ueniisiry

Cantilever fixed prostheses utilizing dental implants:

A 10-year retrospective analysis
Curtis M. Becker, DDS, MSD'

Objective; The dental literature has been unclear about long-term success of fixed cantilever prostheses
supported by dental implants. The disappointing results reported when cantilever fixed partial dentures
(FPDs) are supported with natural teeth are notdirectiy applicable to implant cantilever FPDs. This article
reports on 10 years of implant-retained fixed prostheses primarily in the maxillary arch using the ITI dental
implant system. Method and materials: Sixty cantilever prostheses using 115 ITI dental implants on 36
patients were placed and monitored over a 10-year period. Results: No implant fractures, abutment frac-
tures, porcelain fractures, prosthesis fractures, soft fissue recession, or radiographie bone loss were
recorded. All 60 cantilevered prostheses remain in satisfactory function. Conclusion; Positive, long-term
results, using implant-retained cantilever FPDs can be achieved by: (1) using a rough surface implant of
4.1 mm or greater; (2) using an implant/abutment design that reduces stacked moving parts and reduces
the implant-to-crowns ratio; and ¡3) using a cementable prosthesis design that eliminates the need for oc-
clusal screw retention. (Quintessence Int 2004,35:437-44 f)

Key words: cantilever prosthesis, implant, osseointegration

Early implant-retained prosthesis utilized cantilevers

CLINICAL RELEVANCE: implant-retained cantilever
fixed partial dentures can be an adjunct to tooth replace-
ment and can provide treatment alternatives for compro-
mised situations.
antilever fixed partial dentures (FPDs) utilizing
C natural tooth abutments have a reported poor
prognosis'--" ranging from 36% failure^-^ to 40%
failure-' in 5 to 7 years. Cross-arch stabilization can
improve the long-term prognosis to single-digit failure
rates over 5 to 8 years,^'' but prosthetic difficulties and
stringent periodontal prerequisites/maintenance'"'
have rendered the cantilever FPD using natural teeth
as abutments risky, technically difficuft, and unpre-
dictable for periodontal and restorative dentists.
'Private Practice, Denver, Colorado; and Associate Clinical Professor,
Department ol Restorative Dentistry, University o( Colorado Health
Science Center, School of Dentistry, Denver, Colorado
Reprint requests: Dr Curtis M, Becker, Left Bank Prcfessioral Building,
5055 E. Kentucky, Denver, Colorado 80246. E-mail: oebecker@earthlink.net
via a bar/clip removable prosthesis* or a screw-retained
"hybrid" or -'fixed/removable" prosthesis.*-^ These im-
plant-retained cantilever prostheses proved to be more
reliable than cantilever FPDs using natural tooth abut-
ments particularly when utilized in the mandible.'
These early implant-retained prostheses all utilized
cross-arch stabilizing designs with fixed (screw-re-
tained) spfinting of the dental implants. Complications
of implant-retained fixed and removable prostheses
have been reported.^^^^ These complications/failures
were primarily reported on machine surface, external
hex, and 3.75-mm diameter implants. These failures
centered around abutment screw loosening/frac-
ture,'°-'^ occlusal screw loosening/fracture,"'^^-^ im-
plantfi-acture,^'"^^*prostheses fi-acture'""^ and crestai
bone loss-^-'-^' There seems to be no consensus as to
whether crestai bone loss occtirs prior to implant frac-
ture or whether implant fi-acture causes bone loss.^-^"
A higher incidence of implant fracture has been re-
ported in fixed parfial dentures supported by only two
implants.'^•^^'^-' As a result of these disappointing re-
ports, few restorafive dentists have been willing to rec-
ommend FPD cantilever prostheses for their implant
patients, particularly in the posterior maxilla.

437
Quintessence International

1993 1994 1995 1995 1997 1998 1999 2000 2001 2002 2003
Perceived objections to FPD implant-retained can-
tilever prostheses may be unfounded with the advent
of technological improvements to implant components
and design: (1) Roughened surfaces to dental implants
increases bone apposition, strength, and retention'''-^'';
and (2) wider-diameter implants (4.1 mm or greater)
have eliminated implant fracture.*^ While wide-plat-
form machine surface implants have shown a higher
failure rate,™ this has not been the experience with a
rough surface implant de s ign^^ ••"•"; (3) elimination of
stacked components and microgaps*'' can reduce pros-
theses/ abutment movetnent and improve the crown-
to-implant ratio; (4) cemented components eliminate
fracture or loosening of occlusal screws and eliminates
the controversy''-'-'^ over "static loading" or "misfit"
(passive fit).«'-"
This atlicle will report on 10 years experience in a
private practice setting, usitig the clinical considera-
tions proposed by Becker and Kaiser** for implant-re-
tained cantilever FPDs.
METHOD AND MATERIALS
Between May 1993 and May 2003, 60 cantilever PPD
restorations were placed on 35 patients (18 women and
17 men) from the ages of 33 to 73 years (Fig 1), All
FPDs were placed on ITI (Institut Straumann AG)
rough-surface implants. There were 115 implant abut-
ments: 76 at 4.1-mm transosseous diameter and 39 at
4.8-mm transosseous diameter including 6 wide-neck
implants (4.8-mm transosseous diameter and 6.5-mm
occlusal platform). Twelve of the implants were placed
immediately after extraction of the tooth, and 103 im-
plants were placed with a delayed healing approach.
Three prostheses were screw retained (all in the maxil-
438
Fig 1 Graph depicting when and how many ot the 35
patients in this study received implant-retained can-
tilever fixed partial dentures between 1993 and 2003.
lary arch), and 57 were cemented with zinc oxyphos-
phate cement (Fleck's, Mizzy). There were 30 two-abut-
ment one-cant il ever FPDs (Fig 2), 19 three-abutment
one-cantilever FPDs (Fig 3), 10 two-abuttnent two-can-
tilever FPDs (Fig 4), and 1 one-abutment one-can-
tilever FPD (Fig 5), Six FPDs were in the mandible, all
cantilevering preniolars. Fifty-four FPDs were in the
maxilla: 20 replacing molars; 26 replacing lateral in-
cisors; 6 replacing prcmolars; and 2 replacing cuspids.
RESULTS
Over the 10-year period, one screw became loosened,
and two prostheses needed to be recemented, both
within 1 month of initial placement. This suggests op-
erator error in the initial cementation. There occurred
no framework fracture; porcelain fracture (there were
two incidents of minor porcelain chipping, which was
handled by smoothing the eftected area with a polish-
ing wheel); implant fracture; abutment fracture; oc-
clusal screw fracture; soft tissue recession in the es-
thetic zone; or radiographie evidence of bone loss.
There was complete patient satisfaction for all patients
for the entire duration of the study.
DISCUSSION
Implant-retained cantilever FPDs provide restorative
and surgical implant chnicians with some unique and
needed treatment options. By using cantilevers, fewer
implants are needed, which reduces cost. Implant-re-
tained fixed prostheses can be considered in risky
areas by avoiding implants to sinus areas or other min-
imal bone sites. Parallel problems for the surgeon can
Volume 35, Number 6, 2004
 R g 2a Tycica. aosterior cantilever FPD Fig 2b -mm solid abut- Fig 2c Rac c g ' s ; - :" --=-i-^eiained
uölizingt.'.o rro^an-s. menisf fixed cant ; . ; ' zzym^- : ' aalient in
Rg 2a. impiariis nao oeerr in piace for 4

Fig 3a Typical posterior cantilever FPD Fig 3b --nm solid abut- Fig 3c - Í ^ I ^ - E C ^ :- - ; ; ' • - - ; • . ? . ' s a
utilizingöiieeimplants. me-.; ; fixée ^ i " " . =.=' i;:::^!:r.£:;r£ T;: ;^=:=': :n
Fig 3a. Impianis had been in pkaca tor 4
years.

Fig 4a Iypical anierior cantilever FPD Fig 4D ir~p!a-i:ä .'.'tr ¿ 5-rr~ acutn^erts Fig 4c -a-:^' •iz:z-^:' :' ~ZL-'--e-
wiih two ponBcs (maxillary right and left lat- in place fw patient in Fig 4a. ta-e::i-:5-:-i-:i:;¿:-.^;:i--
eials) utitiziRg two rmplants in tfie rigtit and tilever c-•:::-555; cr ca; i ' : ' =iç -lä.
lefî centrât posffion- innptants hsa been in place ¡or 3 years.

Fig 5 Ten-year radiographie comparison

of a single-implant cantilever FPD.

Quintessence Pnlemalional 439

 3eGker
he reduced by keeping fixed prostheses to three or
fewer implants,'*' When two implants are needed for a
three-unit FPD, the surgeon has the discretion to
choose the two sites with the best bone and have con-
fidence that the prostheses will be successful regard-
less of the pontic location. The size of the implant di-
ameter was not shown to be a factor in long-term
success as long as it was 4.1 mm or wider. Six of the
patients were smokers, but this had no adverse effect
on outcome of osseointegration or the longevity of the
prostheses, which is consistent with the findings of
Kumar et a!,'" when using rough-surface implants.
Immediate placement of implants into fresh extracfion
sites did not affect the outcome of cantilever prosthesis
longevity, wbich is consistent with the results of other
immediate implant studies,^'-^''
CONCLUSION
Positive long-term results, using implant-retained can-
tilever FPDs, can be achieved by: (1) using a rough-sur-
face implant of 4.1-mm or greater diameter; (2) using
an implant/abutment design that reduces stacked mov-
ing parts and reduces the implant-to-crowns ratio; and
(3) using a cementable prosthesis design that eliminates
the need for occlusal screw retention.
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