Resin Bonded Bridges: Techniques for Success

Resin bonded bridges: IN BRIEF • Gain a contemporary understanding of the role of resin bonded bridges in PRACTICE techniques for success replacing missing teeth. • Learn how to improve survival and aesthetics of resin bonded bridges. K. A. Durey,1 P. J. Nixon,2 S. Robinson3 and M. F. W.-Y. Chan4 • A ‘quick reference’ summary of things to consider clinically and technically, to improve outcome. VERIFIABLE CPD PAPER

Resin bonded bridges are a minimally invasive option for replacing missing teeth. Although they were first described over 30 years ago, evidence regarding their longevity remains limited and these restorations have developed an undeserved reputation for failure. This article provides a brief review of the literature regarding bridge success and continues to high- light aspects of case selection, bridge design and clinical procedure which may improve outcome.

INTRODUCTION By using a RBB it is possible to provide a both general practice and hospital settings Resin bonded or resin retained bridges fixed replacement for missing teeth which reported that a high proportion of prac- (RBBs/RRBs) are minimally invasive fixed is essentially reversible and does not com- titioners used unfavourable techniques.8 prostheses which rely on composite resin promise the abutment tooth. This is espe- It seems reasonable to assume that with cements for retention. These restorations cially important for young patients who improved education and careful planning, were first described in the 1970s and since may be more likely to experience endo- outcome could be improved. this time they have evolved significantly. dontic complications as a result of exten- The aim of this article is to re-evaluate The first type of RBB was the Rochette sive tooth preparation. the role of RBBs in fixed prosthodontics Bridge, which relied on the retention Despite this recognised advantage, the and provide a guide for practitioners with generated by resin cement tags through role of RBBs as definitive restorations regard to case selection, bridge design and a characteristic perforated metal retainer.1 remains somewhat controversial due to a clinical techniques in order that successful However, longevity of this type of restora- lack of long term prospective data regard- outcomes may be achieved. tion was limited and in an effort to address ing success. The majority of information this, methods of altering the surface of is based on the results of longitudinal FACTORS AFFECTING SUCCESS the metal retainer to enhance microme- studies, many of which have been poorly Case selection chanical retention were developed.2 The controlled, used a variety of cements and term ‘Maryland Bridge’ resulted from the preparation techniques making it difficult i) Patient factors development of a type of electrochemi- to isolate factors affecting outcome.4 Restoration of missing teeth aims to cal etching at the University of Maryland. Recent systematic reviews have esti- improve oral function, aesthetics and More recently bridge retention has been mated the five-year survival rates for restore occlusal stability. However, inter- enhanced by the development of resin bridgework as 87.7% for resin bonded vention should be considered carefully as cements which bond chemically to both prostheses4 and just over 90% for con- in some cases it may be detrimental to the the tooth surface and the metal alloy. ventional bridges depending on design.5 remaining dentition.9-11 From a clinician’s perspective, the main Although these rates are lower than the General factors such as the health, age of advantage of RBBs is that, in compari- 94.5% success6 reported for implant the patient, their expectations, local factors son to conventional bridge preparations, retained single crowns over the same five related to dental health and the missing they are conservative of tooth structure.3 year follow up, resin bonded bridgework tooth itself need to be taken into account. has the advantages of being less invasive, For example in older patients with reduced requiring a shorter total treatment time manual dexterity it may be appropriate to 1*Specialist Registrar in Restorative Dentistry, 2,4Con- sultant in Restorative Dentistry, Leeds Dental Institute, and less financial commitment. accept a shortened dental arch rather than Clarendon Way, Leeds, LS2 9PU; 3Senior Lecturer in In contrast to these favourable esti- replacing a lost posterior unit. If a tooth Clinical Dentistry, University of Queensland, University 7 of Queensland, Turbot Street, Brisbane, Australia mations of RBB success, Hussey et al. must be replaced, a RBB may be preferable *Correspondence to: Dr Kathryn Durey reported high failure rates when they used to a removable partial denture (RPD) espe- Email: [email protected] the number of recement fees claimed to cially where there is a history of signifi- Refereed Paper gauge the success of RBBs in NHS gen- cant periodontal disease or dental caries.9 Accepted 16 June 2011 DOI: 10.1038/sj.bdj.2011.619 eral practice. Additionally, a recent study As they are minimally invasive, RBBs can ©British Dental Journal 2011; 211: 113-118 of RBB designs employed by dentists in also provide a temporary option for young

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patients who have suffered the early loss of an anterior tooth. This situation would otherwise condemn the patient to years of denture wear until growth has ceased and an implant or definitive bridge can be considered. RBBs have the advantages of taking minimal clinical time12 and rarely requiring anaesthetic, therefore they may be appro- a b priate for patients who are apprehensive of dental treatment or unable to commit to more involved treatment involving multiple appointments. However, the patient should still be dentally motivated and caries and periodontal disease should be under control before embarking on fixed prosthodontics. In addition, managing c d expectations with regard to aesthetic out- Fig. 1 a) Older patient with a history of successfully treated periodontal disease and come and longevity should be considered dissatisfaction with partial denture. b) Remaining teeth lingually tilted with increased an important part of treatment planning.13 mobility. c) Provision of multiple (5) cantilever RBBs mimicking root exposure and staining of If expectations are unrealistic, patient sat- natural teeth. d) Note novel bucco-occlusal retaining wing used on lingually tilted molar tooth isfaction with the final result is likely to be low. there has been significant tooth wear. to have undergone some resorption and ii) Abutment tooth selection Additionally, the alignment or angulation have reduced length however, they may When selecting abutment teeth, investi- of teeth may affect the degree to which a also be ankylosed and so are well placed gations should be carried out to ensure retainer can be extended. Crowding may to act as abutments. endodontic and periodontal health. reduce access and rotations may mean that Periodontal support should be assessed full wraparound is difficult to achieve. An iii) Occlusal features considering bone levels and root configu- unconventional approach may be neces- When planning for RBBs, a detailed assess- ration. Although a history of periodontal sary, for example in Figure 1, where a ment of both static and dynamic occlusal disease and reduced bone support does buccal retaining wing has been used on a relationships is crucial to optimise success. not exclude bridgework (Fig. 1), the use lingually tilted molar in an effort to avoid A wax up on articulated casts gives a valu- of abutments with active periodontal dis- the undercut lingual area that proved dif- able view from the palatal aspect aiding ease should be avoided as increased func- ficult to access. the assessment of the amount of interoc- tional loading may increase the rate of If periodontal support and coronal con- clusal space available for the retainer periodontal destruction.14 dition are favourable, any teeth, including wings and pontics.13 It is important that Coronally, there should be sufficient retained deciduous teeth,15 can act as abut- the pontic is not involved in guidance dur- enamel available for bonding. The denti- ments over an appropriate span. Deciduous ing mandibular excursive movements.16 If tions of hypodontia patients are frequently molars can make particularly good abut- this is unachievable, guidance should be associated with a degree of microdontia ments as they are multirooted and have a shared with other natural teeth. reducing the amount of tooth structure large coronal surface area which allows If there is insufficient space for an aes- available. Surface area may also be com- full extension of the retainer wing. The thetic pontic, adjustment of opposing teeth promised if teeth are restored or where roots of retained deciduous teeth are likely could be considered. Alternatively space

Fig. 2 Hypodontia case demonstrating two cantilever RBBs to replace UL 3 and ULE. Note the extent of coverage of metal retainers, characterisation of porcelain work and ovate style pontic to achieve good aesthetics

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may be gained with localised anterior be maintained separately to restorative composite build ups to adjust guidance treatment, either with removable ortho- patterns or by cementing the restoration dontic retainers or orthodontic bonded at an increased OVD on the retainer.17 wire retainers. If a fixed-fixed design is With both of these options the occlusion required, contact in excursive movements would then be allowed to re-establish over and intercuspation should be on the a period of months through passive erup- retainer only.19 tion.18 Cementing restorations high does not appear to increase the risk of abut- i) Retainer wing coverage ment teeth proclining or the restoration The surface area covered by an RBB retainer Fig. 3 Upper central incisor following lengthening of clinical crown height using 19 debonding, however, the authors suggest has been shown to affect retention. It is electrosurgery that this technique should be used to make accepted that 180° wraparound retainers only modest and controlled changes to constitute the ideal design, but this must the occlusion. be balanced with the demand for aesthet- eventually leads to fatigue failure.27 Base Parafunctional forces increase the likeli- ics. Retainers on posterior teeth may be metal alloys are highly rigid and therefore hood of restoration failure, especially where extended to include coverage of the palatal can be used in thin section without risk the occlusion has not been accounted for. and lingual cusps and a proportion of the of flexing, making them ideally suited for Any habits should be identified during the occlusal surface (Fig. 2) to increase the sur- use in RBB retainers. In vitro research has assessment phase and the patient should face area and improve retention. If neces- shown that base metal retainers of less be counselled to avoid habits like nail and sary, the surface area for bonding can be than 0.7 mm thickness have less resistance pen biting. Where bruxism is suspected the maximised by crown lengthening, either to dislodgement28 and therefore 0.7 mm prescription of a night guard or occlusal with conventional periodontal flaps or with as a minimum dimension should be stipu- splint should be considered.2 electrosurgery (Fig. 3). Electrosurgery is par- lated in the technical prescription. Where ticularly relevant for young patients who there is insufficient interocclusal space to Bridge design have short clinical crown heights, a substan- accommodate a retainer of this thickness, It has been widely reported that RBBs tial proportion of whom present following teeth can be reduced to create space or the are more successful as cantilevers than orthodontics wearing retainers which can be bridge can be cemented high as previously as fixed-fixed restorations.20-23 Despite associated with gingival hyperplasia. If teeth described.17,18 Clinicians should verify this evidence a high number of dentists are restored, fillings should be replaced with adequate thickness of the metal retainer continue to use fixed-fixed designs and fresh composite restorations, which will before cementation to ensure sufficient double abutments.8 bond more favourably to the resin cement rigidity, for example using an Iwansson Resin bonded bridges with multiple abut- enhancing retention of the bridge.26 crown gauge (UnoDent Ltd, Witham, ments are more likely to debond due to the Essex, UK). differential movement of abutment teeth, ii) Technical features A locating tag or seating lug should be especially where occlusal contact involves Any flexing of the metal bridge retainer extended over the incisal edge of anterior the natural tooth surface. In these cases exerts stress on the cement lute that teeth (Fig. 4) to help to locate the retainer occlusal force leads to the tooth and the retainer being driven apart causing failure of the cement lute.19 Where two abutment teeth have been used it is unlikely that both retainers will debond simultaneously. When only one retainer fails, the bridge is likely to remain in situ promoting the development of caries beneath the failed retainer.20,21,24 There are, however, some situations in which a fixed-fixed design may be the most appropriate. These include large pontic spans and where abutment teeth are small and sufficient surface area for retention can only be gained by using one abutment at either end of the span. It has also been suggested that fixed-fixed RBBs can provide a form of orthodontic retention, particularly where teeth have been Fig. 4 Extension of retainer wing into existing palatal access cavity to improve resistance de-rotated.25 However, it is the view of the and retention form. Also note incisal seating lug authors that orthodontic retention should

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correctly and resist cervical displacement of the retainer during cementation. It can be removed with a bur after cementation and the metal polished as needed. iii) Aesthetics The aesthetics of a RBB are determined by the retainer wing, the porcelain work and how the soft tissues are managed. Metal a b connectors may shine-through translucent incisors causing them to appear grey and in fact Djemal et al.19 reported that the metal of the retainer was the most common reason for patient dissatisfaction with their RBB. Greying can be reduced to a degree by the use of opaque cement and careful c d retainer design, avoiding extending the Fig. 5 a) Young patient presenting with developmentally missing lateral incisors. Note the metal to within 2 mm of the incisal edge, central incisors are barrel shaped and the canines diminutive. b) Ridge preparation at the where the enamel becomes relatively more pontic site, note the central incisors and canines have been built up using composite resin translucent. In cases where the retainer to improve dimensions. c) Resin bonded bridges in situ replacing the lateral incisors. d) The emergence profile created following ridge preparation and use of an ovate pontic gives a cannot be disguised by opaque cements, it pleasing aesthetic result may be necessary to reconsider the choice of abutment tooth or place composite labi- ally as a veneer. retention,29 however, most authorities now degradation and reduced bond strength The shade of the porcelain should be advocate minimal preparation, within with time. In contrast, Panavia (Karrary conveyed to the technician by means of enamel,30 or no preparation at all.17,19 Co. Ltd, Osaka, Japan) demonstrates pro- a shade map, which can include details Vertical grooves are the particular fea- longed high bond strengths. This is due of characterisation features if appropriate ture which has been identified as reducing to formation of a chemical bond between (Fig. 2). The shade should be taken in natu- stresses on the cement bond31 and increas- the phosphate group of the cement mon- ral light at the beginning of the appoint- ing resistance to debonding forces.29,32 omer and the oxide layer of the metal ment when the teeth are hydrated. A good However, preparation involves irrevers- retainer. Sandblasting to create micro- quality digital photograph with the chosen ible damage to abutment teeth for what mechanical interlocking should be car- shade tab in situ can be a valuable aid for is reported to be only a limited benefit,19 ried out before cementation to further the technician. and even when minimal preparation is enhance retention. intended, dentine exposure is likely during RBB cementation requires an uncontam- iv) Pontic design preparation.24 Bond strength to dentine is inated, etched and primed enamel or den- Several alternatives for pontic design have lower than that that can be achieved to tine surface to generate maximum bond been described based on the pontic-ridge enamel which may affect bridge retention. strengths. In vitro research has shown relationship. The most commonly used Additionally dentine exposure increases that achieving uniform and ideal etching of these is the modified ridge lap pontic, the chance of sensitivity between appoint- of enamel surfaces is variable, especially which allows reasonable aesthetics and ments and the risk of caries if the area is on lingual surfaces of lower posterior facilitates hygiene. In aesthetically criti- not sealed adequately at cementation. teeth where moisture control is difficult.33 cal areas, the authors’ preferred alterna- A situation in which more extensive Audenino et al.34 found that the use of rub- tive to this is the ovate pontic, which has preparation can be justified is when teeth ber dam during cementation reduced the a convex profile to the soft tissue fitting are restored. Preparation may be devel- risk of the restoration debonding; however, surface helping to create a good emergence oped into restorations to produce longi- in contrast, Marinello et al.35 reported the profile (Fig. 2). When designing the pontic, tudinal grooves, occlusal rests and boxes isolation method used had no significant it is important to relate the gingival level on posterior teeth, and into access cavity effect on bridge outcome. It is the experi- to that of the adjacent natural teeth. restoration on anterior teeth. This helps to ence of the authors that, if patients are promote axial loading and creates resist- compliant, adequate moisture control can Clinical techniques ance form (Fig. 4). be achieved in the upper anterior region i) Need for tooth preparation using the cotton wool rolls and saliva ejec- ii) Cementation tors. Elsewhere in the mouth rubber dam The need for tooth preparation for RBBs is Developments in resin cements have is advisable and a split dam technique a subject of debate. Previous research used helped to increase restoration longevity. can be utilised to facilitate seating of more extensive preparations to enhance Early composite resin materials exhibited the restoration.

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PRACTICE iii) Ridge preparation A disadvantage of all bridgework is its Table 1 Factors related to success of resin bonded bridges inability to replace soft tissue. In cases Case selection with vertical ridge defects, pink porce- lain36 or composite may be used to rep- • Patient selection: are they motivated/compliant? licate the gingival margins. However, the • Does the space need to be restored? What options are there for restoration? amount of soft tissue this can replace is • Abutment tooth quality: is the tooth periapically and periodontally healthy? Is there periodontal limited as the restoration becomes bulky support adequate? Is there sufficient enamel surface area for bonding and how translucent is and compromises oral hygiene. Matching the enamel? gingival shade and characterisation is • Tooth position: is spacing and alignment of natural teeth favourable? How large is the pontic also challenging. span and will the abutment(s) support this span length? When there is adequate ridge height, • Occlusal assessment: is there sufficient space for a pontic of the right shape and size and the retainer, or does this need to be created? soft tissue management aims to create a • Parafunctional habits: are there any habits that can be eliminated or do they need to be realistic emergence profile and interden- managed as part of the treatment plan? tal papilla. This can be done clinically by • Expectations: has enough information been provided? Are the patient’s expectations realistic defining the pontic site with a high speed with regard to aesthetics and longevity? bur or electrosurgery37 immediately before Bridge design impression taking (Fig. 5). Alternatively, the master cast may be relieved in the lab • Retainer of 0.7 mm thickness and the soft tissues adjusted at fit. If the • Full retainer extension as allowed by aesthetic demands clinician is unable to alter the cast them- selves, the depth of relief required (taking • Minimal ICP contact in to account the compressibility of the • Careful management of excursive contacts to avoid undue forces on pontic tissues clinically at the pontic site), should • Use of an ovate pontic were aesthetics are important be conveyed to the technician. Where electrosurgery has been carried Clinical techniques out and the patient is wearing a RPD, this • Replace existing restorations with composite can be relined to help to maintain the gingival contour between appointments. If • Ensure adequate clinical crown height or crown lengthen to increase bonding area if necessary there is any relapse, electrosurgery can be • Create space for the restoration: opposing tooth adjustment, preparation of abutment tooth or repeated or the pontic modified at bridge fit. cement at increased OVD • Preparation: for unrestored teeth use minimal preparation, on restored teeth, extend preparations DEALING WITH FAILURE into restorations to increase resistance form Biological reasons for failure include car- • Assess shade accounting for opaque cement and possible grey shine through of retainer wing ies and periodontal disease but these occur • Prepare the pontic site to improve gingival profile when needed for aesthetics relatively rarely.4 To prevent complications • Excellent moisture control during cementation and use of a resin cement with a phosphate oral health education, encompassing oral monomer eg Panavia hygiene instruction and advice regard- • Protect the final result:provide a night guard or orthodontic retention if required ing diet and the use of fluoride, should be provided at the treatment planning stage and finalised following bridge cementa- If a bridge debonds there are two an occlusal perspective: have they devel- tion. Where a fixed-fixed design has been options: remake or recement. If a one oped a new parafunctional habit or has the used, patients should be warned of the risk off event such as trauma has resulted in occlusion changed in ICP or lateral excur- of one retainer debonding and to report decementation, recementing the restora- sion as a result of restoration or tooth wear this immediately if they feel that the bridge tion may well be appropriate. However, of adjacent or opposing teeth? is loose. studies have shown that once a bridge has If the decision is made to recement The most common technical reason debonded it is more likely to fail again39 a RBB, the metal retainer should be air for RBB failure is debonding.5 Although and recementing for a second time is gen- abraded and any cement residue removed authors have reported that debonding does erally ill advised as replacing the bridge carefully from the tooth before attempting not appear to affect patient satisfaction19,38 has been found to have a higher success this. Where the restoration is cantilevered, and there is usually limited damage to rate.35,39 This is probably because in the recementation is usually straightforward. abutment teeth, it is an inconvenience. majority of failed cases, there is an inher- Where there is a fixed-fixed design and Other technical problems which may ent problem with bridge design which may only one side is loose, attempts can be necessitate remake of the bridge include have been present at initial cementation made to remove the retainer that is still structural damage and shade match dete- and/or developed since. With this in mind, in place with the help of an ultrasonic rioration which can be a result of natural the restoration itself should be examined scaler. Alternatively, depending on the tooth discoloration or porcelain changes. and the patient should be reassessed from length of span, the debonded retainer can

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be sectioned and the bridge left in situ as design of resin-bonded bridges in general dental 25. Garnett M J, Wassell R W, Jepson N J, Nohl F S. practice and hospital services. Prim Dent Care 2004; a cantilever.2 Survival of resin-bonded bridgework provided 11: 87–89. for post-orthodontic hypodontia patients with 9. Jepson N J, Moynihan P J, Kelly P J, Watson G W, missing maxillary lateral incisors. Br Dent J 2006; CONCLUSION Thomason J M. Caries incidence following restoration 201: 527–534. of shortened lower dental arches in a randomized 26. Walls A W, Nohl F S, Wassell R W. Crowns and other Resin bonded bridges can be highly effec- controlled trial. Br Dent J 2001; 191: 140–144. extra-coronal restorations: resin-bonded metal res- 10. Knoernschild K L, Campbell S D. Periodontal tissue torations. Br Dent J 2002; 193: 135-135, 141–142. tive in replacing missing teeth, restoring responses after insertion of artificial crowns and 27. Northeast S E, van Noort R, Shaglouf A S. Tensile oral function and aesthetics and result in fixed partial dentures.J Prosthet Dent 2000; peel failure of resin-bonded Ni/Cr beams: an experi- 84: 492–498. mental and finite element study.J Dent 1994; high levels of patient satisfaction. They 11. Rashid S A, Al-Wahadni A M, Hussey D L. The 22: 252–256. represent a minimally invasive, cost effec- periodontal response to cantilevered resin-bonded 28. Ibrahim A A, Byrne D, Hussey D L, Claffey N. Bond bridgework. J Oral Rehabil 1999; 26: 912–917. strengths of maxillary anterior base metal resin- tive and long lasting treatment modality. 12. Verzijden C W, Creugers N H, van’t Hof M A. bonded retainers with different thicknesses. Given thorough patient assessment and the Treatment times for posterior resin-bonded bridges. J Prosthet Dent 1997; 78: 281–285. Community Dent Oral Epidemiol 1990; 18: 304–308. 29. De Kanter R J, Creugers N H, Verzijden C W, Van’t use of careful clinical techniques (Table 1), 13. Tredwin C J, Setchell D J, George G S, Weisbloom M. Hof M A. A five-year multipractice clinical study on the authors suggest that RBBs should be Resin-retained bridges as predictable and success- posterior resin-bonded bridges. J Dent Res 1998; ful restorations. Alpha Omegan 2007; 100: 89–96. 77: 609–614. considered more frequently as the restora- 14. Lindhe J, Svanberg G. Influence of trauma from 30. Botelho M. Design principles for cantilevered resin- tion of choice for short spans. occlusion on progression of experimental peri- bonded fixed partial dentures.Quintessence Int odontitis in the beagle dog. J Clin Periodontol 1974; 2000; 31: 613–619. The authors are very grateful for the excellent 1: 3–14. 31. Ziada H M, Orr J F, Benington I C. Photoelastic stress standard of technical support provided by 15. Robinson S, Chan M F. New teeth from old: treat- analysis in perforated (Rochette) resin bonded Mr Kevin Wilson, Senior Dental Technician, ment options for retained primary teeth. 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Marinello C P, Kerschbaum T, Heinenberg B et al. Oral Implants Res 2008; 19: 131–141. 20. Chan A W, Barnes I E. A prospective study of can- Experiences with resin-bonded bridges and splints ‑ 5. Pjetursson B E, Bragger U, Lang N P, Zwahlen M. tilever resin-bonded bridges: an initial report. Aust a retrospective study. J Oral Rehabil 1987; Comparison of survival and complication rates of Dent J 2000; 45: 31–36. 14: 251–260. tooth-supported fixed dental prostheses (FDPs) and 21. Olin P S, Hill E M, Donahue J L. Clinical evaluation 36. Alani A, Maglad A, Nohl F. The prosthetic manage- implant-supported FDPs and single crowns (SCs). of resin-bonded bridges: a retrospective study. ment of gingival aesthetics. Br Dent J 2011; Clin Oral Implants Res 2007; 18 Suppl 3: 97–113. Quintessence Int 1991; 22: 873–877. 210: 63–69. 6. Jung R E, Pjetursson B E, Glauser R, Zembic A, 22. van Dalen A, Feilzer A J, Kleverlaan C J. A literature 37. Elder A R, Djemal S. 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