Direct and Indirect Restorations for Endodontically Treated Teeth- A Systematic Review and Meta-Analysis, IAAD 2017 Consensus Conference Paper.

Direct and Indirect Restorations for Endodontically Treated Teeth: A Systematic Review and Meta-analysis, IAAD 2017 Consensus Conference Paper Xin Shua / Qing-qing Maib / Markus Blatzc / Richard Priced / Xiao-dong Wange / Ke Zhaof Purpose: The

primary objective of this systematic review was to compare treatment outcomes of direct and indirect permanent restorations in endodontically treated teeth, and provide clinical suggestions for restoring teeth after endodontic treatment. Materials and Methods: Electronic

databases (Medline, EMBASE, CENTRAL) and gray literature were screened for articles in English that reported on prospective and retrospective clinical studies of direct or indirect restorations after endodontic treatment with an observation period of at least 3 years. Primary outcomes were determined to be short-term (≤ 5 years) and medium-term (> 5 and ≤ 10 years) survival. Secondary outcomes included restorative and endodontic success of restored teeth. The quality of included studies and risk of bias were assessed using Cochrane Collaboration’s tool for RCTs (randomized controlled trials), the Newcastle-Ottawa Scale for cohort stud ies, and the Agency for Healthcare Research and Quality (AHRQ) methodology checklist for cross-sectional studies. The GRADE system was used for assessing collective strength of the overall body of evidence. Results: Of

2547 screened articles, only 9 (2 RCTs, 3 retrospective cohort studies, 3 cross-sectional studies) met the inclusion criteria, and 8 studies were used in the meta-analysis. In general, indirect restorations (mostly full crowns) showed higher 5-year survival (OR 0.28, 95% CI 0.19-0.43, p < 0.00001) and 10-year survival (OR 0.20, 95% CI 0.12-0.31, p < 0.00001) than direct restorations. However, there was no statistical difference in shortterm (≤ 5-years) restorative success (OR 0.32, 95% CI 0.05-2.12, p = 0.24) and endodontic success (OR 0.88, 95% CI 0.72-1.08, p = 0.22). Conclusions: Based

on current evidence, there is a weak recommendation for indirect restorations to restore endodontically treated teeth, especially for teeth with extensive coronal damage. Indirect restorations using mostly crowns have higher short-term (5-year) and medium-term (10-year) survival than do direct restorations using composite or amalgam (GRADE quality of evidence: low to moderate), but no difference in short-term (≤ 5 years) restorative success (low quality) and endodontic success (very low quality). There is a need for high-quality clinical trials, especially well-designed RCTs. Keywords: endodontic

treatment, direct restorations, indirect restorations, survival rates, success rates, apical

periodontitis. J Adhes Dent 2018; 20: 20: 183–194. doi: ##.####/j.jad. ##.####/j.jad.a##### a#####

Submitted for publication: 09.09.17; accepted for publication: 28.03.18

a

Master’s Student, Department of Prosthodontics, Guanghua School of Stoma- tology, Sun Yat-sen University, Guangzhou, China. Performed the literature search, data extraction extraction and statistical statistical analysis, wrote the manuscript.

e

Staff Dentist, Department of Prosthodontics, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China. Co-corresponding author, proofread the manuscript, contributed substantially to discussion.

b

Staff Dentist, The 3rd Dental Center, Peking University School of Stomatology, Beijing, China. Co-first author, performed the literature search, data extraction and statistical analysis.

f

Professor, Department of Prosthodontics, Guanghua School of Stomatology, Sun Yat-sen University, Guangzhou, China. Idea, consulted on statistical evaluation, proofread the manuscript, contributed substantially substantially to discussion.

c

Professor, Department of Preventive and Restorative Sciences, University of Pennsylvania School of Dental Medicine, Philadelphia, PA, USA. Idea, proofread the manuscript, contributed substantially substantially to discussion.

d

Professor, Department of Clinical Dental Sciences, Faculty of Dentistry, Dal- housie University, Halifax, NS, Canada. Proofread the manuscript, contributed substantially to discussion. discussion.

Vol 20, No 3, 2018

Correspondence: Ke Zhao, Hospital of Stomatology, School of Stomatology, Sun Yat-sen University, 54 Ling-yuan West Street, Guangzhou, China 510055. Tel: +86-20-8380-2805; e-mail: [email protected]. Co-corresponding author: Xiao-dong Wang, Prosthodontics Department, Guang- hua School of Stomatology, Sun Yat-sen University, Guangzhou, China. e-mail: [email protected]

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Shu et al

treated teeth (ETT) are more susceptible Endodontically to biomechanical failure compared to vital teeth,

MATERIALS AND METHODS

mostly due to the amount of internal tooth structure that is

Literature Search and Study Selection

removed during endodontic treatment and the loss of coro-

An electronic search of published English literature in Med-

nal hard tissue.60,71 The prognosis of ETT depends not only on the quality of endodontic treatment, but also on the subsequent restorative techniques. 32 Reported reasons for ex-

line via Pubmed, EMBASE (Excerpt Medica Database) via OVID, and CENTRAL (Cochrane Central Register of Controlled Trials) via OVID databases up to March 2017 was conducted. Search strategies are detailed in appendix 1.

32

traction of teeth after endodontic treatment include endodontic failures, prosthodontic complications, coronal and root fracture, caries, or periodontal

disease. 7

Utilizing ClinicalTrials.gov, Open Grey, and Google Scholar, gray literature was searched for potentially suitable unpub-

The best way to restore ETT has been extensively dis-

lished clinical trials, including conference abstracts, unpub-

cussed but is still controversial concerning the best type of final restoration. 21,76 Conventional restoration modality in-

lished and ongoing studies, nationally and internationally registered trials, doctoral dissertations. Hand searching

volves fabricating a full-coverage crown with or without a post,48 as this was believed to provide better protection and reinforcement of the remaining tooth structure. 5,32,33

was also conducted for relevant references. All titles and abstracts were screened based on the following inclusion criteria:

However, complete crown restoration usually also requires extensive tooth preparation and new occlusal schemes. In

addition, the loss of anatomic structures such as cusps, ridges, and the pulp chamber roof may decrease the



Patients and teeth (P): adult and adolescent patients with endodontically treated permanent teeth. There were no restrictions by gender or position of tooth.



Intervention (I): indirect restorations including full-coverage

tooth. 5

(any type of complete crown or endocrown) and partial-

Although direct amalgam and composite restorations were recommended in 2003 as conservative restorative

coverage (any type of inlay, onlay, and partial crown) restorations with or without posts, using permanent materials. Control (C): direct restorations using permanent material (including composite and amalgam), with or without posts.

strength of the remaining

techniques with 10-year survival rates of 82.4% and 85.2%, respectively,16 more recent studies of large numbers of patients treated by general dentists give a median longevity of





direct posterior composite restorations between 5 and 8 years.43,59,61,72

Maximum preservation of healthy tooth structure is the main goal of restorative dentistry. Therefore, with recent advances in bonding technologies, adhesively bonded ceramic inlay or onlay restorations have been suggested in several in vitro studies. 33,41,65,77 Some indicate that only



Outcomes (O): only studies with a follow-up of at least 3 years were included, and the follow-up periods were classified as short-term (≥ 3 and ≤ 5 years), mediumterm (> 5 and ≤ 10 years), and long-term (> 10 years). Primary outcomes: survival of restored teeth. The survival criterion used in this study was defined as the tooth-restoration complex being in situ.



Secondary outcomes: restorative and endodontic suc-

complete coverage can provide sufficient protection and en-

cess of restored teeth. Restorative success was defined

complex, 15 while

others claim the decision to place full-coverage crowns or onlays should depend on the amount of remaining tooth

as tooth and restoration present and clinically acceptable, no repair needed. Endodontic success referred to no signs or symptoms of pulpal or apical pathology ac-

structure.67

cording to clinical and radiological examinations, no end-

Many clinicians prefer using direct composite restorations to restore ETT due to their good esthetic properties, relatively low cost, ease of handling, and preservation of dental structures. 5,12 Some laboratory studies indicate that there is no significant difference in the load required to fracture ETT that have received direct or indirect restorations.12,27 However, it was later reported that indirect ceramic restorations may pose a higher risk of catastrophic

odontic intervention needed.

sure the longevity of the tooth-restoration

tooth

fracture. 12 Results

of thermomechanical loading in-



Study design (S): randomized and nonrandomized controlled clinical trials, observational study designs including cohort (prospective and retrospective), case-control, and cross-sectional.

A full text was obtained of all relevant and potentially rele-

vant studies. Two review authors independently assessed the full-text papers, and disagreements between the two

dicated that ceramic restorations behave similarly to direct restorations when the same ca vity preparations were used, and it was concluded that small conservative endodontic access cavities can be safely and simply restored

reviewers were resolved by direct discussion, or by a third reviewer if no agreement could be reached. For missing or

with direct adhesive restorations and composite. 27

ous data. For the same clinical trial with multiple publica-

Therefore, the aim of this s ystematic review was to evaluate treatment outcomes of direct and indirect restorations to provide clinical recommendations for restoring endodonti-

tions, only the latest was included in the analysis.

cally treated teeth.

Two reviewers independently scrutinized the full text of included studies. A data extraction table was employed to extract detailed information on: author(s), year of publica-

184

unclear information in the articles obtained, the corresponding authors were contacted by e-mail to confirm the ambigu-

Data Extraction

The Journal of Adhesive Dentistry

Shu et al tion, study design, participants, follow-up time, sample size of each group, type, material and brand (if available) of the

restoration as well as the post (if used), and the outcomes

judgements about quality of evidence and strength of recommendations.

All studies, regardless of the risk of bias and methodological quality, were included in the quantitative synthesis.

of each study.

When collecting the survival rate data, information provided in the publication was used directly. For outcomes ex-

Statistical Analysis and Heterogeneity

pressed as Kaplan-Meier survival curves, data were extracted

Pooled data of all the outcomes were subjected to metaanalysis to estimate the odds ratio (OR) and 95% confidence intervals (CI) using the Cochrane Collaboration Re-

using the freeware software Engauge Digitizer (ver. 5.1 http://markummitchell.github.io/engauge-digitizer). The Engauge Digitizer software accepts image files (eg, PNG, JPEG, from those graphs. For consistent studies, the extracted data

view Manager (Ver. 5.3). To test the reliability of evidence, outcomes of fixed-effect models and random-effect models were compared, but considering the unexplained heteroge-

were deemed precise enough to be included in the meta-

neity between studies, only random-effect estimates were

analysis, while for inconsistent studies with no reply from the author, data were excluded from quantitative analysis. Other

reported, to be more conservative. Cochran’s Q test was applied for analyzing the hetero-

initial data were obtained by contacting the authors. Due to national differences and writing styles, the termi-

geneity between included studies, and no heterogeneity

nology used in included studies varies. For standardization,

wise, the I 2 statistic was used to quantify the statistical

confirmatory e-mails were sent to the authors to ascertain

heterogeneity, and the threshold was determined as Co-

the restoration types and materials; further, descriptions

chrane recommended, ie, 0% to 40%: might not be important; 30% to 60%: may represent moderate heterogeneity;

and TIFF) containing graphs, and recovers the data points

were adjusted accordingly in the data extraction table. For authors who did not reply, the original text was used.

was determined if the p-value was higher than 0.1. Other-

50% to 90%: may represent substantial heterogeneity; 75% to 100%: considerable heterogeneity. For outcomes

Risk of Bias

with substantial or considerable heterogeneity, sensitivity

Two reviewers independently evaluated the methodological

analysis was carried out by comparing the fixed and ran-

qualities of included studies according to the guidance pro-

dom-effect estimates, considering subgroup analysis, and

vided by the Journal of Evidence-based

Medicine. 79

testing for excess of studies with significant results.

Cochrane Collaboration’s tool (http://handbook-5-1. cochrane.org/) was used to assess the risk of bias of RCTs. The domains of sequence generation, allocation concealment, and selective outcome reporting were addressed

RESULTS

in the tool.

The initial electronic search yielded 3497 records (1358 in

The Newcastle-Ottawa Scale (http://www.ohri.ca/ programs/clinical_epidemiology/oxford.asp) was applied for assessing cohort studies. Using the tool, each study was judged on 8 items, categorized into 3 groups: the

selection, comparability, and outcome of exposed and non-exposed cohort. Stars were awarded for each study

(up to 9 stars) for quick visual assessment. Studies awar ded with 6 or more stars were regarded as high-quality studies.

For cross-sectional studies, the Agency for Healthcare Research and Quality ( AHRQ) methodology checklist (https://www.ncbi.nlm.nih.gov/books/NBK35156/) was applied. This is a methodological quality assessment tool using an 11-item checklist, and the AHRQ recommends it for assessment of cross-sectional studies. An item would

Medline, 1379 in OVID, 758 in Central, and 2 from handsearching and gray literature), and 2547 records were found after removing the duplicates. From these 2547 records, 49 potentially pertinent records were selected after

screening the titles and abstracts. Full-text articles were retrieved for eligibility assessment, and 40 articles were excluded with reasons (different definition of survival rates: n = 1;13 insufficient follow-up time: n = 2; 44,78 only indirect

restorations were used: n = 19; 8,9,14,21,22,25,39,40,42,5153,57,58,62,68,69,74,80 only direct restorations were used: n = 182-4,11,20,26,29,34,35,38,45,47,50,55,63,64,75,81). Ultimately, only 9 articles met the inclusion criteria, and all included studies had a parallel design. Some of the included studies provided specific data in their publications, including the studies by: Aquilino et al 7 and Pratt et al 56 in

be scored “0” if it was answered “NO” or “UNCLEAR”; if it was answered “YES”, then the item was give a score of “1”. Article quality was assessed as follows: low quality = 0–3; moderate quality = 4–7; high quality = 8–11.

short-term (5 years) survival analyses, Aquilino et al 7 and

For every outcome of meta-analysis, the quality of the

Hommes et al,36 and Dawson et al18 in endodontic success assessments. Their information was used directly. For stud-

evidence was assessed using the GRADE (Grading of Rec-

Dammaschke et al 16 in medium-term (10 years) analyses,

Skupien et al70 and Mannocci et al46 in short-term (≤ 5 years) restorative success assessments, Frisk et al, 28

tions) approach by GRADEprofiler (Ver 3.6). The GRADE ap-

ies with Kaplan-Meier survival curves, 56,73 data extracted from Engauge Digitizer were compared with the available

proach was used for collective grading of the overall body of

information in the text to test the precision of the figure. For

evidence in this review, as the study designs vary; more-

consistent studies,56 the extracted data were deemed pre-

over, it is also a systematic and explicit approach to making

cise enough to be included in the meta-analysis; while for

ommendations, Assessment, Development and Evalua-

Vol 20, No 3, 2018

185

Shu et al Table 1

Characteristics of included studies

Author (year)

Study design

Follow-up

Age in years

Teeth

Indirect restorations Direct restorations (n*) (n*)

Outcomes

Skupien70 (2016)

RCT

5 years

42.2 ± 11.5

Endodontically treated teeth with extensive coronal damage

Porcelain-fused-tometal crowns bonded with composite cement, with fiber posts (n = 27)

Composite fillings with fiber posts (n = 30)

Cumulative success and survival (KaplanMeier survival and success curve); clinical performance**

Mannocci 46 (2002)

RCT

3 years

35–55, mean 48

Endodontically treated premolars with class II lesions

Porcelain-fused-tometal crowns bonded with Zinc phosphate cement, with fiber posts (n = 57)

Composite fillings with fiber posts (n = 60)

1-, 2-, 3-year failure rates

Pratt56 (2016)

Retrospective 8 years cohort

Mean 46

Endodontically treated posterior teeth

Crowns (n = 441)

Amalgam or composite fillings (n = 198)

Cumulative survival (Kaplan-Meier survival curve)

Dammaschke 16 Retrospective 10 years (2012) cohort

18–76

Endodontically treated posterior teeth

Crowns or partial crowns (n = 441)


Cumulative survival (Kaplan-Meier survival curve); 10-year survival rate

Tickle73 (2008) Retrospective 7.7 years cohort

20–60, 49.2±10.3

Endodontically Crowns (n = 67) treated mandibular first molar

Composite fillings (n = 107)

Cumulative survival (Kaplan-Meier survival curve)

Aquilino 7 (2002)

Retrospective 10 year s cohort

54.1±15.2

Endodontically treated teeth

Crowns (n = 129)


Failure number; 5, 10-year survival rate

Dawson18 (2016)

Crosssectional

/

20–89


Crowns with posts (n = 275)

Amalgam or composite fillings with posts (n = 179)

Periapical status

Frisk28 (2015)

Crosssectional

/

20–70


Crowns or inlays (n = 1475)

Amalgam or composite Periapical status resin fillings (n = 1159)

Hommes 36 (2002)

Crosssectional

/

Not mentioned


Crowns (n = 305)


Periapical status

*n: number of teeth. **Clinical performance refers to assessment of each restoration’s esthetic, functional and biological properties, according to FDI criteria.

inconsistent studies with no reply from the author, 73 data

vided 5-year survival results. Meta-analysis showed that in-

were excluded from quantitative analysis.

direct restorations have a higher survival rate than do direct

Three retrospective cohort studies were selected for analy-

restorations (OR 0.28, 95% CI 0.19–0.43, p < 0.00001). No heterogeneity was detected between the studies

sis of short-term and medium-term survival, 2 RCTs were

(p = 0.55, I 2 = 0%).

Therefore, 8 studies were included in the meta-analyses.

included for evaluation of restorative success, and 3 cross-

sectional studies were subjected to endodontic success

Ten-year Survival (Fig 4)

assessment. The process of searching and study selection

In respect to medium-term (> 5 and ≤ 10 year survival), the 8-year survival results of Pratt et al 56 were originally

is outlined in Fig 1. The characteristics of included studies are detailed in Table 1.

Risk of bias and quality assessments are presented in Fig 2 (RCTs), Table 2 (cohort studies), and Table 3 (crosssectional studies). For RCTs, the risk of performance bias

included in the meta-analysis, but it significantly increased the heterogeneity because of different follow-up times (Aquilino et al7 and Dammaschke et al16 were both 10 years), and was therefore ultimately excluded from meta-analysis.

and detection bias was high. The Newcastle-Ottawa scores of cohort studies ranged from 5 to 7 asterisks with half of the studies showing high-quality. The methodological quali-

Higher survival rates for indirect restorations were observed in 10-year assessment (OR 0.20, 95% CI 0.120.31, p < 0.00001), and no heterogeneity was detected

ties of included cross-sectional studies showed only 1 study

(p = 0.94, I 2 = 0%).

had high quality.

Restorative Success (Fig 5) Five-year survival (Fig 3) Two retrospective studies 7,56 were included in the assess-

Two RCTs reported the ≤ 5-year success rates, and metaanalysis indicated that direct and indirect restorations do not differ significantly in success rates (OR 0.32, 95% CI

ment of short-term (≤ 5-year) survival, both of which pro-

0.05-2.12, p = 0.24). Moderate to substantial heterogene-

Survival of Tooth-Restoration Complex

186


Shu et al Table 2

Quality assessment of cohort studies with the Newcastle-Ottawa Scale

Pratt et al56

Tickle et al7

Dammaschke et al16

Aquilino et al7

Selection

***

****

***

1) Representativeness of the exposed cohort 2) Selection of the non-exposed cohort 3) Ascertainment of exposure 4) Demonstration that outcome of interest was not present at start of study

c a* a* a*

b* a* a* a*

**** b* a* a* a*

Comparability

*

1) Comparability of cohorts on the basis of the design or analysis

a*

Outcome

**

1) Ascertainment of outcome 2) Was follow-up long enough for outcomes to occur? 3) Adequacy of follow up of cohorts Total scale

b* a* d *****

c a* a* a*

**

**

b* a* c *******

** b* a* c ******

b* a* d *****

* Studies with 6 or more asterisks were regarded as high-quality studies.

Table 3

Quality assessment of cross-sectional studies with ARHQ methodology checklist

1) Define the source of information (survey, record review) 2) List inclusion and exclusion criteria for exposed and unexposed subjects (cases and controls) or refer to previous publications 3) Indicate time period used for identifying patients 4) Indicate whether or not subjects were consecutive if not population-based 5) Indicate if evaluators of subjective components of study were masked to other aspects of the status of the participants 6) Describe any assessments undertaken for quality assurance purposes (eg, test/retest of primary outcome measurements) 7) Explain any patient exclusions from analysis 8) Describe how confounding was assessed and/or controlled 9) If applicable, explain how missing data were handled in the analysis 10) Summarize patient response rates and completeness of data collection 11) Clarify what follow-up, if any, was expected and the percentage of patients for which incomplete data or follow-up was obtained Total scale

Dawson et al18

Frisk et al28

Hommes et al36

1 0

1 0

1 0

1 0 0

1 0 0

0 0 0

1

1

1

1 1 1 1 1

0 0 0 1 0

0 1 0 0 0

8

4

3

* Article quality was assessed as follows: low quality = 0–3; moderate quality = 4–7; high quality = 8–11.

ity was detected between the 2 studies, but this was not statistically significant (p = 0.15, I 2 = 52%). The main reasons for failure were restoration fractures, secondary caries

in direct groups, and post debonding; marginal gaps were revealed by radiographs in both groups.

Meta-analysis showed no difference in the incidence of apical periodontitis (AP) for direct or indirect restorations (OR 0.88, 95% CI 0.72-1.08, p = 0.22) with statistically nonsignificant moderate heterogeneity (p = 0.21, I 2 = 36%). The results for periapical status of ETT with composite or

amalgam fillings are different. Hommes et al 36 found the Endodontic Success (Fig 6)

rate of AP to be significantly higher (p < 0.01) in composite

Three cross-sectional studies investigated the periapical status (endodontic success) of directly vs indirectly re-

(40.5%) than amalgam (28.4%) restorations, as supported

stored teeth and composite vs amalgam restorations.

associated with the occurrence of AP. However, Dawson et

Vol 20, No 3, 2018

by Frisk et al,28 who found that composite restorations were

187

Shu et al al18 reported no difference in the frequency of AP between teeth restored with composite and amalgam fillings.

As for ETT without extensive coronal destruction, direct composite restorations are mainly indicated for teeth with minimal or moderate tooth structure loss. 10 Some evidence

GRADE Assessment

suggested that for similar cuspal coverage, direct and indi-

The SoF (summary of findings) table created by GRADEprofiler is presented in Figs 7–9. Among the 4 outcomes analyzed in this review, survival (short-term and medium-term)

rect methods showed similar outcomes, and decided that preference should be given to direct over indirect restorations because they are more time effective and less

and restorative success of restored teeth showed low to moderate quality, compared with very low quality of end-

costly.6,19,24 However, the accuracy and skills of the practi-

odontic success.

tioners could significantly influence decision to repair or replace direct restoration. 45 For example, direct restorations are technique sensitive with greater risks of polymer-

ization shrinkage, marginal discrepancies, microleakage, undesirable proximal contacts, and secondary caries. 5,12

DISCUSSION

On the other hand, indirect restorations (inlay/onlay) have that indirect restorations (mainly crowns) would provide in-

a reduced composite shrinkage volume, limited to the resin luting layer, and therefore increase the marginal adaptation

creased short-term (5-year) and medium-term (10-year) sur-

of restorations.37

The present systematic review and meta-analysis suggested

vival for endodontically treated teeth compared with direct

Failure of restorative treatment may be influenced by the

restorations (mainly composite and amalgam fillings). Indi-

position of the tooth. In a long-term study of ETT, mandibu-

rect restorations also showed better esthetic, functional, and biological properties, but no difference in short-term

lar premolars and maxillary and mandibular anterior teeth

(≤ 5 years) restorative success or endodontic success.

types, and molars demonstrated the worst survival out-

were reported to have longer survival times than other tooth

The search strategies for this systematic review covered

comes, possibly because of difficulties in endodontic treat-

both published studies and gray literature, but abstracts

ment and the subsequent restoration. 13 A large practice-

and articles published in languages other than English were not searched. Publication bias could not be assessed due

based study analyzing direct restoration longevity showed a higher annual failure rate (AFR) of 5.2% in molars compared

to the limited number of studies. All of the outcomes

to anterior teeth (4.4%) and premolars (4.0%). 45

showed satisfactory reliability.

Another controversial issue is whether to place a post after endodontic treatment. In vitro studies showed that

Reasons for extraction of ETT are mainly nonrestorable carious destruction, endodontic issues, and tooth fracture.16,78 Crowns are expected to provide a better coronal seal to prevent bacterial recontamination of residual tooth

tissue.13 Studies

placement of fiber post could significantly i mprove the fracture resistance of ETT. 1 A long-term clinical investigation (at

least 5 years) found that the survival rate of teeth with a

showed that 85% of extracted ETT were not crowned, due to the presence of more nonrestorable caries compared with crowned teeth. 78 Crowns may also serve to protect the tooth from the risk of fracture, 13 as crowned ETT demonstrated a significantly lower fracture

fiber post amounted to 94.3%, and for teeth without a post,

rate than teeth provided with a filling. 16

core.23

Traditionally, most clinicians prefer to use posts followed

by crown restorations for

ETT; 14 however,

full-coverage

it was 76.3% (p < 0.001). 31 However, other investigators believe that preparation of a post space might increase the

chance of root fracture, 30 so that posts should only be used when other options were not available to retain a In this review, indirect restorations (mainly crowns) had better outcomes in tooth-restoration complex survival, pos-

crowns may not be necessary. A retrospective study investigated 189 posterior ETT restored with indirect composite onlays, and suggested this method can be a viable option

sibly because crowns could provide better protection in

for the restoration of posterior ETT (tooth survival 100%,

rect restorations might serve as a more stable restoration

restoration survival 96.8%, with median follow-up time of 37

technique in the long run, as the effect of 10-year results

months). 14 Another

(OR 0.20) was larger than that of 5-year results (OR 0.28). Meta-analysis of restorative success showed no statisti-

study also showed that gold partial

crowns displayed a comparable fracture rate compared with

such a study pool of teeth with substantial tooth structure loss in areas of high masticatory forces. In addition, indi-

full-coverage crowns for ETT. 16 However, the decision on whether to place a crown or a partial-coverage restoration should also depend on functional requirements and the amount of remaining tooth structure. 10,17,54 According to some studies in vital teeth, the risk of failure has been

cal difference between the two restorations, probably because of limited sample size and observation time. However, a comparison of the two included studies showed

showed to increase by 30% to 40% for every extra missing

results.

wall.54 An occlusal cavity preparation could reduce tooth

In terms of endodontic success, results differed among studies, especially when comparing amalgam and compos-

stiffness by 20%, compared to 63% for a MOD (mesial-occlusal-distal) cavity.14 Therefore, crowns are still crucial to provide enough coronal protection, if ETT have been extensively damaged by caries or endodontic treatment. 32,78

188

that with the increase in observation time (from 3 years to

5 years), indirect restorations exhibited more favorable

ite fillings. Studies published in different years exhibited opposing outcomes, probably because the quality of com-

posites was better in more recent studies as a result of The Journal of Adhesive Dentistry

Shu et al

n o i t a c i f i t n e d I

g n i n e e r c S

y t i l i b i g i l E

Initial electronic search results: Medline via Pubmed: n = 1358 EMBASE via OVID: n = 1379 CENTRAL via OVID: n = 758 Handsearching and gray literature searching: n = 2 Records after duplicates removed: n = 2547 Records screened: n = 2547 Full-text articles retrieved for eligibility assessment: n = 49 Articles included in present systematic review: n = 9

n o i s u l c n I

Fig 1

Records excluded based on title and abstract: n = 2498

Articles excluded with reasons: n = 40 •Different difinition of survival rates: n = 1 •Insufficient follow-up time ( < 3 years): n = 2 •Only indirect restorations were used: n = 19 •Only direct restorations were used: n = 18

Articles included in meta-analysis: n = 8

Flow diagram.

the development of materials, techniques and instruments

for placement of filling materials. 30 A systematic review suggested that composite restorations in the posterior region still have reduced longevity and a greater likelihood of

) s a i b n o i t c e l e s ( n o i t a r e n e g e c n e u q e s m o d n a R

secondary caries when compared to amalgam restorations. 49 The quality of coronal restorations may have an impact on the periapical status by influencing coronal leakage.30 A previous systematic review published in 2012 and updated in 2015 discussed a similar topic by comparing single crowns vs direct restorations for ETT, but included only

one clinical trial; insufficient evidence was found to support

either treatment option. 66 However, our systematic review included 2 RCTs and 7 observational studies, and reached

a conclusion in meta-analysis, which may be helpful for clinical practice. This is possibly because of more compre-

) s a i b n o i t c e l e s ( t n e m l a e c n o c n o i t a c o l l A

) s a i b e c n a m r o f r e p ( l e n n o s r e p d n a s t n a p i c i t r a p f o g n i d n i l B

) s a i b n o i t c e t e d ( t n e m s s e s s a e m o c t u o f o g n i d n i l B

) s a i b n o i t i r t t a ( a t a d e m o c t u o e t e l p m o c n I

) s a i b g n i t r o p e r ( g n i t r o p e r e v i t c e l e S

s a i b r e h t O

hensive search strategies in 3 databases, coverage of gray

literature, and inclusion of observational studies. In addi-

Mannocci 2002

+

?

–

–

–

+

?

Skupien 2016

+

+

–

–

+

+

?

tion, multiple and rigorous quality assessment was applied

for different study designs. Use of a collective evidence grading system (GRADE) further improved the quality of this systematic review.

The present study also had some limitations, eg, that most of the conclusions were drawn from retrospective

Fig 2

Risk of bias summary (RCTs).

cohort studies mostly including skilled operators, with ma-

terials available in the 1990s. Well-designed RCTs with large sample sizes are needed using today’s materials and general dentists, especially for endodontically treated

teeth with minimal or moderate coronal tooth structure loss.

Vol 20, No 3, 2018

189

Shu et al

Study or Subgroup

Aquilino (2002) Pratt 2016

indirect Events Total

8 36

Total (95% CI)

direct Events Total

17 45

129 441 570

Odds Ratio Weight M-H, Random, 95% CI

74 198

22.0% 78.0%

0.22 [0.09, 0.54] 0.30 [0.19, 0.49]

272

100.0%

0.28 [0.19, 0.43]

62 Total events 44 Heterogeneity: Tau2= 0.00; Chi 2 = 0.36, df = 1 (p = 0.55), I 2 = 0% Test for overall effect: Z = 5.89 (p < 0.00001)

Fig 3

0.01

indirect

Aquilino (2002) Pratt 2016

direct

Odds Ratio

Odds Ratio

M-H, Random, 95% CI

M-H, Random, 95% CI

Events

Total

Events

Total

Weight

14 22

129 388

28 32

74 135

39.3% 60.7%

0.20 [0.10, 0.41] 0.19 [0.11, 0.35]

209

100.0%

0.20 [0.12, 0.31]

Total (95% CI)

517

60 Total events 36 2 2 Heterogeneity: Tau = 0.00; Chi = 0.00, df = 1 (p = 0.94), I 2 = 0% Test for overall effect: Z = 7.01 (p < 0.00001)

Study or Subgroup

Mannocci (2002) Pratt 2016

0.01

direct

Odds Ratio

Events

Total

Events

Total

3 1

54 27

4 8

53 30

57.7% 42.3%

0.72 [0.15, 3.39] 0.11 [0.01, 0.91]

83

100.0%

0.32 [0.05, 2.12]

Total (95% CI)

0.1 1 10 Favors [indirect] Favors [direct]

100

81

Odds Ratio

Weight M-H, Random, 95% CI

60 Total events 36 Heterogeneity: Tau2= 0.99; Chi 2 = 2.08, df = 1 (p = 0.15), I 2 = 52% Test for overall effect: Z = 1.18 (p = 0.24)

M-H, Random, 95% CI

0.01


100

Forest plot of short-term restorative success.

indirect Study or Subgroup

Dawson (2016) Frisk (2015) Hommez (2002) Total (95% CI)

Events

72 333 90

Total

direct Events

Total

62 179 275 1475 261 1159 305 1418 413 2055

1751

Odds Ratio

Odds Ratio

Weight M-H, Random, 95% CI

19.7% 51.9% 28.4%

0.70 [0.47, 1.06] 1.00 [0.83, 1.21] 0.81 [0.59, 1.11]

100.0%

0.88 [0.72, 1.08]

462 Total events 495 Heterogeneity: Tau2= 0.01; Chi 2 = 3.12, df = 2 (p = 0.21), I 2 = 36% Test for overall effect: Z = 1.22 (p = 0.22)

Fig 6

100

Forest plot of 10-year survival analysis.

indirect

Fig 5


Forest plot of 5-year survival analysis.

Study or Subgroup

Fig 4

Odds Ratio M-H, Random, 95% CI

M-H, Random, 95% CI

0.5

0.7 1 1.5 Favors [indirect] Favors [direct]

2

Forest plot of endodontic success.

CONCLUSIONS

vival than direct restorations using composite or amalgam,

but no significant difference was found in short-term Based on current evidence, there is a weak recommendation

(≤ 5-year) restorative success. However, further research is

for indirect restorations to restore endodontically treated teeth, especially for teeth with extensive coronal damage. Indirect restorations consisting mostly of crowns have a

likely to have an important impact on our confidence in the estimate of effect and may change the estimate, because the evidence is of low to moderate quality. Indirect and di-

higher short-term (5-year) and medium-term (10-year) sur-

rect restorations showed no significant difference in end-

190


Shu et al Survival of ETT with direct or indirect restorations Patient or population: patients with Settings: survival of ETT Intervention: Indirect restorations Comparison: Direct restoration

Outcomes

endodontically treated teeth (ETT)

Illustrative comparative risks* (95% CI) Assumed risk

5-year survival

Relative effect (95% CI)

No of Participants (studies)

Direct restorations

Indirect restorations

228 per 1000

76 per 1000

OR 0.28

842

(53 to 113)

(0.19 to 0.43)

(2 studies)

75 per 1000

OR 0.20

726

(46 to 111)

(0.12 to 0.31)

(2 studies)

Follow-up: 5 years 10-year survival

Corresponding risk

287 per 1000

Follow-up: 10 years

Quality of the evidence (GRADE)

Comments

low1,2,3 moderate1,3

*The basis for the assumed risk (eg, the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence

interval; OR: Odds ratio.

GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate. 1 All studies are observational studies and thus would start with low quality rating. 2 Downgraded 1 level for imprecise (data of Pratt’s study were extracted from the Kaplan-Meier survival curves). 3 Upgraded 1 level for large effect based on observational studies without important risk of bias or other limitations

Fig 7

showing an OR

0.5 with at least consistent studies.

<

GRADE SoF survival rate.

Restorative success of ETT with direct or indirect restorations Patient or population: patients with endodontically Settings: restorative success of ETT Intervention: Indirect restorations Comparison: Direct restoration

Outcomes

treated teeth (ETT)

Illustrative comparative risks* (95% CI) Assumed risk

5-year success

Corresponding risk



Direct restorations


145 per 1000

51 per 1000

OR 0.32

164

(8 to 264)

(0.05 to 2.12)

(2 studies)

Follow-up: 3 – 5 years


Comments

low1,2,3,4



GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate. 1 Both studies are RTCs so would start with high quality rating. 2 Downgraded 1 level for Imprecision (optimal information size n < 400 and wide CI). 3 Downgraded 1 level for high RoB in both studies (lack of concealment and lack of blinding). 4 Downgraded 1 level for moderate heterogeneity (52%).

Fig 8

GRADE SoF restorative success rate.

Endodontic success of ETT with direct or indirect restorations Patient or population: patients with endodontically Settings: endodontic success of ETT Intervention: Indirect restorations Comparison: Direct restoration

Outcomes

treated teeth (ETT)

Illustrative comparative risks* (95% CI)

Endodontic success



240 per 1000

OR 0.88

3806

(205 to 279)

(0.72 to 1.08)

(3 studies)

Assumed risk

Corresponding risk

Direct restorations


264 per 1000


Comments

very low1,2



GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate. 1 All studies are 2 Downgraded 1

Fig 9

observational studies and thus would start with low quality rating. level for high RoB in 2/3 studies (falilure to adequately control confounding).

GRADE SoF endodontic success rate.

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Shu et al

odontic success (rate of apical periodontitis), but we are very uncertain about the estimate as a result of very low quality of evidence.

High-quality clinical trials are needed, especially welldesigned RCTs. Future studies should better control the confounding factors by restricting the position of teeth, extent of coronal damage, use of post, and quality of end-

odontic treatment. RCTs are expected to have a larger sample size and longer observation time. Moreover, under

the principle of maximum preservation of healthy tooth structure, studies involving restoring endodontically treated teeth with minimal coronal loss, or studies comparing indirect restorations of full or partial coverage, are also of great interest and significance.

ACKNOWLEDGMENTS The authors would like to thank the Chinese Cochrane Center at the West China School of Medicine, Sichuan University, which provided the theoretical guidance for this systematic review.

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Clinical relevance: Indirect

restorations chiefly using crowns have higher a short-term (5-year) and mediumterm (10-year) survival rate than direct restorations using composite or amalgam, but no difference was detected in short-term (≤ 5-year) restorative and endodontic success.

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APPENDIX 1 SEARCH STRATEGIES A. MEDLINE via Pubmed search strategy (24th Mar, 2017)

B. EMBASE via OVID search strategy (24th Mar, 2017)

((endodontic*[Title/Abstract]) OR nonvital[Title/Abstract]) ((root canal therapy[MeSH Terms]) OR root canal[Title/Ab-

1 2 3 4

*endodontics/ (endodontic* or nonvital or pulpless).ab. exp “root canal therapy”/ (“root canal” or root-filled).ab.

stract]) OR root-filled[Title/Abstract]

5

(root adj6 (therap$ or fill$ or treat$ or resect$)).

6 7 8 9 10 11 12

ab. (direct* or indirect*).ab. *tooth prosthesis/ (restoration* or restored or restorative).ab. 7 or 8 6 and 9 *resin/ (“composite resin” or composite or resin or amalgam).ab.

(((composite[Title/Abstract]) OR resin*[Title/Abstract]) OR composite resins[MeSH Terms]) OR amalgam[Title/Ab-

13

(crown* or endocrown* or inlay* or onlay* or over-

stract]

14 15

lay* or veneer*).ab. (partial and crown*).ab. 10 or 11 or 12 or 13 or 14

OR pulpless[Title/Abstract] endodontics[MeSH Terms]

((fill*[Title/Abstract]) OR therap*[Title/Abstract]) OR treat*[Title/Abstract] #4 AND root[Title/Abstract] #1 OR #2 OR #3 OR #5 (direct*[Title/Abstract]) OR indirect*[Title/Abstract]

((((dental restorations, permanent[MeSH Terms]) OR dental

prosthesis[MeSH Terms]) OR restoration*[Title/Abstract]) OR restored[Title/Abstract]) OR restorative[Title/Abstract] #7 AND #8

((((((((crowns[MeSH Terms]) OR crown[Title/Abstract]) OR endocrown*[Title/Abstract]) OR partial crown*[Title/Abstract]) OR inlays[MeSH Terms]) OR inlay[Title/Abstract]) OR onlay*[Title/Abstract]) OR overlay*[Title/Abstract]) OR

16 17

stract]) OR randomly[Title/Abstract]

(((((((controlled[Title/Abstract]) OR clinical trial[Title/Abstract]) OR prospective[Title/Abstract]) OR retrospective[Title/Abstract]) OR pilot[Title/Abstract]) OR longitudinal[Title/Abstract]) OR cohort[Title/Abstract]) OR case series[Title/Abstract]) OR case-control*[Title/Abstract] #13 OR #14 #6 AND #12 AND #15 (“in vitro”[Title]) OR “ex vivo”[Title] #16 NOT #17 Filter: English

194

((clinical and trial) or prospective or retrospective or pilot or longitudinal or cohort or “case series” or

veneer*[Title/Abstract] #9 OR #10 OR #11

((randomized[Title/Abstract]) OR randomised[Title/Ab-

(randomized or randomised or randomly or controlled).ab.

18 19 20

case-control*).ab. 16 or 17 1 or 2 or 3 or 4 or 5 15 and 18 and 19

C. CENTRAL (Cochrane Central Register of Controlled Trials) via OVID (25th Mar, 2017) 1 2 3 4

exp Endodontics/ (endodontic* or nonvital or pulpless).af. (root and canal).af. root-filled.af.

5

(root adj6 (therap$ or fill$ or treat$ or resect$)).af.

6 7 8 9 10

1 or 2 or 3 or 4 or 5 (direct* or indirect*).af. dental prosthesis.mp. or exp Dental Prosthesis/ (restoration* or restored or restorative).af. exp Composite Resins/

11

(composite resin or composite or resin or amal-

12 13 14 15

gam).af. exp Dental Restoration, Permanent/ 8 or 9 or 12 7 and 13 exp Crowns/

16

(crown* or endocrown* or inlay* or onlay* or over-

17 18 19 20

lay* or veneer*).af. exp Inlays/ (partial and crown*).af. 10 or 11 or 14 or 15 or 16 or 17 or 18 6 and 19


Direct and Indirect Restorations for Endodontically Treated Teeth- A Systematic Review and Meta-Analysis, IAAD 2017 Consensus Conference Paper.

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