E.

Romeo Systematic review of the survival rate

S. Storelli
and the biological, technical, and aes-
thetic complications of fixed dental
prostheses with cantilevers on
implants reported in longitudinal
studies with a mean of 5 years
follow-up

Authors’ affiliations: Abstract

E. Romeo, Dipartimento di Medicina, School of
Dentistry, Prosthodontics, Università degli Studi di
Milano, Chirurgia, Odontoiatria, AO San Paolo
S. Storelli, Dipartimento di Medicina, Università
degli Studi di Milano, Chirurgia, Odontoiatria, AO
San Paolo
Corresponding author:
S. Storelli
Dipartimento di Medicina, Università degli Studi di
Milano, Chirurgia, Odontoiatria, AO San Paolo,
Italy
Tel.: +39 0250319003
Fax: +39 0250319040
e-mail: stefano.storelli@studioplinio.it
Conflicts of interest:
The authors declare that they have no potential conflicts.
Objective: A systematic review was carried out to evaluate the success and survival rate of
implants supporting cantilever prosthesis, as well as the incidence of technical and biological
complications.
Material and Methods: A MEDLINE search was conducted up to December 2011 for studies with a
mean follow-up of 5 years or more. Two independent reviewers screened the retrieved articles and
extracted the data independently. Data on survival, failure, mechanical/technical and biological
complications were analyzed.
Results: One-hundred and sixty articles were selected as abstract. Only 18 underwent a full-text
analysis and only six were included in the study. The estimated cumulative survival rate of implants
supporting cantilevered prosthesis was 98.9% (95% CI: 97.4–99.5%), whereas ICFDP survival was
estimated to be about 97.1% (95% CI: 90.1–99.2%). Implant failures before prosthetic delivery
were not considered.Biological complications were estimated to be 5.7% (95% CI: 4.2–7.6%) at
implant level after 5 years.Technical complications were analyzed: the most common complications
were veneer fractures (5-year estimate: 10.1%; 95% CI: 3.7–16.5%) and abutment screw fractures
(5-year estimate: 1.6%; 95% CI: 0.8–3.5%). Decementation and screw loosening were estimated to
be at 5 years 5.9% (95% CI: 1.7–16.8%) and 7.9% (95% CI: 3.2–18.2%), respectively. Implant
fracture was rare (5-year estimate: 0.7%; 95% CI: 0.1–4.7%); no framework fracture was reported.
Radiographic bone level changes did not yield statistically significant differences. No aesthetic
outcome was reported.
Conclusions: ICFDPS can be considered a reliable treatment: the systematic review assessed that
there is no increase in complication rate due to the presence of the cantilever.

Anatomically determined implantology over dimensional bone structure sufficient to hold

Date:
Accepted 09 June 2012
To cite this article:
Romeo E., Storelli S. Systematic review of the survival rate
and the biological, technical and esthetic complications of
fixed dental prostheses with cantilevers on implants reported
in longitudinal studies with a mean of 5 years follow-up.
Clin. Oral Implants Res. 23(Suppl. 6), 2012, 39–49
doi: 10.1111/j.1600-0501.2012.02551.x
time has changed to a prosthetically guided
implantology. This involved a different surgi-
cal approach that would allow almost ideal
anatomical conditions to be obtained to be
able to position the implants in a favorable
position from a prosthetic point of view (Chi-
apasco et al. 2009). Over time, surgical recon-
structive procedures were developed and
scientifically validated to obtain ideal condi-
tions such as maxillary sinus lifts, guided
bone regeneration and bone regeneration by
means of autologous and heterologous bone
grafts. These procedures provide a three-
the implants in a prosthetically guided posi-
tion which must then support the implant-
prosthetic rehabilitation (Klinge et al. 2009).
All these procedures involve longer treat-
ment times, higher morbidity, and complica-
tions as well as an increase in costs, which
do not always make these solutions sustain-
able on a large scale (Esposito et al. 2009,
2010).
Over time, scientific research has focused
on the validation of all the techniques that
allow the cost-benefit ratio of the implant
treatment to be optimized, such as the short

© 2012 John Wiley & Sons A/S 39

Romeo & Storelli. Systematic review of cantilever prostheses

implants, tilted implants or the implant-sup- ing the incidence of technical, biological and Exclusion Criteria
ported fixed partial or complete dentures aesthetic complications that have occurred. Papers with a less than 5-year follow-up were
with cantilever extensions (Aglietta et al. The focused question that the present review excluded, as well as letters, in vitro studies,
2009; Annibali et al. 2012). is trying to answer is the following: “What is and narrative reviews. Studies on overden-
With regard to the prosthetic rehabilitation the survival rate of implants supporting IC- tures and complete rehabilitations were also
on natural teeth, a review of literature shows FDP with a mean of 5 years or more follow- excluded. Studies from which data on
that the survival at 5 years of cantilever pros- up, of implant-supported fixed dental prosthe- selected outcome variables could not be
theses is lower (81.8–95% CI 78.2–84.9%) ses (ICFDP) rehabilitation with a mean of retrieved or calculated were not considered.
than FDP with end tooth abutment (89.1% – 5 years or more follow-up and to what extent
CI 81–93.8%) (Pjetursson et al. 2004a; Tan do biological, technical, and aesthetic com- Selection of studies
et al. 2004). plications occur on ICFPD?”. The primary Two independent reviewers (ER and SS)
For implant-supported dentures, several outcome was to evaluate the survival of screened the 2038 papers retrieved from the
papers evaluated the success and survival rates implant and ICFDP and the secondary one, electronic search for possible inclusions in
of implant-prosthetic rehabilitations with can- the biological, technical and aesthetic com- the review. A consensus on the studies to be
tilever extensions, mainly showing an implant plications of implants and ICFDP: selected was reached after discussion; 1658
behavior similar to that of fixed partial den- articles were excluded on the basis of the
tures without extensions. However, some title and another 362 on the basis of the
Material and Methods abstract. Kappa score for the selection of the
papers identified a higher percentage of techni-
cal and biological complications for follow-up paper was 0.89. (Fig. 1)
Publications on the subject in English were The reasons for excluding the papers were
times of more than 5 years (Zurdo et al. 2009).
searched to select articles up to December mean follow-up of less than 5 years and/or
One of the most critical aspects of
2011. no specific data on cantilever rehabilitations,
implant-supported dentures with cantilever
A systematic review was conducted search- papers on natural teeth or on overdentures,
extensions, with regard to the classical bio-
ing an electronic database (MEDLINE, Pub- in vitro and non-clinical studies.
mechanical parameters, is the risk of func-
Med) for articles published in English in peer- Full-text articles were obtained for the 18
tional overloading of the implant near the
reviewed journals between 1966 and December selected publications. Hand searches were
cantilever extension, in relation to the length
2011 concerning studies on humans. The key performed on bibliographies of the selected
of the extension and especially related to
words used were: “fixed partial dentures” articles as well as of identified narrative
non-axial loads. The presence of functional
(MESH); “implant” AND/OR “bridges”, “fixed reviews. The hand search did not identify
overloading has proven to be the cause of
dental prostheses”, “cantilever”, “extension”; any additional articles.
implant failure due to the occurrence of
“dental implant” (MESH); “cantilever”. The 18 full texts were independently
micro-fractures at the bone level and not at
The following journals were hand searched assessed by the two reviewers. Six studies
the bone-implant contact point, which can-
from 2007 to December 2011: Clinical Oral were found to qualify for inclusion, whereas
not be repaired through normal bone remod-
Implants Research, International Journal of 12 studies had to be excluded (Fig. 1). Any
elling (Isidor 1996, 1997).
Periodontics and Restorative Dentistry, Jour- disagreement was resolved by discussion.
Other papers present contrasting results
nal of Periodontology, Journal of Clinical The exclusion of the 12 papers is motivative,
and the systematic reviews of the most
Periodontology and International Journal of as shown in Table 1.
recently published literature would show that
Oral and Maxillofacial Implants, Journal of
there is no statistically significant difference
Prosthetic dentistry, Journal of Prosthodon- Excluded studies
in terms of bone resorption in prostheses
tics, Journal of Oral Rehabilitations. More- Of the 12 excluded studies, nine had a mean
with cantilever extensions compared to those
over, the bibliographies of the selected follow-up less than 5 years, three were
without extensions, and the presence of a
articles and relevant reviews were thoroughly focused on fixed complete rehabilitations,
higher incidence of biological and technical
screened. and two did not provide full analyses of com-
complications relating to the prosthesis.
Two systematic literature reviews were plications or specific data on fixed partial
Inclusion Criteria cantilever rehabilitations on implants. Some
published in 2009. The first review (Zurdo
The first selection of studies were prospec- studies had more than one reason for being
et al. 2009) considered the articles published
tive or retrospective studies reporting on excluded.
up to 2008, whereas the second review (Agli-
FPDPs with cantilever extensions with a
etta et al. 2009) considered those up to 2007.
mean follow-up period of 5 years (Wennström Data extraction
In the latter analysis, the estimated survival
& Palmer 1999). The objective was to find All papers included were searched for infor-
rates of implant-supported prostheses with
RCT, Cohort and Case-Control studies on mation regarding survival and complication
cantilever extensions by means of meta-anal-
the topic. The primary outcomes were rates for both implants and cantilever reha-
ysis, would be 93.4% (95% CI): 84.1–98%] at
implant and Prosthetic survival. Therefore, bilitation. Rehabilitation was considered a
5 years and 88.9% (95% CI: 70.8–96.1%) at
studies included had to present data on survival if it was present at the last follow-up
10 years.
implant and prosthesis survival. Secondary visit without modifications. Implants were
The objective of this review is to assess
outcomes were mechanical and technical considered as survivals if they were present
the studies on implant-supported fixed partial
complications (implant-related and prosthe- at the follow-up examination. Soft tissue
rehabilitations with cantilever extensions
sis-related), biological complications (peri-im- complications as well as peri-implantitis
(ICFDP) up to the end of 2011 with follow-up
plantitis, etc.) as well as the evaluation of were included in the biological complica-
times with a mean of 5 years, analyzing the
marginal bone loss. tions. Mechanical complications were consid-
implant and prosthetic prognosis and evaluat-

40 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/39–49 © 2012 John Wiley & Sons A/S

Fig. 1. Search process and Kappa score calculation
Table 1. Excluded articles (cohort studies) after full-text examination and reasons for exclusion
Reference
Blanes et al. (2007)
Nedir et al. (2006)
Tawil et al. (2006)
Becker (2004)
Romeo et al. (2003)
Johansson & Ekfeldt (2003)
Kucey (1997)
Ranger et al. (1995)
Shackleton et al. (1994)
Gallucci (2009)
Mumcu (2011)
De Santis (2011)
ered to be all events affecting the integrity of
the implant and its abutment. Technical
events were considered to be those affecting
prosthetic rehabilitation. All data were
reported in tables to allow analysis.
Statistical analysis
Failure and complication rates were calcu-
lated by dividing the number of events
(implant failures or prosthetic complications)
by total exposure time. Failures and compli-
cations were directly extracted from the
publications, as well as the mean follow-up
time. Exposure time was calculated by multi-
plying the mean follow-up time by the num-
ber of implants or ICFDPs available.
The mean follow-up was directly extracted
from the articles (Hälg et al. 2008), supple-
mented as adjunctive information from the
author of the original papers (Wennström
© 2012 John Wiley & Sons A/S
Romeo & Storelli. Systematic review of cantilever prostheses
Reason for exclusion
Implant-based data analysis Information regarding number
of prosthesis with cantilever extensions, prostheses
survival and/or complications not available
Mean follow-up <5 years
Mean follow-up <5 years, selected outcomes not retrievable
Mean follow-up <5 years
Mean follow-up <5 years
Mean follow-up <5 years
Mean follow-up <5 years, cantilevered bridges were all
fixed complete dental prosthesis (FCDP)
Cross-sectional study design
Mean follow-up <5 years, focus on FCDP
Data on complete rehabilitations (FCDP)
Mean follow-up <5 years
Mean Follow-up <5 years
et al. 2004a,b; Eliasson et al. 2006; Kreissl
et al. 2007) or calculated from the original
database (Brägger et al. 2005; Romeo et al.
2009).
The total number of events was considered
to be Poisson distributed for a given sum of
implant exposure years, and Poisson regres-
sion with a logarithmic link function and
total exposure time per study as an offset var-
iable was used (Kirkwood & Sterne 2003a,
2003b). Event rates for implants and prosthe-
sis were calculated by dividing the total
number of events by the respective total
exposure time in years.
To assess the heterogeneity of the study-
specific event rates, the Spearman goodness-
of-fit statistics and associated P-values were
calculated. If the goodness-of-fit P-value was
<0.05, indicating heterogeneity, random-
effects Poisson regression (with g-distributed
41 |
random effects) was used to obtain a sum-
mary estimate of the event rates. Five-10-year
survival proportions were calculated via the
relationship between event rate and survival
function S, S(T) 1⁄4 exp (T ? event rate), by
assuming constant event rates (Kirkwood &
Sterne 2003a, 2003b). Ninety-five per cent
confidence intervals of the summary esti-
mates of the event rates obtained from the
Poisson regression were reported. The 95%
CIs for survival probabilities were obtained
using the 95% confidence limits from the
summary event rates.
For the analysis of the reported radio-
graphic bone loss, the mean difference
between FDPs with and without cantilevers
and its standard error was calculated for each
study. These study-specific differences were
then meta-analyzed using the inverse-vari-
ance weighting method.
All analyses were performed using Stata
(Stata Corporation, College Station, TX,
USA), version 10.
Results
The selection process for the identification of
the five papers is shown in Fig. 1. The typol-
ogy of the study as well as the data of the
patients analyzed are reported in Table 2. No
RCT comparing the outcomes of implant-
supported FPDs and ICFDPs was found.
Three studies were specifically designed to
test ICFDPs (Wennstrom et al. 2004; Halg
et al. 2008; Romeo et al. 2009), whereas for
the other three studies the ICFDP data were
Clin. Oral Implants Res. 23(Suppl. 6), 2012/39–49
Romeo & Storelli. Systematic review of cantilever prostheses

Table 2. Study and patient’s characteristics of the reviewed publications

Study (year of Characteristic of implant No. Of Mean Age Age range
publication) Study design Implant system systems patients of Patients of patients Smokers Setting
Wennstrom Prospective Astra Techs Dental Self-tapping screws, 28 57 NR 14 non smokers University
et al. 2004 Implant System machined or tioblast
Bragger 2005 Prospective Straumann Dental Solid screw, hollow 14 42.9 20–78 University
Implant screw, hollow cylinder
Kreissl et al. Prospective 3i Osseotite Osseotite, 20 NR NR University
2007;
Romeo et al. Prospective Straumann Dental Solid screws 59 63 42–100 Excluded > 15 sig/ University/
2009 Implant Systems die Private
Practice.
Eliasson 2006 Retrospective Bra°nemark System Turned surface 178 NR NR University
Halg et al. Retrospective Straumann Dental Solid screw, hollow 27 61.9 44–83 Private
2008 controlled Implant Systems screw, hollow cylinder practice

NR: not reported

extracted from the article or supplemented
by the authors (Bragger et al. 2005; Eliasson
et al. 2006; Kreissl et al. 2007).
Among the papers selected, four were pro-
spective cohort studies (Wennstrom et al.
2004; Bragger et al. 2005; Kreissl et al. 2007;
Romeo et al. 2009) and the other two were
retrospective controlled studies (Eliasson
et al. 2006; Halg et al. 2008). The paper from
Wennstrom (2004) retrieved data on ICFPD
from a wider prospective study on rehabilita-
tion of periodontal susceptible patients from
the same author (Wennstrom 2004b).
The total number of patients in the
selected studies was directly reported or sup-
plemented by the authors and ranged
between 14 and 84, followed for a mean 5–
9.8 years. One study (Halg 2008) was con-
ducted in a private practice, four studies in a
university environment (Wennstrom 2004;
Bragger et al. 2005; Eliasson et al. 2006;
Kreissl et al. 2007) and one study in both
(Romeo et al. 2009). Implant manufacturers
tested in the study were: Astra Tech Dental
Implant System (Astra, Moelndal, Sweden)
(Wennstrom et al. 2004); Branemark System
(Nobel Biocare AB, Göteborg, Sweden) (Elias-
son et al. 2006); Osseotite (3i-Implant Innova-
tions, West Palm Beach, FL, USA) (Kreissl
et al. 2007), and Straumann Dental Implant
System (Institut Straumann AG, Basel, Swit-
zerland) (Bragger et al. 2005; Halg et al. 2008;
Romeo et al. 2009). The types of implant
tested were mostly solid screws, whereas hol-
low screws and hollow cylinders were
reported in three studies (Bragger et al. 2005;
Kreissl et al. 2007; Halg et al. 2008).
The selected studies reported a total of 568
implants and 255 ICFDPs. A total of 498
implants and 222 ICFDPs were available for
final analysis. (Table 3). The number of IC-
FDP ranged from 18 to 84. Prosthetic rehabil-
itations with ICFDPs were used in all sectors
of the mouth, upper and lower jaws and ante-
rior and posterior areas. Distal, mesial and
distal and mesial cantilevers were used.
(Table 3).
Only two studies (Halg et al. 2008; Romeo
et al. 2009) directly reported about ICFDP
supported by only one implant for a total of
17 rehabilitations. Only two studies reported

Table 3. General information on implants and ICFDPs in the selected studies

Total no. No. of No. of
of implants Total no. ICFDPs Ratio
Study (year implants available for of ICFDPs available crown Implant length
of placed analysis Placed for analysis units/ (mean or Implant Type of Location of Mechanism of
publication) (patients) (patients) (patients) (patients) implants range; mm) Diameters Extention reconstructions retention
Wennström NR (28) 66 (24) 28 (28) 24 (24) 1.6 12.7 NR Distal 16 maxilla, 8 Screw
et al. mandible Retained
(2004a,b)
Brägger 33 (14) 33 (14) 18 (14) 18 (14) 1.84 NR NR 16 11 maxilla, 7 5 screw
et al. (2005) mesial, 6 mandible retained, 13
distal cemented
Kreissl et al. 61 (20) 61 (20) 23 (20) 23 (20) NR NR NR 18 Maxilla and Screw
(2007) mesial, Mandible Retained
15 distal
Romeo 148 (59) 116 (45) 75 (59) 59 (45) 1.97 10,2 mm (8–14) 3.3–4.1 – 4.8 32 33 maxilla/26 Screw
et al. 2009; mesial; mandible retained/
27 distal cemented
TOTAL NR (121) 276 (103) 144 (121) 124 (103)
Eliasson 209 (84) 176 (71) 84 (84) 71 (71) 1,6 NR NR Mesial, NR Screw
et al. (2006) distal, Retained
bilateral
Hälg et al. 46 (27) 46 (27) 27 (27) 27 (27) 1.65 6–12 3.3 or 4.1 12 13 maxilla, 14 Cemented
(2008) mesial, mandible
15 distal
TOTAL 255 (111) 222 (98) 111 (111) 98 (98)

ICFDPs, implant supported, cantilever fixed dental prostheses; NR, not reported.

42 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/39–49 © 2012 John Wiley & Sons A/S
 Romeo & Storelli. Systematic review of cantilever prostheses

Table 4. Annual failure rates and survival of implants

Study (year of No. of implants available Mean follow-up No. of Total implants Estimated failure rate (per Estimated survival rate
publication) for analysis (patients) time (years) Failures exposure time 100 implant years) after 5–10 years (%)
Wennström 66 (24) 5 2 330 0.61 97%
et al. (2004a,b)
Brägger et al. 33 (14) 9.4 1 310.2 0.32 98.4
(2005)
Kreissl et al. 61 (20) 5 1 305 0.33 98.4
(2007)
Romeo et al. 116 (45) 8 0 928 0 100
(2009)
TOTAL 276 (103) 4 98.9% (CI 95.9–99.7)
Eliasson et al. 176 (71) 9,8 3 1724,8 0.13 99.4
(2006)
Hälg et al. 46 (27) 5 2 230 0.87 95.7
(2008)
TOTAL 222 (98) 5 98.7 (CI 96.2–99.5)
Summary 98.9% (CI 97.4–99.5)
estimate (95%
CI) *
*
Based on Poisson regression, test for heterogeneity, P = 0.09.
CI, confidence interval.

the mean length of the cantilever (Wenn-
strom et al. 2004; Romeo et al. 2009) and
most of the rehabilitation described in all six
studies had only one element in extension
and were located in posterior areas. Only one
study reported the exact area of treatment in
combination to the exact rehabilitation (e.g.
how many implants supported the restoration
in a specific area of the mouth) (Halg et al.
2008). Therefore, it was not possible to sepa-
rate data in respect of location and prosthetic
design.
Four studies reported that the crown units
to implant ratio was within the range of 1.6
and 1.97 (Wennstrom et al. 2004; Bragger
et al. 2005; Halg et al. 2008; Romeo et al.
2009). Retention systems used were screw-
retained (Wennstrom 2004; Eliasson et al.
2006; Kreissl 2007), cemented (Halg et al.
2008) and both (Bragger et al. 2005; Romeo
et al. 2009). Three publications had a mean
observation time of 5 years, one (Romeo
2009) of 8 years, and two almost 10 years
(Bragger et al. 2005; Eliasson et al. 2006).
Implant survival
Early failures were not considered in the
meta-analysis: nine implants of 498 were
reported lost after load. Implant fracture was
the cause of the failure of three implants,
two were lost due to severe peri-implantitis
whereas the reasons for the loss of the
remaining implants were not specified.
Data on implant length were reported in
three studies (Wennstrom et al. 2004; Halg
et al. 2008; Romeo et al. 2009), whereas data
on implant diameter were reported in two
studies (Halg et al. 2008; Romeo et al. 2009)
as shown in Table 3. Data on opposite denti-
tion were provided by three studies (Wenn-
strom et al. 2004; Halg et al. 2008; Romeo
et al. 2009).
The survival rate of implants was calcu-
lated cumulating data from all studies and
separating data for prospective and retrospec-
tive studies alone. The survival rate ranged
in the different studies between 98.4% and
100%, with a summary estimate survival rate
of 98.9 (95% CI: 97.4–99.5%) after 5 years,
calculated with a standard Poisson regression
analysis (Table 4).
The estimated implants survival rate of
prospective and retrospective studies was cal-
culated with a standard Poisson regression
analysis to be 98.9% (95% CI: 95.9–99.7%)
and 98.7% (CI: 96.2–99.5%), respectively
(Table 4).

Table 5. Annual failure rates and survival of ICFDPs

Study (year of No. of ICFDPs available for Mean follow-up No. of Total ICFDPs Estimated failure rate (per Estimated survival rate after
publication) analysis (patients) time (years) Failures exposure time 100 ICFDP years) 5–10 years (%)
Wennström 24 (24) 5 2 130 1.54 92.6
et al. (2004a,b)
Brägger et al. 18 (14) 9.4 3 169.2 1.77 91.5
(2005)
Kreissl et al. 23 (20) 5 1 115 0.87 95.7
(2007)
Romeo et al. 59 (45) 8 0 472 0 100
2009;
TOTAL 124 (103) 6 95.4 (CI 84.8–98.6%)
Eliasson et al. 71 (71) 9.8 0 695.8 0 100
(2006)
Hälg et al. 27 (27) 5 3 135 2.22 89.5
(2008)
TOTAL 98 (98) 3 98.2% (CI 61.8–99.9%)
Summary 0.58 (0.26–1.11) 97.1% (CI 90.1–99.2%)
Estimate (95%
CI) *
*
Based on random-effects Poisson regression, test for heterogeneity, P = 0.02.
ICFDPs, implant-supported cantilever fixed dental prostheses; CI, confidence interval.

© 2012 John Wiley & Sons A/S 43 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/39–49
Romeo & Storelli. Systematic review of cantilever prostheses

ICFDP survival was defined as a technical complication (Sal-

complication rate (per 100

10.4% (CI 7.5–14.4%)

An ICFPD prosthesis was considered to have
survived when there was no modification
during the observation time and the rehabili-
prostheses years)
Estimated ICFDP
vi & Bragger 2009).
Data on implant fractures were reported by
all studies. Two events were related to

tation was still in situ. Outcomes in respect reduced diameter implants (3.3 mm) (Halg
to ICFPD failure and survival rates are sum- et al. 2008) one event to a hollow cylinder
2.96
2.32
marized in Table 5. implant (Bragger 2005)
Of the 222 ICFPDs followed for at least
0,74
Based on these outcomes, the cumulative
5 years, nine were reported lost as a conse- estimate for implant fractures is 0.7% (95%
quence of implant loss, abutment fracture,
complication rate (per

CI: 0.1–4.7%) (Table 7).

5,7% (CI 7.6–4.2%)

superstructure fracture or decementation or Screw abutment fractures were reported by

100 implant years)
Estimated implant

screw loosening. Bragger 2005 (1 event), Eliasson 2006 (3

1.61
1.18

The reasons for the loss were indicated in events) and Kreissl 2007 (1 event). Statistical
0,43

two studies (Wennstrom et al. 2004; Halg et al.
2008), implant fracture was the cause for the
loss of three cases, whereas the need to remake
the supra-structure was the cause for one case.
No. of Biological
analysis revealed a cumulative estimate of
screw fractures of 1.6% (95% CI: 0.8–3.5%)
(Table 7).
Framework fractures were not reported in

(peri-implantitis)

The survival rate of ICFPDs was calculated any study, whereas veneer fractures consti-
Complications

cumulating data from all studies and separat- tuted the most frequent of all technical com-
ing data for prospective and retrospective plications. The studies combined reported a
(5)
(2)
(1)
(8)

studies alone. The survival rate ranged in the total of 36 events. Some studies reported that
5
11
1
17

different studies between 89.5% and 100%, more than one event occurred in the same
with a summary estimate survival rate of restoration. Specifically, Kreissl (2007)
exposure

97.1% (95% CI: 90.1–99.2%) after 5 years,

ICFDPs

reported 4 ICFPDs supported by more than

169.2
Total

time

472
135

calculated by a standard Poisson regression two or three implants that experienced eight
analysis (Table 4). veneer fractures. Romeo (2009) reported 22
The estimated ICFPDs survival rate of pro- events on 17 restorations. Wennstrom (2004),
exposure
implants

spective and retrospective studies was calcu- Bragger (2005), Eliasson (2006) and Halg
310.2
Total

time

928
230

lated by a standard Poisson regression (2008) reported that all veneer fractures hap-
analysis to be 95.4% (95% CI: 84.8–98.6%) pened in different rehabilitations. (Table 8)
Based on Poisson regression, test for heterogeneity, P = 0.45 (implant years), 0.17 (prostheses years).
follow-

and 98.2% (CI: 61.8–99.9%), respectively Statistical analysis revealed a cumulative

(years)
Mean

(Table 5). estimate of veneer fractures of 10.1 (95% CI:

9.4
up

8
5

3.7–16.5%) (Table 8).

Biological complications Loss of retention for cemented prosthesis
No. of ICFDPs

Biological complications were reported in

available for

was indicated in three studies with a total of

(patients)

three publications for a total of 165 implants six ICFDP been affected, whereas for the
(14)
(45)
(27)
(86)
analysis

(Bragger et al. 2005; Halg et al. 2008; Romeo screw loosening, five papers indicated a total
18
59
27
104

et al. 2009) and are listed in Table 6. Peri-im- of 14 ICFDP affected (Table 8).
plantitis was reported, whereas data on soft The study-specific, estimated 5-year loss of
No. of implants

tissue complications (i.e. peri-implant muco- retention rate for cemented ICFDP varied
available for

sitis or recessions) were not always reported. between 0.83% and 1.64% with a summary
(patients)

(100)

Hälg et al. (2008) and Romeo et al. (2009)

(14)
(59)
(27)

estimate of 5.9% (95% CI: 1.7–16.8%) after

analysis

reported data on peri-implantitis. Neither of 5 years, calculated by a standard Poisson

33
116
46
165

them provided any information on the diag- regression (Table 8).

nostic parameters adopted. Romeo points out
*

The study-specific estimated loss of reten-

Cumulative 5–10 years complication rate (95% CI)

that nine cases of bone loss were diagnosed
using x-ray measurements whereas two cases
of peri-implantitis were clinically diagnosed.
The estimated 5-year biological complica-
tion rate implant based varied between 15.1
Table 6. Biological complications
tion rate for screw-retained prosthesis per
100 ICFDP years varied between 0% and
4.35% with a summary estimate of 7.9%
(95% CI: 3.2–18.2%) and was calculated with
a standard Poisson regression (Table 8).

and 2.1% with a summary estimate of 5.7%

(95% CI: 4.2–7.6%) after 5 years and was cal-
Study (year of publication)

Radiographic bone level changes

culated with a standard Poisson regression Romeo (2009) only gave average bone loss,
CI, confidence interval.
Brägger et al. (2005)

(Table 6). whereas other papers do not provide data for

Romeo et al. (2009)
Hälg et al. (2008)

bone changes (Bragger 2005; Eliasson 2006;

Mechanical and technical complications Kreissl 2007) (Table 9).
Damage to the integrity of implants or abut- Wennstrom (2004) and Halg (2008) com-
ments was defined as mechanical complica-
TOTAL

pared the bone level changes around the

tions whereas damage to prosthetic implants supporting the cantilever with
*

rehabilitations (meso- and suprastructures) those supporting standard FPDs, assessing

44 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/39–49 © 2012 John Wiley & Sons A/S
 Romeo & Storelli. Systematic review of cantilever prostheses

Table 7. Mechanical complications: implant/abutment related complications

Total
No. of implants Mean implants No of Estimated rate of No. of Estimated rate of abutment or
Study (year of available for follow-up exposure Implant implant fractures (per abutment or screw fractures (per 100
publication) analysis time (years) time fracture 100 implant years) screw fractures patients/year)
Wennström et al. 66 (24) 5 330 0 0 1 0.59
(2004a,b)
Brägger et al. 33 (14) 9.4 310.2 1 0.32 1 0.87
(2005)
Kreissl et al. (2007) 61 (20) 5 305 0 0 0 0
Romeo et al. (2009) 116 (45) 8 928 0 0 0 0
Eliasson et al. 176 (71) 9,8 1724,8 0 0 3
(2006)
Hälg et al. (2008) 46 (27) 5 230 2 0.87 0 0
Cumulative 5– 498 (201) 3 0.7% (0.1–4.7%) 1.6 (CI 0.8–3.5%)
10 year
complication rates
(95% CI)
*
Based on random-effects Poisson regression, test for heterogeneity P < 0.001 for veneers fractures.
Based on Poisson regression, test for heterogeneity P = 0.78 for abutment screw fractures.
ICFDPs, implant-supported cantilever fixed dental prostheses; CI, confidence interval.

the difference on bone height at prosthesis
installation and over time. The difference
between the bone loss of the implant closest
to the cantilever extension was 0.23–
0.39 mm (weighted mean 0.31 mm, 95% CI
0.15–0.46 mm) compared with 0.05–0.23 mm
(weighted mean 0.14 mm, 95% CI: 0.04–
0.32 mm) at the end implant or a randomized
selected implant in the control group
(Table 10).
Aesthetic outcome
No studies have reported about aesthetic out-
comes.
Discussion
The objective of this systematic review of the
literature was to assess the implant survival
and the incidence of technical, biological, and
aesthetic complications in implant-supported
prosthetic rehabilitations with cantilever
extensions in longitudinal studies with a fol-
low-up time of a mean of 5 years. The system-
atic reviews of the literature on traditional
partial fixed dentures showed that the
10 years prognosis of tooth-supported pros-
thetic rehabilitations with cantilever exten-
sions is much less than that without
extensions. In a systematic review of the liter-
ature in 2007, Pjetursson found that the proba-
bility of survival at 5 years was 93.8% for
conventional FPDs, and 91.4% for traditional
prostheses with cantilever extensions,
whereas at 10 years, the probability of survival
was 89.2% (95% confidence interval (CI: 81–
93.8%) for traditional fixed dentures on natu-
ral teeth and 80.3% (95% CI: 47.7–85.2%) for
prostheses with cantilever extension.
It is therefore evident that the survival data
of conventional dentures on natural teeth
with cantilever extensions is clearly lower
than the data of conventional dentures with-
out extensions.
Aglietta’s systematic review of the litera-
ture in 2009 showed the implant-supported
survival rate, calculated by standard Pois-
son’s regression analysis, was 98.5% (95%
CI: 97.1–99.3%) at 5 years and 97.1% (CI:
94.3–98.5%) at 10 years. The estimated
annual failure rate was estimated to be 0.29
(95% CI: 0.15–0.59). This review included six
papers with survival and number of compli-
cations with follow-up times with a mean of
5 years. The results of this literature review
showed how the survival of implant-sup-
ported prosthetic rehabilitations with cantile-
ver extensions is predictable. The 5-year
implant-supported survival rate is 98.9% and
is therefore similar to the 95.4% implant-
supported survival rate in implant-supported
fixed partial dentures without extensions
(Pjetursson et al. 2004). However, the study
with follow-up close to 10 years (Bragger
2005; Eliasson 2006) have 98.4% and 99.4%
survival rate compared to the 92.8% survival
rate reported in Pjetursson’s 2007 review on
rehabilitations on implants without exten-
sions.
The present review did not consider early
failures, since they would not help in the
comparison between the two prosthetic
designs. The estimated annual failure rate for
100 implant years is 0.22, compared to the
0.94 reported in the literature on implant-
supported prostheses without cantilever
extensions at 5 years (Pjetursson et al. 2004).
With regard to the prosthetic survival rate,
the data obtained through analysis of the
papers were 97.1 at 5 years to 10 years, com-
pared to 95.2% at 5 years and 86.7% at
10 years for implant-supported prostheses
without cantilever extensions (Pjetursson
2007). This difference may be due to the
small number of implants/rehabilitations
included in the present review in comparison
to the total number of implants/rehabilita-
tions available without cantilever. Moreover,
since most studies included are retrospective,
there might be a bias in patient selection
especially when cantilever is used to avoid
major surgeries in patients with different risk
factors (age, smoke, periodontal susceptibil-
ity, etc.).
Mechanical and technical complications
Pjetursson et al. (2004) suggested that
implant fracture and loss of suprastructures
should be considered a major complication,
abutment, veneer or framework fracture as a
medium complication and abutment or screw
loosening, loss of retention, loss of veneer
hole sealing or veneer chipping fracture as a
minor complication. In this article, instead, a
different approach was used, to divide compo-
nent-related complications (implant and
abutments) from rehabilitation-related com-
plications (veneer fractures, framework frac-
tures, etc.).
The outcome of the prosthetic rehabilita-
tions was analyzed. Mechanical complica-
tions such as implant fracture were observed
in three different patients in two papers
(Bragger 2005; Halg 2008). The other studies
selected do not report fractures. The authors
do not provide much explanation for the
event but stress that these events occurred in
narrow implants (3.3 mm diameter) and hol-
low cylinder implants. In a systematic review

© 2012 John Wiley & Sons A/S 45 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/39–49
Romeo & Storelli. Systematic review of cantilever prostheses

by Pjetursson (2004), the cumulative inci-

Estimated rate of
screw loosening
dence for implant fracture was 0.4%, com-

retained ICFDP
(per 100 screw
pared to 0.7% estimated in the present
review. This observation may lead to the

1.67

4.35
year)
conclusion that the cantilever itself is not

-
the only variable for such events, but that
loosening other factors should be taken into consider-
ation, such as implant diameter, implant site,
No. of

screw
cases

parafunctions, etc.
2

14
From a technical point of view, veneering
fractures occurred most frequently (36 cases)
exposure
retained
ICFDPs
screw-

and are the most common complication. Sev-

695.8
Total

time

-
120

47

115

104
eral other studies reported similar rates of
ceramic fractures in different rehabilitations.
screw loosening
retained ICFDPs

The estimated 5-year veneer fracture rate was

No. of screw-

available for

calculated in the present review to be 10.1%

(3.7–16.5%). In a systematic review (Pjeturs-
analysis

son 2004) the estimated 5-year veneer frac-

24

23

13

-
71

136
ture rate was calculated to be 13.2% (8.3–
20.6%) and it was pointed out how veneer
retention (per
rate of loss of

chipping is quite common on FPDs on natu-

100 ICFDP
Estimated

ral teeth and on implants.

1.64

0.74
year)
-

-
0,83

Other events such as screw loosening and

decementation were documented as similar
retention

to FDP without cantilevers.

cases of
loss of
No. of

Another important factor to consider in

understanding mechanical/technical compli-
-

cations is the type of antagonist. Loading

cemented

exposure

forces increase in posterior areas, as is well

ICFDPs

122.2
Total

time

documented in literature (Duyck et al. 2000).

-

-
368

135

The type of antagonist, the location of the

Based on random-effects Poisson regression, test for heterogeneity P < 0.001 for veneers fractures.

rehabilitation, and its design may be impor-

available for

tant for success.

Table 8. Technical complications: veneer fractures and decementation/screw loosening

cemented

Based on Poisson regression, test for heterogeneity P = 0.78 for abutment screw fractures.
retention

Moreover, no studies reported how occlusal

analysis
ICFDPs

loss of
No. of

contacts were defined on cantilevers. The

ICFDPs, implant-supported cantilever fixed dental prostheses; CI, confidence interval.
-

13

46

27

86

definition of a protocol for occlusal contacts

may help to reduce chipping and prosthetic
Estimated rate

fractures (per
100 patients/

complications. The role of such factors is

of veneer

still to be understood.
year)
0.83

0.59

6.96

2.96
4.7

Marginal bone loss

Two studies reported bone loss over time for
fractures
veneers
No. of

each implant (Wennstrom 2004; Halg 2007),

whereas Romeo (2009) only reported the
1

17

36

mean marginal bone loss of all placed

exposure

implants. Halg and Wennstrom reported

169.2
ICFDPs

695,8
120

115

472

135
Total

small bone resorption, much below the level

time

suggested by Albrektsson et al. (1986).

Romeo et al., on the other hand, reported a
follow-

(years)
Mean

time

mean of 1.1 mm of resorption after 8 years.

9.4

9.8
up

Even if this is acceptable, in terms of the suc-

for analysis

cess of the rehabilitations, the difference is

(patients)
available

evident. Marginal bone loss does not seem to

24 (24)

18 (14)

23 (20)

59 (45)

71 (71)

27 (27)

98 (98)
ICFDPs
No. of

be affected by the presence of a cantilever

prosthesis, as several studies have reported
(Blanes 2007). Although it has been demon-
Cumulative 5
et al. (2004a,

Romeo et al.

complication
Kreissl et al.
publication)

et al. (2005)

et al. (2006)
Wennström
Study (year

rates (95%
Hälg et al.

strated that non-occlusal forces may lead to

–10 year
Brägger

Eliasson

strain and to loss of osseointegration over

(2007)

(2008)
2009;

time (Isidor 1996–1997), clinical evidence of

CI)
of

b)

such events still needs to be provided. The

46 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/39–49 © 2012 John Wiley & Sons A/S
 Romeo & Storelli. Systematic review of cantilever prostheses

Table 9. Radiographic bone loss around ICFDPs and IFDPs without cantilever extensions
Study (year Mean Mean bone Mean bone No. of IFDPs Mean Mean bone Mean bone
of No. of follow-up loss (SD) loss per year without follow-up loss (SD) loss per year Mean difference in bone loss
publication) ICFDPs (years) (mm) (mm) cantilever (years) (mm) (mm) per year (mm)
Wennström 24 5 0.49 (0.89) 0.1 23 5 0.38 (0.65) 0.08 0.02
et al.
(2004a,b)
Hälg et al. 24 5.3 0.23 (0.63) 0.04 25 5.3 0.09 (0.43) 0.02 0.03
(2008)
Summary ? 0.025 (0.023–0.073) P- 0.31
estimate
(95% CI) *
*
Meta-analysis of mean differences with P = 0.95 for heterogeneity.
ICFDPs, implant-supported cantilever fixed dental prostheses; SD, standard deviation; CI, confidence interval.

Table 10. Radiographic bone loss around implants in proximity of cantilever extensions and control implants supporting FDPs without cantilever
extensions
No. of Mean Mean Total
Study (year implants follow- Mean Mean bone follow- controls Mean Mean bone
of close to up bone loss loss per No. of up exposure bone Loss loss per Mean difference in bone
publication) extension (years) (SD) (mm) year (mm) Controls (years) time (SD) (mm) year (mm) loss per year (mm)
Wennström 24 5 0.39 (1.04) 0.08 23 5 115 0.23 (0.67) 0.05 0.03
et al.
(2004a,b)
Hälg et al. 24 5.3 0.23 (0.71) 0.04 24 5.3 127.2 0.05 (0.45) 0.01 0.03
(2008)
Summary 0.033 (0.02–0.087) P-0.14
estimate
(95% CI) *
*
Meta-analysis of mean differences with P = 0.974.
SD, standard deviation; CI, confidence interval; FDP, fixed dental prosthesis.

presence of many other variables (mandible/
maxilla, smoking habits, periodontal suscep-
tibility, buccolingual extension of the pros-
thesis and interarch distance, implant design
and surface characteristics) may need to be
studied to understand the relative influence
of each variable on bone resorption.
Biological complications and peri-implantitis
Halg (2007) reported peri-implantitis: four
cases of peri-implantitis were reported, three
in the non-cantilever group and one in the
cantilever group. Romeo et al. reported two
cases of peri-implantitis of 116 implants. In a
recent review, Zitzman et al. (2008), peri-im-
plantitis comprised between 26% and 56% of
the cases. Although an important and rela-
tively common complication, the data regard-
ing the peri-implant susceptibility of
cantilever rehabilitation still need to be
proved.
Aesthetic outcome
No studies have reported about aesthetic out-
comes, nor it was addressed in previous
reviews on the same topic. Therefore, it’s not
possible to draw any conclusion on the aes-
thetic outcome of ICFDP.
Conclusions
A total of six studies with 498 implants and
222 ICFPD were taken into consideration.
Although the literature available is limited,
with non-homogeneous study design and
follow-up, the present systematic review
assessed that there is no increase in biologi-
cal or technical complication rate due to the
presence of the cantilever. Therefore, ICFDPS
over implants can be considered a reliable
treatment in partially edentulous patient
with survival rate similar to the standard
FDP on implants.
Group consensus
The group agreed that ICFDP rehabilitations
appear to be a reliable treatment option in
partially edentulous areas;
On the basis of the present literature, the
prevalence of implant failure, mechanical,
technical, and biological complications and
MBL rates appear to be similar to the
standard FDP rehabilitations. The group
opinion is that ICFDP rehabilitations could
be indicated in cases where more complex
treatment is needed for end abutment
FDPs.
However, since there is no data showing
the effect of the actual cantilever extension
on failure and complications, the opinion of
the group is to limit as much as possible the
extension of the cantilever until supported by
additional studies.
Clinical recommendations
Based on the available evidence deriving from
studies on partially edentulous patients the
group recommends:
1). ICFDP with one cantilever of the size a
premolar supported by two or more
implants is a valid treatment concept in
partially edentulous patients with sur-
vival rates similar to the standard FDP
on implants. There is limited evidence to
support the use of ICFDP supported by
one implant.
2). The use of ICFDP could be a safe and
valid treatment alternative to avoid
implantation in compromised anatomical
locations and to reduce costs.

© 2012 John Wiley & Sons A/S 47 | Clin. Oral Implants Res. 23(Suppl. 6), 2012/39–49
Romeo & Storelli. Systematic review of cantilever prostheses
Research reccomendations
The group concluded that based on the avail-
able evidence evaluated in the present three
reviews (Jung et al., Pjetursson et al., Romeo
& Storelli):
• There is a clear need for improvement,
not only in the design of clinical studies
but also in the quality of reporting in the
field of implant- supported reconstruc-
tions.
• Publications on all observational clinical
studies must fulfill the present recom-
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