Because all-ceramic and metal-ceramic crowns require the removal of such large quantities of tooth structure, there has been considerable interest in less destructive alternatives. The ceramic veneer has emerged as a means of producing an esthetic result on otherwise intact anterior teeth that are marred by severe staining or developmental defects restricted to the facial surface of the tooth (Fig 6-17). This restoration also can be used to restore moderate incisal chipping and small proximal lesions. The use of a veneer requires only minimal tooth preparation and therefore offers an alternative to crowns that is attractive to the patient and dentist alike.
The features and capabilities of the 12 types of singletooth restorations described in this chapter are shown in Table 6-1.
Table 6-1 Features and applications of single-tooth restorations
R estoration Longevity
Every dentist would like to be able to answer the patient’s question, “How long will my restoration last?” Logical though this question may be,
unfortunately it is impossible to answer directly. We cannot predict the life span of a pair of shoes or a television set, and these everyday items are not custom made, nor do they perform their service in a hostile biologic
environment, submerged in water.
Clinical studies of restoration longevity have produced widely disparate figures. As a general rule, cast restorations will survive in the mouth longer than amalgam restorations, which in turn will last longer than composite resin restorations. 14 A compilation of five studies of 676 patients concluded that amalgam restorations exhibit a 50% failure rate between 5.5 and 11.5 years, with an extrapolated life expectancy of 10 to 14 years.15
Meeuwissen et al16 reported a 10-year survival rate of 58% for amalgam
restorations in Dutch military patients; Arthur et al17 reported an 83%
survival rate for the same time span in a US military population. Qvist et al18 found that 50% of the amalgam restorations in a group of Danish patients had failed at 7 years. Christensen19 estimated a 14-year longevity for amalgam restorations. In selected populations, amalgam restorations of unspecified types or sizes in one study14 have shown 10-year survival rates as high as 72%. A 15-year survival rate of 72.8% was reported for simple amalgams in another study.20
A survey of 571 fixed prosthodontists, nonspecialist restorative dentists, and dental school faculty projected an average life span of 11.2 years for simple amalgams and 6.1 years for complex amalgams.21 One group of 125 complex amalgams was reported to have a 76% survival rate at 15 years,20 whereas another group of 171 complex amalgam restorations exhibited a 50%
survival rate at 11.5 years.22
Composite resin restorations have not been included in many longevity studies. A study of dental school patients that did incorporate them reported a 10-year survival rate of 55.9%.14 Another report, based on a general patient population, described a shorter life span for composite resin restorations, with 50% of them having failed in 6.1 years.23
Mount24 disclosed an overall success rate of 93% for 1,283 glass-ionomer restorations for up to 7 years, with the rate varying from 2% to 36%
depending on the class of cavity and the brand of cement. In that study, the patients evaluated had been treated by only two dentists, and not all of the restorations had been in place for the full 7-year span of the study. While promising, these figures must be assessed cautiously until longer studies of a broader population have been completed.
Schwartz et al,25 after studying a group of 791 failed restorations, reported mean life spans, at failure, of 10.3 years for full crowns, 11.4 years for three- quarter crowns, and 8.5 years for porcelain jacket crowns (anterior all-
ceramic crowns). The mean life span for all fixed prosthodontic restorations was 10.3 years. Walton and associates,26 evaluating a group of 424
restorations, found full crowns lasting 7.1 years, partial veneer crowns 14.3 years, metal-ceramic crowns 6.3 years, inlays and onlays 11.2 years, and porcelain jacket crowns 8.2 years.
The dentists responding to Christensen’s survey estimated the longevity of crowns to be from 21 to 22 years.19 The estimates supplied by the
respondents to a survey by Maryniuk and Kaplan21 were 12.7 years for metal- ceramic crowns and 14.7 years for all-gold restorations. Kerschbaum,27 examining German insurance records, found 91.5% of gold crowns still in the mouth after 8 years. In a review of records in 40 Dutch dental offices,
Leempoel et al28 told of 10-year survival rates of 98% and 95.3% for full crowns and metal-ceramic crowns, respectively.
A compilation of longevities from several studies is presented in Table 6- 2.
The question of longevity is an important one to consider when choosing treatment for a patient. The more destructive the preparation required for the restoration, the greater the potential risk for the tooth and ultimately the greater expense. In 1989, it was estimated that if a crown were placed in a patient’s mouth at age 22, at a fee of $425, attendant services and
replacements of that crown would cost the patient nearly $12,000 considering an average life expectancy of 75 years.32 Today, the original fee may be
double, or $850, with a corresponding doubling of the subsequent effect, resulting in a cost to the patient of nearly $24,000.
Table 6-2 Longevity of single-tooth restorations
R eferences
1. Potts RG, Shillingburg HT Jr, Duncanson MG Jr. Retention and resistance of preparations for cast restorations. J Prosthet Dent 1980;43:303–308.
2. Kishimoto M, Shillingburg HT Jr, Duncanson MG Jr. Influence of preparation features on retention and resistance. Part I: MOD onlays. J Prosthet Dent 1983;49:35–39.
3. Holt RA, Nordquist RE. Effect of resin/fluoride and holmium:YAG laser irradiation on the resistance to the formation of caries-like lesions. J Prosthodont 1997;6:11–19.
4. Hicks J, Winn D 2nd, Flaitz C, Powell L. In vivo caries formation in enamel following argon laser irradiation and combined fluoride and argon laser treatment: A clinical pilot study. Quintessence Int 2004;35:15–20.
5. American Dental Association Council on Scientific Affairs. Statement on Dental Amalgam. Revised August 2009. http://www.ada.org/1741.aspx.
Accessed 29 May 2011.
6. European Commission, Scientific Committee on Emerging and Newly
Identified Health Risks. The Safety of Dental Amalgam and Alternative Dental Restoration Materials for Patients and Users, 6 May 2008.
http://ec.europa.eu/health/ph_risk/committees/04_scenihr/docs/scenihr_o_016.pdf Accessed 29 May 2011.
7. Kidd EA, O’Hara JW. The caries status of occlusal amalgam restorations with marginal defects. J Dent Res 1990;69:1275–1277.
8. Krupa D. Press Release: Review and Analysis of the Literature on the Potential Health Effects of Dental Amalgams. 9 December 2004.
http://www.lsro.org/amalgam/frames_amalgam_home.html.
9. Mondelli J, Steagall l, Ishikiriama A, de Lima Navarro MF, Soares FB.
Fracture strength of human teeth with cavity preparations. J Prosthet Dent 1980;43:419–422.
10. Reagan SE, Schwandt NW, Duncanson MG Jr. Fracture resistance of wide-isthmus mesio-occulusodistal preparations with and without amalgam cuspal coverage. Quintessence Int 1989; 20:469–472.
11. Kent WA, Shillingburg HT, Duncanson MG, Nelson EL. Fracture resistance of ceramic inlays with three luting materials. J Dent Res 1991;70(1 suppl):561.
12. Livaditis GJ. Etched-metal resin-bonded intracoronal cast restorations.
Part II: Design criteria for cavity preparation. J Prosthet Dent 1986;56:389–395.
13. Bodell RW, Kent WA, Shillingburg HT, Duncanson MG. Fracture
resistance of intracoronal metallic restorations and three luting materials. J Dent Res 1991;70(1 suppl):562.
14. Bentley C, Drake CW. Longevity of restorations in a dental school clinic.
J Dent Educ 1986;50:594–600.
15. Maryniuk GA. In search of treatment longevity—A 30-year perspective. J Am Dent Assoc 1984;109:739–744.
16. Meeuwissen R, van Elteren P, Eschen S, Mulder J. Durability of amalgam restorations in premolars and molars in Dutch servicemen. Community Dent Health 1985;2:293–302.
17. Arthur JS, Cohen ME, Diehl MC. Longevity of restorations in a U.S.
military population. J Dent Res 1988;67(1 suppl):388.
18. Qvist V, Thylstrup A, Mjör IA. Restorative treatment pattern and longevity of amalgam restorations in Denmark. Acta Odontol Scand 1986;44:343–349.
19. Christensen GJ. The practicability of compacted golds in general practice
—A survey. J Colo Dent Assoc 1971;49:18–22.
20. Smales RJ. Longevity of cusp-covered amalgams: Survivals after 15 years. Oper Dent 1991;16:17–20.
21. Maryniuk GA, Kaplan SH. Longevity of restorations: Survey results of dentists’ estimates and attitudes. J Am Dent Assoc 1986;112:39–45.
22. Robbins JW, Summitt JB. Longevity of complex amalgam restorations.
Oper Dent 1988;13:54–57.
23. Qvist V, Thylstrup A, Mjör IA. Restorative treatment pattern and longevity of resin restorations in Denmark. Acta Odontol Scand 1986;44:351–356.
24. Mount GJ. Longevity of glass ionomer cements. J Prosthet Dent 1986;55:682–685.
25. Schwartz NL, Whitsett LD, Berry TG, Stewart JL. Unserviceable crowns and fixed partial dentures: Life-span and causes for loss of serviceability. J Am Dent Assoc 1970;81:1395–1401.
26. Walton JN, Gardner FM, Agar JR. A survey of crown and fixed partial denture failures: Length of service and reasons for replacement. J Prosthet Dent 1986;56:416–421.
27. Kerschbaum T. Long-term prognosis of crowns and bridges today [in German]. Zahnarztl Mitt 1986;76:2315–2320.
28. Leempoel P, de Haan A, Reintjes A. The survival rate of crowns in 40 Dutch practices. J Dent Res 1986;65:565.
29. Swift EJ, Friedman MJ. Critical appraisal. Porcelain veneer outcomes.
Part I. J Esthet Restor Dent 2006;18:54–57.
30. Burke FJ, Lucarotti PS. Ten-year outcome of porcelain veneers placed within the general dental services in England and Wales. J Dent
2009;37:31–38.
31. Bernardo M, Luis H, Martin MD, et al. Survival and reasons for failure of amalgam versus composite posterior restorations placed in a randomized clinical trial. J Am Dent Assoc 2007;138:775– 783.
32. Cohen BD, Milobsky SA. Monetary damages in dental-injury cases. Trial Lawyers Quarterly 1989;20:80–81.
Table 6-1 Features and applications of single-tooth restorations
R e s to r a ti o n S i ze o f l e s i o n
Lo nge v i ty r a ti ng
F P D a b utme nt
R P D a b utme nt I ntr a c o r o na l
Glass
ionomer Incipient 5 No No
Composite resin
Incipient to moderate
4 No No
Simple amalgam
Incipient to moderate
1 No Yes
Complex
amalgam Large 3 No Yes
Metal inlay Moderate 2 No Yes
Ceramic inlay Moderate 3 No No
MOD onlay Moderate
to large 1 No Yes
E xtr a c o r o na l
Partial coverage crown
Large 1 Yes Yes
All-metal
crown Large 1 Yes Yes
Metal- ceramic crown
Large 2 Yes Yes
All-ceramic
crown Large 3 No No
Ceramic
veneer Incipient 3 No No
FPD, fixed partial denture; RPD, removable partial denture; NA, not applicable; rev, reverse; prox, proximal.
*Dependent on tooth position, location of restoration (mesial or distal), and patient expectation.
†Structurally sound, but not esthetic.
‡An acceptable compromise treatment if cusps are capped with amalgam.
§May offer some protection in conjunction with etching and bonding.
||When used with a core or foundation restoration.
¶Can be used to replace an incisal corner.
Table 6-2 Longevity of single-tooth restorations
I nv e s ti ga to r ( s ) Typ e o f s tud y
N o . o f
r e s to r a ti o ns G l a s s i o no me r
C o mp o s i te
Bentley and
Drake14 Clinical 1,207 — 55.9% at 10
Maryniuk15 Clinical* 1,940 —
Meeuwissen
et al16 Clinical 8,492 —
Arthur et al17 Clinical 2,200 —
Qvist et al18,23 Clinical 442 — 50% at 6.1 y
Christensen19 Survey 731 —
Smales20 Clinical 768 —
Maryniuk and
Kaplan21 Survey 571 —
Robbins and
Summit22 Clinical 128 —
Mount24 Clinical 1,283 93% at 7
y Schwartz
et al25 Clinical 791 —
Walton et al26 Clinical 451 —
Kerschbaum27 Clinical 9,737 —
Leempoel et al28 Clinical 10,000 —
Swift and
Friedman29 Clinical 372 —
Burke and
Lucarotti30 Clinical 2,562 —
Bernardo et al31 Clinical 1,748 — 93.6% at 7
—, not included in study. *A complilation and interpretation of five clinical studies. †Average of survival rates for anterior, premolar, and molar crowns.
‡Inversely varied with no. of surfaces restored.