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Distal Cantilevers and Implant Dentistry

Article  in  The International journal of oral & maxillofacial implants · September 2012

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 Distal Cantilevers and Implant Dentistry
Georgios E. Romanos, DDS, PhD, Prof Dr med dent1/Bhumija Gupta, BDS2/Steven E. Eckert, DDS, MS3

Purpose: The use of distal cantilevers in fixed implant-supported prostheses is often discussed in dental
literature in relation to implant restorations. The aim of this study was to conduct a systematic review of the
literature in an effort to identify factors related to the long-term success of distal cantilevers. In addition, a
more traditional review was conducted to determine complications associated with this type of prosthetic
design. Material and Methods: A systematic literature review was conducted of all published articles
identified through a search of MEDLINE from January 1980 through June 2011 using the terms “crestal
bone loss,” “dental implants,” “distal cantilevers,” “marginal bone loss,” and “periodontal disease.” An initial
review was conducted of titles and a second review was performed using full abstracts. Articles were thus
identified to assess studies that met the inclusion criteria that described fixed complete dental prostheses
utilizing distal cantilevers. In vivo studies were included for data extraction while in vitro and animal studies
were used for descriptions of clinical or mechanical performance. Results: Following the method described,
from an initial identification of 49 studies, a total of 14 human clinical studies were found that met the
inclusion criteria and provided data associated with clinical performance. An additional 5 studies detailed
in vitro research. It was noted that the majority of studies lacked specific data but, nonetheless, provided
subjective and objective information regarding the use of cantilevers. The follow-up period of human studies
ranged from 1 to 10 years. Weighted averages demonstrate a prosthetic survival rate of 95% during a
follow-up period of 7.3 ± 2.6 years. The descriptive studies demonstrate that the most frequent complication
was screw loosening, which was observed equally in virtually all studies, even if controlled torque was used
to connect abutments and prostheses. Porcelain chipping and esthetic veneer fracture were described,
although data associated with these occurrences were not available for systematic review. Conclusions:
Based on 19 articles (including 14 human studies), it was difficult to derive data-based conclusions regarding
the use of cantilever prostheses other than an approximate 95% prosthetic survival rate. Subjective and
objective information from these studies demonstrated a distinct preference for the use of distal cantilever
prostheses, as few risks are associated with these prostheses. Careful evaluation of the studies shows that
cantilevers provide a treatment option without a high risk of complications. Int J Oral Maxillofac Implants
2012;27:1131–1136

Key words: complications, crestal bone loss, distal extension, implant-retained prostheses

D istal cantilevers have been discussed in fixed

prosthodontics as a method to reestablish occlu-
sion when there are no posterior teeth to support a
prosthesis.1–7 Extrapolation of the findings in natural
dentition toward implant dentistry has led to consider-
able debate within the dental implant community.1–9
1Professor and Associate Dean for Clinical Affairs, Department
of Dental Medicine, Stony Brook University, School of Dental
Medicine, Stony Brook, New York.
2Resident, Advanced Education in General Dentistry (AEGD),
Division of General Dentistry, Eastman Institute for Oral
Health, University of Rochester, Rochester, New York.
3 Professor Emeritus, Mayo Clinic, College of Medicine,
Rochester, Minnesota.
Correspondence to: Dr Georgios E. Romanos, Department
of Dental Medicine, Stony Brook University, School of Dental
Medicine, 184C Sullivan Hall, Stony Brook, NY 11794-8705.
Fax: 631-632-3116. Email: georgios.romanos@stonybrook.edu
There are various implant dentistry treatment con-
cepts using distal cantilever prostheses with reports
of long-term success.1–5,8,9 Some of the reasons for
incorporating the distal cantilever design in implant-
supported prostheses include a reduction in the num-
ber of implants used to support a prosthesis, which also
has a concomitant reduction in the cost of the restora-
tions; a decreased need for surgical intervention; and a
simplification of surgery in those anatomical areas that
are associated with the inferior alveolar nerve vascular
bundle or the sinus floor. When planning a distal canti-
lever, factors such as abutment selection, control of the
magnitude of forces, and rigidity/strength of connec-
tors are not fully understood.7
The purpose of the present systematic review was to
determine what data exist to support the use of distal
cantilever prostheses on implants and to demonstrate
complications that can be encountered.

The International Journal of Oral & Maxillofacial Implants 1131

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Romanos et al

Table 1  Studies with Complete Dental Prostheses

Author (study type)
Gallucci et al8
(clinical ­prospective)
Semper et al9
Maló et al10
(clinical study)
Wolfinger et al11
Maló et al12 ­
(retrospective ­clinical study)
Katsoulis et al13 ­
(2-year clinical trial)
Aim/objectives Implant total and type
To evaluate the primary complications associated with 237 Straumann implants; hybrid
mandibular fixed implant-supported rehabilitations with distal prostheses with ­distal extension
cantilevers over 5 years of function. cantilevers
To retrospectively determine whether a relationship exists 313 implants; many different
between the length of the distal bar extension and the amount systems
of marginal bone loss around implants supporting cantilevered
bar-retained dentures.
To develop and document a simple, safe, and effective surgical 176 Nobel Biocare immediately
and prosthetic protocol for immediate function. loaded implants
To suggest a simple, reliable, and documented method for 144 Brånemark System ­implants
immediate implant loading of complete-arch mandibular
prostheses.
To evaluate immediate function of four implants supporting a 128 Brånemark System TiUnite
fixed prosthesis in the completely edentulous maxilla. implants
To analyze maintenance service of fixed maxillary prostheses 193 Nobel Biocare implants
and overdentures based on conventional titanium bars and
CAD/CAM.

Material and Methods
The following PICO (patient problem, intervention,
comparison, and outcome) question was developed: In
patients with anatomical limitations that prevent the
placement of dental implant retainers on the most dis-
tal aspect of the anticipated dental prosthesis, would
distal implant-supported cantilever prostheses provide
acceptable clinical performance when compared with
traditional tooth-retained distal cantilever prostheses?
The following focused questions were addressed
regarding implant-supported prostheses: (1) Are dis-
tal cantilevers a viable option for implant-supported
prostheses? and (2) Are there specific complications
that can be anticipated with distal cantilever prosthe-
ses? A review of the dental literature was conducted
in an effort to identify articles that would address the
PICO question. A MEDLINE search was used to identify
appropriate publications. The database was searched
from January 1980 through June 2011 using the fol-
lowing terms in different combinations: “crestal bone
loss,” “dental implants,” “distal cantilevers,” “marginal
bone loss,” and “periodontal disease.”
Articles identified in the initial search were then cat-
egorized as experimental studies (in vitro or laboratory
studies), in vivo human studies, or in vivo animal studies.
For the literature to be included, the following eligibil-
ity criteria were used: case reports, retrospective stud-
ies, randomized clinical trials, articles with a reference
list of potentially relevant original and review articles,
and articles published only in English in peer-reviewed
journals. Data extraction was to be considered only for
case series, cohort studies, and randomized clinical trials.
Case reports and experimental studies were analyzed for
descriptive information.
Titles and abstracts of articles were independently
screened by two authors (GER and BG) and checked
for agreement. Since the search terms applied to both
implant- and natural tooth–supported prostheses, the
identified articles were then sorted using the category
of implant or natural tooth to identify the method of
support. The full text of the articles that were judged
by title and abstract to be relevant was read, and data
or descriptive material were abstracted and compiled.
Results
Based on the inclusion criteria, 14 articles were identified
that presented clinical material that could be abstracted.
Clinical Studies with Complete Dental
Prostheses
A total of six studies were identified that presented
information on performance of complete dental fixed
restorations with distal cantilevers in human clinical
studies.8–13 The implant survival rate ranged from 80% to
100%.8,10–12 Weighted averages demonstrated a pros-
thesis survival rate during a 7.3 ± 2.6–year follow-up
period of 95%.
Complications were observed in the categories of
prosthetic complications and bone loss. There was no
clearly documented etiology for the different compli-
cations. The lack of consistent reporting of information

1132 Volume 27, Number 5, 2012

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 Romanos et al

Patients (n) Follow-up Complications reported Results

45 5y 7 cases of screw loosening/­fracture; Implant survival rate: 100% (237/237)
20 events of fracture of the acrylic Prosthesis survival rate: 95.5% (43/45)
resin base or teeth
48 4y No correlation shown between use of No statistically significant bone loss was
cantilever design and bone loss related to cantilever length

44 NA (retrospective) 5 implants lost Prosthesis survival rate: 100%

24 5y No prosthesis failure reported; Prosthesis survival rate: 100%

Implant loss seen with immediate Implant cumulative survival rate: 97%
loading
32 6 and 12 mo, 3 implants lost Implant survival rate: 97.6%
retrospectively
41 (16 gold bar implant 2y Fracture of matrices and bar exten- High success reported for Titanium bar
overdentures, 12 tita- sions occurred only in gold bar overdenture group; fractures of the gold
nium, 13 CAD/CAM) overdenture group bar extensions; no implants failed

led to an inability to accumulate data regarding com-
plications and, consequently, data are presented as
they relate to each individual study (Table 1). Examples
of the complications reported are screw loosening/
fracture, fracture of the acrylic resin denture base, as
well as fracture of bars at the solder joint in gold versus
titanium restorations. There is no clear information in
these studies about the thickness of titanium or gold-
alloy frameworks.
Clinical Studies with Partial Dental Prostheses
A total of eight studies discussed the clinical perfor-
mance of prostheses in partially edentulous patients
when distal cantilever prostheses were used. The par-
tially edentulous studies did not provide sufficient
data for extraction. The publications did not report
time-dependent data of the different complications. In
addition, some studies reported an implant and pros-
thesis survival rate of 100% after 10 years14 or implant
and prosthesis success rates of 100%.15 Other reports16
showed an implant survival rate of 96.9%.
Studies that evaluated prosthetic performance in pa-
tients who had distal cantilevers in the management of
partial edentulism demonstrated no specific complica-
tions related to the cantilevered design (Table 2). Each of
the studies14–21 subjectively reported distal cantilevers to
be a successful prosthetic approach with no predictable
adverse events related to the cantilever design. None of
the studies demonstrated the incidence or prevalence
of complications, providing information regarding the
infrequency of these observations. Similarly, fixed tooth-
supported partial dentures, with periodontally involved
teeth as abutments, including distal cantilevers, did not
show any failures after occlusal adjustment and compre-
hensive treatment planning.
In Vitro Studies
In general, biomechanical studies represented the ma-
jority of in vitro studies assessing the performance of
cantilever prostheses.22–26 Most of these studies ap-
peared to demonstrate that the implant associated
with the most distal retainer of the prosthesis is placed
under compressive force when the forces are limited to
the cantilever portion of the prosthesis. Implants that
are located anterior to this distal supporting implant
are generally under tensile force when loads are ap-
plied to the distal cantilever. Additional biomechanical
studies identified increased moments of force related
to longer (more than one tooth) cantilevers. If the can-
tilever was longer, it would create increased compres-
sive strength on the most distal abutment site, along
with greater tensile load on the medial implant sites.
In addition, variations in angulation of the implants
may affect the magnitude of force. However, there is
no evidence regarding negative clinical outcomes of
implants placed with angulations (tilted implants) and
their distal cantilevers,1 even if the load distributions
were unfavorable.
Photoelastic models23 of a moderately resorbed
edentulous human mandible were used to assess the
effects of cantilever length on load transfer to the man-
dible. Disproportionate increases in maximum stress
occurred when cantilever length was increased. Minor
variations in implant angulation had a distinct effect

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Romanos et al

Table 2  Studies with Partial Dental Prostheses

Implant total No. of implant
Author (study type) Aim/objective and type cantilevers
Becker14 To evaluate 10 years of implant-retained fixed prostheses, primar- 115 Straumann 60
(clinical ­prospective) ily in the maxilla. implants

Hälg et al16 To analyze whether a cantilever extension on an FPD supported 78 Straumann 27

(clinical follow up) by implants increased the amount of peri-implant bone loss or implants
technical complications compared with reconstructions without
cantilevers.
Eliasson et al17 To evaluate and compare the long-term performance of FPDs sup- 375 Brånemark 146 implant-­
ported by 2 or 3 implants. System implants supported FPDs
Brägger et al18 To evaluate incidences of technical/biologic complications and 33 Straumann 22
failures occurring in a cohort of consecutive partially edentulous implants
patients with fixed reconstructions on implants.
Romeo et al15 To assess the clinical outcomes of patients treated with implant- 116 Straumann 8 in maxilla
(clinical prospective supported FPDs with cantilevers after a mean follow-up of 8 years. implants 41 in mandible
cohort)

Wennström et al19 To analyze whether the inclusion of cantilever extensions increased 48 Astra Tech 48
­(retrospective clinical) the amount of marginal bone loss at free-standing, implant- implants
supported, FPDs over a 5-year period of functional loading.

Kreissl et al20 To report incidences of technical problems, screw loosening, 205 Biomet 3i 23
­(prospective) screw fracture, fracturing of veneering porcelain, and framework implants
fracture in implant-supported FPDs and assess the survival and
success rates (event-free survival) after 5 years of function.
Johansson and To present treatment outcomes and patient reactions to rehabilita- 285 Brånemark 285
Ekfeldt 21 tion with implant-supported FPDs. System implants
(retrospective)

on stress magnitude with maximal apical stresses in
the distal tilted implants.
Naturally occurring masticatory forces were as-
sessed in dentitions with mandibular implant-sup-
ported fixed prostheses with bilateral distal two-unit
cantilevers opposing complete dentures.26 Based on
this study, closing and masticatory forces increased
distally. It was also observed that premature occlu-
sal contacts resulted in a significant redistribution of
forces. There were also stress contributions from each
cantilever unit, but the maximal vertical bending stress
in the cantilever joint with the distal implant was not
significantly influenced by the occlusal interferences.
Discussion
There were eight studies related to partially edentu-
lous patients and six studies in completely edentulous
patients. These studies present results with a follow-up
period ranging from 1 to 10 years regarding prosthetic
or implant survival. Descriptive studies demonstrate
that the most frequent complication was screw loos-
ening, while porcelain fracture and esthetic veneer
fracture were also observed. With a prosthetic survival
rate of 95% for the use of distal cantilevers in cases
of complete edentulism, this treatment approach ap-
pears to be a predictable treatment modality. These
figures compared favorably with previous descriptions
of distal cantilevers retained by natural anterior teeth.
A previous study by Nyman et al27 with distal can-
tilever fixed prostheses using periodontally compro-
mised teeth as abutments showed a high long-term
success rate with extensive documentation. Fixed
tooth-supported prosthetic restorations, including dis-
tal cantilevers, did not demonstrate any failures when
the occlusion was well adjusted after comprehensive
treatment planning.28 This study does not evaluate
the prosthetic restoration per se since the focus of the
study was the long-term prognosis of periodontally

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 Romanos et al

Patients (n) Follow-up Complications reported Results

36 10 y No implant fractures, abutment fractures, porcelain All prostheses were satisfactory and
fractures, prosthesis fractures, soft tissue recession, functional; 100% success rate
or radiographic bone loss reported
54 3 to 12.7 y 18.5% technical complications in cantilever group 95.7% survival rate; no significant bone
(mean, 5.3 y) loss

123 10.5 y 2 veneer fractures and 7 screw loosenings 100% success rate

14 10 y Porcelain fracture Implant-supported FPDs had a better

success rate compared with tooth- and
implant-supported FPDs; 3 failures
45 8.2 y Esthetic veneer fracture; no prosthetic failure Implant success and survival rates
observed during the follow-up examinations were 90.5% and 100%, respectively;
Prosthetic success and survival rates
were 57.7% and 100%, respectively
24 5y Bone level change at FPDs placed in the maxilla No correlation between cantilever and
was significantly greater than that for FPDs in the bone loss
mandible

76 5y 6.7% screw loosening; 3.9% screw fracture; Cantilever FPDs showed the lowest
8 veneer fractures success rate of 68.6%

83 53.9 mo 12% of gold screws and 17% of abutment screws 96% success rate.
showed “not acceptable” loosening; prostheses
made in gold acrylic and titanium acrylic had more
complications and showed greater need for repair
than metal-ceramic restorations

compromised teeth. When comparing implant reten-
tion with tooth retention, it is possible that the mobility
of the natural tooth compensates for posterior occlusal
contact since tooth mobility allows prosthetic mobili-
ty. Conversely, with distal cantilevers supported by im-
plants in the anterior portion of the arch, there will be
very limited mobility associated with framework flex. It
may be testimony to the superior anchorage provided
by the implant that allows these cantilever prostheses
to function as they do.
With the advent of the Brånemark approach utiliz-
ing complete-arch implant-supported cantilever pros-
theses, the distal cantilever has gained acceptance in
implant dentistry.29,30 Technical complications such as
fracture of the acrylic resin teeth and prosthesis base
were causes for failures for mandibular fixed implant-
supported rehabilitations with distal cantilevers.8
Some authors31–44 attempted to summarize the causes
of failures/complications of implants in association
with distal cantilevers. Insufficient metal thickness, in-
ferior solder joints, parafunctional habits of patients,
incorrect framework design, excessive cantilever
length, and inadequate strength of alloys have all been
reported as causes of prosthesis failure.
Conclusions
After a systematic review of the literature and a tra-
ditional literature review, it can be concluded that,
based upon 2,444 implants used to support distal can-
tilever prostheses, a 95% implant survival rate may be
achieved. Prosthetic survival reported in these articles
demonstrates a 95% prosthesis survival rate. These re-
sults are similar to previous publications where distal
cantilevers were used with natural tooth retention.
It appears that the use of distal cantilevers provides
predictable and reliable clinical outcomes. Descrip-
tive studies failed to present compelling evidence of
increased rates of mechanical complications.

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 Romanos et al
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