Ante's law is not evidence based Ben Balevi JADA 2012;143(9):1011-1012

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RESEARCH

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Antes law is not evidence based

A critical summary of Lulic M, Brgger U, Lang NP, Zwahlen M, Salvi GE. Antes (1926) law revisited: a systematic review on survival rates and complications of fixed dental prostheses (FDPs) on severely reduced periodontal tissue support (published correction appears in Clin Oral Implants Res 2008;19[3]:326-328). Clin Oral Implants Res 2007;18(suppl 3):63-72. Ben Balevi, DDS, MSc Main results. Six retrospective studies met the inclusion criteria. A meta-analysis incorporating the results of only two studies (84 participants at baseline [with 17 dropouts] and 79 FDPs) yielded an estimated FDP survival rate of 96.4 percent (95 percent confidence interval [CI], 94.6-97.6 percent) after five years and 92.9 percent (95 percent CI, 89.5-95.3 percent) after 10 years. These results were comparable with published survival rates of FDPs with abutments that satisfied Antes law. Conclusions. The long-term prognosis of FDPs with abutments that have severely reduced periodontal support depends on proper control of periodontal disease, strict adherence to a maintenance care program and rigid splinting of mobile abutment teeth.
The review described in this critical summary was funded by the Clinical Research Foundation for the Promotion of Oral Health, University of Bern, Switzerland.

Systematic review conclusion. The long-term prognosis of a fixed dental prosthesis (FDP) with abutments that have severely reduced periodontal support depends on the maintenance of a healthy periodontium. Critical summary assessment. Although the results of this review are limited by the quantity and quality of included articles, there appears to be no scientific evidence requiring that in fixed dental prosthesis (FDP) design, the total periodontal membrane area of the abutment teeth must equal or exceed that of the teeth to be replaced1 (Antes law). Evidence quality rating. Limited.

Clinical question. In adult patients who have a fixed dental prosthesis (FDP) that has healthy periodontal tissue support, would abutments that have severely reduced periodontal tissue support (that is, those not satisfying Antes law1), compared with abutments that have no or minimally reduced periodontal tissue support (that is, those satisfying Antes law), lead to lower FDP survival rates? Review methods. The reviewers searched one electronic database (PubMed) through September 2006 and hand searched

seven relevant journals. They considered only prospective and retrospective cohort studies published in the English language. They included in the review only studies of FDPs with abutment teeth that did not meet the requirements of Antes law, according to clinical and radiographic data. The primary outcomes the reviewers measured and calculated were the five- and 10-year survival rates of these FDPs. They then compared the outcomes with published survival rates of FDPs that had abutment teeth satisfying Antes law.

Dr. Balevi maintains a private practice in general dentistry in Vancouver, British Columbia, Canada, and has an appointment to the faculty of medicine, University of British Columbia, Vancouver. He also is an evidence reviewer for the American Dental Association. Address reprint requests to Dr. Balevi, Faculty of Medicine, University of British Columbia, No. 306, 805 W. Broadway, Vancouver, British Columbia, Canada V5Z 1K1, e-mail drben@dentalben.com.

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COMMENTARY

Importance and context. Antes law states that the total periodontal membrane area of the abutment teeth must equal or exceed that of the teeth to be replaced.1 For more than 80 years, this law has been taught in standard textbooks of prosthodontics as an important condition influencing FDP design.2,3 If Antes law is shown not to be evidence based, then the option of an FDP supported by abutments with healthy but compromised periodontal bone support would be viable for patients and clinicians to consider. Strengths and weaknesses of the systematic review. The authors of this review sought to answer a well-focused question and provided a complete description of the criteria used to include and exclude articles. However, the review is limited by the authors decision to search only one database and to include only English-language articles. Also, they conducted no assessment of selection agreement between two independent reviewers (in other words, they provided no statistic). The findings of the six retrospective studies included are well summarized, but discussion is lacking regarding the risk of bias or of heterogeneity among the studies. For example, it is unclear whether the authors were consistent in applying to all the included studies the criteria used to determine whether an FDP satisfied Antes law. The lack of consistency between studies allowed for only two studies to be included in the meta-analysis. Also, the authors did not assess the potential risk of publication bias to their review. Strengths and weaknesses of the evidence. The six included studies were of the lower-quality retrospective design. Furthermore, the authors could not find a single clinical study in which the investigators compared the survival rates between FDPs that did not meet the requirements of Antes law and those that did. Hence, this left the authors to make comparisons between the results of studies of each respective FDP design. Nevertheless, the results of all reviewed studies appeared to demonstrate consistently that FDPs placed on severely compromised periodontally supported abutments were serviceable. Only two studies, which included only 79 FDPs and had a high overall participant dropout rate (20 percent), were eligible for meta-analysis. Nevertheless, the estimated five- and 10-year survival rates of 96 and 92 percent, respectively, are slightly higher than the 10-year survival rate of 89.1 percent (95 percent CI, 81-93.8 percent) reported in Tan and

colleagues4 systematic review of FDPs that involved abutments with generally good periodontal support. Lulic and colleagues explained the slight difference as possibly being caused by operator bias because their own review included FDPs in patients who were treated and whose FDPs were maintained regularly by clinical specialists, in contrast to those in the review by Tan and colleagues,4 which included FDPs completed by general dentists and dental students. Also, Tan and colleagues meta-analysis consisted of 2,881 FDPs, compared with only 79 in this review. However, investigators in two studies that were published after this review and that met its inclusion criteria also confirmed the impressive long-term prognosis of FDPs that were supported by periodontally healthy tissue but that had compromised bone-supported abutments.5,6 Implications for dental practice. With well-maintained, healthy periodontal tissue support, FDPs not satisfying Antes law have survival rates comparable with the high rates of FDPs that do satisfy Antes law. Therefore, the design of an FDP does not necessarily have to satisfy Antes law. I
Disclosure. Dr. Balevi did not report any disclosures. Critical Summaries is supported by grant G08 LM008956 from the National Library of Medicine and the National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Md. These summaries, published under the auspices of the American Dental Association Center for Evidence-Based Dentistry, are prepared by practitioners trained in critical appraisal of published systematic reviews who work under the mentorship of experts. The summaries are not intended to, and do not, express, imply or summarize standards of care, but rather provide a concise reference for dentists to aid in understanding and applying evidence from the referenced systematic review in making clinically sound decisions as guided by their clinical judgment and by patient needs. For more information on the evidence quality rating provided above and additional critical summaries, please visit http://ebd.ada.org. 1. Ante LH. The fundamental principles of abutments. Mich State Dent Soc Bull 1926;8:14-23. 2. Shillingburg HT. Fundamentals of Fixed Prosthodontics. 3rd ed. Chicago: Quintessence; 1997:92. 3. Rosenstiel SF, Land MF, Fujimoto J. Contemporary Fixed Prosthodontics. 4th ed. St Louis: Mosby Elsevier; 2006:95. 4. Tan K, Pjetursson BE, Lang NP, Chan ES. A systematic review of the survival and complication rates of fixed partial dentures (FPDs) after an observation period of at least 5 years, III: conventional FPDs. Clin Oral Implants Res 2004;15(6):654-666. 5. Cabanilla LL, Neely AL, Hernandez F. The relationship between periodontal diagnosis and prognosis and the survival of prosthodontic abutments: a retrospective study. Quintessence Int 2009;40(10):821-831. 6. Bragger U, Hirt-Steiner S, Schnell N, et al. Complication and failure rates of fixed dental prostheses in patients treated for periodontal disease (published online ahead of print Dec. 16, 2010). Clin Oral Implants Res 2011;22(1):70-77. doi:10.1111/j.1600-0501.2010.02095.x.

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