Jose Zurdo
Cristina Romao
Jan L. Wennstrom
Authors affiliations:
Jose Zurdo, Cristina Romao, Institute for
Postgraduate Dental Education, University of
Central Lancashire, UK
Jan L. Wennstrom, Department of Periodontology,
Institute of Odontology, The Sahlgrenska Academy
at University of Gothenburg, Sweden
Correspondence to:
Jose Zurdo
Institute for Postgraduate Dental Education
Greenbank Building, Room 304
University of Central Lancashire
Preston PR1 2HE
UK
Tel.: 44 116 270 87 52
Fax: 44 116 270 0664
e-mail: jose.zurdo@btopenworld.com
Conflicts of interest:
The authors declare no conflicts of interest.
Date:
Accepted 20 May 2009
To cite this article:
Zurdo J, Romao C, Wennstrom JL. Survival and
complication rates of implant-supported fixed partial
dentures with cantilevers: a systematic review.
Clin. Oral Impl. Res. 20 (Suppl. 4), 2009; 5966.
doi: 10.1111/j.1600-0501.2009.01773.x
c 2009 John Wiley & Sons A/S
 59
Survival and complication rates of
implant-supported fixed partial dentures
with cantilevers: a systematic review
Key words: cantilever extensions, complications, fixed partial dental prosthesis, implant-
supported, survival, systematic review
Abstract
Objective: The objective of the present systematic review was to analyze the potential
effect of incorporation of cantilever extensions on the survival rate of implant-supported
fixed partial dental prostheses (FPDPs) and the incidence of technical and biological
complications, as reported in longitudinal studies with at least 5 years of follow-up.
Methods: A MEDLINE search was conducted up to and including November 2008 for
longitudinal studies with a mean follow-up period of at least 5 years. Two reviewers
performed screening and data abstraction independently. Prosthesis-based data on survival/
failure rate, technical complications (prosthesis-related problems, implant loss) and
biological complications (marginal bone loss) were analyzed.
Results: The search provided 103 titles with abstract. Full-text analysis was performed of 12
articles, out of which three were finally included. Two of the studies had a prospective or
retrospective casecontrol design, whereas the third was a prospective cohort study. The 5-
year survival rate of cantilever FPDPs varied between 89.9% and 92.7% (weighted mean
91.9%), with implant fracture as the main cause for failures. The corresponding survival rate
for FPDPs without cantilever extensions was 96.396.2% (weighted mean 95.8%).
Technical complications related to the supra-constructions in the three included studies
were reported to occur at a frequency of 1326% (weighted mean 20.3%) for cantilever
FPDPs compared with 012% (9.7%) for non-cantilever FPDPs. The most common
complications were minor porcelain fractures and bridge-screw loosening.
For cantilever FPDPs, the 5-year event-free survival rate varied between 66.7% and 79.2%
(weighted mean 71.7%) and between 83.1% and 96.3% (weighted mean 85.9%) for non-
cantilever FPDPs.
No statistically significant differences were reported with regard to peri-implant bone-level
change between the two prosthetic groups, either at the prosthesis or at the implant level.
Conclusion: Data on implant-supported FPDPs with cantilever extensions are limited and
therefore survival and complication rates should be interpreted with caution. The
incorporation of cantilevers into implant-borne prostheses may be associated with a higher
incidence of minor technical complications.
The selection of prosthetic options to re- option in situations where local condi-
place missing teeth should be based on tions of the residual edentulous ridge pre-
scientific evidence. The incorporation of clude the possibility to place an implant.
cantilever extensions into implant-borne However, it has been claimed that cantile-
reconstructions may be considered as an ver extensions increase the risk of bending
Zurdo et al  Survival and complication rates of implant-supported fixed partial dentures with cantilevers
overload and that this in turn may com-
promise the prognosis of the prosthetic
rehabilitation (Rangert et al. 1995). In a
series of recent systematic reviews, the
information available in the literature on
the success/survival rates and the inci-
dence of biological and technical complica-
tions of different designs of tooth and
implant-supported fixed prosthesis was
summarized (Lang et al. 2004; Pjetursson
et al. 2004a, 2004b, 2007; Tan et al. 2004;
Jung et al. 2008; Pjetursson & Lang 2008).
These reviews revealed that the incidence
of technical complications was signifi-
cantly higher for implant-supported than
for tooth-supported prostheses. For tooth-
supported prostheses, technical complica-
tions were found to be more frequent for
cantilever than for end-abutment pros-
theses. However, the extent to which can-
tilevers may affect the survival and
complication rates of implant-supported
fixed dental prostheses (FDPs) was not
analyzed in these reviews.
Long-term clinical studies have demon-
strated that implant-supported full-arch re-
constructions with bilateral cantilevers in
the mandible exhibited high survival rates
(Adell et al. 1981, 1990; Albrektsson et al.
1988). However, it has been suggested that
certain cantilever lengths may decrease the
survival of the prostheses (Shackleton et al.
1994). There are inherent biomechanical
differences in the implant treatment of
completely edentulous arches and posterior
partially edentulous segments, as the par-
tial prosthesis does not benefit from cross-
arch stabilization and, therefore, is more
susceptible to bending loads (Rangert et al.
1997).
In vitro studies revealed that implant-
supported cantilever prostheses lead to a
high stress concentration at the marginal
bone level of the implants, particularly at
the implant closest to the cantilever exten-
sion (Sertgoz & Guvener 1996; Stegaroiu et
al. 1998; Zampelis et al. 2007), which was
considered to pose a risk for marginal bone
loss at the implants. On the other hand,
experimental studies in the dog model
showed that excessive static loading of
implants did not result in marginal bone
loss or loss of osseointegration, but that the
bone tissue adjacent to the loaded implants
exhibited a greater density compared with
unloaded implants (Gotfredsen et al.
2001a, 2001b). Implant loss as a result of
60 | Clin. Oral Impl. Res. 20 (Suppl. 4), 2009 / 5966
excessive occlusal load in a lateral direction
was demonstrated in experimental studies
in a monkey model (Isidor 1996, 1997),
suggesting that it is possible to induce loss
of osseointegration to the implant, but not
marginal bone loss, when forces are beyond
the repair potential of the bone. However,
in humans, the biological impact of exces-
sive load remains unclear.
The focus question for the current sys-
tematic review was To what extent do
cantilevers affect survival and complica-
tions of implant-borne reconstructions in
the partially dentate patient. Hence, the
aims defined were to analyze the potential
effect of the incorporation of cantilever
extensions on (i) the survival (or failure)
rate of implant-supported fixed partial
dental prostheses (FPDPs) and (ii) the in-
cidence of technical and biological compli-
cations, as reported in longitudinal studies
with at least 5 years of follow-up.
Materials and methods
Search strategy
A protocol to be followed was agreed upon
by the authors before the initiation of the
literature search. Anticipating very few, if
any, randomized clinical trials (RCT) re-
lated to the focused topic, the decision was
taken to use a broad search strategy.
An initial electronic search on MED-
LINE (PubMed) from 1966 up to and
including November 2008 was conducted
for English-language articles published in
the dental literature, using the keywords
dental implants AND cantilever(s). The
search yielded 103 references to be
screened for possible inclusion based on
titles and abstracts.
Inclusion criteria
Systematic reviews and longitudinal pro-
spective/retrospective studies (RCT, con-
trolled clinical trials and cohort studies)
reporting data with regard to the outcome
of treatment with implant-supported
FPDPs with cantilever extensions after a
mean function time of at least 5 years were
accepted for inclusion. The selection of a
function time of at least 5 years was based
on the consensus from a previous work-
shop regarding the recommended follow-up
time for evaluation of implant therapy
(Wennstrom & Palmer 1999). Further, the
studies should include prosthesis-based
data on success, survival or loss rate, tech-
nical complications (prosthesis-related pro-
blems, implant loss) and/or biological
complications (marginal bone loss).
Exclusion criteria
Letters, experimental studies and narrative
reviews were explicitly excluded. Studies
with o10 patients examined at the end of
follow-up, and studies focusing on over-
dentures were also excluded. Studies from
which data on selected outcome variables
could not be directly retrieved or calculated
were not considered.
Selection of studies
Two independent reviewers (JZ and CR)
screened the 103 abstracts retrieved from
the electronic search for possible inclusion
in the review. Ten abstracts were accepted
for inclusion by both reviewers, and further
three by just one reviewer. After discussion,
a consensus was reached to include one of
the latter publications and reject the other
two articles. The Kappa score for agree-
ment between the reviewers for screening
of abstracts was 0.85 (Fig. 1). Full-text
articles were obtained of the 11 selected
publications. In addition, hand searches
were performed on bibliographies of the
selected articles as well as of identified
narrative reviews. Four publications were
found that reported data on subject samples
that were included in the already identified
studies. Such repeated reports were grouped
together. One further article was identified
for inclusion after the hand search.
The two reviewers independently assessed
the 12 full-text articles to determine whether
they fulfilled the defined criteria for final
inclusion. Any disagreement was resolved
by discussion. Three studies were found to
qualify for inclusion in the review, while
nine studies had to be excluded (Fig. 1).
Excluded studies
Out of the nine studies that were excluded
following full-text analysis, seven had a
mean follow-up less than 5 years, includ-
ing two studies focusing on complete
FDPs, and in further two studies selected
outcomes could not be retrieved (Table 1).
Data extraction
Data were extracted independently by the
two reviewers using a data extraction form
c 2009 John Wiley & Sons A/S

 Zurdo et al  Survival and complication rates of implant-supported fixed partial dentures with cantilevers

(mm or crown units); implant system

Initial electronic search
used, number and length of implants
103 titles/abstracts
involved in the FPDPs; and type of
antagonist dentition.
 Technical complications were divided
Independent screening by 2 reviewers
into three categories:

i. Lost reconstructions i.e. reconstruc-

Kappa score 0.85
tions not in situ at the follow-up
examination.
10 abstracts agreed by both reviewers
ii. Lost implants (including reasons for
the loss).
3 to discuss:
iii. Complications related to the supras-
1 abstract included,
2 rejected tructure fractures or deformations of
the framework or veneers, loss of reten-
11 abstracts selected for full-text review tion and screw or abutment loosening.

Further hand-searching;  Biological complications marginal

1 article included for bone loss at the FDP level and at the
full-text review (*)
implant next to the cantilever, respec-
tively.
12 selected for full-text review
Studies in which data on a certain vari-
able were lacking or could not be calculated
Excluded 9 articles were scored as not reported for the vari-
able in question. Weighted mean values
and the 95% confidence interval (CI) for
3 studies included in review
the various outcomes were calculated.

(*) Five further publications related to 5 of the originally selected

were also included to retrieve further data, but were not counted Results
towards the final number of included papers as they reported
on the same patient material. The literature search confirmed the inex-
Fig. 1. Process of identifying the studies included in the review, from an initial 103 titles/abstracts. istence of publications on RCT comparing
the outcomes of implant-supported FPDPs
with and without cantilever extensions.
Table 1. Excluded articles (cohort studies) after full-text examination and reasons for
exclusion Characteristics of the included studies
Reference Reason for exclusion (Table 2)
The study characteristics of the three pub-
Blanes et al. (2007) Implant-based data analysis
Information regarding number of prosthesis with lications that qualified for inclusion
cantilever extensions, prostheses survival and/or (Wennstrom et al. 2004; Kreissl et al.
complications not available 2007; Halg et al. 2008) are presented in
Nedir et al. (2006) Mean follow-up o5 years
Tawil et al. (2006) Mean follow-up o5 years, selected outcomes
Table 2. Two of the studies had a prospec-
not retrievable tive or a retrospective casecontrol design,
Becker (2004) Mean follow-up o5 years whereas the third was a prospective cohort
Romeo et al. (2003) Mean follow-up o5 years study. In one study (Wennstrom et al. 2004)
Johansson & Ekfeldt (2003) Mean follow-up o5 years
Kucey (1997) Mean follow-up o5 years, cantilevered bridges all included patients had a 5-year follow-up,
were all fixed whereas in the other two studies the follow-
complete dental prosthesis (FCDP) up time among the patients ranged between
Ranger et al. (1995) Cross-sectional study design
0 and 12.7 years, with a reported mean
Shackleton et al. (1994) Mean follow-up o5 years, focus on FCDP
follow-up time of 55.3 years.
The implant systems used in the studies
were ITI (Straumann AG, Waldenburg,
previously agreed upon. Disagreement re-  Number of subjects included at base- Switzerland, one study), Astra (Astra
garding data extraction was resolved by line and at the follow-up examination; Tech AB, Molndal, Sweden, one study)
discussion and consensus. The following number and characteristics of the and 3i (Implant Innovation Inc., West
variables were recorded: FPDPs; extension of cantilever segment Palm Beach, FL, USA, one study).

c 2009 John Wiley & Sons A/S

 61 | Clin. Oral Impl. Res. 20 (Suppl. 4), 2009 / 5966
Zurdo et al  Survival and complication rates of implant-supported fixed partial dentures with cantilevers

Table 2. Characteristics of the included studies

Reference Type of Number of Implant Follow-up Number of Mean Cantilever Type of Comments
study patients system period reconstructions number of extension antagonists
in years implants
(range) in prosthesis
Mean length
of implants
(range)
Casecontrol studies
Halg et al. Retrospective 54 ITI Mean 5.3 Cant: 27 Cant: 1.7 1 crown Teeth or Cant: 8
(2008) years Non-C: 27 Non-C: 1.2 unit FPDPs of 27 patients
(312.7) 10.1 mm (26 prostheses) on teeth with single
(612) 2 crown units implant
(1 prosthesis) Non-C: 22
of 27
patients
with single
implant
Wennstrom Prospective 45 Astra 5 years Cant: 24 Cant: 2.6 Mean 9 mm Teeth or
et al. (2004) Tech Non-C: 26 Non-C: 2.8 FPDPs
12.7 mm on teeth
(819 mm) except 1
(implant-
supported
FPDP)
Cohort studies
Kreissl et al. Prospective 76 3i Mean 5 Cant: 23 Cant: 2.7 NR NR Non-C: 46 of
(2007) years Non-C: 89 Non-C: 1.6 89 patients
(080 NR with single
months) implant

NR, not reported; Cant, cantilever FPDP; Non-C, non-cantilever FPDP; FPDP, fixed partial dental prostheses.

The total number of prostheses included
in the three studies was 216 (74 with and
142 without cantilever extensions), with
the number of cantilever prostheses vary-
ing between 23 and 27 among the studies.
The mean number of implants supporting
the prostheses ranged between 1.7 and 2.7
for cantilever FPDPs and between 1.2 and
2.8 for non-cantilever FPDPs. In the study
by Halg et al. (2008), eight (30%) of the 27
included cases in the cantilever FPDP
group had only one implant supporting
the cantilever reconstruction. Two of the
studies (Kreissl et al. 2007; Halg et al.
2008) included a large proportion of sin-
gle-implant restorations in the non-canti-
lever group, 52% and 81%, respectively.
Data on the mean length of implants
and cantilever extensions were available
in two studies (Wennstrom et al. 2004;
Halg et al. 2008). The mean overall length
of the implants varied between 10.1 and
12.7 mm, while the length of the cantilever
extension was described as crown units in
one study (one unit in all but one FPDP) or
as a mean length in millimeters in the
other (9 mm). The two casecontrol stu-
dies also provided information regarding
the type of antagonist dentition, which,
in all cases but one (implant supported
FPDP), was natural teeth or tooth-sup-
ported FPDPs.
Loss of prostheses and implants (Table 3)
Information regarding failure (loss) rates for
prostheses with and without cantilevers
could be retrieved from all three included
studies. The loss of cantilever prostheses
ranged between 4.3% and 11.1% (weighted
mean 8.1%, 95% CI 4.212) compared
with 3.74.5% (4.2%, 95% CI 3.74.7)
for FPDPs without cantilevers. Hence, the
calculated weighted mean 5-year survival
rate was 91.9% (95% CI 8895.8) for
cantilever FPDPs and 95.8% (95% CI
95.396.3) for FPDPs without cantilevers.
The reasons for loss of the prostheses in the
cantilever groups in the two casecontrol
studies (Wennstrom et al. 2004; Halg et al.
2008) were reported to be fracture of an
implant (three cases) and need for remaking
the supra-construction (one case), while
the two events in the non-cantilever groups
were due to implant fracture. In the cohort
study (Kreissl et al. 2007) biological com-
plications were indicated as the reason for
the loss of prostheses (one cantilever and
four non-cantilever prostheses).
Implant loss during the 5-year function
period was reported in all three studies. In
each of the two casecontrol studies the
implant loss was two (3.2%/4.3%) for the
cantilever group and one (1.4%/3.1%) for
the non-cantilever group, all due to frac-
tures. The corresponding figures for the
cantilever and non-cantilever FDP groups
in the cohort study (Kreissl et al. 2007)
were one (1.6%) and four (2.8%), respec-
tively, and all were reported to have been
lost as a consequence of biological compli-
cations. The weighted mean 5-year rate of
implant loss was 2.9% (95% CI 1.44.5)
for cantilever FPDPs compared with 2.4%
(95% CI 1.43.5) for non-cantilever FPDPs.
Technical complications supra-constructions
Technical complications related to the su-
pra-constructions in the three included
studies were reported to occur at a frequency
of 1326% (weighted mean 21.6%, 95% CI
11.931.2) for cantilever-FPDPs compared
with 012% (10.3%, 95% CI 2.118.5) for
non-cantilever FPDPs. The most common
complications were minor porcelain frac-
tures and bridge-screw loosening. Wenn-
strom et al. (2004) reported a total of six
incidences (three bridge-screw loosening

62 | Clin. Oral Impl. Res. 20 (Suppl. 4), 2009 / 5966 c 2009 John Wiley & Sons A/S

 Zurdo et al  Survival and complication rates of implant-supported fixed partial dentures with cantilevers

Table 3. Technical and biological complications implant-supported FPDPs

Reference Technical complications 5 years Biological complications 5 years Comments
Lost prostheses Lost implants Complications Marginal bone loss
n (%) n (%) supra- (mean mm)
construction
Prosthesis Implant
n (%)
next to
cantilever
Casecontrol studies
Halg et al. Cant: 3 Cant: 2 Cant: 6 Cant: 0.23 Cant: 0.23 The losses of prostheses were due to
(2008) (11.1%) (4.3%) (22%) Non-C: 0.09 Non-C: 0.05 implant fractures (2 Cant and 1 Non-
Non-C: 1 Non-C: 1 Non-C: 0 C) and need for remaking the
(3.7%) (3.1%) (0%) supraconstruction (1 Cant).
All lost implants were due to
fracture
No significant difference in bone
loss Cant vs. Non-C
33% smokers in Cant, 11% in Non-C
Baseline: prosthesis installation
Peri-implantitis affected 4 implants
(1 Cant vs. 3 Non-C)
Wennstrom Cant: 2 Cant: 2 Cant: 3 Cant: 0.49 Cant : 0.39 The losses of prostheses were due to
et al. (8.3%) (3.2%) (13%) Non-C: 0.38 Non-C: 0.23 implant fractures
(2004) Non-C: 1 Non-C: 1 Non-C: 3 All lost implants were due to
(3.8%) (1.4%) (12%) fracture
No significant difference in bone
loss Cant vs Non-C
42% smokers in Cant, 19% in Non-C
Baseline: prosthesis installation
Peri-implantitis NR
Cohort studies
Kreissl Cant: 1 Cant: 1 Cant: 6 NR NR All lost prostheses were due to
et al. (4.3%) (1.6%) (26%) implant loss
(2007) Non-C: 4 Non-C: 4 Non-C: 11 Reasons for loss of implants not
(4.5%) (2.8%) (12%) reported
% smokers not reported
No radiographic analysis
Peri-implantitis NR
Weighted Cant: 8.1% Cant: 2.9% Cant: 20.3% Cant: 0.35 Cant: 0.31 Event free survival rate:
mean (4.212) (1.44.5) (12.827.9) (0.10.6) (0.10.5) Cant: 71.7% (64.279.1)
(95% CI) Non-C: 4.2% Non-C: 2.4% Non-C: 9.7% Non-C: 0.23 Non-C: 0.14 Non-C: 85.9% (77.794.1)
(3.74.7) (1.43.5) (1.917.6) (  0.10.6) (00.3)

NR, not reported; Cant, cantilever FPDP; Non-C, non-cantilever FPDP; FPDP, fixed partial dental prostheses.

and three minor porcelain fractures), equally
distributed between the cantilever and the
non-cantilever FDP groups. Halg et al.
(2008) also reported six events, but all occur-
ring in the cantilever-FDP group (one supra-
structure fracture, four minor porcelain frac-
ture, and one re-cementation). Of a total of
17 complications described in the cohort
study by Kreissl et al. (2007), six belonged
to the cantilever group, corresponding to an
incidence rate of 26% as compared with
12% in the non-cantilever group.
Event-free survival rate
By taking all technical complications re-
ported under consideration, the event-free
survival rate over 5 years was calculated.
For cantilever FPDPs the event-free survi-
val rate was 66.7%79.2% in the various
studies (weighted mean 71.7%, 95% CI
64.279.1) and for non-cantilever it was
FPDPs 83.1%96.3% (weighted mean
85.9%, 95% CI 77.794.1).
Biological complications (Table 3)
Bone-level changes were assessed only in
the two casecontrol studies (Wennstrom
et al. 2004; Halg et al. 2008). In both
studies, the baseline radiograph was ob-
tained at prosthesis installation and assess-
ments of bone changes were performed at
the FDP, implant and site levels. As for the
standardization of the radiographic techni-
que, one study (Wennstrom et al. 2004)
reported the use of a custom-made stent to
optimize the reproducibility of projection
geometry, while the other study (Halg et al.
2008) used only a standardized parallel
long-cone technique.
The mean bone loss at the FDP level in
the cantilever and non-cantilever groups in
the two studies amounted to 0.23
0.49 mm (weighted mean 0.35 mm, 95%
CI 0.100.61) and 0.090.38 mm (weighted
mean 0.23 mm, 95% CI  0.05 to 0.52),
respectively. The magnitude of bone loss at
the implant closest to the cantilever exten-
sion (implant level) was 0.230.39 mm
(weighted mean 0.31 mm, 95% CI 0.15
0.46) compared with 0.050.23 mm
(weighted mean 0.14 mm, 95% CI  0.04
to 0.32) at the end implant or a randomized
selected implant in the control group.
Potential influence on peri-implant mar-
ginal bone loss of various confounding
factors was analyzed in the two studies
using multivariate regression analysis.
Jaw of treatment (maxilla), and in one of
the studies smoking habits (Wennstrom

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 63 | Clin. Oral Impl. Res. 20 (Suppl. 4), 2009 / 5966
Zurdo et al  Survival and complication rates of implant-supported fixed partial dentures with cantilevers

et al. 2004), was associated with a signifi-
cantly increased magnitude of marginal
bone loss. Type of FPDPs (with or without
cantilever extension) had no significant
effect on marginal bone loss.
Discussion
In the present systematic review, the in-
cidence of loss and technical and biological
complications of FDPs with cantilever ex-
tensions were described. To address the
focus question to what extent do cantile-
vers affect survival and complications of
implant borne reconstructions in partially
edentulous patients, the approach in the
search was to identify longitudinal studies,
prospective or retrospective, with at least
5 years of follow-up and reporting prosthe-
sis-based data. It is generally acknowledged
that longitudinal studies with a time span
of at least 5 years are required to properly
evaluate the outcome of implant treatment
(Wennstrom & Palmer 1999; Berglundh
et al. 2002; Pjetursson et al. 2004a).
Although we accepted for inclusion studies
that presented data for a cohort with a
mean follow-up of 5 years, only three
studies qualified for inclusion. In a pre-
vious systematic review on implant ther-
apy (Berglundh et al. 2002), it was
suggested to exclude studies in which
o80% of the initial subject sample had
been followed for 5 years. If this criterion
had been applied, only one study (Wenn-
strom et al. 2004) would qualify for inclu-
sion since in the other two studies (Kreissl
et al. 2007; Halg et al. 2008) only 4665%
of the implant constructions were observed
for a period of 5 years. However, because of
the scarcity of identified studies addressing
the issue of cantilever extensions, we
decided to retain these studies.
Based on the three studies included in
the current review, the calculated overall 5-
year prosthesis survival rate was 92% for
cantilever FPDPs, compared with 96% for
non-cantilever FPDPs. Although these fig-
ures may indicate a somewhat inferior
performance for the cantilever prostheses,
the results should be interpreted with cau-
tion because the sample size is small. The
overall prosthesis survival rate in the in-
cluded studies was comparable with the
results of a previous systematic review on
implant-supported FDPs (Pjetursson et al.
2004a), in which a meta-analysis including
14 studies yielded an overall estimated
survival rate of 95% (95% CI 92.296.8)
after 5 years.
The event-free survival rate, i.e. the
proportion of reconstructions that re-
mained in function after 5 years without
any technical complications, was esti-
mated to be 72% for FPDPs with cantilever
extension and 86% for FPDPs without
cantilevers. However, the comparison
with the available literature is difficult as
the way in which data are generated and
presented lacks uniformity. In a previous
systematic review on implant-supported
FDPs (Pjetursson et al. 2004a), including
three studies reporting on the incidence of
patients without any complication, the
estimated success rate after 5 years was
61.3% (95% CI 55.366.8). In another
systematic review (Berglundh et al. 2002),
the 5-year incidence of technical complica-
tions for implant-supported FDPs, calcu-
lated at the patient level, was reported to be
25%. Taken together, these data indicate
that technical complications are common
for implant-supported prostheses, both
with and without cantilever extensions.
It has been suggested (Pjetursson et al.
2004a) that technical complications should
be divided into major (implant fracture,
loss of suprastructures), medium (abut-
ment, veneer or framework fracture) and
minor (abutment or screw loosening, loss
of retention, loss of veneer hole sealing,
veneer chipping fracture), and that the type
and number of events should be reported
separately. Implant fractures were in the
two casecontrol studies reported to vary
between 1.4% and 4.3% across the treat-
ment groups. Comparable data reported in
the systematic review by Pjetursson et al.
(2004a, 2004b) on implant-supported
FPDPs in general revealed a cumulative
incidence of 0.4%. The fact that the four
implants that fractured in the cantilever
groups of the two casecontrol studies in-
cluded in the current systematic review
had a narrow diameter (3.33.5 mm) sug-
gests that other factors in addition to the
cantilever extension should be considered
when evaluating the mechanical risks of a
specific prosthetic design. The study by
Halg et al. (2007) had a skewed distribution
in the proportion of narrow implants be-
tween the treatment groups: 39% and 7%
for the cantilever and non-cantilever
groups: respectively. In the other case
control study (Wennstrom et al. 2004),
one of the two implant fractures in the
cantilever group occurred in a patient who
was diagnosed as a bruxer. Furthermore, in
this study the mean height of the supra-
constructions was significantly greater in
the cantilever group than in the non-canti-
lever group, which could be regarded as yet
another potential prosthetic-related factor
that might contribute to the incidence of
technical complications. Nevertheless,
this study reported a low frequency of
technical complications (0.12 incidence/
patient) that were equally distributed
among the groups and comparable with
the calculated 5-year incidence/patient of
0.24 technical complications for FPDs re-
ported in a previous systematic review
(Berglundh et al. 2002).
Another prosthesis-related factor that
has been suggested to contribute to an
increase in the rate of technical complica-
tions is the type of antagonists (Davis et al.
2003). Further, it is well recognized that
loading may be significantly higher in
posterior segments as compared with ante-
rior regions (Rangert et al. 1995) and that
more prosthetic complications may occur
in the posterior regions (Nedir et al. 2006).
In the current review, two studies reported
information about implant position and
type of antagonists. Eighty-five percent to
100% of the FPDPs were placed in the
premolarmolar regions and all were func-
tioning against natural teeth or FPDPs
supported by teeth or implants.
The mean overall marginal bone-level
change after 5 years at the implant-sup-
ported FPDPs reported by two studies in-
cluded in this review was small and well
below the degree of bone loss acceptable
according to the success criteria described
by Albrektsson et al. (1986). Cantilever
extensions did not significantly influence
the bone changes. On the other hand,
factors such as jaw of treatment (maxilla)
and smoking habits appeared to be signifi-
cant for observed peri-implant marginal
bone loss. The presence of cantilever ex-
tensions and its effect on crestal bone loss
were also analyzed in a prospective study
with partially dentate patients who were
restored with FPDPs in the posterior region
(Blanes et al. 2007). Neither the presence of
a mesial nor a distal cantilever had a
significant effect on peri-implant bone

64 | Clin. Oral Impl. Res. 20 (Suppl. 4), 2009 / 5966 c 2009 John Wiley & Sons A/S


loss after an observation period of 6 years.
The biological plausibility that excessive
loading results in increased marginal bone
loss is controversial. Implant failure as a
result of excessive occlusal load in a lateral
direction was demonstrated in experimen-
tal studies in a monkey model (Isidor 1996,
1997), suggesting that it is possible to
induce loss of osseointegration when the
forces are beyond the repair potential of the
bone. However, under clinical conditions,
the biological impact and categorization of
excessive load remains unclear and its
translation into peri-implant marginal
bone loss has not been demonstrated.
Although early observations made in clin-
ical studies suggested an association be-
tween excessive loading and peri-implant
bone loss (Quirynen et al. 1992), bivariate
analyses should be interpreted with caution
because of potential skewed distribution of
confounding factors. Other factors such as
smoking (Lindquist et al. 1997) and max-
illa vs. mandible (Jemt & Lekholm, 1993)
have also been associated with peri-im-
plant bone loss. Both casecontrol studies
included in this systematic review used
multivariate models for analysis and found
cantilever extension to be a factor without
a significant effect on observed marginal
bone loss when the confounding factors
were controlled in the statistical model.
Several other variables related to the
FPDP configuration have been suggested
to influence its loading capacity, such as
the buccolingual occlusal extension of the
prostheses in addition to the above-men-
tioned height of the supra-construction and
the number, position and inclination of the
supporting implants (Rangert et al. 1997).
Also, implant designs and surface rough-
ness influence the boneimplant support
capacity. Hence, determining the potential
effect of one loading-associated factor on
peri-implant crestal bone loss is compli-
cated unless other variables are adequately
controlled in clinical trials.
References meeting the inclusion criteria of the systematic review
Halg, G.A., Schmid, J. & Hammerle, C.H. (2008)
Bone level changes at implants supporting crowns
or fixed partial dentures with or without cantilevers.
Clinical Oral Implants Research 19: 983990.
Kreissl, M.E., Gerds, T., Muche, R., Heydecke, G.
& Strub, J.R. (2007) Technical complications of
c 2009 John Wiley & Sons A/S
 65 |
Zurdo et al  Survival and complication rates of implant-supported fixed partial dentures with cantilevers
Peri-implantitis is an important biologi-
cal complication resulting in bone loss but
was not considered as an outcome in the
current review because of the lack of a
plausible biological relationship with the
presence/absence of cantilever extension.
Information regarding the condition of the
peri-implant tissues in clinical studies re-
lated to dental implants is scarce (Ber-
glundh et al. 2002). The incidence of peri-
implantitis was reported in one study in-
cluded in the current review (Halg et al.
2008); 5.1% of the prostheses were af-
fected. The cumulative incidence of peri-
implantitis and soft tissue complications
for FPDPs after 5 years was estimated to be
8.6% in a previous systematic review (Pje-
tursson et al. 2004a, 2004b). A more recent
systematic review (Zitzmann & Berglundh
2008) described alarmingly higher figures.
They retrieved data from two study sam-
ples and peri-implantitis was found in
these studies in 28% and  56% of the
subjects.
In the current review, only three studies
were included and only one study pre-
sented data with 480% of the patients
followed for 5 years. Of the excluded stu-
dies not fulfilling the criterion of a mini-
mum mean follow-up of 5 years, high
short-term survival rates (95.6100%)
were reported in three longitudinal studies
with a mean follow-up time ranging be-
tween 3.9 and 4.5 years (Johansson &
Ekfeldt 2003; Romeo et al. 2003; Becker
2004). In another excluded study (Nedir et
al. 2006), comparative data of the prosthe-
tic complications associated with different
implant prosthetic designs were presented.
After a mean follow-up of 3.3 years (44%
of the patients followed for 5 years), the
complication rate for FPDPs (the majority
placed in the posterior regions) was 29.4%
for the cantilever and 7.9% for non-canti-
lever prostheses.
It is obvious from this systematic review
that there is a need for additional prospec-
implant-supported fixed partial dentures in par-
tially edentulous cases after an average observa-
tion period of 5 years. Clinical Oral Implants
Research 18: 720726.
Wennstrom, J., Zurdo, J., Karlsson, S., Ekestubbe,
A., Grondahl, K. & Lindhe, J. (2004) Bone level
tive controlled clinical studies with at least
5 years of follow-up to properly determine
to what extent cantilever extensions may
affect the survival and complications of
implantborne reconstructions.
Conclusions
Within the limitations of the current review,
the following conclusions can be made:
 The 5-year survival rate was high for
both cantilever and non-cantilever
FPDPs (91.9% vs. 95.8%).
 The most common reason for loss of
FPDPs with cantilever extensions was
implant fracture.
 The incorporation of cantilevers into
implant-borne prostheses was asso-
ciated with a higher incidence of tech-
nical complications related to the
supra-constructions (20.3% vs. 9.7%
for non-cantilever FPDPs). Minor por-
celain fractures and bridge-screw loos-
ening were the most common technical
complications.
 For cantilever FPDPs the 5-year event-
free survival rate was 71.7% compared
with 85.9% for non-cantilever FPDPs.
 The incorporation of cantilevers into
implant-borne prostheses did not have
any significant effect on the amount of
peri-implant marginal bone loss, either
at the prosthesis level or at the implant
next to the cantilever.
Clinical implications
An implant-supported FPDP with a short
cantilever extension (one tooth unit) is an
acceptable restorative therapy, and might be
considered as an alternative to procedures
that require more advanced surgery (e.g.
sinus graft, etc.) or for esthetic reasons.
change at implant-supported fixed partial dentures
with and without cantilever extension after 5
years in function. Journal of Clinical Perio-
dontology 31: 10771083.
Clin. Oral Impl. Res. 20 (Suppl. 4), 2009 / 5966
Zurdo et al  Survival and complication rates of implant-supported fixed partial dentures with cantilevers
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