A Health Technology Assessment Report on: Different ... · A Health Technology Assessment Report on: ... A Health Technology Assessment Report on Different retention systems used

DENT655-HealthTechnologyAssessment

AHealthTechnologyAssessmentReporton:DifferentretentionsystemsusedforEndostealImplantsupportedprosthesisinpartiallyedentuloussites

by

MuraliRamamoorthia

withtheexpertassistanceof

ShahrokhEsfandiarib

April2015

ReportNo:S2015.03

aMasterscandidate,FacultyofDentistry,McGillUniversity,Montreal,CanadabAssociateProfessor,DivisionofOralHealthandSociety,FacultyofDentistry,McGillUniversity

FormoreinformationcontactDr.ShahrokhEsfandiariatshahrokh.esfandiari@mail.mcgill.ca

“The views expressed in this report are those of the author(s) and do not necessarily reflect the views of the Faculty of Dentistry, McGill University. This report was developed for the course ‘DENT 655- Health Technology Assessment’ and assumes a call from general dentists to assist decision-making in dental offices, clinical and hospitals. All are welcome to make use of it. However, to help us estimate the impact, it would be deeply appreciated if users could inform us whether it has influenced policy decisions in any way.”

Suggested citation: Ramamoorthi M & Esfandiari S. (2015). A Health Technology Assessment Report on Different retention systems used for endosteal implant supported prosthesis in partially edentulous sites (Report no: S2015.03). Montreal, Faculty of Dentistry, McGill University. Retrieved from:

https://www.mcgill.ca/dentistryohs/courses-and-events/dent-655/hta-reports

RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.

Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada.

AcknowledgementsThe authors would like to acknowledge following individuals for their contributions in this

report.

Dr. Aparna Narvekar, MDS, Canada. provided her valuable assistance in search strategy,

data extraction and critical appraisal of the included studies.

These following individuals kindly provided their feedback on this report.

Dr. Amrita Kumari, BDS

Masters Candidate

Faculty of Dentistry, McGill University

Canada.

Dr. Sadaf Farookhi, BDS

Masters Candidate


Canada.

Dr. Vivek Verma, BDS, MSc

Masters Candidate


Canada.



TableofContents

LIST OF TABLES, FIGURES, GRAPHS

GLOSSARY

EXECUTIVE SUMMARY ……………………………………………………………1-2

1. INTRODUCTION………………………………………………………………….3-8

1.1. Context 1.1.1. Partially edentulous condition 1.1.2. Epidemiology 1.1.3. Importance of treating partial Edentulism 1.1.4. Various therapeutic options 1.1.5. Rationale in choosing Implant supported prosthesis 1.1.6. Importance of retention system in implant treatment

1.2. Retention system options. 1.3. Issues

2. OBJECTIVES ……………………………………………………………………...8-9

3. METHODS………………………………………………………………………10-20 3.1. Systematic review & Meta-analysis methods

3.1.1. Literature search strategy. 3.1.2. Selection criteria and methods. 3.1.3. Data extraction strategy. 3.1.4. Critical Appraisal of included studies. 3.1.5. Data analysis & meta-analysis

methods. 3.2. Economic analysis.

3.2.1. Type of economic evaluation. 3.2.2. Model structure. 3.2.3. Data inputs. 3.2.4. Costs & Perspective 3.2.5. Assumptions.

4. RESULTS………………………………………………………………………20-50 4.1. Selection of primary studies. 4.2. Study characteristics. 4.3. Critical appraisal of included studies. 4.4. Data synthesis 4.5. Economic Evaluation

5. DISCUSSION…………………………………………………………………..50-55 5.1. Summary of clinical evidence.


Dent-655HealthTechno ogyAssessment.FacultyofDentistry.McG Un vers ty,Canada

5.2. Ethical and legal considerations. 5.3. Strengths and limitations of the systematic review.

5.3.1. Strengths. 5.3.2. Limitations.

6. CONCLUSION……………………………………………………………………56

7. REFERENCES.

8. ANNEXURES.

ListofTables. 1. Therapeutic option available for managing partial edentulism

2. Comparison between single implant Vs 3 unit FPD

3. List of survival events

4. Search strategy.

5. Inclusion and exclusion criteria

6. PRISMA flow diagram.

7. Basic study characteristics of the included studies.

8. Analysis of excluded studies.

9. Analysis of included studies.

10. Results for Failure rate.

11. Results for Survival rate

12. Results for Event free rate

13. Failure rate by prosthesis and implant characteristics..

14. Survival rate by prosthesis and implant characteristics.

15. Minor and major complication events.

16. Data input in economy model.

17. Summary of results for outcome: Failure, survival

List of Figures:

1. Markov transition model.

2. Decision tree.

3. Meta – analysis [Forest plot] of failure, survival and event free effective rate using both

models.

4. ICER slopes – single crowns

5. ICER slopes- FPD.



Acronyms&Abbreviations:

Ab- Abutment.

AAID- American Academy of

Implant Dentistry.

ACC: All Ceramic crown

CAD-CAM: Computer assisted

design/Computer aided milling.

C/CL – Cantilever FPD

Cem- Cemented

Comp- Complications

CD- Complete denture

FPD- Fixed partial denture

FDP- Fixed denture prosthesis

GPT- Glossary of Prosthodontic

terms.

IAC- Integrated abutment crown.

ICER- Incremental Cost

effectiveness ratio

IS - Implant supported

IT-S –Implant tooth supported.

M-C- Mechano-chemical

OD-Over denture

PFM: Porcelain fused to metal

PBM: Porcelain fused to base metal.

PFG: Porcelain fused to Gold.

Ret-Retention

RPD: Removable partial denture.

S- Single crown

Sp-splinted crown

VAD- Virtually aided design.



Glossary:

Abutment: The portion of an implant

above the neck used to provide support

for a fixed, fixed-detachable or

removable dental prosthesis.

Abutment screw: that component which

secures the dental implant abutment to

the dental implant body.

Abutment post: that component of a

dental implant abutment which extends

into the internal structure of a dental

implant and is used to provide retention

and/or stability to the dental implant

abutment.

Angled abutment: The prosthetic

coupling component of an implant

designed to fitted with a crown or other

anchorage attachment: available in a

variety of angles upto 35◦.

Antirotation component: a component

of the implant body-hexagonal, tapered

[morse] or with some other internal

design placed to prevent unwanted

abutment rotation.

Cantilever: a beam or bridge segment

which is unsupported at one end.

Cantilever FPD: a fixed bridge which is

unsupported at one end.

Cement: a bonding substance designed

to temporarily or permanently bond

prosthesis to implants or natural teeth.

Ceramics: compounds of a metal and

oxygen formed of chemically and

biochemically stable substances that are

strong, hard bonding, brittle and inert

non- conductors of thermal and electric

energy characterized by ion

Crown: the portion of a tooth protruding

into the mouth for purpose of chewing or

a prosthetic replacement of this structure.

Endosseous implant: a device placed

within alveolar or basal bone designed to

serve as a prosthetic abutment.

Fabrication: the construction of a

structure or prosthesis.

Implant crown: a casting placed over an

implant abutment designed to assume the

role of a natural crown.

Implant loading: placement of

prosthetic devices to bring an implant

into function.

Implant prosthesis: a denture supported

in whole or in part by implants.



Implant system: a coordinated set of

instruments and supplies designed to

perform the various steps of implant

insertion, prosthetic reconstruction. It

represent a specific concept, inventor or

patent.

Luting agent: any material used to attach

or cement restorations to prepared tooth

or implant abutment.

Metal ceramic: tooth/implant retained

fixed dental prosthesis that uses a metal

substructure upon which a ceramic

veneer is fused.

Porcelain: a ceramic material formed of

infusible elements joined by lower fusing

materials.

Prosthesis: an artificial device used to

substitute for a lost or under functioning

body part.

Prosthesis screw: a screw designed to

fasten a prosthesis to an implant or to

bone.

1


ExecutiveSummary:

Background:

Knowing the success/failure rate, survival rate, type and incidence of maintenance

events associated with each retention type and associated costs help the dentist in choosing

appropriate retention system.

Objectives:

To assess the various retention types used for the partially edentulous implant supported

fixed prosthesis in terms of following outcomes: success, failure, survival and cost

effectiveness.

Methods:

Three tier electronic database search [ I. MEDLINE via OVID, EMBASE, PUBMED, II-

Cochrane reviews, CENTRAL, INAHTA, CADTH, CRD, III- clinical trials.org, google

scholar, IADR abstracts, Journal databases] supplemented by manual search was

conducted to identify best, good, fair graded study designs reporting of atlas one year

follow-up. Neither language, nor date of publication restrictions applied. Randomized

clinical trials, controlled clinical trials, prospective studies, and retrospective with follow-

up clinical examination study designs reporting retention methods with relevant clinical

outcomes [Prosthesis success/failure/ technical complications/mechanical

complications/biomechanical complications, implant failure] were included. Selected

studies were critically analyzed using EHPP” Quality assessment tool for quantitative

studies”. Those studies that scored poor in the quality assessment were excluded from data

synthesis. Two reviewers independently carried out the screening of eligible studies. Data

from the studies that scored strong or medium in the quality assessment were used to

estimate 5 yr, 10 yr, 20 yr success, failure and complication results. The data was

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categorized into sub groups based on Prosthesis design, Implant characteristics, Abutment

characteristics and the edentulous site. Chi square test was used to investigate the

heterogeneity. Markov Cost effectiveness model was used to analyze the cost

effectiveness.113 from 3875 [initial search] were selected for quality assessment. Kappa

inter reviewer agreement was 0.957 at stage 1, and 0.857 at stage 2. 15 % of the studies

were rated as strong, 77% as medium and 8% as weak based on the quality assessment tool.

The strong and medium [n=104] studies were selected for data extraction and analysis.

Among 104, 14.42% were RCTs, 4.8% CCTs, 53.84% prospective studies and 26.92%

retrospective.

Key limitations of this report are related to the poor availability of data and the suitability

of available data for statistical pooling. So the research question “Do different retention

systems affect the survival, event free and failure rates of IS- prosthesis” is not fully

answered.

Conclusion:

From the evidence generated from the studies meeting the inclusion criteria, within

limitations, cement retained prosthesis [single crown and FPD] is comparatively better than

screw retained prosthesis in partially edentulous patients.

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1. INTRODUCTION1.1. Context and Issues: 1.1.1. PartialEdentulism

Partial Edentulism can be defined as absence of some but not all of natural teeth1,3.

Dental caries and periodontal disease are the major causes of partial tooth loss. The partially

edentulous patients are diverse in nature with wide variations in physical and health

conditions. Traditionally these patients are categorized into four types based on the site of

missing teeth: Class 1- Bilateral edentulous areas located posterior to remaining natural

teeth, Class 2- unilateral edentulous area located posterior to remaining natural teeth, Class

3- a unilateral edentulous area with natural teeth both anterior and posterior to the missing

area, Class 4- single but bilateral [i.e. crossing the midline] edentulous area located anterior

to the remaining natural teeth3.

1.1.2. Epidemiology

Based on ACP and AAID, 178 million people [about 10% population] in US are

partially edentulous. This number is expected to be around 200 million in the next 15 years.

Approximately 2.3 million implant supported crowns are made annually4,5. Canadian

Health Measure Survey [CHMS 2007-2009] reported that 14.6% of Canadian adults aged

20 to79 years have fewer than 21 teeth6. 21.4% of population aged 15 to 74 years use partial

prosthesis and 71.5% of 65 to 74 years old are partially edentulous.7

1.1.3. ImportanceoftreatingpartialEdentulism

Tooth loss is a permanent irreversible condition. The consequence of tooth loss is

associated with loss of function, speech, loss of self-esteem and deterioration in the quality

of life. Tooth loss in the anterior region results in significant esthetic impact. Managing

4


tooth loss in partial edentulism is considered as an essential necessity to improve one’s

form and function.8

1.1.4. Availabletherapeuticoptions

Partial tooth loss is majorly categorized into tooth-supported (those with teeth

both anterior and posterior to the missing teeth) and tooth-tissue supported (teeth either

anterior or posterior to the edentulous space)9. The possible therapeutic options for partial

edentulism are summarized in the following Table-1

Table: 1. Therapeutic options for partial edentulism:

Tooth Supported Tooth-Tissue Supported

- Removable partial denture[RPD] - Fixed partial denture[FPD] - Implant supported prosthesis

- Removable partial denture[RPD] - Implant supported prosthesis

1.1.5. RationaleinchoosingImplantsupportedprosthesis

Among the possible therapeutic options RPDs have the lowest patient acceptance

rate in dentistry. The success rate of the conventional RPD was estimated as 40% at 5 years

and 20% at 10 years10. Mobility of abutment teeth, greater plaque retention, higher

incidence of caries, speech and taste inhibition, non-compliance of use are some of the

disadvantages associated with the RPD11-13. If the adjacent teeth are intact or with minor

restorations, conventional FPD is used.

FPD has been the treatment of choice for replacing missing teeth in partial edentulism for

more than six decades. The mean life span was estimated as 9.6 to 10.3 years14. Creugers

et al [1994] calculated the survival rate for FPD as 74% based on 42 reports with mean

observation period of 15 years15. Libby [1997] in his report mentioned that 15% abutment

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teeth supporting FPD required endodontic therapy, and over 20% of the abutments are at

caries risk16.

Salient conclusions have emerged from anecdotal studies that RPD may be associated with

problems of patient compliance, acceptance and tissue tolerance; while FPD with the

sacrifice of sound tooth structure and risk of pulpal injury. Additionally, economic

comparisons between dental implants and FPDs in partially edentulous cases concluded

that implant supported prostheses would be cost effective in the long term. The detailed

initial cost and maintenance comparisons for 30 years is shown in the table-2. This is based

on the assumption that a young patient receives a FPD which has to be replaced at 10 yr,

20 yr, & 30 yr[ initial cost 2700$+ 3 x 2700$= 10,800 $ total cost] and Implant supported

single crown replacing the crown at 10 yr, 20 yr, 30 yr [ initial cost= 4000$ +3 x 900$=

6700]. Breakeven point reached at 7 years.

Initialcost 10years 20years 30years

Singleimplant

supportedcrown4000 4900 5800 6700

3unitFPD 2000 5400 8100 10800

Table 2: Economic comparison [Cumulative investment] between single implant supported crown and three unit fixed partial denture17.

Furthermore, maximum number of posterior teeth safely replaced with

conventional FPD is ideally two, but three is acceptable. Implants have been an alternative

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to other therapeutic options for more than 30 years. To date, implants indicate comparable

or better success rates compared with FPD/RPD19-22. Based on the facts and its virtue of

restoring missing teeth without damaging adjacent teeth or supporting structures, implant

supported prosthesis may be the ideal choice for treating partially edentulous patients.

1.1.6. Importanceofretentionsysteminimplanttreatment

Almost 15 years after its use in completely edentulous patients, dental implants

were proposed to support prosthesis in partially edentulous conditions17,20 in 1983 by Zarb.

To date, the five year survival rate is estimated to be more than 90% for most of the implant

systems20. Implants have no resilience in the bone and the fit between the implant and the

superstructures is responsible for the development of biomechanical stresses and associated

events23. Among the various parameters that determine the survival of implant supported

prosthesis, the method to retain the prosthesis to the implant or superstructure determine

the nature and complexity of maintenance events it undergoes over its life span. Thus, the

type of connection [retention system] between the prosthesis and implant influences the

complication rate and longevity of the replacement24-29.

1.2. Retentionsystem options.

Three types of retention systems were reported in the literature for the partial

edentulism: 1. The prosthesis screwed onto the implant directly 2. The prosthesis screwed

to abutment 3. The prosthesis cemented to abutment. The first and second methods are

termed as screw retained implant supported prosthesis and the third one is called as cement

retained prosthesis. However, for this report we would like to consider the retention systems

as follows 1. Screw retained 2. Cement retained and 3. Mechano-chemically retained. The

third category is based on the availability of screwless, cementless system to

7


attach the prosthesis to implants30. The category (the prosthesis screwed onto implant

directly) in the traditional classification is included in the mechano-chemical retention

system. This is because the crown is chemically bonded (porcelain fired on the metal coping)

over a metal substructure which later screwed to the implant. This is similar to screwed

abutment.

1.3. Issues:

Today a dentist has a difficult task of choosing implant systems and its components.

Dental Implants are translated from the phase of development [1990s] to phase of

predictable implants in 2000, now we are in phase of confusion as a result of numerous

implant systems and a variety of associated components. The numbers of available implant

systems grown from 98 in 2000 to 600 in 2008 from atleast 146 different manufacturers20,

31. Moreover, it is further complicated with 1500 different abutments varied by material,

shape, size, diameter, length, and surface and interface geometry. Virtually all major

manufacturers documented success rates more than 90%20, 32. Although long-term

predictability is well documented, the major issue is the long-term stability of abutment and

prosthesis31.This is primarily determined by the retention system used to attach the

prosthesis to the implants. Choosing an appropriate dental implant system from hundreds

of implant systems and thousands of different available components, is simplified by

choosing the type of retention system. Nevertheless, available evidence in choosing

retention system is impeded by the paucity of literature or extrapolation of results from

completely edentulous conditions.

• About 36 reviews, 7 meta-analysis and 2 consensus statements reported, either

directly or indirectly the outcomes of implant supported prosthesis in partially

8


edentulous patients. The available systematic reviews and meta-analysis have been

mainly focused on implant survivals and technical complications with little evidence

between the incidence and retention systems. Moreover, the observations and results

are mixed with data from both partially edentulous and completely edentulous

patients. Very little information is available comparing the different retention

systems used in partial edentulism.

• Partially edentulous patients differ substantially from completely edentulous

patients by anatomy, biomechanics [bite force, tooth wear, occlusal scheme] and

microbiology. Hence, extrapolating results from completely edentulous or mixed

with completely edentulous cannot be justified.

• Lack of evidences in costs associated in maintaining the prosthesis.

2. OBJECTIVES

The aim of this health technology report is to systematically review the literatures

to assess the outcome of different retention systems used in partially edentulous patients to

support the implant prosthesis and to determine the type of retention systems that can be

recommended for clinical application. Thus, the objectives are to assess the effects of

different retention systems (screw retained, cement retained, mechano-chemically

retained) used for Endosseous implant supported prosthesis in partially edentulous patients

in the terms of following outcomes:

§ Failure.

§ Survival

§ Event free

§ Cost effectiveness

9


Failure is defined as implant which is not in service or not able to support the prosthesis.

i.e. implant is completely lost/ fractured.

Survival is defined as implant that is in service, but the prosthesis may or may not be. If

the prosthesis and implant components remains insitu but require minor corrections in

order to continue its function, it is termed as minor complication events. If the prosthesis

or implant components need major modifications to continue its function, it is termed as

major complication events. The comprehensive list of minor and major complications

events are enumerated in the table: 3

Table: 3 List of survival events

Minor Complication events Major complication events

• Abutment screw loosening • Prosthesis screw loosening • Decementation, fracture of luting

cements. • Porcelain fracture/ Ceramic chip

that did not necessitate replacement of prosthesis.

• Loss of screw access hole. • Total loss of retention. • Biological events that does not

require change of prosthesis/ implant components [ just require oral prophylaxis]

• Abutment screw fracture • Prosthesis screw fracture • Abutment fracture • Porcelain fracture/ Ceramic chip

that necessitate replacement of prosthesis.

• Biological events that require change of prosthesis/ implant components

• Crown remake • Crown lost

Event free is defined as prosthesis being free of all complications and symptom-free over

the entire observation period. The report seeks to answer the following focused research

question: Do the different retention methods affect the success, failure, survival and cost

of Endosseous supported prostheses for partially edentulous patients aged 15 to 90 years?


10

3. METHODS3.1. Systematic review

3.1.1.Literaturesearchstrategy.

Published literature was identified by searching Ovid interface: MEDLINE

in process & other non-indexed citations, EMBASE and PUBMED. The search was

not restricted to the year of publication and the search date was until Jan 30th 2015.

Regular alerts were established to update the search until April 7th 2015. Both

National library of medicine MeSH and keywords were used. The comprehensive

literature search strategy is shown in table-4. Health technology databases [INHATA,

CRD, Cochrane registry and CADTH] were searched for existing health technology

reports. CENTRAL and clinicaltrials.gov were searched for the clinical trials. Google

scholar and IADR abstracts were searched to identify grey literatures. The literature

search was further complimented by searching the major journal database( Wiley, Elsevier,

Quintessence, Sage pub) that publishes dental implant studies and the bibliographies

of systematic reviews, meta-analysis and consensus statements.

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Table-4: Literature search strategy

Focused Question: Does different retention methods affect the success, failure, survival and cost of Endosseous supported prostheses for partially edentulous patients aged

15 to 90 years?

Population Partially edentulous patients aged 15 to 90 years.

#1 ((((((edentulous*) AND partial*)) OR ((dentulous*) AND partial*)) OR ((partial) AND ((dental arch) OR dental arch*))) OR (((partial edentulism) OR partial edentulous*) OR jaw, edentulous, partially))))

Intervention Endosseous implant supported prostheses

#2 (((((((((dental implants, single tooth) OR ((((((dental*) AND implant*) AND endosseous*)) OR ((dental*) AND implant*)) OR (((dental implants) OR dental implant*) OR dental implantation, endosseous))))

Comparison Screw retained/Cement retained/Screwless, cementless/mechano- chemical

# 3(((((((dental) OR dental*)) AND ((bridge) OR bridge*))) OR ((((dental) OR dental*)) AND ((crown) OR crown*))) OR ((((denture, partial, fixed) OR dental prosthesis retention)) OR (((((dental prosthesis) AND implant) AND supported)) OR ((((((((((((((((((dental prosthesis, implant supported) OR implant supported prosthesis*) OR implant supported prostheses) OR dental implant-abutment design) OR implant crown*) OR implant bridge*) OR suprastruct*) OR implant suprastruct*) OR fixed partial denture) OR fixed partial denture*) OR fixed denture partial) OR fixed denture partial*) OR FPD) OR FDP) OR (crown and bridge)) OR (crown* AND and bridge*)) OR crowns) OR bridges)))))) AND ((((((((screw) AND fixation)) OR screw fixation)) OR ((screw retain) OR ((((dental*) AND screw*)) OR ((((((screw*) AND retention*)) OR ((screw retained) OR screw-retained))) OR ((screw retained crown*) OR screw retained crown)))))) OR ((chemomechanically bonded) OR ((dental cement*) OR ((((cement) AND retention)) OR ((((cement) AND retained)) OR (((((((((((cementation) OR cement retain) OR cement retained) OR cement retention) OR cement fixation) OR screwless) OR integrated abutment crown) OR integrated abutment crowns) OR locking-taper implant) OR locking-taper implant*) OR dental cements)))))))

Outcome success, Failure, survival and cost

#4 (((economic analysis) OR (((cost benefit analysis) OR cost-benefit analysis) OR cost effectiveness))) OR (((((patient safety) OR safety)) OR ((((((((((((((screw) OR cement) OR ceramic*) OR porcelain*) OR crown*) OR denture, partial, fixed) OR bridge*)) OR abutment)) AND ((fracture) OR deformation))) OR (((dental leakage) OR screw loosening) OR abutment loosening)) OR (((((((((((((((survival) OR survival analysis) OR survival rate) OR success) OR success rate) OR longevity) OR failure) OR prosthesis failure) OR crown failure) OR bridge failure) OR abutment failure) OR treatment outcome) OR loss of retention)) OR ((((((((((((technical*) OR biological*) OR prosthetic*) OR prosthodontic*) OR restorative*) OR esthetics*)) AND ((complication) OR complicat*))) AND failure*)) OR ((((((((technical*) OR biological*) OR prosthetic*) OR prosthodontic*) OR restorative*) OR esthetics*)) AND ((complication) OR complicat*))))))))

Databases 1. Ovid MEDLINE, EMBASE, PUBMED. 2. Cochrane registry, CENTRAL, INAHTA, CADTH, CRD 3. clinicaltrials.gov, Google scholar, Journal database [Wiley, Elsevier, Quintessence, Sagepub]

Search Strategy Database 1: #1&#2&#3&#4 Database 2&3 : “oral implants”, “dental implants”, “ partially edentulous jaw”, “implant supported prostheses”, “ fixed partial denture”, “crown and bridge”, “single crowns”, “Endosseous dental implants”.

Filters None Journals searched through the journal database

Implant dentistry, IJOMI, Clinical oral implants & research, JDR, JPD, IJP, JOP, JOR, JOI.

Dent-655HealthTechnologyAssessment.FacultyofDentistry.McGillUniversity,Canada.

12

3.1.2. Selection criteria and methods.

Three sets of sequential inclusion and exclusion criteria were used at title, abstract

and full text review process. The detailed inclusion and exclusion criteria are tabulated in

the table-5. Language restriction was not applied at the initial stage. Study observation

periods less than one year and less than ten patients were excluded. Systematic reviews,

meta-analysis and consensus statements were excluded after full text review. Retrospective

studies without clinical follow up examinations were excluded. This was done to avoid

potential or possible inaccuracies in description that are purely based on patient self-reports

or chart reviews. In the case of multiple reports of same cohort at different time periods,

reports with longer observation time was included.

Two reviewers [MR, AN] carried out the review process [Title screening, abstract

screening, full text evaluation] independently to identify the potentially relevant articles to

be included in this report, based on the inclusion and exclusion criteria. Selected full text

articles were retrieved and assessed independently for possible inclusion. Disagreements

between the reviewers were discussed until consensus was reached. Kappa inter author

agreement was carried out at the abstract screening, full text selection to validate the inter

author agreement.


13

Table-5: Inclusion and Exclusion Criteria Inclusion Exclusion

Title Review

Human subjects. Endosseous Implant supported single crowns, FPDs RCTs, Controlled clinical trials, Retrospective, Prospective studies, Case reports, case series, Systematic reviews, Meta-analysis. Cement retained, screw-retained, integrated abutment crowns, mechano-chemical retained prosthesis

Invitro studies. Animal studies. Expert opinion, letter to editor, narrative reviews, overviews Over dentures. Completely edentulous

Abstract Screening

Human subjects. RCTs, Controlled clinical trials, Retrospective, Prospective studies. Systematic reviews, Meta-analysis

Studies less than 10 patients. Studies based on questionnaire or interviews. Studies which doesn’t report atleast one outcome measure as defined earlier. Case reports, Case series. Combination prosthesis.

Full text evaluation

Human subjects. RCTs, Controlled clinical trials, Prospective studies, retrospective studies with clinical follow up examination Studies reported details of supra structure characteristics. English & Indexed publications.

Non-English. No characteristics of implants, supported prosthesis. Observation period less than 1 year after loading. Multiple studies of same trial /study Retrospective studies without clinical follow up. Systematic reviews, Meta-analysis. Studies from which data on outcome variable are not directly retrievable or not able to be calculated. Studies considering only biologic complications [peri-implantitis, marginal bone loss, radiolucency, bleeding index, suppuration, recession, fistula/sinus, soft tissue lesions] without considering technical or prosthodontic or mechanical complications. No clinical outcome reviewed at the follow up visit


14

3.1.3. Data extraction strategy.

A priori (pre-drafted) extraction table covering the patient characteristics, implant

and prosthesis characteristics, type of retention, study characteristics and the outcome of

study were used to extract the data from the selected full text studies (Annexure 1,2).

Information on the following outcomes, failure of implants after prosthesis placement,

failure of prosthesis, minor technical complications, major technical complications,

biological complications, event free prosthesis were extracted from the selected studies.

3.1.4. Critical Appraisal of included studies.

The authors selected effective public health practice project quality assessment tool

(Annexure 3) to critically appraise the selected studies. The tool rated the quality of article

as strong, moderate or weak based on six domains: selection bias, study design,

confounders, blinding, data collection, withdrawals and dropout33, 34. Those studies, which

scored weak, were excluded from the final analysis.

3.1.5. Data analysis and Meta –analysis methods.

Information on failure of implants after loading, abutment screw loosening,

prosthesis screw loosening, crown loosening, re-cementation, abutment screw fracture,

abutment fracture, prosthesis screw fracture, minor porcelain chip, major porcelain/ceramic

veneer fracture, loss of retention, implant fracture, minor biological events and major

biological events were abstracted from the publications directly. From this information,

failure event rate, survival rate based on complication events and event free rate [1- failure

events + complication events] were calculated by dividing the total

15


number of events by total prosthesis exposure time. The total prosthesis exposure time is

sum of

1. Exposure time of prosthesis that was followed for the whole observation period.

2. Exposure time of prosthesis until implant is failed.

3. Exposure time of prosthesis until it is dropout from the observation for those

patients that did not complete the observation period due to change of address,

death of the patient and missed appointments.

If this information was not available for all these three parameters, multiplying total

number of prosthesis and the mean observation period derived the total exposure time.

The number of events or event free was considered to be a Poisson distribution. Poisson

regression would be an appropriate option for rate data where the rate is a count of events

occurring to a unit of observation. When analyzing pooled data from several clinical studies,

the estimated event rate/100 reconstructions/year is a useful parameter for statistical

comparison of the risk for complication or failure at 3,5,10 years. Based on the hypothesis

when the event rate �is constant over time, the proportion of the event free population

decreases exponentially over time. This proportion is exactly the same as the survivor

function s(t) = e-�t where �is the event rate and t is time of observation. Using this 5year,

10 year, 15 year, 20 year and 25 year cumulative survival proportion, failure proportion,

and event free proportion were calculated for the each studies with 95% confidence interval.

The detailed formula and data used for calculating each proportion is shown in the

annexure 4.

Anticipating reasonable heterogeneity among the selected studies [study population,

sample size, study setting, objectives] random effect model was used to obtain the summary

16


estimate of the proportions. Goodness of fit statistics was used to reassure the heterogeneity

of study specific event rate and associated P value was calculated. P value <0.05 indicates

heterogeneity, further I2 statistics were also reported along with the P value. Where there is

no statistical heterogeneity observed, both models were used to calculate the proportion

rate and forest plot was generated. Subgroup analysis [by prosthesis design, abutment

material type, prosthesis material type, implant-abutment connection type, edentulous site,

abutment-implant attachment mechanism, luting type] was performed using Meta

regression to identify the outcome differences. All P values were two sided.

All statistical and meta-analysis calculations were carried out using commercially available

software comprehensive meta-analysis [CMA, Biostat, Englewood, NJ,USA] and Stata

version 13.1[ Stata corp LP, college station Tx,USA].

3.2. Economic analysis. 3.2.1. Type of economic evaluation.

The evaluation was a cost effective analysis with the incremental cost effectiveness

as the primary outcome measure.

17

3.2.2. Model structure.

Cost effectiveness was determined as the ratio between survival probabilities of

each treatment modality divided by total fee for that treatment. A Markov model was built

to stimulate the lifetime of an implant supported prosthesis in partially edentulous patients.

A decision tree over a 15 year period was developed to estimate event free rate which was

defined as reconstructions and implants are free from any symptoms and complication

events. The model estimates the lifetime cost and longevity for each type of retention

system.

Fig1. Markov transition Model

18

Fig:2: Decision Tree

3.2.3. Data inputs.

All outcome data was based on the results of our meta-analysis. We assume, this

2011-2012 ADA survey35 was used to calculate the associated clinical cost[Annexure-5].

The lab cost associated with each prosthesis was obtained from the various commercial

laboratory websites and averaged. The overhead costs [labor costs] were obtained from the

US labor statistics36 [Annexure-6]. Associated patient time and dentist productivity time

were not included in this analysis.. Markov transition model was constructed first with

parameters and then it is transformed into decision tree. At the starting point our strategy

model was event free. Cost effective ratio was calculated to determine the treatment

modalities rank.

3.2.4. Costs.

19

The costs incorporated within the model included those initial costs of placing

implants, abutments and crowns and direct cost associated with minor /major

adjustments/remakes. This analysis was conducted from the perspective of North America

with costs adjusted to 2015[4.3% cumulative rate of inflation]37.

3.2.5. Assumptions. The following assumptions were made in this economic evaluation:

- Initial cost for screw retained and cement retained are same assuming that

implant does not need any adjuvants or grafts.

- All costs were obtained from ADA 2011-12 survey and the charges of a

general dentist were used, Further the 2011-2012 price list in US dollars were

adjusted to 2015 April 15th [ 4.3% inflation rate].

- Only direct cost involved in replacement is considered [overhead cost, loss

of time by operators & patient other indirect costs are not considered because

of lack of information on public domain and heterogeneity in methods,

materials and average per hour earnings.

- FPD is considered as 3 unit supported with two free standing implants.

- If the implant is failed after loading, we assume patient is not going for a new

implant.

- Minor complication events are prosthetic screw tightening and/ abutment

screw tightening, and occlusal material replacement/porcelain chip

adjustment for screw retained prosthesis and recementation & adjustment for

cement retained prosthesis.

- Major complication event means: screw – maintenance [screw replacement

and abutment replacement], Cement- sectioning of old prosthesis, abutment

20

replacement and crown remake. Assuming cement-retained prosthesis has

limited retrievability option and screw retained has more abutment

replacement rather than crown remakes.

4. RESULTS 4.1. Selection of primary studies

The literature search identified 896 citations. Upon screening the titles and

abstracts, 329 potential relevant publications were retrieved for further scrutinizing.

Among the 329, 216 citations were excluded. Thus 113 studies were selected for inclusion

into qualitative and quantitative analysis. Of those 113, nine studies were excluded from

final inclusion based on the quality score/( weak). Total 104 studies were included in the

meta analysis. To be considered for inclusion, a study needed to have atleast one outcome

of interest. The study selection process is shown in PRISMA flow chart in table-6. Table-

7 summarizes the basic characteristics of the included studies. Table -8, 9 briefs the

analysis of excluded and included studies.

21

Table 6: PRISMA Flow diagram

Recordsidentifiedthroughdatabasesearching

(n=2518)

Additionalrecordsidentifiedthroughothersources

(n=1357)

Recordsafterduplicatesremoved(n=896)

Recordsscreened(n=896)

Recordsexcluded(n=567)

Full-textarticlesassessedforeligibility(n=329)

Full-textarticlesexcluded,withreasons(n=216)

Studiesincludedinquantitativesynthesis

(meta-analysis)(n=104)

Studiesincludedinqualitativesynthesis

(n=113)

Eligibility

22

Table-7:BasicCharacteristicstableNo Reference Retention

type Study design

No of Patients M F T

Age range

No of Implants

No of prosthesis

Prosthesis design

Observation period

Drop outs

Study setting

1 Akca, 2008 Cement Prospective 13 16 29 31-73 64 49 FPD 24m-30m 0 University 2 Andersen,

2001 Cement Prospective 33 24 57 31-33 65 65 S 5 Yr 8/57 University

3 Andersson, 2003

Screw, cement

Prospective 26 29 55 17-54 60 60 S 3 Yr 5/60 University

4 Andersson, 1998

Screw, cement

RCT 14 18 32 15-71 103 36 FPD 5 Yr 6/36 Multi

5 Aparicio, 2001

Screw Retrospective 10 15 25 49-59 101 29 FPD 21-87 m 5/32 University

6 Avivi-Arber, 1996

Cement Prospective 22 19 41 14.5-63.9

49 49 S 1.8 Yr University

7 Balleri, 2010 Screw Prospective 6 14 20 38-63 40 20 FPD 1 Yr 0 University 8 Balshi 1996 Screw Prospective 15 29 46 30-70 71 73 S,SP 3 Yrs 0 University 9 Bambini,

2001 Screw Retrospective 35 24 59 38-65 40 20 FPD 1 Yr 0 NR

10 Becker, 2004 Screw, cement

Retrospective 17 18 35 33-75 115 60 C 10 Yrs - NR

11 Becker, 1995 Screw Retrospective 6 16 22 48-73 24 24 S 24m 2/24 Specialist clinic 12 Behneke,

2000 Screw- cement

Prospective 27 28 55 17-81 114 68 S,FPD 5 Yr 15/114 University

13 Bergenblock, 2012

Cemented Prospective 22 25 57 15-57 65 65 S 17-19 Yr 13/65, 10/57

Specialist clinic

14 Bischof, 2006 Screw, cement

Prospective 91 121

212

22-88 249 237 S, FPD 2 Yr Private

15 Bonde 2010 Cemented Retrospective 29 22 51 - 55 55 S 7.5-12 Yr 3 University 16 Bragger 2005 Screw-

cement Prospective 34 55 89 26-88 102 69

22 S

FPD 8-12 Yrs - University

17 Brown, 2011 Screw CCT 9 18 27 21-71 28 28 S 1 Yr 2/28 University 18 Cabello, 2013 Screw-

cement Prospective 7 7 14 34-71 14 14 S 1 Yr 0 Private

19 Camargos Gde, 2012

Screw- cement

Retrospective 12 32 44 24-72 71 71 S 2-13 Yr 3 University

20 Cannizzaro, 2008

Cemented RCT 19 21 40 18-64 108 108 S 3 Yr 0 Private

21 Cannizzaro, 2013

Cemented RCT 19 21 40 21-72 82 32 SP 5 Yr 1 Private

23

No Reference Retention type

Study design

No of Patients Age range

No of Implants

No of prosthesis

Prosthesis design

Observation period

Dropouts Study setting M F T

22 Cannullo 2013

Cemented RCT 11 6 20 29-81 20 20 S 2 Yr 0 Multicenter

23 Cha, 2013 Screw, cement

Retrospective 57 63 120 18.8-81.1

136 136 S 5 Yr 0 Nr

24 Cho, 2004 Screw Prospective 50 56 106 20-74 213 107 S, FPD 3-7 Yr 0 University 25 Cooper,

2007 Cemented RCT 21 26 47 30.6(A) 53 53 S 3 Yr 11/53 University

26 Cordioli, 1994

Screw Prospective 17 30 47 15-67 67 67 S 5-6 Yr 4/47 -

27 De Boever, 2006

Screw, cement

Prospective 48 57 105 25-86 283 80 92

S FPD

40m - University

28 Drago, 2003 Cement Prospective 22 51 73 17-72 110 110 S 1Yr - - 29 Engquist,

1995 Cemented Retrospective 32 26 58 26(A) 82 82 S 1,2,5 Yr - University

30 Esposito, 2014

Cemented RCT 7 8 15 28-68 38 38 S 3 Yr 0 Multicenter

31 Glauser, 2004

Cemented Prospective 11 16 27 26-75 54 54 S 1-4 Yr - -

32 Gotfredsen, 2012

Cemented Prospective 10 10 20 18-59 20 20 S 10 Yr 1 University

33 Grandi, 2012

Cemented RCT 11 17 28 39-64 56 28 SP 1 Yr 0 Multicenter

34 Gulje, 2013 Screw RCT 48 47 95 26-70 208 95 SP 1 Yr 2 Multicenter 35 Gunne, 1994 Screw Prospective 42% 58% 159 18-70 521 197 FPD 3 Yr 5 Multicenter 36 Haas 2002 Screw Prospective 35 36 71 10-69 76 76 S 5 Yr 2 University 37 Halg, 2008 Cemented Prospective 21 33 54 24-83 78 54 FPD 5.3 Yr - Private 38 Hartlev,

2013 Cemented Retrospective 34 21 65 17-82 55 55 S 33m - Private

39 Henry 1995 Cemented Prospective 29 14 43 16-70 53 51 S 1 Yr 2 - 40 Henry 1996 Screw Prospective - - 92 - 106 106 S 5 Yr 18 Multicenter

41 Hosny, 2000 Screw Prospective 6 12 18 37-65 78 18 FPD 14 Yr 0 University

42

Hosseini, 2013

Cemented Prospective 24 35 59 18-50 98 98 S 3 Yr 0 University

43 Jacobs, 2010 Screw Split 6 12 18 32-63 95 - FPD 16 Yr 6/18 University

44 Jemt, 2009 Screw, cement

Retrospective 25 10 35 18-75 41 41 S 10 Yr 11/35 University

24

No Reference Retention type

Study design No of Patients Age range

No of Implants

No of prosthesis

Prosthesis design

Observation period

Dropouts Study setting M F T

45 Jemt, 2003 Screw Prospective 15 27 42 25-74 170 63 FPD 5 Yr 7 University 46 Jemt, 1993 Screw Prospective 36 31 67 22-78 259 94 FPD 5 Yr 7/67 University 47 Jemt, 1992 Screw Prospective 42 45 97 16-77 354 127 FPD 1 Yr 14/97 University 48 Karlsson,

1997 Cemented Prospective 26 21 47 16-69 47 47 S 2 Yr 4/47 Multicenter

49 Khraisat, 2008

Cemented Retrospective 23 26 49 17-85 87 87 S 1-6 Yr - Multicenter

50 Kourtis, 2004

Screw, cement

Prospective 171 234 405 18-83 1692 1111 S,FPD, SC, CL

1-12 Yr - Private

51 Kreissl, 2007 Screw Prospective 29 47 76 18-76 205 112 SC,C,FPD 5 Yr 0 - 52 Krennmair,

2002 Screw, cement

Retrospective 45 67 112 16.5-56.8

146 146 S 7 Yr - -

53 Krennmair, 2010

Cemented Retrospective 82 134 216 45.2-63.4

295 180 S,FPD 3 Yr - Private

54 Krennmair, 2011

Cemented Retrospective 11 27 38 38-62 76 36 FPD 3 Yr 2/38 -

55 Larsson, 2010

Cemented CCT 6 12 18 37-70 - 25 FPD 5 Yr - University

56 Lee, 2011 Cemented Prospective 68 93 161 20-79 207 207 S 3 Yr - University 57 Lekholm,

2006 Screw Retrospective 9 7 16 43-87 112 24 S,FPD 10Yr 37% Public service

58 Lekholm 1999

Screw Prospective 54 73 127 18-70 461 197 FPD 10Yr 40 Public service

59 Levine, 2007 Cemented Retrospective 182 228 410 18-78 499 499 S 54m - Multi clinic 60 Lindh, 2001 Screw Prospective 182 228 410 18-78 95 95 S 2 Yr 6 University 61 Linkevicius,

2009 Cement CCT 11 8 19 23-71 46 46 FPD 1yR 3 Private

62 Malo, 2000 Screw, cement

Retrospective 18 31 49 14-70 94 23 31

FPD S

4 Yr - Private

63 Mangano, 2001

Cemented Retrospective 33 36 69 16-61 80 80 S 3.5 Yr - -

64 Mericske-Stern, 2001

Screw, cement

Prospective 24 48 72 19-82 109 109 S 1-9 Yr 3 -

65 Mertens, 2011

Screw- cement

Prospective 5 12 17 40-83 49 31 4

S FPD

5 Yr 2 University

66 Montero, 2012

Screw, cement

Prospective 44 27 71 34.6-59.2

93 93 S 26.2m - University

25

No Reference Retention

type Study design No of Patients Age

range No of

Implants No of

prosthesis Prosthesis

design Observation

period Drop outs

Study setting M F T

67 Muftu, 1998 Cemented Prospective 84 84 168 - 432 432 S 4 Yr 2 - 68 Naert, 1992 Screw Retrospective 52 94 146 21-83 509 217 FPD 77m - University 69 Nedir, 2006 Screw

Cement Prospective 91 145 236 18-89 465 171

93 S

FPD 8 Yr 0 Private

70 Nissan, 2011 Screw, cement

Prospective 16 22 38 38-70 221 76 FPD 18-180m 0 Private

71 Ormianer, 2006

Cemented Prospective 9 9 18 18-62 22 22 S 30m - Private practice

72 Ortorp, 2008 Screw CCT 39 65 104 27-78 351 120 FPD 10 Yr 35/104 - 73 Palmer, 2005 Cemented Prospective 10 11 21 27-65 21 - FPD,C 3 Yr - - 74 Palmer, 2012 Mechano

chemical Prospective 7 22 29 18-70 28 28 S 3 Yr 1 Hospital

75 Palmer, 2000 Cemented Prospective 5 10 15 16-48 15 15 S 5 Yr - Hospital 76 Pieri, 2011 Cemented RCT 14 24 38 >18

YRS 40 40 S 1 Yr 2 University

77 Pistilli, 2013 Cemented RCT - - 40 - 171 - FPD 1 Yr 2 Private 78 Polizzi, 1999 Cemented Prospective 8 13 21 13-58 30 30 S 3 Yr - - 79 Pozzi, 2014 Cemented RCT - - 34 39-59 88 88 S 1 Yr 0 Multicenter 80 Pozzi, 2012 Cemented Prospective 15 12 27 38-77 81 37 FPD 3 Yr - -

81 Priest, 1999 Cement Prospective 41 58 99 15-76 112 112 S 10Yr 0

82 Romanos, 2000

Cemented Retrospective 29 22 51 34.5-55.7

58 58 S 1.71 Yr 0 -

83 Romeo 2006 Screw, cement

Prospective 61 68 129 52(A) 265 95 S FPD

6.4 Yr 0 -

84 Santing, 2013 Screw, cement

Prospective 29 31 60 >18 Yr

60 60 S 18m 0 University

85 Scheller, 1998 Cemented Prospective 47 35 82 14-73 99 97 S 5 Yr - Multicenter

86 Schmit 1993 Screw Prospective 17 15 32 16.1-63.2

40 40 S 2.9 Yr 0 -

87 Scholander, 1999

Cemented Retrospective 96 87 183 16-71 259 258 S 1-9 Yr University

88 Schropp, 2008 Screw, cement

Prospective 21 24 45 20-74 42 42

Cl 5 Yr - -

89 Schwartz-Arad, 1999

Cemented Retrospective 28 27 55 20-68 78 78 S 5Yr - University

26

No Reference Retention

type Study design

No of Patients Age range

No of Implants

No of prosthesis

Prosthesis design

Observation period

Dropouts

Study setting M F T

90 Schwarz, 2012

Cemented Retrospective - - 241 57.3(A) 533 350 S,FPD 6.9Yr - University

91 Singer, 1996 Cemented Prospective 29 41 70 19-71 225 92 FPD 3Yr - Hospital 92 Sorrentino,

2012 Cemented Retrospectiv

e 39 73 112 18-69 81 81 S 6Yr University

93 Thomsson, 2008

Screw, cement

Retrospective

47 36 83 - 310 89 FPD FPD 1Yr - -

94 Turkyilmaz, 2006

Cemented Prospective 11 8 19 39(A) 36 36 S 3Yr - -

95 Urdaneta, 2008

IAC (Mechano-chemical)

Retrospective

25 34 59 57.2(A) 326 326 S 1.5 Yr 21 -

96 Vanlioglu 2013

Cemented Retrospective

46 49 95 41.2(A) 231 177 S,Sp,FPD 5-10Yr - -

97 Vigolo, 2012 Screw- cement

RCT 8 10 18 27-42 36 36 S 10Yr 2 Private

98 Visser, 2011 Cemented RCT 44 49 93 18-63 92 92 S 5Yr 1 99 Wannfors,

1999 Screw- cement

Prospective 39 30 69 17-72 80 80 S 5Yr 4 University

100 Watson, 1999

Screw- cement

Prospective 16 10 26 22-63 33 33 S 3-4Yr 5 University

101 Wennstrom, 2005


23 17 40 20-71 44 39 S 5Yr 11 University

102 Yaltirik, 2011


- - 28 18-65 48 48 S,FPD 5Yr - University

103 Zembic, 2013

Screw Cement

RCT 8 14 22 41.3(A) 40 40 S 5Yr - -

104 Zembic, 2012

Cement RCT 21 26 47 17-76 57 57 S 1Yr 3 Multicenter

28

Table-8:Analysisofexcludedarticles

Reasonforexclusion NumberofarticlesNon-English 3Non-Indexed 2

Multiplereports 8ResultsmixedwithCompletely

edentulousreconstructions

17

Unabletoextractnecessarydata 29Noinformationonretentionsystem 91Lessthanoneyearobservation 1

Systematicreviews,Meta-analysis,Consensusreports

44

Chartreview/patientinterview/retrospectivewithnoclinicalfollowup

21

Table-9:AnalysisofIncludedstudies

Cementretained Screwretained Mechano-chemicalretainedTotalNoof

Prosthesis6178 3029 361

TotalObservationperiod[yr]

29228.64 15412.66 2039.14

TotalNoofsinglecrown

4711 1005 333

TotalNoofSplintedcrown

345 398 28

TotalNoofcantlileverFPD

173 120 -

TotalNoofFPD 949 1506 -NoofRCTstudydesign

12 4 0

NoofCCTstudydesign

7 3 1

NoofProspectivestudydesign

39 28 1

NoofRetrospectivestudydesign

23 16 1

Studiesbasedonqualityscore:Strong-19Medium-85Weak-9

StudiesbasedonyearofpublicationBefore2000-28,2001-2010-43,2011-2015–32

29


4.2. Study Characteristics:

The studies were published over a 23 year period between 1992 and 2015. The

studies reported on three retention system [screw, cement and mechano-chemical] and four

prosthesis design [Single crown, Splinted crown, Cantilever FPD, FPD]. One RCT and 25

observational studies compared atleast two retention systems. The 104 included studies

reported on over 5317 patients between the age of 15 and 90 with 9568 implant supported

reconstructions to manage partial edentulism[ 6049;single crowns, 771; splinted crowns,

293 ; cantilever FPD,2455; FPDs]. Most of the studies [n=44] were done in university

setting. 18 studies reported about the abutment material, 23 studies reported on prosthesis

material, 19 on implant characteristics, and 21 studies reported about the location of

prosthesis [maxilla/ mandible]. The type of luting agent used for cement retained prosthesis

was reported in 17 studies.

4.3. Critical appraisal of included studies and interauthor agreement.

Nine of the 113 included studies scored weak in two or more than one domains and

19 studies didn’t score weak in any of the domains. Among the domains, the most weak

score was for the study design. The detailed scores achieved by each included study was

reported in annexure-8. Kappa inter author agreement was rated very good at the all three

stages. [Title and abstract screening- 0.957, full text evaluation- 0.857, full text screening -

quality scoring of full text-0.952]. The detailed calculations were shown in the annexure-7.

4.4. Data synthesis.

A total of 9568 reconstructions were analyzed with a total exposure time of 46,553.18 years.

Of these 6049 [63.3%] were single crowns, 771 splinted crowns[8%], 293 cantilever

FPD[3%], 2455 FPD[25.7%]. The failure rate , survival rate and event free rate for the three


30RetentionsystemsforImplantsupportedprosthesisinpartiallyedentuloussites.

retention systems and weighing of each study are shown in the figures-1[meta-analysis,

forest plot]. A total of 65 studies reported on cemented, 26 on screw retained and 2 on

mechano-chemical retained single crowns. The failure rate of cemented IS-S

(1.3%[0.97;1.7]), screw IS-S (1.8[1.1;3.1]), and mechano-chemical I-S-S

(1.4[0.9;2.1]).[Table-10]. There were no statistical difference between the different retention

systems and failure outcome.[Table-13]. Table-11 and Table 12 shows the survival rate of

different retention system and sub group variables. Statistically significant differences of

survival rate were demonstrated between the following groups. Screw[8.2%], mechano-

chemical[7.8%] I-S Vs Cement[4.2%], cement splinted crowns Vs screw splinted crowns,

Cement FPD and Screw FPD, Anterior cement retained IS- prosthesis and anterior screw

retained IS-prosthesis. There were no statistical difference between abutment material,

prosthesis material, cement type and implant characteristics [external vs internal hex].

[Table -14]. The relation between survival and complication types in single crowns and FPD

was tabulated in the table-15. The cement retained single crown was statistically different

from screw retained in minor complication events. However, there were no differences seen

with other variables. The annexure -8 shows the meta regression of sub group analysis.


31

Table-10: Failure :

Retention & Type

No of studie s

No of prosthesi s

Total exposur e

Annual /100 yr

5 yr 10 yr 15 yr 20 yr 25 yr

Cement -S

65 4719 19814.6 3

1.3[0.97;1.7 ]

2.5[1.8;3.4]

3.5[2.5;5] 4.4[3.1;6.2]

5.1[3.5;7.2] 5.7[3.9;8]

Screw-S 26 1005 7322.68

1.8[1.1;3.1]

3.5[2;6] 3.7[2.2;6.1]

3.8[2;6.8] 4[2.1;7.4] 4.2[2.2;8]

MC-S 2 333 1955.14

1.4[0.9;2.1]

1.59[1.2;2.2 ]

3.1[1.7;5.6]

4.5[2.8;7.4]

6.1[4;9.2] 7.5[5.1;10.8]

Cement - FPD

19 949 4206.4 1.4[0.8;2.5]

4.2[2.7;6.7]

6.8[4.2;10.7 ]

8.6[5.2;13.8 ]

10.2[6.1;16.5 ]

11.6[6.9;18.9 ]

Screw- FPD

22 1506 8700.43

1.5[0.8;2.6]

3[1.8;4.9] 3.5[1.9;6.2]

3.9[2.1;7.2]

4.3[2.2;8] 4.7[2.2;8.7]

Cement- splinted

5 345 1502.6 1.3[0.3;5.6]

2.1[.3;12.9]

2.4[.30;18.8 ]

2.6[.22;23.8 ]

2.74[.2;28.26 ]

2.9[0.2;32.4]

Screw- splinted

6 398 1399.6 1.6[0.6;4] 2.5[0.6;8.8]

2.6[0.5;13.2 ]

2.7[0.4;17] 2.8[0.3;20.4]

2.9[0.3;23.6]

Cement- Cantilever FPD

5 173 1091.5 1.3[.3;5] 3.1[1.2;7.8]

3.9[7;18.8] 4.4[7;24.5] 4.8[6;30] 5.2[6;34.9]

Screw– cantilever FPD

5 120 560.2 0



Table-11: Survival

Retention& Type

No of studies

No of prosthesis

Total exposure

Annual /100 yr

5 yr 10 yr 15 yr 20 yr 25 yr

Cement -S 65 4719 19814.63 4.2[3.2;5..4]

14.5[11.4;18.3]

25.5[20.4;31.3]

35.1[28.3;42.6]

43.2[35.1;51.6]

51[38.2;64.8]

Screw-S 26 1005 7322.68 8.5[5.5;12.9]

26.6[19.6;35.1]

42[32.1;.52.5] 50[39.5;61.9] 55.7[43.3;67.3]

59.3[45.9;71.3]

MC-S 2 333 1955.14 7.8[0;9.98] 31.3[4.2;82.7]

54.3[6.3;95.4] 67.8[6.5;98.4] 71.6[5.7;99.1]

87.2[7.8;9.98]

Cement - FPD

19 949 4206.4 4.5[[2.5;8.1]

12.8[6.9;22.7]

21.3[11.3;36.4]

29[15.6;47.5] 36.1[20.1;56] 41.8[24.1;61.9]

Screw-FPD

22 1506 8700.43 7.9[5.4;11.4]

21[13.9;30.5] 32.6[20.8;47.2]

42.6[26.9;59.9]

50.9[32.5;69.1]

57.1[37;75]

Cement- splinted

5 345 1502.6 2.2[1.1;4.5] 6.6[1.9;20.7] 9.4[1.6;39.1] 11.7[1.5;53] 13.9[1.5;63.4]

15.9[1.4;71.1]

Screw- splinted

6 398 1399.6 5.7[2.3;13.4]

23.5[10.8;43.8]

41.8[21.5;65.3]

56.1[33.2;76.6]

66.3[44.8;82.7]

72.8[53.9;85.9]


5 173 1091.5 4.4[0.5;19] 12.8[1;68] 20.4[1.7;78.6] 24.5[2.7;78.9] 29.6[3.6;82.8]

35.6[4.2;87.3]


5 120 560.2 4.3[1.7;10.7]

12.5[5.8;24.8]

18.7[7.1;40.7] 22.9[8;50.4] 26.1[8.4;57.4]

28.6[8.7;62.9]



Table-12: Event free

Retention& Type

No of studies

No of prosthesis

Total exposure

Annual /100 yr

5 yr etd 10 yr etd 15 yr etd 20 yr etd 25 yr etd

Cement -S

65 4719 19814.63 95.6[92.8;98.4]

79.9[71.6;88.3] 66.5[53.9;79] 57.9[43.7;72.2]

51.4[36.7;66] 46[31.6;60.4]

Screw-S 26 1005 7322.68 90.9[87.6;93.4]

72.7[64.2;79.7] 57.6[46.9;67.5]

48.8[37.3;60.4]

43.9[31.8;56.7]

40.2[27.6;54.2]

MC-S 2 333 1955.14 92.3[62.1;99.9]

85.5[10.4;99.9] 78.3[2.3;99.8]

70.8[0.7;99.9]

62.8[0.2;99.9]

54.7[0.1;99.9]

Cement - FPD

19 949 4206.4 95.1[91.5;97.2]

85.12[74.62;91.7]

74.7[59.1;85.9]

65.2[47.6;79.5]

56.9[39.3;72.9]

50.7[33.6;67.6]

Screw-FPD

22 1506 8700.43 91.6[88.1;94.1]

77.6[68.2;84.9] 65.6[51.4;77.5]

55.4[38.7;71] 47.2[29.8;65.4]

41.6[24.1;61.5]

Cement- splinted

5 345 1502.6 97.4[94.9;98.7]

93.1[70;98.8] 89.9[47.3;98.9]

87.1[32.5;99] 84.6[22.7;99] 82.2[16.2;99.1]

Screw- splinted

6 398 1399.6 94.2[85.3;97.8]

76[53.5;89.7] 57.1[32.5;78.7]

42.8[22.4;66] 33.2[17.4;54.1]

28.4[15.3;46.5]


5 173 1091.5 95.6[65.8;99.6]

87[30.2;99] 79.1[19.5;98.3]

74.4[18.4;97.4]

68.9[14.6;96.6]

45.6[36.5;55]


5 120 560.2 95.7[89.3;98.3]

87.5[75.2;94.2] 81.3[59.3;92.9]

77.1[49.6;92] 73.9[42.6;91.6]

71.4[37.1;91.3]

34

Table-13.Failure rate by prosthesis and implant characteristics

Variables Retention type

No of studies

No of prosthesis

Exposure time[yr]

No of Failure events

Estimated event rate/100 yr

P Value

Single crown Cement 65

26

2

4711

1005

333

19774.63

7322.68

1955.14

80

16

6

1.3

1.8

1.4

0.14

Screw

Mechano- chemical

Splinted crown

Cement 5

6

1

345

398

28

1502.6

1399.6

84

4

2

0

1.2

0.5

0.6

Screw

Mechano- chemical

Cantilever FPD

Cement 5

5

173

120

1091.5

560.2

3

0

1.3

0.3

Screw

FPD Cement 19

22

949

1506

4206.4

8700.43

26

38

1.4

1.5

Screw Titanium Abutment

Cement

Screw

8

3

487

87

1679.21

505

4

0

0.2

0

0.3747 Ceramic abutment

Cement

Screw

4

3

206

158

1866

694

4

0

0.2

0

PFM Cem

ent

Scre

w

9

7

304

310

1335.2

1305.12

4

1

0.3

0.1

0.2854

All-Ceramic Cement

Screw

4

3

225

61

1259.4

181

3

0

0.2

0.1

Internal hex Cement

Screw

8

2

992

91

3018.07

366.94

11

0

0.4

0

0.3416 External hex Cem

ent

Scre

w

7

2

654

20

1279

28

8

1

0.6

3.6

Anterior Cement 7 270 1052.1 4 0.4



Screw 2 78 183.94 0 0

0.6183 Posterior Cem

ent

Scre

w

7

5

739

346

2137.29

1648.94

5

3

0.7

0.9

Permanent cement

Cement 8 472 2083.64 6 1.3

0.110 Temporary cement

Cement 9 857 2506.76 15 1.8

Table-14. Survival rate by prosthesis and implant characteristics

Variables Retention type

No of studies

No of prosthesis

Exposure time

No of events


P Value

Single crown Cement

Screw

Mechano- chemical

65

26

2

4711

1005

333

19774.63

7322.68

1955.14

586 260

62

4.2[3.2;5.4]

8.5[5.5;12.9]

7.8[0;9.98]

0.0266*

0.0382*

0.0338*

Splinted crown

Cement

Screw

5

6

345

398

1502.6

1399.6

32 56

2.2[1.1;4.5]

5.7[2.3;13.4]

Cantilever FPD

Cement

Screw

5

5

173

120

1091.5

560.2

41 13

4.4[0.5;19]

4.3[1.7;10.7]

FPD Cement

Screw

19

22

949

1506

4206.4

8700.43

172 447

4.5[2.5;8.1]

7.9[5.4;11.4]

Titanium Abutment

Cement Screw

8

3

487

87

1679.21

505

47 0

2.8

0

0.8993 Cera

mic abutment

Cement Screw

4

3

206

158

1866

694

4 0

0.2

0 PFM Cement

Screw 9

7

304

310

1335.2

1305.12

55 78

4.11

5.9

0.2681

All-Ceramic Cement Screw

4

3

225

61

1259.4

181

35 8

2.77

4.4



Internal Hex Cement

Screw 8

2

992

91

3018.07

366.94

76 32

2.5 8.7

0.0522 External hex Cement

Screw 7

2

654

20

1279

28

84 20

6.5

7.1 Anterior Cement

Screw

7

2

270

78

1052.1

183.94

12 14

1.14

7.6

0.0385*

Posterior Cement

Screw

7

5

739

346

2137.29

1648.94

71 70

3.3

4.2

Permanentcement

Cement 8 472 2083.64 107 5.1 0.923

Temporarycement

Cement 9 857 2506.76 121 4.8

Table-15:MinorandMajorcomplicationevents

Retention type


P Value

Single crown- Minor complications

Screw

Cement

8.3[5.7;11.8]

3.4[2.5;4.6]

0.0012*

0.6977 0.4460

0.1643

Single crown- Major complications

Screw

Cemen

t

3.8[2.4;6]

2.0[1.5;2.5]

FPD- Minor complications

Screw

Cement

6.8[3.9;11.4]

4.3[2.4;7.5] FPD-Major complications

Screw

Cement

3.0[2.1;4.4]

1.5[0.8;2.7]



Figure1:Meta–analysisoffailure,survivalandeventfreerateofsinglecrown,splintedcrown,CantileverFPD,FPD.

Annual failure rate- Single crown screw retained

Model Study nam e Subgroup within study Statistics for each study Event rate and 95% C I Weight (Fixed) Weight (Random ) Residual (Fixed)

Event Lower Upper Relative Relative Relative Relative S td S td S td S td S td S td rate lim it lim it Z-Value p-Value weight weight weight weight Residual Residual Residual Residual Residual Residual

Vigolo, 2012 R C T 0.005556 0.000011 0.736499 -1.635832 0.101875 0.73 0.73 -0.40 -0.40

Avivi-Arber, 1996 Pros 0.019231 0.001192 0.243612 -2.753358 0.005899 3.58 3.58 -0.02 -0.02

Balshi, 1996 Pros 0.022727 0.001407 0.277410 -2.629174 0.008559 3.57 3.57 0.11 0.11

Bragger 2005 Pros 0.166667 0.009511 0.806422 -1.038888 0.298857 3.04 3.04 1.51 1.51

Brown, 2011 Pros 0.018519 0.001149 0.236411 -2.781304 0.005414 3.59 3.59 -0.04 -0.04

Cabello, 2013 Pros 0.038462 0.002363 0.403194 -2.231889 0.025622 3.51 3.51 0.49 0.49

Cho, 2004 Pros 0.012500 0.000777 0.170774 -3.070295 0.002138 3.61 3.61 -0.33 -0.33

Henry, 1996 Pros 0.003774 0.000170 0.077908 -3.519880 0.000432 2.91 2.91 -1.07 -1.07

Kourtis 2004 Pros 0.062500 0.003793 0.538588 -1.854075 0.063728 3.43 3.43 0.84 0.84

Kreissl, 2007 Pros 0.010638 0.000662 0.148561 -3.187938 0.001433 3.61 3.61 -0.45 -0.45

Mericske-Stern, 2001 Pros 0.007003 0.000688 0.067409 -4.172560 0.000030 5.18 5.18 -0.90 -0.90

Montero, 2012 Pros 0.005882 0.000367 0.087074 -3.616702 0.000298 3.63 3.63 -0.88 -0.88

Santing, 2013 Pros 0.014706 0.000914 0.195875 -2.951224 0.003165 3.60 3.60 -0.21 -0.21

Schropp, 2008 Pros 0.166667 0.009511 0.806422 -1.038888 0.298857 3.04 3.04 1.51 1.51

Wannfors, 1999 Pros 0.011111 0.000691 0.154296 -3.156263 0.001598 3.61 3.61 -0.41 -0.41

Watson, 1999 Pros 0.031250 0.001926 0.350276 -2.389954 0.016850 3.54 3.54 0.34 0.34

Zembic, 2013 Pros 0.125000 0.007325 0.734442 -1.287099 0.198060 3.20 3.20 1.32 1.32

Bambini, 2001 Retro 0.015152 0.000941 0.200794 -2.929291 0.003397 3.60 3.60 -0.19 -0.19

Becker, 1995 Retro 0.020000 0.001240 0.251266 -2.724274 0.006444 3.58 3.58 0.01 0.01

Camargos Gde, 2012 Retro 0.009434 0.000588 0.133659 -3.275287 0.001056 3.62 3.62 -0.53 -0.53

Cha 2013 Retro 0.018868 0.004724 0.072287 -5.534935 0.000000 14.34 14.34 -0.06 -0.06

Cordioli, 1994 Retro 0.007353 0.000458 0.106860 -3.455777 0.000549 3.63 3.63 -0.71 -0.71

Engquist, 1995 Retro 0.007463 0.000465 0.108308 -3.445072 0.000571 3.63 3.63 -0.70 -0.70

Jemt, 2009 Retro 0.026316 0.001626 0.309619 -2.519484 0.011753 3.56 3.56 0.21 0.21

Krennmair, 2002 Retro 0.009259 0.000577 0.131461 -3.288856 0.001006 3.62 3.62 -0.55 -0.55

Scholander, 1999 Retro 0.166667 0.009511 0.806422 -1.038888 0.298857 3.04 3.04 1.51 1.51

Fixed 0.019655 0.011666 0.032934 -14.463112 0.000000 Random 0.019655 0.011666 0.032934 -14.463112 0.000000 -0.50 -0.25 0.00 0.25 0.50



Annual Survival rate- Single crown screw retained

Model Groupby Subgroupwithinstudy

Studyname Subgroupwithinstudy Statisticsfor eachstudy Eventrateand95% CI



Annual Event free rate- Single crown screw retained

Model Groupby

Subgroupwithinstudy

Studyname Subgroupwithinstudy Statistics for eachstudy Eventrate and95% CI

Event Lower Upper

Pros

Avivi-Arber, 1996

Pros

rate limit limit

0.950000 0.758753 0.991363

Z-Value p-Value

3.208628 0.001334 Pros Balshi, 1996 Pros 0.913043 0.697090 0.979553 3.036186 0.002396 Pros Bragger 2005 Pros 0.995455 0.000000 1.000000 0.512659 0.608190 Pros Brown, 2011 Pros 0.730769 0.532939 0.865891 2.258394 0.023921 Pros Cabello, 2013 Pros 0.961538 0.596806 0.997637 2.231889 0.025622 Pros Cho, 2004 Pros 0.992523 0.776466 0.999803 2.629835 0.008543 Pros Henry, 1996 Pros 0.886792 0.811160 0.934576 6.714735 0.000000 Pros Kourtis 2004 Pros 0.999617 0.000000 1.000000 0.407428 0.683694 Pros Kreissl, 2007 Pros 0.982143 0.861192 0.997953 3.599380 0.000319 Pros Mericske-Stern, 2001 Pros 0.946312 0.881676 0.976578 6.531975 0.000000 Pros Montero, 2012 Pros 0.939930 0.864164 0.974674 5.989567 0.000000 Pros Santing, 2013 Pros 0.985294 0.804125 0.999086 2.951224 0.003165 Pros Schropp, 2008 Pros 0.833333 0.193578 0.990489 1.038888 0.298857 Pros Wannfors, 1999 Pros 0.772727 0.626844 0.873122 3.401848 0.000669 Pros Watson, 1999 Pros 0.750000 0.482486 0.906133 1.842429 0.065412 Pros Zembic, 2013 Pros 0.875000 0.265558 0.992675 1.287099 0.198060 Fixed Pros 0.882594 0.847463 0.910489 13.074992 0.000000 Random Pros 0.895853 0.844550 0.931596 9.179229 0.000000 RCT Vigolo, 2012 RCT 0.994444 0.263501 0.999989 1.635832 0.101875 Fixed RCT 0.994444 0.263501 0.999989 1.635832 0.101875 Random RCT 0.994444 0.248300 0.999990 1.615084 0.106293 Retro Bambini, 2001 Retro 0.983051 0.798391 0.998824 2.964902 0.003028 Retro Becker, 1995 Retro 0.812500 0.608574 0.923533 2.803830 0.005050 Retro Camargos Gde, 2012 Retro 0.946154 0.840520 0.983217 4.665279 0.000003 Retro Cha 2013 Retro 0.913208 0.842540 0.953895 6.821540 0.000000 Retro Cordioli, 1994 Retro 0.958541 0.874303 0.987155 5.124839 0.000000 Retro Engquist, 1995 Retro 0.893939 0.793822 0.948590 5.332297 0.000000 Retro Jemt, 2009 Retro 0.971429 0.679924 0.998166 2.492495 0.012685 Retro Krennmair, 2002 Retro 0.955679 0.853565 0.987619 4.601219 0.000004 Retro Scholander, 1999 Retro 0.833333 0.193578 0.990489 1.038888 0.298857 Fixed Retro 0.917794 0.884706 0.942008 12.611398 0.000000 Random Retro 0.924363 0.875886 0.954880 8.934533 0.000000 Fixed Overall 0.898202 0.874592 0.917784 18.143504 0.000000 Random Overall 0.910954 0.865173 0.942227 9.771934 0.000000

-1.00 -0.50 0.00 0.50 1.00



Annual Survival rate- FPD screw retained

Model Groupby

Subgroupwithinstudy

Study name Subgroupwithinstudy Statistics for eachstudy Event rate and 95% CI

Event Lower Upper rate limit limit Z-Value p-Value

CCT Jacobs, 2010 CCT 0.038194 0.007171 0.179197 -3.710016 0.000207 CCT Jemt, 2003 CCT 0.107937 0.051770 0.211450 -5.201697 0.000000 CCT Nissan, 2011 CCT 0.129187 0.054366 0.276834 -3.945301 0.000080 Fixed CCT 0.103066 0.060796 0.169424 -7.389126 0.000000 Random CCT 0.092914 0.035435 0.222152 -4.355296 0.000013 Pros Bischof, 2006 Pros 0.166667 0.009511 0.806422 -1.038888 0.298857 Pros Bragger 2005 Pros 0.060000 0.009982 0.287794 -2.922333 0.003474 Pros Cho, 2004 Pros 0.061765 0.023939 0.150163 -5.400776 0.000000 Pros Hosny, 2000 Pros 0.003205 0.000022 0.324138 -2.247721 0.024594 Pros Jemt, 1993 Pros 0.185106 0.118927 0.276553 -5.580980 0.000000 Pros Kourtis 2004 Pros 0.001542 0.000079 0.029354 -4.265058 0.000020 Pros Kreissl, 2007 Pros 0.062500 0.003793 0.538588 -1.854075 0.063728 Pros Lekholm, 1999 Pros 0.021320 0.008217 0.054175 -7.758086 0.000000 Pros Lindh, 2001 Pros 0.153846 0.078851 0.278597 -4.435370 0.000009 Pros Mertens, 2011 Pros 0.166667 0.009511 0.806422 -1.038888 0.298857 Pros Nedir, 2006 Pros 0.007353 0.000145 0.274710 -2.443604 0.014541 Pros Ortorp, 2008 Pros 0.040000 0.016446 0.094063 -6.822091 0.000000 Fixed Pros 0.092336 0.068612 0.123178 -13.877971 0.000000 Random Pros 0.062391 0.034410 0.110521 -8.505211 0.000000 Prosp Balleri 2010 Prosp 0.033333 0.002053 0.366305 -2.341017 0.019231 Fixed Prosp 0.033333 0.002053 0.366305 -2.341017 0.019231 Random Prosp 0.033333 0.001486 0.444065 -2.100091 0.035721 RCT Andersson, 2003 RCT 0.023529 0.001046 0.356726 -2.328449 0.019888 Fixed RCT 0.023529 0.001046 0.356726 -2.328449 0.019888 Random RCT 0.023529 0.000780 0.426552 -2.129078 0.033248 Retro Aparicio 2001 Retro 0.179131 0.077889 0.360519 -3.143446 0.001670 Retro Jemt 1992 Retro 0.157480 0.103906 0.231541 -6.884352 0.000000 Retro Malo 2000 Retro 0.020833 0.001291 0.259416 -2.693957 0.007061 Retro Naert, 1992 Retro 0.096260 0.062491 0.145446 -9.364651 0.000000 Retro Thomsson, 2008 Retro 0.015152 0.000941 0.200794 -2.929291 0.003397 Fixed Retro 0.122733 0.092934 0.160398 -12.374040 0.000000 Random Retro 0.105439 0.049360 0.211084 -5.111971 0.000000 Fixed Overall 0.105274 0.087248 0.126509 -20.187424 0.000000 Random Overall 0.076785 0.045549 0.126600 -8.774542 0.000000

-1.00

-0.50

0.00

0.50

1.00

Annual Failure rate- FPD screw retained

Model Groupby

Subgroupwithinstudy



CCT Jacobs, 2010 CCT 0.013514 0.000840 0.182466 -3.013245 0.002585 CCT Jemt, 2003 CCT 0.006349 0.000285 0.125188 -3.185672 0.001444 CCT Nissan, 2011 CCT 0.012821 0.000797 0.174501 -3.051781 0.002275 Fixed CCT 0.010682 0.002037 0.054034 -5.327979 0.000000 Random CCT 0.010682 0.002037 0.054034 -5.327979 0.000000 Pros Bischof, 2006 Pros 0.166667 0.009511 0.806422 -1.038888 0.298857 Pros Bragger 2005 Pros 0.023810 0.001473 0.287375 -2.594443 0.009474 Pros Cho, 2004 Pros 0.007246 0.000452 0.105451 -3.466324 0.000528 Pros Hosny, 2000 Pros 0.010204 0.000635 0.143238 -3.218263 0.001290 Pros Jemt, 1993 Pros 0.005263 0.000328 0.078521 -3.696708 0.000218 Pros Kourtis 2004 Pros 0.001767 0.000110 0.027584 -4.476852 0.000008 Pros Kreissl, 2007 Pros 0.062500 0.003793 0.538588 -1.854075 0.063728 Pros Lekholm, 1999 Pros 0.012690 0.003678 0.042835 -6.840679 0.000000 Pros Lindh, 2001 Pros 0.028846 0.005821 0.130947 -4.244253 0.000022 Pros Mertens, 2011 Pros 0.166667 0.009511 0.806422 -1.038888 0.298857 Pros Nedir, 2006 Pros 0.014286 0.000888 0.191192 -2.972503 0.002954 Pros Ortorp, 2008 Pros 0.000833 0.000002 0.291377 -2.240881 0.025034 Fixed Pros 0.017192 0.008780 0.033392 -11.653315 0.000000 Random Pros 0.017192 0.008780 0.033392 -11.653315 0.000000 Prosp Balleri 2010 Prosp 0.033333 0.002053 0.366305 -2.341017 0.019231 Fixed Prosp 0.033333 0.002053 0.366305 -2.341017 0.019231 Random Prosp 0.033333 0.002053 0.366305 -2.341017 0.019231 RCT Andersson, 2003 RCT 0.027778 0.001715 0.322082 -2.478848 0.013181 Fixed RCT 0.027778 0.001715 0.322082 -2.478848 0.013181 Random RCT 0.027778 0.001715 0.322082 -2.478848 0.013181 Retro Aparicio 2001 Retro 0.016667 0.001035 0.217152 -2.859126 0.004248 Retro Jemt 1992 Retro 0.003906 0.000244 0.059299 -3.910605 0.000092 Retro Malo 2000 Retro 0.020833 0.001291 0.259416 -2.693957 0.007061 Retro Naert, 1992 Retro 0.007093 0.001374 0.035771 -5.879303 0.000000 Retro Thomsson, 2008 Retro 0.015152 0.000941 0.200794 -2.929291 0.003397 Fixed Retro 0.009612 0.003335 0.027382 -8.530584 0.000000 Random Retro 0.009612 0.003335 0.027382 -8.530584 0.000000 Fixed Overall 0.014842 0.008850 0.024790 -15.718108 0.000000 Random Overall 0.014635 0.008023 0.026548 -13.576574 0.000000

-0.50

-0.25

0.00

0.25

0.50



Annual event free rate- FPD screw retained

Model Groupby

Subgroupwithinstudy



CCT Jacobs, 2010 CCT 0.961806 0.820803 0.992829 3.710016 0.000207 CCT Jemt, 2003 CCT 0.885714 0.781010 0.943950 5.171040 0.000000 CCT Nissan, 2011 CCT 0.870813 0.723166 0.945634 3.945301 0.000080 Fixed CCT 0.893598 0.826588 0.936697 7.363886 0.000000 Random CCT 0.904259 0.777400 0.962325 4.423640 0.000010 Pros Bischof, 2006 Pros 0.833333 0.193578 0.990489 1.038888 0.298857 Pros Bragger 2005 Pros 0.940000 0.712206 0.990018 2.922333 0.003474 Pros Cho, 2004 Pros 0.938235 0.849837 0.976061 5.400776 0.000000 Pros Hosny, 2000 Pros 0.996795 0.675862 0.999978 2.247721 0.024594 Pros Jemt, 1993 Pros 0.814894 0.723447 0.881073 5.580980 0.000000 Pros Kourtis 2004 Pros 0.998458 0.970646 0.999921 4.265058 0.000020 Pros Kreissl, 2007 Pros 0.937500 0.461412 0.996207 1.854075 0.063728 Pros Lekholm, 1999 Pros 0.965990 0.929306 0.983966 8.513610 0.000000 Pros Lindh, 2001 Pros 0.817308 0.688867 0.900393 4.174726 0.000030 Pros Mertens, 2011 Pros 0.833333 0.193578 0.990489 1.038888 0.298857 Pros Nedir, 2006 Pros 0.992647 0.725290 0.999855 2.443604 0.014541 Pros Ortorp, 2008 Pros 0.959167 0.904865 0.983054 6.843212 0.000000 Fixed Pros 0.904139 0.873848 0.927757 14.249805 0.000000 Random Pros 0.931230 0.881320 0.961078 8.501217 0.000000 Prosp Balleri 2010 Prosp 0.966667 0.633695 0.997947 2.341017 0.019231 Fixed Prosp 0.966667 0.633695 0.997947 2.341017 0.019231 Random Prosp 0.966667 0.562179 0.998476 2.117155 0.034247 RCT Andersson, 2003 RCT 0.976471 0.643274 0.998954 2.328449 0.019888 Fixed RCT 0.976471 0.643274 0.998954 2.328449 0.019888 Random RCT 0.976471 0.579112 0.999202 2.143574 0.032067 Retro Aparicio 2001 Retro 0.820869 0.639481 0.922111 3.143446 0.001670 Retro Jemt 1992 Retro 0.842520 0.768459 0.896094 6.884352 0.000000 Retro Malo 2000 Retro 0.979167 0.740584 0.998709 2.693957 0.007061 Retro Naert, 1992 Retro 0.896647 0.846367 0.931798 9.324532 0.000000 Retro Thomsson, 2008 Retro 0.984848 0.799206 0.999059 2.929291 0.003397 Fixed Retro 0.874167 0.836332 0.904257 12.369371 0.000000 Random Retro 0.890984 0.787126 0.947547 5.191462 0.000000 Fixed Overall 0.891737 0.870608 0.909774 20.432194 0.000000 Random Overall 0.918468 0.869205 0.950238 8.993620 0.000000

-1.00

-0.50

0.00

0.50

1.00

Annual Failure rate- Splinted crown- screw retained


Studyname Subgroupwithinstudy Statistics for eachstudy Eventrate and95%

CI Event Lower Upper rate limit limit Z-Value p-Value

os Esposito, 2014 os 0.031250 0.001926 0.350276 -2.389954 0.016850

Fixed os 0.031250 0.001926 0.350276 -2.389954 0.016850

Random os 0.031250 0.001926 0.350276 -2.389954 0.016850

Pros Gulje, 2013 Pros 0.021277 0.005328 0.081081 -5.356606 0.000000 Pros Balshi, 1996 Pros 0.019231 0.001192 0.243612 -2.753358 0.005899 Pros Kourtis 2004 Pros 0.002475 0.000155 0.038284 -4.236636 0.000023 Pros Kreissl, 2007 Pros 0.013514 0.000840 0.182466 -3.013245 0.002585

Fixed Pros 0.014425 0.005061 0.040408 -7.834642 0.000000 Random Pros 0.014425 0.005061 0.040408 -7.834642 0.000000

Retro Bambini, 2001 Retro 0.017857 0.001108 0.229623 -2.808198 0.004982 Fixed Retro 0.017857 0.001108 0.229623 -2.808198 0.004982

Random Retro 0.017857 0.001108 0.229623 -2.808198 0.004982 Fixed Overall 0.016088 0.006393 0.039899 -8.643384 0.000000

Random Overall 0.016088 0.006393 0.039899 -8.643384 0.000000

-0.50

-0.25

0.00

0.25

0.50



Annual Survival rate- Splinted crown- screw retained

Model Groupby

Subgroupwithinstudy Studyname Subgroupwithinstudy Statisticsfor eachstudy Eventrateand95% CI


os Esposito,2014 os 0.044444 0.003975 0.351510 -2.448754 0.014335

Fixed os 0.044444 0.003975 0.351510 -2.448754 0.014335

Random os 0.044444 0.001787 0.547122 -1.846204 0.064863

Pros Gulje,2013 Pros 0.159574 0.098552 0.247986 -5.898870 0.000000 Pros Balshi,1996 Pros 0.053333 0.009748 0.243820 -3.231581 0.001231 Pros Kourtis2004 Pros 0.027039 0.011711 0.061184 -8.239383 0.000000 Pros Kreissl,2007 Pros 0.027778 0.003899 0.172561 -3.505620 0.000456

Fixed Pros 0.088355 0.058925 0.130444 -10.471005 0.000000 Random Pros 0.056237 0.016814 0.171936 -4.428083 0.000010

Retro Bambini,2001 Retro 0.061728 0.013538 0.239765 -3.403019 0.000666 Fixed Retro 0.061728 0.013538 0.239765 -3.403019 0.000666

Random Retro 0.061728 0.004616 0.482773 -2.010903 0.044336 Fixed Overall 0.084558 0.057501 0.122690 -11.255774 0.000000

Random Overall 0.055679 0.019879 0.146324 -5.199319 0.000000

-0.50

-0.25

0.00

0.25

0.50

Annual event free rate- Splinted crown- screw retained


Study name Subgroupwithinstudy Statistics for eachstudy Event rate and 95%

CI Event Lower Upper rate limit limit Z-Value p-Value

os Esposito, 2014 os 0.955556 0.648490 0.996025 2.448754 0.014335

Fixed os 0.955556 0.648490 0.996025 2.448754 0.014335

Random os 0.955556 0.414220 0.998473 1.761047 0.078230

Pros Gulje, 2013 Pros 0.819149 0.728173 0.884506 5.637066 0.000000 Pros Balshi, 1996 Pros 0.946667 0.756180 0.990252 3.231581 0.001231 Pros Kourtis 2004 Pros 0.972961 0.938816 0.988289 8.239383 0.000000 Pros Kreissl, 2007 Pros 0.972222 0.827439 0.996101 3.505620 0.000456 Fixed Pros 0.899765 0.854632 0.932000 10.163661 0.000000 Random Pros 0.941930 0.807431 0.984314 4.036581 0.000054 Retro Bambini, 2001 Retro 0.938272 0.760235 0.986462 3.403019 0.000666 Fixed Retro 0.938272 0.760235 0.986462 3.403019 0.000666 Random Retro 0.938272 0.469473 0.996184 1.875694 0.060697 Fixed Overall 0.904907 0.864119 0.934380 10.956172 0.000000 Random Overall 0.943086 0.839884 0.981255 4.784000 0.000002

-1.00

-0.50

0.00

0.50

1.00



Annual failure rate- Cantilever FPD- screw retained



Event rate

Lower limit

Upper limit

Z-Value p-Value

Prosp Balleri 2010 Prosp 0.071429 0.004315 0.577249 -1.747718 0.080513 Prosp Bischof, 2006 Prosp 0.041667 0.002556 0.424563 -2.170448 0.029973 Prosp Kourtis 2004 Prosp 0.006410 0.000400 0.094260 -3.554791 0.000378 Prosp Kreissl, 2007 Prosp 0.020833 0.001291 0.259416 -2.693957 0.007061 Fixed Prosp 0.024827 0.006172 0.094506 -5.099261 0.000000 Random Prosp 0.024827 0.006172 0.094506 -5.099261 0.000000 retro Beckerr 2004 retro 0.125000 0.007325 0.734442 -1.287099 0.198060 Fixed retro 0.125000 0.007325 0.734442 -1.287099 0.198060 Random retro 0.125000 0.007325 0.734442 -1.287099 0.198060 Fixed Overall 0.033832 0.009701 0.111245 -5.157336 0.000000 Random Overall 0.034868 0.009191 0.123344 -4.787186 0.000002

-0.50

-0.25

0.00

0.25

0.50

Annual Survival rate- Cantilever FPD- screw retained



Event rate

Lower limit

Upper limit

Z-Value p-Value

Prosp Balleri 2010 Prosp 0.071429 0.004315 0.577249 -1.747718 0.080513 Prosp Bischof, 2006 Prosp 0.041667 0.002556 0.424563 -2.170448 0.029973 Prosp Kourtis 2004 Prosp 0.016940 0.003043 0.088656 -4.598558 0.000004 Prosp Kreissl, 2007 Prosp 0.060870 0.011595 0.263684 -3.137460 0.001704 Fixed Prosp 0.037413 0.013530 0.099217 -6.110740 0.000000 Random Prosp 0.037413 0.013530 0.099217 -6.110740 0.000000 retro Beckerr 2004 retro 0.125000 0.007325 0.734442 -1.287099 0.198060 Fixed retro 0.125000 0.007325 0.734442 -1.287099 0.198060 Random retro 0.125000 0.007325 0.734442 -1.287099 0.198060 Fixed Overall 0.042925 0.016510 0.107001 -6.191768 0.000000 Random Overall 0.042925 0.016510 0.107001 -6.191768 0.000000

-0.50

-0.25

0.00

0.25

0.50

Annual Event free rate- Cantilever FPD- screw retained

Model Group by

Subgroup within study

Study name Subgroup within study Statistics for each study Event rate and 95% CI


Prosp Balleri 2010 Prosp 0.928571 0.422751 0.995685 1.747718 0.080513

Prosp Bischof, 2006 Prosp 0.958333 0.575437 0.997444 2.170448 0.029973

Prosp Kourtis 2004 Prosp 0.983060 0.911344 0.996957 4.598558 0.000004

Prosp Kreissl, 2007 Prosp 0.939130 0.736316 0.988405 3.137460 0.001704

Fixed Prosp 0.962587 0.900783 0.986470 6.110740 0.000000

Random Prosp 0.962587 0.900783 0.986470 6.110740 0.000000

retro Beckerr 2004 retro 0.875000 0.265558 0.992675 1.287099 0.198060

Fixed retro 0.875000 0.265558 0.992675 1.287099 0.198060

Random retro 0.875000 0.265558 0.992675 1.287099 0.198060

Fixed Overall 0.957075 0.892999 0.983490 6.191768 0.000000

Random Overall 0.957075 0.892999 0.983490 6.191768 0.000000

-1.00 -0.50 0.00 0.50 1.00



Annual Failure rate- Single crown(Mechano-chemical)

Model Studyname Subgroup within study Statistics for each study Event rate and 95% CI

Event Lower Upper

rate limit limit Z-Value p-Value

Andersen 2001 Prosp 0.062500 0.003793 0.538588 -1.854075 0.063728

Uradenta 2010 Retros 0.003125 0.000448 0.021451 -5.809752 0.000000

Fixed 0.008165 0.001645 0.039507 -5.847501 0.000000

Random 0.011838 0.000612 0.189817 -2.916576 0.003539

-1.00 -0.50 0.00 0.50 1.00

Annual success rate- Single crown(Mechano-chemical)

Model Subgroup within study Statistics for each study Ev ent rate and 95% CI

Ev ent Lower Upper


Andersen 200P1rosp 0.2000000.0377500.614365 -1.4671160.142344

Uradenta 201R0 etros 0.0286440.0151490.053506-10.6125330.000000

Fixed 0.0359560.0197860.064473-10.4987470.000000

Random 0.0667270.0089970.360227 -2.5054670.012229

-1.00 -0.50 0.00 0.50 1.00

Annual event free rate- Single crown(Mechano-chemical)

Model Subgroup within study Statistics for each study Ev ent rate and 95% CI

Ev ent Lower Upper


Andersen 200P1rosp 0.0625000.0037930.538588-1.8540750.063728

Uradenta 201R0etros 0.8610000.8190370.89448611.3907480.000000

Fixed 0.8544350.8112120.88911511.1209150.000000

Random 0.4477760.0096880.985340-0.0930230.925885

-1.00 -0.50 0.00 0.50 1.00



Annual failure rate- Single crown cemented

Model Group by




CCT Andersen, 2001 CCT 0.010 0.001 0.136 -3.261 0.001 CCT Bergenblock, 2012 CCT 0.003 0.000 0.185 -2.651 0.008 CCT Gotfredsen, 2012 CCT 0.024 0.001 0.287 -2.594 0.009 Fixed CCT 0.012 0.002 0.065 -4.876 0.000 Random CCT 0.012 0.002 0.065 -4.876 0.000 PROS Andersson, 1998 PROS 0.009 0.001 0.107 -3.592 0.000 PROS Avivi-Arber, 1996 PROS 0.025 0.002 0.298 -2.558 0.011 PROS Behneke 2000 PROS 0.014 0.000 0.587 -1.810 0.070 PROS Bischof, 2006 PROS 0.004 0.000 0.046 -4.301 0.000 PROS Bragger 2005 PROS 0.007 0.000 0.108 -3.445 0.001 PROS Cabello, 2013 PROS 0.167 0.010 0.806 -1.039 0.299 PROS Cooper, 2007 PROS 0.010 0.001 0.136 -3.261 0.001 PROS Drago 2003 PROS 0.005 0.000 0.068 -3.808 0.000 PROS Glauser, 2004 PROS 0.009 0.001 0.129 -3.302 0.001 PROS Haas, 2002 PROS 0.010 0.001 0.090 -3.925 0.000 PROS Henry 1995 PROS 0.009 0.001 0.134 -3.275 0.001 PROS Hosseini, 2013 PROS 0.005 0.000 0.076 -3.726 0.000 PROS Karlsson, 1997 PROS 0.010 0.001 0.146 -3.203 0.001 PROS Kourtis, 2004 PROS 0.004 0.000 0.056 -3.954 0.000 PROS Lee, 2011 PROS 0.003 0.000 0.035 -4.675 0.000 PROS Linkenvicus 2009 PROS 0.071 0.004 0.577 -1.748 0.081 PROS Mericske-Stern, 2001 PROS 0.063 0.004 0.539 -1.854 0.064 PROS Mertens, 2011 PROS 0.016 0.001 0.206 -2.907 0.004 PROS Montero, 2012 PROS 0.102 0.013 0.496 -1.975 0.048 PROS Muftu, 1998 PROS 0.016 0.008 0.034 -10.775 0.000 PROS Ormianer, 2006 PROS 0.022 0.001 0.268 -2.662 0.008 PROS Palmer, 2000 PROS 0.031 0.002 0.350 -2.390 0.017 PROS Polizzi, 1999 PROS 0.006 0.000 0.367 -2.197 0.028 PROS Priest 1999 PROS 0.001 0.000 0.307 -2.216 0.027 PROS Romeo 2006 PROS 0.003 0.000 0.315 -2.267 0.023 PROS Santing, 2013 PROS 0.018 0.001 0.230 -2.808 0.005 PROS Scheller, 1998 PROS 0.004 0.000 0.085 -3.462 0.001 PROS Schropp, 2008 PROS 0.012 0.001 0.167 -3.088 0.002 PROS Schwarz, 2012 PROS 0.004 0.000 0.030 -5.240 0.000 PROS Turkyilmaz, 2006 PROS 0.014 0.001 0.191 -2.973 0.003 PROS Wannfors, 1999 PROS 0.014 0.001 0.182 -3.013 0.003 PROS Watson 1999 PROS 0.026 0.002 0.310 -2.519 0.012 PROS zembic 2013 PROS 0.013 0.001 0.178 -3.033 0.002 Fixed PROS 0.014 0.009 0.020 -20.309 0.000 Random PROS 0.014 0.009 0.020 -20.309 0.000 RCT Cannizzaro, 2013 RCT 0.006 0.000 0.091 -3.582 0.000 RCT Cannizzaro, 2008 RCT 0.005 0.000 0.069 -3.795 0.000 RCT Canullo, 2013 RCT 0.024 0.001 0.287 -2.594 0.009 RCT Pieri, 2011 RCT 0.012 0.001 0.167 -3.088 0.002 RCT Pozzi, 2014 RCT 0.006 0.000 0.083 -3.650 0.000 RCT Vigolo, 2012 RCT 0.006 0.000 0.737 -1.635 0.102 RCT Visser, 2011 RCT 0.005 0.000 0.080 -3.681 0.000 RCT Zembic, 2012 RCT 0.018 0.002 0.114 -3.990 0.000 Fixed RCT 0.010 0.004 0.025 -9.351 0.000 Random RCT 0.010 0.004 0.025 -9.351 0.000 RETRO Bonde, 2010 RETRO 0.009 0.001 0.127 -3.315 0.001 RETRO Camargos Gde, 2012 RETRO 0.025 0.002 0.298 -2.558 0.011 RETRO Cha 2013 RETRO 0.013 0.001 0.234 -2.704 0.007 RETRO Engquist, 1995 RETRO 0.033 0.002 0.366 -2.341 0.019 RETRO Hartlev, 2013 RETRO 0.011 0.001 0.149 -3.188 0.001 RETRO Jemt, 2009 RETRO 0.021 0.001 0.259 -2.694 0.007 RETRO Khraisat, 2008 RETRO 0.006 0.000 0.084 -3.642 0.000 RETRO Krennmair, 2002 RETRO 0.004 0.000 0.097 -3.248 0.001 RETRO Krennmair, 2010 RETRO 0.006 0.001 0.062 -4.224 0.000 RETRO Levine, 2007 RETRO 0.001 0.000 0.016 -4.945 0.000 RETRO Malo, 2000 RETRO 0.016 0.001 0.206 -2.907 0.004 RETRO Mangano, 2001 RETRO 0.006 0.000 0.091 -3.582 0.000 RETRO Romanos, 2000 RETRO 0.020 0.003 0.114 -4.157 0.000 RETRO Scholander, 1999 RETRO 0.002 0.000 0.034 -4.080 0.000 RETRO Schwartz-Arad, 1999 RETRO 0.007 0.000 0.101 -3.497 0.000 RETRO Singer, 1996 RETRO 0.028 0.002 0.322 -2.479 0.013 RETRO Sorrentino, 2012 RETRO 0.008 0.001 0.085 -3.896 0.000 RETRO Thomsson, 2008 RETRO 0.028 0.002 0.322 -2.479 0.013 RETRO Vanlioglu, 2013 RETRO 0.004 0.000 0.060 -3.899 0.000 RETRO Wennstrom, 2005 RETRO 0.011 0.001 0.151 -3.172 0.002 RETRO Yaltirik, 2011 RETRO 0.075 0.006 0.530 -1.872 0.061 Fixed RETRO 0.011 0.006 0.019 -15.053 0.000 Random RETRO 0.011 0.006 0.019 -15.053 0.000 Fixed Overall 0.012 0.009 0.017 -27.379 0.000 Random Overall 0.012 0.009 0.017 -27.379 0.000

-0.25

-0.13

0.00

0.13

0.25



Annual survival rate- Single crown cemented

Model Group by Subgroup within study



CCT Andersen, 2001 CCT 0.082 0.032 0.196 -4.733 0.000 CCT Bergenblock, 2012 CCT 0.017 0.003 0.102 -4.212 0.000 CCT Gotfredsen, 2012 CCT 0.050 0.007 0.282 -2.870 0.004 Fixed CCT 0.057 0.026 0.120 -6.785 0.000 PROS Andersson, 1998 PROS 0.016 0.002 0.103 -4.111 0.000 PROS Avivi-Arber, 1996 PROS 0.171 0.059 0.405 -2.590 0.010 PROS Behneke 2000 PROS 0.014 0.000 0.587 -1.810 0.070 PROS Bischof, 2006 PROS 0.015 0.004 0.053 -6.403 0.000 PROS Bragger 2005 PROS 0.025 0.006 0.107 -4.696 0.000 PROS Cabello, 2013 PROS 0.500 0.059 0.941 0.000 1.000 PROS Cooper, 2007 PROS 0.046 0.013 0.151 -4.533 0.000 PROS Drago 2003 PROS 0.009 0.001 0.062 -4.670 0.000 PROS Glauser, 2004 PROS 0.027 0.005 0.126 -4.273 0.000 PROS Haas, 2002 PROS 0.046 0.016 0.124 -5.502 0.000 PROS Henry 1995 PROS 0.115 0.053 0.234 -4.693 0.000 PROS Hosseini, 2013 PROS 0.058 0.026 0.125 -6.449 0.000 PROS Karlsson, 1997 PROS 0.128 0.058 0.256 -4.397 0.000 PROS Kourtis, 2004 PROS 0.010 0.002 0.052 -5.262 0.000 PROS Lee, 2011 PROS 0.043 0.023 0.081 -9.069 0.000 PROS Linkenvicus 2009 PROS 0.071 0.004 0.577 -1.748 0.081 PROS Mericske-Stern, 2001 PROS 0.034 0.001 0.677 -1.605 0.109 PROS Mertens, 2011 PROS 0.016 0.001 0.206 -2.907 0.004 PROS Montero, 2012 PROS 0.050 0.003 0.475 -2.029 0.042 PROS Muftu, 1998 PROS 0.012 0.005 0.027 -9.887 0.000 PROS Ormianer, 2006 PROS 0.036 0.004 0.260 -2.877 0.004 PROS Palmer, 2000 PROS 0.027 0.001 0.388 -2.245 0.025 PROS Polizzi, 1999 PROS 0.006 0.000 0.366 -2.198 0.028 PROS Priest 1999 PROS 0.008 0.001 0.061 -4.550 0.000 PROS Romeo 2006 PROS 0.016 0.002 0.132 -3.615 0.000 PROS Santing, 2013 PROS 0.025 0.002 0.223 -2.964 0.003 PROS Scheller, 1998 PROS 0.041 0.016 0.105 -6.161 0.000 PROS Schropp, 2008 PROS 0.025 0.004 0.157 -3.617 0.000 PROS Schwarz, 2012 PROS 0.140 0.101 0.191 -9.587 0.000 PROS Turkyilmaz, 2006 PROS 0.020 0.002 0.184 -3.163 0.002 PROS Wannfors, 1999 PROS 0.148 0.065 0.304 -3.728 0.000 PROS Watson 1999 PROS 0.083 0.017 0.326 -2.812 0.005 PROS zembic 2013 PROS 0.014 0.001 0.179 -3.067 0.002 Fixed PROS 0.066 0.055 0.080 -25.439 0.000 RCT Cannizzaro, 2013 RCT 0.025 0.006 0.094 -5.116 0.000 RCT Cannizzaro, 2008 RCT 0.046 0.019 0.106 -6.606 0.000 RCT Canullo, 2013 RCT 0.024 0.001 0.287 -2.594 0.009 RCT Pieri, 2011 RCT 0.025 0.004 0.157 -3.617 0.000 RCT Pozzi, 2014 RCT 0.006 0.000 0.083 -3.650 0.000 RCT Vigolo, 2012 RCT 0.026 0.002 0.310 -2.519 0.012 RCT Visser, 2011 RCT 0.030 0.009 0.093 -5.703 0.000 RCT Zembic, 2012 RCT 0.175 0.097 0.296 -4.444 0.000 Fixed RCT 0.066 0.043 0.098 -11.913 0.000 RETRO Bonde, 2010 RETRO 0.027 0.006 0.124 -4.317 0.000 RETRO Camargos Gde, 2012 RETRO 0.025 0.002 0.298 -2.558 0.011 RETRO Cha 2013 RETRO 0.067 0.017 0.231 -3.606 0.000 RETRO Engquist, 1995 RETRO 0.033 0.002 0.366 -2.341 0.019 RETRO Hartlev, 2013 RETRO 0.063 0.020 0.181 -4.450 0.000 RETRO Jemt, 2009 RETRO 0.009 0.000 0.417 -2.109 0.035 RETRO Khraisat, 2008 RETRO 0.034 0.011 0.102 -5.671 0.000 RETRO Krennmair, 2002 RETRO 0.101 0.054 0.181 -6.353 0.000 RETRO Krennmair, 2010 RETRO 0.033 0.012 0.087 -6.376 0.000 RETRO Levine, 2007 RETRO 0.023 0.013 0.041 -12.564 0.000 RETRO Malo, 2000 RETRO 0.097 0.032 0.261 -3.677 0.000 RETRO Mangano, 2001 RETRO 0.014 0.002 0.084 -4.494 0.000 RETRO Romanos, 2000 RETRO 0.008 0.001 0.121 -3.353 0.001 RETRO Scholander, 1999 RETRO 0.028 0.014 0.057 -9.371 0.000 RETRO Schwartz-Arad, 1999 RETRO 0.069 0.029 0.156 -5.557 0.000 RETRO Singer, 1996 RETRO 0.088 0.018 0.341 -2.731 0.006 RETRO Sorrentino, 2012 RETRO 0.008 0.001 0.085 -3.896 0.000 RETRO Thomsson, 2008 RETRO 0.028 0.002 0.322 -2.479 0.013 RETRO Vanlioglu, 2013 RETRO 0.002 0.000 0.080 -3.299 0.001 RETRO Wennstrom, 2005 RETRO 0.009 0.000 0.168 -2.968 0.003 RETRO Yaltirik, 2011 RETRO 0.050 0.002 0.558 -1.815 0.070 Fixed RETRO 0.041 0.031 0.053 -22.950 0.000 Fixed Overall 0.057 0.049 0.065 -36.776 0.000

-0.25

-0.13

0.00

0.13

0.25



Annual Failure rate- FPD cemented

Model Group by




Favours A Favours B

Annual Survival rate- FPD cemented

Model Group by Subgroup within study



CCT Gunne, 1999 CCT 0.011 0.001 0.151 -3.172 0.002 CCT Linkevicius, 2009 CCT 0.056 0.003 0.505 -1.947 0.052 CCT N issan, 2011 CCT 0.031 0.005 0.167 -3.680 0.000 Fixed CCT 0.028 0.007 0.099 -5.165 0.000 PROS Akca, 2008 PROS 0.038 0.009 0.146 -4.321 0.000 PROS Bragger 2005 PROS 0.051 0.012 0.195 -3.809 0.000 PROS Halg, 2008 PROS 0.009 0.001 0.129 -3.302 0.001 PROS Kourtis, 2004 PROS 0.011 0.002 0.054 -5.479 0.000 PROS Mertens, 2011 PROS 0.167 0.010 0.806 -1.039 0.299 PROS Pozzi, 2012 PROS 0.013 0.001 0.178 -3.033 0.002 PROS Romeo 2006 PROS 0.007 0.000 0.187 -2.777 0.005 PROS Schwarz, 2012 PROS 0.177 0.127 0.243 -7.549 0.000 Fixed PROS 0.121 0.088 0.164 -11.019 0.000 RCT Andersson 2003 RCT 0.054 0.008 0.295 -2.823 0.005 RCT Larsson, 2010 RCT 0.152 0.057 0.348 -3.086 0.002 RCT Pistilli 2013 RCT 0.012 0.001 0.167 -3.088 0.002 Fixed RCT 0.096 0.041 0.209 -4.847 0.000 RETRO Krennmair, 2010 RETRO 0.046 0.015 0.131 -5.241 0.000 RETRO Krennmair, 2011 RETRO 0.053 0.013 0.194 -3.879 0.000 RETRO Singer, 1996 RETRO 0.090 0.046 0.168 -6.351 0.000 RETRO Vanlioglu, 2013 RETRO 0.006 0.000 0.324 -2.287 0.022 RETRO Yaltirik, 2011 RETRO 0.024 0.001 0.287 -2.594 0.009 Fixed RETRO 0.066 0.039 0.108 -9.574 0.000 Fixed Overall 0.096 0.075 0.123 -15.979 0.000

-0.25

-0.13

0.00

0.13

0.25

Favours A Favours B



Annual survivall rate- splintedcrowns cemented

Model Group by



Event Lower Upper


CCT Linkevicius, 2009 CCT 0.019 0.001 0.236 -2.781 0.005

Fixed CCT 0.019 0.001 0.236 -2.781 0.005

Random CCT 0.019 0.001 0.236 -2.781 0.005

PROS Grandi, 2012 PROS 0.017 0.001 0.223 -2.834 0.005

PROS Kourtis, 2004 PROS 0.023 0.010 0.051 -8.687 0.000

Fixed PROS 0.022 0.010 0.048 -9.136 0.000

Random PROS 0.022 0.010 0.048 -9.136 0.000

RCT Cannizzaro, 2013 RCT 0.031 0.004 0.191 -3.380 0.001

Fixed RCT 0.031 0.004 0.191 -3.380 0.001

Random RCT 0.031 0.004 0.191 -3.380 0.001

RETR Vanlioglu, 2013 RETR 0.011 0.000 0.480 -1.996 0.046

Fixed RETR 0.011 0.000 0.480 -1.996 0.046

Random RETR 0.011 0.000 0.480 -1.996 0.046

Fixed Overall 0.022 0.011 0.045 -10.314 0.000

Random Overall 0.022 0.011 0.045 -10.314 0.000

-0.25 -0.13 0.00 0.13 0.25

Annual failurerate- cantilever FPD cemented

Model Group by




pros Bischof, 2006 pros 0.005 0.000 0.299 -2.335 0.020 Fixed pros 0.005 0.000 0.299 -2.335 0.020

Random pros 0.005 0.000 0.299 -2.335 0.020 retro Halg, 2008 retro 0.014 0.001 0.261 -2.596 0.009 retro Kourtis, 2004 retro 0.014 0.001 0.191 -2.973 0.003 retro Palmer 2005 retro 0.025 0.002 0.298 -2.558 0.011 retro Beckerr 2004 retro 0.009 0.001 0.129 -3.302 0.001

Fixed retro 0.015 0.003 0.059 -5.724 0.000 Random retro 0.015 0.003 0.059 -5.724 0.000

Fixed Overall 0.013 0.003 0.050 -6.165 0.000 Random Overall 0.013 0.003 0.050 -6.165 0.000

-0.50

-0.25

0.00

0.25

0.50



Annual SURVIVAL rate- cantilever FPD cemented

Model Group by




pros Bischof, 2006 pros 0.041 0.009 0.172 -3.904 0.000 Fixed pros 0.041 0.009 0.172 -3.904 0.000

Random pros 0.041 0.002 0.470 -2.038 0.042 retro Halg, 2008 retro 0.056 0.011 0.234 -3.374 0.001 retro Kourtis, 2004 retro 0.038 0.007 0.187 -3.608 0.000 retro Palmer 2005 retro 0.281 0.125 0.515 -1.843 0.065 retro Beckerr 2004 retro 0.006 0.000 0.168 -2.833 0.005

Fixed retro 0.126 0.063 0.233 -5.067 0.000 Random retro 0.068 0.015 0.267 -3.198 0.001

Fixed Overall 0.103 0.055 0.185 -6.251 0.000 Random Overall 0.061 0.016 0.212 -3.779 0.000

-0.50

-0.25

0.00

0.25 0.50

Annual Failurel rate- splintedcrowns cemented

Model Group by




CCT Linkevicius, 2009 CCT 0.019 0.001 0.236 -2.781 0.005

Fixed CCT 0.019 0.001 0.236 -2.781 0.005

Random CCT 0.019 0.001 0.270 -2.617 0.009

PROS Grandi, 2012 PROS 0.017 0.001 0.223 -2.834 0.005

PROS Kourtis, 2004 PROS 0.002 0.000 0.032 -4.365 0.000

Fixed PROS 0.006 0.001 0.041 -5.095 0.000

Random PROS 0.006 0.001 0.046 -4.791 0.000

RCT Cannizzaro, 2013 RCT 0.025 0.003 0.191 -3.236 0.001

Fixed RCT 0.025 0.003 0.191 -3.236 0.001

Random RCT 0.025 0.002 0.227 -2.947 0.003

RETR Vanlioglu, 2013 RETR 0.026 0.002 0.310 -2.519 0.012

Fixed RETR 0.026 0.002 0.310 -2.519 0.012

Random RETR 0.026 0.001 0.348 -2.372 0.018

Fixed Overall 0.014 0.004 0.045 -7.018 0.000

Random Overall 0.014 0.004 0.050 -6.438 0.000

-0.25 -0.13 0.00 0.13 0.25

4.5:Economicanalysis:

The total initialcost for IS-Singlecrown is 4608.06$and$9816.08 for3unit IS-FPD

includingthelabcost.Thecostthataccountsformaintenance[minoradjustmentormajor

replacement]weretabulatedintable-16.



Table-16.Cost

Type&design

Initialcost[$]

Minorcomplicationcharges[$]

Majorcomplicationcharges[$]

Totalcost

Effectiveness[Eventfreerate%]

Singlecrown-Cemented

4608.06 224.15 2305.64 5339.03 60.5

Singlecrown-screwretained

4608.06 322.94 935.68 5244.44 45.5

FPD-Cemented

9816.08 448.30 5848.18 11406.67 62.4

FPD-Screwed

9816.08 645.84 1770.40 10819.43 43.5

The 15 year calculated cumulativeminor andmajor complication eventswere used as

probabilitytocalculatethetotalcostsofeachrestoration.[Minor:71.2%-screwretained

singlecrown,39.9%cementsinglecrown,63.94%screwFPD,36.23%CementFPD.Major:

43.44%Screwretainedsinglecrown,25.91%cementretainedsinglecrown,47.5%screw

FPD, 20.14% Cement FPD]. Annexure-7 is used to interpret the results of the cost

effectiveness.

5. Discussion.5.1. Summaryofclinicalevidence:

This report was undertaken to help dental practitioner to take evidence based

decision on choosing the retention system for implant supported prosthesis. To our

knowledge,thisisthefirstofsuchreportsonretentionsystemsusedforIS-prosthesis.This

reportaddressesthefailure,complicationrates,eventfreerateofIS-prosthesisinpartially

edentulouspatients.



Allofthe104studiesreportedonfailure,complicationeventswereseparatedbased on

theretentionsystem.Theestimatedfailurerate/100prosthesisyearisinrangeof 0.3%-

1.8%[1.3-1.8forsinglecrown,1.3-1.6 forsplintedcrowns,0.3-1.3forcantileverFPDs,1.4-

1.5 forFPDs].Table-17comprehensivelysummarizesthefailurerate,survivalratefor the

differentretentionsystems,differentprosthesisdesign,differentabutmentandprosthesis

material for 15 years. 15 years were chosen because most of the restorative dental

materialshave lifespanof10-15years.Tocomparethecostsandeffectsof screwand

cementretention,ICERratioisused.Meancosteffectivenessratioswerecalculated[mean

costdividebymeaneffectiveness].ICERratioforcementvsscrewis6.304forsinglecrown

and30.5forFPD.ICERSlopesforsinglecrownsandFPDareshowninfigures4and5.The

credibilityoftheresultsdependsontheassumptionsanddata.

Our findings suggest that Cement retainedprosthesis performwell compared to other

retentionsystemexceptforcantileverFPD.Theresultsofourreviewisinagreementwith

theprevioussystematicreviews39-53

- Weber2007 :Estimatedevent freerate/100prosthesisyearfor IS-Single

crown[cement-95.6%,screw-90.9%].

- Pjetursson2012:failurerateofIS-FPD.4.4%after5yearsand6.9%after10

yearscomparabletothepresentresult4.2%after5yearsand6.8%after 10

years.

- Aglieta2009:annualfailurerateofcantileverFPD1.18,whichiscomparable

tothe1.4%inthisreport.



- Weber2007,Sailer2012;higherminorcomplicationeventsof screw

retentioncomparedtocementones.

- Wittenben2014reportedfailurerateofscrewIS-Sas1.85%[0.65;5.29] in

theirreview,thisisinagreementtothe1.8%[1.1;3.1]inthisreport.

Fig-4:ICERSlopesforsinglecrowns

Fig-5:ICERSlopesforFPD

53Table17:Estimatedfailurerate,survivalrate

Variables Retention type Failure

rate[%] 5 yr failure rate

10 yr failure arte

15 yr failure arte

Survival rate

5 yr survival rate

10 yr survival arte

15 yr survival arte

Single crown Cement Screw Mechano-chemical

1.3 1.8 1.4

2.5 3.5 1.59

3.5 3.7 3.1

4.4 3.8 4.5

4.2 8.5 7.8

14.5 26.6 31.3

25.5 42 54.3

35.1 50.7 67.8

Splinted crown Cement Screw

1.3 1.6

2.1 2.5

2.4 2.6

2.6 2.7

6.1 5.6

6.6 23.5

9.4 41.8

11.7 56.1

Cantilever FPD Cement Screw

1.4 0

3.1 0

3.9 0

4.4 0

2.2 4.3

12.8 12.5

20.4 18.7

24.5 78.9

FPD Cement Screw

1.4 1.5

4.2 3

6.8 3.5

8.6 3.9

4.5 7.7

12.8 21

21.3 32.6

29 42.6

Titanium Abutment

Cement Screw

0.2 0

0.99 0

1.98 0

2.95 0

2.8 0

13.06 0

24.42 0

34.29 0

Ceramic abutment

Cement Screw

0.2 0

0.99 0

1.98 0

2.95 0

0.2 0

0.99 0

1.98 0

2.9 0

PFM Cement Screw

0.3 0.1

1.4 0.5

2.95 0.99

4.4 1.48

4.1 5.9

18.53 25.54

33.63 44.56

45.93 58.72

All-Ceramic Cement Screw

0.2 0

0.9 0

1.98 0

2.95 0

2.7 4.4

19.74 11.75

22.11 58.10

31.27 72.28

Internal Hex Cement Screw

0.4 0

1.9 0

3.9 0

5.8 0

2.5 8.7

35.27 27.74

47.79 50.83

62.28 65.52

External hex Cement Screw

0.6 3.6

2.9 16.4

5.8 30.2

8.6 41.72

6.5 7.1

27.74 29.98

47.79 50.83

62.28 65.5

Anterior Cement Screw

0.4 0

1.98 0

3.9 0

5.8 0

11.4 7.6

43.44 31.61

68.01 53.23

81.91 68.01

Posterior Cement Screw

0.7 0.9

3.4 4.4

6.7 8.6

9.9 12.6

33.2 4.24

80.98 19.1

96.38 34.57

99.31 47.05

54

5.2. Ethicalandlegalconsiderations

Wedidnot identifyany literaturepertainingtoethical, social,socio-politicaland

legalissuesrelatedtoretentionsystemsusedforimplantsupportedreconstructions.Thus,

we are unable to report any such risks associatedwith the use of different retention

systems.Nonetheless,onthebasisofincludedstudieswecanconfirmthatscrewretained,

cementretainedsinglecrown,splintedcrown,cantileverFPD,FPDandmechano-chemical

retainedsinglecrownsaregloballyinuse.

5.3. Strengthandlimitations.

5.3.1. Strength

1. Themajor strengthof this report is the inclusionof16RCT’s;no systematic

reviewsareavailablewithmorethan6RCTssofar.

2. Intenseliteraturesearch:Thesystematicreviewwasconductedaccordingtoa

prespecifiedprotocol,usingstandardapproachforcollectingevidence, data

extraction,qualityassessmentandanalysis.

3. Thesystematicreviewincludedthreeretentionsystems;thisisthefirstreport

thatcomprehensivelyaddressesdifferentretentionsystemsusedinIS- partial

reconstructions.

4. Evidencewasanalyzedandpresentedusingmeta-analysisandMetaregression.

Robustness ofmeta-analysis findings is supportedby similarity between the

findingsofthisreportandpreviouslyreportedsystematicreviews.

55



5. Addresstheheterogeneityindefiningthesuccessoutcomebyincluding event

freeasanoutcome.

5.3.2. Limitations:

1. Themajorityofthestudiesdidnotdifferentiatebetweenthetypesofabutment

material,prostheticmaterial,lutingagentsthuslimitingthenumberofstudies to

beincludedinsubgroupanalysis.

2. One of the major shortcoming was the inclusion of both prospective and

retrospectivestudieswhichlimitstheexternalvalidity.

3. Mostof the studieswereconducted in the institutionalenvironment [university

setting],whichlimitsthegeneralizabilityoftheresults.

4. ThecostanalysiswasdonefromanorthAmericanperspective[inUS$],however

thecostmayvarybetweendifferentregionsandthisanalysisisintendedonly to

providearoughestimatetothecliniciansnotanexhaustiveeconomicanalysis.

Thefollowingsuggestionsweremadebasedonourinference

- Improvingthereportingofstudyfindingsinliteratureswithcomprehensive

informationonretentionsystems,prosthesisdesign,abutmentdesign and

material.

- Design prospective comparison trials to evaluate the different retention

systemwitheconomicevaluationasoneoftheoutcome.

56



6. Conclusion:

The objective of this report was to assess the effectiveness of different retention

systems and to determine the cost effectiveness of retention systems used for treating

partially edentulous patient with IS- prosthesis. Results from the systematic review

and meta-analysis suggest that there were no statistically significant differences in

failure rates between the retention systems and the prosthesis design. However the

survival rate was better with cement retained single crown and FPD. There were no

differences between major events but statistically significant differences with minor

events. In conclusion, within the limitations of this review cement retained prosthesis

fared better than the screw retained single crown and FPDs in relation to cost

effectiveness.


57

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• Canullo L. Clinical outcome study of customized zirconia abutments for single- implant restorations. International Journal of Prosthodontics. 2007;20(5):489-93.

• Eliasson A, Eriksson T, Johansson A, Wennerberg A. Fixed partial prostheses supported by 2 or 3 implants: A retrospective study up to 18 years. International Journal of Oral and Maxillofacial Implants. 2006;21(4):567-74.

• Froum SJ, Cho SC, Cho YS, Elian N, Tarnow D. Narrow-diameter implants: a restorative option for limited interdental space. International Journal of Periodontics & Restorative Dentistry. 2007;27(5):449-55.

• Knauf M, Gerds T, Muche R, Strub JR. Survival and success rates of 3i implants in partially edentulous patients: results of a prospective study with up to 84-months' follow-up. Quintessence International. 2007;38(8):643-51.

• Levine RA, Clem D, Beagle J, Ganeles J, Johnson P, Solnit G, et al. Multicenter retrospective analysis of the solid-screw ITI implant for posterior single- tooth replacements. The International journal of oral & maxillofacial implants. 2002;17(4):550-6.

• Levine RA, Clem DS, 3rd, Wilson TG, Jr., Higginbottom F, Solnit G. Multicenter retrospective analysis of the ITI implant system used for

single-tooth replacements: results of loading for 2 or more years. The International journal of oral & maxillofacial implants. 1999;14(4):516-20.

• Linkevicius T, Vladimirovas E, Grybauskas S, Puisys A, Rutkunas V. Veneer fracture in implant-supported metal- ceramic restorations. Part I: Overall success rate and impact of occlusal guidance. Stomatologija / issued by public institution "Odontologijos studija" [et al]. 2008;10(4):133-9.

• Norton MR. Biologic and mechanical stability of single-tooth implants: 4- to 7-year follow-up. Clinical Implant Dentistry & Related Research. 2001;3(4):214-20.

• Nothdurft F, Pospiech P. Prefabricated zirconium dioxide implant abutments for single-tooth replacement in the posterior region: evaluation of peri-implant tissues and superstructures after 12 months of function. Clinical Oral Implants Research. 2010;21(8):857-65.

Excluded articles 1. Abad-Gallegos M, Gomez-Santos L, Sanchez-Garces MA, Pinera-Penalva M, Freixes-Gil J, Castro-Garcia A, et al. Complications of guided surgery and immediate loading in oral implantology: A report of 12 cases. Medicina Oral, Patologia Oral y Cirugia Bucal. 2011;16(2):e220-e4. 2. Abboud M, Koeck B, Stark H, Wahl G, Paillon R. Immediate loading of single-tooth implants in the posterior region. The International journal of oral & maxillofacial implants. 2005;20(1):61-8. 3. Aglietta M, Siciliano VI, Zwahlen M, Brägger U, Pjetursson BE, Lang NP, et al. A systematic review of the survival and complication rates of implant supported fixed dental prostheses with cantilever extensions after an observation period of at least 5 years. Clinical oral implants research. 2009;20(5):441-51. 4. Allen PF, McMillan AS, Smith DG. Complications and maintenance requirements of implant-supported prostheses provided in a UK dental hospital. British dental journal. 1997;182(8):298-302. 5. Andersson B, Odman P, Lindvall AM, Branemark PI. Five-year prospective study of prosthodontic and surgical single-tooth implant treatment in general practices and at a specialist clinic. The International journal of prosthodontics. 1998;11(4):351-5. 6. Andersson B, Taylor A, Lang BR, Scheller H, Scharer P, Sorensen JA, et al. Alumina ceramic implant abutments used for single-tooth replacement: a prospective 1- to 3-year multicenter study. The International journal of prosthodontics. 2001;14(5):432-8. 7. Astrand P, Engquist B, Anzen B, Bergendal T, Hallman M, Karlsson U, et al. A three-year follow-up report of a comparative study of ITI Dental Implants and Branemark System implants in the treatment of the partially edentulous maxilla. Clinical implant dentistry and related research. 2004;6(3):130-41. 8. Bahat O, Handelsman M. Use of wide implants and double implants in the posterior jaw: a clinical report. The International journal of oral & maxillofacial implants.

1996;11(3):379-86. 9. Balshi TJ, Ekfeldt A, Stenberg T, Vrielinck L. Three-year evaluation of Branemark implants connected to angulated abutments. The International journal of oral & maxillofacial implants. 1997;12(1):52-8. 10. Barrachina-Diez JM, Tashkandi E, Stampf S, Att W. Long-term outcome of one-piece implants. Part II: Prosthetic outcomes. A systematic literature review with meta-analysis. International Journal of Oral & Maxillofacial Implants. 2013;28(6):1470-82. 11. Behneke A, Behneke N, d'Hoedt B, Wagner W. Hard and soft tissue reactions to ITI screw implants: 3-year longitudinal results of a prospective study. International Journal of Oral & Maxillofacial Implants. 1997;12(6):749-57. 12. Behr M, Lang R, Leibrock A, Rosentritt M, Handel G. Complication rate with prosthodontic reconstructions on ITI and IMZ dental implants. Internationales Team fur Implantologie. Clinical oral implants research. 1998;9(1):51-8 13. Berglundh T, Persson L, Klinge B. A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. Journal of clinical periodontology. 2002;29 Suppl 3:197-212; discussion 32-33. 14. Bianco G, Di Raimondo R, Luongo G, Paoleschi C, Piccoli P, Piccoli C, et al. Osseointegrated implant for single-tooth replacement: a retrospective multicenter study on routine use in private practice. Clinical Implant Dentistry & Related Research. 2000;2(3):152-8. 15. Bidra AS, Rungruanganunt P. Clinical Outcomes of Implant Abutments in the Anterior Region: A Systematic Review. Journal of Esthetic and Restorative Dentistry. 2013;25(3):159-76. 16. Block MS, Gardiner D, Kent JN, Misiek DJ, Finger IM, Guerra L. Hydroxyapatite-coated cylindrical implants in the posterior mandible: 10-year observations. The International journal of oral & maxillofacial implants. 1996;11(5):626-33. 17. Block MS, Lirette D, Gardiner D, Li L, Finger IM, Hochstedler J, et al. Prospective

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ii


Annexe-1BasicCharacteristicstable-Prioriform

No

Retentiontype

Studydesign

Quality

score

NoofPatients

Agerange

NoofImplants

Noofprosthe

sis

Prosthesis

design

Observation

period

Dropouts

Studysetting

M F T

Annexure-2:Prioriform

RCT CCT

Prospective Retrospectiveee

Strong Medium Weak

Ref: Screwed Cemented/IAC Total patient: M

F No of Implants No of Single crowns

No of FPDS No of Splinted crowns

No of T-IS FPD No of cantilever FPD

No of fs-FPD Brand name

PFM/PBM PFG

All ceramic Resin

Custom abutment Prefabricated

Observation period Mean observation

Total lost to follow up Lost due to failure

Minor porcelain chip occlusal/prosthetic screw loosening

Abutment screw loosening

Re cementation

crown loosening Prosthetic/occlusal screw fracture

Abutment screw fracture

abutment fracture

Crown remade Minor biological events

Major biological events Total Failure

At the start: Finalfollowup:

Total Minor : TotalMajor:

Without events: Survival:

21

Maxilla-

Mandible-

Anterior-

Posterior- Any other in results: Titanium Screw- Gold Screw-

Cement type-

Screw access hole-

Occlusal material to cover- Other:

i

Annexe-3.Criticalappraisaltool

Reference Studydomain Strong[1] Moderate[2] Weak[3]

SelectionBias

StudyDesign

Confounders

Blinding

DataCollection

Withdrawalsand

dropout

Finalratingofthearticle

Strong[Noweakratings]inanyofthedomains

Moderate[oneweakrating]

Weak[Twoormoreweakrating]

Annexe-4:Formulasusedforcalculation

Failureratecalculation:

Nooffailure/totalprosthesisobservationtime=Failure rate.

FailurerateX100=Estimatedannualfailurerate/100prosthesis/year

5yearfailureproportion=1-exp(-5xfailurerate)





Survivalratecalculation:

Noofcomplicationevents=Minortechnicalevents+minorbiologicalevents+majortechnical

events+majorbiologicalevents

Noofcomplicationevents/totalprosthesisobservationtime=survivalrate.

SurvivalrateX100=Estimatedannualsurvivalrate/100prosthesis/year

5yearSurvivalproportion=1-exp(-5xsurvivalrate)





Eventfreeratecalculation:

Noofevents=complicationevents+failureevents

Noofevents/totalprosthesisobservationtime=event rate.

Eventfreerate=1-eventrate

EventfreerateX100=Estimatedannualeventfreerate/100prosthesis/year

5yearEventfreeproportion=exp(-5xfailurerate)


15yearEventfreefailureproportion=exp(-15xfailurerate)

20yearEventfreefailureproportion=exp(-20xfailure rate)


Annexure-5:ADAsurvey

Code Treatment Generaldentist Specialist

D0120 Periodicexamination 44.10 57.34

D0220 IOPA 25 26.41

D0431 Treatingmucosalabnormalities 61.84

D0470 Diagnosticcast 87.19

D1110 Prophylaxis 82.08 100.61

D2330 Resinbasedcomposite[1surface] 139.84

D2920 Crownrecementation 89.27 110.29

D6010 Implantsurgicalplacement 1741 2040.55

D6056 Prefabricatedabutmentincluding

placement

604.50 696.72

D6057 Customabutmentincluding

placement

760.93 880.85

D6059 PFGCrown 1246.11 1583.10

D6066 PFMcrown 1316.98 1709.84

D6080 Maintenance[screwreplacement,

reinsertion]

174.75 224.30

D6930 RecementationofFPD 133.78 163.67

D9120 Sectioningtheprosthesis 131.63

D9951 Adjustment 125.54 180.23

D9440 Afterscheduledhour 155.26

Annexure-6Meanhourlywage[USLaborstatistics]

Dentist 80.20

Dental

assistant

17.02

Dentallab

technician

19.69

Receptionist 15.62

Annexure-7:-Kappainterauthoragreement

Title & Abstract screening

Reviewer1

Yes No

Reviewer2 Yes 322 18

No 0 556

Number of observed agreements: 878 ( 97.99% of the observations)

Number of agreements expected by chance: 478.4 ( 53.39% of the observations)

Kappa= 0.957 SE of kappa = 0.010 95% confidence interval: From 0.937 to 0.977

Full Text evaluation:

Reviewer1

Yes No

Reviewer2 Yes 128 9

No 14 178




Critical appraisal:

Reviewer1

Strong Moderate Weak

Reviewer2 Strong 17 2 0

Moderate 0 85 0

Weak 0 0 9




Annexure-8: Meta regression

Regression of Rate on FAILURE

0.06

0.05

0.04

0.03

0.02

0.00

-0.01

-0.02

-0.03

-0.04

M C S

FAILURE

M-Mechano-chemical,C-Cement, S-Screw

Regression of Rate on FAILURE

0.06

0.05

0.04

0.03

0.02

0.00

-0.01

-0.02

-0.03

Y = 0.0127 - 0.0095 if FAILURE = C - 0.0083 if FAILURE = S

-0.04

M C S

FAILURE

M-Mechano-chemical,C-Cement, S-Screw

Regression of Rate on FAILURE[ABUTMENT TYPE]

0.05

0.04

0.03

0.02

0.01

-0.01

-0.02

-0.03

Y = 0.0099 - 0.0062 if FAILURE = SCR

-0.04

CEMENT SCREW

FAILURE

Regression of Rate on FAILURE[Implant-abutment connectionT TYPE]

0.06

0.05

0.04

0.03

0.01

0.00

-0.01

-0.02

Y = 0.0042 - 0.0027 if reteention failur

-0.03

cement screw

retention failure

R

ate

Regression of Rate on FAILURE[Prosthesis materialT TYPE]

0.01

0.01

0.01

0.01

0.00

0.00

0.00

0.00

Y = 0.0027 0.00 - 0.0018 if reteention failur

-0.01

cement screw

reteention failure

Regression of Rate on FAILURE[edentulous locationT TYPE]

0.01

0.01

0.01

0.00

0.00

0.00

0.00

0.00 Y = 0.0027 - 0.0008 if reteention failur

-0.01

cement screw

retention failure

Regression of Rate on survival-Prosthesis design

0.00

-0.50

-1.00

-1.50

-2.00

-2.50

-3.00

-3.50

-4.00

-4.50

-5.00

Y = -3.1763 + 0.8022 if Retention-Surv + 0.6259 if Retention-Surv + 0.6487 if Retention-Surv

C M S SC

Retention-Survival

C-Cantilever,M-FPD,s-Singlecrown,sc—Splintedcrown

Regression of Rate on FAILURE[Prosthesis materialT TYPE]

0.01

0.01

0.01

0.01

0.00

0.00

0.00

0.00

Y = 0.0027 0.00 - 0.0018 if reteention failur

-0.01

cement screw

reteention failure

Lo

git e

ve

nt r

ate

Regression of Rate on survival-Abutment material

25.00

20.00

15.00

10.00

5.00

0.00

-5.00

-10.00

-15.00

-20.00

-25.00

-30.00

Y = -5.2714 + 0.3345 if Retention-Surv

-35.00

ceramic ti

Retention-Survival

Regression of Rate on survival-Prosthesist material

0.00

-1.00

-2.00

-3.00

-4.00

-5.00

-6.00


-7.00

ceramic PFM

Retention-Survival

Regression of Rate on survival-Implant abutment connection

6.00

4.00

2.00

0.00

-2.00

-4.00

-6.00

-8.00

-10.00

-12.00


-14.00

external hex Internal hex

Retention-Survival

Annexure-9: Cost effectiveness ICER slope interpretation guidelines.

Annexure-10:[ICERCalculationforsinglecrown]

Annexure11:ICERCalculationforFPD

Documents

A Health Technology Assessment Report on: Different ... · A Health Technology Assessment Report on: ... A Health Technology Assessment Report on Different retention systems used