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-
toration with one or more abutments at one end and
unsupported at the other end.’ A class I lever system is
created if vertical and oblique forces directed to the pontic
result in forces on the abutment teeth greater than the ap-
plied stress.2 The relationship between biology and me-
chanics and the stress distribution within physiologic lim-
itations to the supporting structures is critical with a can-
tilever FPD.
FORCES AND STRESS DISTRIBUTION
Wright and Yettram, using the finite element method of
stress analysis in a two-dimensional form, demonstrated
that a nonaxial force applied on a single tooth elevated
forces in the periodontal membrane compared with an ax-
ial load on the same tooth. The forces were magnified as the
loading on the tooth became more oblique. Wright and
Yettram also confirmed that the force increased on the
periodontal membrane of a single tooth abutment with a
cantilever if the point load was direct to the free end of the
extension. If two abutment teeth with a cantilever were
*Instructor, Department of Oral Rehabilitation.
bSenior Clinical Lecturer, Department of Oral Rehabilitation.
‘Lecturer, Department of Oral Rehabilitation.
10/1/34664
splinted, both teeth resisted the rotating movement, and
the force on the periodontal membrane for both teeth was
diminished.
Henderson et a1.2used a practical model and a laboratory
model of a three-abutment posterior FPD with strain
gauges. In both models, forces transmitted to the abut-
ments through the cantilevered pontics were resisted by
rotational and tilting movements ofthe abutments but not
parallel to the vertical axis of the abutment roots. More
than 50 % of the force applied to the cantilever pontic was
absorbed by the abutment nearest the cantilever pontic,
but the addition of abutment teeth lessened the force on
the distal abutment.
Glantz et a1.4used six linear strain gauges and one rosette
gauge to record functional deformation in a conventional
six-unit mandibular FPD in a partially edentulous patient.
All gauges exhibited elongation when the FPD was func-
tionally loaded. The distal abutment retainer was then re-
moved, converting the FPD to a five-unit cantilever FPD,
and all gauges recorded contraction. The direction of prin-
cipal strain under the rosette gauge shifted more than 60
degrees on removal of the distal retainer. This study dem-
onstrated that clinical deformation differed from a labora-
tory model having the same distribution.5
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-
ducers were inserted into prosthetic restorations to regis-
ter occlusal forces during light tooth-tapping, chewing,
swallowing, and maximal biting. They demonstrated that
despite the activity, the distal cantilevered unit was sub-
jected to comparatively less stress than the contralateral
posterior abutment with equal or smaller than local ante-
rior forces. The diminished forces on the cantilever units
are attributed to a deflection of the cantilever units and not
to intrusion of the adjoining abutments.
In a comparative study of patients restored with cross-
arch FPDs with bilateral terminal abutments, an average
of 26% of the voluntary muscular capacity was activated
during chewing compared with 37 % in the bilateral termi-
nal abutment group.7 The differences were explained by
the unilateral lack of terminal abutments causing lateral
bending forces that activate peripheral inhibitory feedback
reactions from the periodontal and/or TMJ mechanore-
cept0rs.s
Axially directed masticatory forces are more consistently
influenced by the periodontal support with cross-arch ex-
tension FPD with unilateral cantilevers9 The less the pe-
riodontal ligament area, the smaller the occlusal force ex-
erted, suggesting that the mastication of dentitions with
unilateral posterior two-unit cantilevers is modulated more
by the mechanoreceptors of the periodontal membrane
than by dentitions with bilateral, terminal abutments. Ex-
cessive bending forces from the cantilevers can alter the
feedback control mechanism from the periodontal mecha-
noreceptors, magnifying neuromuscular sensitivity. How-
ever, the periodontal tissues do not affect the local forces
on the distal unit of the cantilever because of the deflection
of the cantilever.6
The importance of the mechanoreceptor mechanism of
the periodontal membrane was emphasized by Randow
and Glantz.l” They discovered that there was a definite
difference in the biomechanic reactions on cantilever load-
ing between vital and nonvital teeth. The tolerable loading
levels in nonvital teeth were twice that of vital teeth. Nev-
ertheless, the vital and nonvital teeth had the same level of
tolerable loading when the abutments were anesthesized.
They concluded that the vital teeth with optimal bone
support had a more efficient form of mechanoreceptor
function at lower degrees of bending than nonvital teeth.
This elevated response may also explain the greater me-
chanical failure associated with endodontically treated
abutment teeth.
THE ROLE OF OCCLUSION
Longitudinal studiesi’* l2 have confirmed that dentition
can be rehabilitated by use of FPDs with cantilever pontics
on specific, isolated abutments that are periodontally
compromised. Stable FPDs were successful despite indi-
vidual hypermobile abutment teeth. Prolonged stability
THE JOURNAL OF PROSTHETIC DENTISTRY
was achieved by periodontal treatment and the develop-
ment of a stable, nontraumatizing occlusion. Balancing
contacts were established to prevent migration, tilting, and
increasing mobility when there was a possibility of FPD
mobility during mandibular movements.
The masticatory forces are decreased with periodontally
compromised teeth in dentitions with cross-arch unilateral
posterior two-unit cantilever FPDs. The quadrants with
the cantilevers were never designated as the preferred
chewing side.g Thus, if the occlusion is stable and the can-
tilever free from premature contacts, the cantilever would
be only inadvertantly subjected to large forces.
Antonoff13 stated that cantilever FPDs were more fre-
quently indicated when reduced stress was inherent, as
with a complete denture in the opposing dentition. How-
ever, Randow et a1.i4 reported no major clinical signifi-
cances between technical failures of cantilevered FPDs and
the type of opposing dentitions. They suggested that a
well-supported, stable complete denture could also gener-
ate high functional loading.
Wright1 believed that it was desirable to transfer the load
from the cantilever to the abutment teeth by establishing
the pontic as an occlusal stop and by narrowing the occlusal
table of the pontic but not as a “disoccluder.” An accept-
able guideline was to design the buccolingual width of the
pontic no broader than the narrowest retainer.
BIOMECHANICAL CONSIDERATIONS
The mechanics of the cantilever FPD require the abut-
ment adjacent to the replacement tooth to possesssuitable
periodontal support, l3 because the greatest functional
stress is directed to the nearest abutment.z Conversely, the
abutment tooth farthest from the pontic should be ex-
tremely retentive to resist the vertical dislodgement im-
parted by the cantilevered pontic.2, l3
Ewing15 cited the following criteria crucial for successin
evaluating the cantilever principle: acceptable periodontal
attachment and alveolar support, favorable root length and
shape, sufficient crown length, and a harmonious arch-to-
arch and tooth-to-tooth relationship. Wright and Yettram
concluded that a cantilever FPD should have at least two
abutments and not replace more than one tooth. When a
cantilevered pontic is placed posteriorly, additional abut-
ments may be included to withstand the strong forces of the
muscles of mastication.’
Echardson16 estimated a maximal force of 700 N acting
on the cantilever and believed that such a force could de-
stroy the FPD adjacent to the cantilever. However, Lun-
dgren and Laurel16 reported that the greatest individual
local force was 150 N if all stresses were actively concen-
trated at the distal cantilever unit. They claimed that such
forces were unlikely to occur in natural function unless the
cantilevers are subjected to premature contacts of inordi-
nate and nonclinical size.
485

Laurel1 and Lundgrens claimed that a unilateral poste-
rior two-unit cantilever FPD with reduced periodontal
support had a better longitudinal prognosis considering
material strength. The increased vertical space allows
thicker FPD components and reduced periodontal support
allows less chewing and biting force.
Giantz et a1.4illustrated that the greatest strain in can-
tilevered FPDs was recorded mesial to the most distal re-
tainer, identifying this region as vulnerable. In extensive
oral rehabilitation with numerous edentulous spaces, the
distal retainer should be designed as complete crowns with
near parallel walls on the tooth preparation to ensure re-
tention.
Porcelain-to-gold cantilever restorations are commonly
contraindicated because of porcelain fracture due to in-
creased bending movement at the junction of pontic and
retainer.13 In a posttreatment study of 316 FPDs after 6 to
7 years, Randow et a1.14discovered a linear relationship
between the frequency of technique failures, such as frac-
tures and loss of retention (8% to 34%), and the total of
cantilever pontics in the restoration.
Failures were more common when the distal abutments
were nonvital, possibly because of systematic, excessive
strain directed to the nonvital teeth. Because these pro-
gressive types of fractures are time-dependent, fatigue may
be a crucial consideration. Most restorative fractures
occurred mesial to the most distal cantilevered abutments.
The maximal strength of most luting cements is
compressive, the minimal strength is tensile, and the shear
strength has an interval value. Apically directed forces on
the cantilever direct tensile forces to the cement of the
retainer farthest from the cantilever. The tooth prep-
aration of the abutment should have adequate vertical
length and parallel sides to resist tensile shear forces. The
cement should also possess maximal tensile and shear
strength.17
A literature review did not clearly identify specific solu-
tions to improve the prognosis of the FPD cantilever, but
emphasized the need to analyze the individual biologic and
technologic conditions of each patient. The prognosis will
improve if:
1. Abutment teeth have long roots and acceptable alveo-
lar support.
2. Tooth preparations for abutments have adequate
length and parallel-sided walls.
3. Vital abutment teeth are included.
4. The number of abutments are increased but the num-
ber of pontics are decreased.
5. The retainers are bilateral and the pontics are unilat-
eral.
6. The occlusion is well equilibrated and harmonious.
7. Complete crowns are of the veneer type.
8. Connectors of the distal abutment tooth adjacent to
the pontic are sturdy.
9. The patient’s hygiene is exemplary.
486
HIMMEL ET AL
10. The restorative material used for the FPD is extremely
rigid.
11. The cement has a high tensile strength.
CLINICAL APPLICATIONS
Cantilever FPDs with adequate periodontal support
have universal application, l3 but special emphasis is ex-
tended to cantilever FPDs as an alternative to RPDs.18~ls
Epidemiologic studies have verified that mandibular an-
terior teeth are retained intraorally the longest; thus resto-
rations for elderly patients are commonly complete maxil-
lary dentures and mandibular RPDs. A common complica-
tion of the mandibular RPD is resorption of the maxillary
anterior alveolar ridge, described by Kelly20 as the “com-
bination syndrome.”
Budtz-Jorgensen et alla reported on 27 patients treated
with maxillary complete dentures and distally extension
cantilever FPDs. All 27 patients, including those who for-
merly adapted well to the RPD, expressed a pronounced
improvement in mastication and in the stability of the
complete maxillary denture. After 2 years, all FPDs were
intact and the abutments asymptomatic. Budtz-Jorgenson
and Isidorls compared 27 patients treated with mandibu-
lar distal extension cantilever FPDs and 26 patients with
mandibular RPDs, and concluded that symptoms of man-
dibular dysfunction were significantly aggravated in the
RPD group during the 2-year study. The occlusion was
satisfactory after 2 years in 90% of the FPD group but in
only 76% of the RPD group. In the FPD group there was
sparse need for further dental treatment, whereas in the
RPD group 22 carious teeth were restored, including eight
major adjustments of the sublingual bar.
The cantilever FPDs require at least two abutment
teeth.3 The only documented exception permitting a single
abutment is the replacement of a maxillary lateral incisor
with the canine as an abutment.13 Although a healthy ca-
nine commonly exhibits adequate periodontal support, the
pontic, without a mesial rest on the central incisor, acts as
a lever arm, causing a belated orthodontic movement of the
canine.
LOSSof contact between the pontic and central incisor
also invites food impaction. The prognosis is improved if
the incisors have a near edge-to-edge occlusal relationship
without occlusal contact on the lateral incisor. These res-
torations should be considered when the central incisor is
intact and esthetic or when an implant is impracticable.
Premolars may be replaced by cantilevered FPDs to avoid
involvement of a canine or a preexisting FPD, but double
abutments or splinted teeth are indicated.13
A cantilevered FPD is favored to replace molars and
avoid a unilateral RPD, but does not improve masticatory
efficiency. The pontic prevents supraeruption of an oppos-
ing tooth or encourages stability for an opposing removable
prosthesis.
APRIL 1992 VOLUME 67 NUMBER 4
CANTILEVER FIXED PARTIAL DENTURE
An alternative to the cantilever FPD could be osseointe-
grated implants to enhance mastication.21 As osseointe-
grated implants become more popular, the need for the
tooth-supported cantilever FPD may decline but it will re-
main an alternative treatment if implants are contraindi-
cated for anatomic, medical, economic, or psychologic rea-
sons.
SUMMARY
The current, optimal treatment for replacing missing
teeth is an FPD secured at both ends. The cantilever is
considered a compromise but is preferred to the RPD, es-
pecially for unilateral edentulous dentitions.
There is consensus that an increase in abutment teeth
with a reduction in the number and size of cantilevered
pontics is essential. Although abutments should have suit-
able periodontal support, investigators have demonstrated
that extensive cross-arch FPDs with cantilevers can be in-
serted with a minimal periodontal ligament if the occlusion
is stable and harmonious. The deflective capacity of the
cantilever with the stimulation of the mechanoreceptors in
the periodontium reduces the stress on the restoration
aiding the compromised periodontal ligament. The in-
creased vertical space allows the construction of a thicker
restoration and, with the reduced stress, moderates the
mechanical failures of the prosthesis. The cantilever FPD
is most suited to clinical situations with less stress, but in-
vestigators disagree that a removable prosthesis in the op-
posing dentition generates less stress.
The stress distribution in the cantilevered FPD requires
the abutment adjacent to the pontic to have suitable alve-
olar support, and the preparation of the farthest abutment
must be near parallel to prevent dislodgement of the
retainer.
Technical failures are more common when nonvital teeth
are abutments, because deterioration of tooth structure can
be insidious. More occlusal force can also be inadvertently
extended to nonvital teeth because their pain threshold is
more tolerant. Investigators have differed as to whether
functional force exerted on cantilever FPDs is sufficient to
destroy the restoration.
Geriatric patients prefer the comfort of a cantilever FPD
to an RPD, and less maintenance is required at subsequent
appointments. With the rapid advancement of osseointe-
grated implants, the cantilever FPDs may be used spar-
ingly.
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THE JOURNAL OF PROSTHETIC DENTISTRY
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Reprint requests to:
DR. RAPHAEL Prto
DEPARTMENT OF ORAL REHABILITATION
THE MAURICE AND GABRIELA GOLDSCHLEGER SCHOOL OF DENTAL MEDICINE
TEL AVIV UNIVERSITY
TEL AVIV, ISRAEL
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