pyrig

No Co

ht
t fo
rP

by N
ub
Ten-year Survival of Anterior All-ceramic Resin-bonded

Q ui
lica
tio
te n
Fixed Dental Prostheses
ot

n
ss e n c e fo r

Matthias Kerna / Martin Sasseb

Purpose: To evaluate the long-term outcome of all-ceramic resin-bonded fixed dental prostheses (RBFDPs) made
with a two-retainer design or a cantilever single-retainer design.
Materials and Methods: Overall, 38 anterior RBFDPs were made from a glass-infiltrated alumina ceramic (In-Ce-
ram). Sixteen RBFDPs had a two-retainer design, while 22 RBFDPs had a cantilever single-retainer design. Phos-
phate monomer containing luting agents were used either after silica coating and silanation or after air-abrasion
only. The mean observation time in the two-retainer group was 120.2 months and in the single-retainer group
111.1 months.
Results: No restoration debonded. In the two-retainer group unilateral and bilateral fractures of the connectors
occurred. In the case of unilateral fracture, the pontic remained in situ as a cantilever RBFDP for several years.
In the single-retainer group, only one FDP fractured and was lost 48 months after insertion. The 10-year survival
rate was 73.9% in the two-retainer group and 94.4% in the single-retainer group. When unilateral fracture of a
FDP was taken as a criterion for failure, the 10-year survival rate decreased to 67.3% in the two-retainer group.
Conclusion: Cantilever all-ceramic RBFDPs are an adequate alternative to two-retainer RBFDPs.
Keywords: adhesive, all-ceramic restoration, alumina ceramic, cantilever fixed dental prosthesis, ceramic bond-
ing, ceramic fracture, resin-bonded fixed dental prosthesis, survival rate.

J Adhes Dent 2011; 13: 407–410 Submitted for publication: 31.03.11; accepted for publication: 08.08.11
doi: 10.3290/j.jad.a22096

T wo-retainer all-ceramic resin-bonded fixed dental pros-

theses (RBFDPs) made from the glass-infiltrated alu-
mina ceramic In-Ceram (Vita; Bad Säckingen, Germany)
were introduced in the early 1990s as a treatment op-
tion for missing incisors.5 Unfortunately, the all-ceramic
RBFDPs showed a relatively high fracture rate within the
first observation year.11 However, most unilaterally frac-
tured restorations remained in function as a cantilever
a Professor and Chair, Department of Prosthodontics, Propaedeutics and
Dental Materials, Christian-Albrechts University, Kiel, Germany. Idea, study
design, patient recall, wrote manuscript, statistical analysis.
b Assistant Professor, Department of Prosthodontics, Propaedeutics and Den-
tal Materials, Christian-Albrechts University, Kiel, Germany. Patient recall,
proofread manuscript, contributed to discussion.
Correspondence: Prof. Dr. Matthias Kern, Department of Prosthodontics, Pro-
paedeutics and Dental Materials, School of Dentistry, Christian-Albrechts Uni-
versity, Arnold-Heller-Str. 16, 24105 Kiel, Germany. Tel: +49-431-597-2874,
Fax: +49-431-597-2860. e-mail: mkern@proth.uni-kiel.de
RBFDP over five and more years.12 Because of the clini-
cal survival of the unilaterally fractured RBFDPs, in 1997
cantilever all-ceramic RBFDPs were suggested as an even
more conservative treatment approach.10 The cantilever
design eliminates shear and tensile forces resulting from
splinting two abutments with differential movements in
the two-retainer design, thus reducing the risk of debond-
ing.10 In addition, cantilever RBFDPs will come out when
debonding occurs, while with two retainers, they might
debond unilaterally, resulting in a high caries risk.3 During
a medium-term observation time of 5 years, cantilever all-
ceramic RBFDPs showed a better survival rate than two-
retainer all-ceramic RBFDPs,12 which is in agreement with
data on metal-ceramic RBFDPs.14
As no long-term data on all-ceramic RBFDPs have been
published yet, it was the purpose of this follow-up study
to evaluate the long-term clinical outcome of all-ceramic
resin RBFDPs with a cantilever single-retainer design and
to compare it with that of the two-retainer design after
10 years.

Vol 13, No 5, 2011 407

Kern and Sasse
Table 1 Frequency distribution of pontic location
Two-retainer RBFDPs
Central incisors Lateral incisors Total
Maxilla 5 4 9 0
Mandible 6* 1 7
Total 11 5 16
*In the mandible, two RBFDPs replaced both central incisors. The other RBFDPs replaced only one tooth.
MATERIALS AND METHODS
Overall, 38 anterior resin-bonded fixed dental pros-
theses (Table 1) were made from the glass-infiltrated
alumina ceramic In-Ceram, which was veneered with
Vitadur-Alpha (Vita; Bad Säckingen, Germany).
Sixteen RBFDPs with the two-retainer design were
made from In-Ceram alumina with the slip cast tech-
nique.5 They were inserted in 14 patients between 1991
and 1995. The bonding surfaces of the alumina ceramic
were tribochemically silica coated and then silanated
(Rocatec procedure, 3M ESPE; Seefeld, Germany).8,9 Af-
ter applying rubber-dam to the abutment teeth and etch-
ing the enamel for 30 s with 36% phosphoric acid, the
restorations were inserted using a phosphate-­monomer-
containing luting resin (Panavia TC, Kuraray; Osaka,
­Japan).
Twenty-two RBFDPs with a cantilever single-retainer
design were made with the In-Ceram-Celay copy-milling
technique and were inserted in 16 patients between
1996 and 2002.10 Fourteen restorations were made
from In-Ceram alumina and 8 were made from In-Ceram
zirconia containing about 26% zirconia. The bonding
surfaces of the single-retainers were air abraded with
50-µm alumina particles at 0.25 MPa pressure. After
rubber dam application and etching the enamel for 30 s
with phosphoric acid, the cantilever restorations were in-
serted, also using a phosphate-monomer-containing lut-
ing resin (Panavia 21 TC, Kuraray).The alumina ceramic
framework of the RBFDPs consisted of one or two lingual
retainer wings with a connector to the pontic. The desired
minimal dimensions of the ceramic frameworks were a
connector thickness of 2 mm in the labio-lingual direc-
tion and 3 mm in connector height in the cervico-incisal
direction. The thickness of the ceramic retainer wings
was 0.5 to 0.7 mm. No protrusive dynamic contacts on
the pontics were allowed.
The preparation of the abutment teeth was conserva-
tive and only within the enamel.6,7 It included a lingual
veneer, a groove on the cingulum and a small proximal
box preparation (dimensions: 2 mm x 1 mm x 0.5 mm;
Fig 1). The tooth preparation design provided a definite
seat for the restoration but did not provide any mechani-
cal retention.
408 The Journal of Adhesive Dentistry
pyrig
No Co
ht
t fo
rP
by N
ub
Q ui
lica
Single-retainer RBFDPs
tio
te ot n
n
ss e n c e
fo r
Central incisors Lateral incisors Total
16 16
4 2 6
4 18 22
P­atients were recalled every year for a clinical examina-
tion to evaluate the restorations with regard to function
and possible failures. Patients who moved out of the re-
gion and could not come for a clinical examination were
contacted by phone in order to ask if the restoration was
still functioning. In case any treatment in the area of the
restoration was reported by the patient, the respective
dentist was contacted via telephone.
Using the Kaplan and Meier method,4 the survival rates
of the restorations were analyzed for two criteria, fractures
and loss of the restoration, and the Gehan-Wilcoxon test
was used to compare the survival rates statistically.1 In
the two-retainer group, a unilateral fracture did not neces-
sarily led to a loss of the restoration but converted the
two-retainer RBFDP into a cantilever RBFDP.
RESULTS
In the two-retainer group, the mean observation time
was 120 ± 83 months with a minimum of 3 and a maxi-
mum of 231 months. In the single-retainer group, the
mean observation time was 111 ± 44 months with a
minimum of 37 and a maximum of 171 months.
None of the RBFDPs lost retention, but seven fractures
of the alumina frameworks occurred at the connectors.
In the two-retainer group, a restoration with a maxillary
central incisor pontic fractured after 3 months at both
connectors and one restoration with a mandibular incisor
pontic was accidentally removed alio loco. In addition,
five restorations of the two-retainer group fractured at one
connector, but the restorations remained in situ as canti-
lever RBFDPs for several years. The unilaterally fractured
RBFDPs consisted of two maxillary central incisor pontics
and three maxillary lateral insicor pontics. One unilateral
fracture was caused by trauma, the other failures occurred
during normal mastication. The two unilaterally fractured
central incisor RBFDPs were removed and replaced with
implants after 22 and 61 months, respectively.
In the single-retainer group, only one restoration made
from In-Ceram alumina with a maxillary lateral incisor pon-
tic fractured after 48 months and was replaced by a new
all-ceramic RBFDP which served its clinical purpose for
another 96 months without problems.
 pyr
No Kern
Co andigSasse

ht
t fo
rP

by N
ub

Q ui
lica
tio
te ot n

n
ss esn c e
fo r

p
Fig 1   Schematic drawing of the applied palatal and proximal c
veneer preparation. v = veneer, b = box, c = small chamfer,
s = small shoulder, p = pinhole.

Criterion: Restoration in situ Criterion: Restoration in

(in part with unilateral fracture) situ and no fracture
100% 100%

80% 80% *: P < 0.05 (Gehan-Wilcoxon test)

Survival rate

ns: P > 0.05 (Gehan-Wilcoxon test) Survival rate

60% 60%

40% 40%
two retainers (N = 16)
20% two retainers (N = 16) 20% one retainer (N = 22)
one retainer (N = 22)
0% 0%
0 24 48 72 96 120 144 168 192 219 240 0 24 48 72 96 120 144 168 192 219 240

Observation time (months) Observation time (months)

Fig 2   Survival curves of all-ceramic RBFDPs (N = 38) accord- Fig 3   Survival curves of all-ceramic RBFDPs (N = 38) accord-
ing to the method of Kaplan and Meier,4 criterion: restoration ing to the method of Kaplan and Meier,4 criterion: restoration
in situ. ns = difference is not significant. in situ without any fracture. *= difference is significant.

The 10-year survival rate according to Kaplan-Meier
was 73.9% in the two-retainer group and 94.4% in the
single-retainer group, when only restorations which had
been removed were considered as failures (Fig 2). How-
ever, due to the limited number of restorations, this dif-
ference was not quite statistically significant, as shown
by the Gehan-Wilcoxon test (p = 0.056).
However, when unilateral fractures of restorations in
the two-retainer group were taken as a criterion for failure,
the 10-year survival rate decreased to 67.3% in this group
(Fig 3). Considering fractures, the survival rates of the two
groups were statistically significantly different, as shown
by the Gehan-Wilcoxon test (p = 0.013).
DISCUSSION
All-ceramic RBFDPs made from a glass-infiltrated alumina
ceramic with a two-retainer design showed a high fracture
rate within the first years of clinical service. The reason for
the high fracture rate might be the differential movement
of the abutment teeth during function, especially during
protrusive and lateral movements under tooth contact. In
contrast, in the single-retainer RBFDPs, the pontic always
moves with the one abutment tooth, which prevents shear
and torque forces on the pontics and its connectors. The
improved long-term clinical outcome of single-retainer
RBFDPs vs two-retainer RBFDPs agrees well with findings
of studies on RBFDPs with metal frameworks.2,14 How-
ever, it should be noted that due to technological progress,
fabrication techniques and materials changed during the
course of the study.5,10 Thus, differences between retainer
groups might also be partly related to these parameters.
For the single-retainer FDPs, it is assumed that the peri-
odontal receptors of the abutment teeth prevented an over-
loading of the pontics during mastication, because cantilever
pontics transfer higher tilting forces to abutment teeth than
pontics fixed between two retainers. Such tilting forces might
have alerted the patient not to overload the pontic. No clini-
cally relevant movement or tilting of the abutment teeth was
recorded in the current study, which corroborates well with a
study on metal-ceramic cantilever RBFDPs.2
Overall, the ten-year survival rate in the current study
(73.9% to 94.4%) compares well with the 5-year survival

Vol 13, No 5, 2011 409

Kern and Sasse
rate of RBFDPs in a recent meta-analysis,13 which was cal-
culated as 87.7% (95% CI: 81.6% to 91.9%). It should be
noted, however, that the current results support only the
indication for cantilever all-ceramic RBFDPs in the anterior
but not in the posterior region of the mouth.
All clinical failures were caused by fractures of the
In-Ceram alumina framework. In contrast, none of the 8
cantilever RBFDPs made from In-Ceram zirconia failed. In
no instance did the ceramic-resin-enamel bond fail, as
the retainer wings always remained bonded to the abut-
ment teeth. Although the preparation of the abutment
teeth allowed a defined insertion of the restoration dur-
ing bonding, it was small and had no retentive form. The
functioning of the restorations relied completely on the
resin bond and not on additional mechanical retention.
The methods of bonding to the glass-infiltrated alumina
ceramic used in this study were chosen because of their
effectiveness shown in a previous laboratory studies.9
The methods included tribochemical silica coating and
silanating of the alumina ceramic, followed by bonding
the ceramic restorations to the abutment teeth using the
phosphate-monomer-containing composite resin Pana-
via. For the single-retainer group, the alumina ceramic
was only air abraded and then the retainer was bonded
­using the phosphate-monomer-containing composite
resin Panavia 21. Therefore, this study shows that the
glass-infiltrated alumina ceramic In-Ceram can be bonded
clinically successfully over the long-term using the phos-
phate-monomer-containing composite resin Panavia after
silica-coating and silanating of the bonding surfaces or
using Panavia 21 after air abrasion of the oxide ceramic.
CONCLUSION
Cantilever all-ceramic resin-bonded fixed dental prosthe-
ses made from high-strength oxide ceramics present a
viable treatment alternative to two-retainer resin-bonded
fixed dental prostheses in the anterior region with re-
duced clinical complications.
410 The Journal of Adhesive Dentistry
pyrig
No Co
ht
t fo
REFERENCES rP
by N
ub
Q ui
lica
tio
1. Analytical Software.Statistix 9. User’s Manual.Tallahassee:Analytical
Software, 2008:421-423. te ot n
n
2. Botelho MG, Leung KC, Ng H, Chan K. A retrospective ssclinical
fo r
en c e
evaluation
of two-unit cantilevered resin-bonded fixed partial dentures. J Am Dent
Assoc 2006;137:783-788.
3. Hussey DL, Linden GJ. The clinical performance of cantilevered resin-
bonded bridgework. J Dent 1996;24:251-256.
4. Kaplan EL, Meier P. Nonparametric estimation from incomplete observa-
tions. J Am Statist Assoc 1958;53:457-481.
5. Kern M, Knode H, Strub JR. The all-porcelain, resin-bonded bridge. Quin-
tessence Int 1991;22:257-262.
6. Kern M, Schwarzbach W, Strub JR. Stability of all-porcelain, resin-
bonded fixed restorations with different designs. An in vitro study. Int J
Prosthodont 1992;5:108-113.
7. Kern M, Fechtig T, Strub JR. Influence of water storage and thermal cy-
cling on the fracture strength of all-porcelain, resin-bonded fixed partial
dentures. J Prosthet Dent 1994;71:251-256.
8. Kern M, Thompson VP. Sandblasting and silica coating of a glass-infil-
trated alumina ceramic: Volume loss, morphology, and changes in the
surface composition. J Prosthet Dent 1994;71:453-461.
9. Kern M, Thompson VP. Bonding to a glass infiltrated alumina ceramic:
Adhesion methods and their durability. J Prosthet Dent 1995;73:
240-249.
10. Kern M, Gläser R. Cantilevered all-ceramic, resin-bonded fixed partial
dentures. A new treatment modality. J Esthet Dent 1997;9:255-264.
11. Kern M, Strub JR. Bonding to alumina ceramic in restorative dentistry
over up to five years. J Dent 1998;26:245-249.
12. Kern M. Clinical long-term survival of two-retainer and single-retainer
all-ceramic resin-bonded fixed partial dentures. Quintessence Int
2005;36:141-147.
13. Pjetursson BE, Tan WC, Tan K, Brägger U, Zwahlen M, Lang NP. A sys-
tematic review of the survival and complication rates of resin-bonded
bridges after an observation period of at least 5 years. Clin Oral Im-
plants Res 2008;19:131-141.
14. van Dalen A, Feilzer AJ, Kleverlaan J. A literature review of two-unit canti-
levered FPDs. Int J Prosthodont 2004;17:281-284.
Clinical relevance: In the anterior region, only one re-
tainer is required when using all-ceramic resin-bonded
fixed dental prostheses. Using only one retainer
makes this prosthetic treatment less invasive and
improves the clinical outcome compared to using two-
retainers.