Journal of Dentistry 65 (2017) 51–55

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Journal of Dentistry
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Full Length Article

Ten-year outcome of zirconia ceramic cantilever resin-bonded fixed dental MARK

prostheses and the influence of the reasons for missing incisors
⁎
Matthias Kern , Nicole Passia, Martin Sasse, Christine Yazigi
Department of Prosthodontics, Propaedeutics and Dental Materials, School of Dentistry, Christian-Albrechts University, Kiel, Germany

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: This clinical study evaluated the long-term outcome and survival rate of all-ceramic cantilever resin-
All-ceramics bonded fixed dental prostheses (RBFDPs) made of zirconia-ceramic with a single-retainer design to replace
Anterior teeth missing incisors. In addition, whether the reason for missing incisors has an influence on the longevity of RBFDPs
Cantilever fixed dental prosthesis was analyzed.
Congenitally missing teeth
Materials and methods: One hundred and eight zirconia ceramic cantilever RBFDPs were provided for 87 pa-
Debonding
tients. Seventy-five RBFDPs replaced maxillary incisors and 33 mandibular incisors. The restorations were
Resin-bonded fixed dental prosthesis
Survival rate subsequently categorized into 3 groups according to the reasons for missing teeth (congenitally missing, trauma
Zirconia ceramic bonding and other reasons). The patients were followed up annually, and the restorations were assessed for function and
aesthetics. The mean observation time of the RBFDPs was 92.2 ± 33 months.
Results: Six debondings and 1 loss of restoration were recorded. The lost restoration was removed at the patient’s
request after a small chip occurred on the mesial edge of the pontic. Three of the 6 observed debondings were
caused by traumatic incidents. All debonded RBFDPs were rebonded successfully with no further complications.
Zirconia ceramic RBFDPs yielded a 10-year survival rate of 98.2% and a success rate of 92.0%.
Conclusions: Anterior zirconia ceramic cantilever RBFDPs provided excellent clinical longevity. The reasons for
missing incisors did not influence the longevity of the cantilever RBFDPs.

1. Introduction closure, resin-bonded fixed dental prostheses (RBFDPs), implants, and

Missing teeth in the anterior aesthetic region represent an urgent
need for dental intervention and often require an early treatment
strategy that restores both the aesthetic and functional aspects of the
dentition [1]. Missing anterior teeth may be congenital or occur as a
result of traumatic incidents, caries and periodontitis [1–3].
Congenital absence of teeth is one of the most common malforma-
tions in humans [3]. In the permanent dentition, with the exclusion of
third molars, the prevalence of congenitally missing teeth on different
continents ranges between 0.15% and 16.2% [4]. Maxillary lateral in-
cisors are the most commonly affected teeth in the anterior region
[5,6]. They are also the most common congenitally missing teeth bi-
laterally [4,7].
Traumatic events are another main reason for missing incisors [2],
whether as a direct result of an incident or as a late complication.
Maxillary central incisors are most frequently affected by trauma [8].
The main treatment options in these situations are the auto-
transplantation of deciduous or permanent teeth, orthodontic space
conventional fixed dental prostheses (FDPs) [1,3].
Cantilever resin-bonded fixed dental prostheses (RBFDPs) are con-
sidered a minimally invasive treatment approach to the replacement of
single missing anterior teeth and provide excellent clinical outcomes,
high survival rates and great patient satisfaction [9–12]. Fiber-re-
inforced composite RBFPDs offer a good aesthetic outcome, but are
considered short-term prostheses [1]. Metal-ceramic RBFDPs provide a
long-term and successful option when designed as single-unit cantilever
prostheses [13,14]. Cantilever all-ceramic RBFDPs have demonstrated
clinically excellent outcomes in terms of durability, outcome, aesthetics
and function, whether made from glass-infiltrated alumina ceramic or
from zirconia ceramic [15–19].
Additionally, RBFDPs have many advantages. They require a simple
and conservative preparation, are low in cost and are a reversible
treatment option, with no risk of pulpal irritation, no need for an-
esthesia, and minimal risk of caries development; in addition, they are a
valid option for young patients [11]. Moreover, these restorations de-
monstrated a high survival rate of up to 81.8% after 18 years of clinical

⁎
Corresponding author at: Department of Prosthodontics, Propaedeutics and Dental Materials, School of Dentistry, Christian-Albrechts University, Arnold-Heller-Str. 16, 24105 Kiel,
Germany.
E-mail address: mkern@proth.uni-kiel.de (M. Kern).

http://dx.doi.org/10.1016/j.jdent.2017.07.003
Received 23 January 2017; Received in revised form 28 June 2017; Accepted 4 July 2017
0300-5712/ © 2017 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
M. Kern et al. Journal of Dentistry 65 (2017) 51–55

service [15].
A recent systematic review on the rehabilitation of patients with
congenitally missing teeth [3], concluded that the best restorative re-
placement was with dental implants. Conventional prosthetics, in-
cluding RBFDPs, was considered an inferior treatment option with
lower success and survival rates. However, this systematic review in-
cluded no clinical studies using cantilever RBFDPs despite cantilever
RBFDPs demonstrating excellent success and survival rates in such si-
tuations [15].
To the authors’ best knowledge, no studies have evaluated the in- Fig. 1. Schematic drawing of the preparation design. C = light cervical chamfer,
fluence of the cause of the missing teeth on the clinical performance of S = light incisal finishing shoulder, B = small proximal box, P = small pinhole; Fig.
cantilever all-ceramic RBFDPs [12]. The purpose of this clinical study reprinted with permission from M. Kern, RBFDPs. Resin-Bonded Fixed Dental Prostheses -
Minimally Invasive – Esthetic – Reliable, 1st ed., Quintessence, Berlin, 2017.
was to determine the long-term success and survival rates of cantilever
zirconia ceramic RBFDPs replacing incisor teeth. Additionally, the
study was designed to determine whether the reasons for missing in-
cisors would influence these rates. The null hypotheses of this study
were that the success and survival rates of cantilever zirconia ceramic
RBFDPs would not be influenced by the reasons for missing incisors.

2. Materials and methods

This retrospective clinical evaluation was approved by the ethics

committee of the Christian-Albrechts University at Kiel, Germany.
Between October 2001 and December 2013, 87 patients with missing
incisors and an indication for RBFDPs received 108 anterior cantilever
RBFDPs made from zirconia ceramic. The patients were selected based
on the following inclusion criteria:
1. Patients with 1 or 2 missing incisors.
2. Abutment teeth were caries-free or had minor defects that could be
covered by the retainer wing. The available bonding area on sound
enamel had to be at least 30 mm2.
3. Abutment teeth without periodontitis.
4. Edentulous space width corresponded to the size of the missing
tooth.
5. Appropriate occlusion that allowed the application of a retainer
wing with a thickness of at least 0.7 mm.
6. Retention phase of at least 3 months after active orthodontic treat-
ment.
7. Patient commitment to attend annual recall appointments.
Patients were informed about the treatment modality and possible
treatment alternatives and signed an informed consent form. The pa-
tients were 61% female and 39% male with the youngest patient being
13 years old and the oldest being 78, with a mean age of 32 ± 20 years.
The preparation of the abutment was minimally invasive, limited to
the enamel and was carried out as described previously [11,17]. The
preparation of the retainer consisted of a thin lingual veneer design, a
fine incisal finishing shoulder and a fine cervical chamfer. The finish
line in the proximal area did not extend farther than the proximal
contact. A small box of approximately 2 × 2 × 0.5 mm was prepared
proximally. Additionally, a pinhole was created on the cingulum, and
finally all sharp edges and surfaces were carefully smoothed. A sche-
matic drawing of the preparation design is depicted in Fig. 1.
Impressions were taken and then poured with die stone.
Restorations were designed using CAD/CAM technology, milled out of
presintered zirconia ceramic blocks, and then densely sintered and
manually veneered. The minimum thickness for the retainer wing was
0.7 mm. The minimum zirconia ceramic dimensions of the proximal
connector were 2 mm (horizontally) × 3 mm (vertically). During the
final clinical try-in appointment, marginal adaptation, fit, aesthetics,
proximal contacts and static and dynamic occlusion were all carefully
examined.
Prior to insertion, the bonding surfaces of the restorations were air-
abraded with 50-μm alumina particles (0.25 MPa blasting pressure until
the year 2009 and thereafter 0.1 MPa pressure) and then cleansed
Fig. 2. Lingual view of 2 cantilever zirconia ceramic RBFDPs.
ultrasonically in 99% isopropanol. Rubber dam was used for isolation,
and the enamel was etched with 37% phosphoric acid for 30s, and then
the restorations were adhesively bonded using 1 of 2 adhesive luting
systems (Panavia 21 TC, Kuraray, or Multilink Automix after applica-
tion of Metal/Zirconia Primer, Ivoclar-Vivadent). An oral view of 2
cantilever zirconia ceramic RBFDPs is shown in Fig. 2.
Fifty-nine patients received 1 cantilever RBFDP, 21 patients each
received 2 cantilever RBFDPs, while 7 patients missing both maxillary
lateral incisors received cantilever RBFDPs splinted at the midline by
connecting their retainer wings to maintain the orthodontic closure of a
midline diastema. The number and distribution of replaced missing
teeth are shown in detail in Table 1.
Patients were recalled at least annually to examine and assess the
restorations both functionally and aesthetically. Patients who could not
attend a clinical examination for any reason were contacted by tele-
phone and interviewed about the status of their RBFDP. Patients were
categorized according to the reason for the missing tooth into 3 cate-
gories: congenitally missing (G1), traumatic incidents (G2) and other
reasons (G3), including periodontitis, caries and orthodontic treatment.
One patient (1 restoration) was excluded from this analysis as the
reason for the missing tooth was unknown. The RBFDPs replaced teeth
that were congenitally missing in 59.6% of the cases, missing because of
traumatic incidents in 13.2% and for other reasons in 27.2%. Table 2
specifies the number of teeth and the cause of missing teeth.
The data were collected, coded, tabulated and input to a PC using
Statistical Package for Social Science (SPSS 20.0 for Windows, SPSS Inc,
Chicago, IL, USA). Using the Kaplan-Meier method, the success and
survival rates of the restorations were analyzed considering 2 failure
criteria: debonding for success and loss of the restoration for survival
Table 1
Frequency distribution of pontic location.
Pontic location Maxilla Mandible Total
Central incisors 13 26 39
Lateral incisors 69a 7 76
Total 82 33 115
a
In the maxilla, seven restorations replaced both missing lateral incisors.

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M. Kern et al. Journal of Dentistry 65 (2017) 51–55

Table 2
Frequency distribution of cause of missing teeth (one RBFDP with unknown cause ex-
cluded).

Cause for missing teeth Number of missing teeth Percentage%

Congenitally missing (G1) 68 59.6

Traumatic incidents (G2) 15 13.2
Other reasons (G3) 31 27.2
Total 114 100

rates. The Log-Rank test was used to compare the survival rates of
groups for these 2 criteria.

3. Results
Fig. 3. Cumulative success rate (debonding as failure criterion) for all RBFDPs.

The mean observation time was 92.2 ± 33 months with a

minimum of 35 months and a maximum of 185 months. Six patients
with 8 restorations did not present to follow-up for at least 24 months
and could not be interviewed by phone. They were considered as drop-
outs (censored data). Within the observation time, 6 debonding in-
cidents and 1 lost restoration were recorded. Of these, 2 patients were
orthodontically pretreated, while the others received no orthodontic
treatment. The distribution of complication incidents among groups is
shown in Table 3.
The first debonding occurred after 11 months when the patient was
hit in the face while playing with her preschool daughter. The second
happened after 22 months and was the result of an accidental hit on the
restoration by the patient’s friend. The third took place after 54 months
because of a traumatic incident during vacation. For the last 3 de-
bondings, the patients were not able to specify any reason. Four of 94
RBFDPs luted with Panavia 21 TC debonded (4.2%), while 2 of 14
RBFDPs luted with Multilink Automix debonded (14.2%). In 1 patient, Fig. 4. Cumulative success rate (debonding as failure criterion) related to the cause of
missing incisors. G1 = congenitally missing, G2 = missing because of trauma,
rebonding was done with Multilink Automix and with Panavia 21 TC in
G3 = missing for other reasons.
the other patients. All 6 rebonded restorations were followed up, and no
further complications were recorded. One RBFPD was removed because
the patient requested an implant-supported crown to replace the 4. Discussion
missing tooth after a small chip occurred on the mesial edge of the
RBFDP pontic. Three of 6 debonding prostheses were caused by traumatic incidents
When debonding was considered a complication, the success rate and all 6 restorations were successfully rebonded and remained func-
(survival with complication) was 92.0% after 10 years (Fig. 3). Group tionally and aesthetically successful. No framework fractures occurred
G1 had a success rate of 98.5%, whereas the 10-year success rates for in any of the zirconia RBFDPs, even after traumatic impact. However, 3
groups G2 and G3 were 76.9% and 89.2%, respectively (Fig. 4). How- minor chips of the veneering ceramic were recorded. The only lost re-
ever, because of the low number of debondings, no statistically sig- storation was removed after minor incisal chipping at the patient’s re-
nificant difference was detected among the 3 groups (p = 0.128, Log quest.
Rank test). Anterior all-ceramic cantilever single-retainer RBFDPs made from
When the loss of a restoration was considered a failure, the overall zirconia ceramic showed a highly successful clinical outcome after 10
survival rate was 98.2% after 10 years. Groups G1 and G3 showed a years of clinical service. This equals the survival rate of cantilever
survival rate of 100%, whereas the survival rate for group G2 was RBFDPs with a single retainer made from a glass-infiltrated alumina
90.0%. With only 1 failed RBFDP in group G2, a statistical analysis was ceramic, in which the survival rate was 95.4% after 10 years [15]. In
not meaningful. the follow-up of RBFDPs made from glass-infiltrated alumina, no de-
All RBFDPs remained in function once the 6 debonded restorations bonding incidents were recorded, but 2 fractures of the alumina fra-
were rebonded. As the only lost restoration was removed at the pa- mework occurred. These fractures took place at the proximal connector
tient’s request and not because of failure, the survival rate of RBFDPs between the pontic and the retainer wing. In contrast, in the case of
made of zirconia ceramic can be considered to be 100%. RBFDPs made of zirconia ceramic, overloading, even by traumatic
impacts resulted in debonding rather than fracture of the framework;
zirconia has twice the flexural strength of glass-infiltrated alumina
ceramic [20]. This makes rebonding of the zirconia RBFDPs possible
Table 3 and free of complications, whereas alumina RBFDPs with failures and
Distribution of complication incidents. fractures in the framework will require a replacement restoration.
This excellent outcome is supported by the results of a recent long-
Group Debonding Loss of restoration
term evaluation, in which success and survival rates of 100% were re-
G1 1 0 corded for anterior metal-ceramic cantilever RBFDPs after 18 years
G2 2 1 compared with success and survival rates of only 10% and 50% of their
G3 3 0
2-retainer metal-ceramic counterparts [13]. The lower survival rate of
Total 6 1
the 2-retainer RBFDP design can be attributed to the differential

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M. Kern et al.
movement of the 2 abutment teeth, resulting in a shear force on the
wing of the retainer and consequent debonding of RBFDPs [16].
The high success rate reported in this long-term study agrees with
that of other studies using densely sintered zirconia as framework
material for cantilever RBFDPs [18,19]. After 4 years of clinical service
the survival rate of 15 zirconia ceramic RBFDPs replacing anterior
missing incisors was 100%. Two debondings were successfully re-
bonded, but no fractures or chipping of the ceramic material occurred
[19]. In a second study, 24 single-unit RBFDPs made of zirconia
ceramic showed a survival rate of 100% and a success rate of 82.4%
after 3 years of clinical service [18].
In the current study, the cause of missing teeth did not affect the
outcome in regard to both criteria (debonding and loss of restoration).
Therefore, the null hypotheses, that the cause does not influence either
the success rate or and survival rates of zirconia RBFDPs, were ac-
cepted. In a recent systematic review on the occlusal rehabilitation for
patients with congenitally missing teeth, the success rate, survival rate
and the annual failure rate for the treatment alternatives were recorded
and a conclusion favoring implant treatment was drawn [3]. The mean
survival rate for autotransplantation was 89.6% after a mean follow-up
of 12.5 years for deciduous teeth and 94.4% after 7.6 years for per-
manent teeth. An annual failure rate of 1% was recorded for both
treatment modalities. The survival rates for implants and conventional
prostheses were 95.3% and 60.2% after 4.6 and 8.4 years, respectively,
with annual failure rates of 3% for implants and 5% for conventional
prostheses. In the previous systematic review, RBFDPs were categorized
and rated as conventional prostheses along with all other different
prosthetic varieties retained by teeth as having a 60.2% survival rate,
which led to a wrong assumption. The results of our study, however,
where RBFDPs replaced congenitally missing teeth showed a survival
rate of 100% and a success rate of 98.5% after 10 years rates. These
rates surpass those obtained by any of the previous treatment alter-
natives, including implants. This outperformance reported by our study
agrees with the findings of another study comparing the performance of
RBFDPs and that of single implants in replacing a single missing tooth
after an observation time of close to 10 years [21]. The long-term
success rate for implant-supported crowns was lower, whereas the oc-
currence of biological complications was significantly higher among the
implants (25.6%) than the RBFDPs (7.7%).
In conclusion, RBFDPs and implants are both minimally invasive
treatment options for the replacement of single anterior missing teeth,
with comparable levels of longevity and patient satisfaction. However,
RBFDPs have the advantage of being an eligible option for young pa-
tients (as young as 10 years old), which is contraindicated for treatment
with implants. Additionally, the replacement of a single anterior
missing tooth with RBFDPs is still possible for those with limited
available space (< 7 mm) or with angled roots of adjacent teeth; im-
plantation placement in such individuals requires orthodontic treat-
ment. Moreover, when compared with single implants, RBFDPs are a
reversible option, require shorter treatment time, cost less and require
less demanding postoperative care [10,21].
The results highlight the excellent clinical outcome of cantilever
RBFDPs made of zirconia ceramic for the replacement of anterior
missing teeth. However, these results support only the use of zirconia
ceramic RBFDPs in the anterior region. This design is not suitable for
the molar region, where the use of 2-abutment inlay-retained zirconia
FDPs might be the treatment of choice [22].
This retrospective clinical study has certain limitations. Eight of the
108 restorations (7.4%) could not be followed over the complete ob-
servation time as they were not available for recall for at least 24
months. However, it seems unlikely, especially for early drop-outs, that
these RBFDPs failed, as patients in Germany have a 2-year warranty and
would probably have shown up in the case of failure. On the other
hand, a high number of patients were adolescents still living at home
with their parents when they received the RBFDPs. After finishing high
school, many may have moved out of the area, explaining late drop-
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Journal of Dentistry 65 (2017) 51–55
outs. As compared with another retrospective study on single-retainer
RBFDPs over only 6 years, where 28.6% of the restorations [23] could
not be followed, the drop-out rate of 7.4% in the current study seems
reasonable.
In addition, 27 patients with 32 restorations could only be contacted
for their most recent recall by telephone. Although they reported in
person that their cantilevered RBFDP had not debonded and was
functioning well, we were concerned that the patient might not able to
detect complications such as caries at the bonding margins. However,
unlike 2-retainer RBFDPs, where unilateral debonding of 1 retainer
wing might not be detected, any debonding of single-retainer RBFDPs
would be quite obvious to the patient as it would completely lose its
retention. With this in mind, the telephone interview might reflect the
true bonding of zirconia ceramic RBFDPs.
5. Conclusion
Anterior zirconia ceramic cantilever RBFDPs showed excellent
clinical longevity independently of the cause of the missing teeth.
Clinical relevance
All-ceramic cantilever RBFDPs provide an excellent minimally in-
vasive treatment alternative to implants and conventional prosthetic
methods when single missing anterior teeth need to be replaced.
Acknowledgments
The authors would like to acknowledge the patients for their kind
cooperation, the support of the departmental staff and and dental
technicians, especially R. Gerhardt and B. Schlueter, for the laboratory
work.
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