CLINICAL ARTICLE

Minimally Invasive Preparation and Design of a

Cantilevered, All-Ceramic, Resin-Bonded, Fixed Partial
Denture in the Esthetic Zone: A Case Report and
Descriptive Review
CHRISTOPHER A. BARWACZ, DDS*, MARCELA HERNANDEZ, DDS, MS, R. HENRY HUSEMANN, MDT, CDT, TE

ABSTRACT
Resin-bonded, fixed partial dentures have the potential to offer a minimally invasive, fixed-prosthetic approach to tooth
replacement in patients who may not be candidates for implant therapy. However, traditional preparation protocols
often recommend extensive preparation designs on two abutment teeth, thereby potentially compromising the
long-term health of the adjacent abutments and often resulting in unilateral debonding of one of the retainers in the
long term. In light of advances in high-strength ceramic systems capable of being reliably bonded to tooth structure
and offering improved esthetic outcomes, as well as clinical and case-series research demonstrating improved
survivability of cantilevered resin-bonded fixed partial dentures, new preparation designs and methodologies can be
advocated. The following case report demonstrates the clinical application of sonoabrasion, coupled with a dental
operating microscope, to minimally prepare a single abutment for a cantilevered, all-ceramic resin-bonded fixed partial
denture. Relevant historic and contemporary literature regarding double versus single-retainer resin-bonded fixed
partial dentures are reviewed, as well as clinical conditions that are most favorable for such restorations to have an
optimal long-term prognosis.

CLINICAL SIGNIFICANCE
If appropriate clinical conditions exist, a cantilevered, all-ceramic, resin-bonded, fixed partial denture may be the most
conservative means of tooth replacement in a patient who is not a candidate for an endosseous implant.
(J Esthet Restor Dent 26:314323, 2014)

INTRODUCTION
Implant therapy has the potential to oer patients a
predictable, minimally invasive, xed, and potentially
esthetic replacement solution to partial edentulism.
However, there are many patients for whom a
single-tooth implant may not be the rst or optimal
choice for tooth replacement yet still seek a xed
replacement strategy. These patients include those who

have compromised immune status or other

uncontrolled systemic diseases that would negatively
impact surgical healing, are pregnant, have incomplete
skeletal growth, have insucient apical root spacing to
enable placement of an implant, are heavy tobacco
users, or have nancial limitations. Patients who fulll
specic clinical criteria can potentially benet from
contemporary minimally invasive adhesive approaches
that enable a xed prosthetic replacement via the use of

*Assistant Professor, Craniofacial Clinical Research Center, The University of Iowa College of Dentistry, Iowa City, Iowa

Clinical Associate Professor, Department of Family Dentistry, The University of Iowa College of Dentistry, Iowa City, Iowa

Instructional Resource Associate, Department of Prosthodontics, The University of Iowa College of Dentistry, Iowa City, Iowa

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a cantilevered, all-ceramic, resin-bonded, xed partial

denture (RBFPD).
RBFPDs were rst proposed in the early 1970s1 and, in
the intervening 40 years, have continued to evolve their
design and luting protocols based on advancements in
prosthetic materials and adhesive systems. Howe and
Denehys2 initial designs of such prostheses advocated
for the incorporation of perforated metallic retainers to
optimize retention of the adhesive luting agent.
Livaditis and Thompson3 subsequently developed a
method for etching nonperforated, nonprecious metal
alloy retainers that improved the longevity of the
resin-metal retainer bond by protecting the resin
interface from abrasion or leakage. To prevent
premature failure or unilateral debonding, designs for
RBFPDs often promoted mechanical resistance with
design elements such as rest seats,4 channels and/or
slots,5 struts,6 and grooves.7 Such preparation strategies,
however, sacriced additional tooth structure and often
moved the preparation into dentin, making such a
restoration signicantly more invasive and
potentially prone to developing caries if a retainer
debonded.
Since the early to mid 1990s, all-ceramic RBFPDs were
subsequently optimized for the anterior esthetic region,
facilitating predictable bonding to tooth structure and
enhanced esthetics by eliminating the requirement for
metallic retainers that lowered the value of the
abutment teeth that supported them.8,9 Initial
all-ceramic, two-retainer RBFPDs demonstrated a high
incidence of unilateral framework failure because of
fracture, which left the pontic bonded to a single
retainer in a cantilevered fashion, often for a signicant
amount of time.10 Rarely were there instances of failure
at the ceramic-resin-enamel bond, consistent with in
vitro studies that demonstrated that resin bond
strengths of such all-ceramic RBFPDs exceeded
the fracture strength of the all-ceramic
RBFPDs.9,11,12
Concurrent with investigations into all-ceramic
RBFPDs, multiple investigators documented the
prolonged survival of two-retainer RBFPDs that had
become unilaterally debonded and essentially

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transformed into cantilevered RBFPDs. These

investigators thus proposed a cantilevered design as a
de facto approach in minimizing shear and torque
stresses placed on RBFPD frameworks that was
attributed to dierential movement of the abutments
during function, ascribable to their respective
periodontal ligaments.1318
Subsequent clinical trials and case-series studies have
independently demonstrated the potential for high
success rates not only for metal-ceramic cantilevered
RBFPDs16,17,1923 but additionally for cantilevered
all-ceramic RBFPDs of various high-strength ceramic
systems.2427 Unfortunately, long-term, randomized,
prospective, clinical trial data directly comparing the
clinical survival and complications associated with
metal-ceramic RBFPDs, as compared with all-ceramic
RBFPDs of either design, are absent in the literature.
Such data would be valuable to clinicians to oer
evidence-based criteria on which to base clinical
treatment. With regard to all-ceramic RBFPDs, Kern
evaluated the long-term survival of both two-retainer
and cantilevered anterior RBPFDs, and reported a
5-year survival rate of 73.9% in the two-retainer group
and 92.3% in the single-retainer group.26 If unilateral
fracture of the two-retainer group was accepted as a
criterion for failure, the 5-year survival decreased to
67.3%. Emerging data are therefore promising with
regard to the potential for cantilevered, all-ceramic
RBPFDs to serve as a minimally invasive treatment
modality for patients who are not candidates for,
capable of, or interested in having a single-tooth
implant restoration. Often, a treatment strategy
including cantilevering an all-ceramic RBFPD is
overlooked by clinicians because of lack of
familiarity or comfort with such a treatment
approach.
The following case report documents the use of
minimally invasive diamond oscillating instrumentation,
with the aid of a dental operating microscope, to
prepare and restore a congenitally missing maxillary
lateral incisor using a cantilevered, all-ceramic RBFPD
fabricated from lithium disilicate (IPS e.max Press,
Ivoclar Vivadent, Amherst, NY, USA) in a patient who
was not a candidate for implant therapy.

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FIGURE 1. A, Frontal view of initial clinical presentation demonstrating asymmetry of the maxillary central incisors and the
congenitally missing maxillary left lateral incisor. B, Lateral view of initial clinical presentation demonstrating inadequate residual
ridge volume and soft-tissue texture apical to site #10.

Case Report
A 17-year-old healthy male was referred to the authors
intramural practice at The University of Iowa, College
of Dentistry for evaluation and replacement of the
maxillary left lateral incisor (#10), which was
congenitally missing (Figure 1). The patient had recently
completed comprehensive orthodontics that included
space preparation of #10 for an eventual single-tooth
implant (Figure 2). However, the patient had yet to
complete skeletal growth and was nearing departure for
post-secondary education, therefore precluding implant
therapy. The patient expressed desire for a xed
restoration for the time period leading up to a
single-tooth implant; therefore, the established
treatment plan called for an RBFPD as a long-term
provisional restoration. Such a strategy enabled the
patient to complete skeletal growth and to decide upon
an optimal time to pursue implant therapy based on the
patients biological, personal, and nancial
circumstances. Additionally, the prosthesis provided
long-term orthodontic stability of the adjacent
abutments that was critical to future implant therapy
success. The patient was informed of the alveolar bone
and soft-tissue deciency at site #10 and was oered a
subepithelial connective-tissue graft prior to restoration
fabrication to aid in esthetic integration of the RBFPD.

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FIGURE 2. Periapical radiograph at conclusion of

comprehensive orthodontic treatment to provide space for a
future endosseous implant after completion of skeletal growth.

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FIGURE 3. A, Preoperative palatal view of maxillary anterior dentition. B,View of centric occlusion (note the minimal
overbite/overjet, allowing for minimal forces to be placed on the retainer wing, connector, and cantilevered pontic of the all-ceramic
resin-bonded, fixed partial denture).

The patient declined this option and preferred to

defer this treatment until implant therapy could
commence.
Clinical evaluation of the patients maxillary anterior
segment revealed asymmetry of the central incisors
alignment and length, with #9 presenting 0.7 mm
shorter in length and 0.5 mm lingual displacement
compared with #8. The patient requested that the
central incisors display symmetry of length and
prominence, and an additive direct composite
restoration for #9 was included in the treatment plan.
The teeth adjacent to site #10 revealed intact,
noncarious, virgin teeth (Figure 3A). Additionally,
occlusal analysis revealed a slight anterior open bite,
and an endend canine relationship on the patients left
side (Figure 3B). The occlusal scheme, combined with a
desire by the patient for a minimally invasive yet
durable xed restoration, resulted in a scenario optimal
for a cantilevered RBFPD. The patient was informed
that minimal preparation would be necessary and that
upon eventual commencement of implant therapy,
the connector could be sectioned, and the
remaining porcelain wing left bonded to the
cingulum of #11.
The preparation of abutment #11 was facilitated by use
of a dental operating microscope (OPMI pico, Carl
Zeiss Meditec AG, Jena, Germany) and an oscillating

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FIGURE 4. Diamond oscillating tips (left: hemispherical

micro-tip no. 33, KaVo Dental; right: modified-shoulder sonic
tip SF847KR.000.016, Komet) used for micropreparation of
abutment tooth #11.

handpiece (KaVo SONICex LUX 2003/L, KaVo

Dental, Charlotte, NC, USA) with a hemispherical
microtip (microtip no. 33, KaVo SONICex) and a
modied-shoulder sonic tip (SF847KR.000.016, Komet
USA, Rock Hill, SC, USA) (Figure 4) under rubber dam
isolation. Simultaneously, a direct composite restoration
involving the facial and incisal surfaces of #9 was
carried out using shades B1B (Filtek Supreme Ultra, 3M
ESPE, St. Paul, MN, USA), BL2 and MW (Estelite
Omega, Tokoyama Dental America, Encitas, CA, USA)
using a layering technique. The nal preparation

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FIGURE 5. A, Palatal view of maxillary anterior dentition after preparation completion. B, Direct view of abutment preparation,
the dimensions of the preparation were 6.0 mm (height) 5.2 mm (width) 0.5 mm (depth) and were limited to enamel throughout.

FIGURE 6. A, Master cast provided to ceramist. B, Completed cantilevered, all-ceramic resin-bonded, fixed partial denture
(RBFPD) (IPS e.max press). C, Cantilevered, all-ceramic RBFPD seated on master cast.

dimensions on the retainer #11 were 5.2 mm in width,

6.0 mm in height, and 0.5 mm in depth, and were
limited to enamel throughout the preparation
dimensions (Figure 5).

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A mounted master cast of the clinical situation was

provided to the ceramist (Figure 6A), and a
cantilevered, all-ceramic (IPS e.max Press, Ivoclar
Vivadent) RBFPD was fabricated using a BL3 ingot

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(Figure 6B). Upon cutback, Opal Eect 3 powder was

applied from the incisofacial third to the cervical third
of the pontic, and T blue and T clear were layered in
the incisal third to adequately mimic incisal eects. The
restoration was glazed and subsequently mechanically
glazed with rubber wheels and polishing compound to
match the luster of the adjacent teeth. The adaptation
and t of the restoration were veried on the master
cast (Figure 6C).
The completed cantilevered, all-ceramic RBFPD was
seated intraorally before application of the rubber dam
to verify proper coronal form, shade, and texture match
to the adjacent natural dentition. Proper seating,
proximal contact, and marginal adaptation were also
assessed at this stage, and no adjustments were
required. The anterior sextant was isolated under
rubber dam with cervical oss ligatures, and the
restorations complete seating and marginal adaptation
were once again veried. The internal aspect of the
retainer was acid-etched with 5% hydrouoric acid (IPS
etching gel, Ivoclar Vivadent) and silanated with silane
(Bis-Silane, Bisco, Inc., Schaumburg, IL, USA)
according to the manufacturers instructions. The
preparation was treated with 35% phosphoric acid
(Ultra-Etch, Ultradent, South Jordan, UT, USA) for 30
seconds, then rinsed and dried thoroughly. A total-etch
adhesive resin (All-Bond 3, Bisco, Inc.) was
subsequently applied to both the restoration intaglio
and previously etched preparation according to
manufacturer instructions, and light-cured for 30
seconds. The RBFPD was luted with a translucent
light-curing resin adhesive cement (RelyX Veneer, 3M
ESPE) to ensure color stability. Centric and excursive
occlusion was veried, and margins were polished with
silicone carbide brushes (Jiy Brushes, Ultradent). A
nal radiograph (Figure 7) was made to verify cement
removal, and proper hygiene around the prosthesis was
demonstrated and discussed with the patient. The
patient was recalled at 1-year follow-up (Figure 8) and
revealed no evidence of chipping, loosening, or rotation
of the prosthesis, or any biological complications of the
abutment tooth, and was very satised with the
functional and esthetic integration with the remaining
dentition (Figure 9). The patient also felt more socially
condent with a xed restoration as a long-term

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FIGURE 7. Immediate post-op periapical radiograph of

completed restoration.

provisional prosthesis as compared with a removable

appliance.

DISCUSSION
Cantilevered, all-ceramic RBFPDs represent a
progression in the coupling of minimally invasive and
adhesive dentistry. Such restorations lead to less
morbidity and biological complications of adjacent
abutment teeth and superior esthetic outcomes as
compared with traditional xed partial dentures for
appropriate patients. Advances in high-strength
ceramic systems such as milled zirconium oxide as well
as milled or pressed lithium disilicate have enabled the
fabrication of robust and esthetic cantilevered,
all-ceramic RPFPDs. Such systems enable predictable
bonding to tooth substrate and oer the potential for
enhanced esthetics when compared with
metallic-retainer RBFPDs. Recent clinical studies

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FIGURE 8. Clinical views of completed case at 1 year post-insertion (note gingival health apical to the pontic and connector):
A, frontal view; B, lateral view; C, palatal view; D, incisal view.

FIGURE 9. A, Centric retracted view. B, Smile photograph demonstrating acceptable esthetic integration with the remaining
dentition.

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utilizing these ceramic materials for cantilevered

RBFPDs have demonstrated promising results in the 3to 5-year follow-up timeframe.
Sasse and colleagues reported a randomized, clinical
trial evaluating 30 patients restored with cantilevered,
all-ceramic RBFPDs fabricated with zirconium oxide
retainers and frameworks with two adhesive systems.27
The study demonstrated a 3-year survival rate of 93.1%,
if debonding was considered as a technical failure, and
100% survival if only the nal loss of the RBFPD,
notwithstanding rebonded RBFPDs, was a criterion for
success. The investigators reported two debonding
events in this cohort that were attributable to traumatic
events (hits/pushes on chin and/or teeth). A second
case-series study evaluated the clinical outcomes of
cantilevered, all-ceramic RBFPDs fabricated with IPS
e.max Press for tooth replacement in the anterior
maxilla and mandible.25 A total of 35 patients (17
maxillary sites, 18 mandibular sites) were treated and
recalled for a mean of 64.57 months (range 3569
months). The study reported no incidences of
prosthesis debonding, no postoperative sensitivity or
recurrent caries, or any prosthesis chipping or
fracturing. Excellent 3- to 5-year survival outcomes in
controlled studies as well as successful documented
case reports28,29 of cantilevered, all-ceramic RBFPDs are
encouraging to practitioners who are presented with
patients who may desire a xed restoration in an
anterior, bounded edentulous site either as a long-term
provisional restoration or an alternative denitive
restoration to a single-tooth implant.
Two factors are of critical importance when evaluating
if a patient is a good candidate for a cantilevered,
all-ceramic RBFPD. The rst contributing factor to
evaluate is the patients occlusion. It is the authors
experience that patients who present with mutually
protected occlusion including canine or group function
tend to have more successful outcomes with
cantilevered RBFPDs. Prioritization of minimizing
lateral and protrusive forces on the cantilevered pontic
is of utmost concern for this restoration design.
Patients who possess minimal vertical space because of
a deep overbite or supraeruption of opposing teeth
make poor candidates for this treatment approach.

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Such situations limit the height and width (and hence

strength) that can be established for the connector
region of the all-ceramic prosthesis,30 as well as place
the restoration under greater stress in excursive
movements because of steeper inclines that must be
overcome for the patient to function. The second
critical factor to evaluate is the tooth that requires
replacement. Hussey and Linden16 reported that
signicant dierences exist in the performance of
cantilevered RBFPDs based on the teeth that they were
replacing. In their study, cantilevered RBFPDs replacing
maxillary central incisors and canines had a tenfold
higher failure rate, when compared with maxillary
lateral incisors and premolars, as well as mandibular
incisor and premolar teeth. Therefore, in addition to
occlusion, the candidate tooth for replacement must
also be taken into account by the clinician when
assessing the potential success of a cantilevered,
all-ceramic RBFPD. It is of interest to note that Sun and
colleagues.25 did not include central incisors or canines
in their case-series study that reported 100% success.
The clinical case presented here was optimized not only
by accounting for factors present clinically, such as an
anterior open bite, anterior disclusion, and group
function in lateral excursive movements, but also by the
micropreparation methodologies employed.
Sonoabrasion via the use of oscillating diamond-coated
tips, as well as enhanced visualization of the eld via a
dental operating microscope, allowed the authors a high
degree of control and accuracy while preparing the
canine abutment. Such sonoabrasive preparation
methodologies have been demonstrated to result in less
tooth substance loss after preparation as compared with
traditional rotary instrumentation31 and have
traditionally been proposed for Class II cavity lesion
preparation32,33 or nishing of prosthetic margins prior
to prosthetic nal impressions.34 To the authors
knowledge, this is the rst report of oscillating
instrumentation being employed for the preparation of
an abutment for a cantilevered, all-ceramic RBFPD.
When appropriate clinical conditions are present,
cantilevered, all-ceramic RBFPDs are more conservative
in nature, require less time for the clinician to prepare
and impress, and are less burdensome to deliver than

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conventional double-retainer, all-ceramic RBFPDs. For

patients with limited nancial means, laboratory costs
will also be less as compared with conventional
double-retainer RBFPDs. Additionally, there is
signicantly less potential for developing recurrent
caries on a partially debonded retainer wing for a
cantilevered prosthesis, as such an event will
immediately lead to loss of the prosthesis, prompting
the patient to return to the practitioner for rebonding
or repair.

3.

4.

5.

6.

7.

In conclusion, the cantilevered, all-ceramic RBFPD is a

uniquely positioned prosthesis that can serve as either a
minimally invasive denitive prosthesis for patients who
are not candidates for implant therapy, or as a
long-term xed provisional prosthesis for the patient
who may desire to pursue implant therapy at a later
time, should skeletal growth, health, or nances be of
concern. In order to obtain data that could potentially
validate the treatment strategy employed in this case
report, future case-series, or more ideally, randomized,
clinical trial studies including larger populations with
longer follow-up periods (greater than 5 years) are
warranted. Given that health care is increasingly
moving toward minimally invasive approaches when
surgical intervention is deemed necessary,35,36 it seems
natural that such trends are increasingly being
seen in private and academic dentistry,37 where
surgical procedures are completed and/or taught
routinely.

8.

9.

10.

11.

12.

13.

14.

DISCLOSURE
15.

The authors declare no potential conicts of interest

with respect to the authorship and/or publication of
this article.

17.

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Reprint requests: Christopher A. Barwacz, DDS, The University of Iowa,

College of Dentistry, Craniofacial Clinical Research Center, W425 Dental
Science Building, Iowa City, IA 52242-1010, USA; Tel.: 319-384-3002;
Fax: 31-9353-5375; email: chris-barwacz@uiowa.edu

Journal of Esthetic and Restorative Dentistry

Vol 26 No 5 314323 2014

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