410 >

clinical review

The longevity of restorations -

a literature review
SADJ October 2015, Vol 70 no 9 p410 - p413

NA Fernandes1, ZI Vally2, LM Sykes3

Abstract
Dentists need to consider various factors when choosing
ACRONYMs
restorative materials, with the longevity of restorations be- CEREC: C  hairside Economical Restoration of Esthetic
Ceramics
ing one of the most important criteria. Replacement of failed
FPD: Fixed partial dentures
restorations constitutes over 60% of operative procedures,
GIC’s: Glass ionomer cements
leading to high annual costs. This literature review compares
PFM: Porcelain fused to metal
the survival rates of different restorative materials used for
YST:  Yttrium-stabilized tetragonal type
both direct and indirect restorations. A literature search
was carried out using Pubmed to identify all articles on re-
storative materials published from 1974 to 2014, of which 22 that a restoration survives (survival rate), is often used as a
were included in this review. For direct restorations, amal- measure of clinical performance. Replacing failed restora-
gam showed the highest survival rates (22.5 years), with tions constitutes about 60% of all operative procedures car-
an average survival rate of 95% over 10 years, followed by ried out by dentists, with estimated annual costs of around
composite resins (90% over 10 years), and glass ionomer $5 billion in the USA alone.1 Restorations have a limited
cements (65% over 5 years). For indirect restorations, gold lifespan and once a tooth is restored, a “restorative cycle”
restorations are still the “gold standard” with a 96% over commences, where the restoration will likely be replaced
10 years survival rate, followed by porcelain-fused-to-metal many times throughout the lifetime of the patient.3 Dentists
crowns (PFM) (90% over 10 years), and all ceramic crowns are obliged to inform their patients about the survival rates
(75-80% over 10 years). Amongst the ceramic restorations, of different materials and restorative procedures. This will
eMax shows the longest survival rate (90% over 10 years), allow the patients to make informed decisions regarding
and Zirconia the lowest (88% over five years). The longevity their treatment options. The United States Public Health
of restorations depends on many factors, including: materi- Service (USPHS) criteria have been used most widely to
als used, type of restorative procedure, patient parameters, determine the clinical performance of restorations. This
operator variables, and local factors. requires two independent examiners and uses a grading
system based on a number of observations (eg. retention,
colour match, secondary caries, etc.). For each observation
Introduction
there is a grading from Alpha (perfect), Bravo (less perfect),
A wide variety of materials are used by dentists in the to Charlie (complete failure).1 The majority of the articles re-
restoration of teeth. Many factors need to be considered viewed in this paper used these criteria in their evaluation,
by both the dentist and the patient when choosing the with the main focus being on survival rates.
optimal restorative material for each procedure, with the
longevity of that particular restorative material being one
of the most important.1,2
Determinants of restoration
longevity
Restoration success is the demonstrated ability of a resto- A wide variety of both patient and clinician variables will
ration to perform as expected, whereas the length of time influence the longevity of restorations.4 These include:

Caries index, where a high index is often associated with a

1. NA Fernandes: BDS. Registrar, Department of Prosthodontics,
low restoration longevity, usually due to recurrent caries.5
School of Dentistry, Faculty of Health Sciences, University of Pretoria.
2. ZI Vally: BDS, MDent (Pros). Senior Specialist, Department of
Prosthodontics, School of Dentistry, Faculty of Health Sciences, Restoration size, with larger restorations having great-
University of Pretoria. er failure rates due to their greater surface area, making
3. LM Sykes: BDS, MDent (Pros). Head of Clinical Unit and Associate them more susceptible to recurrent caries, fracture, and
Professor, Department of Prosthodontics, School of Dentistry, restoration failures.5
Faculty of Health Sciences, University of Pretoria.

Corresponding author Tooth position, with molars having lower restoration sur-
NA Fernandes: vival rates than anterior teeth.5 This relates to restorations
Department of Prosthodontics, School of Dentistry, Faculty of Health being larger on posterior teeth and sustaining greater oc-
Sciences, University of Pretoria. E-mail: [email protected]
clusal forces, affecting their longevity.
www.sada.co.za / SADJ Vol 70 No. 9
clinical review <
411

Clinician variables: more experienced clinicians have those required for demineralization to occur.11 Current ap-
higher restoration survival rates. proaches have seen the introduction of new nanocom-
posite materials which release fluoride (F-), calcium (Ca 2+),
Patient parameters may also play a role. Studies found and phosphate (PO4) ions. These calcium and phosphate
that those who regularly change dentists had their resto- ions combine to form hydroxyapatite [Ca10(PO4)6(OH)2],
rations replaced more frequently, while restoration failures thus strengthening the tooth and combating secondary
are highest among older patients and lowest in the 4-18 caries.12 More studies and further development of these
year age group. This may purely be due to older patients new materials is however needed.
having older restorations, however, caries incidence is
also higher in the elderly due to changes in their stoma- Glass ionomer cements (GIC’s)
tognathic system, impaired motor function, and reduced
As mentioned, GIC’s make an excellent dentine replace-
salivary flow rates, amongst others.5
ment as a lining or base when managing dentinal caries
but lack the physical properties needed to be used alone
How long should restorations last? for posterior restorations.2 In addition, they are more read-
A literature search was undertaken using Pubmed in the ily lost interproximally where reduced saliva flow leads to
identification of relevant articles published from 1974 up sustained low pH levels. Improved saliva flow on other
to and including 2014.The following keywords were used: tooth surfaces helps restore the resting pH levels.11 These
longevity, restorations, prosthodontics, crowns, all ce- materials are most effective buffers in acidic environments
ramic, zirconia, CAD/CAM, amalgam, composite, lifespan, and are also excellent luting agents. Their primary use is
survival. Twenty two articles have been included in this for restoring Class V cavities, primary teeth, and in the ART
review, which covers both direct and indirect restorative technique (atraumatic restorative treatment). In primary
materials as well as different manufacturing techniques. teeth GIC’s have a 93-98% survival (over the longevity span
of the tooth), and a median survival of 30-42 months in per-
Direct restorations manent teeth. Their annual failure rate when used alone as
Amalgam a restorative material is estimated to be 7%.4
This is still one of the most commonly used restorative ma-
terials in posterior teeth in some countries. It’s use is how-
ever declining due to higher aesthetic demands of patients
and their concerns over mercury toxicity.6 It has a unique
ability to seal itself over time by a phenomenon known as
“creep”,7 which has been defined as “the deformation of
a metal under a load that is below its proportional limit”.8
Dental amalgams have been shown to “creep” as a con-
sequence of low-frequency cyclic stresses resulting from
mastication and from thermal changes during ingestion of
hot and cold food. The material expands with internal cor-
rosion and phase changes, which will fill in the microscopic
space at the tooth-amalgam interfaces. The median surviv-
al time of amalgam has been estimated to be 22.5 years,2
with some studies showing annual failure rates of 3%.4

Composite resin
Early composite resin materials showed failure rates as
high as 50% after 10 years.2 This has drastically improved
with the introduction of newer products. These materials
can currently be classified as nanofilled, microfilled, or mi-
cro/nanohybrid materials with filler quantities varying from
42-55%. Of these, the hybrid composites performed the
best with annual failure rates of 1.5-2%, most often as
a result of restoration fracture.9 The major drawbacks of
these materials are polymerization shrinkage and polym-
erization stress. These have the potential to initiate fail-
ure at the composite-tooth interface which will result in
post-operative sensitivity and the opening of pre-existing
enamel microcracks. Newer low stress flowable base ma-
terials can overcome some of these problems by reducing
the amount of stress generated during polymerization (1.4
MPa compared with 4 MPa for other flowable compos-
ites).10 Such restorations should be followed up periodi-
cally for early detection of problems as once failures e are
initiated there is usually a rapid progression. The place-
ment of glass ionomer cement liners under composites
further improved their success rates and is now regarded
as a “gold standard” procedure especially in posterior
teeth. These cements resist caries formation in the adja-
cent tooth structure by maintaining the pH at levels above
412 > clinical review

Indirect restorations tetragonal. Zirconia ceramics used in dentistry are of the

Gold crowns and inlays Yttrium-stabilized tetragonal type (YST), which offer excel-
These are considered the “gold standard” against which lent mechanical performance, strength, and fracture resist-
all other restorations are measured in terms of longev- ance.16 This is possible by the “phase transformation effect”
ity. The most common biological reason for their failure that these materials undergo (tension induced tetragonal-
is secondary caries, with retention loss being the most to-monoclinic phase transformation).14 The net result is a
common technical cause of default. Studies have shown volumetric expansion which compresses cracks to prevent
survival rates to range from 96% over 10 years, 87% over propagation and enhances toughness to resist fractures.
20 years, to 74% over 30 years2 with a mean failure rate of Cracking and crazing of the veneering porcelain is of major
1.4% in the posterior permanent dentition.4 concern with some studies reporting this problem in as
many as 50% of cases after only two years.2 This is the
Porcelain fused to metal (PFM) crowns result of chewing forces being exerted on a very weak
These restorations have been reported to have a 97% 10 90MPa feldspathic veneering porcelain, with the underlying
year survival rate.2 The majority of failures (65%) occur in 1000MPa zirconia substructure remaining intact, leading to
the anterior region (traumatic zone), and have been attrib- ultimate failure of the restoration. Such chipping can also
uted to eccentric chewing forces, iatrogenic factors, ac- be attributed to rapid cooling protocols during fabrication
cidents, and inadvertent contact with instruments during when firing the veneering feldspathic porcelain onto the zir-
surgical operations.13 conia substructure.14 This can be overcome to some extent
by ensuring slower cooling when the final restoration is re-
moved from the furnace.14 These restorations have survival
All ceramic crowns rates of 96% after two years, and 94% after four years,2 but
Many different types of materials are available for all-ce- longer term clinical studies are still needed.
ramic restorations. These can be chosen depending on the
properties required for a particular clinical situation (such as Ceramic inlays and onlays
aesthetic concerns versus the need for strength).2
IPS-Empress inlays and onlays have been shown to have
The lifetime of these materials depends on the presence survival rates of 96% after 4.5 years, and 91% after seven
of incidental cracks and their propagation under intra-oral years.2 With the introduction of CAD/CAM systems into
conditions.14 There are substantial differences in material dentistry, in particular the CEREC (Chairside Economical
properties of the different ceramics, and thus they should Restoration of Esthetic Ceramics) system, clinicians are
be considered separately. now able to use composite resin and ceramic materials to
fabricate indirect restorations.17 The CEREC 1 system was
Heat pressed, reinforced ceramics mainly used for chairside fabrication of inlays and onlays
Leucite-reinforced (eg. IPS Empress I) is reported to have with long-term studies showing adequate survival rates of
a 99% survival rate after 3.5 years, and a 95% survival 97% over five years, and 90% over 10 years.2 The main
after 11 years, with better success reported for ante- reasons for failure of these restorations were the result of
rior restorations.2 The IPS EMax system is comprised of ceramic fracture (feldspathic porcelain), followed by frac-
lithium disilicate (Li2O2SiO2) glass ceramic and zirconium tures to the underlying supporting tooth. With advances
dioxide (ZrO2) materials which are suitable for pressing, in technology, the CEREC 2 system was capable of pro-
but can also be used with the CAD/CAM technologies. ducing inlays, onlays, full and partial crowns with survival
This is a highly durable, very strong (360-400MPa flexural rates of 87% over seven years. The current CEREC 3 sys-
strength) ceramic which can overcome some of the prob- tem will manufacture veneers, short bridges, and implant
lems encountered with the chipping off of porcelain which abutments, with survival rates for these being 95-97%
is commonly encountered in zirconia restorations. Studies over five years.18
have shown their survival rates to be promising, with sys-
tematic reviews showing these to be in the region of 96% Fixed partial dentures (FPD’s / bridges)
after five years.15 These can be divided into PFM and all ceramic. Studies
have shown survival rates to be 92% over 10 years, and 75%
Slip-cast glass-infiltrated ceramics over 15 years for the PFM type, 93% survival rates over five
These include magnesia, alumina, and zirconia infiltrated var- years for zirconia, and 89% survival rates over five years for
iants, with some studies showing survival rates of 92-100% all ceramic FPD’s. The sharp decline in survival rates after
over five years for the magnesia and alumina variants.2 10 years (PFM) can be attributed to material fatigue (of the
restoration or luting cements), recurrent caries, or retention
Metal oxide ceramics loss. FPD’s on implants have 87% 10-year survival rates.2
These materials usually contain alumina or zirconia which
confer a toughness and superior fracture resistance but Resin bonded fixed partial dentures
also inferior aesthetics due to the inherent opacity found in (Maryland)
the high-density metal oxide crystals. Clinical studies have
Longevity rates for these types of restorations vary widely,
shown Procera Alumina crowns to have success rates of
with some studies showing 88% five year survival rates.
98% over 5 years, and 94% over 10 years.2 Zirconia has
They are mostly lost due to de-bonding. Those in the
been referred to as “ceramic steel” because of its superior
anterior regions seem to survive longer than those in the
material properties. It is a crystalline dioxide of zirconium,
posterior regions. Posterior restorations in the maxilla
with mechanical properties similar to those of metals and a
survive longer than those in the mandible, possibly due to
colour similar to that of teeth. Zirconia crystals are organ-
greater masticatory forces being applied to the posterior
ized into three different patterns: monoclinic, cubic, and
mandible causing more frequent de-bonding at this site.
www.sada.co.za / SADJ Vol 70 No. 9
clinical review <
413

When these restorations are re-bonded there are greater 10. Van der Vyver P. Clinical application of a new flowable base
failure rates, with 40% failing after their first re-bonding material for direct and indirect restorations. International Den-
and 60% failing after second re-bonding respectively. tistry South Africa. 2010;12(5):18-27.
Inappropriate case selection, and design flaws will not be 11. Knight GM, McIntyre JM, Craig GG, Zilm PS, Gully NJ. An
in vitro investigation of marginal dentine caries abutting com-
corrected by re-bonding these types of restorations, which
posite resin and glass ionomer cement restorations. Austral-
can explain their high failure rates.2 ian Dental Journal. 2007;52(3):187-92.
12. Xu HHK, Weir MD, Sun L, Moreau JL, Takagi S, Chow LC,
Endodontically treated teeth Antonucci JM. Strong nanocomposites with Ca, PO4, and
When restoring endodontically treated teeth, the use of F release for caries inhibition. Journal of Dental Research.
2010;89(1):19-28.
the sandwich technique, where a glass ionomer base is
13. Ozcan M, Niedermeier W. Clinical study on the reasons for
covered with overlying composite resin, is the preferred and location of failures of metal-ceramic restorations and sur-
method for minimizing coronal leakage.19 When there is vival of repairs. The International Journal of Prosthodontics.
inadequate tooth structure remaining, cast post and core 2002;15(3):299-302.
restorations have been found to have success rates of 14. Tinschert J, Natt G, Mohrbotter N, Spiekermann H, Schulze
90% over 10 years.20 If pre-fabricated posts need to used, KA. Lifetime of alumina- and zirconia ceramics used for crown
fibre-reinforced posts offer better long-term success and bridge restorations. Journal of Biomedical Materials Re-
compared with metal posts, as these tend to cause more search. Part B: Applied biomaterials. 2007;80(B):317-21.
root fractures due to their higher modulus of elasticity 15. Ivoclar/Vivadent. IPS e.max scientific report. 2001-2013;vol.2.
compared with dentine.21 Sealer selection is also impor- 16. Saridag S, Sevimay M, Pekkan G. Fracture resistance of teeth
restored with all-ceramic inlays and onlays: an in vitro study.
tant with AH-26 (epoxy sealer) offering better resistance
Operative Dentistry. 2013;38(6):626-34.
to leakage than ZOE (zinc oxide eugenol) based sealers.19 17. Tsitrou E, Helvatjoglou-Antoniades M, Pahinis K, van Noort R.
Endodontically treated teeth can have survival rates of Fracture strength of minimally prepared resin bonded CEREC
97% over 5-8 years if adequately restored.22 inlays. Operative Dentistry. 2009;34(5):537-43.
18. Fasbinder DJ. Clinical performance of chairside CAD/CAM
Conclusion restorations. Journal of the American Dental Association.
2006;137(9)Suppl:22S-31S.
The longevity of restorations is dependent on a multitude 19. Kurtzman GM. Improving endodontic success through coro-
of factors making it difficult to compare success rates. nal leakage prevention. Dental Tribune Asia Pacific edition.
Based on current findings, we can, however, convey evi- 2012:20-3.
dence-based information to our patients regarding antici- 20. Balkenhol M, Wostmann B, Rein C, Ferger P. Survival time of
pated restoration survival rates. It is essential to establish cast post and cores: a 10-year retrospective study. Journal of
effective communication with our patients so that they can Dentistry. 2007;35:50-8.
make informed decisions regarding their treatment. 21. Fahmy NZ. Effect of dowel material and design on the fracture
resistance of premolars. Dentistry. 2012;2(1):1-8.
References 22. Hannahan JP, Eleazer PD. Comparison of success of implants
1. Kim KL, Namgung C, Cho BH. The effect of clinical perform- versus endodontically treated teeth. Journal of Endodontics.
ance on the survival estimates of direct restorations. Restora- 2008;34(11):1302-5.
tive Dentistry and Endodontics. 2013;38(1):11-20.
2. Schwass DR, Lyons KM, Purten DG. How long will it last? The
expected longevity of prosthodontic and restorative treatment.
New Zealand Dental Journal. 2013; Sep :98-105.
3. Chadwick B, Treasure E, Dummer P, Dunstan F, Gilmour A,
Jones R, Phillips C, Stevens J, Rees J, Richmond S. Chal-
lenges with studies investigating longevity of dental restora-
tions- a critique of a systematic review. Journal of Dentistry.
2001;29:155-61.
4. Goldstein GR. The longevity of direct and indirect posterior
restorations is uncertain and may be affected by a number of
dentist-, patient-, and material-related factors. Journal of Evi-
dence- based Dental Practice. 2010;10:30-1.
5. McCracken MS, Gordan VV, Litaker MS, Funkhouser
E, Fellows J, Shamp D, Qvist V, Meral JS, Gilbert GH. A
24-month evaluation of amalgam and resin-based compos-
ite restorations. Journal of the American Dental Associa-
tion.2013;144(6):583-93.
6. Ioannidis G, Paschalidis TH, Petridis HP, Anastassiadou V.
The influence of age on tooth-supported fixed prosthetic res-
toration longevity. A systematic review. Journal of Dentistry.
2010;38:173-81.
7. Rho YJ, Namgung C, Jin BH, Lim BS, Cho BH. Longevity of
direct restorations in stress-bearing posterior cavities: a retro-
spective study. Operative Dentistry. 2013;38(6):572-82.
8. Osbourne JW. Creep as a mechanism for sealing amalgams.
Operative Dentistry. 2006;31(2):161-4.
9. Rodolpho PA, Donassollo TA, Cenci MS, Loguercio AD, Mo-
raes RR, Mronkhorst EM, et. al. 22-year clinical evaluation of
the performance of two posterior composites with different
filler characteristics. Dental Materials. 2011;27:955-63.