Direct or Indirect Restorations: The Choice is Yours!

Objectives: Anterior teeth extensively damaged by dental caries, tooth surface loss or trauma may be repaired by using either direct or indirect restorations. Clinical situations where significant loss of tooth structure has occured, require careful treatment planning and management to optimise results. The best evidence-based approach can be expected to enhance the prognosis of the tooth. This systematic review aimed to appraise clinical studies published between 2003 and 2018; which assessed the survival rates of: i) direct restorations (resin composites and GIC) and ii) indirect restorations (all-ceramic and metal-ceramic crowns) for heavily restored anterior teeth.


Methods: Following the literature review, inclusion and exclusion criteria were prepared. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines was used. Electronic searches were carried out using Ovid Medline and Embase databases with appropriate search terms, supplimentd by a hand search. The studies were assessed using the Methodological Index for Non-Randomised Studies (MINORS). The survival rates for direct and indirect restorations were evaluated with a minimum follow-up period of five years.
Results: 1285 articles were initially identified, with 7 fulfilling the inclusion criteria. No randomised controlled trials were identified. A meta-analysis was undertaken; forest and funnel plots were used to illustrate findings. Pooling of results indicated that the survival rate at five years was 97% for crowns. There were inconclusive results for the direct restorations due to the high heterogeneity between the studies. This indicated poor quality of evidence from those studies.
Conclusions: Indirect restorations have shown a higher success rate over five years compared with their direct counterparts, which may be sensitive to operator technique. However, more robust research, which directly compares the two types of restorations and also addresses potential confounding and risk factors, is required before definitive decisions are undertaken regarding the management of heavily restored anterior teeth.