Prosthodontics

Design principles for cantiievered resin-bonded

fixed partial dentures
Michael Botelho, BDS, MSc, MRD
Recent ciinicai studies show 2-unit cantiievered resin-bonded lixed partial dentures to be as retenuve ot
more retentive than their lixed-fixed counterparts. The fact that the 2-unit prosthesis is successful adds
value to the ciinicai use ol resin-bonded fixed partial dentures because the single-abutment prosthesis
is even simpler and more cost effective than fixed-fixed designs. However, there is no evidence-based
information relating to design principies tor abutment preparation and framework design tor the single-
abutment, singie-retainer prosthesis. The aim of this report is to suggest principies of design for the 2-unit
cantiievered fixed partiai denture, based on information gained from studies on fixed-fixed designs.
(Quintessence internationai 2000:31:613-619)
Key words: abutment, oantilevered, fixed partial dentures, fixed-fixed design, resin-bonded
E
vidence-based information continues to support the
clinical appropriateness of resin-bonded fixed par-
tial dentures (RBFPD) with recent clinical studies
showing improved retention rates over earlier studies.'-'
It is noteworthy that clinical studies show 2-unit can-
tiievered RBFPDs to be as successful, if not more suc-
cessful, than their fixed-fixed counterparts."*-^ However,
the use of cantiievered prostheses is contrary to estab-
lished recommendations in prosthodontic textboolis,"^
clinical papers,^'" and evidence-based information."
There are only a handful of reports relating to can-
tiievered RBFPDs and fewer stili that mention design
principles of tooth preparation and framework design
for these prostheses. The aim of this report is to sug-
gest design principles for tooth preparation and frame-
work designs for 2-unit cantiievered RBFPDs. These
design principles are extrapolated from in vitro and in
vivo research on fixed-fixed RBFPDs.
ADVANTAGES OF SINGLE-ABUTMENT,
SINGLE-RETAINER RBFPDs
If 2-unit cantiievered and 3-unit fixed-fixed RBFPDs
showed identical retention rates, the cantiievered
prosthesis would be the preferred restorative option
based on fundamental clinical advantages. The 2-unit
Assistart Professor, Discipline of Orai Rehabilitation, Uniuersity ol Hong
Kong. Prince PhJiip Denial Hospital, University of Hong Kong, Hong Kong.
Reprint requests: Dr Mioliaei Boielho, Discipline of Orai Rehabiiitation,
University o Hong Kong, Prince Phiiip Dentai Hospital, 34 Hospitai Road,
Hong Kong. E-maii: boteltio@tii(usua,liku.hk
RBFPD is not only more conservative to tooth tissue
than its fixed-fixed counterparts, but is quicker to pre-
pare, easier to record an impression for, and simpler
to cement {Fig 1). These factors along with lower labo-
ratory costs should make the treatment item a more
affordable restorative treatment option for patients
seeking dental care. Also, 2-unit canfilevered designs
do not have the troublesome possibility of carles
under a partially debonded retainer, as may occur with
fixed-fixed RBFPDs; a debonded cantiievered RBFPD
will simply fall out. and the pafient will return for pos-
sible recementation.
CLINICAL STUDIES ON CANTILEVERED RBFPDs
Three of the earliest reports describing cantiievered
RBFPD's longevity were from the United Kingdom
and were part of larger studies investigating tbe ciini-
cai performance of RBBs provided in dental
schools'^"''' (Table 1). Wben combined, tbese studies
investigated 919 RBBs, of wbich 160 were can-
tiievered RBFPDs, and, in all 3, cantiievered RBFPDs
were more retentive tban their fixed-fixed counter-
parts {Table 1), In a later study, Brabant^ also showed
cantiievered designs to be more successful tban fixed-
fixed designs; bowever, the mean service life and
actual number of cantiievered RBFPDs placed was
not stated {Table 1).
Hussey and Linden'' were the first to exclusively
examine the ciinicai performance of cantiievered
RBFPDs. They analyzed data from 142 RBFPDs and
showed a 78% retention rate witb a total mean life of
36.8 montbs. The results showed that ali of the 17
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613
Boteiho
Fig 1 Caritiievered prosthesis stiowing an improved geometric
canfiguiation to the retainer to increase ngidity in comparison to
ttie iraditionai C-shaped retainer. An ocolusai bar is extended
between the retainer ends to form a more rigid D-shaped retainer.
Fig 2 This 3-unit fixed-fixed RBFPD inas partiaiiy debonded on
tiie canine abutment. Note the occiusal contact marks seen on the
wear facet of ttiis abutment in laterai excursion. The bebond is
most iiisely due to the dynamic occiusai contacts on the tooth,
forcing it away from the fixed retainer and the poorer resislance
form ot this abutment, in comparison (o (he premoiar.
TABLE 1 Clinical results from reports investigating cantilevered resin-bonded fixed partial dentures
No. of RBFPDs
Hussey et al.
1991'^
400
No, ot cantilevered HBFPDs 70
Mean service iite
Retention rate of
cantilevered RBBs
32.4 mo
8 3%
Dunne/Miliar
1993'3
382
47
101 mo
79 %
Gilmour/Ali.
1995'-'
137
43
24.5 mo
72%
Brabant,
1997
838
12.1%
1984-1994
9 7%
Hussey/Linaen,
1996"
142
142
36 mo
88%
Briggs et al.
1996=
54
54
27 mo
80%
3oteiho et ai.
2000'5
33
33
30 mo
97%
debonds occurred in the maxillary arch with 11 of the
failures occurring when the central incisors or canines
were replaced. The cause of the higher risk of failure
of these prostheses was attributed to the smaller sur-
face area available for bonding when a lateral incisor
was used as an abutment and to the higher occlusal
forces applied to canine teeth.
Briggs et ai"' reported 11 debonds out of 54 can-
tilevered RBFPDs with an average service life of 26.7
months. Ten of the 11 cantilevered RBFPDs debonded
in the maxilla. In this study, debonded fixed partial
dentures appeared to remain successful atter rccemen-
tation, and no RBB debonded more than once.
In a more recent review, Boteiho et al'^ reported
only 1 debond out of 33 cantilevered RBFPDs, giving a
96% success rate with a mean service life of 30 months.
It was also reported that none of the prostheses was
observed to have tipped or drifted, despite 7 can-
tilevered prostheses judged as having greater than 50%
bone loss. All of these reports, however, describe short-
term results, and further investigations are required to
assess their long-term use and clinical success.
The clinical success of cantilevered RBFPDs is
claimed to be based on the independent free-standing
nature of the prosthesis rather than on any modifica-
tion in tooth preparation or framework design. This
design is thought to eliminate adverse interabutment
stresses on the cement bond during function.''^'^
Occlusal contacts on tootb tissue rather than on the
retainer framework have been reported fo contribute
to debonding of fixed-fixed RBFPDs (Fig 2)."-ie
Because of the freestanding nature of cantilevered
FPDs, such adverse occlusal contacts are not possible.
In ciinical studies on cantilevered RBFPDs, tooth
preparation appeared to vary considerably, with only
3 reports briefly describing tooth preparations,
Hussey and Linden'' performed simple tooth prepara-
tion with intraenamel preparation allowing wrap-
around and cingulum rests. It was not known if the
11 posterior cantilevered RBFPDs were placed with
the use o occlusal rests. Briggs et al' described mini-
mal preparations with guide planes, cingulum stops,
and occlusal rests. A less conservative preparation
was described by Brabant^ for fixed-fixed and can-
tilevered fixed partial dentures with a chamfer finish
line, grooves on opposing surfaces wifh an apical
stop, and a "central pinhole" if a second groove was
not possible.
614
Voiume 31, Number 9.
ot el ho
It appears that both minimal preparatoti and reten-
tive tooth preparations for RBFPDs are quite success-
ful; however, the minimal preparation designs did
show a 12% to 20% debond rate over a relatively short
time period.
Because of the potential improvement for the reten-
fion rate for cantilevered RBFPDs, the use of resis-
tance features is preferred to maximize clinical success.
However, hecause the main advantage of RBFPDs is
that they conserve tooth tissue, preparation designs
should not be complex or extensive as this would
defeat the purpose of conservation.
DESIGN PRINCIPLES FOR
2-UNIT CANTILEVERED PROSTHESES
There is no evidertce-based information regarding can-
tilevered design options for RBFPDs. A clinical case
report has described a cantilevered RBFPD design with
an extension of the occlusal framework on abutments
with medium-sized restorations.'* The mesio-occlusodis-
tal (MOD) amalgam restorations were replaced with sil-
ver-cement-glass-ionomer cement, which was later pre-
pared with mesial and distal hoxes and an occlusal
isthmus. In addition, the retainer covered the abutment
wifh a '.'i crownlike coverage, although the buccal and
palatal cusp tips were not covered. The mesial and distal
ends of the retainer were joined through the occlusal
isthmus that was said to increase the retainer rigidity
and surface area for bonding. However, this type of
tooth preparation is not appropriate for teeth with mini-
mal or no restoration. Also, the use of an abutment with
a moderately sized MOD restoration and 'i coverage
retainer may not be appropriate for a RBPPD because
the tooth resistance form may be derived from a poten-
tially weakened palatal cusp. Long-term loading may
lead to fatigue fracture of the cusp.
As little or no evidence-based information exists for
the preparation design of the single-abutment, single-
retainer RBFPD, it is necessary to transfer principles
of design based on fixed-fixed studies. The design of
cantilevered RBFPDs relates to tooth preparation and
framework design. Tooth preparation should be con-
servative while, at the same time, allowing optimal
resistance form. Ideally, it should be confined within
enamel and should maximize the surface area of the
abutment for bonding. The framework should be rigid
and have optimal resistance form while allowing good
oral hygiene practices.
Surface area for bonding
Maximizing the surface area for bonding is one of the
most important features for success of any resin-
bonded restoration. To achieve this, axial preparation
is recommended to lower the height of contour,'' and
with a carefully chosen path of insertion, the survey
line can be lowered so as to limit fhe amount of tooth
preparation. Most often, a lingual or palatal path of
insertion will mean that the approximal surface and
occlusal surface of the tooth will reqtiire preparation
and that the iingual and palatal surfaces require little
or no reduction (Fig 3). To keep the preparation as
conservative as possihie, a knife-edge margin is chosen
because it can easily and accurately be achieved by
contouring the wax to an acute emergence angle on
an investment model (Fig 4).
Abutment resistance form
Abutment resistance form is necessary to prevent Ihe
retainer from being displaced during function; this is
achieved by wraparound, occlusal coverage, and the
use of resistance features such as grooves or pinholes.
Coverage of the occlusal surface of posterior fixed-
fixed RBFPDs has been shown to improve retention
of retainers in vitro.-" In vivo, the use of multiple rest
seats,' occlusal channels (slots),^ and occlusal struts'^
have been shown to be clinically successful.
Proximal grooves have been recommended by
investigators for anterior fixed-fixed RBFPDs to com-
pensate for the lack of wraparound.''^' In vitro, the use
of 2 grooves per abutment, in comparison to no
grooves, has been shown to significantly increase
resistance to debonding on both anterior^---' and pos-
terior-"* prostheses. These in vitro findings are sup-
ported by clinical data in which anterior teeth pre-
pared with grooves show better clinical retention than
teeth with no grooves.''^"' From this evidence, the
natural progression is fo use grooves for anterior sin-
gle abutments; however, the 3 clinical studies report-
ing exclusively on cantilevered fixed partial dentures
do not mention the use of grooves as part of the
preparation design.-*''^ While this might imply that
grooves might not be essential for success of can-
tilevered RBFPDs, it should he remembered that the
failure rate is up fo 2O''/ii over short time periods.
Therefore, on anterior teeth, the use of grooves on the
proximai surface of the single-abutment retainer is
preferred to maximize clinical retention (Fig 5).
Retainer resistance form
Retainer resistance form is necessary to prevent func-
tional and parafunctional stresses that flex the retainer
and break the cement bond. Prevention of such flexing
is possible through increasing retainer thickness or
changing the geometric configuration of the retainer
(see Fig 1), While studies have shown thicker retainers
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615
Fig 3 A lingual path ot insertion will lower the height of contour
on the palatal surlace negating the need tor signiticant tooih
preparation on this surface. Preparation is then confined lo the
mesial surtace where the height ol contour is usjally high. A small
amount ot preparation may aiso be required on the distopaiatal
surtace ot the abutment to lower the survey line The preparation
of the ocolusal bar is most satisfactodly performed with a round
bur to create a U-shaped trough that will allow a range of paths
for insertion for the retainer A midpalatai groove is prepared with
a No. 169 or No t70 tungsten carbide bur to give resistance tc
occlusal loading on the pontic.
Fig 5 Opposing axial grooves are prepareO a( light angies to the
tooth surfaoe to give the abutment resistance form The grooves
are prepared usi palatal to the conlacf point and should not be
grealer than the widlh of the bur To ensure there is no undercut,
grooves are prepared as slightly tapering toward each other.
Fig 4 P'elormed wa sheets ol 0.8-mm thickness are heated in
warm water, adapted to ttie investment die. and seaied down at
the margins with a heated instrument. The gingival margin is then
smoothed to create an acute emergence profile that is compatible
with good oral hygiene practices.
Fig 6 The second premolars were nol seieoted as abutments
(as is usually recommended] because the residual tooth tissue
was considered compromised Instead, a distai cantilever from
the canine was chosen with eiiminatlon ot the paiatai cusps on the
pontic to eliminate adverse occiusai contacts. Because of the
ciosed-bite between the maxiliary and mandibular canines, it was
decided to cement the prostheses in supraocciusion to prevent
the need (or any tooth reduction. Nole the paiatai cingulum stieit
to direct supraocciuding forces axiaily
to decrease the stress on the cement bond" and
increase bonding strength,^^ there is no evidence-based
recommendation for fhe optitnal retainer thickness for
RBFPDs. The range of thicknesses investigated has
been 0.3 to 0.7 mm,^'-^^ and as thicker frameworks will
be more rigid, it is suggested that retainers should be
more than 0.7 mm thick.
Occlusion
It has heeti suggested that occlusal contacts on can-
tilevered ponties should be kept light to minimize
forces that may debond the retainer.'" One clinical sit-
uation requires special mention. The use of a canine
abittmenf-premolar pontic distal cantilever should
have special design modification because of the poor
resistance form of the palatal surface of the canine to
occlusal loading on the premolar pontic. In this case,
fhe palatal cusp of the premolar may be retnoved to
minimize adverse forces on the abutment (Pig 6).
The restoration of anterior teeth with a "closed-
hite" requires the creation and tnaintenance of
occlusal clearance for the retainer. While palatal
preparation of the maxillary incisors and incisai edges
616
Volume 31, Number 9
Boielho
Fig 7a The small 2-surtace cavity still leaves this potential abul-
meni with sufficient enamel tor tDonding and residual tooth tissue
lor resistance torm to retain a prosthesis.
Fig 7b The cavity was restored with resin composite.
Fig 7c Axial giooves were prepared on the mesial surfaoe of the
restoration to give additional resistance form.
Fig 7d The final prosLhesis with an occlusal bar cemented with
resiri adhesive cement.
of the mandibular incisors is possible, predictable pro-
visionalizaticn is not easily achieved, and loss of some
of the prepared occlusal clearance may require further
reduction of the mandibular incisors or retainer at the
time of cementation. An alternative technique has
been suggested whereby the finai restoration is
cemented in supraocclusion, allowing the RBFPD to
act as an orthodontic appliance until intercuspal tooth
contacts are re-established^ (Fig 6),
Previously restored abutments
The presence of caries on a tooth does not preclude
its use as an abutment for a cantilevered RBFPD. In
fact, if the restoration is small and the location strate-
gic, it can be incorporated into the framework design
for additional resistance form. Dentai materials that
are compatible wifh the final adhesive luting cement
prior to preparation shouid be used for such restora-
tions. As a guide, abutments with small 2-surface
restorations are considered appropriate for RBFPDs
(Figs 7a to 7d).
The use of endodontically treated teeth for abut-
ments is usually avoided; however, if the remaining
tooth tissue is virtually intact and the alternative abut-
ment compromised, the root-filled tooth can be used.
The restored access cavity can be prepared with intra-
coronal pinholes, which will not weaken the tooth,
instead of the extracoronal surface (Fig 8).
Proposed cantilevered designs
Anterior abutments. The first stage of cantilevered
RBFFD preparation for anterior abutments begins with
selecting a path of insertion that will create a low sur-
vey line and therefore minimize the amount of tooth
preparation. Axial tooth preparation to the height of
contour of the tooth is performed when appropriate,
and finally, the opposing grooves or pinholes are pre-
pared (Fig 5).
It is considered most appropriate to prepare
grooves with a tapered tungsten carbide bur such as a
No. 169 or No. 170, Grooves should be positioned
just palatal to the contact point and be oriented on
Quintessence International 617
Boteiho
Fig 8 To minimize further tootii tissue destruction, the restored
access cavity ol this root-fiiled tooLh was prepared wilh 2 intra-
coronai pinhoies rattier than extraccronal axiai grooves This abut-
ment was chosen because Ihe iaterai incisor has a smali surface
area tor bonding.
Fig 9 For any abutment, the path of insertion of the tramework is
lirst planned (as shown by the surveying rod), and then the heigint
of contour is reduced to maximize the surface area tor bonding.
The grooves are prepared aiong the path of this insertion ust
paiatal to the contact point.
Fig 10 This fixed-fixed RBFPD was remade with a D-shaped
cantiievered retainer when it was discovered that the 0.6 mm C-
Shape molar retainer couid be distorted with finger pressure.
the path of insertion of the framework {Fig 9), To bc
conservative, grooves should bc no greater tban the
width of the bur. To provide adequate resistance,
grooves sbould have a definite apical stop and palatal
axial wall.
It is not always possible lo place grooves of suffi-
cient length on tbe distoproximal surface of tbe abut-
ment A pinhole or slot can be placed on the lingual
surface parallel to the opposing groove. However, the
use of grooves for resistance form is preferred to pin-
hoies because they are easier to prepare, record an
impression, cast, and fit the final framework.
The use of cingulum stops has been proposed to
provide resistance to gingival displacement;''^ how-
ever, this use does not take into account tbat most, if
not all. Class I or II incisor tootb contacts direct
forces obliquely to the long axis of the tooth and not
in a gingival direcfion. Also, if grooves are used, then
the need of cingulum stops is superseded.
Posterior abuttnents. The design and preparation
of posterior abutments is the same in principle for
anterior abutments with some minor modifications.
Tbe use of opposing interproximal grooves is not usu-
ally possible, because of adjacent teeth, and not appro-
priate, because tbeir placement would not resist
occlusal forces on the pontic. Clinical experience bas
shown, wben trying in castings, that tbe use of a mid-
palatal groove offers some resistance form to occlusal
loading on the ponfic {sec Fig 3),
The geometric shape of RBB retainers on posterior
abutments has classicaily been C-shaped. Personal
clinical experience has sbown that C-shaped retainers
can be distorted between tbe fingers {Fig 10), and it is
recommended that the retainer ends should he joined
to "brace tbe arms" of the prosthesis.' This will con-
vert a flexible C-shape retainer to a rigid D-shape
retainer {sec Fig 1). Tbe provision of an occlusal bar
between the retainer ends may not require tooth
preparation if there is sufficient occlusal clearance. If
occlusal clearance is sufficient, it is recommended that
coverage of the palatal or lingual cusp be achieved;'
this will not only increase retainer rigidity but also the
surface area for bonding.
618 Voiume 3 1, Number q or
Bot el t i o
CONTRAINDICATIONS FOR
CANTILEVERED RBFPDs
Abtitments requiring cuspal proteetion or having a
restoration larger than a Class II are not good candi-
dates for cantilevered RBFPDs. Also, patients with a
history of drifting teeth or poor bone support with
uncontrolled periodontal disease may not be suitable
because of the possibility of abuttnent drifting. At
present, it is not recommended to cantilever a molar-
sized pontic from a molar abutment because the
greater leverage forces from the pontic may cause
uncontrolled tooth movement.
CONCLUSION
The single-abutment, single-retainer RBFPD is the
preferred prosthesis design when replacing single pon-
tics anterior to the premolar tooth. Such a design is
not only more cost effective to the operator and the
patient but also appears to be a more simple and pre-
dictable prosthesis than its fixed-fixed counterpart.
Further studies are required to detennine if the use of
grooves, pinholes, and occlusal bars offer improved
success over more conservative designs.
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