Anterior Cantilever Resin-Bonded Fixed Dental Prostheses:

A Review of the Literature

Bilal Mourshed, DDS, MSc,1 Abdulaziz Samran, DDS, MSc, DMD,2,3,4 Amal Alfagih, DDS, MSc,5
Ahalm Samran, DDS, MSc,5 Saleem Abdulrab, DDS, MSc,6 & Matthias Kern, Prof Dr Med Dent Habil2
1
Department of Prosthodontics, Al-Farabi Dental College, Riyadh, Saudi Arabia
2
Department of Prosthodontics, Propaedeutics and Dental Materials, School of Dentistry, Christian-Albrechts University, Kiel, Germany
3
Department of Fixed Prosthodontics, School of Dentistry, Ibb University, Ibb, Yemen
4
Department of Prosthodontics & Restorative Dental Sciences, School of Dentistry, Dar-Aluloom University, Riyadh, Saudi Arabia
5
Shiny Centrals Dental Private Center, Riyadh, Saudi Arabia
6
Department of Restorative Dental Sciences, Al-Farabi Dental College, Riyadh, Saudi Arabia

Keywords
Survival rate; cantilever; RBFDPs, review.
Correspondence
Abdulaziz Samran, Department of
Prosthodontics, Propaedeutics and Dental
Materials, School of Dentistry,
Christian-Albrechts University, Arnold-Heller
Strasse 16, 24105 Kiel, Germany.
E-mail: asamran@proth.uni-kiel.de
The authors declare there are no conflicts of
interest.
Accepted September 4, 2016
doi: 10.1111/jopr.12555
Abstract
Purpose: This review evaluated the survival rate of single retainer anterior resin-
bonded fixed dental prostheses (RBFDPs) to determine whether the choice of material
affects their clinical outcome.
Materials and Methods: An electronic search of the English peer-reviewed dental
literature in PubMed was conducted to identify all publications reporting on cantilever
RBFDPs until May 2016. Study information extraction and methodological qual-
ity assessments were accomplished by two reviewers independently. The searched
keywords were as follows: “resin-bonded, single retainer, all-ceramic resin-bonded
fixed dental prostheses (RBFDPs), all-ceramic RBFDPs, cantilever resin, RBFDPs,
cantilever resin-bonded bridge, two units cantilevered, two-unit cantilevered, metal-
ceramic cantilever, and metal-ceramic.” Furthermore, the ‘‘Related Articles’’ feature
of PubMed was used to identify further references of interest within the primary
search. The bibliographies of the obtained references were used to identify pertinent
secondary references. Review articles were also used to identify relevant articles.
After the application of exclusion criteria, the definitive list of articles was screened
to extract the qualitative data, and the results were analyzed.
Results: Overall 2588 articles were dedicated at the first review phase; however,
only 311 studies were left after the elimination of duplicates and unrelated studies.
Seventeen studies passed the second review phase. Five studies were excluded because
they were follow-up studies of the same study cohort. Twelve studies were finally
selected.
Conclusions: The use of cantilever RBFDPs showed promising results and high
survival rates.

In 1955, Buonocore’s introduction of bonding heralded new
possibilities in dentistry.1 In 1973, Rochette introduced the
concept of bonding a metal retainer (gold alloy) to enamel
using adhesive technology and showed that a more conserva-
tive preparation of the abutment teeth for fixed dental pros-
theses (FDPs) is possible than for that of cemented conven-
tional crown-retained FDPs.2 Knowledge has evolved since
then, and cobalt or nickel chromium are the desired alloys for
resin-bonded fixed dental prostheses (RBFDPs).3 However, the
most interesting modification was the use of oxide ceramics
instead of metals as the framework material for the concept in
the early 1990s. Nevertheless, many problems were associated
with this treatment concept, such as high failure rates caused by
debonding of metal-based RBFDPs and the fractures of all-
ceramic RBFDPs.4 However, to date, the clinical outcomes of
RBFDPs are compelling because of significant improvements
in materials and clinical techniques.
During the past 40 years, RBFDPs have evolved to a pre-
dictable treatment alternative for the replacement of missing
teeth. Nonetheless, the treatment modality using single retainer
all-ceramic RBFDP retainers evolved by chance5 when unilat-
erally fractured two-retainer RBFDPs remained in function as a
cantilever RBFDP for 5 or more years.6 The main advantages of
single retainer RBFDPs are the simplicity of the minimally in-
vasive preparation design and reduced financial costs. Another
advantage of this treatment compared with the two-retainer

266 Journal of Prosthodontics 27 (2018) 266–275 

C 2016 by the American College of Prosthodontists

Mourshed et al
design is that unrecognized unilateral debonding with high
caries risk will not occur. The use of cantilever RBFDPs elim-
inates the stress in the bonding interface caused by differential
mobility of abutment teeth when using the two-retainer design.
When selecting a two-retainer design, both abutments should
have similar mobility, otherwise the weaker abutment may de-
tach from the enamel, thereby compromising the entire result.7
In the cantilever RBFDPs, the pontic generally moves with the
single abutment tooth, which prevents shear and torque forces
resulting from the splinting of two abutments with differential
movements, particularly during protrusive and lateral move-
ments under tooth contact. In addition, the periodontal receptors
of the abutment teeth are assumed to prevent pontic overload-
ing during mastication, therefore minimizing the risk of moving
or tilting the abutment tooth.6 Additionally, cantilever pontics
might transfer higher tilting forces to their abutment teeth than
pontics fixed between two retainers. Such tilting forces regis-
tered by the periodontal receptors of the abutment teeth6 might
have alerted the patient not to overload the pontic.
With the advancement of new resin cements with improved
bonding capacity and types of materials, cantilever RBFDPs
might be an alternative treatment to conventional crown-
retained FDPs. Most restorations used in previous studies
were made of either metal,3,8-16 alumina-,6,17 or zirconia-based
ceramics.18-22 This review aims to evaluate the survival rate
of single retainer anterior RBFDPs to determine whether the
choice of material affects their clinical outcomes.
Materials and methods
Search methods
A broad search of the English peer-reviewed dental literature
was conducted in PubMed to identify all publications reporting
on cantilever RBFDPs until May 2016. The searched keywords
were as follows: “resin-bonded, single retainer, all-ceramic
resin-bonded fixed dental prostheses (RBFDPs), all-ceramic
RBFDPs, cantilever resin, RBFDPs, cantilever resin-bonded
bridge, two units cantilevered, two-unit cantilevered, metal-
ceramic cantilever and metal-ceramic.” Furthermore, the ‘‘Re-
lated Articles’’ feature of PubMed was used to identify further
references of interest within the primary search. The bibliogra-
phies of the obtained references were used to identify pertinent
secondary references. Review articles were also used to identify
relevant articles. After the application of exclusion criteria, the
definitive list of articles was screened to extract the qualitative
data, and the results were analyzed.
Inclusion criteria
1. Human subjects
2. English language
3. Studies on anterior all-ceramic and metal-ceramic can-
tilever RBFDPs
4. Randomized controlled clinical trials (RCTs), controlled
clinical trials (CCTs), retrospective studies (RSs), and
prospective studies (PSs)
5. Recent publications; starting from 2000
6. Studies with a minimum observation time of 2.5 years
7. Single retainer anterior RBFDPs
Journal of Prosthodontics 27 (2018) 266–275 
C 2016 by the American College of Prosthodontists
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Cantilever Resin-Bonded Fixed Dental Prostheses
First electronic and hand search 2588 articles
Independent selected by 2 reviewers 311 titles
(Abstracts obtained)
Discussion discarded
294 titles
Total full text 17, screened for
inclusion/exclusion criteria
5 Studies were
excluded for second
12 studies selected and included in the final phase
analysis
Figure 1 Search strategy used to identify the included studies.
Exclusion criteria
1. Animal studies
2. Papers in a language other than English
3. In vitro and finite element analysis studies
4. Case reports, case studies, and posterior RBFDPs
5. Studies before 2000
6. Short-term studies (less than 2.5 years)
7. Posterior RBFDPs
Results
Overall, 2588 articles were discovered at the first review phase;
however, only 311 studies were left after the elimination of
duplicates and unrelated studies. Seventeen studies passed the
second review phase. Of these 17 studies, 5 studies were ex-
cluded because they were follow-up studies of the same study
cohort.6,11-13,18 Finally, the literature search revealed 12 stud-
ies with observation periods of 3 years to 18 years (Fig 1,
Table 1).8,10,14-17,19-24 The quantitative data were extracted from
the 12 full-text articles (Tables 2, 3). Of these studies, only one
study was an RCT.19 Five studies were RSs,8,15,16,20,24 and the
other six were PSs.10,14,17,21-23
Tooth preparation
Two important variables, namely, tooth preparation and pros-
thesis design, are related to the clinical success of RBFDPs.11
Features such as grooves, rest seats, pits, occlusal channels, and
guide planes have been shown to improve retention.25-27 Many
investigators used grooves in their research,10,14,17,19,20 and the
survival rate was 100% with metal-ceramic, 90% with glass-
infiltrated alumina ceramic (In-Ceram),10 100% with metal-
ceramic (non-precious),14 92.3% with glass-infiltrated alumina
(In-Ceram alumina and In-Ceram zirconia),17 100% with zir-
conia (e.max ZirCAD) veneered with IPS e.max Ceram,19
and 100% with zirconia (IPS e.max ZirCAD) with veneer-
ing ceramic.20 As shown in Table 4, many articles stated that
the preparation did not provide any mechanical retention and
therefore relied completely on the resin bond.17,19,21 In addi-
tion, one article did not report any preparation at all.24 Notably,
the survival rates of these studies were 92.3%, 100%, 100%,
and 96.6%. All investigators also agreed that the preparation
267
 268
Table 1 List of the included literature

Study Observation No. of

Study design period restorations Materials used Failure type Success rate Survival rate Cement type Note

Botelho et al14 PS 18 years 13 Metal-ceramic No failure 100% 100% Panavia

Klink and Hüttig22 PS 35 months 23 Zirconia (various) 1 debonding 76%-82.4% 100% Multilink Variolink
2 chip-off
1 tooth movement
Sasse and Kern21 PS 6 years 42 Zirconia (various) 2 debondings 95.2% 100% Panavia 21 TC
1 carious lesion
Saker et al10 PS 5 years 20 Metal-ceramic No failures 100% Panavia 21 TC
20 Glass-infiltrated 3 debondings 90%
alumina 2 fractures
Cantilever Resin-Bonded Fixed Dental Prostheses

(In-Ceram)
Sailer and RS 5 years 15 Zirconia (various) 2 debondings 100% Panavia 21 TC No catastrophic
Hämmerle20 failure
Botelho et al8 RS 10 years 111 Metal-ceramic) 6 debondings in the Mx: Incisors Mx∗ : Incisors Panavia or Mixed study (anterior
maxilla 93.9% 97.0% Panavia 21 and posterior)
3 debondings in the Canine 80% Canine 80%
mandible
Mn: Incisors Mn∗ : Incisors
85.2% 88.9%
Canine 100% Canine 100%
Sun et al23 PS 4 years 35 Lithium disilicate No failures 100% Variolink
(IPS e.max
Press)
Sasse and Kern19 RCT 5 years 16 Zirconia (IPS 1 debonding (caused 93.8% 100 % Panavia 21 TC 100% survival rate
e.max ZirCAD) by trauma) because no
catastrophic failure

Journal of Prosthodontics 27 (2018) 266–275 

occurred
14 1 debonding (caused 92.9% 100 % Metal/Zirconia
by trauma) primer Multilink
Automix
Sailer et al24 RS 6 years 20∗ Glass ceramics No failure 100% 6 types of Mixed study (anterior
(93.9% IPS cements∗∗ and posterior)
e.max Press
and 6.1% IPS
Empress)

(Continued)
Mourshed et al

C 2016 by the American College of Prosthodontists

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Mourshed et al Cantilever Resin-Bonded Fixed Dental Prostheses

**Tetric Flow (Ivoclar Vivadent) for 67.3% of restorations, Tetric Ceram (Ivoclar Vivadent) for 14.3%, RelyX (3M ESPE) for 8.2%, Panavia F (Kuraray) for 6.1%, HFO (Optident) for 2.0%, and Variolink (Ivoclar
should be conservative at the lingual aspect with a supragingi-

cantilever full retain

Mixed study (fix and
Mixed study (fix-fix
val finish line and without penetration into dentine. According

and cantilever)

and RBFDPs)
to Table 4 and the survival rates, tooth preparation design on
Note single retainer RBFDPs did not reveal a strong influence on
retention.

*Treated in one private practice with six different types of cement. Data of anterior RPFDPs were extracted from the original article because they had been reported separately from posterior RBFDPs.
Clinical survival
Survival is defined as a prosthesis that is in situ at the time of
Cement type

review, irrespective of its condition and recementation.28 All

Panavia 21 TC

Panavia 21

Panavia 21
Panavia or studies agreed that cantilever RBFDPs have promising clinical

Panavia or
survival and functional longevity,6,8,10,14,17-24 although some
fracture6,10 and debondings8,10,15,16,18,20-22 occurred because of
material choice, trauma, or unknown reasons. The survival rate
of the RBFDPs was 100% in most studies, as follows: Sasse and
Survival rate

Kern 100%,21 Saker et al 90% to 100%,10 Sailer and Hämmerle

100%,20 Botelho et al 80% to 100%,8 Sun et al 100%,23 Sasse
92.3%

and Kern 100%,19 Sailer et al 96.6%,24 Kern and Sasse 92.3%,17

61%
NC

Botelho et al 100%,14 and Klink and Huttig 100%.22 However,

one study was in contrast to all other studies and showed a
survival rate of 61%.15
PS: prospective study, RCT: randomized clinical trial, RS: retrospective study, Mx: Maxilla, Mn: Mandible. NM: not mentioned, NC: not clear.
Success rate

Failure
NM
NM

If the prosthesis was debonded or absent at the time of clinical

evaluation, then it would be considered a “failure.”8 Failure
was generally confined to debonding, fracture, carious lesion,
and rotation; however, debonding was the most common type
Failure type

1 carious lesion

of failure observed in this review (Table 1).

25 debonding

2 debondings
1 fracture

Clinical experience
Clinical experience was not an influencing factor, as observed
in the RBFDPs placed by dental undergraduates (student) or
staff in one study.8 In addition, the debonding rate was not sig-
Materials used

Glass-infiltrated

Metal-ceramic
Metal-ceramic

nificantly different between the student group (including under-

(In-Ceram

In-Ceram
alumina/

zirconia)

graduate and postgraduate students) and full-time staff. Con-

alumina

versely, results were statistically significant when comparing

both supervised students and junior student hospital staff to se-
nior members of staff.16 In addition, the service life of RBFDPs
placed by full-time staff members was significantly longer than
restorations

that placed by the student group and junior members.8,16

No. of

22

18
62

Patient satisfaction
In Botelho et al’s study, approximately 95.2% of the patients
were satisfied with the RBFDP esthetics.8 Moreover, patient
59.3 months
Observation

29 months
period

satisfaction with the overall RBFDP experience was also high,

10 years

with an average assessment score of 9.0/10.8,23

Failure location
design
Study

Most debondings and fractures occurred in the maxilla

RS

RS
PS

(Table 1), but most studies did not localize the failure location.
Nevertheless, Sasse and Kern8,21 and Botelho et al8 stated that
no statistically significant difference could be observed when
Table 1 Continue

Vivadent) for 2.0%.

17
Kern and Sasse

comparing the rate of failure of cantilever RBFDPs replacing

Garnett et al16

maxillary incisors versus cantilever RBFDPs replacing incisors

Chai et al15

in the mandible. Additionally, the survival rate was not signifi-

Study

cantly affected by the location of maxillary central incisor and

maxillary lateral incisor replacement.10

Journal of Prosthodontics 27 (2018) 266–275 

C 2016 by the American College of Prosthodontists 269
 270
Table 2 List of the quantitative data of 8 definitive studies on all-ceramic cantilever RBFDPs

No. and type of

Type of Range of No. of No. of anterior failures during No. of failures after Failure
Study restoration follow up Patients Restorations Material used Failure type the first year the first year correction Note

Klink and All-ceramic 35 months 18 24 Veneered zirconia 1 debondings 1 Tooth movement 2 Chip-off Successful
Hüttig22 Mx:17 Mn:6 (various) 2 chip-off 1 Debonding
1 tooth move.
Sasse and All-ceramic 6 years 37 42 Veneered zirconia 2: debonding 2 Debonding (11M) 1 Carious lesion Successful No catastrophic
Kern21 Mx:26 (various) 1: caries (61.4M∗ ) failure
Mn:16
Saker et al10 All-ceramic 5 years 40 20 Veneered 3: debonding 2 Fracture (6 and NR Successful NR
Cantilever Resin-Bonded Fixed Dental Prostheses

Mx:20 glass-infiltrated 2: fracture 12 M)

alumina
(In-Ceram)
Sailer and All-ceramic 5 years 15 15 Veneered zirconia 2: debonding 2 Debonding (1.3 No failure Successful No catastrophic
Hämmerle20 Mx:12 Mn:3 (various) and 5.4 M) failure
Sasse and All-ceramic 5 years 25 16 Veneered zirconia 1: debonding 1 Debonding 1 Carious lesion Successful No catastrophic
Kern19 Mx:8 (e.max ZirCAD) 1: rotation (11.1M) (61.4M) failure with
Mn:8 Panavia 21
14 1: debonding No failure 1 Debonding Successful No catastrophic
Mx:11 Mn:3 (20.8M) failure with
Multilink Automix
Sun et al23 All-ceramic 4 years 35 35 Veneered lithium No failure No failure No failure No failure 100% Success
Mx:17 Mn:18 disilicate (e.max
Press)
Sailer et al24 All-ceramic 6 years NC 20 Glass-ceramic No failure No failure No failure No failure No catastrophic
6.1% (IPS failure.
Empress) lithium This study was for

Journal of Prosthodontics 27 (2018) 266–275 

disilicate 93.9% anterior and
(e.max Press) posterior teeth.
100% Success
Kern and All-ceramic 10 years 16 22 Veneered 1: fracture No failure 1 Fracture (48M) Successful (a
Sasse17 Mx:16 Mn:6 glass-infiltrated new
alumina restoration
(In-Ceram Al/Zr) was
inserted)
Mourshed et al

C 2016 by the American College of Prosthodontists

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Mourshed et al Cantilever Resin-Bonded Fixed Dental Prostheses

Debonding

Mixed study (fix-fix

This study was for

posterior teeth
When cantilever RBFDPs were used, the main limitation was

and cantilever)
Mixed study (fix,
cantilever and
100% success

100% success
anterior and
the high debonding rate, particularly for traditional metal-

Note

RBFPDs)
ceramic RBFDPs.4,8,15,16 However, Saker et al10 and Botelho
et al14 stated that using adhesive resin cement showed pre-
dictable results, as no debondings were observed during the
observation period. Early debonding of two zirconia ceramic
RBFDPs was observed in two investigations,20,22 whereas late
correction
Failure

No Failure
No failure

and very late debondings were reported in other studies on zir-

conia RBFDPs (IPS e.max ZirCad veneered with IPS e.max
Ceram).18,21 However, in their long-term studies, Kern and
NC

NC

NR
Sasse17 and Botelho et al14 did not observe any debonding
No. of failures

2: debonding
first year
after the

in the cantilever RBFDPs. All cantilever RBFDP debondings

1: caries
No Failure
No failure

were successfully recemented and remained in situ without any

further problems in all studies. Debonding was often caused by
NC

NC

trauma19,21 or unknown reasons.10,20,21

No. and type

during the
of failures

first year

Fracture
No Failure
No failure

No failure

Generally, fracture, as a complication of all-ceramic cantilever

RBFDPs, seldom occurs. Fracture occurring in glass-infiltrated
NC

NC

alumina ceramic was reported in two studies.10,17 Neverthe-

25 debonding

less, Sun et al23 recorded no fractures during their 5-year study

2: debonding
9 debonding
Failure type

1: caries

using IPS e.max Press ceramic. The lack of fracture in metal-

No failure

No failure

ceramic RBFDPs (nonprecious) indicates its reliability versus

glass-infiltrated RBFDPs.8,10,13 However, no fractures on zir-
conia ceramic RBFDPs were observed in studies using zirconia
ceramic.17,19-21
PFM (veneered

PFM (veneered

PFM (veneered

PFM (veneered

PFM (veneered
Material used

CoCr alloy)
NiCr alloy)

NiCr alloy)

NiCr alloy)

NiCr alloy)

Carious lesions
NR: not reported, NC: not clear. *This study is a comparative study between metal and all-ceramic RBFDPs.
Table 3 List of the quantitative data of 4 definitive studies on metal-ceramic cantilever RBFDPs

Carious lesion was observed in three cases.15,19,21 The reported

caries lesion was mostly located on the lingual surface of a
cantilever RBFDP abutment tooth, but not under the retainer
No. of anterior
Restorations

wing. Therefore, the cause of this carious lesion might not be

111 Mx:76

related to the RBFDPs.

Mn:35
Mx: 13

Mx: 62

Materials used
20

18

Different studies used traditional metal-ceramic cantilever

No. of Patients

RBFDPs.8,14-16 One of them compared traditional metal-

NR (mix.

NC (mix.
study)

study)

ceramic (non-precious) and all-ceramic RBFDPs made from

glass-infiltrated alumina ceramic.10 Several investigators used
NC
13

20

zirconia material in their studies (IPS e.max ZirCad veneered

with IPS e.max Ceram),18-21 and in one study different zirco-
59.3 months
follow up
Range of

nia materials were used.22 Other investigators preferred to use

29 months
18 years

10 years

5 years

other types of all-ceramic materials (such as glass-infiltrated

alumina and lithium disilicate ceramics).10,23,24 However, in
Kern and Sasse’s long-term study,17 glass-infiltrated alumina
ceramic was used.
restoration

Metal-ceramic

Metal-ceramic
Metal-ceramic

Metal-ceramic

Metal-ceramic
Type of

Cementation
Sailer et al24 used six types of cements for anterior and pos-
terior single retainers Tetric Flow (Ivoclar Vivadent), Tet-
ric Ceram (Ivoclar Vivadent), RelyX (3M ESPE), Panavia F
(Kuraray), HFO (Optident), and Variolink (Ivoclar Vivadent)
14

Garnett et al16
Botelho et al8
Botelho et al

Saker et al10

for 67.3%, 14.3%, 8.2%, 6.1%, 2.0%, and 2.0% restorations,

Chai et al15

respectively. After 5 years, the survival rate of the examined

Study

RBFDPs was 100% without debonding. Klink and Hüttig22

used Variolink and Multilink as a cements and the survival rate

Journal of Prosthodontics 27 (2018) 266–275 

C 2016 by the American College of Prosthodontists 271

Cantilever Resin-Bonded Fixed Dental Prostheses
Table 4 Summary of preparation designs and materials used for anterior cantilever RBFDPs
Study Materials/Cements used
Botelho et al 14
– PFM (NiCr alloy), veneered with
feldspathic ceramic
– The cement was Panavia
Klink and Hüttig22 – Zirconia framework (various) veneered
with feldspathic ceramic (various)
– The cement was Multilink and Variolink
Sasse and Kern21 – Zirconia framework (IPS e.max ZirCAD)
veneered with feldspathic ceramic (IPS
e.max Ceram)
– The cement was Panavia 21TC
Saker et al10 – PFM (CoCr alloy)
– The cement was Panavia 21 TC
– Glass-infiltrated alumina framework
(In-Ceram)
– The cement was Panavia 21 TC
Sailer and – Zirconia (IPS e.max ZirCAD) veneered
Hämmerle20 with feldspathic ceramic (Initial, GC)
– The cement was Panavia 21 TC
Botelho et al8 – PFM (NiCr alloy)
– The cement was Panavia or
Panavia 21
Sun et al23 – Glass Ceramic (IPS e.max Press)
veneered with feldspathic ceramic
– The cement was Variolink
Sasse and Kern19 – Zirconia (IPS e.max ZirCAD) was
veneered with feldspathic ceramic (IPS
e.max Ceram)
– The cement was Panavia 21 TC
Kern and Sasse17 – Glass-infiltrated alumina/ zirconia
(In-Ceram) veneered with feldspathic
ceramic
– The cement was Panavia 21 TC
272
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Mourshed et al
Preparation designs
r The initial tooth preparation technique included broad coverage of enamel,
supragingival margins, marginal ridge, and cingulum rests on each abutment,
but without penetration into dentine.
r If possible, the retention form was improved by including proximal grooves
and additional rests. External 180° + circumferential retainer preparation was
rarely used.
r 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 preparation.
r The tooth preparation design provided a definite seat for the RBFDP but did
not provide any mechanical retention.
r The preparation used a notch and a shallow proximal box.
r The preparation of the abutment teeth provided a definite seat for the
restoration but without mechanical retention.
r Functioning of the restorations therefore relied completely on the resin bond.
r Minimal preparation at the lingual aspect with a supragingival finish line, and
ended at approximately 1 mm below the incisal edge of the abutment tooth
on the lingual side.
r A shallow groove (2 mm length, 1 mm width, 0.5 mm depth) was prepared
at the mesial side of the abutment tooth that aided the path of insertion.
r No cingulum rest seat was prepared
r The minimally invasive preparation design was a mesial and distal vertical
groove (6° taper) and a tiny slot at the lingual cingulum region
r The general design principles consisted of maximizing the surface area for
bonding, thereby increasing the resistance form of the tooth preparation and
framework design. Consequently, the survey line of the abutment tooth was
lowered as necessary, and had a slightly lingual path of insertion. An axial
preparation to interproximal surfaces was confined to increase the surface
area for bonding.
r The axial surface reduction ranged within 0.5 to 0.8 mm, with window
preparation without incisal edge involvement. Cervically, a shallow chamfer
(0.5 mm) was prepared equigingivally.
r The proximal reduction was within 0.5 to 1 mm. The chamfer on the cervical
area should be at the supragingival margin to avoid the exposing of the root
cingulum area.
r Guide planes of the adjacent abutment teeth were incorporated within the
interproximal surface. Undercuts of the proximal surfaces of the abutment
teeth were removed to ensure framework passivity.
r 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 preparation.
r The tooth preparation design provided a definite seat for the RBFDP but did
not provide any mechanical retention.
r 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 preparation (dimensions: 2 mm × 1 mm × 0.5 mm).
r The tooth preparation design provided a definite seat for the restoration but
did not provide any mechanical retention.
(Continued)
Journal of Prosthodontics 27 (2018) 266–275 
C 2016 by the American College of Prosthodontists

Mourshed et al
Table 4 Continued
Study Materials/Cements used
Sailer24
– Glass ceramics (93.9% IPS e.max Press
and 6.1% IPS Empress)
– 6 different types of cement
Garnett et al16 – PFM (NiCr alloy), veneered with
feldspathic ceramic
– The cement was Panavia or
Panavia 21
Chai et al15 – PFM (NiCr alloy), veneered with
feldspathic ceramic
– The cement was Panavia,
or Panavia 21
was 100%. Sasse et al18 investigated the bonding of two ad-
hesive luting systems (Multilink-Automix with metal/zirconia
primer and Panavia 21) to RBFDPs. No difference between
the bonding systems was detected clinically. In addition, most
studies8,10,13,17,19-21 used phosphate monomers containing com-
posite resin cements, such as Panavia 21, and reported a sur-
vival rate up to 100%. On the other hand, a low survival rate
and a greater debonding rate were seen in two studies,15,16
although the same resin cements were used. This might be
due to operator experience, as some of the cantilever RBFDPs
were placed by graduate students and senior staff. Phosphate
monomers containing composite resin cements (Panavia) used
with zirconia19-21 or metal frameworks10,13 showed survival
rates of 100% (Table 1); however, using the same cement ma-
terial with glass-infiltrated alumina ceramic, the survival rate
decreased to 90%.10
Several RBFDP framework surface treatments were sug-
gested in the included studies. These strategies fall into two
categories: 1) treatments that roughen and activate the surface
(usually by air-abrasion with 50 µm alumina particles) and
then using a phosphate monomer luting resin,8,10,14,15,17,19,21 or
2) that combine various micromechanical surface treatments
and adhesive primers to achieve chemical bonding between the
cement and the RBFDP framework.20,22 Unfortunately, three
studies did not report the method of surface treatment of the
retainer wings.16,23,24
Discussion
This review aimed to evaluate the clinical performance of can-
tilever RBFDPs in the anterior area. This kind of treatment may
be considered a valid treatment alternative to single implant or
conventional crown-retained FDPs, particularly in young pa-
tients or patients with medical contraindications for implant
surgery. RBFDPs achieve clinical outcomes in longevity that
compare well with those of conventional FDPs.25 The impor-
tant improvement is the change of the RBFDP design from two
or more retainers to a single retainer. In addition, the cantilever
RBFDPs have become standard clinical teaching practice to
undergraduate students in several dental schools.9 A number
of factors, such as preparation design, type of cement used,
Journal of Prosthodontics 27 (2018) 266–275 
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Cantilever Resin-Bonded Fixed Dental Prostheses
Preparation designs
r No preparation
r Unknown
r The preparation of the abutment teeth was supported by cingulum rests,
and the stability and retention of the RBFDP were optimized by providing
maximum palatal and lingual tooth coverage by the metal framework
patient selection, and choice of different materials, might be
responsible for the improvement in the survival rates of the can-
tilever RBFDPs; However, the main problem associated with
cantilever RBFDPs was debonding,4 specifically in the tradi-
tional metal-ceramic RBFDPs.8 The debonding of cantilever
RBFDPs may be caused by design, resistance form of tooth, or
luting cement. The majority of the included studies8,10,15-17,19-21
used phosphate monomers containing composite resins, such as
Panavia 21, and showed promising results. Furthermore, recent
laboratory studies29-34 indicated using phosphate monomers
containing composite resins to provide a reliable resin bond to
glass-infiltrated alumina ceramic and densely sintered zirconia
ceramics without any glass phase when the bonding surface of
the ceramics is air-abraded prior to bonding. The resin cement
with a specific primer for zirconia ceramic (Multilink-Automix
with Metal/Zirconia-Primer) also achieved statistically signifi-
cantly lower bond strength to air-abraded zirconia ceramic than
phosphate monomers containing resin cement (Panavia 21).35,36
Nevertheless, no significant difference in clinical RBFDP sur-
vival was detected between these bonding systems. The type
of material may also be one of the reasons that could lead to
debonding. Although debonding failure was observed in tradi-
tional metal-ceramic cantilever RBFDPs in retrospective stud-
ies with a large number of RBFDPs,8,15,16 the studies included
in the present review showed no failure in debonding in two
other studies.10,13 However, in Saker et al’s comparison study,10
metal-ceramic cantilever RBFDPs showed good results versus
glass-infiltrated all-ceramic RBFDPs, as no debondings were
observed during the observation period. The author justified
the result by the high elastic modulus of the metal, even in thin
sections, and the affinity of the metal for oxygen to form oxides
on the metal surface may have facilitated bonding with resin.10
Conversely, debonding occurred in each study that used zirconia
as material (5%-7%),19-22 and no failure occurred in retention
in Kern and Sasse17 and Botelho et al’s long-term studies.14 An-
other possibility of debonding that may play an important role
in retention is tooth isolation during cementation; however, in
the 4-year research period of their study, Gilmour and Ali37 in-
vestigated the effect of using a rubber dam during cementation
and concluded that 35% of the rubber dam assisted RBFDPs
debonded. Without a rubber dam, this percentage increased to
273

Cantilever Resin-Bonded Fixed Dental Prostheses
43%. Nonetheless, these numbers were too small to draw final
conclusions.
Clinical operator or experience may also have an influence
on the clinical success of cantilever RBFDPs. Although the
retention rate of RBFDPs placed by staff was slightly higher
than that of the student group, the difference was not statistically
significant.8 This result may be attributed to the independent
characteristics of cantilever RBFDPs that are not subjected to
adverse interabutment stresses.8 In addition, clinical experience
was not an influencing factor, as observed in the RBFDPs placed
by dental undergraduates (student) or staff.8 In contrast, results
were statistically significant when comparing both supervised
students and junior student hospital staff to senior members of
staff.16 Additionally, two studies reported that junior staff had
higher debonding rates than students, although their RBFDPs
had longer clinical survival.38,39 This phenomenon is caused by
the higher complexity of cases for staff showing potentially a
poorer prognosis; however, in another study, junior staff and
consultants did better than students for cantilevered RBFDPs,3
thereby indicating that skill level may be related to success.
In addition, occlusion scheme analysis plays an important role
in debonding. Patients with group function involving multiple
posterior teeth or canine protection occlusions are very helpful
regarding the success of cantilever RBFDPs.24 All the pontics
should be designed free of contact during protrusive and lateral
movements.24 However, debonding may also occur because of
trauma, food culture (eating hard candy, corn nuts, hard nuts,
and popcorn hulls) or certain habits of the patient (any abnormal
behavior of patients, such as nail-biting, finger sucking, or use
of anterior teeth to open or cut hard things).
Ceramic fracture might also influence the survival rate of
RBFDPs and may cause failure in cantilever RBFDPs, par-
ticularly in the connector area. All fractures in the cantilever
RBFDPs were in ceramic material (alumina ceramic-based
restorations).10,17 This observation is attributed to many fac-
tors, such as the dimensions of the connector and curvature
of the occlusogingival embrasure around the connector area,
the mechanical properties of the materials used, and the torque
movements of the abutment teeth.17 Notably, the fracture of
glass-infiltrated alumina ceramic in this study exceeded the
debonding rate. Nevertheless, these results support previous
laboratory findings that showed that the resin bond strength of
such glass-infiltrated alumina ceramic RBFDPs exceeded their
fracture strength.40-43
In the obtained literature, no fractures occurred using a
zirconia ceramic (IPS e.max ZirCad veneered with IPS e.max
Ceram).18-21 Zirconia exhibits the highest fracture strength and
fracture toughness of all dental ceramics and can be applied
in different indications with good outcomes. This observation
is supported by the good results reported for zirconia FDPs
(zirconia framework veneered with feldspathic ceramic).44-46
For the cantilever RBFDPs, the periodontal receptors of the
abutment teeth are assumed to prevent pontic overloading
during mastication, because cantilever pontics transfer higher
tilting forces to abutment teeth than pontics fixed between two
retainers. Such tilting forces might have alerted the patient
not to overload the pontic; however, a minor rotation was
observed,19 although the patient was Class II, and no occlusal
forces were applied on the retainer. In another study, one tooth
274 Journal of Prosthodontics 27 (2018) 266–275 
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Mourshed et al
movement was recorded and retreated by the orthodontist.22
Increased tooth mobility and bone loss was not recorded in any
of the specific anterior cantilever RBFDP studies, although
several mixed studies (anterior and posterior) stated the
occurrence of mobility and bone loss, but without mentioning
the area or location. In addition, Rashid et al47 reported
minor statistically significant disadvantages of the abutments
related to pocket depth, but did not observe differences in
tooth mobility. No significant differences were also found on
the location of the cantilever RBFDPs.8-10,21 Nevertheless,
Hussey and Linden3 followed up 142 FDPs (116 mandibular
and 26 maxillary ones), and all debonded FDPs were in the
maxilla. The maxillary central incisors were most endangered,
followed by the canines and lateral incisors. Regarding patient
satisfaction, the use of cantilever RBFDPs as an alternative
treatment was a highly recommended option.8 The recent
results of a systematic review and meta-analysis study by Wei
et al48 suggested that cantilever RBFDPs had better survival
rates than two retainer fixed-fixed RBFDPs, which is in agree-
ment with the present review. In this review, only studies with
anterior missing teeth treated by both two-retainer fixed-fixed
and cantilever RBFDPs in the same study were included.
Conclusion
The use of cantilever RBFDPs showed promising results and
high survival rates. Furthermore, the use of zirconia ceramic
and phosphate monomers containing resin cements will min-
imize the fracture and debonding rate of anterior all-ceramic
cantilever RBFDPs.
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