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Q U I N T E S S E N C E I N T E R N AT I O N A L

Clinical long-term survival of two-retainer and

single-retainer all-ceramic resin-bonded
fixed partial dentures
Matthias Kern, DMD, PhD1

Objectives: All-ceramic resin-bonded fixed partial dentures (RBFPDs) were introduced as

a conservative treatment approach 15 years ago. The purpose of this prospective study
was to evaluate the long-term clinical survival of RBFPDs made with a conventional two-
retainer design or a cantilever single-retainer design. Method and materials: A total of 37
anterior RBFPDs were made from the glass-infiltrated alumina ceramic In-Ceram. Sixteen
RBFPDs with a conventional two-retainer design were inserted in 14 patients, and 21
RBFPDs with a cantilever single-retainer design were inserted in 16 patients. Panavia or
Panavia 21 were used as luting agents either after silica-coating and silanation or after air-
abrasion only. Patients were recalled every year for a clinical examination to evaluate the
restorations with regard to function and possible failures. The mean observation time in
the two-retainer group was 75.8 months, and in the single-retainer group it was 51.7
months. Results: No restoration debonded. In the two-retainer group, one restoration was
lost because it fractured after 3 months at both connectors and one restoration was
removed alio loco accidentally. Also in this group, four RBFPDs fractured within 15
months after insertion at one connector, but the pontic remained in situ as a cantilever
RBFPD for several years. In the single-retainer group, only one FPD fractured and was lost
48 months after insertion. The 5-year survival rate was 73.9% in the two-retainer group
and 92.3% in the single-retainer group. When unilateral fracture of a FPD was taken as cri-
terion for failure, the five-year survival rate decreased to 67.3% in the two-retainer group.
Conclusions: Cantilever all-ceramic resin-bonded fixed partial dentures made from high-
strength oxide ceramics present a promising treatment alternative to two-retainer RBFPDs
in the anterior region. (Quintessence Int 2005;36:141–147)

Key words: adhesive, all-ceramic restoration, alumina ceramic, cantilever fixed partial
denture, ceramic bonding, ceramic fracture, resin-bonded fixed partial
denture, success rate

All-ceramic resin-bonded fixed partial den- metal-ceramic RBFPDs in terms of esthetics

tures (RBFPDs) made from the glass-infiltrat-
ed alumina ceramic In-Ceram (Vita) were
introduced in the early 1990s for the anterior
region because they present advantages over
1
Professor and Chairman, Department of Prosthodontics,
Propaedeutics and Dental Materials, School of Dentistry,
Christian-Albrechts University, Kiel, Germany.
Reprint requests: Prof Dr Matthias Kern, Department of
Prosthodontics, Propaedeutics and Dental Materials, School
of Dentistry, Christian-Albrechts University, Arnold-Heller-Str
16, 24105 Kiel, Germany. E-mail: mkern@proth.uni-kiel.de
and biocompatibility.1 Unfortunately, such
two-retainer all-ceramic RBFPDs showed a
relatively high fracture rate within the first year
of clinical service.2 However, most unilaterally
fractured restorations remained in function as
cantilever fixed partial dentures for 5 or more
years.
Figures 1 to 7 present a clinical case of a
19-year-old male patient who received two
all-ceramic RBFPDs to replace his maxillary
lateral incisors. Unfortunately, one of the
restorations fractured after 10 months when
the patient was hit on his right central incisor.

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Kern

Fig 1 (left) Nineteen-year-old male patient with two congenitally missing maxillary lateral incisors.
Fig 2 (center) Two-retainer all-ceramic RBFPDs made from the glass-infiltrated alumina ceramic In-Ceram and veneered with Vitadur alpha.
Fig 3 (right) Bonding of the RBFPDs with Panavia TC after air abrasion, silica coating, and silane application to the retainer wings.

Fig 4 (top left) Occlusal view of the inserted two-retainer all-ceramic RBFPDs.
Fig 5 (center) Frontal view of the inserted all-ceramic RBFPDs.
Fig 6 (right) Incisal fracture of the right central incisor caused by a traumatic blow to
the mouth 10 months after insertion of the RBFPDs.
Fig 7 (bottom left) Occlusal view of the unilaterally fractured all-ceramic two-retainer
RBFPD. The fractured restoration remained in situ as a two-unit cantilever RBFPD.

However, both restorations remained in clini- METHOD AND MATERIALS

cal service for more than 12 years.
Because of the clinical survival of the uni-
laterally fractured RBFPDs, in 1997 cantilever
all-ceramic RBFPDs were suggested as an
even more conservative treatment approach.3
Figures 8 to 16 present a clinical case of an
18-year-old male patient who received two all-
ceramic RBFPDs to replace both missing
maxillary lateral incisors.
The purpose of this prospective study was
to evaluate the clinical survival of all-ceramic
RBFPDs with a cantilever single-retainer
design and to compare it with that of the pre-
viously used conventional two-retainer
design.
A total of 37 anterior resin-bonded fixed par-
tial dentures (Table 1) were made from the
glass-infiltrated aluminum oxide ceramic In-
Ceram, which was veneered with Vitadur-
Alpha (Vita). All clinical procedures for 24 of
the RBFPDs were done by the author; for the
other 13 restorations, all clinical steps were
performed by postgraduate students under
close supervision of the author.
Sixteen RBFPDs with the conventional
two-retainer design were made from In-
Ceram alumina with the slip cast technique.1
They were inserted in 14 patients between
1991 and 1995. Before bonding the restora-
tions with Panavia TC (Kuraray), the bonding

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142 VOLUME 36 • NUMBER 2 • FEBRUARY 2005
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Figs 8 to 10 Eighteen-year-old male patient with two congenitally missing upper lateral incisors.

Fig 11 (left) Veneer preparation of the palatal abutment surface within the enamel (unprepared enamel marked with blue ink).
Fig 12 (center) Single-retainer all-ceramic RBFPDs made from the glass-infiltrated alumina ceramic In-Ceram and veneered with Vitadur alpha.
Fig 13 (right) Bonding of the RBFPDs with Panavia 21 TC after air abrasion of the retainer wings.

Figs 14 to 16 Views of the inserted single-retainer all-ceramic RBFPDs.

Ta b l e 1 Frequency distribution of pontic location

Two-retainer Single-retainer
RBFPDs RBFPDs

Central Lateral Central Lateral

incisors incisors Total incisors incisors Total

Maxilla 5 4 9 0 15 15
Mandible 6 1 7 4 2 6
Total 11 5 16 4 17 21

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Q U I N T E S S E N C E I N T E R N AT I O N A L
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Fig 17 Schematic drawing of the applied palatal and
proximal veneer preparation. v = veneer, b = box, c =
small chamfer, s = small shoulder, p = pinhole.
surface of the alumina ceramic was tribo-
chemically silica-coated and then silanated
(Rocatec procedure, 3M Espe).4 A dry work-
ing field was achieved intraorally by applying
a rubber dam to the abutment teeth.
Because of the above-described initial
results with the two-retainer design,2 from
1996 only RBFPDs with a cantilever single-
retainer design were made. Therefore, 21
cantilever single-retainer design RBFPDs
were made with the In-Ceram-Celay copy-
milling technique; these were inserted in 16
patients.3 Thirteen of these RBFPDs were
made from In-Ceram alumina between 1996
and 1998. After the stronger In-Ceram zirco-
nia containing about 26% zirconium oxide
was available, 8 RBFPDs were made be-
tween 1999 and 2001 from this material to
take advantage of the progress in ceramic
materials. The bonding surfaces of the single
retainers were air-abraded with 50 µm alu-
minum oxide powder at 2.5 bars pressure,
and the luting agent Panavia 21 TC (Kuraray)
was used for bonding after rubber dam appli-
cation because by that time it was known that
silica coating was not necessary when using
Panavia.5,6
The ceramic framework of the fixed partial
dentures consisted of one or two lingual
retainer wings with a connector to the pontic.
The minimal dimensions of the In-Ceram
frameworks were 2 mm connector thickness
in labiolingual direction and 3 mm connector
height in cervicoincisal direction. The thick-
ness of the ceramic retainer wings was 0.5 to
0.7 mm. There were no dynamic occlusal
contacts on the pontics.
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144 VOLUME 36
The preparation of the abutment teeth was
conservative and only within the enamel. It
included a lingual veneer, a groove on the
cingulum, and a small proximal box prepara-
tion (dimensions: 2 mm
1 mm
0.5 mm).
The tooth preparation design provided a def-
inite seat for the restoration but did not pro-
vide mechanical retention (Fig 17).
Patients were recalled every year for a clin-
ical examination to evaluate the restorations
with regard to function and possible failures.
The RPFPDs were inspected for signs of
fracture in the ceramic or debonding of the
retainer wings, and for abutment movement
or increased abutment mobility as compared
to the initial findings documented by casts
and patient records, respectively. Patients
who moved out of the region and could not
come for a clinical examination were con-
tacted by phone and asked if the restoration
was still functioning without any problems.
Using the Kaplan-Meier method,7 the sur-
vival rates of the restorations were analyzed
for two criteria, fractures and loss of the
restoration. In the two-retainer group, a uni-
lateral fracture did not necessarily lead to
loss of the restoration but converted the con-
ventional RBFPD into a cantilever FPD.
RESULTS
The mean observation time for the two-retain-
er group was 76 ± 46 months with a minimum
of 3 and a maximum of 146 months. The
mean observation time for the single-retainer
group was 52 ± 17 months with a minimum of
25 and a maximum of 86 months.
In the two-retainer group, one restoration
with a maxillary central incisor pontic was lost
because it fractured after 3 months at both
connectors, and one restoration with a
mandibular incisor pontic was removed alio
loco accidentally. Also in the two-retainer
group, four restorations fractured within 15
months after insertion at one connector, but
the pontic remained in situ as a cantilever
restoration for up to 12 years. The unilaterally
fractured RBFPDs consisted of two maxillary
central incisor pontics and two maxillary later-
al insicor pontics. One unilateral fracture was
• NUMBER 2 • FEBRUARY 2005
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Fig 18 Survival curves of all-ceramic RBFPDs accord-
ing to the method of Kaplan and Meier7 (N = 37), suc-
cess criterion: restoration in situ.
caused by trauma; the other failures occurred
during normal mastication. Two of the unilat-
erally fractured RBFPDs were removed after
22 and 61 months, respectively. In the single-
retainer group only one restoration with a
maxillary lateral incisor pontic fractured and
so was lost 48 months after insertion. Despite
ceramic fractures, all retainer wings remained
bonded to the abutment teeth.
The 5-year survival rate according to
Kaplan-Meier was 73.9% in the two-retainer
group and 92.3% in the single-retainer group
when only restorations that had been
removed were considered as failures (Fig
18). However, due to the limited number of
restorations, this difference was not statisti-
cally significant as shown by the Gehan-
Wilcoxon test (P > .05).
However, when unilateral fractures of
restorations in the two-retainer group were
taken as criterion for failure, the 5-year suc-
cess rate decreased to 67.3% in this group
(Fig 19). Considering fractures, the success
rates of the two groups were statistically sig-
nificantly different as shown by the Gehan-
Wilcoxon test (P = .014).
DISCUSSION
All-ceramic RBFPDs made from the glass-
infiltrated alumina ceramic In-Ceram with a
two-retainer design showed a high fracture
rate within the first years of clinical service.
The reason for the high fracture rate may be
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Q U I N T E S S E N C E I N T E R N AT I O N A L
Kern
Fig 19 Survival curves of all-ceramic RBFPDs
according to the method of Kaplan and Meier7 (N =
37), success criterion: restoration in situ without any
fracture.
the differential movement of the abutment
teeth during function, especially during pro-
trusive and lateral movements under tooth
contact. However, in the single-retainer
RBFPDs, the pontic always moves with the
one abutment tooth, which prevents shear
and torque forces on the pontics and the
connectors. The improved long-term clinical
outcome of single-retainer RBFPDs as com-
pared to two-retainer RBFPDs is in agree-
ment with findings of studies on RBFPDs
with metal frameworks, as shown by a recent
literature review.8
However, this study was not a randomized
clinical trial; it evolved over time with the pro-
gression of ceramic materials and increased
knowledge in bonding technology. Given
that the ceramic materials and ceramic pro-
cessing and bonding procedures had been
changed between the different retainer
groups, the better outcome of the single-
retainer group might not only be related to
retainer design but also to the other factors.
In spite of these limitations, this study shows
that the simplified single-retainer design has
a promising clinical outcome, which justifies
its usage.
For the single-retainer FPDs it is assumed
that the periodontal receptors of the abut-
ment teeth prevented overloading of the pon-
tics during mastication. No clinically relevant
movement or tilting of the abutment teeth was
recorded in the current study, which is in
agreement with a study on metal-ceramic
cantilever RBFPDs.9 Therefore, it seems that
the proximal contact of the cantilever pontic
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Q U I N T E S S E N C E I N T E R N AT I O N A L
Kern
to the adjacent tooth sufficiently prevents
tooth migration. However, our results support
such cantilever resin-bonded fixed partial
dentures only for the anterior region of the
mouth.
All clinical failures were caused by frac-
tures of the alumina ceramic FPD framework.
In no instance did the ceramic-resin-enamel
bond fail, as the retainer wings always
remained bonded to the abutment teeth.
These results support previous laboratory
findings which showed that the resin bond
strength of such alumina ceramic RBFPDs
exceeded their fracture strength.10–13
The preparation of the abutment teeth
allowed a defined insertion of the restoration
during bonding but was small and had no
retentive form. Functioning of the restorations
relied completely on the resin bond and not
on additional mechanical retention. The
methods of bonding to the glass-infiltrated
alumina ceramic used in this study were cho-
sen because of its effectiveness shown in a
previous laboratory studies.4,6 The methods
included first tribochemically silica coating
and silanating the alumina ceramic and then
bonding the ceramic restorations to the abut-
ment teeth using the phosphate monomer
containing composite resin Panavia. Next, for
the single-retainer group the alumina ceram-
ic was only air-abraded and then retainer
bonded using the phosphate monomer con-
taining composite resin Panavia 21. As no
debonding occurred, the bonding methods
used did not influence the clinical outcome.
However, the study shows that oxide ceram-
ics, such as In-Ceram alumina and In-Ceram
zirconia, can be bonded intraorally with
phosphate monomer containing composite
resin for long-term success.
Recent laboratory studies14–19 suggest
that phosphate monomers containing com-
posite resins such as Panavia 21 and
Panavia F also provide a reliable resin bond
to densely sintered alumina and zirconia
ceramic without the glass phase when the
bonding surface of the ceramics is air-abrad-
ed prior to bonding.
Because of clinical fractures experienced
with In-Ceram FPDs and the further
improved fracture strength and fracture
toughness of zirconia ceramic, we recently
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146 VOLUME 36
began to use densely sintered zirconia
ceramic as framework material for all-ceram-
ic RBFPDs (Figs 20 to 24). Using the Cerec 3
Inlab system (Sirona) the zirconia ceramic
framework can easily be milled out of pre-sin-
tered zirconia ceramic blocks (YZ-cubes,
Vita). After the framework is milled, it is
densely sintered in a special furnace. After
try-in the zirconia framework is veneered with
a feldspathic ceramic and bonded to the
abutments with tooth-colored phosphate
monomer containing resin (Panavia 21 or
Panavia F 2.0). It is assumed that the use of
densely sintered zirconia ceramic will broad-
en the indication for cantilever resin-bonded
all-ceramic FPDs and will further improve
longevity.
CONCLUSIONS
Cantilever all-ceramic RBFPDs made from
high-strength oxide ceramics present a
promising treatment alternative to two-retain-
er RBFPDs in the anterior region.
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Fig 20 (left) Frontal view a 19-year-old female patient with two congenitally missing maxillary lateral incisors after orthodontic closure of
a diastema mediale.
Fig 21 (center) Milled zirconia ceramic framework from a pre-sintered block (In-Ceram yz-cubes, Vita).
Fig 22 (right) Try-in of the densely sintered zirconia ceramic framework.

Fig 23 (left) Inserted all-ceramic RBFPD with two cantilever pontics.The two retainers were splinted
to retain the orthodontic result and prevent an opening of the diastema mediale.
Fig 24 (right) One week after insertion of the all-ceramic restoration.

8. van Dalen A, Feilzer AJ, Kleverlaan J. A literature
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dont 2004;17:281–284.
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