A case for the cantilever bridge

The patient, a middle aged female, regularly attended the practice. Her ex-husband was a colleague
and the patients financial resources were extremely limited. Her husband had always cared for her
teeth but since the divorce she had to fend for her self.
She presented with some discomfort on her right mandibular first and second molars (igure !".
The furcation lesion on the first molar left no other choice but an extraction. The second molar was
root treated and then it was decision time, to be heavily influenced by finances. #mplant supported
crown for the first molar and crown for the second molar$ %r bridge with abutments on the second
molar and second premolar$ &oth these options were discarded in favour of a cantilever bridge
consisting of an abutment on the second molar and a pontic to replace the extracted first molar. The
second premolar (igure '" was considered too wea( and too ris(y to be used as an abutment and it
was explained to the patient that should this tooth fail, she would need to have it replaced by an
implant supported crown. She accepted the treatment plan and it was subse)uently carried out.
The cantilever bridge functioned well but eventually the crown on the second premolar failed by
becoming decemented with a fragment of fractured dentine remaining attached to the restoration
(igures * and +".
This fracture line was a few millimeters subgingivally (igure ,"
Figure 1
Figure 2
Figure 3
Figure 5
Figure 4
This was deemed a minor disaster at first but careful rethin(ing led to the decision to simply resect
the marginal gingiva and recement the crown. This was easily and )uic(ly carried out (igures -
and ."
and a post-operative radiograph confirmed excellent repositioning of the restoration with attached
fragment (igure /".
The patient was dismissed with a detailed explanation of the ris(s and complications and advised of
the very real possibility of the need for an implant supported crown in the near future.
This case was interesting in more ways than one. irstly, the decision not to use the second
premolar as a bridge abutment was proven correct by the eventual fracture of the premolar. Had
this tooth been part of the new bridge the entire, expensive restoration would have been severely
compromised. 0ow the situation can be rather simply managed by means of a single implant. 1nd
in the mean time it was possible to buy some more time for the patient by recementing the crown.
Secondly, the concept of a cantilever bridge once again proved to be very useful. The premolar had
failed and fractured most probably as a result of severe occlusal forces yet the cantilever bridge
survived, despite these forces. 2ractitioners are somewhat reluctant to utilise the concept of a
cantilever bridge because it flies in the face of their gut feel and experience. 3e all (now how easy
it is for a three unit bridge consisting of two abutments and one pontic to fail, so it is natural to shy
away from only one abutment to support a pontic. 4et this case as well as many others have proven
these fears unfounded. The reality is that cantilever bridges can in carefully selected cases be very
successful. 2ractitioners are reminded of the advantages of lower cost as well as ease of hygiene
(no floss threaders or super floss" of a simple cantilever bridge.
Thirdly, implantologists would in this case have argued for the wholesale extraction of the lower
right second premolar as well as both lower molar teeth, thus re)uiring the placement of three
implants. &ut this approach was totally out of the )uestion because of the patients financial
situation. 1s it stands the cantilever bridge is proving to function well and if and when the premolar
finally fails the patient might 5ust be in the position to afford a single implant. #f the cantilever
bridge also fails a few years down the line the patient may possibly also afford that treatment.
There is also the very real scenario of implant failures to consider. #mplants are not without their
complications and ris(s. The literature is replete with examples of failed osseo-integration,
paraesthesia of the lip and prosthodontic failures. There is simply no guarantee that an implant
supported prosthesis will function without problems.
Figure 6
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Figure 8
inally, we have to face the real world. 3hen a patient is really desperate and under severe
financial duress, is it ethical to even suggest treatment that is clearly beyond the means of the
patient$ #n this case the patient had not even the remotest chance to afford extensive implant
therapy and the 6compromise7, if it was that, was the treatment as it was carried out.
What do our readers think?