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Resin-Bonded Bridges − the Problem Or the Solution?: Part 1 Assessment and Design

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Resin-Bonded Bridges − the Problem Or the Solution?: Part 1 Assessment and Design RestorativeDentistry Jasneet Singh Gulati Sara Tabiat-Pour, Sophie Watkins and Avijit Banerjee Resin-Bonded Bridges − the Problem or the Solution?: Part 1 Assessment and Design Abstract: Resin-bonded bridges (RBBs) have an important role to play in the minimally invasive prosthodontic replacement of missing teeth. This treatment modality is perceived to have a high clinical failure rate by some practitioners, which may be associated with poorly planned and executed designs and adhesive techniques. This paper, the first part of a two-part series, discusses the important planning stages in the successful provision of RBBs, including assessment, appropriate abutment selection and design considerations. The second part of this series will focus on the clinical stages of RBB provision. CPD/Clinical Relevance: This paper aims to provide the general dental practitioner with a guide to appropriate case selection and an overview of the planning stages involved for the provision of RBBs. Dent Update 2016; 43: 506–521 How long can RBBs last? of 87.7% at 5 years,2 deeming them an When can RBBs be used? Resin-bonded bridges (RBBs) acceptable and minimally invasive (MI) RBBs have an important role have been used to replace teeth in short method of restoring modest-sized spaces to play in restorative dentistry, with edentulous spans with increasing success in the dental arch. It has often been their indications extending beyond the since the 1970s.1 A systematic review by considered that they are an under-utilized replacement of lateral incisors. They restoration modality in general dental Pjetursson et al reported a survival rate are a MI way of replacing missing teeth practice due to a perceived high rate of compared to conventional bridgework10 clinical failure, which may be associated or implants, usually not requiring local with incorrect design and execution.3 anaesthetic, making the procedure suitable Jasneet Singh Gulati, BDS, A recent prospective study of 771 for patients who are needle phobic or do PgCert(DentEd), MFDS RCPS(Glas), adhesive bridges by King et al found that not wish to go through lengthy surgical Dental Core Trainee 1 (gulatij@gmail. most failures of RBBs occurred within the com), Sara Tabiat-Pour, BDS, MSc, treatment. RBBs are an option where there first four years, and that very few failed MFDS RCS(Eng) FDS(Rest Dent) RCS, thereafter, with an estimated survival rate may be a lack of 3-dimensional space or Consultant in Restorative Dentistry, of 80.4% at 10 years.4 In this single-centre bone for implant placement. The benefits of Sophie Watkins, BDS, MSc FDS(Rest shorter appointments and associated cost Dent), RCPS FDS RCS(Eng), Consultant study, because the point of failure was compared to conventional bridgework and in Restorative Dentistry, Guy’s & St. recorded as the first de-bond, the overall Thomas’ NHS Foundation Trust, King’s survival in clinical service may have been implant-supported restorations, are also Health Partners and Avijit Banerjee, greater where bridges had been re-bonded favoured by patients. BDS, MSc, PhD(Lond), LDS FDS(Rest successfully. An evidence-informed However, as with any form of Dent), FDS RCS(Eng) FHEA, Professor summary of key papers assessing RBBs has treatment, the use of RBBs is not without of Cariology and Operative Dentistry/ been given in Table 1.4-9 limitations and success is associated with Honorary Consultant and Clinical Careful case selection, appropriate appropriate case selection and planning. As Lead, Restorative Dentistry, KCL Dental design and attention to operative detail are with the provision of any restoration, the Institute at Guy’s Hospital, King’s Health key factors for the clinical longevity of RBBs patient must be well motivated with good Partners, London UK. and will therefore be covered in this paper. oral hygiene and primary dental disease 506 DentalUpdate July/August 2016 RestorativeDentistry 4 6 Authors (Year King et al (2015) - Botelho et al Djemal et al (1999) - Pröbster and Henrich Hussey and Linden Berekally and Smales of publication) University of Bristol (2014)5 - Faculty Eastman Dental Institute for (1997)7- Johannes (1996)8 - The Queen’s (1993)9 – Adelaide Dental Hospital and of Dentistry, The Oral Healthcare Sciences, Gutenberg University, University of Belfast, Dental Hospital, School, United Kingdom University of Hong University of London, United Mainz, Germany Northern Ireland, United Australia Kong Kingdom Kingdom Design of Prospective Retrospective Retrospective Prospective Retrospective Prospective study Number of 771 211 832 325 142 262 RBBs (including 38 hybrids/ (including 205 movable connector and 199 ‘Maryland’ bridges’ splint type bridges) 34 ‘Rochette’ bridges of various deigns) Definition of - First de-bond - First de-bond - First de-bond - First de-bond - Second de-bond - First de-bond RBB failure - Fractured porcelain or - Extraction of the - Fractured porcelain or - Loose retainer - Fractured porcelain metal abutment tooth metal - CARS or metal - Diagnosis of caries - Diagnosis of CARS - Diagnosis of CARS associated with - Others including aesthetic - Others including restorations and failure and periodontal loss abutment tooth sealants (CARS) - Others of abutment fracture and including aesthetic periodontal loss of failure abutment Survival 80.8% at 5 years 84.4% with a mean Median survival of 61% at 5 years 88% at 3 years Median survival (excluding life service of 9.4 7.83 years of 2.60 years for rebond data) 80.4% at 10 years years ‘Maryland’ bridges 70% at 3 years when pontic failures are excluded from failure definition Survival No rebonding data 97% at 5 years No rebonding data 76% at 5 years, 60% 94% at 3 years No rebonding data (including 91% at 10 years after 10 years rebond data) 84% at 15 years Anterior vs Anteriors (552) Anteriors (111) Anteriors (604) Anterior (279) Anterior (131) Anterior (150) Posterior RBBs Posteriors (219) Posteriors (100) Posterior (228) Posterior (46) Posterior (11) Posterior (78) (n) Posterior RBBs are Posterior RBBS are more likely to fail by an twice as likely to No significant difference in No significant No comparison made No difference in odds ratio of 1.79 debond compared survival difference in survival – results to anterior RBBs survival were not statistically significant Cantilever vs Cantilever (476) All RBBs were Cantilever (171) All RBBs were Fixed- All RBBs were cantilever. Most Maryland Fixed-fixed Fixed-fixed (295) cantilever Fixed-fixed (424) Fixed. bridges were Fixed- RBBs (n) Fixed-fixed RBBs are Fixed-fixed RBBs are more fixed (93%). more likely to fail by an likely to fail by an odds odds ratio of 2.23 ratio of 1.94 Unrestored Unrestored or new No comparisons No comparisons possible Unrestored (236) No comparisons No comparisons vs Restored restoration (706) possible Restored (89) possible possible Abutments Old restorations (65) The presence of an No influence old restoration is of presence of associated with higher restoration failure by an odds ratio of 3.21 Table 1. A table summarizing the seminal papers studying RBBs over the last 22 years. Significant points have been highlighted in grey. July/August 2016 DentalUpdate 507 RestorativeDentistry Preparation Minimal preparation (357) No comparisons No comparisons possible No preparation (65) No comparisons Non retentive vs Non- Intermediate or maximal possible Slice-cut, grooves and possible preparation (58) preparation preparation (414) pinholes, or extensive Retentive preparation Intermediate or preparation (260) (170) maximal preparation No significant Non-retentive RBBs are more likely difference in survival preparation RBBs are to fail by an odds ratio more likely to fail by of 2.85 an odds ratio of 1.82 However, this was not significant when pontic failures were excluded from failure definition Perforated vs All retainers were All retainers were Perforated (105) All retainers were All retainers were Perforated (34) Unperforated unperforated unperforated Unperforated (727) unperforated unperforated Unperforated (228) Retainer Perforated retainers are Perforated retainers more likely to fail by an odds are more likely to ratio of 1.38 fail by an odds ratio of 1.88 Critique The protocol suggested in Abutment teeth were The period of study (1978 The period of study All abutment teeth were This study used two of bridge this paper is in agreement prepared, where – 1993) covered many (1984 – 1995) covered minimally prepared different alloys for construction with our suggested necessary, to lower developments of resin many developments within enamel with a casting, of which both protocol protocol: the survey line to retained cast restorations. of resin retained wraparound design and contained beryllium. - Nickel Chromium increase wraparound Therefore there are many cast restorations. cingulum rests. Beryllium containing alloy of at least 0.7mm of the retainer. This variables in their bridge Therefore there are Nickel chromium alloy alloys are no longer thickness was achieved by axial construction protocol many variables in their used, air abraded with 50 used due to concerns - Unperforated retainers, preparation of the including the choice of bridge construction microns alumina prior to about their safety, air abraded with 50 interproximal surfaces. resin cement, casting alloy protocol including the fitting. and the availability microns alumina Anterior abutment and techniques for metal choice of resin cement, Rubber dam isolation was of alternative metal - Chemically adhesive teeth were prepared preparation casting
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