Implant-retained cantilever fixed prosthesis: Where and when
Curtis M. Becker, DDS, MSD,a and David A. Kaiser, DDS, MSDb
University of Colorado Health Science Center, Denver, Colo., and University of
Texas Health Science Center at San Antonio, San Antonio, Texas
Statement of problem. Many clinical situations are suitably treated with cantilevered implant-supported
cemented fixed restorations.
Purpose. This article details the indications for the restorative dentist to use a cantilever fixed prosthesis
after insertion of ITI dental implants.
Conclusion. The use of implants to support cantilevered fixed partial dentures has been successful in
selected clinical situations. (J Prosthet Dent 2000;84:432-5.)
T he early prosthodontic restorations with implants
for an edentulous arch often involved cantilever
devices, whether an extended bar/clip substructure1
or a screw-retained “hybrid” or “fixed/removable”
prosthesis.2-3 When patients demanded more extensive
use of implants for posterior quadrants and partially
edentulous areas, cantilever prostheses over implants
were considered.
The cantilever became popular because of the small
diameter implants available (fear of fracture) and the
necessity for the use of the shorter implant lengths to
avoid anatomic structures such as sinuses or inferior
alveolar nerves. Adell et al4 reported a 8.7% fracture
rate for the Brånemark implant body after a 10-year
prospective study. The early objections to cantilevered
prostheses may be unfounded with the advent of
implant surface texture treatment to promote more
bone apposition for identical implant length,5-13 wider
diameter implants, and elimination of microgaps14 that
have improved the crown-to-implant ratio. Buser et al5
monitored 2346 ITI implants and recorded no fractures
with 4.1 mm solid screws after 8 years.15 This article dis-
cusses certain conditions in which cantilevered prostheses
retained by dental implants were advantageous.
CLINICAL CONSIDERATIONS
The ultimate goal of an implant-retained prosthesis
is to ensure that the esthetic and functional needs of
the patient are met with minimal discomfort and lim-
ited complications. Prosthodontic designs have dictated
implant placement, so it was logical to develop pros-
thetic designs that minimized alignment problems.
Esthetic restrictions, poor quality bone in a specific
site, and the need for extensive bone grafting are crit-
ical considerations. In general, it has been wise to use
2 or more implant abutments when designing can-
aAssociate
Clinical Professor, School of Dentistry, University of
Colorado Health Science Center.
bProfessor, Department of Prosthodontics, Dental School, University
of Texas Health Science Center at San Antonio.
432 THE JOURNAL OF PROSTHETIC DENTISTRY
tilevered prostheses. This general rule may be affected
by the anticipated or lack of forces on the prostheses
and the size of a cantilever pontic.
Alignment problems
Alignment of implants that are sufficiently parallel
for placement of multiunit prostheses has always been
a challenge. Early examples of poor alignment and
prosthetic gymnastics required for even compromised
prosthetic results are legendary. These problems have
been largely controlled with improved communication
between the surgeon and restorative dentist, pre-
dictable grafting techniques, well-designed guide
stints, and more durable prosthetic components.
There are conditions in which implant alignment is
arduous. For example, to align an implant placed in
the central position of the maxilla with one placed in
the canine area is difficult because of the angulation of
bone. Implants often flare from each other, but with
the innovative design of a cantilevered prostheses,
implants need not be parallel (Fig. 1).
Extensive bone grafting
Extensive bone grafting, particularly in sinus areas,
may complicate the entire treatment plan and even
diminish long-term success. If esthetic require-
ments have allowed first molar occlusion with ade-
quate bone anterior to sinuses in premolar regions,
then distal cantilevered prostheses may be the treat-
ment of choice (Fig. 2).
Esthetic restrictions
The maxillary lateral incisor and mandibular incisor
are difficult areas to place implants because of narrow
dimensions. Implants with narrow diameters are suit-
able for individual implant prostheses but are ques-
tionable as abutments for multiunit prostheses.
Implants are usually avoided in the maxillary lateral
incisor position and mandibular incisor positions. In
general, splinted restorations have been restricted to
3 to 4 units.16
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A B C

Fig. 1. A, Flared, nonparallel solid abutments. B, Final restoration with cantilever right and
left maxillary lateral incisors. C, Radiograph showing cantilever right and left maxillary later-
al incisors.

A B
Fig. 2. A, Prosthesis with triple abutted left maxillary canine, first and second premolars,
upper left maxillary first molar, and distal cantilever maxillary first molar. B, Radiograph
showing cantilever.

Placement of wide-diameter implants in central
positions and cantilevered lateral incisors (Fig. 3) is
preferable when missing multiple maxillary anterior
teeth. Likewise, a mandibular incisor may be can-
tilevered from a wide-diameter implant in the canine
position and is superior to insertion of 2 implants in
approximation.
Bone quality
The quality and quantity of bone in a desired
implant site can often be determined by high-quality
radiographs. Sometimes a deficient site can be
bypassed by the redesign of the prosthesis to include a
cantilevered pontic for the compromised site (Fig. 4).
The need to insert an implant in a compromised site
that may have required grafting or has poor
osseointegration can be eliminated.
Nonosseointegration of implants
In the early years of implant usage, failure to
osseointegrate was high by present standards (10%).3
Although initial failure before loading is rare today
(less than 1%),15 it occurs occasionally. When an
implant is lost during initial healing, a decision is need-
ed to replace the implant. Reentry delays prosthetic
placement for several months, causes more discomfort,
and increases costs for a patient, and there is no guar-
antee that the results will be identical to the first
surgery. The decision for reinsertion of a lost implant
may be avoided if the planned prosthesis design can be
augmented to include a cantilevered pontic in the
location of a failed implant. The decision to include a
cantilevered prosthesis depends on the number of
implants available for the prosthesis and osseous
support around the implants.
SUMMARY
Dental literature has been unclear about long-term
success when cantilever prostheses have been supported
by dental implants. The questionable results when
cantilevers are selected with natural teeth17 are not
directly extrapable to implant prostheses. Early failures
with narrow, external hex, machined-surface
implants3,4 are not a valid comparison to the wider,
roughened, single-stage implants currently avail-
able.3,15
REFERENCES
1. Brånemark PI, Zarb GA, Albrektsson T. Tissue-integrated prostheses
osseointegration in clinical dentistry. Chicago: Quintessence; 1985.
p. 283-7.
2. Brånemark PI, Zarb GA, Albrektsson T. Tissue-integrated prostheses

OCTOBER 2000 433

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A C

B D
Fig. 3. A, Multiple missing teeth in anterior after auto accident. B, Large body implants (4.8 mm) in
maxillary canine and left canine positions. C, Solid abutments placed at 35 N·cm. D, Final restora-
tion with cantilever pontics replacing right and left maxillary lateral incisors supported by implants
in area of maxillary central incisors. Single tooth implant was used for maxillary left canine.

A B C

Fig. 4. A, Master cast with 2 implants to support cantilever maxillary left canine. B, Fixed par-
tial denture with implants maxillary left first and second premolar areas to support cantilever
maxillary left canine. C, Radiograph of cantilever maxillary left canine.

osseointegration in clinical dentistry. Chicago: Quintessence; 1985.
p. 241-70.
3. Adell R, Lekholm U, Rockler B, Brånemark P. A 15-year study of
osseointegrated implants in the treatment of the edentulous jaw. Int J
Oral Surg 1981;10:387-416.
4. Adell R, Eriksson B, Lekholm U, Brånemark P, Jemt T. Long-term follow-up
study of osseointegrated implants in the treatment of totally edentulous
jaws. Int J Oral Maxillofacial Implants 1990;5:347-59.
5. Buser D, Schewk R, Steinemann S, Fiorellini J, Fox C, Stich H. Influence
of surface characteristics on bone integration of titanium implants. A
histomorphometric study in miniature pigs. J Biomed Mater Res
1991;25:889-902.
6. Wilke HJ, Claes L, Steinemann S. The influence of various titanium sur-
faces on the interface shear strength between implant and bone. Adv
Biomater 1990;9:309-14.
7. Cochran DL, Simpson J, Weber H, Buser D. Attachment and growth of
periodontal cells on smooth and rough titanium. Int J Oral Maxillofac
Implants 1994;2:289.
8. Cochran D, Nummikowski P, Higginbottom F, Herman J, Makins S, Buser
D. Evaluation of an endosseous titanium implant with sandblasted and
acid-etched surface in the canine mandible: radiographic results. Clin
Oral Implants Res 1996;7:240-52.
9. Klekkevold PR. Osseointegration enhanced by chemical etching of the
titanium surface. Clin Oral Implants Res 1997;8:442-7.
10. Boyan B, Batzer R, Keiswetter K, Lui Y, Cochran D, Szmuckler-Moncler
S, et al. Titanium surface roughness alter responsiveness of MG63
osteoblast-like cells to 1 alpha, 25-(OH)2D3. J Biomed Mater Res
1998;39:77-85.
11. Cochran DL, Schenk R, Lussi A, Higginbottom F, Buser D. Bone response
to unloaded and loaded titanium implants with a sandblasted and acid-
etched surface. A histometric study on the canine mandible. J Biomed
Mater Res 1998;40:1-11.
12. Buser D. The interface shear strength of titanium implant with a sand-
blasted and acid-etched surface. A biomechanical study in the maxilla of
miniature pigs. J Biomed Mater Res 1999;45:75-83.
13. Buser D. Removal torque values of titanium implants in the maxilla of
miniature pigs. A direct comparison of sandblasted and acid-etched with
machined and acid etched screw implants. Int J Oral Maxillofac Implants
1998;13:611-9.
14. Cochran D, Herman J, Schenk R, Higginbottom F, Buser D. Biologic

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width around titanium implants. A histometric analysis of the implant- Copyright © 2000 by The Editorial Council of The Journal of Prosthetic
gingival junction around unloaded and loaded non-submerged implants Dentistry.
in the canine mandible. J Periodontol 1997;68:186-98. 0022-3913/2000/$12.00 + 0. 10/1/110259
15. Buser D, Mericske-Stern R, Bernard J, Behneke A, Behneken N, Hint H,
et al. Long-term evaluation of nonsubmerged ITI implants. Part I: 8-year
life table analysis of a prospective multi-center study of 2359 implants.
Clin Oral Implants Res 1997;8:161-72.
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17. Selby A. Fixed prosthodontic failure. Aust Dent J 1994;39:150-6.

Reprint requests to:

DR DAVID A. KAISER
DIVISION OF PROSTHODONTIC DENTISTRY
UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER
7703 FLOYD CURL DR
SAN ANTONIO, TX 78284-7890
FAX: (210)567-6376
E-MAIL: Kaiser@uthscsa.edu doi:10.1067/mpr.2000.110259

Changes in the masticatory function of complete denture

Noteworthy Abstracts wearers after relining the mandibular denture with a soft
of the denture liner
Current Literature Hayakawa I, Hirano S, Takahashi Y, Keh ES. Int J Prosthodont
2000;13:227-31.
Purpose. This study examined the changes in the masticatory function of complete denture wear-
ers after relining the mandibular prosthesis with a soft liner.
Material and methods. Six completely edentulous patients participated in the study. All patients
had worn complete dentures for more than 10 years. New complete maxillary and mandibular
dentures were fabricated for each patient using a heat-polymerized acrylic resin (Akron GC,
Tokyo, Japan). Adjustments were completed over a 1-month period, and all patients were free of
discomfort during chewing. Maximum biting force, masticatory performance, masticatory
rhythm, chewing time, chewing strokes, and muscular activity were recorded for each patient.
Each mandibular prosthesis was then relined with a soft denture liner (Kurepeet Dough, Kureha,
Kurcha, Tokyo, Japan). After insertion of the relined prostheses, the same adjustment procedures
and tests were completed. A paired t test (α=.05) was completed to compare the data.
Results. Masticatory performance and maximum biting force increased significantly after place-
ment of the soft liners. After the reline procedure, the number of chewing strokes and chewing
time were significantly lower. No significant difference was noted in the mean muscular activity
after the reline procedures were completed.
Conclusion. Relining the mandibular dentures of the limited number of patients in this study
resulted in increased masticatory function with no change in muscular activity when compared
with the prostheses without soft liners. 33 References. —DL Dixon

OCTOBER 2000 435