PERSPECTIVES
Three-unit fixed prostheses versus
implant-supported single crowns
n the past, there were only
I a few alternatives for the
replacement of one missing
tooth, the best of which
was a cemented three-unit
fixed partial denture (FPD). His-
torically, the three-unit FPD has
been the most used and most
successful therapy for single-
tooth replacement. However, the
proven success of dental im-
plants during the last decade
has made the decision regarding
how to replace one missing tooth
confusing for both dentists and
patients. Sometimes the best
treatment is an FPD; sometimes
it is an implant-supported
crown. There are numerous fac-
tors to consider when deciding
whether to place a dental im-
plant that will replace the one
missing tooth, or whether to pre-
pare the two teeth adjacent to
the missing tooth and place an
FPD. Which is the best choice?
In this column, I will list and
discuss several factors that
relate to the decision concerning
Gordon J. Christensen, DDS, MSD, PhD
Copyright ©2008 American Dental Association. All rights reserved.
O B S E R VAT I O N S
the replacement of a missing
tooth with either a three-unit
FPD or an implant and a crown,
and I will express my own obser-
vations on the potential for suc-
cess of the two treatment alter-
natives. I hope the information
will assist practitioners in edu-
cating patients as they make
this often difficult decision.
PATIENTS’ INTEREST
There is no question that
patients are interested in
replacing their missing teeth
with root-form dental implants.
They often express the opinion
that they do not want to “cut
down” their healthy teeth to
support the “bridge” and the
missing tooth replacement. I
have encountered many patients
who will not consider an FPD,
and they demand an implant
supporting a single crown. How-
ever, most patients do not have
the education and background to
determine when to place an im-
plant and when to replace the
JADA, Vol. 139 http://jada.ada.org
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tooth with a fixed bridge. In my
opinion, all patients with a
missing tooth should be pro-
vided with adequate information
to make a legitimate judgment
about the two major restorative
alternatives and the potential
negative effects of leaving the
missing tooth unrestored.
COST OF SINGLE-TOOTH
REPLACEMENT
Patients view both treatment
alternatives as expensive. I sug-
gest that the dentist assist them
in accepting the cost by inform-
ing them about the significant
integrated laboratory and clin-
ical costs, as well as the expense
of materials and implants.
In a comparison of the clinical
fees, I found that the fee for a
three-unit FPD is less than that
for an implant and crown, if the
teeth adjacent to the missing
tooth space are sound and do not
require restorations. If the teeth
on both sides of the missing
tooth space are defective and
need crowns, most dentists, logi-
cally, suggest an FPD to replace
the missing tooth instead of one
implant because of the lower
February 2008 191
PERSPECTIVES OBSERVATIONS

TABLE before loading can occur, the

Fees for single-tooth replacement therapies.* range of time allowed for im-
plant integration usually is four
REPLACEMENT THERAPY COST to six months. The time to make
Implant-Supported Crown the crown adds another two
Surgical placement of implant (American Dental $1,565 weeks for a cumulative treat-
Association [ADA] Code† D6010)
Abutment for implant $605 (mean) ment time of 41⁄2 to 61⁄2 months for
Prefabricated (ADA Code D6056) $549 some implant-supported crowns.
Custom (ADA Code D6057) $660
Crown, porcelain fused to metal (PFM), high-noble metal‡ $1,119 If the implant is loaded immedi-
TOTAL $3,289 ately after placement, the time
Three-Unit Fixed Partial Denture (FPD) Without an for treatment includes only the
Implant time needed to make the crown,
PFM crown, retainer, high-noble metal (ADA Code D6750) $874 × 2 = $1,748
PFM pontic, high-noble metal (ADA Code D6240) $866 which usually is about two
TOTAL $2,614 weeks for most practitioners.
Single Implant, Abutment and Crown on Implant, The treatment time for a
With Restoration of Adjacent Teeth With Single three-unit FPD without an
Crowns

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Implant, abutment, PFM crown, high-noble metal (as
above)
Two single PFM crowns, high-noble metal
(ADA Code D2750) on teeth adjacent to implant
TOTAL
* Source: American Dental Association.1
† All codes listed are published in American Dental Association.2
‡ The fee may be slightly lower if noble metal is used in the crown or somewhat higher if the
provisional restoration has an additional cost.
overall cost for the patient.
The table presents current
available fee data from the
American Dental Association
(ADA)1 regarding implant-
supported crown treatment
costs, shown according to the
2007-2008 edition of Current
Dental Terminology.2
If the teeth to be used as
abutments for the fixed pros-
thesis are not in need of crowns,
a three-unit FPD without an
implant is less expensive than
placing an implant, an abut-
ment and a crown. The table
shows the fees as reported by
the ADA.1
If the decision is made to
place a single implant, an abut-
ment and a crown on the im-
plant in the missing tooth area,
as well as to restore the two
defective teeth adjacent to the
implant-supported crown with
single crowns, the fee is signifi-
cantly higher than those for
either of the two alternatives
$3,289
$873 × 2 = $1,746
$5,035
described previously (Table).
A comparison of the three
potential treatment alternatives
shows that a three-unit FPD
costs $2,614; the implant, abut-
ment and crown are about 1.3
times that cost ($3,289); and the
implant, abutment and crown
with the two single crowns on
adjacent teeth are about 1.9
times the cost of the three-unit
FPD ($5,035).
Cost is a factor in making this
important decision, and when
dentists counsel patients regard-
ing the most appropriate thera-
py, they should incorporate fees
as part of the decision-making
process.
TIME INVOLVEMENT
Time involvement is a major
factor in some clinical situations
surrounding the replacement of
a single tooth. If the practitioner
decides that because of bone
quality or quantity, the implant
must integrate into the bone
implant usually is only two
weeks. Some patients want to
have the replacement accom-
plished as quickly as possible,
and that often makes them favor
having an FPD instead of under-
going implant therapy.
EXPECTED SERVICE
LONGEVITY
Most patients are interested in
how long a restoration is ex-
pected to serve. Estimates for
service longevity vary widely,
and it is difficult to compare the
two techniques in this respect.
Many studies have reported
estimates for crown and FPD
longevity.3-10 The reports range
from a few years of service to as
high as 84 percent survival of
the FPDs at 20 years,10 with
recurrent caries being the most
reported reason for failure.
Data on the survival of single-
tooth implant-supported crowns
are more difficult to locate. Sur-
vival of the implant itself usually
is reported at approximately 95
percent across many years.11-16
However, most studies do not
report the survival of the crowns
on the implants. One would
assume that the individual
crowns would have a restoration
service potential similar to the
porcelain-fused-to-metal abut-

192 JADA, Vol. 139 http://jada.ada.org February 2008

Copyright ©2008 American Dental Association. All rights reserved.

ment crowns in the studies cited
earlier, but caries obviously
would not be a failure factor
with the implants. On the basis
of my observations across sev-
eral decades of placing crowns
on both natural teeth and
implants, I suggest that single
crowns placed over implants
should last at least 20 years
from a functional standpoint.
However, their esthetic lon-
gevity may be some years
shorter owing to tissue
shrinkage, which causes an
unacceptable esthetic appear-
ance and loss of superficial color
fired onto the crowns.
DIFFICULTY OF THE
TREATMENT
As a prosthodontist who has
placed many single-tooth
replacement implants and the
subsequent abutments and
crowns, I can state that the pro-
cedure is relatively easy to
accomplish for healthy patients
who have adequate bone. Simi-
larly, average three-unit FPDs
are relatively easy to accom-
plish. I judge that the two tech-
niques are similar in complexity,
except that many dentists whose
orientation is restorative care do
not place implants, and so they
must delegate that aspect of the
procedure to a dentist competent
in surgery.
DISCOMFORT FOR THE
PATIENT
When observing the many clin-
ical procedures of individual
dentists and typical patients
requiring the replacement of one
tooth, I have noted that either
technique can be almost pain-
less—or painful, if the dentist
uses more intensive procedures.
Most patients tell me that for a
day or two after crown prepara-
tion procedures, the soft tissue
Copyright ©2008 American Dental Association. All rights reserved.
PERSPECTIVES
around the tooth preparations is
irritated. Similarly, most of my
patients who receive single
implants inform me that there is
mild discomfort and awareness
of the surgical area for the first
few days, but the pain disap-
pears after that time. In my
experience, most patients re-
ceiving a single implant do not
feel it is necessary to take the
analgesics prescribed on an as-
I suggest that single crowns
placed over implants should
last at least 20 years from
a functional standpoint.
However, their esthetic
longevity may be some
years shorter owing
to tissue shrinkage.
needed basis. Regarding discom-
fort or anxiety on the patient’s
part, the implant and the subse-
quent abutment and crown may
seem more painful than the
three-unit FPD because of the
stigma associated with the word
“surgery,” which frightens some
patients.
ORAL HYGIENE
My experience with many pa-
tients receiving either of these
treatments leads me to conclude
that the two treatments, if
accomplished well, do not differ
in permitting the patient to
accomplish adequate oral
hygiene. However, pontics on
FPDs often are made in so-
called “ridge lap” forms, which
commonly are observed coming
from laboratories and, unfortu-
nately, are accepted by some
practitioners. Such ridge-lap
anatomy is difficult to clean on
an FPD. Properly fabricated
JADA, Vol. 139 http://jada.ada.org
OBSERVATIONS
crowns for implants are no more
difficult to clean than are natu-
ral teeth.
ESTHETIC RESULT
This subject could fill an entire
book. Either procedure has limi-
tations relative to the eventual
esthetic result. Either procedure
can be excellent or poor estheti-
cally, depending on the bone and
soft tissue present, the clini-
cian’s skill and the laboratory
technician’s skill. Each of the
procedures may have esthetic
limitations related to the pres-
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ence of anatomical anomalies,
tooth malalignment, soft-tissue
irregularities or lack of adequate
underlying bone. Often, surgical
procedures are necessary to cor-
rect the defects before treatment
begins for either an FPD or a
single crown over an implant. It
is my opinion that in a typical
clinical situation, either tech-
nique can produce adequate-to-
excellent esthetic results, but
that occasionally prerestorative
oral surgical or periodontal
treatment is necessary to
achieve optimum esthetic
results for either therapy.
OTHER FACTORS
The following factors also can
influence the decision to select
one therapy over another:
dsmoking, which usually is
considered to be negative rela-
tive to placement of implants;
dpoor oral hygiene history,
which may indicate that implant
placement could be better than
repair and retention of question-
able teeth;
dphysical activities, such as
potentially traumatic athletic
activity, which may require res-
torations that resist breakage;
dretained, mobile, periodon-
tally treated teeth that may be
better restored with conven-
February 2008 193
PERSPECTIVES OBSERVATIONS
tional FPDs than with implants;
dbruxism and clenching that
usually indicate the need for
high-strength restorations.
SUMMARY
Historically, three-unit FPDs
have served patients well in
replacing a single missing tooth.
However, the three-unit FPD
procedure is invasive if teeth
adjacent to the space are not in
need of restorations. The tech-
nique of implant placement and
restoration of the missing tooth
with an implant-supported
crown is replacing the three-
unit FPD procedure. Research
appears to indicate that the
single-implant procedure and
implant-supported crown have
greater longevity than does the
FPD restoration on natural
teeth. It appears that the state
of the art is, whenever possible,
placing a single implant-
194 JADA, Vol. 139 http://jada.ada.org February 2008
Copyright ©2008 American Dental Association. All rights reserved.
supported crown to replace a
single missing tooth. ■
Dr. Christensen is the director, Practical
Clinical Courses, and co-founder and senior
consultant, CR Foundation, Provo, Utah. He
also is the dean, Scottsdale Center for Den-
tistry, Ariz. Address reprint requests to Dr.
Christensen at CR Foundation, 3707 N.
Canyon Road, Suite 3D, Provo, Utah 84604.
The views expressed are those of the author
and do not necessarily reflect the opinions or
official policies of the American Dental
Association.
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