Australian Dental Journal 2000;45:1.

31
A prospective study of cantilever resin-bonded
bridges: An intial report
A. W. K. Chan,* I. E. Barnes
Abstract
A prospective study was undertaken in a dental
teaching hospital to compare the clinical perform-
ance of cantilever resin-bonded bridges with a
fixed-fixed design for the replacement of a maxillary
permanent incisor. A total of 25 anterior resin-
bonded bridges was placed in 24 patients. The
prostheses were evaluated over 14 to 45 months.
During the evaluation period only one fixed-fixed
type debonded, which was subsequently rebonded
successfully. There was no debond in the cantilever
group. The short-term, initial findings showed that
cantilever resin-bonded bridges performed as
successfully as their fixed-fixed counterparts and
were considered to be an acceptable form of
restoration.
Key words: Cantilever, resin-bonded bridge.
(Recei ved for publ i cati on June 1998. Revi sed
September 1998. Accepted September 1998.)
adhesive resins, such as Panavia (Kuraray Co. Ltd,
Osaka, Japan) that chemically bonds to enamel and
alloy by means of 4-META, has helped to increase
the rate of success of resin-bonded bridges.
6
The major advantage of resin-bonded bridges is
the conservat i ve nature of the abutment preparat i o n s.
Full-coverage preparation for conventional bridge-
work requires a substantial reduction of tooth
substance, which may result in iatrogenic pulpal
injuries.
7
This is particularly true for young patients
who usually have large pulps but short clinical
crowns. Incorrectly designed bridges can also lead to
periodontal damage. However, since the retainer
margin of a resin-bonded bridge can always be
placed supragingivally, this is not only kind to the
p e riodontium but also simplifies impression and
finishing procedures. As preparations are largely
confined to the enamel, they may be undertaken
without the use of local anaesthesia, which further
reduces dental anxiety and stress in pat i e n t s.
C h a i rside and laborat o ry time are less than for
conventional bridges and, therefore, resin-bonded
bridges are usually less costly. As a result, resin-
bonded bridges are currently regarded as a suitable
treatment alternative to full preparation bridgework
in selected patients.
8
With these advantages, resin-
bonded bridges have gained in popularity.
However, since its introduction, the main concern
with this type of bridgework has been its longevity.
The clinical performance of resin-bonded bridges
has been reviewed by many authors with a range of
success report e d .
9 - 1 3
For instance, some authors
reported failure rates as low as 11.5 per cent in the
anterior part of the mouth.
8-10,14
However, when used
to replace posterior teeth, the outcome was much
less predictable and the failure rate could be as
high as 83.3 per cent.
10
Despite these variations,
resin-bonded bridges are currently accepted as an
effective treatment modality for the restoration of
missing teeth in various clinical situations.
Resin-bonded cantilever bridges replacing single
teeth have been reported in one study to have the
Introduction
The development of resin-bonded bridges has
been a significant advance in modern restorative
dentistry. A periodontal splint which relied on the
e x t rusion of acid-etch retained resin composite
through perforations in the cast gold framework for
retention was first introduced more than 20 years
ago.
1
It was later described as a resin-bonded bridge
with perforated retaining wings and such prostheses
were subsequently called Rochette bridges.
2
Since
then, a variety of methods has been developed to
retain the special luting resin to the fitting surface of
the metal framework.
3-5
More recently, gritblasting
with 50 m aluminium oxide has been reported to
produce a surface which is sufficiently retentive for
use with luting resins which are able to form
chemical bonds to metallic surfa c e s.
6
The use of these
*Clinical Assistant Professor, Conservative Dentistry, Faculty of
Dentistry, The University of Hong Kong, Prince Philip Dental
Hospital, Hong Kong.
Former Professor Pergigian Operatif, Ketua Jabatan Pergigian
Operatif, Fakulti Pergigian, Universiti Kebangsaan Malaysia, Kuala
Lumpur, Malaysia.
SCI ENTI FI C A R T I C L E
Australian Dental Journal 2000;45:(1):31-36
lowest debond rate.
12
Another retrospective study
showed that cantilever resin-bonded bridges per-
formed as successfully as fixed-fixed types.
15
Indeed,
removal of the debonded retainer, which effectively
converts the bridge into a cantilever design, is an
accepted means of managing partially debonded
resin-bonded bridges (Fig. 1).
There have been several reports describing the
construction of cantilever resin-bonded bridges.
16-18
It has been suggested that the cantilever design may
be more resistant to debonding caused by occlusal
l o a d i n g, for example, in situations where the abu t m e n t
teeth are periodontally invo l ve d .
1 9
H owe ve r , n o
systematic prospective study has directly compared
the clinical performance of fixe d - f i xed with cantileve r
resin-bonded bridges.
The purpose of this prospective study was to
compare the clinical performance of cantilever with
f i xe d - f i xed type resin-bonded bridges for the
r e p l a c ement of a single maxillary permanent incisor.
Materials and methods
Selection criteria
Patients who satisfied all of the following criteria
were selected from the patient pool in a dental
teaching hospital (The Prince Philip Dental Hospital,
Hong Kong) and informed consent was obtained.
1. A single permanent maxillary central or lateral
incisor was missing.
2. Sound or minimally restored abutment(s) with
an adequate enamel surface area for bonding were
present. (Teeth with large restorations or enamel
defects, partially erupted teeth, or teeth with short
clinical crowns were not deemed suitable for use as
abutments.)
3. Angle Class I or II (division 1) incisal relation-
ships were present with stable posterior support.
4. An absence of abnormal oral habits with
excessive occlusal function or parafunction, such as
pencil chewing or bruxism.
Grouping
Patients were divided randomly into two treat m e n t
groups as follows:
Group A (fixed-fixed; FF): the missing tooth was
replaced with a fixe d - f i xed resin-bonded bri d g e , w i t h
r e t a i n e rs on the abutment teeth on each side of the gap.
Group B (cantilever; CL): the missing tooth was
replaced using a cantilever resin-bonded bri d g e , w i t h
a single retainer on one of the adjacent abutment
teeth, usually the incisor.
Patient factors
The total number of patients in the study was 24.
Nine (37.5 per cent) were males and 15 (62.5 per
cent) were females. Their ages at the time of insert i o n
of the bridges ranged from 15 to 56 years. There
were 14 patients requiring one single upper central
incisor replacement, and eight patients required one
single upper lateral incisor replacement. One patient
required the replacement of both congenitally missing
upper lateral incisors, and one other required the
replacement for a large diastema between the two
upper central incisors. The distribution of bridges is
shown in Table 1.
Clinical and laboratory procedures
The anterior retainers were designed with the
concern for satisfactory appearance.The initial tooth
preparation technique included broad coverage of
enamel, supragingival margins, marginal ridge and
cingulum rests on each abutment and no penetra-
tion into dentine. If possible, the retention form
was improved by including proximal grooves and
additional rests. External 180-plus circumferential
retainer preparation was rarely used. After tooth
preparation, a full-arch working impression was
made with an addition silicone impression material
in a custom tray. The outline of the bridge framewo r k
was then drawn on the working cast by the single
operator.
All bridges were constructed by one dental
technician from the Dental Technology Unit of the
dental hospital, using the refractory cast method.
The pattern was waxed up directly on the refractor y
cast, sprued, then invested with a phosphate-bonded
i nvestment mat e rial (DVP Investment; Whip Mix
Corp., Louisville, Kentucky, USA). Fo l l owing cast-
ing with a non-precious metal alloy (Optimum;
Matech Inc, Sylmar, California, USA), the metal
framework was t r a n s f e rred to the first master stone
cast for porcelain build-up (Vita-Omega; V i t a
Z a h n fa b ri k , Bad Sckingen, G e rm a ny ) . For the
cantilever group, incisal hooks were provided to
assist retainer location at the try-in stage (Fig. 2).
After a satisfactory try-in, the bridges were return e d
to the laborat o ry for glazing and polishing, and the
retainer surfaces gritblasted with 5 0 m aluminium
oxide powder at a pressure of 5 2 0 k Pa . T h e
prostheses were cemented with Pa n avia under
rubber dam isolation, following the m a n u fa c t u r e r s
i n s t ru c t i o n s. All of the clinical procedures were
performed by one operator.
Recall and evaluation
Recalls and evaluations were carried out at one
month, three months and then every six months.
Retention was the only criterion used for clinical
success. At follow-up, prostheses were categorized as
being either satisfactory or debonded (failed). Any
debonded bridges were to be treated as outlined
below. Not all of these methods were used.
32 Australian Dental Journal 2000;45:1.
Australian Dental Journal 2000;45:1. 33
If any prosthesis of Group A (FF) debonded on
both retainers but otherwise exhibited no major
d e f e c t s , p r ovided that no drift of the abu t m e n t
teeth had occurred, it was to be rebonded after re-
gritblasting. Partially debonded prostheses were to
be converted into a cantilever design by the removal
of the failed retainer. If other bridges failed, they
would be remade, and therefore excluded from the
study.
Debonded prostheses in Group B (CL) would be
identified easily by the patients, because the bridges
would fall out.They were to be recemented after re-
gritblasting if no major defect was detected.
Results
A total of 25 upper anterior resin-bonded bridges
was placed in 24 patients. Twelve were of the fixed-
fixed type while the remaining 13 were cantilevers.
The bridges were evaluated after periods ranging
from 14 to 45 months. The mean lengths of clinical
service of the fixed-fixed and cantilever groups were
33 and 35 months, respectively.
During the evaluation period, only one fixed-fixed
bridge debonded, three months after cementation.
An attempt was made to convert it into a cantilever
design but the bridge became detached duri n g
sectioning of the debonded wing. Eventually the
bridge was recemented as a cantilever bridge and it
was still in function 40 months later (Fig. 1).There
was no debond in the cantilever group. Fishers
Exact Test showed that there was no significant
difference in retention rate between the two groups
at the p<0.05 level.
Discussion
There have been several reports on cantilever
resin-bonded bridges. However, the authors are
u n aware of any prospective study that has been
published. In the present study, the bridges were
confined to the replacement of maxillary incisors in
order to reduce the number of clinical variables.
The choice of abutment for the cantilever group
was based on two criteria: (i) the occlusion and (ii)
the surface area available for bonding. It has been
suggested that the larger the enamel surface area,
then the greater the bridge retention.
20
For instance,
the maxillary central incisor will normally be used to
retain a cantilever resin-bonded bridge replacing the
lateral incisor because it has a larger surface area for
bonding than the canine, and also usually a more
favourable occlusal loading.
Table 1. The distribution of replaced teeth
Patient Tooth Bridge type Abutment(s) Service time
(n=24) replaced (CL/FF) (months)
A 11 FF 12,21 45
B 22 CL 21 45
C 22 CL 21 45
D 21 CL 11 45
E 21 CL 11 45
F between 11,21 FF 11,21 44
G* 21 FF 11,22 43
H 12 CL 11 42
22 FF 21,23 42
I 12 CL 11 39
J 12 FF 13,11 37
K 21 FF 11,22 34
L 12 CL 11 33
M 21 CL 11 33
N 12 FF 13,11 33
O 11 CL 21 30
P 21 FF 11,22 30
Q 21 FF 11,22 30
R 11 FF 21,22 28
S 22 FF 21,23 28
T 12 CL 13 26
U 11 FF 12,21 18
V 21 CL 11 18
W 11 CL 21 18
X 11 FF 12,21 14
F i g . 1 . (a) Pa l atal view of a resin-bonded bridge replacing tooth 21. The retainer on tooth 22 had debonded.
(b) The debonded retainer on tooth 22 was sectioned and the bridge was conve rted into a cantilever design.
a b
From the preliminary findings, the presence of
preparations with proximal grooves, marginal ridges,
cingulum rest seats, gingival finishing margins and
an accurate bonding technique appeared to be
adequate for a good prognosis. External 180-plus
circumferential retainer preparation may not be
n e c e s s a ry. Besides assisting seating of the bri d g e wo r k ,
especially for the cantilever design, tooth preparation
can allow for an increased metal thickness of the
retainers, which may reduce their flexion and hence
reduce the shear-peel forces on the cement junction.
The relatively low debond rate in this initial report
may be because only short-span bridges (single
tooth replacements) were included, as long-span
bridges usually have higher failure rates than shorter
spans.
20
In addition, strict moisture control was used
during cementation, which is critical for a successful
bond to etched enamel. The most predictable method
to achieve this is the use of rubber dam isolation.
The short-term service of the bridges may also
account for the low debond rate.
There was no secondary caries detected with the
retained bridges, possibly due to the short-term
service of the bridges and a fluoridated water supply
in Hong Kong since the 1960s. There was no obvious
change in mobility of the abutment(s) in both
groups.
There were no debonds in the cantilever group. It
can be postulated that the differential displacement
of the abutment teeth within the periodontium in
the fixe d - f i xed gr o u p, both in magnitude and
direction, is sufficient to develop stress concentra-
tions between the tooth and the framework with
subsequent loosening of the retainer(s). However, it
is still not clear how much this differential move m e n t
of the abutment teeth in relation to occlusal loads
c o n t ri butes to the debonding of fixe d - f i xed designs. O n
the other hand, the inherent shock absorber function
of the periodontal apparatus may counteract occlusal
forces on the bridgework in the cantilever group, as
the bridge can move together with the abutment
tooth in the same direction and magnitude upon
occlusal function.As a result, stress concentration at
the cement-metal interface may be reduced.
There are other advantages of using the cantilever
d e s i g n . The fixe d - f i xed design demands more accuracy
in impression taking, fitting the bridge and occlusal
adjustment, especially in cases of mobile or crowded
abutment(s).By contrast, the cantilever design is less
demanding technically to prepare as, in general, only
one tooth is involved.The path of bridge insertion is
also not so critical with the cantilever design (Fig.3).
In addition, there are also situations where only one
suitable abutment tooth is present. The major
advantage of the cantilever design is that the bridge
will dislodge if it debonds, which is not always the
case with fixe d - f i xed designs and, t h e r e f o r e ,e x t e n s i ve
caries can be prevented from developing under a
debonded resin-bonded retainer. F u rt h e rm o r e ,
postal or telephone contacts can be used to assess
the retention status of a cantilever bridge if the
p atient cannot attend the subsequent review
appointment. Finally, plaque control for a cantilever
bridge is easier than for a conventional bridge as
ordinary dental floss can be used without special
plaque control aids such as floss threaders.
In areas where the public water supplies are
fluoridated, as in Hong Kong, caries experience is
low in the younger population. As a result, patients
apprehensive of dental procedures, with missing
anterior teeth, sound aesthetic abutments, large
pulps and short clinical crowns can present a difficult
restorative problem. It is unclear what effect the
destructive procedures of full-crown preparation has
on the long-term viability of the pulp. H owe ve r ,
full-crown preparations are known to be associated
with increased risk of failure compared with less
d e s t ru c t i ve options, p a rticularly in the yo u n g
patients.
7,21
This is unfortunate, since pulpal vitality
is an important factor in the long-term success of a
restoration.
22,23
For this reason, it is advantageous to
avoid any irr e ve rsible damage to the teeth. R e m ova b l e
partial dentures have been a recommended solution
in the past with a reluctant acceptance of their
effect on soft tissue health. Implants are another
option. However, a simple and relatively inexpensive
t e c h n i q u e , such as resin-bonded bridges that combine
restoration of arch integrity and improvement of
appearance with minimal tooth preparation or
extensive soft tissue coverage, is a valid alternative.
Although the dental literature suggests that resin-
bonded bridges are less successful when compared
with conventional bridges,
9
the absence of extensive
tooth preparation maintains a relat i vely intact
tooth which can be preserved until better bonding
techniques are developed. Every effort to maintain
this conservative trend of minimal tooth preparation
must be encouraged, which is shown especially
with cantilever designs. H owe ve r , p atients who
34 Australian Dental Journal 2000;45:1.
Fig.2. An incisal hook was incorporated to assist the sitting of the
bridge. It was removed at a later stage.
Australian Dental Journal 2000;45:1. 35
receive fixed-fixed resin-bonded bridges should be
urged to seek an early appointment with their dental
practitioner if they notice any changes which may
indicate failure of the bridge. Regular recalls are
mandatory to detect unnoticed partial debonding, to
avoid the development of extensive caries under a
debonded retainer (Fig. 4).
While retention was the only criterion used for
clinical success in the present study, in no instances
were there any technical problems such as fractured
prostheses, or any periodontal problems around the
resin-bonded bri d g e s. C o rrectly formed pontics
and the routine supragingival placement of the
retainer margins were most likely responsible for the
good gingival health. There was no obvious tooth
m ovement or drifting noticed in the cantileve r
group.
The major complication with the resin-bonded
bridges placed in the anterior region was the metal
f r a m e work showing through thin or translucent
anterior teeth, giving the teeth a grey appearance.
This problem was alleviated to a certain extent by
using an opaque resin cement and ending the incisal
margin of the preparation 1 mm short of the incisal
edge. Cantilever resin-bonded bridges can replace
missing teeth over a short span only: the longer the
span, then the greater the rotational and torquing
effects on the retainers , and overloading will probably
result in fa i l u r e . A sound abutment tooth with
adequate support is required and the occlusion must
be favourable. Aesthetic possibilities may be limited
when the edentulous space is wider than the tooth to
be replaced, but which can be corrected by resizing
the adjacent abutments with the retainers used in
c o nventional bridge designs. Difficulties may also
be encountered when handling cantilever bridges at
the try-in and cementation stages, and the incisal
hook is helpful in this regard (Fig. 2).While a fixed-
fixed bridge can act as an orthodontic retainer, a
cantilever bridge is less predictable in this respect,
especially in situations where post-ort h o d o n t i c
stability is not certain.
Conclusion
This report presented the initial findings of a long-
term prospective clinical study of anterior cantilever
resin-bonded bri d g e s. The resin-bonded bri d g e s
were in service for 14 to 45 months with a mean
length of clinical service of 34 months.
The initial findings suggest that with proper
patient selection and a well-fitting and retentive
framework, the resin-bonded bridge is a conservative
alternative to the traditional fixed prosthesis and it is
eminently suited to the young and apprehensive
patient.
Although the small sample size, with only one
failure, did not make the comparative assessment of
the performance of the two resin-bonded designs
conclusive, the results suggest that the cantilever
design seems to work as well as the fixed-fixed type,
and should be used where possible for an anterior
single pontic resin-bonded bridge.
There is a need for further prospective studies to
observe the performance of cantilever resin-bonded
b ridges over the long term , and to compare this
performance against other bridge designs, both in
the anterior and posterior regions.
Acknowledgements
The authors would like to express appreciation for
the technical support provided by Miss S. C. Wong,
Dental Technician, Dental Technology, The Prince
Philip Dental Hospital, Hong Kong.
Fig.3. Palatal view of a cantilever resin bonded bridge. Note that the anterior crowding created a situation with critical path of insertion.
Fig. 4. Extensive caries developed under a debonded retainer.
3 4
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Address for correspondence/reprints:
Dr Alex W. K. Chan,
Clinical Assistant Professor,
Conservative Dentistry,
Faculty of Dentistry,
The University of Hong Kong,
The Prince Philip Dental Hospital,
34 Hospital Road,
Hong Kong.
36 Australian Dental Journal 2000;45:1.