Received: 5 January 2018 | Revised: 11 March 2018 | Accepted: 23 April 2018

DOI: 10.1111/jerd.12389

REVIEW ARTICLE

Clinical procedures, designs, and survival rates of all-ceramic

resin-bonded fixed dental prostheses in the anterior region:
A systematic review

AQ4 Emre Tezulas DDS, MSc | Coskun Yildiz DDS, PhD | Buket Evren DDS, PhD |
Yasemin Ozkan DDS, PhD

Department of Prosthodontics, Marmara

University, Istanbul, Turkey
Correspondence
Dt. Emre Tezulas, Department of
Prosthodontics, Faculty of Dentistry,
Marmara University, _Istanbul, Turkey.
Email: emretezulas@gmail.com
Abstract
Objectives: The aim of this study is to systematically review all the clinical articles about all-
ceramic resin-bonded fixed dental prosthesis (RBFDP) in the anterior region and assess their
designs, clinical procedures, and survival rates. A systematic review was conducted after searching
electronic databases Pubmed/Medline and EBSCOhost Research Databases for articles published
in English between 1987 and July 2017.

Materials and Methods: The inclusion criteria were selected as all clinical studies, original design
clinical reports and clinical reports (follow-up time more than 1 year) since all clinical information in
the literature are desired to be included in the present review.

Results: The initial electronic search generated 472 articles from Pubmed/Medline and 464
articles from EBSCOhost Research Databases. After selection of the articles due to the inclusion
criteria, a final sample of 29 original studies are decided as: 1 randomized controlled clinical trial, 4
clinical controlled trials, 4 prospective cohort studies, 2 retrospective cohort studies, 6 original
design clinical reports and 12 clinical reports. After evaluation of the selected articles, it is likely
that cantilever design all-ceramic RBFDPs are more successful than two retainers design in the
anterior region however, there is limited evidence for this result in the literature.

Conclusion: Well designed randomized controlled clinical trials with large sample size are still
needed to achieve more accurate results about the clinical success rate of different RBFDPs
designs in the anterior region.

KEYWORDS
AQ1 adhesive bridges, resin bonded fixed dental prostheses

1 | INTRODUCTION tissue grafting4 might be necessary before the placement of the

There are different treatment options in dentistry for the rehabilitation
of anterior tooth loss including implant supported prosthesis (ISP), tra-
ditionally fixed bridge prosthesis (FBP), resin-bonded fixed dental pros-
thesis (RBFDP). In recent years, ISP has gained importance when
replacing missing single teeth adjacent to caries free teeth.1,2 However,
it is not possible to place the implant directly to the edentulous area in
every patient. Especially if there is the deficiency of hard and soft tis-
sues in the edentulous area, bone augmentation3,4 and connective
implant. Therefore, in such situations due to the complex surgical pro-
cedures, increased cost of the treatment and fear of surgery, patients
may prefer tooth supported prostheses instead. If the patient is
younger than 18 then implant placement should be postponed until
adulthood due to potential complications with implant infra-position.5
Among tooth supported restorations, FBP is the most invasive option
because it has been reported that crown preparations require removal
of 63% to 72% of the total sound tooth structures.6 Therefore, in
young patients when the size of the pulp chamber is considered, the

J Esthet
EsthetRestor
RestorDent.
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308
probability of the need for endodontic treatment might be increased
7
due to crown preparation. Esthetics and function of the patient can be
achieved with the RBFDP as a minimally invasive treatment
alternative.8
RBFDP was first described by Rochette as a technique for splinting
periodontally compromised mandibular anterior teeth.9 RBFDP using
metal frameworks were used in the mid-1970s.9,10 Metal-ceramic
RBFDP with an electrolytic etching of the metal surface11 became
widely known as Maryland fixed dental prosthesis in the early
1980’s.12 The main esthetic problem in a conventional RBFDP is the
use of a metal framework which may cause the abutment teeth to lose
its natural translucency and become greyish when bonded to the lin-
gual surface.13 With further advances in adhesive techniques and
ceramic materials, new esthetic treatment options with all-ceramic
14
adhesive fixed dental prostheses are now possible.
The rationale of this review is to report all different designs and
clinical procedures together with clinical survival rates of all-creamic
RBFDP’s in the anterior region. None of the previously published
reviews in the literature mentioned all of these details for all-ceramic
RBFDPs in the anterior region.15–18
Every original case or clinical report has unique properties that
some researchers might be attracted to perform a long-term clinical
research about them. These cases might have an unique design, unique
clinical procedures of all-ceramic RBFDPs in the anterior region so it
was decided to add the original case and clinical reports to the present
review together with the other clinical studies. As the different ideas of
the original case and clinical reports are important for the authors, the
scope of the search is desired to be extended by deciding the follow
up time as at least 1 year. So that, all the cases in the literature that
had a clinical value wanted to be included in this review.
The aim of this study is to systematically review all the clinical
articles about all-ceramic RBFDP in the anterior region and assess their
clinical procedures, designs, and survival rates. Therefore, the present
review might provide new long-term clinical research areas that might
be performed in the future for determining the survival rates of differ-
ent clinical procedures and designs of all-ceramic RBFDP’s in the ante-
rior region.
2 | MATERIALS AND METHODS
A systematic review was conducted after searching electronic data-
bases Medline/Pubmed and EBSCOhost Research Databases for
articles published in English between 1987 and July 2017. The search
text words included “all ceramic resin bonded bridges,” “all ceramic
resin bonded fixed dental prostheses,” “all ceramic adhesive bridges,”
“all ceramic acid etched bridges,” and “all ceramic Maryland bridges.” All
the titles and abstracts were screened in detail. Articles related to all-
ceramic RBFDP in the anterior region were specified and full texts of
these articles were collected by the reviewers. Subsequently, the full
texts were divided into groups according to the type of the studies.
Inclusion and exclusion criteria were decided according to the type of
F1 the study and were outlined in Figure 1. The inclusion criteria were
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TEZULAS
TEZULAS ET AL..
ET AL
selected as all clinical studies, original design case reports and clinical
reports (follow-up time more than 1 year) since all clinical information
in the literature are desired to be included in this review. Therefore, full
texts that did not meet the inclusion criteria were excluded.
3 | RESULTS
The initial electronic search generated 472 articles from Pubmed/Med-
line and 464 articles from EBSCOhost research databases. After related
articles are selected, the review process included 50 articles. Then full
texts of the selected articles are screened due to the inclusion and
exclusion criteria and resulted in a final sample of 29 original studies: 1
randomized controlled clinical trial (RCT), 4 clinical controlled trials
(CCT), 4 prospective cohort studies (PCS), 2 retrospective cohort stud-
ies (RCS), 6 original design clinical reports (ODCR), and an additional 12
clinical reports (CR).
After agreement on all the full texts, the ODCRs are used for
reporting a classification of designs, CRs are used for reporting clinical
procedures and RCT, CCTs, PCSs, and RCSs are used for reporting
both clinical procedures and clinical survival rates of all-ceramic RBFDP
in the anterior region.
3.1 | Classification of designs
In literature, there are four different designs in all-ceramic RBFDP in
the anterior region. The first and most common design is lingual
retainer design that is divided into two types. The first type is classical
two retainer design which has two lingual retainers connected to both
of the neighboring teeth.14 The second type is cantilever design that
has only one lingual retainer connected to only one of the neighboring
tooth.19 Therefore, there is a modification of two lingual retainer design
that is used for the rehabilitation of two lower incisor missing patient.20
As this design had two pontics, the framework was made from zirconia
to prevent fracture of the pontics, as zirconia has the highest failure
load.21
The second design is laminate veneer retained all-ceramic RBFDP
that connects both of the neighboring teeth.22 Laminate veneer
retained design might be indicated when there is a factor that compro-
mises the esthetic of the neighboring teeth.
The third design was inlay-like retained design that have four
extensions which fit into the two grooves that were prepared on both
of the supporting neighbor teeth.23 The RBFDP fits into the four paral-
lel grooves like inlay retained bridges.
Fourth design was made by Heymann that has no retainers at all
and pontic was connected both of the neighboring teeth by only adhe-
sive connection with composite connectors.24 Only feldspathic porce-
lain was used as a pontic. Heymann was described this as Carolina
bridge design and he reported four years of successful clinical follow-
up.24
In literature, there are long-term clinical studies that only investi-
gate classical two lingual retainer design or cantilever design. There
was no long-term studies about laminate veneer retained design, inlay-
like retainer design, and Carolina bridge design. Therefore, further

COLOR IN ONLINE AND PRINT
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FIGURE 1 Prisma flow diagram of the review processSource: Moher et al. (2009)
studies are needed for determining the clinical survival rates of these
three designs.
In rest of this review, the clinical procedures of RBFDPs and clini-
cal studies of classical two lingual retainers and cantilever lingual
T1 T2 retainer designs will be discussed (Tables 1 and 2).
3.2 | Clinical procedures of all-ceramic RBFDPs
Patient selection criteria are the most important factor for the clinical
success of all-ceramic RBFDPs in the anterior region. Clinical and radio-
graphic examination of the abutment teeth must be done carefully. Abut-
ment teeth must have adequate periodontal health and root support.25
Occlusion of the patient must be examined in detail. Increased overbite
26–29
and bruxism are always considered as the contraindication.
Diagnostic wax-up is recommended for obtaining a three-
dimensional representation of the anticipated functional and aesthetic
treatment outcome. Minimally invasive preparation is recommended
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| 3
309
and restricted on the enamel for achieving proper bonding force.30 AQ2
Also all-ceramic RBFDP can be fabricated without any preparation.31
There may be different preparation designs but lingual veneers, small
proximal boxes and cingulum grooves are common in most of the
articles.32–36 Proximal boxes provide the thickness of the connector and
path of insertion of the RBFDPs. Therefore, they must be prepared paral-
lel to each other. Cingulum grooves that are placed in the center of the
lingual fossa facilitate the exact three-dimensional seating of the frame-
work. For better stress distribution, all sharp line angles must be rounded
with suitable burs. In addition, oscillating handpiece with diamond tips
can be used for the preparation of the abutment teeth with the use of a
dental operating microscope.37 Prior to final impression a control impres-
sion might be done to verify the proper path of insertion.38
Double cord retraction technique and vinyl polysiloxane or poly-
ether impression material are suitable for the final impression. An
impression for the opposing arch, interocclusal record in maximum
intercuspation and shade of the final restoration must be obtained. In
 17088240, 2018, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.12389 by University Of Rochester, Wiley Online Library on [11/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
4
310| TEZULAS
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ET AL

T A B LE 1 Classification of selected studies

Two neighbor teeth supported design Single neighbor tooth supported design (Cantilever design)
Type of study Type of Study

Glass infiltrated alumina ceramic (In Ceram)

Kern et al.14 (1991) ODCR Kern et al.19 (1997) ODCR

Pospiech et al.23 (1996) ODCR Foitzik et al.30 (2007) CR

Galiatsatos26 (2014) PCS Saker et al.50 (2014) CCT

Moslehifard et al.43 (2014) CR Kern34 (2017) PCS

Feldspatic Porcelain

Heymann24 (2006) ODCR

Lithium Disilicate (IPS Emax Press, IPS Empress 2)

Ozcan et al.25 (2002) CR Barwacs et al.36 (2014) CR

48
Ozyesil et al. (2006) CR
44
Cakan et al. (2009) CR
39
Zeghbroeck (2011) CR
22
Bissasu et al. (2014) ODCR

Zirconia (Yttria- partially stabilized tetragonal zirconia polycrystalline)

Turker et al.20 (2005) ODCR Sasse et al.35 (2012) RCT

45 31
Duarte et al. (2009) CR Maggio et al. (2012) CR
38 29
Stylianou et al. (2016) CR Sailer et al. (2014) RCS
40 36
Viana et al. (2016) CR Sasse et al. (2014) PCS
41
Komine et al. (2015) CR
46
Klink et al. (2016) PCS
48
Kern et al. (2017) RCS

Abbreviations: CCT, controlled clinical trial; CR, clinical report; ODCR, original design clinical report; PCS, prospective cohort study; RCS, retrospective
cohort study; RCT, randomized controlled clinical trial.

addition, an intra-oral digital impression can be taken because it is
much faster than classical impression and there is no risk of a gag
39
reflex. This is very advantageous, especially for elderly patients.
addition to digital impression, chairside construction of the RBFDPs by
39
CAD/CAM made the fabrication procedure much more faster
there might be no need for a provisional restoration. However, if fabri-
cation of the all-ceramic RBFDPs needs extra time, then fabrication of
T A B LE 2 Studies that compare cantilever design and classical two
retainers design
the provisional restorations must be considered. Provisionalization of
the edentulous area might be recommended not only for esthetic rea-
In sons but also to avoid slight tooth movements during treatment, espe-
cially following orthodontic treatment.40
so The matrix of the duplicate cast of the wax-up can be used with
dual-cure bis-acryl material for the fabrication of the provisional resto-
rations. After contouring, finishing, and polishing of the provisional res-
toration, it is bonded to the palatal surfaces of the abutment teeth with
a spot-etch and bonding technique.38 Inaddition, provisionalization can
be done with a composite tooth fixed on the buccal surfaces of the

Type of study
abutment teeth with an orthodontic wire and dental composite so the
prepared dental surfaces are not used and are kept untouched as they
Glass infiltratred alumina ceramic (In Ceram)
are reproduced in the dental impression.40
32
Kern (2005) CCT After fabrication of the framework, a try-in visit is made for verify-
33
Kern et al. (2011) CCT ing the path of the draw, fit and margins of the frameworks. For the

Lithium Disilicate (IPS Emax Press, IPS Empress 2)

Ries et al.28 (2006)
Abbreviation: CCT, controlled clinical trial.
cantilever design RBFDPs a small, extra wing might be fabricated on
the framework to facilitate the correct placement during try-in.31 Ovate
CCT
pontic design might be chosen to achieve more esthetic results in the
definitive RBFDPs.38

TEZULAS AL..
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TEZULAS ET
After fabrication of the definitive all-ceramic RBFDPs, provisional
restoration is removed and definitive RBFDP is tried intraorally. Precise
adaptation of the wings and pontic areas, proper marginal fit and inter-
proximal contacts, as well as aesthetic integration of shade and texture
with adjacent teeth, is verified and approved with patient.41
For different all-ceramic materials, different surface treatments can
be used. Tribochemical silica coating can be used with all-ceramic
RBFDPs. Tribochemical silica coating is a combined surface treatment
that forms a silica layer with the effect of airborne particle abrasion
with silica-coated alumina particles. 42
Inaddition, the bonding surfaces
of the all-ceramic RBFDPs are modified with airborne-particle abrasion
with aluminum oxide particles under air pressure at a certain distance.
For achieving high strength bonding to these modified surfaces, dual-
polymerizing resin cement that have phosphate monomers are
recommended. 43,44
However, Duarte et al. 45
described clinical application of a modi-
fied zirconia surface that was named NobelBond (Nobel Biocare,
€teborg, Sweden). The modified surface showed increased bond
Go
strengths compared with airborne particle abraided surfaces. In addi-
tion, because of intricate surface, no phosphate monomer is necessary
for bonding to this high strength ceramic.
In addition, with zirconia framework in addition to airborne-
particle abrasion, dual-cure resin cement with metal zirconia primer can
be used for the cementation of RBFDPs. 46
The second cementation
technique for zirconia framework is veneering of the interproximal
spaces with felspathic ceramics and the buccal surfaces of the
retainer’s wings with a thin ceramic coating to allow an adhesive
cementation. In this case, adhesive cementation procedure is the same
with adhesive surfaces of the RBFDPs made of lithium disilicate. They
are first etched with 5% hydrofluoric acid then conditioned with silane
agent and can be cemented with a dual polymerizing composite resin
cement.40,47
Before cementation of the definitive RBFDPs, rubber-dam isola-
tion is recommended. After rubber-dam application, preparation surfa-
ces of the teeth are first cleaned with pumice and etched with 37%
phosphoric acid for 30 seconds on the enamel. Etched surfaces are
rinsed and adequately dried to allow application of the bonding agent
in a thin layer. For final cementation, adhesive resin cement in the
same shade of the restoration or translucent shade is applied to the
adhered surfaces and the restoration is placed in the right position. To
achieve the right position of the RBFDPs a silicone index might be also
31
used. Before light-curing, excessive cement is thoroughly removed
with microbrushes and tooth floss. After polymerization, explorer and
sharp scaler or surgical scalpel might be used for the removal of the
excessive cement.
After final seating, the occlusion is evaluated and adjusted in maxi-
mum intercuspation and protrusive and laterotrusive movements with
diamond rotary instruments. Minimal contact with the pontic during
excursions must be achieved. After finishing the restorations an occlu-
sal guard might be fabricated for the patient to wear at night. Instruc-
tions for proper oral hygiene around and beneath the restoration must
be given to the patient. In addition, the patient is encouraged to return
at 6-month recall intervals for evaluation and maintenance purposes.
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311
3.3 | Clinical studies: Classical two lingual retainers
design or cantilever design
In 2005, Kern published a clinically controlled trial study that compared
two-retainer and single retainer glass-infiltrated alumina ceramic
RBFDPs.32 He published these patients after 5 years, 10 years, and 15
years follow-ups32–34 (Table 3). After 5 years and 10 years follow-up, T3
they concluded that lingual cantilever design glass-infiltrated alumina
ceramic RBFDPs presented viable treatment alternative to two lingual
retainer design RBFDPs in the anterior region with reduced clinical
complications. In both studies, clinical success rate of the cantilever
design was higher than two retainer lingual design. In between 5 and
10 years, they did not report any extra complications. After 15 years,
they only published the data of lingual cantilever design RBFDP made
of glass-infiltrated alumina ceramic. They concluded that all-ceramic
cantilever design RBFDPs show excellent longevity.
Ries et al.28 compared the clinical success of cantilever design with
two lingual retainer design RBFDPs made of lithium disilicate (Table 3).
They concluded that survival rate of cantilever design RBFDPs is supe-
rior to that of two lingual retainers RBFPDs.
Sasse et al.35,36 published two articles with cantilever design
RBFDPs made from zirconia. In the first study, they compared different
bonding systems.35 These bonding systems were Panavia 21 TC (Kur-
aray, Tokyo, Japan) and Multilink Automix (Ivoclar Vivadent, Liechten-
stein) with zirconia primer (Table 3). They concluded that cantilever
design RBFDPs made from zirconia present a promising treatment
alternative for the replacement of missing incisors and both of the
bonding systems showed successful clinical results. In the second
study, they evaluated clinical success of cantilever design RBFDPs
made from zirconia36 (Table 3). They concluded that the use of all-
ceramic cantilever design RBFDPs was recommended for the anterior
region.
Sailer et al.29 made a retrospective study to assess the survival rate
and technical and biological rates of the anterior single retainer cantile-
ver zirconia ceramic RBFDPs (Table 3). They concluded that anterior
zirconia ceramic cantilever design RBFDPs exhibited excellent clinical
outcomes. Therefore, they suggested that this treatment technique
should be considered as an alternative to single implant crowns in the
future.
Saker et al.47 evaluated the clinical performance of cantilever
design RBFDPs made of either metal-ceramic or glass-infiltrated alu-
mina ceramic (Table 3). They concluded that metal-ceramic and all-
ceramic RBFDPs did not show the significant difference in terms of
clinical survival for replacement of missing anterior incisors.
Galliatsatos et al.26 studied the clinical survival of the two lingual
retainer design RBFDPs made from glass-infiltrated alumina ceramic in
the anterior region (Table 3). At the end of 96 months follow-up their
results suggested that when the indications and patients were selected
appropriately the overall outcome and clinical behavior of the two lin-
gual retainers design all-ceramic RBFDPs are satisfactory. Their success
rate was higher than the success rate of two lingual retainer design
group of the study of Kern et al.32,33; however, lower than the success
rate of cantilever design group of the same study.
 6

T A BL E 3 Details of the RCT, CCT, PCS, and RCS articles that are included in this review
|
312

Mean
Number of Prosthesis Tooth Connector Size Retainer wing Surface Rubber-dam Resin Fallow-up
restorations Design preparation Material (height x depth) Thickness Treatment isolation Cement Time Success Rate

*Kern M.32 37 Two Retainer Aluminum 3 3 2 mm2 0.5–0.7 mm Tribochemically YES Panavia TC 76 months 67.3% (n 5 16)
(2005) (CCT) Design (n 5 16) Oxide silica-coated and (Kuraray) (n 5 16)
silanated (n 5 16) (n 5 16)
(Rocatec
Procedure,
3M ESPE)

In-Ceram
(n 5 16)

Cantilever design Restricted on the In-Ceram Air abraided 50 lm YES Panavia 21 TC 52 months 92.3% (n 5 21)
(n 5 21) enamel, Lingual Alumina aluminum oxide (Kuraray) (n 5 21)
veneer, Cingulum (n 5 13) at 2.5 bar (n 5 21) (n 5 21)
Groove, Small
proximal box
(2 3 1 3
0.5 mm3)

In-Ceram
Zirconia
(n 5 8)

Celay Copy
Milling

Cantilever Design In-Ceram Alumina Air abraided 50 lm Panavia 21 TC 111 months 94.4% (n 5 22)
(n 5 22) (n 5 14) aluminum oxide at (Kuraray) (n 5 22)
0.25 MPa (n 5 22) (n 5 22)

In-Ceram
Zirconia
(n 5 8)

Celay Copy
Milling

33
*Kern et al. 38 Two Retainer Aluminum Oxide Not-reported Not-reported Tribochemically YES Panavia TC 120 months 67.3% (n 5 16)
(2011) (CCT) Design (n 5 16) In-Ceram silica-coated (Kuraray) (n 5 16)
(n 5 16) and silanated (n 5 16)
(n 5 16) (Rocatec
Procedure,
3M ESPE)

*Kern et al.34 22 Cantilever Design In-Ceram 3 3 2 mm2 0.5–0.7 mm Air abraided Panavia 21 TC 188.7 months 95.4%
(2017) (PCS) (n 5 22) Alumina 50lm aluminum (n 5 22)
(n 5 14) oxide at 0.25 216 months
MPa (15 s).
TEZULAS

81.8%
TEZULAS ET
ET AL
AL..

(Continues)

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 T A B LE 3 (Continued)
TEZULAS

Mean
TEZULAS ET

Number of Prosthesis Tooth Connector Size Retainer wing Surface Rubber-dam Resin Fallow-up
ET AL
AL..

restorations Design preparation Material (height x depth) Thickness Treatment isolation Cement Time Success Rate

In-Ceram
Zirconia (n 5 8)

Celay Copy Milling

Ries et al.28 (2006) 38 Two Retainer Restricted on the Empress 2 4 mm 3 0.4 mm 5% HF Silane YES Not-reported 21.2 months 60.3% (n 5 17)
(CCT) Design (n 5 17) enamel, Minimal (n 5 26) not-reported (Monobond, (n 5 17)
lingual veneer, Ivoclar Vivadent)
Cingulum Groove,
Shallow proximal
box

Cantilever Emax Ivoclar

Design (n 5 21) Vivadent (n 5 12)

15.1 months 90.9% (n 5 21)

(n 5 21)

Sasse et al.35 30 Cantilever A definite seat but Zirconia (IPS e.max Not-reported Not-reported Air abraided Not- Panavia 21 TC 41.7 months 93.3% (n 5 16)
(2012) (RCT) Design no mechanical ZirCAD veneered 50 lm aluminum reported (Kuraray)
retention with IPS e.max oxide at 0.25 MPa (n 5 16)
Ceram, Ivoclar
Vivadent)

Multilink Automix with 92.9% (n 5 14)

metal zirconia
primer (n 5 14)
(Ivoclar Vivadent)

Sasse et al.36 (2014) 42 Cantilever Design Oral veneer Zirconia (Cerec InLab Not-reported Not-reported Air abraided 50 lm YES Panavia 21 TC 61.8 months 91.1%
(PCS) preparation with 3D CAD/CAM aluminum oxide (Kuraray)
a notch and a prox- system (Sirona) at 0.25 MPa
imal box and after Ultrasonic
sinterization cleaning with
veneered 97% isopropyl
with IPS e.max alcohol
Ceram

Sailer et al.29 (2014) 15 Cantilever design Mesial and distal Zirconia (Y-TZP 3 3 2 mm2 0.5 mm Cleaned with YES Panavia 21 TC 49.4 months 100%
(RCS) vertical Groove (6 White stage alcohol, silane (Kuraray)
degree taper), tiny zirconia blanks, IPS (Clearfil Porcelain
slot at cingulum e.max ZirCAD, Bond)
Ivoclar and Cerion,
Straumann CAD/
CAM systems
(Cerec InLab 3D
Sirona) and Etkon/
Cares (Straumann)
veneered with zir-
|

conia veneering
7
313

ceramic (Initial, GC)

(Continues)

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 8

T A B LE 3 (Continued)
|
314

Mean
Number of Prosthesis Tooth Connector Size Retainer wing Surface Rubber-dam Resin Fallow-up
restorations Design preparation Material (height x depth) Thickness Treatment isolation Cement Time Success Rate

Galliatsatos et al.26 54 Two Retainer Lingual side 1 mm Glass infiltrated Not-reported 0.5 mm Air abraided with YES Variolink II (Ivoclar, 96 months 85.18% (n 5 54)
(2014) (PCS) Design from the gingival alumina aluminum oxide Vivadent)
margin, 1 to 1.5 mm ceramic (Korax 250, Bego)
from incisal edge (In-ceram)
champher finish
line, Shallow
proximal box on
each abutment
teeth (2 3 2 3
0.5 mm3)

Coated with silane

(Monobond S,
Ivoclar, Vivadent)

47
Saker et al. (2014) 40 Cantilever Design Palatal side 1 mm be- Nonprecious alloy Not-reported 0.5 mm Air abraided 50lm YES Panavia 21 34 months 100% (n 5 20)
(CCT) low the incisal edge (Wiroclast aluminum oxide (Kuraray) 90% (n 5 20)
Cobalt-choromium
alloy, Bego)
(n 5 20)

Shallow groove on the

mesial side (2 3 1

3 0.5 mm3)

No cingulum rest Glass-infiltrated alumi- Ultrasonically

na ceramic (In-cer- cleaned in 96%
am) (n 5 20) alcohol for 1 min.

Klink et al.46 (2016) 24 Cantilever Design Preparation was Zirconia Not-reported Not-reported Air abraided 50 lm Not- Multilink 35 months 82.4% (n 5 24)
(PCS) performed (CAD/CAM aluminum oxide reported (n 5 22) (Ivoclar
as Sasse et al.35 Zirconia Ceramill at 1 bar. Vivadent)
described. (n 5 16)

Cerec 3, e.max Zir-

CAD, Ivoclar (n 5 3)

Zirconia primer Variolink (n 5 2)

or monobond (Ivoclar
plus (Ivoclar Vivadent) Vivadent)

Zirkonzahn, ICE Zirkon

(n 5 1)

Organical R&K,
Noritake Kanata,
Kuraray (n 5 2)
TEZULAS

Cercon, Cercon HT,

TEZULAS ET
ET AL

Degudent (n 5 2))
AL..

(Continues)

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 TEZULAS
TEZULAS ET
ET AL
AL..

T A B LE 3 (Continued)

Mean
Number of Prosthesis Tooth Connector Size Retainer wing Surface Rubber-dam Resin Fallow-up
restorations Design preparation Material (height x depth) Thickness Treatment isolation Cement Time Success Rate

Kern et al.48 (2017) 115 Cantilever Design Restricted on the Zirconia (designed 3 3 2 mm2 0.7 mm Air abraided 50lm YES Panavia 21 92.2 months 92% (n 5 115)
(RCS) enamel, thin lingual by CAD/CAM and alumina particles TC (Kuraray)
veneer design, fine milled out of (0.25 MPa until
incisal finishing presintered zirconia year 2009 and
shoulder, fine cer- ceramic blocks and thereafter 0.1 MPa)
vical champher, densly sintered and
small proximal box manually veneered)
(2 3 2 3 0.5 mm3)
and cingulum
pinhole (Minimum
bonding area was
30 mm2 on sound
enamel)

Multilink Automix with

metal/zirconia
primer (Ivoclar
Vivadent)

Ultrasonically cleaned in
99% isopropanol

(*) indicates multiple publications in the same study cohort.

| 9
315

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10
316 | TEZULAS
Klink et al.46 evaluated zirconia-based cantilever design anterior
RBFDPs (Table 3). They used many zirconia materials from different
brands with their own CAD/CAM systems. After 35 months follow-up,
they concluded that cantilever design RBFDPs survive well for the
replacement of single anterior tooth in short term.
In 2017, Kern et al.47 made a retrospective study that have eval-
uated the long-term survival rates of anterior cantilever zirconia
ceramic RBFDPs. In addition, they evaluated the influence of the cause
of the missing teeth on the clinical performance of RBFDPs. Among all
the reported studies, their study have largest number of restorations.
In addition, among the reported studies that have zirconia ceramic and
cantilever design, the longest follow-up time was performed in this
study (Table 3). They concluded that anterior cantilever zirconia
ceramic RBFDPs showed excellent clinical longevity independently of
the cause of the missing teeth.
All the complications such as debonding, caries, partial or total
fracture and in the cantilever design, tilting of the abutment teeth were
considered as a failure of the all-ceramic RBFDPs while reporting the
clinical success rates of the studies reported in this review.
As a result, CCTs that compare cantilever design and classical two
retainers design showed that cantilever design is more successful than
two retainers design RBFDPs in the anterior region.28,32,33 Also most
of the PCSs, and RCSs showed high success rates for cantilever design
RBFDP in the anterior region that supports the results of
CCTs.29,34,36,46,48
4 | DISCUSSION
Most of the current clinical studies showed that cantilever design
RBFDPs are superior than two-retainers design in the anterior
region.29,32–36,46-48 However, there are limited number of RCTs and
CCTs in the literature; therefore, the level of evidence of this result is
mainly from cohort studies as mentioned before in the previous review
articles.15,16
In addition, none of the studies in the literature reported the type
of functional occlusion of the patients or matched the results of their
studies with this variety. However, according to the authors’ opinion,
the functional occlusion type of the patient is very important for the
all-ceramic RBFDPs because in each occlusion type different forces
may focus RBFDPs. In canine protected articulation50 the force on the
canine might have adverse effects on the two lingual retainer design
RBFDPs if one of the abutment teeth is canine. In this situation, during
chewing activity, the force on the canine tooth might be transferred to
the central incisor via the two retainer design RBFDPs. This might
explain why the authors find two lingual retainer design less successful
than cantilever design.26,28,32,33 So, cantilever design might be a good
choice of treatment as the canine has the lateral forces during chewing,
the pontic can move towards the same direction with the canine tooth.
In addition, if there is difference between the mobilities of the two
neighboring abutment teeth than cantilever design might be
preferred.19
17088240, 2018, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.12389 by University Of Rochester, Wiley Online Library on [11/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
TEZULAS ET AL..
ET AL
However, in the group function articulation,49 the lateral forces on
the canine might decrease because of premolars, and even molars,
share this lateral force during chewing action. So, if there is group func-
tion articulation then the two lingual retainer designs might be consid-
ered as a treatment alternative. In addition, if there are relatively short
clinical crowns of the abutment teeth and bonding surface is very lim-
ited than two lingual retainer designs might be preferred.38
5 | CONCLUSION
It is likely that cantilever design all-ceramic RBFDPs are more success-
ful than two retainers design in the anterior region, however, there is
limited evidence for this result in the literature. So, well designed RCTs
with large sample size are still needed that have much more standardi-
zation such as type of functional occlusion and the missing tooth of the
patient to achieve more accurate results about the clinical survival rate
of different RBFDPs designs.
DISCLOSURE STATEMENT
The authors do not have any interest in the companies or products
used in this study.
ACKNOWLEDGEMENTS
There are no acknowledgements.
RE FE RE NC ES
[1] Mayer TM, Hawley CE, Gunsolley JC, Feldman S. The single-tooth
implant: a viable alternative for single-tooth replacement.
J Periodontol. 2002;73(7):687–693.
[2] Vanlıo
glu BA, Kahramano €
glu E, Ozkan Y, Kulak-Ozkan Y. Clinical
and radiographic evaluation of early loaded maxillary anterior single-
tooth bone-level implants. Int J Oral Maxillofac Implants. 2014;29(6):
1369–1373.
[3] Pieri F, Aldini NN, Marchetti C, Corinaldesi G. Esthetic outcome and
tissue stability of maxillary anterior single-tooth implants following
reconstruction with mandibular block grafts: a 5-year prospective
study. Int J Oral Maxillofac Implants. 2013;28(1):270–280.
[4] Kolerman R, Nissan J, Mijiritsky E, Hamoudi N, Mangano C, Tal H.
Esthetic assessment of immediately restored implants combined
with GBR and free connective tissue graft. Clin Oral Implants Res.
2016;27(11):1414–1422.
[5] Zitzmann NU, Arnold D, Ball J, Brusco D, Triaca A, Verna C. Treat-
ment strategies for infraoccluded dental implants. J Prosthet Dent.
2015;113(3):169–174.
[6] Edelhoff D, Sorensen JA. Tooth structure removal associated with
various preparation designs for anterior teeth. J Prosthet Dent.
2002;87(5):503–509.
[7] Bergenholtz G, Nyman S. Endodontic complications following peri-
odontal and prosthetic treatment of patients with the advanced
periodontal disease. J Periodontol. 1984;55(2):63–68.
[8] Durey KA, Nixon PJ, Robinson S, Chan MF. Resin bonded bridges:
techniques for success. Br Dent J. 2011;211(3):113–118.
[9] Rochette AL. Attachment of a splint to enamel of lower anterior
teeth. J Prosthet Dent. 1973;30(4):418–423.

TEZULAS AL..
ET AL
TEZULAS ET
[10] Howe DF, Denehy GE. Anterior fixed partial dentures utilizing the
acid-etch technique and a cast metal framework. J Prosthet Dent.
1977;37(1):28–31.
[11] Livaditis GJ, Thompson VP. Etched castings: an improved retentive
mechanism for resin-bonded retainers. J Prosthet Dent. 1982;47(1):
52–58.
[12] Livaditis GJ. Cast metal resin-bonded retainers for posterior teeth.
J Am Dent Assoc. 1980;101(6):926–929.
[13] Weng D, Ries S, Richter EJ. Treatment of a juvenile patient with a
maxillary all-ceramic resin-bonded fixed partial denture: a case
report. Quintessence Int. 2002; 33:584–588.
[14] Kern M, Knode H, Strub JR. The all-porcelain, resin-bonded bridge.
Quintessence Int. 1991;22:257–262.
[15] Wei YR, Wang XD, Zhang Q, et al. Clinical performance of anterior
resin-bonded fixed dental prostheses with different framework
designs: A systematic review and meta-analysis. J Dent. 2016;47:1–
7.
[16] Chen J, Cai H, Ren X, Suo L, Pei X, Wan Q. A systematic review of
the survival and complication rates of all-ceramic resin-bonded fixed
dental prostheses. J Prosthodont. in press; https://doi.org/10.1111/
jopr.12678.
[17] Thoma DS, Sailer I, Ioannidis A, Zwahlen M, Makarov N, Pjetursson
BE. A systematic review of the survival and complication rates of
resin-bonded fixed dental prostheses after a mean observation
period of at least 5 years. Clin Oral Implants Res. 2017;28(11):1421–
1432.
[18] Mourshed B, Samran A, Alfagih A, Samran A, Abdulrab S, Kern M.
Anterior cantilever resin-bonded fixed dental prostheses: a review
of the literature. J Prosthodont. 2018;27(3):266–275.
[19] Matthias K, RAINER C. Cantilevered all-ceramic, resin-bonded fixed
partial dentures: a new treatment modality. J Esthet Dent. 1997;9
(5):255–264.
[20] Turker SB, Guvenli SY, Arikan A. Replacement of two mandibular
central incisors using a zirconium resin-bonded fixed partial denture:
a clinical report. J Prosthet Dent. 2005;94(6):499–503.
[21] Tinschert J, Natt G, Mautsch W, Augthun M, Spiekermann H. Frac-
ture resistance of lithium disilicate-, alumina-, and zirconia-based
three-unit fixed partial dentures: a laboratory study. Int J Prostho-
dont. 2001;14:231–238.
[22] Bissasu SM, Al-Houri NA. Replacement of missing lateral incisors
with lithium disilicate glass-ceramic veneer-fixed dental prostheses:
a clinical report. Clin Case Rep. 2014;2(4):128–132.
[23] Pospiech P, Rammelsberg P, Unso €ld F. A new design for all-ceramic
resin-bonded fixed partial dentures. Quintessence Int. 1996;27:753–
758.
[24] Heymann HO. The Carolina bridge: a novel interim all-porcelain
bonded prosthesis. J Esthet Restor Dent. 2006;18(2):81–92.
[25] Ozcan M, Akkaya A. New approach to bonding all-ceramic adhesive
fixed partial dentures: a clinical report. J Prosthet Dent. 2002;88(3):
252–254.
[26] Galiatsatos AA, Bergou D. Clinical evaluation of anterior all-ceramic
resin-bonded fixed dental prostheses. Quintessence Int. 2014;45:9–
14.
[27] Sun Q, Chen L, Tian L, Xu B. Single-tooth replacement in the ante-
rior arch by means of a cantilevered IPS e.max Press veneer-
retained fixed partial denture: case series of 35 patients. Int J Pros-
thodont. 2013;26(2):181–187.
[28] Barwacz CA, Hernandez M, Husemann RH. Effect of design of all-
ceramic resin-bonded fixed partial dentures on clinical survival rate.
Int J Periodontics Restorative Dent. 2014;26(5):314–319.
17088240, 2018, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.12389 by University Of Rochester, Wiley Online Library on [11/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
| 317
11
[29] Sailer I, Hämmerle CH. Zirconia ceramic single-retainer resin-bonded
fixed dental prostheses (RBFDPs) after 4 years of clinical service: a
retrospective clinical and volumetric study. Int J Periodontics Restor-
ative Dent. 2014;34(3):333–343.
[30] Foitzik M, Lennon AM, Attin T. Successful use of a single-retainer
all-ceramic resin-bonded fixed partial denture for replacement of a
maxillary canine: a clinical report. Quintessence Int. 2007;38:241–
246.
[31] Maggio MP, Bergler M, Kerrigan D, Blatz MB. Treatment of maxil-
lary lateral incisor agenesis with zirconia-based all-ceramic resin-
bonded fixed partial dentures: a case report. Am J Esthet Dent.
2012;2:226–237.
[32] Kern M. Clinical long-term survival of two-retainer and single-
retainer all-ceramic resin-bonded fixed partial dentures. Quintes-
sence Int. 2005;36:141–147.
[33] Kern M, Sasse M. Ten-year survival of anterior all-ceramic resin-
bonded fixed dental prostheses. J Adhes Dent. 2011;13:407–410.
[34] Kern M. Fifteen-year survival of anterior all-ceramic cantilever
resin-bonded fixed dental prostheses. J Dent. 2017;56:133–135.
[35] Sasse M, Eschbach S, Kern M. Randomized clinical trial on single
retainer all-ceramic resin-bonded fixed partial dentures: influence of
the bonding system after up to 55 months. J Dent. 2012;40(9):783–
786.
[36] Sasse M, Kern M. Survival of anterior cantilevered all-ceramic resin-
bonded fixed dental prostheses made from zirconia ceramic. J Dent.
2014;42(6):660–663.
[37] Barwacz CA, Hernandez M, Husemann RH. Minimally invasive prep-
aration and design of a cantilevered, all-ceramic, resin-bonded, fixed
partial denture in the esthetic zone: a case report and descriptive
review. J Esthet Restor Dent. 2014;26(5):314–323.
[38] Stylianou A, Liu PR, O’Neal SJ, Essig ME. Restoring congenitally
missing maxillary lateral incisors using zirconia-based resin bonded
prostheses. J Esthet Restor Dent. 2016;28(1):8–17.
[39] Van Zeghbroeck L. CAD/CAM treatment for the elderly–a case
report. Gerodontology 2012;29(2):e1176–e1179.
[40] Viana PC, Portugal J, Kovacs Z, Lopes I, Correia A. Resin-bonded
fixed dental prosthesis with a modified treatment surface in a zir-
conia framework: a case report. Int J Esthet Dent. 2016;11:378–
392.
[41] Komine F, Tomic M. A single-retainer zirconium dioxide ceramic
resin-bonded fixed partial denture for single tooth replacement: a
clinical report. J Oral Sci. 2005;47(3):139–142.
[42] Papia E, Larsson C, du Toit M, Vult von Steyern P. Bonding
between oxide ceramics and adhesive cement systems: a systematic
review. J Biomed Mater Res B Appl Biomater. 2014;102(2):395–413.
[43] Moslehifard E, Farid F. Single tooth replacement using inceram resin
bonded fixed partial denture: a clinical report. J Dent (Tehran). 2014;
11:106–110.
[44] Cakan U, Demiralp B, Aksu M, Taner T. Clinical showcase. Replace-
ment of congenitally missing lateral incisor using a metal-free, resin-
bonded fixed partial denture: case report. J Can Dent Assoc. 2009;
75:509–512.
[45] Duarte S Jr, Phark JH, Tada T, Sadan A. Resin-bonded fixed partial
dentures with a new modified zirconia surface: a clinical report.
J Prosthet Dent. 2009;102(2):68–73.
[46] Klink A, Hu €ttig F. Zirconia-based anterior resin-bonded single-
retainer cantilever fixed dental prostheses: a 15- to 61-month fol-
low-up. Int J Prosthodont. 2016;29(3):284–286.
[47] Saker S, El-Fallal A, Abo-Madina M, et al. Clinical survival of anterior
metal-ceramic and all-ceramic cantilever resin-bonded fixed dental
 17088240, 2018, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.12389 by University Of Rochester, Wiley Online Library on [11/03/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
12
318 | TEZULAS
TEZULAS ET AL..
ET AL

prostheses over a period of 60 months. Int J Prosthodont. 2014;27 [51] Barwacz CA, Hernandez M, Husemann RH. Replacing an anterior
(5):422–424. metal-ceramic restoration with an all-ceramic resin-bonded fixed
[48] Kern M, Passia N, Sasse M, Yazigi C. Ten-year outcome of zirconia partial denture: a case report. J Adhes Dent. 2014;26(5):314–316. AQ3
ceramic cantilever resin-bonded fixed dental prostheses and the
influence of the reasons for missing incisors. J Dent. 2017;65:51–
55. How to cite this article: Tezulas E, Yildiz C, Evren B, Ozkan Y.
[49] The Glossary of Prosthodontic Terms: Ninth Edition. J Prosthet Clinical procedures, designs, and survival rates of all-ceramic
Dent. 2017;117(5):C1, e1-e105.
resin-bonded fixed dental prostheses in the anterior region: A
[50] Kern M, Schwarzbach W, Strub JR. Stability of all-porcelain, resin- systematic review. J JEsthet
systematic review. Esthet Restor
Restor Dent.
Dent. 2018;30:307–318.
2018;00:1–12. https://
bonded fixed restorations with different designs: an in vitro study.
https://doi.org/10.1111/jerd.12389
doi.org/10.1111/jerd.12389
Int J Prosthodont 1992; 5:108–113.