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-
tology, Sun Yat-sen University, Guangzhou, China. Performed the literature
search, data extraction and statistical analysis, wrote the manuscript.
b Staff Dentist, The 3rd Dental Center, Peking University School of Stomatology,
Beijing, China. Co-first author, performed the literature search, data extraction
and statistical analysis.
c Professor, Department of Preventive and Restorative Sciences, University of
Pennsylvania School of Dental Medicine, Philadelphia, PA, USA. Idea, proof-
read the manuscript, contributed substantially to discussion.
d Professor, Department of Clinical Dental Sciences,  Faculty of Dentistry, Dal-
housie University, Halifax, NS, Canada. Proofread the manuscript, contributed
substantially to discussion.
e Staff Dentist, Department of Prosthodontics, Guanghua School of Stomatology,
Sun Yat-sen University, Guangzhou, China. Co-corresponding author, proof-
read the manuscript, contributed substantially to discussion.
f Professor, Department of Prosthodontics, Guanghua School of Stomatology,
Sun Yat-sen University, Guangzhou, China. Idea, consulted on statistical evalu-
ation, proofread the manuscript, contributed substantially to discussion.
Correspondence: Ke Zhao, Hospital of Stomatology, School of Stomatology,
Sun Yat-sen University, 54 Ling-yuan West Street, Guangzhou, China 510055.
Tel: +86-20-8380-2805; e-mail: zhaoke@mail.sysu.edu.cn.
Co-corresponding author: Xiao-dong Wang, Prosthodontics Department, Guang-
hua School of Stomatology, Sun Yat-sen University, Guangzhou, China. e-mail:
wxwei_2000@163.com

Vol 20, No 3, 2018 183

Shu et al
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
removed during endodontic treatment and the loss of coro-
nal hard tissue.60,71 The prognosis of ETT depends not only
on the quality of endodontic treatment, but also on the sub-
sequent restorative techniques.32 Reported reasons for ex-
traction of teeth after endodontic treatment include end-
odontic failures, prosthodontic complications, coronal and
root fracture, caries, or periodontal disease.7
The best way to restore ETT has been extensively dis-
cussed but is still controversial concerning the best type of
final restoration.21,76 Conventional restoration modality in-
volves fabricating a full-coverage crown with or without a
post,48 as this was believed to provide better protection
and reinforcement of the remaining tooth structure.5,32,33
However, complete crown restoration usually also requires
extensive tooth preparation and new occlusal schemes. In
addition, the loss of anatomic structures such as cusps,
ridges, and the pulp chamber roof may decrease the
strength of the remaining tooth.5
Although direct amalgam and composite restorations
were recommended in 2003 as conservative restorative
techniques with 10-year survival rates of 82.4% and 85.2%,
respectively,16 more recent studies of large numbers of pa-
tients treated by general dentists give a median longevity of
direct posterior composite restorations between 5 and 8
years.43,59,61,72
Maximum preservation of healthy tooth structure is the
main goal of restorative dentistry. Therefore, with recent
advances in bonding technologies, adhesively bonded ce-
ramic inlay or onlay restorations have been suggested in
several in vitro studies.33,41,65,77 Some indicate that only
complete coverage can provide sufficient protection and en-
sure the longevity of the tooth-restoration complex,15 while
others claim the decision to place full-coverage crowns or
onlays should depend on the amount of remaining tooth
structure.67
Many clinicians prefer using direct composite restora-
tions to restore ETT due to their good esthetic properties,
relatively low cost, ease of handling, and preservation of
dental structures. 5,12 Some laboratory studies indicate
that there is no significant difference in the load required
to fracture ETT that have received direct or indirect restora-
tions.12,27 However, it was later reported that indirect ce-
ramic restorations may pose a higher risk of catastrophic
tooth fracture.12 Results of thermomechanical loading in-
dicated that ceramic restorations behave similarly to direct
restorations when the same cavity preparations were
used, and it was concluded that small conservative end-
odontic access cavities can be safely and simply restored
with direct adhesive restorations and composite.27
Therefore, the aim of this systematic review was to eval-
uate treatment outcomes of direct and indirect restorations
to provide clinical recommendations for restoring endodonti-
cally treated teeth.
184
MATERIALS AND METHODS
Literature Search and Study Selection
An electronic search of published English literature in Med-
line via Pubmed, EMBASE (Excerpt Medica Database) via
OVID, and CENTRAL (Cochrane Central Register of Con-
trolled Trials) via OVID databases up to March 2017 was
conducted. Search strategies are detailed in appendix 1.
Utilizing ClinicalTrials.gov, Open Grey, and Google Scholar,
gray literature was searched for potentially suitable unpub-
lished clinical trials, including conference abstracts, unpub-
lished and ongoing studies, nationally and internationally
registered trials, doctoral dissertations. Hand searching
was also conducted for relevant references.
All titles and abstracts were screened based on the fol-
lowing inclusion criteria:
y Patients and teeth (P): adult and adolescent patients
with endodontically treated permanent teeth. There were
no restrictions by gender or position of tooth.
y Intervention (I): indirect restorations including full-coverage
(any type of complete crown or endocrown) and partial-
coverage (any type of inlay, onlay, and partial crown) resto-
rations with or without posts, using permanent materials.
y Control (C): direct restorations using permanent material
(including composite and amalgam), with or without posts.
y Outcomes (O): only studies with a follow-up of at least
3 years were included, and the follow-up periods were
classified as short-term (≥ 3 and ≤ 5 years), medium-
term (> 5 and ≤ 10 years), and long-term (> 10 years).
y Primary outcomes: survival of restored teeth. The sur-
vival criterion used in this study was defined as the
tooth-restoration complex being in situ.
y Secondary outcomes: restorative and endodontic suc-
cess of restored teeth. Restorative success was defined
as tooth and restoration present and clinically accept-
able, no repair needed. Endodontic success referred to
no signs or symptoms of pulpal or apical pathology ac-
cording to clinical and radiological examinations, no end-
odontic intervention needed.
y Study design (S): randomized and nonrandomized con-
trolled clinical trials, observational study designs includ-
ing cohort (prospective and retrospective), case-control,
and cross-sectional.
A full text was obtained of all relevant and potentially rele-
vant studies. Two review authors independently assessed
the full-text papers, and disagreements between the two
reviewers were resolved by direct discussion, or by a third
reviewer if no agreement could be reached. For missing or
unclear information in the articles obtained, the correspond-
ing authors were contacted by e-mail to confirm the ambigu-
ous data. For the same clinical trial with multiple publica-
tions, only the latest was included in the analysis.
Data Extraction
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-
The Journal of Adhesive Dentistry

tion, study design, participants, follow-up time, sample size
of each group, type, material and brand (if available) of the
restoration as well as the post (if used), and the outcomes
of each study.
When collecting the survival rate data, information pro-
vided in the publication was used directly. For outcomes ex-
pressed as Kaplan-Meier survival curves, data were extracted
using the freeware software Engauge Digitizer (ver. 5.1
http://markummitchell.github.io/engauge-digitizer). The En-
gauge Digitizer software accepts image files (eg, PNG, JPEG,
and TIFF) containing graphs, and recovers the data points
from those graphs. For consistent studies, the extracted data
were deemed precise enough to be included in the meta-
analysis, while for inconsistent studies with no reply from the
author, data were excluded from quantitative analysis. Other
initial data were obtained by contacting the authors.
Due to national differences and writing styles, the termi-
nology used in included studies varies. For standardization,
confirmatory e-mails were sent to the authors to ascertain
the restoration types and materials; further, descriptions
were adjusted accordingly in the data extraction table. For
authors who did not reply, the original text was used.
Risk of Bias
Two reviewers independently evaluated the methodological
qualities of included studies according to the guidance pro-
vided by the Journal of Evidence-based Medicine.79
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-
cealment, and selective outcome reporting were addressed
in the tool.
The Newcastle-Ottawa Scale (http://www.ohri.ca/
programs/clinical_epidemiology/oxford.asp) was applied
for assessing cohort studies. Using the tool, each study
was judged on 8 items, categorized into 3 groups: the
selection, comparability, and outcome of exposed and
non-exposed cohort. Stars were awarded for each study
(up to 9 stars) for quick visual assessment. Studies
awarded with 6 or more stars were regarded as high-qual-
ity studies.
For cross-sectional studies, the Agency for Healthcare
Research and Quality (AHRQ) methodology checklist
(https://www.ncbi.nlm.nih.gov/books/NBK35156/) was
applied. This is a methodological quality assessment tool
using an 11-item checklist, and the AHRQ recommends it
for assessment of cross-sectional studies. An item would
be scored “0” if it was answered “NO” or “UNCLEAR”; if it
was answered “YES”, then the item was give a score of
“1”. Article quality was assessed as follows: low qual-
ity = 0–3; moderate quality = 4–7; high quality = 8–11.
For every outcome of meta-analysis, the quality of the
evidence was assessed using the GRADE (Grading of Rec-
ommendations, Assessment, Development and Evalua-
tions) approach by GRADEprofiler (Ver 3.6). The GRADE ap-
proach was used for collective grading of the overall body of
evidence in this review, as the study designs vary; more-
over, it is also a systematic and explicit approach to making
Vol 20, No 3, 2018
Shu et al
judgements about quality of evidence and strength of rec-
ommendations.
All studies, regardless of the risk of bias and method-
ological quality, were included in the quantitative synthesis.
Statistical Analysis and Heterogeneity
Pooled data of all the outcomes were subjected to meta-
analysis to estimate the odds ratio (OR) and 95% confi-
dence intervals (CI) using the Cochrane Collaboration Re-
view Manager (Ver. 5.3). To test the reliability of evidence,
outcomes of fixed-effect models and random-effect models
were compared, but considering the unexplained heteroge-
neity between studies, only random-effect estimates were
reported, to be more conservative.
Cochran’s Q test was applied for analyzing the hetero-
geneity between included studies, and no heterogeneity
was determined if the p-value was higher than 0.1. Other-
wise, the I2 statistic was used to quantify the statistical
heterogeneity, and the threshold was determined as Co-
chrane recommended, ie, 0% to 40%: might not be impor-
tant; 30% to 60%: may represent moderate heterogeneity;
50% to 90%: may represent substantial heterogeneity;
75% to 100%: considerable heterogeneity. For outcomes
with substantial or considerable heterogeneity, sensitivity
analysis was carried out by comparing the fixed and ran-
dom-effect estimates, considering subgroup analysis, and
testing for excess of studies with significant results.
RESULTS
The initial electronic search yielded 3497 records (1358 in
Medline, 1379 in OVID, 758 in Central, and 2 from hand-
searching and gray literature), and 2547 records were
found after removing the duplicates. From these 2547 re-
cords, 49 potentially pertinent records were selected after
screening the titles and abstracts. Full-text articles were
retrieved for eligibility assessment, and 40 articles were
excluded with reasons (different definition of survival rates:
n = 1;13 insufficient follow-up time: n = 2;44,78 only indirect
restorations were used: n = 19;8,9,14,21,22,25,39,40,42,51-
53,57,58,62,68,69,74,80 only direct restorations were used:
n = 182-4,11,20,26,29,34,35,38,45,47,50,55,63,64,75,81).
Ultimately, only 9 articles met the inclusion criteria, and
all included studies had a parallel design. Some of the in-
cluded studies provided specific data in their publications,
including the studies by: Aquilino et al7 and Pratt et al56 in
short-term (5 years) survival analyses, Aquilino et al7 and
Dammaschke et al16 in medium-term (10 years) analyses,
Skupien et al70 and Mannocci et al46 in short-term (≤ 5
years) restorative success assessments, Frisk et al,28
Hommes et al,36 and Dawson et al18 in endodontic success
assessments. Their information was used directly. For stud-
ies with Kaplan-Meier survival curves,56,73 data extracted
from Engauge Digitizer were compared with the available
information in the text to test the precision of the figure. For
consistent studies,56 the extracted data were deemed pre-
cise enough to be included in the meta-analysis; while for
185
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
were excluded from quantitative analysis.
Therefore, 8 studies were included in the meta-analyses.
Three retrospective cohort studies were selected for analy-
sis of short-term and medium-term survival, 2 RCTs were
included for evaluation of restorative success, and 3 cross-
sectional studies were subjected to endodontic success
assessment. The process of searching and study selection
is outlined in Fig 1. The characteristics of included studies
are detailed in Table 1.
Risk of bias and quality assessments are presented in
Fig 2 (RCTs), Table 2 (cohort studies), and Table 3 (cross-
sectional studies). For RCTs, the risk of performance bias
and detection bias was high. The Newcastle-Ottawa scores
of cohort studies ranged from 5 to 7 asterisks with half of
the studies showing high-quality. The methodological quali-
ties of included cross-sectional studies showed only 1 study
had high quality.
Survival of Tooth-Restoration Complex
Five-year survival (Fig 3)
Two retrospective studies7,56 were included in the assess-
ment of short-term (≤ 5-year) survival, both of which pro-
vided 5-year survival results. Meta-analysis showed that in-
direct restorations have a higher survival rate than do direct
restorations (OR 0.28, 95% CI 0.19–0.43, p < 0.00001).
No heterogeneity was detected between the studies
(p = 0.55, I2 = 0%).
Ten-year Survival (Fig 4)
In respect to medium-term (> 5 and ≤ 10 year survival),
the 8-year survival results of Pratt et al56 were originally
included in the meta-analysis, but it significantly increased
the heterogeneity because of different follow-up times (Aq-
uilino et al7 and Dammaschke et al16 were both 10 years),
and was therefore ultimately excluded from meta-analysis.
Higher survival rates for indirect restorations were ob-
served in 10-year assessment (OR 0.20, 95% CI 0.12-
0.31, p < 0.00001), and no heterogeneity was detected
(p = 0.94, I2 = 0%).
Restorative Success (Fig 5)
Two RCTs reported the ≤ 5-year success rates, and meta-
analysis indicated that direct and indirect restorations do
not differ significantly in success rates (OR 0.32, 95% CI
0.05-2.12, p = 0.24). Moderate to substantial heterogene-

186 The Journal of Adhesive Dentistry

 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
statistically significant (p = 0.15, I2 = 52%). The main rea-
sons for failure were restoration fractures, secondary caries
in direct groups, and post debonding; marginal gaps were
revealed by radiographs in both groups.
Endodontic Success (Fig 6)
Three cross-sectional studies investigated the periapical
status (endodontic success) of directly vs indirectly re-
stored teeth and composite vs amalgam restorations.
Meta-analysis showed no difference in the incidence of
apical periodontitis (AP) for direct or indirect restorations
(OR 0.88, 95% CI 0.72-1.08, p = 0.22) with statistically
nonsignificant moderate heterogeneity (p = 0.21, I2 = 36%).
The results for periapical status of ETT with composite or
amalgam fillings are different. Hommes et al36 found the
rate of AP to be significantly higher (p < 0.01) in composite
(40.5%) than amalgam (28.4%) restorations, as supported
by Frisk et al,28 who found that composite restorations were
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
teeth restored with composite and amalgam fillings.
GRADE Assessment
The SoF (summary of findings) table created by GRADEpro-
filer is presented in Figs 7–9. Among the 4 outcomes ana-
lyzed in this review, survival (short-term and medium-term)
and restorative success of restored teeth showed low to
moderate quality, compared with very low quality of end-
odontic success.
DISCUSSION
The present systematic review and meta-analysis suggested
that indirect restorations (mainly crowns) would provide in-
creased short-term (5-year) and medium-term (10-year) sur-
vival for endodontically treated teeth compared with direct
restorations (mainly composite and amalgam fillings). Indi-
rect restorations also showed better esthetic, functional,
and biological properties, but no difference in short-term
(≤ 5 years) restorative success or endodontic success.
The search strategies for this systematic review covered
both published studies and gray literature, but abstracts
and articles published in languages other than English were
not searched. Publication bias could not be assessed due
to the limited number of studies. All of the outcomes
showed satisfactory reliability.
Reasons for extraction of ETT are mainly nonrestorable
carious destruction, endodontic issues, and tooth frac-
ture.16,78 Crowns are expected to provide a better coronal
seal to prevent bacterial recontamination of residual tooth
tissue.13 Studies showed that 85% of extracted ETT were
not crowned, due to the presence of more nonrestorable
caries compared with crowned teeth.78 Crowns may also
serve to protect the tooth from the risk of fracture,13 as
crowned ETT demonstrated a significantly lower fracture
rate than teeth provided with a filling.16
Traditionally, most clinicians prefer to use posts followed
by crown restorations for ETT;14 however, full-coverage
crowns may not be necessary. A retrospective study inves-
tigated 189 posterior ETT restored with indirect composite
onlays, and suggested this method can be a viable option
for the restoration of posterior ETT (tooth survival 100%,
restoration survival 96.8%, with median follow-up time of 37
months).14 Another study also showed that gold partial
crowns displayed a comparable fracture rate compared with
full-coverage crowns for ETT.16 However, the decision on
whether to place a crown or a partial-coverage restoration
should also depend on functional requirements and the
amount of remaining tooth structure.10,17,54 According to
some studies in vital teeth, the risk of failure has been
showed to increase by 30% to 40% for every extra missing
wall.54 An occlusal cavity preparation could reduce tooth
stiffness by 20%, compared to 63% for a MOD (mesial-oc-
clusal-distal) cavity.14 Therefore, crowns are still crucial to
provide enough coronal protection, if ETT have been exten-
sively damaged by caries or endodontic treatment.32,78
188
As for ETT without extensive coronal destruction, direct
composite restorations are mainly indicated for teeth with
minimal or moderate tooth structure loss.10 Some evidence
suggested that for similar cuspal coverage, direct and indi-
rect methods showed similar outcomes, and decided that
preference should be given to direct over indirect restora-
tions because they are more time effective and less
costly.6,19,24 However, the accuracy and skills of the practi-
tioners could significantly influence decision to repair or
replace direct restoration.45 For example, direct restora-
tions are technique sensitive with greater risks of polymer-
ization shrinkage, marginal discrepancies, microleakage,
undesirable proximal contacts, and secondary caries.5,12
On the other hand, indirect restorations (inlay/onlay) have
a reduced composite shrinkage volume, limited to the resin
luting layer, and therefore increase the marginal adaptation
of restorations.37
Failure of restorative treatment may be influenced by the
position of the tooth. In a long-term study of ETT, mandibu-
lar premolars and maxillary and mandibular anterior teeth
were reported to have longer survival times than other tooth
types, and molars demonstrated the worst survival out-
comes, possibly because of difficulties in endodontic treat-
ment and the subsequent restoration.13 A large practice-
based study analyzing direct restoration longevity showed a
higher annual failure rate (AFR) of 5.2% in molars compared
to anterior teeth (4.4%) and premolars (4.0%).45
Another controversial issue is whether to place a post
after endodontic treatment. In vitro studies showed that
placement of fiber post could significantly improve the frac-
ture resistance of ETT.1 A long-term clinical investigation (at
least 5 years) found that the survival rate of teeth with a
fiber post amounted to 94.3%, and for teeth without a post,
it was 76.3% (p < 0.001).31 However, other investigators
believe that preparation of a post space might increase the
chance of root fracture,30 so that posts should only be
used when other options were not available to retain a
core.23
In this review, indirect restorations (mainly crowns) had
better outcomes in tooth-restoration complex survival, pos-
sibly because crowns could provide better protection in
such a study pool of teeth with substantial tooth structure
loss in areas of high masticatory forces. In addition, indi-
rect restorations might serve as a more stable restoration
technique in the long run, as the effect of 10-year results
(OR 0.20) was larger than that of 5-year results (OR 0.28).
Meta-analysis of restorative success showed no statisti-
cal difference between the two restorations, probably be-
cause of limited sample size and observation time. How-
ever, a comparison of the two included studies showed
that with the increase in observation time (from 3 years to
5 years), indirect restorations exhibited more favorable
results.
In terms of endodontic success, results differed among
studies, especially when comparing amalgam and compos-
ite fillings. Studies published in different years exhibited
opposing outcomes, probably because the quality of com-
posites was better in more recent studies as a result of
The Journal of Adhesive Dentistry
 Shu et al

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

Articles included in
meta-analysis: n = 8

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.

Vol 20, No 3, 2018 189

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,

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

Vol 20, No 3, 2018 191

Shu et al
odontic success (rate of apical periodontitis), but we are
very uncertain about the estimate as a result of very low
quality of evidence.
High-quality clinical trials are needed, especially well-
designed RCTs. Future studies should better control the
confounding factors by restricting the position of teeth,
extent of coronal damage, use of post, and quality of end-
odontic treatment. RCTs are expected to have a larger
sample size and longer observation time. Moreover, under
the principle of maximum preservation of healthy tooth
structure, studies involving restoring endodontically
treated teeth with minimal coronal loss, or studies com-
paring indirect restorations of full or partial coverage, are
also of great interest and significance.
ACKNOWLEDGMENTS
The authors would like to thank the Chinese Cochrane Center at the
West China School of Medicine, Sichuan University, which provided
the theoretical guidance for this systematic review.
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Clinical relevance: Indirect restorations chiefly using
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193
Shu et al

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