant survival rate relative to time, and prosthetic
complications relative to time. Surgical success (a
term that can be used interchangably with “survival”
here) as well as prosthetic complications from each
study were recorded. Data were extracted for all time
periods in the original article. Data extraction from
fixed prosthodontic literature was performed to
determine prosthesis success and survival and pros-
thesis complications relative to time of service.
The data were analyzed by Howard Proskin and
associates and are described in an article elsewhere
in this issue. The data are depicted in forest plots
with associated 95% confidence intervals. Data were
surveyed by dichotomization to either the ISC or the
FPD group. The level of influence by factoring RBFPDs
out of this data set was also examined.
Statistical Methods
All studies that reported cumulative proportional
implant survival, implant success, or prosthetic suc-
cess for at least 1 examination and at least 1 treat-
ment were included in the analysis. The cumulative
proportions were assumed to describe all implants in
the treatment group. The last reported implant sur-
vival, implant success, and/or prosthetic success for
each treatment from each article were used to derive
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The International Journal of Oral & Maxillofacial Implants 73
Salinas/Eckert
overall estimates of implant survival, implant success,
and prosthetic success, respectively. In addition to
finding overall estimates for each proportion, the
meta-analysis was performed for different time-
points. A pooled estimate of implant survival, implant
success, and prosthetic success was derived for each
timepoint as well as for the last examination.
Point estimates of implant survival, implant/tooth
success, and prosthetic success from each article are
depicted graphically in forest plots for each timepoint
and overall. The Wilson score method was used to
derive a 95% confidence interval for each proportion.
9,10
A random-effects model was necessary for calcu-
lating the pooled estimates when there was hetero-
geneity between studies. According to the chi-square
test for homogeneity, there was significant hetero-
geneity between studies in almost all cases.
11
A ran-
dom-effects model was used even if homogeneity
was not rejected at the 0.05 level, because there
seemed to be heterogeneity between the studies.
There were a few cases where a treatment group only
included a single study or where all studies in a treat-
ment group had 100% implant survival, implant suc-
cess, or prosthetic success; in these cases, a fixed-
effects model was used to derive the pooled estimate.
The random-effects model was used in all other cases.
The method of generalized estimating equations
was the use of the random-effects model to combine
rates from individual studies.
12
This method
accounted for the between-study variability. Pooled
Wilson score confidence intervals (CIs) were used in
the fixed-effects model. Estimates were computed
using R. 2.2.1 (R Foundation for Statistical Comput-
ing,Vienna, Austria).
RESULTS
A preliminary review of the scientific literature iden-
tified 1,766 articles that were included into a data-
base. No direct comparative studies assessing the
success or survival of ISCs and FPDs were identified
through this literature review. Consequently, the
original plan to perform a systematic review of 2
approaches to therapy was abandoned. Instead, the 2
treatment approaches were evaluated relative to
prognosis. Few studies were identified with overlap-
ping time periods for either FPDs or ISCs. Because
there were no direct comparative studies, most
results provided in this review are descriptive in
nature.
ISC Literature
A secondary search of the literature was combined
with the master list; this produced 174 full-text arti-
cles related to single-implant restorations for which
abstracts were reviewed according to inclusion/
exclusion criteria.
1–3,13–183
A total of 13 of these stud-
ies were excluded by both reviewers. An additional 8
studies were not agreed upon by the reviewers. Con-
sequently, these articles were discussed and ulti-
mately, 7 of the articles were excluded through this
arbitration process (agreement, 95.95%; kappa coeffi-
cient, 0.7666). The second stage of manuscript review
was initiated on the group of 153 articles. After this
screening, 98 articles were agreeably eliminated by
both authors based on inclusion criteria. An addi-
tional 7 articles were in dispute. Discussion and arbi-
tration of these articles allowed inclusion of 3 (agree-
ment, 95.42%; simple kappa coefficient, 0.8976). This
created a total of 51 articles.
*
After hand searching,
an additional 3 articles were included (Figs 1 to
3).
184–186
No articles were added after the cutoff date
of May 31, 2005 (see the ISC Inclusion List available in
the Web edition of this article).
FPD Literature
The fixed prosthodontic literature yielded an initial
list of 265 article abstracts.
1,4–7,44,45,117,132,164,187–447
Five meta-analyses were also found.
1,4–7
A stage I review was conducted and disclosed
mutual acceptance of 156 manuscripts by each
author. One hundred six manuscripts were agreeably
negated by the 2 reviewers, and 3 additional articles
were in dispute. These articles were discussed, result-
ing in the addition of 1 additional article for further
review (agreement, 98.87%; kappa coefficient, 0.9765).
A total of 155 full-text articles were agreed upon. At
Stage II, 30 manuscripts were mutually accepted, 111
174
153
51
3
54
Stage I
Stage II
Hand
searching
Fig 1 Application of inclusion/exclusion criteria to the literature
on single-implant restorations.
* References: 16, 18–23, 25, 26, 30, 42, 52, 55, 57, 65, 70, 71,
74,76, 78, 80, 84, 86–89, 92, 96, 104, 106, 109, 115, 116,
127, 131, 133, 134, 136, 138, 144–146, 150–153, 171, 172,
174, 175, 176
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74 Volume 22, Supplement, 2007
Salinas/Eckert
were mutually rejected, and 14 articles were in dispute.
After discussion, it was agreed to accept 10 of the dis-
puted articles and reject the remainder (agreement,
90.97%; kappa coefficient, 0.7524). Hand searching
provided an additional article, resulting in 41 articles
for data extraction (Figs 3 to 5; see the ISC Inclusion
List available in the Web edition of this article).
**
Characteristics of ISCs
Although many authors described successful treat-
ment, success criteria were rarely identified in arti-
cles. Consequently, results will be described relative
to survival only. ISC articles were surveyed for sur-
vival information. Generally both surgical survival
and prosthetic survival were described. Most fre-
quently implant survival was described in terms of
cumulative survival (Fig 6). Several studies
26,30,70,152
enrolled relatively large numbers of subjects (252 to
282); the survival proportions for these studies were
proportional to those observed in most other stud-
ies.The implants placed in these 4 studies (n = 1,064)
composed 36% of the entire implant population in
this systematic review.
Early reports demonstrated higher numbers of
prosthetic complications, including screw loosening
and fracture. With the development of implants con-
taining internal connections and other strategies for
the partially dentate patient, abutment screw loosen-
ing and fractures were observed less frequently in
more current literature. Implant prosthetic success was
termed as the outcome of the implant prosthesis,
assuming the implant remained integrated, while com-
plications were described if a complication required
intervention but not prosthesis refabrication. Figure 7
illustrates this level of prosthetic success at 60 months.
Immediate loading with a provisional restoration
was assessed in 2 studies with favorable results,
although the study numbers were low and the fol-
low-up period short.
** References: 191, 198, 200, 204, 209, 213, 231, 235, 237,
238, 247, 250, 260, 274, 278, 289, 293, 296, 299, 312, 318,
340, 343, 355, 366, 368, 375, 377, 378, 380, 382, 386, 390,
394, 397, 407, 416, 423, 429, 434, 446
Unknown Fair Average Good Better Best
Small
Medium
Large
Very large
12
10
8
6
4
2
0
No. of studies
Quality
1971–
1975
1981–
1985
1991–
1995
2001–
2005
FPD articles
Implant articles
25
20
15
10
5
0
No. of studies
1986–
1990
1996–
2000
1976–
1980
265
155
40
1
41
Stage I
Stage II
Hand
searching
Fig 4 Application of inclusion/exclusion criteria to the literature
on FPDs.
Fig 3 Article distribution by year.
Fig 2 Size and quality of
implant studies.
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The International Journal of Oral & Maxillofacial Implants 75
Salinas/Eckert
Unknown Fair Average Good Better Best
Small
Medium
Large
Very large
12
10
8
6
4
2
0
No. of studies
Fig 5 Size and quality of FPD
studies.
ISC survival rate at 60 months
References n Quality
Groisman (2001) 271 Fair
Scholander (1999) 259
Schwartz-Arad (1999) 78
Becker (1999) 282 Average
Bianco (2000) 252
Gibbard (2002) 30
Haas (2002) 76
Henry (1996) 107
Davis (2004) 23
Palmer (2000) 15
Scheller (1998) 12
Scheller (1998) 87
Andersson (1998) 65
Romeo (2002) 187
Romeo (2004) 123
Andersson (1998) 19 Better
Andersson (1998) 19
Andersson (1998) 19
Andersson (1998) 19
Gotfredsen (2004) 10
Gotfredsen (2004) 10
Pooled estimate
Implant
0.4 0.5 0.6 0.7 0.8 0.9 1.0
Survival rate
Fig 6 ISC survival rate at 60 months.
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76 Volume 22, Supplement, 2007
Salinas/Eckert
References n Quality
Groisman (2001) 271 Fair
Scholander (1999) 259
Gibbard (2002) 30 Average
Haas (2002) 76
Henry (1996) 107
Davis (2004) 23
Palmer (2000) 15
Scheller (1998) 12
Scheller (1998) 87
Romeo (2002) 187
Andersson (1998) 19 Better
Andersson (1998) 19
Andersson (1998) 19
Andersson (1998) 19
Gotfredsen (2004) 10
Pooled estimate
De Kanter (1998) 100 Unknown
De Kanter (1998) 100
Hochman (2003) 49 Fair
Valderhaug (1991) 108
Leempoel (1995) 1,674
Probster (1997) 325
Ketabi (2004) 74
Berekally (1993) 228
Aquilino (2001) 65
Shugars (1998) 23
Shugars (1998) 42
Samama (1996) 145
Zalkind (2003) 51
Raustia (1998) 82
Glantz (2002) 150 Average
Walton (2003) 515
Behr (1998) 120
Napankangas (2002) 204
Creugers (1990) 203
Besimo (1997) 130
Serdar-Cotert (1997) 60 Good
Walter (1999) 25 Better
Walter (1999) 22
Corrente (2000) 61
Pooled estimate
ImplantFPD
0.4 0.5 0.6 0.7 0.8 0.9 1.0
Prosthetic success rate
Fig 7 ISC prosthetic success rate at 60
months.
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Seven ISC studies were classified as high-quality
prospective studies. The studies so classified were
those that were identified as RCTs,
88
made an effort
to describe esthetic differences by 1- or 2-stage sur-
gical approaches,
186
compared immediate loading of
implants to delayed loading,
134
used a parallel arm
design using different types of materials for abut-
ment connection,
20,173
or prospectively analyzed par-
allel groups of trained clinicians.
18
Several of these
studies had either a large group of subjects and/or
long follow-up periods with minimal attrition.
Most of the studies appeared to have a low level of
prosthetic complication, with the exception of 5 stud-
ies.
22,23,25,74,80
The increased prosthetic complication
rate was perhaps related to early component designs
that were originally developed for the management of
edentulous patients. A total of 2,963 single-tooth
restorations were examined in the 54 studies identified.
Characteristics of FPDs
The prosthetic success rate of FPDs is shown in Fig 7
for comparison with the ISC group. A nongrouped
comparison results in some difference, which is prob-
ably attributed to the variability of the RBFPDs (Fig 8).
Many studies cited disease markers such as caries,
periodontal disease, endodontic pathology, or struc-
tural failures but did not relate these to specific time-
points demonstrating prosthetic survival relative to
time. Several of the conventional FPD studies
described partial veneer retainers
382
or cantilever
designs
23,289,312,355,407
; the FPDs in these studies
equated to less than 30% of the total number of FPDs.
Failures were attributable to mostly biologic para-
meters, such as caries,
274,278,318,377,307
periodontal dis-
ease,
231,250
or endodontic pathology.
231
Structural
complications were related to retention
289,416
or
abutment fracture.
434
The International Journal of Oral & Maxillofacial Implants 77
Salinas/Eckert
ISC prosthetic success rate at 60 months
References n Quality
Hochman (2003) 49 Fair
Valderhaug (1991) 108
Leempoel (1995) 1,674
Aquilino (2001) 65
Shugars (1998) 23
Shugars (1998) 42
Raustia (1998) 82
Glantz (2002) 150 Average
Walton (2003) 515
Napankangas (2002) 204
Walter (1999) 25 Better
Walter (1999) 22
Pooled estimate
De Kanter (1998) 100 Unknown
De Kanter (1998) 100
Probster (1997) 325 Fair
Ketabi (2004) 74
Berekally (1993) 228
Samama (1996) 145
Zalkind (2003) 51
Behr (1998) 120 Average
Creugers (1990) 203
Besimo (1997) 130
Serdar-Cotert (1997) 60 Good
Corrente (2000) 61 Better
Pooled estimate
FPDRB FPD
Fig 8 Implant/tooth prosthetic success rate
at 60 months for conventional FPDs and RBF-
PDs. Note: implant success rate same as Fig 7.
0.4 0.5 0.6 0.7 0.8 0.9 1.0
Prosthetic success rate
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Caries seemed to be the most prevalent complica-
tion in most studies, but some authors
289
remarked
that loss of retention is usually the primary initiating
factor, whereas caries becomes a secondary conse-
quence. Others maintained that retention and caries
are seen prevalently at 2 different timepoints and are
unrelated.
416
Data extraction from studies on RBFPDs demon-
strated a greater degree of variability of long-term
success. Many of the parameters for improving out-
comes cited differences in preparation design, alloy
selection, surface treatment of alloy, framework
design, and pontic number. In contrast to the biologic
failures encountered with conventional FPDs, RBFPDs
demonstrated failure secondary to structural compli-
cations. Some authors maintained that preparation of
the abutment teeth made a significant difference in
long-term survival.
197,200,203,375
Other studies did not
corroborate this suggestion.
368
Alloy treatment with
etching alone versus silicoating was found to
enhance retention in some studies and make a signif-
icant difference in long-term survival.
299,368
Other
studies showed that this factor is not a consideration
in long-term survival.
375
Base metal alloys seem to
enjoy a resistance to debonding in comparison to
palladium alloys. Most of the studies indicated that
debonding at the resin-metal interface is the weak
link and that stresses leading to debonding are trans-
ferred to this interface. Despite suggestions for all of
these preparation variables, contemporary materials,
and surface treatments, the long-term predictability
remains highly variable. Survival data at the 60-
month timepoint were demonstrated in studies by
Berekally and associates,
203
Probster and Henrich,
368
and Creugers and colleagues.
237
Six studies were rated as better studies because of
their prospective design.
235,237,238,377,390,429
Single implant-supported restorations demon-
strated apparent high surgical success rates and high
prosthetic success rates. Surgical failures appear to
occur early. Prosthetic complications also appear to
occur early and gradually taper off over time. Prosthetic
success at 60 months was 95.1% (CI: 92.2%–98.0%).The
60-month timepoint was chosen to survey the greatest
number of studies that documented follow up at this
specific time.
78 Volume 22, Supplement, 2007
Salinas/Eckert
ISC prosthetic success rate at 120 months
References n Quality
Karlsson (1989) 164 Unknown
Hochman (2003) 49 Fair
Valderhaug (1991) 108
Leempoel (1995)
Holm (2003) 94
Aquilino (2001) 65
Shugars (1998) 23
Average
Walton (2003) 515
Napankangas (2002) 204
Pooled estimate
Probster (1997) 325 Fair
Ketabi (2004) 74
Samama (1996) 145
Zalkind (2003) 51
Behr (1998) 120 Average
Corrente (2000) 61 Better
Barrack (1993) 127
Pooled estimate
FPDRB FPD
0.4 0.5 0.6 0.7 0.8 0.9 1.0
Prosthetic success rate
Fig 9 ISC prosthetic success rate at 120
months.
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FPD success was analyzed in 2 different ways. The
first method combined conventional FPDs with
RBFPDs. For this population, prosthetic success was
examined at 60 months (84.0%; CI: 79.1%–88.9%; Fig
7), 120 months (81.3%; CI: 75.9%–86.7%; Fig 9), and
180 months (67.3%; CI: 50.1%–84.5%). The second
method of analysis was to look only at FPDs retained
conventionally. Prosthetic success was 94.0% (CI:
90.7%–97.3%) at 60 months (Fig 8), 87.0% (CI:
82.8%–91.2%) at 120 months, and 67.3% (CI:
50.1%–84.5%) at 180 months.
Several trends are noted within the population of
each group (Table 1). For example, implant-sup-
ported prostheses were at higher risk soon after
implant placement. The ongoing risk of implant fail-
ure was relatively low, but confidence intervals
widened as long-term study enrollment diminished.
Also, FPD studies did not evaluate clinical perfor-
mance at early stages. FPD studies were longer-term
studies, and confidence intervals were quite wide
because of patients/prostheses that were lost to fol-
low-up or low long-term study populations. Also,
more studies of implant-supported prostheses than
FPD studies were found in the “better” and “best”
groups. Finally, FPD studies tended to be smaller
studies of lower quality.
DISCUSSION
The State of the Science of Implant Dentistry was
originally conceived as a systematic review of the sci-
entific literature as it relates to implant and natural
tooth-supported restorations. This systematic review
addressed the PICO question, “In patients requiring
single-tooth replacement, what are the outcomes of
implant- as compared to tooth-supported restora-
tions?” No direct comparative studies were identified
through this review. However, during the data gath-
ering phase of this review, it was clear that a large
volume of scientific literature is available on the sub-
ject of survival of ISCs and FPDs. This information
served to provide the bulk of this review. Efforts were
made to be as inclusive as possible when selecting
articles. This resulted in a large number of articles for
both comparison groups.
During the course of data extraction and analysis
it became quite clear that direct comparisons of
these 2 treatment groups would be difficult. The pri-
mary reasons for this were related to the large num-
ber of different treatment interventions and the myr-
iad of reporting methods used by authors. In
addition, the treatment periods were quite different
between tooth- and implant-supported restorations.
After comprehensive data extraction was performed,
it was clear that the primary outcome for assessment
was simply survival of the restoration, retaining
teeth, or implants. The exact mode of failure was
rarely determined through assessment of the avail-
able literature. Furthermore, direct comparison
between specific time periods was generally not pos-
sible. In general, implant studies reported earlier
data, while tooth-supported studies demonstrated
more long-term data. The exception to this occurred
with the etched and bonded tooth-supported
restorations; these reports were generally shorter in
duration than the other fixed prosthodontic reports.
In preparing this systematic review, the reviewers
were faced with a number of dilemmas. The variety of
procedures performed in fixed prosthodontics on nat-
ural teeth is quite broad. Although it was tempting to
separate data from etched and bonded restorations
from the data pertaining to more conventional fixed
prosthodontic therapy, doing so would have negated
treatment that had been originally described as defin-
itive care. In retrospect, that definitive care may not
have been as long-lasting as anticipated when the
procedures were planned. Of course, there is recogni-
tion that any study could lead the investigators in
positive or negative directions; it is this uncertainty
that is the reason for the investigation. Accepting this,
the reviewers have provided data regarding all fixed
prostheses of all designs and have also separated the
data from the etched and bonded restorations from
more conventionally retained restorations.
In the implant literature there are a number of dif-
ferent implant designs, manufacturers, prosthetic
designs, and general treatment approaches that
have been used. Once again, it was difficult to estab-
lish a subcategory for each treatment method. Con-
sequently, the data from implant-supported prosthe-
ses were analyzed primarily as related to implant
survival and subsequent prosthetic survival.
The International Journal of Oral & Maxillofacial Implants 79
Salinas/Eckert
Table 1 Pooled Data at 60, 120, and 180 Months
Population/timepoint Pooled success (%) CI (%)
Implant-supported restorations
60 mo 95.1 92.2–98.0
120 mo — —
180 mo — —
Tooth-supported FPDs
60 mo 94.0 90.7–97.3
120 mo 87.0 82.8–91.2
180 mo 67.3 50.1–84.5
RBFPDs
60 mo 74.7 66.6–82.8
120 mo 74.2 65.3–83.1
180 mo — —
Salinas.qxd 2/14/07 3:13 PM Page 79
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In both literature sets there was a distinct lack of
consistent data reporting based upon specific time
periods. Many articles described the survival only at
the end of a study period, while other articles pro-
vided life table data from annual patient reassess-
ments. When considering studies that have not pro-
vided time-dependent data, it is often difficult to
determine the actual length of service for any spe-
cific prosthesis. For example, an article that describes
10-year results of a certain treatment method may
actually be reporting results of prostheses in place
for a period ranging from days to 10 years. Many of
these studies failed to report the mean time of ser-
vice; it was left up to the reader/reviewer to interpret
this time of service.
Direct comparison of the implant- and tooth-sup-
ported prosthetic results, given the lack of compara-
tive time periods, was virtually impossible. Despite
the large volume of literature that exists on both top-
ics, the direct comparison of treatment outcomes for
specific time periods was not realistic. To address the
situation it was necessary to either provide descrip-
tive results or attempt to consider the slope of sur-
vival graphs, looking at survival relative to time. But
even this was not possible, given the fact that many
of the studies lacked annualized data. The situation
was further complicated by studies that provided
only cross-sectional data, as inclusion of these stud-
ies into a larger database could not be done with
confidence.
Understanding all the aforementioned caveats, the
reviewers have attempted to provide their impres-
sions of the survival relative to time. Two distinct
impressions are drawn from this information. Survival
within implant-supported prostheses demonstrates a
rapid, although small, early decline followed by long-
term stability. Once the early failure period (generally
the result of failure of the implant to achieve integra-
tion with bone) has passed, the prostheses appear to
demonstrate a predictable long-term service. The
overall early failure rate is generally less than 5% dur-
ing the first year of service. Over the next 5 to 10
years,the failure rate diminishes.
In contrast, fixed prostheses supported by natural
teeth appear to have very low early failure rates. The
exception to this occurs with etched and bonded
restorations, where some reports demonstrate sur-
prisingly high early failure rates in comparison to
conventionally retained FPDs. Long-term survival of
fixed prostheses supported by natural teeth appears
to be lower than the projected long-term survival of
prostheses supported by dental implants. However,
this statement is the result of extrapolation rather
than an observance of long-term survival curves,
since those studies do not exist for ISCs.
Most of the published scientific literature concen-
trated on simple survival of dental implants and sim-
ple survival of FPDs. However, other criteria for
implant success exist which are not routinely applied.
The reason for this could be reluctance on the part of
the authors to claim “success,” inability on the part of
the authors to assess success, or realization that the
success criteria are too stringent for the implants used
in the authors’ studies. Regardless of the reason, most
implant studies continue to discuss survival alone but
have cloaked this discussion under the terms of suc-
cess. In addition, few studies have described compli-
cations associated with implant therapy. Clinicians
certainly recognize that a number of complications
can occur with implant-supported prostheses.
Implant failure or fracture, screw loosening or fracture,
material wear or fracture, and failure of luting agents
are the most commonly described complications. It is
also recognized that implant malposition, soft tissue
recession, bone loss, and unfavorable soft tissue con-
figuration, texture, or color are complications that
must be reported. Since these factors have not been
consistently reported, it is the recommendation of the
authors of this systematic review that it become stan-
dard procedure to record and report these elements
in future scientific publications.
Returning to the initial premise of the State of the
Science of Implant Dentistry workshop, it seems
appropriate to state that definitive answers cannot
be drawn from this systematic review of the litera-
ture. Generalized impressions of the data provide the
reviewers with a perception of the outcome from the
2 different treatment arms, but this impression is
the result of data interpretation rather than simple
data analysis.
Accepting the notion that the scientific data are
not available to answer the question posed by this
workshop, it may be prudent to consider future
avenues of investigation that could achieve this pur-
pose. Certainly it would be almost impossible to cre-
ate a single scientific study that would definitively
address the question of the superiority of either
implants or natural teeth as a means to support pros-
theses. Instead, it may be more prudent to realize
that a series of investigations could be used to
address this question. In that event, clinicians would
benefit from consistent reporting of observed out-
comes. The routine use of life tables with outcomes
reported on an annual basis would make the task of
data compilation much easier. In this situation, an
individual could compile data from published
research, thereby creating a low living low-level sys-
tematic review. Likewise, comparison of studies that
use this method of data reporting would be a sim-
pler process. The average clinician could create
80 Volume 22, Supplement, 2007
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spreadsheets that included pertinent references and
data extracted from those references to be used in
clinical practice. This recommendation alone would,
if followed, provide the basis for a future systematic
review that could provide definitive answers to the
questions posed.
It is also important to understand that the infor-
mation that was available in the scientific literature
primarily related to survival of implants, teeth, or
prostheses. There are a number of other complica-
tions that can occur but are not routinely reported.
Material fracture or wear; biologic complications
such as dental caries, gingivitis, or periodontitis;
tooth or implant fracture; loss of retention; and cos-
metic dissatisfaction should all be reported. Should
future reports include this information, the literature
will convey a much better understanding of the fac-
tors that influence treatment outcomes. Likewise, this
information could be shared with patients to estab-
lish a truly informed consent.
Other suggestions to authors and editors are that
future studies should include a minimum of follow-
up time of 1 year for the majority of implants in the
study. When comparative studies are performed, a
sufficient number of subjects must be enrolled in
each study arm to allow meaningful comparisons.
Failure to populate studies with adequate numbers
of subjects in each study arm results in insignificant
differences even when clinical observations differ.
Although statistical methods such as the Kaplan-
Meier survival curves provide the probability of sur-
vival at specific timepoints, these methods of analy-
sis do not lend themselves well to data extraction
when systematic reviews are conducted. For this rea-
son, it may be prudent for authors to include life
tables along with Kaplan-Meier curves in future pub-
lications. Including both approaches to data analysis
will facilitate future data extraction. In addition, when
studies are underpopulated, data from the under-
populated study will be readily extracted for inclu-
sion in larger synthesized studies.
Since the results of this systematic review demon-
strated that most implant designs perform within 5%
of each other, comparative studies of different
implants designed to compare survival differences
are unlikely to succeed in this regard, unless there are
hundreds of implants in each study arm. If implant
and prosthetic success are the compared outcomes,
the study populations may not need to be as large.
It is the goal of this report to make suggestions
which will allow future analyses to encompass more
meaningful data at multiple timepoints. Inclusion of
the parameters of absolute failure (ie, the causes for
retreatment) is essential for meaningful data analy-
ses. Likewise, general categories of complications
would be valuable for the clinician. Descriptions of
need for retreatment—prosthetic material failure
(restorative material failure, connector failure, com-
ponent failure), implant failure (loss of integration or
fracture), esthetic failure (eg, shade, contour, posi-
tion), implant angulation, soft tissue or inadequacy,
or bone loss—need to be categorized appropriately.
Likewise, there can be complications in each of these
areas that do not require retreatment but do require
additional treatment to maintain, repair, or correct a
problem/complication.
It is hoped that future analyses can incorporate
more in-depth data to arrive at multiple timepoint
conclusions and predict the behavior of implant- and
tooth-supported restorations.
CONCLUSION
This systematic review of the scientific literature
failed to demonstrate any direct comparative studies
assessing clinical performance of single ISC and
FPDs. The study suggests differences at 60 months
between survival of ISCs and FPDs when resin-
bonded and conventionally retained fixed prosthe-
ses were grouped. This difference disappeared when
ISCs were compared with conventionally retained
FPDs at 60 months. For other time periods, direct
comparative data were unavailable.
ACKNOWLEDGMENTS
Statistical analyses presented in this review were conducted by
Howard M. Proskin & Associates, Rochester, New York. The
authors would like to thank Ms Jillian Campbell and Ms Annette
Catlin with their assistance in compiling and processing the data
in this study.
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The International Journal of Oral & Maxillofacial Implants 93
Section 3 Members
Reviewer
Thomas J. Salinas, DDS
Department of Dental Specialties
Mayo Clinic
Rocheser, Minnesota
Co-Reviewer
Steven E. Eckert, DDS, MS
Department of Dental Specialties
Mayo Clinic
Rochester, Minnesota
Section Chair
Clark M. Stanford, DDS, PhD
University of Iowa
Dows Institute for Dental Research
Iowa City, Iowa
Section Secretary
Paul A. Fugazzotto, DDS
Milton, Massachusetts
Jay R. Beagle, DDS, MSD
Indianapolis, Indiana
Dayn C. Boitet, DDS
Orange Park, Florida
James H. Doundoulakis, DMD, MS
New York, New York
John D. Jones, DMD
Department of Prosthodontics
University of Texas Health Science
Center
San Antonio,Texas
Fraya I. Karsh, DMD
New York, New York
Scott E. Keith, DDS, MS
San Francisco, California
Patrick Lloyd, DDS, MS
University of Minnesota
School of Dentistry
Minneapolis, Minnesota
Russell D. Nishimura, DDS
Department of Restorative
Dentistry
UCLA School of Dentistry
Los Angeles, California
Section Participants
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Members of Section 3 evaluated the systematic
review on the outcomes of replacing single teeth
with implants as compared with conventional seg-
mental prostheses. The focused PICO question
addressed by the authors, Thomas J. Salinas and
Steven E. Eckert, of the evidence-based systematic
review is: In patients requiring single-tooth replace-
ment, what are the outcomes of implant- as com-
pared to tooth-supported restorations?
An overriding issue that arose in the formation of
this systematic review was that there are no compar-
ative studies of fixed partial dentures (FPDs) and
implant-supported crowns (ISCs). Thus, criteria were
selected to allow enough time following prosthetic
loading (>2 years post-implant placement) with a
sufficient number of samples being followed (>12)
that would allow for attrition. The consensus of the
section was that the inclusion/exclusion criteria were
appropriate. These were: (1) >2-year follow-up; (2)
>12 restorations; (3) English language; (4) a “pure” sin-
gle-tooth replacement study in humans (ie, a study
that clearly identified single-tooth restorations rela-
tive to other restorations and involved a bounded
edentulous space; and (5) data presented with suc-
cess or survival.
1. Does the section agree that the systematic
review is complete and accurate?
The section agreed that the review was complete
under the parameters of the inclusion and exclusion
criteria. It is important to recognize a limitation of
this review was that the outcomes were assessing a
time-oriented process to retreatment. Ultimately this
is a prosthetic question. Therefore, need for retreat-
ment equals failure. The primary outcome evaluated
was implant retention or fixed partial denture sur-
vival. In most instances the study did not define suc-
cess criteria even though “success” was reported. The
lack of consistency forces this process to accept the
criteria used by the respective author (and the edito-
rial process).
There were attempts made to address the sec-
ondary outcomes such as bone loss, caries, etc. But
the section found only a few studies systematically
reported on these key features, so it was necessary to
revert to the simple criteria of success or survival.
2. Has any new information been generated or
discovered since the review cut-off date?
An online search was performed during the session
in addition to the preconference updated search.
Five articles were identified and printed; each was
assigned to paired section members who provided
an assessment for inclusion. If found to meet the
inclusion criteria, data extraction would be per-
formed. Focus was on the potential impact and pos-
sible modification to the conclusions of the review
article. The section found there were new published
studies since May 2005 but none of the cited studies
were of significant size or outcomes that would influ-
ence the conclusions of the review. These studies
were:
• Romeo E. Lops D, Amorfini L, Chiapasco M, Ghisolfi
M, Vogel G. Clinical and radiographic evaluation of
small-diameter (3.3-mm) implants followed for
1–7 years: A longitudinal study. Clin Oral Implants
Res 2006;17:139–148.The section could not distin-
guish between single-tooth versus implant FPDs
in this study. There was also a dilemma that sur-
vival was cited as being less than success. There-
fore, the section decided to exclude this study.
• Elkhoury JS, McGlumphy EA, Tatakis DN, Beck FM.
Clinical parameters associated with success and
failure of single-tooth titanium plasma-sprayed
cylindric implants under stricter criteria: A 5-year
retrospective study. Int J Oral Maxillofac Implants
2005;20:687–694. The section found that this
study was not based on original research but was
a retrospective survey of a larger prospective
study. Therefore, the section decided to exclude
this study.
• Lindeboom JA, Frenken JW, Dubois L, Frank M,
Abbink I, Kroon FH. Immediate loading versus
immediate provisionalization of maxillary single-
tooth replacement: A prospective randomized
study with BioComp implants. J Oral Maxillofac
Surg 2006;64:936–942. The section found that this
study was only from 6 months to 1 year follow-up.
Therefore, the section decided to exclude this
study.
94 Volume 22, Supplement, 2007
SECTION 3
CONSENSUS REPORT
In patients requiring single-tooth replacement, what are the outcomes of
implants as compared to tooth-supported restorations?
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• Wennstrom JL, Ekestubbe A, Grondahl K, Karlsson
S, Lindhe J. Implant-supported single-tooth
restorations: A 5-year prospective study. J Clin
Periodontol 2005;32:567–574. The section found
that this study was eligible for inclusion (40 sub-
jects, 45 implants, 40 in maxillae and 5 in
mandibles, up to 5-year outcomes).
• De Backer H, Van Maele G, De Moor N, van den
Berghe L, De Boever J. A 20-year retrospective
study of fixed partial dentures. Int J Prosthodont
2006;19:143–153. The section found this to be a
20-year follow-up from a predoctoral dental stu-
dent clinic (193 patients, 322 FPDs). There was no
life table data presentation, making data retrieval
impossible. Also, the sample size was small relative
to the overall pooled sample of 6,000 FPDs; there-
fore, inclusion of this study would have little
impact on the conclusions of the review.
3. Does the section agree with the interpretation
and conclusion of the reviewers?
The section found there was a conclusion that was
not supported by the data.The conclusion was a sub-
jective statement that implants fail early and fixed
prostheses fail later. Implant-supported crown stud-
ies simply do not follow clinical performance for time
periods that were similar to the studies following
FPDs. The ISC studies were typically up to 6 years in
duration, while FPD studies extended to more than
10 years. ISC research was a mixture of prospective
and retrospective studies, while FPD data were retro-
spective in nature. The conclusion was therefore
withdrawn.
4. What further research needs to be done rela-
tive to the PICO question?
The section concluded that additional research is
needed to identify diagnostic and outcome variables
(clinical and patient-specific): clear clinical success
and survival clinical criteria coupled with relevant
patient-specific risk factors (eg, psychological; eco-
nomic; masticatory; genetic/anatomic/biologic; struc-
tural; QOL, etc) must be developed. A method to
obtain these variables may be the goal of a future
consensus conference. Different studies had different
levels of outcome variance.
The section agreed that research is needed to
identify variables (confounders) that can be explana-
tory for the variance observed in clinical trials.
The section felt there must be a standard tem-
plate for data collection, presentation, and publica-
tion. This would not prevent the ability of clinical
case-series to be a part of the literature. A consensus
conference may be needed to obtain this template.
The section report calls for increased diligence on
the part of authors to submit data outcomes, relative
to specific timepoints, that will allow future extrac-
tion and pooling of data in systematic reviews. This
will assist clinicians to continue to manage implant
patients over the long-term for those patients being
consistently reevaluated. Journal editors are encour-
aged to continue to accept manuscripts describing
ongoing systematic recall of patients. Finally, the sec-
tion felt comparative studies of dental outcomes rela-
tive to implant restorations are needed. Examples
would be investigator-initiated multicenter trials,
NIH, industry-based consortiums, etc.
5. How can the information from the systematic
review be applied for patient management?
The section felt application to patient management
will be used to identify the strengths and weak-
nesses of each therapy. Patients should be advised of
the significant difference in outcomes between
resin-bonded FPDs and conventional FPDs or single-
tooth implant restorations. The section felt it was
important that based on the implant systems
included in this review, patients may be advised that
there is little variability in implant survival. The sec-
tion concluded that this assessment will assist in the
development of patient-specific factors and thus
assist in the formulation of a treatment decision tree.
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ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER
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