The cantilever fixed partial denture-A literature review

Raphael Himmel, DMD,a Raphael Pilo, DMD,B David Assif, DMD,b and
Israel Aviv, DMDC
Tel Aviv University, Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv,
Israel

The cantilever fixed partial denture (FPD) is a restoration with one or more
abutments at one end and unsupported at the other end. Forces transmitted
through the cantilevered pontics can cause tilting and rotational movements of the
abutments. In a cross-arch unilateral cantilever FPD, the distal cantilevered unit is
subjected to comparatively less force than the contralateral posterior abutment.
The unilateral lack of terminal abutments causes lateral bending forces that
activate peripheral inhibitory feedback reactions from the periodontal and/or
temporomandibular mechanoreceptors. The greatest strain in distal cantilevered
FPDs is recorded mesial to the most distal retainer because most fractures occur in
this location. To improve the prognosis of the FPD cantilever, the number of
abutments should be increased and the number of pontics decreased. The abutment
teeth need long roots and acceptable alveolar support. Prepared abutments require
adequate length and parallel axial walls. An equilibrated and harmonious occlusion
is necessary, as well as exemplary oral hygiene. A cantilevered FPD with adequate
periodontal support can replace any tooth in the dental arch, but is especially
useful as an alternative to a removable partial denture. The cantilevered FPD
requires at least two abutment teeth. The only documented exception permitting a
single abutment is the replacement of a maxillary lateral incisor with the canine as
an abutment. An alternative to the cantilevered FPD is the osseointegrated
implant. As osseointegrated implants become more popular, the need for the
tooth-supported cantilevered FPD may decline, but it will remain an alternative
treatment modality. (J PROSTHET DENT 1992;6’7:484-7.)

T he cantilever fixed partial denture (FPD) is a res- splinted, both teeth resisted the rotating movement, and
toration with one or more abutments at one end and the force on the periodontal membrane for both teeth was
unsupported at the other end.’ A class I lever system is diminished.
created if vertical and oblique forces directed to the pontic Henderson et a1.2used a practical model and a laboratory
result in forces on the abutment teeth greater than the ap- model of a three-abutment posterior FPD with strain
plied stress.2 The relationship between biology and me- gauges. In both models, forces transmitted to the abut-
chanics and the stress distribution within physiologic lim- ments through the cantilevered pontics were resisted by
itations to the supporting structures is critical with a can- rotational and tilting movements ofthe abutments but not
tilever FPD. parallel to the vertical axis of the abutment roots. More
than 50 % of the force applied to the cantilever pontic was
FORCES AND STRESS DISTRIBUTION absorbed by the abutment nearest the cantilever pontic,
Wright and Yettram, using the finite element method of but the addition of abutment teeth lessened the force on
stress analysis in a two-dimensional form, demonstrated the distal abutment.
that a nonaxial force applied on a single tooth elevated Glantz et a1.4used six linear strain gauges and one rosette
forces in the periodontal membrane compared with an ax- gauge to record functional deformation in a conventional
ial load on the same tooth. The forces were magnified as the six-unit mandibular FPD in a partially edentulous patient.
loading on the tooth became more oblique. Wright and All gauges exhibited elongation when the FPD was func-
Yettram also confirmed that the force increased on the tionally loaded. The distal abutment retainer was then re-
periodontal membrane of a single tooth abutment with a moved, converting the FPD to a five-unit cantilever FPD,
cantilever if the point load was direct to the free end of the and all gauges recorded contraction. The direction of prin-
extension. If two abutment teeth with a cantilever were cipal strain under the rosette gauge shifted more than 60
degrees on removal of the distal retainer. This study dem-
*Instructor, Department of Oral Rehabilitation.
bSenior Clinical Lecturer, Department of Oral Rehabilitation. onstrated that clinical deformation differed from a labora-
‘Lecturer, Department of Oral Rehabilitation. tory model having the same distribution.5
10/1/34664 The cross-arch unilateral two-unit cantilever FPD was

484 APRIL 1992 VOLUME 67 NUMBER 4

CANTILEVER FIXED PARTIAL DENTURE

examined by Lundgren and Laurell.6 Strain gauge trans- was achieved by periodontal treatment and the develop-
ducers were inserted into prosthetic restorations to regis- ment of a stable, nontraumatizing occlusion. Balancing
ter occlusal forces during light tooth-tapping, chewing, contacts were established to prevent migration, tilting, and
swallowing, and maximal biting. They demonstrated that increasing mobility when there was a possibility of FPD
despite the activity, the distal cantilevered unit was sub- mobility during mandibular movements.
jected to comparatively less stress than the contralateral The masticatory forces are decreased with periodontally
posterior abutment with equal or smaller than local ante- compromised teeth in dentitions with cross-arch unilateral
rior forces. The diminished forces on the cantilever units posterior two-unit cantilever FPDs. The quadrants with
are attributed to a deflection of the cantilever units and not the cantilevers were never designated as the preferred
to intrusion of the adjoining abutments. chewing side.g Thus, if the occlusion is stable and the can-
In a comparative study of patients restored with cross- tilever free from premature contacts, the cantilever would
arch FPDs with bilateral terminal abutments, an average be only inadvertantly subjected to large forces.
of 26% of the voluntary muscular capacity was activated Antonoff13 stated that cantilever FPDs were more fre-
during chewing compared with 37 % in the bilateral termi- quently indicated when reduced stress was inherent, as
nal abutment group.7 The differences were explained by with a complete denture in the opposing dentition. How-
the unilateral lack of terminal abutments causing lateral ever, Randow et a1.i4 reported no major clinical signifi-
bending forces that activate peripheral inhibitory feedback cances between technical failures of cantilevered FPDs and
reactions from the periodontal and/or TMJ mechanore- the type of opposing dentitions. They suggested that a
cept0rs.s well-supported, stable complete denture could also gener-
Axially directed masticatory forces are more consistently ate high functional loading.
influenced by the periodontal support with cross-arch ex- Wright1 believed that it was desirable to transfer the load
tension FPD with unilateral cantilevers9 The less the pe- from the cantilever to the abutment teeth by establishing
riodontal ligament area, the smaller the occlusal force ex- the pontic as an occlusal stop and by narrowing the occlusal
erted, suggesting that the mastication of dentitions with table of the pontic but not as a “disoccluder.” An accept-
unilateral posterior two-unit cantilevers is modulated more able guideline was to design the buccolingual width of the
by the mechanoreceptors of the periodontal membrane pontic no broader than the narrowest retainer.
than by dentitions with bilateral, terminal abutments. Ex-
cessive bending forces from the cantilevers can alter the BIOMECHANICAL CONSIDERATIONS
feedback control mechanism from the periodontal mecha- The mechanics of the cantilever FPD require the abut-
noreceptors, magnifying neuromuscular sensitivity. How- ment adjacent to the replacement tooth to possesssuitable
ever, the periodontal tissues do not affect the local forces periodontal support, l3 because the greatest functional
on the distal unit of the cantilever because of the deflection stress is directed to the nearest abutment.z Conversely, the
of the cantilever.6 abutment tooth farthest from the pontic should be ex-
The importance of the mechanoreceptor mechanism of tremely retentive to resist the vertical dislodgement im-
the periodontal membrane was emphasized by Randow parted by the cantilevered pontic.2, l3
and Glantz.l” They discovered that there was a definite Ewing15 cited the following criteria crucial for successin
difference in the biomechanic reactions on cantilever load- evaluating the cantilever principle: acceptable periodontal
ing between vital and nonvital teeth. The tolerable loading attachment and alveolar support, favorable root length and
levels in nonvital teeth were twice that of vital teeth. Nev- shape, sufficient crown length, and a harmonious arch-to-
ertheless, the vital and nonvital teeth had the same level of arch and tooth-to-tooth relationship. Wright and Yettram
tolerable loading when the abutments were anesthesized. concluded that a cantilever FPD should have at least two
They concluded that the vital teeth with optimal bone abutments and not replace more than one tooth. When a
support had a more efficient form of mechanoreceptor cantilevered pontic is placed posteriorly, additional abut-
function at lower degrees of bending than nonvital teeth. ments may be included to withstand the strong forces of the
This elevated response may also explain the greater me- muscles of mastication.’
chanical failure associated with endodontically treated Echardson16 estimated a maximal force of 700 N acting
abutment teeth. on the cantilever and believed that such a force could de-
stroy the FPD adjacent to the cantilever. However, Lun-
THE ROLE OF OCCLUSION dgren and Laurel16 reported that the greatest individual
Longitudinal studiesi’* l2 have confirmed that dentition local force was 150 N if all stresses were actively concen-
can be rehabilitated by use of FPDs with cantilever pontics trated at the distal cantilever unit. They claimed that such
on specific, isolated abutments that are periodontally forces were unlikely to occur in natural function unless the
compromised. Stable FPDs were successful despite indi- cantilevers are subjected to premature contacts of inordi-
vidual hypermobile abutment teeth. Prolonged stability nate and nonclinical size.

THE JOURNAL OF PROSTHETIC DENTISTRY 485

 HIMMEL ET AL

Laurel1 and Lundgrens claimed that a unilateral poste- 10. The restorative material used for the FPD is extremely
rior two-unit cantilever FPD with reduced periodontal rigid.
support had a better longitudinal prognosis considering 11. The cement has a high tensile strength.
material strength. The increased vertical space allows
CLINICAL APPLICATIONS
thicker FPD components and reduced periodontal support
allows less chewing and biting force. Cantilever FPDs with adequate periodontal support
Giantz et a1.4illustrated that the greatest strain in can- have universal application, l3 but special emphasis is ex-
tilevered FPDs was recorded mesial to the most distal re- tended to cantilever FPDs as an alternative to RPDs.18~ls
tainer, identifying this region as vulnerable. In extensive Epidemiologic studies have verified that mandibular an-
oral rehabilitation with numerous edentulous spaces, the terior teeth are retained intraorally the longest; thus resto-
distal retainer should be designed as complete crowns with rations for elderly patients are commonly complete maxil-
near parallel walls on the tooth preparation to ensure re- lary dentures and mandibular RPDs. A common complica-
tention. tion of the mandibular RPD is resorption of the maxillary
Porcelain-to-gold cantilever restorations are commonly anterior alveolar ridge, described by Kelly20 as the “com-
contraindicated because of porcelain fracture due to in- bination syndrome.”
creased bending movement at the junction of pontic and Budtz-Jorgensen et alla reported on 27 patients treated
retainer.13 In a posttreatment study of 316 FPDs after 6 to with maxillary complete dentures and distally extension
7 years, Randow et a1.14discovered a linear relationship cantilever FPDs. All 27 patients, including those who for-
between the frequency of technique failures, such as frac- merly adapted well to the RPD, expressed a pronounced
tures and loss of retention (8% to 34%), and the total of improvement in mastication and in the stability of the
cantilever pontics in the restoration. complete maxillary denture. After 2 years, all FPDs were
Failures were more common when the distal abutments intact and the abutments asymptomatic. Budtz-Jorgenson
were nonvital, possibly because of systematic, excessive and Isidorls compared 27 patients treated with mandibu-
strain directed to the nonvital teeth. Because these pro- lar distal extension cantilever FPDs and 26 patients with
gressive types of fractures are time-dependent, fatigue may mandibular RPDs, and concluded that symptoms of man-
be a crucial consideration. Most restorative fractures dibular dysfunction were significantly aggravated in the
occurred mesial to the most distal cantilevered abutments. RPD group during the 2-year study. The occlusion was
The maximal strength of most luting cements is satisfactory after 2 years in 90% of the FPD group but in
compressive, the minimal strength is tensile, and the shear only 76% of the RPD group. In the FPD group there was
strength has an interval value. Apically directed forces on sparse need for further dental treatment, whereas in the
the cantilever direct tensile forces to the cement of the RPD group 22 carious teeth were restored, including eight
retainer farthest from the cantilever. The tooth prep- major adjustments of the sublingual bar.
aration of the abutment should have adequate vertical The cantilever FPDs require at least two abutment
length and parallel sides to resist tensile shear forces. The teeth.3 The only documented exception permitting a single
cement should also possess maximal tensile and shear abutment is the replacement of a maxillary lateral incisor
strength.17 with the canine as an abutment.13 Although a healthy ca-
A literature review did not clearly identify specific solu- nine commonly exhibits adequate periodontal support, the
tions to improve the prognosis of the FPD cantilever, but pontic, without a mesial rest on the central incisor, acts as
emphasized the need to analyze the individual biologic and a lever arm, causing a belated orthodontic movement of the
technologic conditions of each patient. The prognosis will canine.
improve if: LOSSof contact between the pontic and central incisor
1. Abutment teeth have long roots and acceptable alveo- also invites food impaction. The prognosis is improved if
lar support. the incisors have a near edge-to-edge occlusal relationship
2. Tooth preparations for abutments have adequate without occlusal contact on the lateral incisor. These res-
length and parallel-sided walls. torations should be considered when the central incisor is
3. Vital abutment teeth are included. intact and esthetic or when an implant is impracticable.
4. The number of abutments are increased but the num- Premolars may be replaced by cantilevered FPDs to avoid
ber of pontics are decreased.
involvement of a canine or a preexisting FPD, but double
5. The retainers are bilateral and the pontics are unilat-
eral. abutments or splinted teeth are indicated.13
6. The occlusion is well equilibrated and harmonious. A cantilevered FPD is favored to replace molars and
7. Complete crowns are of the veneer type. avoid a unilateral RPD, but does not improve masticatory
8. Connectors of the distal abutment tooth adjacent to efficiency. The pontic prevents supraeruption of an oppos-
the pontic are sturdy. ing tooth or encourages stability for an opposing removable
9. The patient’s hygiene is exemplary. prosthesis.

486 APRIL 1992 VOLUME 67 NUMBER 4

CANTILEVER FIXED PARTIAL DENTURE

An alternative to the cantilever FPD could be osseointe- 2. Henderson D, Blevins WR, Wesley RC, Seward T. The cantilever type
of posterior fixed partial dentures: a laboratory study. J PROSTHET
grated implants to enhance mastication.21 As osseointe-
DENT 1970;24:47-67.
grated implants become more popular, the need for the 3. Wright KW, Yettram AL. Reactive force distributions for teeth when
tooth-supported cantilever FPD may decline but it will re- loaded singly and when used as fixed partial denture abutments. J
PROSTHET DENT 1979;42:411-6.
main an alternative treatment if implants are contraindi-
4. Glantz PO, Nyman S, Strandman E, Randow K. On functional strain
cated for anatomic, medical, economic, or psychologic rea- in fixed mandibular reconstructions. II. An in viva study. Acta Odontol
sons. Stand 1984;42:269-76.
5. Glantz PO, Strandman E, Svenson SA, Randow K. On functional strain
SUMMARY in fixed mandibular reconstructions. I. An in vitro study. Acta Odontol
Stand 1984,42:241-g.
The current, optimal treatment for replacing missing 6. Lundgren D, Laurel1 L. Occlusal force pattern during chewing and bit-
ing in dentitions restored with fixed bridges of cross-arch extension. II.
teeth is an FPD secured at both ends. The cantilever is
Unilateral posterior two-unit cantilevers. J Oral Rehabil 1986;13:191-
considered a compromise but is preferred to the RPD, es- 203.
pecially for unilateral edentulous dentitions. 7. Lundgren D, Laurel1 L. Occlusal force pattern during chewing and bit-
ing in dentitions restored with fixed bridges of cross-arch extension. I.
There is consensus that an increase in abutment teeth
Bilateral end abutments. J Oral Rehabil 1985;13:57-61.
with a reduction in the number and size of cantilevered 8. Dubner A, Sessle B, Storey A. The neural basis of oral and facial func-
pontics is essential. Although abutments should have suit- tion. New York: Plenum Press, 1978311.
9. Laurel1 L, Lundgren D. Periodontal ligament areas and occlusal forces
able periodontal support, investigators have demonstrated in dentitions restored with cross-arch unilateral posterior two-unit
that extensive cross-arch FPDs with cantilevers can be in- cantilever bridges. J Clin Periodontol 1986;13:33-8.
serted with a minimal periodontal ligament if the occlusion 10. Randow K, Glantz PO. On cantilever loading of vital and non-vital
teeth. An experimental clinical study. Acta Odontol Stand 1986;
is stable and harmonious. The deflective capacity of the
44271-7.
cantilever with the stimulation of the mechanoreceptors in 11. Nyman S, Lindhe J, Lundgren D. The role of occlusion for the stability
the periodontium reduces the stress on the restoration of fixed bridges in patients with reduced periodontal tissue support. J
aiding the compromised periodontal ligament. The in- Clin Periodontol 19X$2:53-66.
12. Nyman S, Lindhe J. A longitudinal study of combined periodontal and
creased vertical space allows the construction of a thicker prosthetic treatment of patients with advanced periodontol disease. J
restoration and, with the reduced stress, moderates the Periodontol 1979;50:163-9.
13. Antonoff SJ. The status of cantilever bridges. Oral Health 1973;63:8-14.
mechanical failures of the prosthesis. The cantilever FPD
14. Randow K, Glantz PO, Zoger B. Technical failures and some related
is most suited to clinical situations with less stress, but in- clinical complications in extensive fixed prosthodontics. An epidemio-
vestigators disagree that a removable prosthesis in the op- logical study of long-term clinical quality. Acta Odontol Stand
posing dentition generates less stress. 1986;44:241-55.
15. Ewing JE. Re-evaluation of the cantilever principle. J PROSTHET DENT
The stress distribution in the cantilevered FPD requires 1957;7:78-92.
the abutment adjacent to the pontic to have suitable alve- 16. Erhardson WS. Fracture mechanics design of dental soldered joints
[Thesis]. Swed Dent J 1980;5:1-62.
olar support, and the preparation of the farthest abutment
17. Shillingburg TH, Jacobi R, Brackett SE. Fundamentals of tooth prep-
must be near parallel to prevent dislodgement of the arations. Chicago: Quintessence Publ, 1987:18-23.
retainer. 18. Budtz-Jorgensen E, Flemming I, Karring T. Cantilevered fixed partial
Technical failures are more common when nonvital teeth dentures in a geriatric population: Preliminary report. J PROSTHET
DENT 1985;54:467-73.
are abutments, because deterioration of tooth structure can 19. Budtz-Jorgensen E, Isidor F. Cantilever bridges or removable partial
be insidious. More occlusal force can also be inadvertently dentures in geriatric patients: A two-year study. J Oral Rehabil 1987;
extended to nonvital teeth because their pain threshold is 14239-49.
20. Kelly E. Changes caused by a mandibular removable partial denture
more tolerant. Investigators have differed as to whether opposing a maxillary complete denture. J PROSTHET DENT 1972;
functional force exerted on cantilever FPDs is sufficient to 27:140-50.
21. Lundgren D, Laurel1 L, Ealk H, Bergendel T. Occlusal force pattern
destroy the restoration.
during mastication in dentition with mandibular fixed partial dentures
Geriatric patients prefer the comfort of a cantilever FPD supported on osseointegrated implants. J PROSTHET DENT 1987; 58:197-
to an RPD, and less maintenance is required at subsequent 203.
appointments. With the rapid advancement of osseointe-
Reprint requests to:
grated implants, the cantilever FPDs may be used spar- DR. RAPHAEL Prto
ingly. DEPARTMENT OF ORAL REHABILITATION
THE MAURICE AND GABRIELA GOLDSCHLEGER SCHOOL OF DENTAL MEDICINE
REFERENCES TEL AVIV UNIVERSITY
TEL AVIV, ISRAEL
1. Wright WE. Success with the cantilever fixed partial denture. J PROS-
THET DENT 1987:55:542-5.

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