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A systematic review of the survival and

complication rates of implant supported fixed
dental prostheses with cantilever extension
after an observation period of at least 5 years

Article in Clinical Oral Implants Research · June 2009

DOI: 10.1111/j.1600-0501.2009.01706.x · Source: PubMed

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Marco Aglietta Niklaus P Lang

University of Naples Federico II The University of Hong Kong
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Marco Aglietta A systematic review of the survival and
Vincenzo Iorio Siciliano
Marcel Zwahlen
complication rates of implant supported
Urs Brägger fixed dental prostheses with cantilever
Bjarni E. Pjetursson
Niklaus P. Lang extensions after an observation period of
Giovanni E. Salvi at least 5 years

Authors’ affiliations: Key words: biological complication, bone loss, cantilevers, dental implant, extensions,
Marco Aglietta, Urs Brägger, Giovanni E. Salvi, fractures, peri-implantitis, success rate, survival rate, systematic review, technical complication
University of Bern, School of Dental Medicine,
Bern, Switzerland
Vincenzio Iorio Siciliano, Department of Abstract
Periodontology, University of Naples, Naples, Italy
Marcel Zwahlen, Research Support Unit, Institute
Objective: The aim of this systematic review was to assess the survival rates of short-span
of Social and Preventive Medicine, University of implant-supported cantilever fixed dental prostheses (ICFDPs) and the incidence of technical
Bern, Bern, Switzerland and biological complications after an observation period of at least 5 years.
Biarni E. Pjetrusson, Department of Reconstructive
Dentistry, University of Iceland, Reykjavik, Iceland Material and methods: An electronic MEDLINE search supplemented by manual searching
Niklaus P. Lang, University of Hong Kong, Prince was conducted to identify prospective or retrospective cohort studies reporting data of at
Philip Dental Hospital, Hong Kong, China
least 5 years on ICFDPs. Five- and 10-year estimates for failure and complication rates were
Correspondence to: calculated using standard or random-effect Poisson regression analysis.
Giovanni E. Salvi
Results: The five studies eligible for the meta-analysis yielded an estimated 5- and 10-year
Department of Periodontology
School of Dental Medicine ICFDP cumulative survival rate of 94.3% [95 percent confidence interval (95% CI): 84.1–98%]
University of Bern and 88.9% (95% CI: 70.8–96.1%), respectively. Five-year estimates for peri-implantitis were
Freiburgstrasse 7
CH-3010 Bern, Switzerland 5.4% (95% CI: 2–14.2%) and 9.4% (95% CI: 3.3–25.4%) at implant and prosthesis levels,
Tel.: þ 4131 632 3551 respectively. Veneer fracture (5-year estimate: 10.3%; 95% CI: 3.9–26.6%) and screw
Fax: þ 4131 632 4915
loosening (5-year estimate: 8.2%; 95% CI: 3.9–17%) represented the most common
e-mail: giovanni.salvi@zmk.unibe.ch
complications, followed by loss of retention (5-year estimate: 5.7%; 95% CI: 1.9–16.5%) and
abutment/screw fracture (5-year estimate: 2.1%; 95% CI: 0.9–5.1%). Implant fracture was rare
(5-year estimate: 1.3%; 95% CI: 0.2–8.3%); no framework fracture was reported.
Radiographic bone level changes did not yield statistically significant differences
either at the prosthesis or at the implant levels when comparing ICFDPs with short-span
implant-supported end-abutment fixed dental prostheses.
Conclusions: ICFDPs represent a valid treatment modality; no detrimental effects can be
expected on bone levels due to the presence of a cantilever extension per se.

Date:
Accepted 12 December 2008
To cite this article:
Aglietta M, Siciliano VI, Zwahlen M, Brägger U,
Pjetursson BE, Lang NP, Salvi GE. A systematic review
of the survival and complication rates of implant
supported fixed dental prostheses with cantilever
extensions after an observation period of at least 5 years.
Clin. Oral Impl. Res. 20, 2009; 441–451.
doi: 10.1111/j.1600-0501.2009.01706.x
The number of patients asking for fixed
implant-supported reconstructions has in-
creased considerably in the past few years
(Bornstein et al. 2008). This therapy is
often limited by financial costs, and also
by clinical situations such as bone defi-
ciencies and/or the presence of anatomical
structures (i.e. maxillary sinus, mental
foramen) in areas where implants have to
be ideally (prosthetically) placed. To treat
such patients, a number of surgical proce-
dures, such as guided bone regeneration
and sinus floor elevation, have been devel-
oped (Boyne & James 1980; Dahlin et al.
1988, 1989, 1991; Lundgren & Nyman
1991; Summers 1994a, 1994b). The in-
creasing cost and morbidity of complex
dental treatment using such approaches,
together with a number of related complica-
tions, may limit the choice of complex
treatment in daily practice (Simion et al.
1995; Chiapasco et al. 2006). An alternative

c 2009 John Wiley & Sons A/S

 441
Aglietta et al . Implants with cantilever extensions

would be the use of fixed dental prostheses
with cantilever extensions that allow a
more straightforward rehabilitation of
edentulous areas (Rodriguez et al. 1994a,
1994b; Shackleton et al. 1994).
In a systematic review on short-span
tooth-supported fixed dental prostheses
(FDPs) with cantilever extensions (Pjeturs-
son et al. 2004b), a meta-analysis showed
low survival and success rates for these
FDPs after a period of 5 and 10 years. In
particular, this therapy was less predict-
able, when compared with other treatment
options, such as single-unit crowns on
implants and tooth- or implant-supported
FDPs (Pjetursson et al. 2004a; Tan et al.
2004; Jung et al. 2008).
In implant-supported FDPs with cantile-
ver extensions (ICFDPs) the distribution of
masticatory forces appeared not to be uni-
formly distributed. Higher strain concen-
trations at the implant sites, especially at
the level of the implant–bone interface
adjacent to the extension, were noted (Ro-
driguez et al. 1993; White et al. 1994;
Rangert et al. 1995; Sertgöz & Güvener
1996; Barbier et al. 1998; Stegaroiu et al.
1998; Akça & Iplikçioğlu 2002). Conse-
quently, a higher incidence of complica-
tions was expected for implant-supported
cantilever FDPs. Moreover, it has been
postulated that the presence of excessive
force concentrations may also lead to bone
loss around implants (Lindquist et al. 1988;
Isidor 1996, 1997). Such excessive forces
may lead to micro-fractures within the
bone in areas of major strain concentra-
tions, where the pressure applied might
exceed the potential for bone repair (Frost
2004).
Clinical studies reported conflicting re-
sults for medium- and long-term outcomes
of ICFDPs. Comparing ICFDPs with im-
plant-supported FDPs without cantilever
extensions (IFDPs), Romeo et al. (2003)
reported an overall implant survival rate
of 97% and a prosthesis success rate of
98% during a follow-up period of 1–7
years. The survival rates were similar for
both treatments and, hence, it was con-
cluded that ICFDPs represented a predict-
may explain these controversies. From the
analysis of the two studies (Romeo et al.
2003; Nedir et al. 2006), the long-term
predictability of reconstructions on im-
plants applying cantilevers remains un-
clear.
Hence, the objective of this systematic
review was to obtain robust estimates of 5
and 10 years of survival and complication
rates of short-span ICFDPs.
Materials and methods
Search strategy and inclusion criteria
A systematic review of the English litera-
ture was conducted for selected articles
published up to December 2007.
Searching was performed using an elec-
tronic database (Medline, PubMed). The
following key word combinations were
applied: ‘implants’ and ‘fixed partial den-
tures’, ‘implants’ and ‘bridges’, ‘implants’
and ‘fixed dental prostheses’, ‘implants’
and ‘partial edentulism’, ‘implants’ and
‘complications’, ‘implants’ and ‘failures’,
‘implants’ and ‘cantilever’, ‘implants’ and
‘extension’.
Moreover, hand-searching of the follow-
ing journals was undertaken from 2005 to
December 2007: Clinical Oral Implants
Research, International Journal of Perio-
dontics and Restorative Dentistry, Journal
of Periodontology, Journal of Clinical
Periodontology and International Journal
of Oral and Maxillofacial Implants. The
First electronic search
1370
Potentially relevant abstracts
retrieved for evaluation: 412
Independently selected abstracts for
full-text analysis by 2 reviewers: 108
Kappa score
0.94
Full-text analysis
98
bibliographies from the selected articles
were screened systematically.
The objective of the search was to screen
the literature for prospective or retrospec-
tive longitudinal cohort studies or con-
trolled studies reporting on ICFDPs with a
mean follow-up period of at least 5 years. A
clinical examination had to be performed at
the end of the follow-up. Publications re-
porting only on patients’ records, question-
naires or interviews were excluded. If
multiple publications reporting on the
same population were found, only the
most recent report was included.
Study selection
Titles and abstracts were initially screened
by two independent reviewers (V.I.S. and
G.E.S.) for possible inclusion. The full-text
analysis of studies of relevance was con-
ducted independently by the reviewers and
disagreement was resolved by discussion.
Agreement between the reviewers was de-
termined using K statistics (Fig. 1).
Data for the meta-analysis were ex-
tracted by two independent reviewers
(M.A. and V.I.S.) and compared. Disagree-
ments were solved by discussion and by
contacting the authors of the original pub-
lications.
Excluded studies
From an original yield of 1370 titles and
412 abstracts, 98 were selected for the full-
text analysis; one publication was found as
a result of the manual search. Ninety-four
Publications excluded
on the basis of the title:
958
Publications excluded
on the basis of the
abstract:
304
Discussion discarded
10 abstracts

able therapy. On the other hand, Nedir Manual search Publications excluded
1 on the basis of the full-
et al. (2006) reported a higher number of text analysis: 94
complications for ICFDPs compared with Final number of
studies included
those encountered for IFDPs (29.4% vs. 5
7.9%). Differences in the study protocol,
populations treated and prosthesis design Fig. 1. Search strategy for implant supported, cantilever fixed dental prostheses (ICFDPs).

442 | Clin. Oral Impl. Res. 20, 2009 / 441–451 c 2009 John Wiley & Sons A/S

 Aglietta et al . Implants with cantilever extensions

publications were excluded because of the
following reasons: Mean observation period
o5 years, no specific data on ICFDPs and
publications reporting data from the same
cohort more than once.
Data extraction
Informations regarding survival and com-
plication rates of both implants and
ICFDPs were extracted. Implant survival
were considered if the implant was present
at the follow-up examination; ICFDP sur-
vival was considered if the prosthesis was
present at the follow-up visit without any
modifications.
Peri-implantitis and soft tissue compli-
cations were included in the category of
biological complications.
As for technical complications, all the
events affecting the implant and/or the
meso- and/or the supra-structures’ integ-
rity were considered. Among them, the
following categories were defined: implant
fractures, veneer fractures, framework frac-
tures, abutment or screw fractures, loss of
retention and screw loosening.
Statistical analysis
By definition, failure and complication
rates are calculated by dividing the number
of events (failures or complications) in the
numerator by the total exposure time
(ICFDP time or implant time) in the de-
nominator.
The numerator could usually be ex-
tracted directly from the publication or
was provided by the authors of the original
papers in cases in which only a part of the
full sample was taken into consideration.
The exposure time was extracted and
calculated by multiplying the mean
follow-up time by the number of implants
or ICFDPs available for the statistical ana-
lysis. The mean follow-up was directly
extracted from the articles (Hälg et al.
2008), supplemented as adjunctive infor-
mation from the author of the original
papers (Wennström et al. 2004; Eliasson
et al. 2006; Kreissl et al. 2007) or calcu-
lated from the original database (Brägger
et al. 2005). Implants or ICFDPs available
for the analysis were defined as all the
fixtures or prostheses, respectively, from
which information was available relative to
the issues considered.
For each study, event rates for ICFDPs
and/or for implants were calculated by
dividing the total number of events by the
total ICFDPs’ or implants’ exposure time
in years. For further analysis, the total
number of events was considered to be
Poisson distributed for a given sum of
implant exposure years, and Poisson re-
gression with a logarithmic link function
and total exposure time per study as an
offset variable was used (Kirkwood &
Sterne 2003a, 2003b). To assess the het-
erogeneity 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 o0.05, indi-
cating heterogeneity, random-effects Pois-
son regression (with g-distributed random
effects) was used to obtain a summary
estimate of the event rates. Five- and 10-
year survival proportions were calculated
via the relationship between event rate
and survival function S, S(T) ¼ exp(  T
 event rate), by assuming constant event
rates (Kirkwood & Sterne 2003a, 2003b).
Ninety-five percent confidence intervals of
the summary estimates of the event rates
obtained from the Poisson regression were
reported. The 95% CIs for the 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 cantile-
vers and its standard error was calculated
for each study. These study-specific differ-
ences were then meta-analysed using the
inverse-variance weighting method.
s
All analyses were performed using Stata
(Stata Corporation, College Station, TX,
USA), version 10.
Results
Included studies
Figure 1 shows the process of identifying
the five studies finally included from an
initial yield of 1370 titles. Descriptive data
relative to the included five studies are
reported in Table 1. Only two studies
were specifically designed to test ICFDPs
(Wennström et al. 2004; Hälg et al. 2008),
whereas for the other three studies, data on
ICFDPs were extracted from the original
samples composed predominantly of end-
abutment, implant-supported FDPs (Bräg-
ger et al. 2005; Eliasson et al. 2006; Kreissl
et al. 2007).
Out of the five included publications,
two were prospective cohort studies (Bräg-
ger et al. 2005; Kreissl et al. 2007), one was
a retrospective cohort study (Eliasson et al.

Table 1. Study and patient’s characteristics of the reviewed publications

Study Study Implant Characteristics No. of Mean age Age range Setting
(year of design system of implant patients of patients of patients
publication) systems (years) (years)
s
Wennström Retrospective Astra Tech Self-tapping screws, 28 57 NR University
et al. (2004) controlled Dental Implant machined or tioblast
System
Brägger et al. Prospective Straumann Solid screw, hollow 14 42.9 20–78 University
(2005) Dental Implant screw, hollow cylinder
s
System
Eliasson et al. Retrospective Brånemark Turned surface NR NR NR University
s
(2006) System
s
Kreissl et al. Prospective 3i Osseotite Osseotite, hollow 20 NR NR University
(2007) screw
Hälg et al. Retrospective Straumann Solid screw, hollow 27 61.9 44–83 Private
(2008) controlled Dental Implant screw, hollow cylinder practice
s
System

NR, not reported.

c 2009 John Wiley & Sons A/S

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Aglietta et al . Implants with cantilever extensions

Table 2. General informations on implants and ICFDPs in the selected studies

Study Total No. of Total No. of Ratio Implant Implant Type of Location Mechanism
(year of no. of implants no. of ICFDPs crown length diameters extention of recons- of retention
publication) implants available ICFDPs available units/ (mean or tructions
placed for analysis placed for analysis implants range; mm)
Wennström 71 66 28 26 1.6 12.7 NR Distal 16 maxilla, Screw
et al. (2004) 8 mandible retained
Brägger 33 33 18 18 1.84 NR NR 16 mesial, 11 maxilla, 5 screw
et al. (2005) 6 distal 7 mandible retained,
13 cemented
Eliasson 209 148 84 61 NR NR NR Mesial, distal, NR Screw
et al. (2006) bilateral retained
Kreissl et al. 61 61 23 23 NR NR NR 18 mesial, Maxilla and Screw
(2007) 15 distal mandible retained
Hälg et al. 46 46 27 27 1.65 6–12 3.3 or 4.1 12 mesial, 13 maxilla, Cemented
(2008) 15 distal 14 mandible

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

2006) and two were retrospective con-
trolled studies (Wennström et al. 2004;
Hälg et al. 2008). The number of patients
was reported in four studies and ranged
between 14 and 28. The publication by
Eliasson et al. (2006) did not report the
number of patients receiving ICFDPs
(Table 1). Only one study was conducted
in a private practice (Hälg et al. 2008),
whereas all the other studies were con-
ducted in an institutional environment
(e.g. university) (Table 1). Four different
commercially available implant systems
were used: Wennström et al. (2004) used
s
the Astra Tech Dental Implant System
(Astra, Moelndal, Sweden), Eliasson et al.
s
(2006) the Branemark System (Nobel
Biocare AB, Göteborg, Sweden), Kreissl
s
et al. (2007) the Osseotite (3i-Implant
Innovations, West Palm Beach, FL, USA)
and Brägger et al. (2005) and Hälg et al.
(2008) the Straumann Dental Implant
s
System (Institut Straumann AG, Basel,
Switzerland). The implants used were
mostly solid screws. However, hollow
screws and hollow cylinders were reported
in three (Brägger et al. 2005; Kreissl et al.
2007; Hälg et al. 2008) and two studies
(Brägger et al. 2005; Hälg et al. 2008),
respectively (Table 1).
The studies reported on a total of 420
implants and 180 ICFDPs, of which 354
and 155 were available for the final analy-
sis, respectively (Table 2). The ICFDPs
were located in both the upper and the
lower jaws. All possible cantilever exten-
sion designs were used (e.g. distal, mesial
and distal þ mesial). Unfortunately, it was
not possible to separate the data with
respect to the location and the prosthetic
design of the ICFDPs.
Three studies (Wennström et al. 2004;
Brägger et al. 2005; Hälg et al. 2008) re-
ported on the number of crown units in
relation to the number of implants: the
mean value ranged between 1.60 and 1.84.
This, in turn, means that there were slightly
more than three units per two implants.
In three studies, ICFDPs were screw
retained and in one they were cemented;
Brägger and colleagues (2005) used both
retention systems (Table 2).
The follow-up period varied between the
studies. Three publications reported a fol-
low-up of 5 years (Wennström et al. 2004;
Kreissl et al. 2007; Hälg et al. 2008),
whereas two publications included a
follow-up of 10 years (Brägger et al. 2005;
Eliasson et al. 2006).
Implant survival
Only data relative to post-loading implant
survival rates (e.g. failures that occurred
after loading, without accounting for im-
plants lost during the initial healing period)
were available. Early failures could not be
considered in the meta-analysis (Table 3).
Overall, from the 354 implants available
for analysis, eight implant losses occurred.
In the publications reporting 5-year results
(Wennström et al. 2004; Kreissl et al. 2007;
Hälg et al. 2008), five losses were regis-
tered. Two of these were related to implant
fractures and one was the consequence of
advanced peri-implantitis. The reasons for
the loss of the remaining two implants
were not specified.
Brägger et al. (2005) and Eliasson et al.
(2006) reported data after 10 years of follow-
up. Three implants out of 181 were lost: one
due to an implant fracture and two due to
the sequellae of advanced peri-implantitis.
The estimated annual failure rate ranged
between 0.13 and 0.87, with a summary
estimate of 0.29 (95% CI: 0.15–0.59)
(Table 3).
The summary estimate of the implant
survival after 5 and 10 years was calculated
with a standard Poisson regression analysis
and amounted to 98.5% (95% CI: 97.1–
99.3%) and 97.1% (95% CI: 94.3–98.5%),
respectively (Table 3).
ICFDPs survival
The survival rate of ICFDPs was defined
as the prostheses remaining in situ
without any modifications during the ob-
servation time. Table 4 summarizes the
outcomes with respect to ICFDP failure
and survival rates.
Of 155 ICFDPs followed for at least 5
years, nine were known to be lost as a
consequence of implant loss and abut-
ment or supra-structure fracture or loss of
retention.
The study-specific estimated 5-year
survival rate varied between 91.5% and
100%.
The estimated annual failure rate per 100
ICFDP years ranged from 0 to 2.22 with
a summary estimate of 1.18 (95% CI:
0.40–3.45).
The estimated survival proportion after 5
and 10 years was derived from a standard
Poisson regression analysis and was 94.3%
(95% CI: 84.1–98%) and 88.9% (95% CI:
70.8–96.1%), respectively.
Biological complications
Biological complications are summarized
in Table 5. Outcomes relative to biological

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 Aglietta et al . Implants with cantilever extensions

Table 3. Annual failure rates and survival of implants

Study Total No. of Mean No. of Total Estimated Estimated Estimated
(year of no. of implants follow-up failures implants failure rate survival rate survival rate
publication) implants available time exposure (per 100 after 5 years after 10 years
placed for analysis (years) time implant years) (%) (%)
Wennström 71 66 5 2 330 0.61 97% 94.1
et al. (2004)
Brägger et al. 33 33 9.4 1 310.2 0.32 98.4 96.8
(2005)
Eliasson et al. 209 148 10.5 2 1459.5 0.13 99.4 98.7
(2006)
Kreissl et al. 61 61 5 1 305 0.33 98.4 96.8
(2007)
Hälg et al. 46 46 5 2 230 0.87 95.7 91.7
(2008)
Total 420 354 8
Summary 0.29 98.5 97.1
estimate (0.15–0.59) (97.1–99.3) (94.3–98.5)
(95% CI)n
n
Based on Poisson regression, test for heterogeneity, P ¼ 0.27.
CI, confidence interval.

Table 4. Annual failure rates and survival of ICFDPs

Study Total No. of Mean No. of Total Estimated Estimated Estimated
(year of no. of ICFDPs follow-up failures ICFDPs failure rate survival rate survival
publication) ICFDPs available for time exposure (per 100 ICFDP after 5 years rate after
placed analysis (years) time years) (%) 10 years (%)
Wennström 28 26 5 2 130 1.54 92.6 85.7
et al. (2004)
Brägger et al. 18 18 9.4 3 169.2 1.77 91.5 83.8
(2005)
Eliasson et al. 84 61 10.5 0 640.5 0 100 100%
(2006)
Kreissl et al. 23 23 5 1 115 0.87 95.7 91.7
(2007)
Hälg et al. 27 27 5 3 135 2.22 89.5 80.1
(2008)
Total 180 155 9
Summary 1.18 94.3 88.9
estimate (0.4–3.45) (84.1–98) (70.8–96.1)
(95% CI)n
n
Based on random effects Poisson regression, test for heterogeneity, P ¼ 0.02.
ICFDPs, implant supported cantilever fixed dental prostheses; CI, confidence interval.

complications were reported in only two
publications (Brägger et al. 2005; Hälg
et al. 2008). Soft tissue complications
(e.g. peri-implant mucositis or soft tissue
recession) were not reported systemati-
cally, and only data on peri-implantitis
were available.
Brägger et al. (2005) defined peri-implan-
titis as probing-pocket depth (PPD)
 5 mm and bleeding on probing (BOP),
with five implants being affected during
9.4 years of follow-up. Hälg et al. (2008)
reported one peri-implatitis case without
providing a specific definition of the diag-
nostic parameters adopted.
On an implant level, these data
yielded a summary estimate for bio-
logical complications of 1.11 (95% CI:
0.4–3.06) per 100 implant years using
standard Poisson regression analysis. The
cumulative complication rate after 5 and
10 years was 5.4% (95% CI: 2–14.2%)%
and 10.5% (95% CI: 3.9–26.4), respec-
tively.
On the prosthesis level, the summary
estimate for biological complications
amounted to 1.97 (95% CI: 0.66–5.8%)
per 100 years, resulting in 9.4% (95% CI:
3.3–25.4%) of ICFDPs showing a biological
complication after 5 and 17.9% (95% CI:
6.4–44.3) after 10 years of function, respec-
tively (Table 5).
Technical complications
Technical complications were defined as
damage to the integrity of the implants or
of the meso- and suprastuctures.
The outcomes of implant fractures are
reported in Table 6a. One study did not
provide informations about implant frac-
tures (Wennström et al. 2004), two studies
registered three fractures (Brägger et al.
2005; Hälg et al. 2008) and other two
studies reported no fractures at all (Eliasson
et al. 2006; Kreissl et al. 2007). More

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Aglietta et al . Implants with cantilever extensions

Table 5. Biological complications

Study No. of No. of Mean Total Total No. of Estimated Estimated
(year of implants ICFDPs follow-up implants ICFDPs biological implant ICFDP
publication) available available (years) exposure exposure complications complication complication
for analysis for analysis time time rate (per 100 rate (per 100
implant years) prostheses years)
Brägger et al. (2005) 33 18 9.4 310.2 169.2 5 1.61 2.96
Hälg et al. (2008) 46 27 5 230 135 1 0.43 0.74
Total 79 45 6
Summary estimate 1.11 1.97
(95% CI)n (0.4–3.06) (0.67–5.84)
Cumulative 5-year 5.4% 9.4%
complication rates (2–14.2%) (3.3–25.4%)
(95% CI)
Cumulative 10-year 10.5% 17.9%
complication rates (3.9–26.4) (6.4–44.3)
(95% CI)
n
Based on Poisson regression, test for heterogeneity, P ¼ 0.20 (implant years), 0.17 (prostheses years).
CI, confidence interval.

Table 6a. Technical complications: implant related complications

Study (year of No. of Mean Total No. of Estimated rate of
publication) implants follow- implants implant implant fractures
available for up time exposure fractures (per 100 implant years)
analysis (years) time
Brägger et al. (2005) 33 9.4 310.2 1 0.32
Eliasson et al. (2006) 148 10.5 1554 0 0
Kreissl et al. (2007) 61 5 305 0 0
Hälg et al. (2008) 46 5 230 2 0.87
Total 288 3
Summary estimate (95% CI)n 0.25
(0.04–1.73)
Cumulative 5-year implant 1.3%
fracture rates (95% CI) (0.2–8.3%)
Cumulative 10-year implant 2.5%
fracture rates (95% CI) (0.4–15.8%)
n
Based on random effects Poisson regression, test for heterogeneity, P ¼ 0.004.
ICFDPs, implant supported cantilever fixed dental prostheses; CI, confidence interval.

specifically, Hälg et al. (2008) reported two
events related to reduced diameter im-
plants (e.g. 3.3 mm in diameter), whereas
Brägger et al. (2005) noted the fracture of
one hollow cylinder implant.
Based on these outcomes, the summary
estimate for implant fractures per 100 im-
plant years was 0.25 (95% CI: 0.04–1.73),
resulting in cumulative implant fracture
rates after 5 and 10 years of 1.3% (95%
CI: 0.2–8.3%) and 2.5% (95% CI: 0.4–
15.8%), respectively (Table 6a).
Technical complications related to su-
prastructure components are reported in
Tables 6b and 6c.
Veneer fractures represented the most
frequent technical complication. They
were reported in every study, with a total
of 16 cases. The statistical analysis re-
vealed a summary estimate of veneer frac-
tures per 100 patient years of 2.18 (95%
CI: 0.80–5.93) (Table 6b).
Abutment or screw fractures were re-
ported in three studies (Brägger et al.
2005; Eliasson et al. 2006; Kreissl et al.
2007), whereas two studies (Wennström
et al. 2004; Hälg et al. 2008) did not report
such an event. In a standard Poisson regres-
sion analysis, the estimated cumulative
rate of screw or abutment fractures over
an observation period of 5 and 10 years was
2.1% (95% CI: 0.9–5.1%) and 4.1% (95%
CI: 1.7–9.7%), respectively (Table 6b).
No framework fractures were reported in
any of the included publications (Table 6b).
In two studies, the prostheses were cemen-
ted (Brägger et al. 2005; Hälg et al. 2008).
The meta-analysis resulted in an estimated
cumulative rate of loss of retention over
an observation period of 5 and 10 years
of 5.7% (95% CI: 1.9–16.5%) and
11.1% (95% CI: 3.7–30.3%), respectively
(Table 6c).
Screw-retained ICFDPs were reported in
four studies (Table 6c). Random-effect
Poisson regression analysis revealed an es-
timated cumulative rate of screw loosening
over an observation period of 5 and 10 years
of 8.2% (95% CI: 3.9–17%) and 15.7%
(95% CI: 7.6–31%), respectively.
Radiographic bone-level changes
Bone loss was reported in two studies
(Table 7; Wennström et al. 2004; Hälg
et al. 2008). In both, radiographic bone-
level changes around implants supporting
prostheses with cantilever extensions were
compared with implant-supported FDPs
without cantilever extensions (IFDPs).

446 | Clin. Oral Impl. Res. 20, 2009 / 441–451 c 2009 John Wiley & Sons A/S

 Aglietta et al . Implants with cantilever extensions

Table 6b. Technical complications: fractures of meso- and suprastructure components

Study No. of Mean Total No. of Estimated No. of Estimated No. of Estimated
(year of ICFDPs follow-up ICFDPs veneers rate of framework rate of abutment rate of
publication) available time exposure fractures veneer fractures framework or screw abutment
for analysis (years) time fractures fractures fractures or screw
(per 100 (per 100 fractures
patients/ patients (per
year) /year) 100 patients/
year)
Wennström et al. 24 5 120 1 0.83 0 0 0
(2004)
Brägger et al. 18 9.4 169.2 1 0.59 0 1 0.59
(2005)
Eliasson et al. 61 10.5 640.5 2 0.31 0 3 0.47
(2006)
Kreissl et al. 23 5 115 8 6.96 0 1 0.87
(2007)
Hälg et al. 27 5 135 4 2.96 0 0 0
(2008)
Total 153 16 0 5
Summary 2.18 – 0.42
estimate (0.8–5.93%) (0.18–1.02)
(95% CI)n
Cumulative 10.3% – 2.1%
5-year (3.9–26.6%) (0.9–5.1%)
complication
rates (95% CI)
Cumulative 19.6% – 4.1%
10-year (7.7–44.7%) (1.7–9.7%)
complication
rates (95% CI)
n
Based on random effects Poisson regression, test for heterogeneity Po0.001 for veneers fractures.
Based on Poisson regression, test for heterogeneity P ¼ 0.78 for abutment screw fractures.
ICFDPs, implant supported cantilever fixed dental prostheses; CI, confidence interval.

Table 6c. Technical complications: loss of retention and screw loosening

Study No. of Mean Total No. of Estimated No. of screw- Mean Total No. of Estimated
(year of cemented follow- cemented cases of rate of loss retained follow- screw cases rate of screw
publication) ICFDPs up time ICFDPs loss of of retention ICFDPs up time retained screw loosening
available (years) exposure retention (per 100 available (years) ICFDPs loosening (per 100
for loss time ICFDP year) for screw exposure screw retained
of retention loosening time ICFDP year)
analysis analysis
Wennström et al. – – – – – 24 5 120 2 1.67
(2004)
Brägger et al. 13 9.4 122.2 2 1.64 5 9.4 47 0 0
(2005)
Eliasson et al. – – – – – 61 10.5 640.5 7 1.09
(2006)
Kreissl et al. – – – – – 23 5 115 5 4.35
(2007)
Hälg et al. 27 5 135 1 0.74 – – – – –
(2008)
Total 40 3 113 14
Summary estimate 1.17 1.71
n
(95% CI) (0.38–3.62) (0.79–3.72)
Cumulative 5-year 5.7% 8.2%
complication rates (1.9–16.5%) (3.9–17%)
(95% CI)
Cumulative 10- 11.1% 15.7%
year complication (3.7–30.3%) (7.6–31%)
rates (95% CI)
n
Based on Poisson regression, test for heterogeneity, P ¼ 0.51 for loss of retention.
Based on random effects Poisson regression, test for heterogeneity P ¼ 0.06 for loss of retention or screw loosening.
ICFDPs, implant supported cantilever fixed dental prostheses; CI, confidence interval.

c 2009 John Wiley & Sons A/S

 447 | Clin. Oral Impl. Res. 20, 2009 / 441–451
Aglietta et al . Implants with cantilever extensions

Table 7. Radiographic bone loss around ICFDPs and IFDPs without cantilever extensions
Study No. of Mean Mean bone Mean bone No. of IFDPs Mean Mean bone Mean bone Mean difference
(year of ICFDPs follow-up loss (SD) loss per without follow-up loss (SD) loss per in bone loss
publication) (years) (mm) year (mm) cantilever (years) (mm) year (mm) per year (mm)
Wennström 24 5 0.49 0.1 23 5 0.38 0.08 0.02
et al. (2004) (0.89) (0.65)
Hälg et al. 24 5.3 0.23 0.04 25 5.3 0.09 0.02 0.03
(2008) (0.63) (0.43)
Summary 0.025
estimate (  0.023–0.073)
(95% CI)n P-value ¼ 0.31
n
Meta-analysis of mean differences with P ¼ 0.95 for heterogeneity.
ICFDPs, implant supported cantilever fixed dental prostheses; SD, standard deviation; CI, confidence interval.

Table 8. Radiographic bone loss around implants in proximity of cantilever extensions and control implants supporting FDPs without
cantilever extensions
Study No. of Mean Mean Mean No. of Mean Total Mean Mean Mean
(year of implants follow-up bone bone loss controls follow-up controls bone bone difference in
publication) close to (years) loss (SD) per year (years) exposure loss (SD) loss per bone loss per
extension (mm) (mm) time (mm) year (mm) year (mm)
Wennström 24 5 0.39 0.08 23 5 115 0.23 0.05 0.03
et al. (2004) (1.04) (0.67)
Hälg et al. 24 5.3 0.23 0.04 24 5.3 127.2 0.05 0.01 0.03
(2008) (0.71) (0.45)
Summary 0.033
estimate (  0.02–0.087)
(95% CI)n P-value ¼ 0.14
n
Meta-analysis of mean differences with P ¼ 0.974.
SD, standard deviation; CI, confidence interval; FDP, fixed dental prosthesis.

At the prosthesis level, meta-analysis
revealed an estimated mean difference in
radiographic bone loss per year of 0.025
(95% CI:  0.023–0.073) in favour of
IFDPs. This difference, however, did not
reach statistical significance (P ¼ 0.31).
The same analysis was conducted by
comparing the radiographic bone loss
around fixtures in the proximity of canti-
lever extensions with control implants
supporting FDPs without cantilever exten-
sions. The radiographic bone level changes
resulted in slightly greater bone loss around
implants in the proximity of cantilever
extensions. However, no statistically sig-
nificant difference was found, with a sum-
mary estimate of difference in bone loss per
year of 0.033 (95% CI:  0.02–0.087;
P40.05) (Table 8).
Discussion
This review is part of a series of systematic
reviews aiming at the evaluation of the
published literature with respect to fixed
reconstructions. The aim of these reviews
was to provide an overview of the types and
incidences of complications related to var-
ious reconstruction designs and to compare
their relative survival and complication
rates. The outcomes of the present sys-
tematic review showed that short-span
FDPs with cantilever extensions repre-
sented a predictable treatment modality.
No major detrimental effects with respect
to peri-implant tissues were observed at
implants in the proximity of cantilever
extensions. It has to be noted, however,
that the majority of ICFDPs analysed in the
present systematic review were incorpo-
rated into premolar and molar areas.
In a meta-analysis on implant supported
reconstructions, an FDP survival rate of
95% after 5 years and an FDP success
rate of 61.3% were reported (Pjetursson
et al. 2004a). The outcomes of these sys-
tematic reviews were recently updated and
summarized in order to propose guidelines
for the choice of the type of reconstruction
to be preferred in different treatment situa-
tions (Pjetursson & Lang 2008). In this
respect, single-unit implant-supported
crowns should be considered as the gold
standard treatment in the rehabilitation of
single- or two-unit gaps (Jung et al. 2008).
Tooth-supported FDPs represent an alter-
native for the rehabilitation of edentulous
spaces where functional and/or aesthetic
aspects of the neighbouring teeth have to be
considered. Tooth- or implant-supported
FDPs were also shown to yield predictable
long-term outcomes, with estimated an-
nual failure rates of 1.14% and 1.43%,
respectively (Pjetursson et al. 2004a; Tan
et al. 2004). Tooth-implant-supported
FDPs (Lang et al. 2004), tooth-supported
FDPs with cantilever extensions (Pjeturs-
son et al. 2004b) and resin-bonded fixed
reconstructions (Pjetursson et al. 2008),
however, have to be considered as second
treatment options, as higher estimated an-
nual failure rates of 2.51%, 2.20% and
4.31%, respectively, can be expected.
In some clinical cases, none of the pre-
viously discussed fixed reconstructions
may be incorporated owing to the fact
that inadequate bone volume may be

448 | Clin. Oral Impl. Res. 20, 2009 / 441–451 c 2009 John Wiley & Sons A/S


diagnosed and/or the available abutments
may be located in strategically unfavour-
able positions. In such situations, the in-
sertion of one or more implants supporting
a cantilever extension may be a reasonable
treatment option.
The results of the present systematic
review revealed that ICFDPs are treatment
variations with high predictability and fa-
vourable long-term outcomes for the pa-
rially edentulous patient. The estimated
failure rate per 100 ICFDP years of 1.18
reported in the present systematic review is
comparable with that of implant-supported
FDPs (e.g. 1.03; Pjetursson et al. 2004a) or
conventional tooth-supported FDPs (e.g.
1.16; Tan et al. 2004).
Moreover, the estimated failure rate per
100 ICFDP years reported in the present
systematic review (e.g. 1.18) compared
more favourably with that of tooth-sup-
ported FDPs with cantilever extensions
(e.g. 2) (Pjetursson et al. 2004b), indicating
that cantilevers supported by implants may
yield lower complication rates than cantile-
vers supported by teeth. Furthermore, the
estimated failure rate per 100 ICFDP years
was substantially lower than that of com-
bined tooth-implant-supported FDPs (e.g.
2.51; Lang et al. 2004). The obvious clinical
advantages of ICFDPs include reduced treat-
ment time and cost, as well as the redun-
dancy of complex reconstructive surgeries.
Moreover, prosthetic reconstructions
like the placement of a single implant
supporting a distal or a mesial cantilever
extension have been propagated for the
restoration of two-unit single gaps in areas
of aesthetic priority. In such situations (i.e.
a missing lateral and central maxillary in-
cisors), the space for the insertion of two
adjacent implants with adequate distances
between them and the neighbouring teeth
is often lacking. Not respecting adequate
distances between implants and neighbour-
ing teeth may result in jeopardy of perio-
dontal structures (Krennmair et al. 2003),
or in increased bone resorption, with the
interdental papillae failing to develop be-
tween adjacent implants (Tarnow et al.
2000; Gastaldo et al. 2004). The placement
of one single implant supporting a mesial or
a distal cantilever extension may resolve
this problem. However, scientific evidence
for this concept is still lacking.
It has to be realized that in the studies
selected for the meta-analysis of this sys-
c 2009 John Wiley & Sons A/S
 449 |
tematic review, a considerable variability
of outcomes was reported. In particular,
some studies showed impressively good
long-term results (Eliasson et al. 2006),
whereas other publications reported a
higher percentage of prostheses lost during
the follow-up (Hälg et al. 2008). Such
discrepancies are also evident from out-
comes of publications reporting on
ICFDPs, but excluded from the present
systematic review. As an example, Becker
(2004) reported no complications in a retro-
spective study on 60 prostheses with can-
tilever extensions. Also, a 100% survival
rate was reported by Johansson & Ekfeldt
(2003) after the analysis of 65 ICFDPs
followed for a mean observation period of
49.6 months. In that study (Johansson &
Ekfeldt 2003), however, a higher complica-
tion rate was found for ICFDPs compared
with FDPs without cantilever extensions.
On the other hand, low survival and high
complication rates were reported in two
recent studies reporting on ICFDPs (De
Boever et al. 2006; Nedir et al. 2006).
The variety of results between the differ-
ent publications selected for the present
systematic review may be explained from
different aspects. First of all, the number of
implant-supporting ICFDPs could have an
effect on the survival and success of the
prostheses. In the papers selected for the
present systematic review, the number of
implants per prosthesis varied between one
and three. It has to be noted that studies
reporting on prostheses with two to three
implants (Eliasson et al. 2006) yielded
better results than studies reporting on
prostheses supported by one to two im-
plants (Hälg et al. 2008).
The position of the cantilever extension
(e.g. mesial or distal or combined) as well
as the length of the cantilever beam (e.g.
one or more extension units) may also have
influenced the outcome. With the excep-
tion of the study by Wennström et al.
(2004), who only reported on distal canti-
lever extensions, all the other publications
reported on both types (mesial and distal) of
extension locations. Owing to the small
sample sizes of subgroups, separate ana-
lyses with respect to extension locations
could not be performed in the present
systematic review.
The length of distal cantilever extensions
(e.g.  or  15 mm) was shown to
influence the survival rate of implant-
Aglietta et al . Implants with cantilever extensions
supported full-arch fixed prostheses
(Shackleton et al. 1994). In four publica-
tions (Brägger et al. 2005; Eliasson et al.
2006; Kreissl et al. 2007; Hälg et al. 2008)
that reported on implant-related technical
complications, three implant fractures
were observed. These events were linked
to the use of hollow-body or reduced-dia-
meter implants. The fact that hollow-body
or diameter-reduced implants affected im-
plant survival (e.g. implant fracture) was
also reported for implant-supported FDPs
without cantilever extensions (Buser et al.
1997; Zinsli et al. 2004). As a conse-
quence, it has to be advocated to avoid
the use of diameter-reduced implants in
the proximity of cantilever extensions in
ICFDPs.
Two studies compared the 5-year out-
comes of ICFDPs and implant-supported
FDPs without cantilever extensions
(IFDPs) (Wennström et al. 2004; Hälg
et al. 2008). Hälg et al. (2008) reported a
difference in the survival rate of ICFDPs
and IFDPs (89.9% vs. 96.3%, Po0.05), as
well as a higher number of technical com-
plications in ICFDPs compared with
IFDPs. On the other hand, no difference
was reported between the two groups with
respect to implant failures and radiographic
bone-level changes. Similarly, Wennström
et al. (2004) reported comparable changes
in radiographic bone levels around implants
supporting ICFDPs with IFDPs.
The present meta-analysis has con-
firmed that no statistically significant dif-
ferences in bone-level changes were
observed between the ICFDPs and the
IFDPs. This is in accordance with the out-
comes reported by Blanes et al. (2007)
documenting the lack of influence of me-
sial or distal cantilever extensions on peri-
implant bone-level changes.
In conclusion, ICFDPs represent a pre-
dictable and reliable treatment for the re-
placement of posterior missing teeth in
partially edentulous patients. The most
frequent technical complications included
veneer fractures, followed by screw loosen-
ing and loss of retention. No detrimental
effects on bone levels were observed around
implants in the proximity of cantilever
extensions.
To date, however, evidence of the effects
of various prosthetic designs (e.g. distal or
mesial cantilever extension), number of
implants supporting ICFDPs and occlusal
Clin. Oral Impl. Res. 20, 2009 / 441–451
Aglietta et al . Implants with cantilever extensions
concepts on the incidence of complications
in ICFDPs is still sparse.
Acknowledgements: This study was
supported by the Clinical Research
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