Direct and Indirect Restorations for Endodontically

Treated Teeth: A Systematic Review and Meta-analysis,

IAAD 2017 Consensus Conference Paper
Xin Shua / Qing-qing Maib / Markus Blatzc / Richard Priced / Xiao-dong Wange / Ke Zhaof

Purpose: The primary objective of this systematic review was to compare treatment outcomes of direct and indirect
permanent restorations in endodontically treated teeth, and provide clinical suggestions for restoring teeth after
endodontic treatment.
Materials and Methods: Electronic databases (Medline, EMBASE, CENTRAL) and gray literature were screened for
articles in English that reported on prospective and retrospective clinical studies of direct or indirect restorations
after endodontic treatment with an observation period of at least 3 years. Primary outcomes were determined to be
short-term (≤ 5 years) and medium-term (> 5 and ≤ 10 years) survival. Secondary outcomes included restorative
and endodontic success of restored teeth. The quality of included studies and risk of bias were assessed using
Cochrane Collaboration’s tool for RCTs (randomized controlled trials), the Newcastle-Ottawa Scale for cohort stud-
ies, and the Agency for Healthcare Research and Quality (AHRQ) methodology checklist for cross-sectional studies.
The GRADE system was used for assessing collective strength of the overall body of evidence.
Results: Of 2547 screened articles, only 9 (2 RCTs, 3 retrospective cohort studies, 3 cross-sectional studies) met
the inclusion criteria, and 8 studies were used in the meta-analysis. In general, indirect restorations (mostly full
crowns) showed higher 5-year survival (OR 0.28, 95% CI 0.19-0.43, p < 0.00001) and 10-year survival (OR 0.20,
95% CI 0.12-0.31, p < 0.00001) than direct restorations. However, there was no statistical difference in short-
term (≤ 5-years) restorative success (OR 0.32, 95% CI 0.05-2.12, p = 0.24) and endodontic success (OR 0.88,
95% CI 0.72-1.08, p = 0.22).
Conclusions: Based on current evidence, there is a weak recommendation for indirect restorations to restore end-
odontically treated teeth, especially for teeth with extensive coronal damage. Indirect restorations using mostly
crowns have higher short-term (5-year) and medium-term (10-year) survival than do direct restorations using com-
posite or amalgam (GRADE quality of evidence: low to moderate), but no difference in short-term (≤ 5 years) restor-
ative success (low quality) and endodontic success (very low quality). There is a need for high-quality clinical trials,
especially well-designed RCTs.
Keywords: endodontic treatment, direct restorations, indirect restorations, survival rates, success rates, apical
periodontitis.

J Adhes Dent 2018; 20: 183–194. Submitted for publication: 09.09.17; accepted for publication: 28.03.18
doi: ##.####/j.jad.a#####

a Master’s Student, Department of Prosthodontics, Guanghua School of Stoma- e Staff Dentist, Department of Prosthodontics, Guanghua School of Stomatology,
tology, Sun Yat-sen University, Guangzhou, China. Performed the literature Sun Yat-sen University, Guangzhou, China. Co-corresponding author, proof-
search, data extraction and statistical analysis, wrote the manuscript. read the manuscript, contributed substantially to discussion.
b Staff Dentist, The 3rd Dental Center, Peking University School of Stomatology, f Professor, Department of Prosthodontics, Guanghua School of Stomatology,
Beijing, China. Co-first author, performed the literature search, data extraction Sun Yat-sen University, Guangzhou, China. Idea, consulted on statistical evalu-
and statistical analysis. ation, proofread the manuscript, contributed substantially to discussion.
c Professor, Department of Preventive and Restorative Sciences, University of
Pennsylvania School of Dental Medicine, Philadelphia, PA, USA. Idea, proof- Correspondence: Ke Zhao, Hospital of Stomatology, School of Stomatology,
read the manuscript, contributed substantially to discussion. Sun Yat-sen University, 54 Ling-yuan West Street, Guangzhou, China 510055.
Tel: +86-20-8380-2805; e-mail: [email protected].
d Professor, Department of Clinical Dental Sciences,  Faculty of Dentistry, Dal- Co-corresponding author: Xiao-dong Wang, Prosthodontics Department, Guang-
housie University, Halifax, NS, Canada. Proofread the manuscript, contributed hua School of Stomatology, Sun Yat-sen University, Guangzhou, China. e-mail:
substantially to discussion. [email protected]

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Shu et al

MATERIALS AND METHODS

E ndodontically treated teeth (ETT) are more susceptible
to biomechanical failure compared to vital teeth, 32
mostly due to the amount of internal tooth structure that is Literature Search and Study Selection
removed during endodontic treatment and the loss of coro- An electronic search of published English literature in Med-
nal hard tissue.60,71 The prognosis of ETT depends not only line via Pubmed, EMBASE (Excerpt Medica Database) via
on the quality of endodontic treatment, but also on the sub- OVID, and CENTRAL (Cochrane Central Register of Con-
sequent restorative techniques.32 Reported reasons for ex- trolled Trials) via OVID databases up to March 2017 was
traction of teeth after endodontic treatment include end- conducted. Search strategies are detailed in appendix 1.
odontic failures, prosthodontic complications, coronal and Utilizing ClinicalTrials.gov, Open Grey, and Google Scholar,
root fracture, caries, or periodontal disease.7 gray literature was searched for potentially suitable unpub-
The best way to restore ETT has been extensively dis- lished clinical trials, including conference abstracts, unpub-
cussed but is still controversial concerning the best type of lished and ongoing studies, nationally and internationally
final restoration.21,76 Conventional restoration modality in- registered trials, doctoral dissertations. Hand searching
volves fabricating a full-coverage crown with or without a was also conducted for relevant references.
post,48 as this was believed to provide better protection All titles and abstracts were screened based on the fol-
and reinforcement of the remaining tooth structure.5,32,33 lowing inclusion criteria:
However, complete crown restoration usually also requires y Patients and teeth (P): adult and adolescent patients
extensive tooth preparation and new occlusal schemes. In with endodontically treated permanent teeth. There were
addition, the loss of anatomic structures such as cusps, no restrictions by gender or position of tooth.
ridges, and the pulp chamber roof may decrease the y Intervention (I): indirect restorations including full-coverage
strength of the remaining tooth.5 (any type of complete crown or endocrown) and partial-
Although direct amalgam and composite restorations coverage (any type of inlay, onlay, and partial crown) resto-
were recommended in 2003 as conservative restorative rations with or without posts, using permanent materials.
techniques with 10-year survival rates of 82.4% and 85.2%, y Control (C): direct restorations using permanent material
respectively,16 more recent studies of large numbers of pa- (including composite and amalgam), with or without posts.
tients treated by general dentists give a median longevity of y Outcomes (O): only studies with a follow-up of at least
direct posterior composite restorations between 5 and 8 3 years were included, and the follow-up periods were
years.43,59,61,72 classified as short-term (≥ 3 and ≤ 5 years), medium-
Maximum preservation of healthy tooth structure is the term (> 5 and ≤ 10 years), and long-term (> 10 years).
main goal of restorative dentistry. Therefore, with recent y Primary outcomes: survival of restored teeth. The sur-
advances in bonding technologies, adhesively bonded ce- vival criterion used in this study was defined as the
ramic inlay or onlay restorations have been suggested in tooth-restoration complex being in situ.
several in vitro studies.33,41,65,77 Some indicate that only y Secondary outcomes: restorative and endodontic suc-
complete coverage can provide sufficient protection and en- cess of restored teeth. Restorative success was defined
sure the longevity of the tooth-restoration complex,15 while as tooth and restoration present and clinically accept-
others claim the decision to place full-coverage crowns or able, no repair needed. Endodontic success referred to
onlays should depend on the amount of remaining tooth no signs or symptoms of pulpal or apical pathology ac-
structure.67 cording to clinical and radiological examinations, no end-
Many clinicians prefer using direct composite restora- odontic intervention needed.
tions to restore ETT due to their good esthetic properties, y Study design (S): randomized and nonrandomized con-
relatively low cost, ease of handling, and preservation of trolled clinical trials, observational study designs includ-
dental structures. 5,12 Some laboratory studies indicate ing cohort (prospective and retrospective), case-control,
that there is no significant difference in the load required and cross-sectional.
to fracture ETT that have received direct or indirect restora-
tions.12,27 However, it was later reported that indirect ce- A full text was obtained of all relevant and potentially rele-
ramic restorations may pose a higher risk of catastrophic vant studies. Two review authors independently assessed
tooth fracture.12 Results of thermomechanical loading in- the full-text papers, and disagreements between the two
dicated that ceramic restorations behave similarly to direct reviewers were resolved by direct discussion, or by a third
restorations when the same cavity preparations were reviewer if no agreement could be reached. For missing or
used, and it was concluded that small conservative end- unclear information in the articles obtained, the correspond-
odontic access cavities can be safely and simply restored ing authors were contacted by e-mail to confirm the ambigu-
with direct adhesive restorations and composite.27 ous data. For the same clinical trial with multiple publica-
Therefore, the aim of this systematic review was to eval- tions, only the latest was included in the analysis.
uate treatment outcomes of direct and indirect restorations
to provide clinical recommendations for restoring endodonti- Data Extraction
cally treated teeth. Two reviewers independently scrutinized the full text of in-
cluded studies. A data extraction table was employed to
extract detailed information on: author(s), year of publica-

184 The Journal of Adhesive Dentistry

 Shu et al

tion, study design, participants, follow-up time, sample size judgements about quality of evidence and strength of rec-
of each group, type, material and brand (if available) of the ommendations.
restoration as well as the post (if used), and the outcomes All studies, regardless of the risk of bias and method-
of each study. ological quality, were included in the quantitative synthesis.
When collecting the survival rate data, information pro-
vided in the publication was used directly. For outcomes ex- Statistical Analysis and Heterogeneity
pressed as Kaplan-Meier survival curves, data were extracted Pooled data of all the outcomes were subjected to meta-
using the freeware software Engauge Digitizer (ver. 5.1 analysis to estimate the odds ratio (OR) and 95% confi-
http://markummitchell.github.io/engauge-digitizer). The En- dence intervals (CI) using the Cochrane Collaboration Re-
gauge Digitizer software accepts image files (eg, PNG, JPEG, view Manager (Ver. 5.3). To test the reliability of evidence,
and TIFF) containing graphs, and recovers the data points outcomes of fixed-effect models and random-effect models
from those graphs. For consistent studies, the extracted data were compared, but considering the unexplained heteroge-
were deemed precise enough to be included in the meta- neity between studies, only random-effect estimates were
analysis, while for inconsistent studies with no reply from the reported, to be more conservative.
author, data were excluded from quantitative analysis. Other Cochran’s Q test was applied for analyzing the hetero-
initial data were obtained by contacting the authors. geneity between included studies, and no heterogeneity
Due to national differences and writing styles, the termi- was determined if the p-value was higher than 0.1. Other-
nology used in included studies varies. For standardization, wise, the I2 statistic was used to quantify the statistical
confirmatory e-mails were sent to the authors to ascertain heterogeneity, and the threshold was determined as Co-
the restoration types and materials; further, descriptions chrane recommended, ie, 0% to 40%: might not be impor-
were adjusted accordingly in the data extraction table. For tant; 30% to 60%: may represent moderate heterogeneity;
authors who did not reply, the original text was used. 50% to 90%: may represent substantial heterogeneity;
75% to 100%: considerable heterogeneity. For outcomes
Risk of Bias with substantial or considerable heterogeneity, sensitivity
Two reviewers independently evaluated the methodological analysis was carried out by comparing the fixed and ran-
qualities of included studies according to the guidance pro- dom-effect estimates, considering subgroup analysis, and
vided by the Journal of Evidence-based Medicine.79 testing for excess of studies with significant results.
Cochrane Collaboration’s tool (http://handbook-5-1.
cochrane.org/) was used to assess the risk of bias of
RCTs. The domains of sequence generation, allocation con- RESULTS
cealment, and selective outcome reporting were addressed
in the tool. The initial electronic search yielded 3497 records (1358 in
The Newcastle-Ottawa Scale (http://www.ohri.ca/ Medline, 1379 in OVID, 758 in Central, and 2 from hand-
programs/clinical_epidemiology/oxford.asp) was applied searching and gray literature), and 2547 records were
for assessing cohort studies. Using the tool, each study found after removing the duplicates. From these 2547 re-
was judged on 8 items, categorized into 3 groups: the cords, 49 potentially pertinent records were selected after
selection, comparability, and outcome of exposed and screening the titles and abstracts. Full-text articles were
non-exposed cohort. Stars were awarded for each study retrieved for eligibility assessment, and 40 articles were
(up to 9 stars) for quick visual assessment. Studies excluded with reasons (different definition of survival rates:
awarded with 6 or more stars were regarded as high-qual- n = 1;13 insufficient follow-up time: n = 2;44,78 only indirect
ity studies. restorations were used: n = 19;8,9,14,21,22,25,39,40,42,51-
For cross-sectional studies, the Agency for Healthcare 53,57,58,62,68,69,74,80 only direct restorations were used:
Research and Quality (AHRQ) methodology checklist n = 182-4,11,20,26,29,34,35,38,45,47,50,55,63,64,75,81).
(https://www.ncbi.nlm.nih.gov/books/NBK35156/) was Ultimately, only 9 articles met the inclusion criteria, and
applied. This is a methodological quality assessment tool all included studies had a parallel design. Some of the in-
using an 11-item checklist, and the AHRQ recommends it cluded studies provided specific data in their publications,
for assessment of cross-sectional studies. An item would including the studies by: Aquilino et al7 and Pratt et al56 in
be scored “0” if it was answered “NO” or “UNCLEAR”; if it short-term (5 years) survival analyses, Aquilino et al7 and
was answered “YES”, then the item was give a score of Dammaschke et al16 in medium-term (10 years) analyses,
“1”. Article quality was assessed as follows: low qual- Skupien et al70 and Mannocci et al46 in short-term (≤ 5
ity = 0–3; moderate quality = 4–7; high quality = 8–11. years) restorative success assessments, Frisk et al,28
For every outcome of meta-analysis, the quality of the Hommes et al,36 and Dawson et al18 in endodontic success
evidence was assessed using the GRADE (Grading of Rec- assessments. Their information was used directly. For stud-
ommendations, Assessment, Development and Evalua- ies with Kaplan-Meier survival curves,56,73 data extracted
tions) approach by GRADEprofiler (Ver 3.6). The GRADE ap- from Engauge Digitizer were compared with the available
proach was used for collective grading of the overall body of information in the text to test the precision of the figure. For
evidence in this review, as the study designs vary; more- consistent studies,56 the extracted data were deemed pre-
over, it is also a systematic and explicit approach to making cise enough to be included in the meta-analysis; while for

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Shu et al

Table 1 Characteristics of included studies

Author (year) Study Follow-up Age in Teeth Indirect restorations Direct restorations Outcomes
design years (n*) (n*)

Skupien70 RCT 5 years 42.2 ± Endodontically Porcelain-fused-to- Composite fillings with Cumulative success
(2016) 11.5 treated teeth with metal crowns bonded fiber posts (n = 30) and survival (Kaplan-
extensive coronal with composite Meier survival and
damage cement, with fiber success curve); clinical
posts (n = 27) performance**

Mannocci46 RCT 3 years 35–55, Endodontically Porcelain-fused-to- Composite fillings with 1-, 2-, 3-year failure
(2002) mean 48 treated premolars metal crowns bonded fiber posts (n = 60) rates
with class II lesions with Zinc phosphate
cement, with fiber
posts (n = 57)

Pratt56 (2016) Retrospective 8 years Mean 46 Endodontically Crowns (n = 441) Amalgam or composite Cumulative survival
cohort treated posterior teeth fillings (n = 198) (Kaplan-Meier survival
curve)

Dammaschke16 Retrospective 10 years 18–76 Endodontically Crowns or partial Amalgam or composite Cumulative survival
(2012) cohort treated posterior teeth crowns (n = 441) fillings (n = 135) (Kaplan-Meier survival
curve); 10-year survival
rate

Tickle73 (2008) Retrospective 7.7 years 20–60, Endodontically Crowns (n = 67) Composite fillings (n = Cumulative survival
cohort 49.2±10.3 treated mandibular first 107) (Kaplan-Meier survival
molar curve)

Aquilino7 Retrospective 10 years 54.1±15.2 Endodontically Crowns (n = 129) Amalgam or composite Failure number; 5,
(2002) cohort treated teeth fillings (n = 74) 10-year survival rate

Dawson18 Cross- / 20–89 Endodontically Crowns with posts Amalgam or composite Periapical status
(2016) sectional treated teeth (n = 275) fillings with posts (n =
179)

Frisk28 (2015) Cross- / 20–70 Endodontically Crowns or inlays Amalgam or composite Periapical status
sectional treated teeth (n = 1475) resin fillings (n = 1159)

Hommes36 Cross- / Not Endodontically Crowns (n = 305) Amalgam or composite Periapical status
(2002) sectional mentioned treated teeth fillings (n = 413)

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

inconsistent studies with no reply from the author,73 data vided 5-year survival results. Meta-analysis showed that in-
were excluded from quantitative analysis. direct restorations have a higher survival rate than do direct
Therefore, 8 studies were included in the meta-analyses. restorations (OR 0.28, 95% CI 0.19–0.43, p < 0.00001).
Three retrospective cohort studies were selected for analy- No heterogeneity was detected between the studies
sis of short-term and medium-term survival, 2 RCTs were (p = 0.55, I2 = 0%).
included for evaluation of restorative success, and 3 cross-
sectional studies were subjected to endodontic success Ten-year Survival (Fig 4)
assessment. The process of searching and study selection In respect to medium-term (> 5 and ≤ 10 year survival),
is outlined in Fig 1. The characteristics of included studies the 8-year survival results of Pratt et al56 were originally
are detailed in Table 1. included in the meta-analysis, but it significantly increased
Risk of bias and quality assessments are presented in the heterogeneity because of different follow-up times (Aq-
Fig 2 (RCTs), Table 2 (cohort studies), and Table 3 (cross- uilino et al7 and Dammaschke et al16 were both 10 years),
sectional studies). For RCTs, the risk of performance bias and was therefore ultimately excluded from meta-analysis.
and detection bias was high. The Newcastle-Ottawa scores Higher survival rates for indirect restorations were ob-
of cohort studies ranged from 5 to 7 asterisks with half of served in 10-year assessment (OR 0.20, 95% CI 0.12-
the studies showing high-quality. The methodological quali- 0.31, p < 0.00001), and no heterogeneity was detected
ties of included cross-sectional studies showed only 1 study (p = 0.94, I2 = 0%).
had high quality.
Restorative Success (Fig 5)
Survival of Tooth-Restoration Complex Two RCTs reported the ≤ 5-year success rates, and meta-
Five-year survival (Fig 3) analysis indicated that direct and indirect restorations do
Two retrospective studies7,56 were included in the assess- not differ significantly in success rates (OR 0.32, 95% CI
ment of short-term (≤ 5-year) survival, both of which pro- 0.05-2.12, p = 0.24). Moderate to substantial heterogene-

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 Shu et al

Table 2 Quality assessment of cohort studies with the Newcastle-Ottawa Scale

Pratt Tickle Dammaschke Aquilino

et al56 et al7 et al16 et al7
Selection *** **** *** ****
1) Representativeness of the exposed cohort c b* c b*
2) Selection of the non-exposed cohort a* a* a* a*
3) Ascertainment of exposure a* a* a* a*
4) Demonstration that outcome of interest was not a* a* a* a*
present at start of study
Comparability *
1) Comparability of cohorts on the basis of the design a*
or analysis
Outcome ** ** ** **
1) Ascertainment of outcome b* b* b* b*
2) Was follow-up long enough for outcomes to occur? a* a* a* a*
3) Adequacy of follow up of cohorts d c d c
Total scale ***** ******* ***** ******
* Studies with 6 or more asterisks were regarded as high-quality studies.

Table 3 Quality assessment of cross-sectional studies with ARHQ methodology checklist

Dawson Frisk et Hommes

et al18 al28 et al36

1) Define the source of information (survey, record review) 1 1 1

2) List inclusion and exclusion criteria for exposed and unexposed subjects (cases and 0 0 0
controls) or refer to previous publications
3) Indicate time period used for identifying patients 1 1 0
4) Indicate whether or not subjects were consecutive if not population-based 0 0 0
5) Indicate if evaluators of subjective components of study were masked to other aspects of 0 0 0
the status of the participants
6) Describe any assessments undertaken for quality assurance purposes (eg, test/retest of 1 1 1
primary outcome measurements)
7) Explain any patient exclusions from analysis 1 0 0
8) Describe how confounding was assessed and/or controlled 1 0 1
9) If applicable, explain how missing data were handled in the analysis 1 0 0
10) Summarize patient response rates and completeness of data collection 1 1 0
11) Clarify what follow-up, if any, was expected and the percentage of patients for which 1 0 0
incomplete data or follow-up was obtained
Total scale 8 4 3
* Article quality was assessed as follows: low quality = 0–3; moderate quality = 4–7; high quality = 8–11.

ity was detected between the 2 studies, but this was not Meta-analysis showed no difference in the incidence of
statistically significant (p = 0.15, I2 = 52%). The main rea- apical periodontitis (AP) for direct or indirect restorations
sons for failure were restoration fractures, secondary caries (OR 0.88, 95% CI 0.72-1.08, p = 0.22) with statistically
in direct groups, and post debonding; marginal gaps were nonsignificant moderate heterogeneity (p = 0.21, I2 = 36%).
revealed by radiographs in both groups. The results for periapical status of ETT with composite or
amalgam fillings are different. Hommes et al36 found the
Endodontic Success (Fig 6) rate of AP to be significantly higher (p < 0.01) in composite
Three cross-sectional studies investigated the periapical (40.5%) than amalgam (28.4%) restorations, as supported
status (endodontic success) of directly vs indirectly re- by Frisk et al,28 who found that composite restorations were
stored teeth and composite vs amalgam restorations. associated with the occurrence of AP. However, Dawson et

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Shu et al

al18 reported no difference in the frequency of AP between As for ETT without extensive coronal destruction, direct
teeth restored with composite and amalgam fillings. composite restorations are mainly indicated for teeth with
minimal or moderate tooth structure loss.10 Some evidence
GRADE Assessment suggested that for similar cuspal coverage, direct and indi-
The SoF (summary of findings) table created by GRADEpro- rect methods showed similar outcomes, and decided that
filer is presented in Figs 7–9. Among the 4 outcomes ana- preference should be given to direct over indirect restora-
lyzed in this review, survival (short-term and medium-term) tions because they are more time effective and less
and restorative success of restored teeth showed low to costly.6,19,24 However, the accuracy and skills of the practi-
moderate quality, compared with very low quality of end- tioners could significantly influence decision to repair or
odontic success. replace direct restoration.45 For example, direct restora-
tions are technique sensitive with greater risks of polymer-
ization shrinkage, marginal discrepancies, microleakage,
DISCUSSION undesirable proximal contacts, and secondary caries.5,12
On the other hand, indirect restorations (inlay/onlay) have
The present systematic review and meta-analysis suggested a reduced composite shrinkage volume, limited to the resin
that indirect restorations (mainly crowns) would provide in- luting layer, and therefore increase the marginal adaptation
creased short-term (5-year) and medium-term (10-year) sur- of restorations.37
vival for endodontically treated teeth compared with direct Failure of restorative treatment may be influenced by the
restorations (mainly composite and amalgam fillings). Indi- position of the tooth. In a long-term study of ETT, mandibu-
rect restorations also showed better esthetic, functional, lar premolars and maxillary and mandibular anterior teeth
and biological properties, but no difference in short-term were reported to have longer survival times than other tooth
(≤ 5 years) restorative success or endodontic success. types, and molars demonstrated the worst survival out-
The search strategies for this systematic review covered comes, possibly because of difficulties in endodontic treat-
both published studies and gray literature, but abstracts ment and the subsequent restoration.13 A large practice-
and articles published in languages other than English were based study analyzing direct restoration longevity showed a
not searched. Publication bias could not be assessed due higher annual failure rate (AFR) of 5.2% in molars compared
to the limited number of studies. All of the outcomes to anterior teeth (4.4%) and premolars (4.0%).45
showed satisfactory reliability. Another controversial issue is whether to place a post
Reasons for extraction of ETT are mainly nonrestorable after endodontic treatment. In vitro studies showed that
carious destruction, endodontic issues, and tooth frac- placement of fiber post could significantly improve the frac-
ture.16,78 Crowns are expected to provide a better coronal ture resistance of ETT.1 A long-term clinical investigation (at
seal to prevent bacterial recontamination of residual tooth least 5 years) found that the survival rate of teeth with a
tissue.13 Studies showed that 85% of extracted ETT were fiber post amounted to 94.3%, and for teeth without a post,
not crowned, due to the presence of more nonrestorable it was 76.3% (p < 0.001).31 However, other investigators
caries compared with crowned teeth.78 Crowns may also believe that preparation of a post space might increase the
serve to protect the tooth from the risk of fracture,13 as chance of root fracture,30 so that posts should only be
crowned ETT demonstrated a significantly lower fracture used when other options were not available to retain a
rate than teeth provided with a filling.16 core.23
Traditionally, most clinicians prefer to use posts followed In this review, indirect restorations (mainly crowns) had
by crown restorations for ETT;14 however, full-coverage better outcomes in tooth-restoration complex survival, pos-
crowns may not be necessary. A retrospective study inves- sibly because crowns could provide better protection in
tigated 189 posterior ETT restored with indirect composite such a study pool of teeth with substantial tooth structure
onlays, and suggested this method can be a viable option loss in areas of high masticatory forces. In addition, indi-
for the restoration of posterior ETT (tooth survival 100%, rect restorations might serve as a more stable restoration
restoration survival 96.8%, with median follow-up time of 37 technique in the long run, as the effect of 10-year results
months).14 Another study also showed that gold partial (OR 0.20) was larger than that of 5-year results (OR 0.28).
crowns displayed a comparable fracture rate compared with Meta-analysis of restorative success showed no statisti-
full-coverage crowns for ETT.16 However, the decision on cal difference between the two restorations, probably be-
whether to place a crown or a partial-coverage restoration cause of limited sample size and observation time. How-
should also depend on functional requirements and the ever, a comparison of the two included studies showed
amount of remaining tooth structure.10,17,54 According to that with the increase in observation time (from 3 years to
some studies in vital teeth, the risk of failure has been 5 years), indirect restorations exhibited more favorable
showed to increase by 30% to 40% for every extra missing results.
wall.54 An occlusal cavity preparation could reduce tooth In terms of endodontic success, results differed among
stiffness by 20%, compared to 63% for a MOD (mesial-oc- studies, especially when comparing amalgam and compos-
clusal-distal) cavity.14 Therefore, crowns are still crucial to ite fillings. Studies published in different years exhibited
provide enough coronal protection, if ETT have been exten- opposing outcomes, probably because the quality of com-
sively damaged by caries or endodontic treatment.32,78 posites was better in more recent studies as a result of

188 The Journal of Adhesive Dentistry

 Shu et al

Identification
Initial electronic search results:
Medline via Pubmed: n = 1358
EMBASE via OVID: n = 1379
CENTRAL via OVID: n = 758
Handsearching and gray literature searching: n = 2
Records after duplicates removed:
n = 2547
Screening

Records screened: Records excluded based on title and abstract: n = 2498

n = 2547
Eligibility

Full-text articles retrieved for Articles excluded with reasons: n = 40

eligibility assessment: n = 49 •Different difinition of survival rates: n = 1
•Insufficient follow-up time (< 3 years): n = 2
•Only indirect restorations were used: n = 19
Articles included in present •Only direct restorations were used: n = 18
systematic review: n = 9
Inclusion

Articles included in
meta-analysis: n = 8

Fig 1 Flow diagram.

the development of materials, techniques and instruments

Blinding of participants and personnel (performance bias)

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

Blinding of outcome assessment (detection bias)

Random sequence generation (selection bias)

secondary caries when compared to amalgam restora-

tions.49 The quality of coronal restorations may have an

Incomplete outcome data (attrition bias)

Allocation concealment (selection bias)

impact on the periapical status by influencing coronal

Selective reporting (reporting bias)

leakage.30
A previous systematic review published in 2012 and up-
dated in 2015 discussed a similar topic by comparing sin-
gle crowns vs direct restorations for ETT, but included only
one clinical trial; insufficient evidence was found to support
either treatment option.66 However, our systematic review
included 2 RCTs and 7 observational studies, and reached
Other bias

a conclusion in meta-analysis, which may be helpful for

clinical practice. This is possibly because of more compre-
hensive search strategies in 3 databases, coverage of gray
literature, and inclusion of observational studies. In addi- Mannocci 2002 + ? – – – + ?
tion, multiple and rigorous quality assessment was applied
for different study designs. Use of a collective evidence Skupien 2016 + + – – + + ?
grading system (GRADE) further improved the quality of this
systematic review.
The present study also had some limitations, eg, that Fig 2 Risk of bias summary (RCTs).
most of the conclusions were drawn from retrospective
cohort studies mostly including skilled operators, with ma-
terials available in the 1990s. Well-designed RCTs with
large sample sizes are needed using today’s materials
and general dentists, especially for endodontically treated
teeth with minimal or moderate coronal tooth structure
loss.

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Shu et al

indirect direct Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
Aquilino (2002) 8 129 17 74 22.0% 0.22 [0.09, 0.54]
Pratt 2016 36 441 45 198 78.0% 0.30 [0.19, 0.49]

Total (95% CI) 570 272 100.0% 0.28 [0.19, 0.43]

Total events 44 62
Heterogeneity: Tau2= 0.00; Chi2 = 0.36, df = 1 (p = 0.55), I2 = 0%
0.01 0.1 1 10 100
Test for overall effect: Z = 5.89 (p < 0.00001) Favors [indirect] Favors [direct]

Fig 3 Forest plot of 5-year survival analysis.

indirect direct Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
Aquilino (2002) 14 129 28 74 39.3% 0.20 [0.10, 0.41]
Pratt 2016 22 388 32 135 60.7% 0.19 [0.11, 0.35]

Total (95% CI) 517 209 100.0% 0.20 [0.12, 0.31]

Total events 36 60
Heterogeneity: Tau2= 0.00; Chi2 = 0.00, df = 1 (p = 0.94), I2 = 0% 0.01 0.1 1 10 100
Test for overall effect: Z = 7.01 (p < 0.00001) Favors [indirect] Favors [direct]

Fig 4 Forest plot of 10-year survival analysis.

indirect direct Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
Mannocci (2002) 3 54 4 53 57.7% 0.72 [0.15, 3.39]
Pratt 2016 1 27 8 30 42.3% 0.11 [0.01, 0.91]

Total (95% CI) 81 83 100.0% 0.32 [0.05, 2.12]

Total events 36 60
Heterogeneity: Tau2= 0.99; Chi2 = 2.08, df = 1 (p = 0.15), I2 = 52%
0.01 0.1 1 10 100
Test for overall effect: Z = 1.18 (p = 0.24) Favors [indirect] Favors [direct]

Fig 5 Forest plot of short-term restorative success.

indirect direct Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI
Dawson (2016) 72 275 62 179 19.7% 0.70 [0.47, 1.06]
Frisk (2015) 333 1475 261 1159 51.9% 1.00 [0.83, 1.21]
Hommez (2002) 90 305 1418 413 28.4% 0.81 [0.59, 1.11]

Total (95% CI) 2055 1751 100.0% 0.88 [0.72, 1.08]

Total events 495 462
Heterogeneity: Tau2= 0.01; Chi2 = 3.12, df = 2 (p = 0.21), I2 = 36% 0.5 0.7 1 1.5 2
Test for overall effect: Z = 1.22 (p = 0.22) Favors [indirect] Favors [direct]

Fig 6 Forest plot of endodontic success.

CONCLUSIONS vival than direct restorations using composite or amalgam,

but no significant difference was found in short-term
Based on current evidence, there is a weak recommendation (≤ 5-year) restorative success. However, further research is
for indirect restorations to restore endodontically treated likely to have an important impact on our confidence in the
teeth, especially for teeth with extensive coronal damage. estimate of effect and may change the estimate, because
Indirect restorations consisting mostly of crowns have a the evidence is of low to moderate quality. Indirect and di-
higher short-term (5-year) and medium-term (10-year) sur- rect restorations showed no significant difference in end-

190 The Journal of Adhesive Dentistry

 Shu et al

Survival of ETT with direct or indirect restorations

Patient or population: patients with endodontically treated teeth (ETT)
Settings: survival of ETT
Intervention: Indirect restorations
Comparison: Direct restoration
Outcomes Illustrative comparative risks* (95% CI) Relative effect No of Participants Quality of the evidence Comments
(95% CI) (studies) (GRADE)
Assumed risk Corresponding risk
Direct restorations Indirect restorations
5-year survival 228 per 1000 76 per 1000 OR 0.28 842
Follow-up: 5 years (53 to 113) (0.19 to 0.43) (2 studies) low1,2,3
10-year survival 287 per 1000 75 per 1000 OR 0.20 726
Follow-up: 10 years (46 to 111) (0.12 to 0.31) (2 studies) moderate1,3
*The basis for the assumed risk (eg, the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the
assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio.
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
1 All studies are observational studies and thus would start with low quality rating.
2 Downgraded 1 level for imprecise (data of Pratt’s study were extracted from the Kaplan-Meier survival curves).
3 Upgraded 1 level for large effect based on observational studies without important risk of bias or other limitations showing an OR < 0.5 with at least consistent studies.

Fig 7 GRADE SoF survival rate.

Restorative success of ETT with direct or indirect restorations

Patient or population: patients with endodontically treated teeth (ETT)
Settings: restorative success of ETT
Intervention: Indirect restorations
Comparison: Direct restoration
Outcomes Illustrative comparative risks* (95% CI) Relative effect No of Participants Quality of the evidence Comments
(95% CI) (studies) (GRADE)
Assumed risk Corresponding risk
Direct restorations Indirect restorations
5-year success 145 per 1000 51 per 1000 OR 0.32 164
Follow-up: 3 – 5 years (8 to 264) (0.05 to 2.12) (2 studies) low1,2,3,4
*The basis for the assumed risk (eg, the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the
assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio.
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
1 Both studies are RTCs so would start with high quality rating.
2 Downgraded 1 level for Imprecision (optimal information size n < 400 and wide CI).
3 Downgraded 1 level for high RoB in both studies (lack of concealment and lack of blinding).
4 Downgraded 1 level for moderate heterogeneity (52%).

Fig 8 GRADE SoF restorative success rate.

Endodontic success of ETT with direct or indirect restorations

Patient or population: patients with endodontically treated teeth (ETT)
Settings: endodontic success of ETT
Intervention: Indirect restorations
Comparison: Direct restoration
Outcomes Illustrative comparative risks* (95% CI) Relative effect No of Participants Quality of the evidence Comments
(95% CI) (studies) (GRADE)
Assumed risk Corresponding risk
Direct restorations Indirect restorations
Endodontic success 264 per 1000 240 per 1000 OR 0.88 3806
(205 to 279) (0.72 to 1.08) (3 studies) very low1,2
*The basis for the assumed risk (eg, the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the
assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; OR: Odds ratio.
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.
1 All studies are observational studies and thus would start with low quality rating.
2 Downgraded 1 level for high RoB in 2/3 studies (falilure to adequately control confounding).

Fig 9 GRADE SoF endodontic success rate.

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Shu et al

odontic success (rate of apical periodontitis), but we are 16. Dammaschke T, Nykiel K, Sagheri D, Schäfer E. Influence of coronal res-
torations on the fracture resistance of root canal-treated premolar and
very uncertain about the estimate as a result of very low molar teeth: a retrospective study. Aust Endod J 2013;39:48–56.
quality of evidence. 17. da Rosa Rodolpho PA, Cenci MS, Donassollo TA, Loguércio AD, Demarco
High-quality clinical trials are needed, especially well- FF. A clinical evaluation of posterior composite restorations: 17-year find-
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designed RCTs. Future studies should better control the 18. Dawson VS, Petersson K, Wolf E, Åkerman S. Periapical status of root-
confounding factors by restricting the position of teeth, filled teeth restored with composite, amalgam, or full crown restorations:
a cross-sectional study of a Swedish adult population. Clin Oral Investig
extent of coronal damage, use of post, and quality of end- 2016;42:1326–1333.
odontic treatment. RCTs are expected to have a larger 19. da Veiga AM, Cunha AC, Ferreira DM, da Silva Fidalgo TK, Chianca TK,
sample size and longer observation time. Moreover, under Reis KR, Maia LC. Longevity of direct and indirect resin composite resto-
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APPENDIX 1 SEARCH STRATEGIES

A. MEDLINE via Pubmed search strategy (24th Mar, B. EMBASE via OVID search strategy (24th Mar,
2017) 2017)
((endodontic*[Title/Abstract]) OR nonvital[Title/Abstract]) 1 *endodontics/
OR pulpless[Title/Abstract] 2 (endodontic* or nonvital or pulpless).ab.
endodontics[MeSH Terms] 3 exp “root canal therapy”/
((root canal therapy[MeSH Terms]) OR root canal[Title/Ab- 4 (“root canal” or root-filled).ab.
stract]) OR root-filled[Title/Abstract] 5 (root adj6 (therap$ or fill$ or treat$ or resect$)).
((fill*[Title/Abstract]) OR therap*[Title/Abstract]) OR ab.
treat*[Title/Abstract] 6 (direct* or indirect*).ab.
#4 AND root[Title/Abstract] 7 *tooth prosthesis/
#1 OR #2 OR #3 OR #5 8 (restoration* or restored or restorative).ab.
(direct*[Title/Abstract]) OR indirect*[Title/Abstract] 9 7 or 8
((((dental restorations, permanent[MeSH Terms]) OR dental 10 6 and 9
prosthesis[MeSH Terms]) OR restoration*[Title/Abstract]) 11 *resin/
OR restored[Title/Abstract]) OR restorative[Title/Abstract] 12 (“composite resin” or composite or resin or amal-
#7 AND #8 gam).ab.
(((composite[Title/Abstract]) OR resin*[Title/Abstract]) OR 13 (crown* or endocrown* or inlay* or onlay* or over-
composite resins[MeSH Terms]) OR amalgam[Title/Ab- lay* or veneer*).ab.
stract] 14 (partial and crown*).ab.
((((((((crowns[MeSH Terms]) OR crown[Title/Abstract]) OR 15 10 or 11 or 12 or 13 or 14
endocrown*[Title/Abstract]) OR partial crown*[Title/Ab- 16 (randomized or randomised or randomly or con-
stract]) OR inlays[MeSH Terms]) OR inlay[Title/Abstract]) trolled).ab.
OR onlay*[Title/Abstract]) OR overlay*[Title/Abstract]) OR 17 ((clinical and trial) or prospective or retrospective
veneer*[Title/Abstract] or pilot or longitudinal or cohort or “case series” or
#9 OR #10 OR #11 case-control*).ab.
((randomized[Title/Abstract]) OR randomised[Title/Ab- 18 16 or 17
stract]) OR randomly[Title/Abstract] 19 1 or 2 or 3 or 4 or 5
(((((((controlled[Title/Abstract]) OR clinical trial[Title/Ab- 20 15 and 18 and 19
stract]) OR prospective[Title/Abstract]) OR
retrospective[Title/Abstract]) OR pilot[Title/Abstract]) OR C. CENTRAL (Cochrane Central Register of
longitudinal[Title/Abstract]) OR cohort[Title/Abstract]) OR Controlled Trials) via OVID (25th Mar, 2017)
case series[Title/Abstract]) OR case-control*[Title/Abstract] 1 exp Endodontics/
#13 OR #14 2 (endodontic* or nonvital or pulpless).af.
#6 AND #12 AND #15 3 (root and canal).af.
(“in vitro”[Title]) OR “ex vivo”[Title] 4 root-filled.af.
#16 NOT #17 5 (root adj6 (therap$ or fill$ or treat$ or resect$)).af.
6 1 or 2 or 3 or 4 or 5
Filter: English 7 (direct* or indirect*).af.
8 dental prosthesis.mp. or exp Dental Prosthesis/
9 (restoration* or restored or restorative).af.
10 exp Composite Resins/
11 (composite resin or composite or resin or amal-
gam).af.
12 exp Dental Restoration, Permanent/
13 8 or 9 or 12
14 7 and 13
15 exp Crowns/
16 (crown* or endocrown* or inlay* or onlay* or over-
lay* or veneer*).af.
17 exp Inlays/
18 (partial and crown*).af.
19 10 or 11 or 14 or 15 or 16 or 17 or 18
20 6 and 19

194 The Journal of Adhesive Dentistry