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Introduction to Fixed Partial Dentures and Bridge Connectors. MiniMini -Residency 2012.
Associate Professor Harry Hughes BDSc Qld, DDS (Hons) Toronto, MS
Michigan.

IS THIS A SIMPLE SPACE MAINTAINER or A DODGY BRIDGE ?????

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Fixed partial dentures

Definition:
A BRIDGE OR FIXED PARTIAL DENTURE is: A prosthetic appliance permanently attached to some of the remaining teeth and replacing a missing tooth or teeth

Ahmad Irfan. Protocols for predictable asthetic dental restorations. 2006, 232 pages, WileyBlackwell Publisher.

Ref: Smith BGN. Planning and making crowns and bridges. 4th. Edition Martin Dunitz, U.K. 2006. Also : Wise Michael. Failure in the restored dentition. This book, published by Quintessence Publishing in 1995 was some 766 pages in length. I can only find that it is now out of print.

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FIXED PARTIAL DENTURES

TYPES OF FPDs: There are six types of FPDS or bridges:
Fixed Fixed or Rigid bridge. Fixed Free or Stress Stress-broken bridge. Cantilever bridge. Spring Cantilever bridge. Maryland or Resin retained bridge. Hybrid bridge with Conventional retainer at one end and a resin retained retainer at the other end. The Hybrid application was for the virgin tooth at one end of the space and the heavily restored tooth at the other end. Many variations were described but all had a poor success rate. 32% failure rate in 48 months.
Ref: Anweigi LM, Ziada HM and Allen PF Clinical performance of hybrid bridges. J Oral Rehabil 2007,34:4,2912007,34:4,291-296
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Components of a bridge.

Abutment: A tooth serving as a support for an FPD Pontic: The artificial tooth/teeth suspended between the abutment teeth Retainers: Restorations cemented to the prepared abutment teeth Connector: The join between the pontic and retainers; either rigid or non-rigid
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SUCCESS RATE WITH DENTAL BRIDGES. The dental bridge has been regarded as the standard of care for decades in the replacement of single and multiple missing teeth. UNFORTUNATELY these days, the only types of bridges that seem to be constructed are full coverage bridges, either metal ceramic or all-ceramic, and that is a great pity because: 1. To obtain optimal functional and esthetic results for metalceramic bridges and all-ceramic bridges, very significant amounts of tooth structure must be removed, especially if the abutment teeth are not parallel . 2. This significant tooth removal has the potential to create endodontic, periodontic, and structural complications, ( and certainly to me, sleepless nights.)
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Unfortunately, the days of using partial coverage gold alloy crowns or even gold inlays for retention have long passed, yet there are many cases where such bridges have lasted in excess of 50yrs. The case shown constructed off a gold crown lasted 53 yrs.
Reference: Nasser U and Russett S. Longevity of a maxillary 2unit cantilevered FPD: Clinical report. J Can Dent Assoc 2006;72(3):253-55

With partial coverage, the abutment preparation design can be tailored to restrict tooth preparation excesses (the infamous teepee preparation,) depending on the occlusion of the case and the esthetics desired. Resin cement has helped in these cases of partial coverage and anterior guidance is easier to RE-ESTABLISH. The result can be esthetic without the underlying metal shadow, as 8 12/03/13 shown in the next slide..

Many studies surveying the long-term survival of dental bridges have been compiled and analyzed to arrive at a generalized outcome. When a broad definition of failure was used combining bridges already removed with those that had technically failed and needed replacement; 87% and 69% were estimated to survive at 10 and 15 years respectively. (Scurria et al. 1998.) It is now generally accepted that bridge survival is approximately 87% at 10 years, dropping to 69% at 15 years.
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In this case a pinledge preparation, one of my absolute favorites, was used on the cuspid abutment. The result was pleasing and this case was prior to the introduction of the ovate pontic which would have improved the esthetics even more.
Reference: Hughes H J Are there alternatives to the porcelain fused to gold alloy bridge ? Austral. D J 1970;15(4):281-287.
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And then there is the problem of the selection of an abutment tooth:

There have been numerous studies showing that endodontically treated anterior teeth are predisposed to long-term failure as bridge abutments. Pier abutments also fall into this category and their problem will be discussed in depth later. (Foster 1991.) Additionally, prospective abutment teeth that were subject to luxation or avulsion injuries, (Majorana et al. 2003,) are at significant risk of requiring future endodontic treatment and would be a poor abutment choice .
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In Australia, Walton , 2002, looked at 515 metal ceramic bridges longitudinally over 15 years and reported similar survival rates.
References: 1. Scurria MS et al. Meta-analysis of fixed partial denture survival: prostheses and abutments. J Prosthet Dent. 1998;79:459 2. Foster LV. The relationship between failure and design in conventional bridgework. J Oral Rehabib. 1991;18:491 3. Majorana A et al. Root resorption in dental trauma: 45 cases followed for 5yrs.Dent Tramautol. 2003;19:262. 4. Walton TR. An up to 15 yr. longitudinal study of 515 metal-ceramic FPDs. Part 1: outcome. Int J Prosthodont. 2002;15:439.

General indications for a Dental Bridge. As a general statement dental bridges should only be used for the replacement of a single or 2 missing teeth, and, according to the Textbooks on Crown and Bridgework; should use abutment teeth that have an equal or greater root surface area to the area being replaced (Antes law 1926).
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Abutment teeth
PRE-REQUISITES FOR A SUCCESSFUL ABUTMENT TOOTH.

Abutment teeth
3. Vital teeth THE TEXTBOOKS SAY: : If vitality in doubt- root treat, then use. HARRY SAYS: : If root treated, always use a cast post-core with ferrule and a gold alloy cervical collar on the crown and only use in short span bridges. But really, if non-vital teeth are used expect a decreased life expectancy regardless of span length. 4. Sufficient remaining tooth structure on the proposed abutment tooth. : Virgin teeth are best, but can you do it??? This is where the Hybrid Bridge already mentioned, was born : Avoid heavily restored teeth
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1. Absence or no history of periodontitis : Maximum bony support : Healthy gingival tissue, no gingivitis 2. Large root surface area and configuration : Multi-rooted teeth with wide root separation : Long roots that are wide bucco-lingually : No short, conical roots
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Walton TR. An up to 15 yr longitudinal study of 515 metal ceramic FPDs. Part 1 Outcome. Int J Prosthodont..2002;15:5,439

5. A favorable crown/root ratio with an absolute minimum of 1:1

ANTES LAW states the root surface area of the abutment teeth should equal or surpass the root surface area of the teeth being replaced by pontics. This old law must be interpreted generously. Remember that Antes Law was suggested in 1926, when the cause of periodontal disease was largely unknown and occlusal understanding and concepts were based around complete denture practice. In the light of current knowledge is it overly cautious??? There is no set level of gingival attachment below which the use of a tooth as an abutment becomes contra-indicated; however, the remaining support must be healthy and the occlusion controlled with no parafunction. Read: Nyman and Ericsson. The capacity of reduced periodontal tissues to support fixed bridgework. J Clin Periodont 1982,9:409
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Abutment teeth

The best: Canines and First molars The worst: Mandibular and maxillary
lateral incisors
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Pontics

Pontic design

Pontic design
: Hygienic
: Modified ridge lap
really used much before the late 1990s

: Ovate (Although first described in 1933, the ovate pontic was not .) : Ridge lap or Saddle

Zitzmann et al. The ovate pontic design: A histologic observation in humans. J Prosthet Dent. 2002;88:375-380 Dylina TJ. Contour determination for ovate pontics. J Prosthet Dent. 1999;82:136-142

Modifedridge lap

Ridge lap (saddle)

Hygienic

Ovate
USED MAINLY IN THE ANTERIOR PART OF THE MOUTH FOR ESTHETICS AND MAINTENANCE 18 REASONS

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Worst

Best

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Cast is scored with a round #3

bur.

UNIQUE OVATE PONTIC DESIGN.

Kim HK, Caseione D. and Knezevic A. Simulated tissue using a unique pontic design. A clinical report. J Prosthet Dent 2009; 102:4, 205.

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Pontics Pontics

The law of BEAMS.

Flexure length3

Flexure depth3

Pontic number: Determines bridge type

: single pontic - short span bridge. : multiple pontics - long span bridge.

Law of Beams (Brumfields Law)-

Deflection varies directly with the cube of the length of the span and inversely with the cube of the occlusogingival thickness of the pontic.
Force on a one pontic bridge = Distance between the abutments. Same force on a 2 pontic bridge = 8xDistance. Same force on a 3 pontic bridge = 27xDistance. Technically, this should influence abutment design, number of abutments, and the design of FPD connectors. Smyd E S. The role of torque, tension and bending in Prosthodontic failures. J Prosthet Dent 1961;11:95-111

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RETAINERS
The retainer selection is dictated by: Length of the edentulous span
Long spans are less rigid. All bridges bend during function and so does the mandible. See the LAW of BEAMS. Dislodging forces tend to act mesiodistally on a bridge as opposed to the mainly buccolingual forces on crowns. Preparations should be modified accordingly with accessory retention boxes, grooves, pins, etc.

DOUBLE ABUTTING.
Even many current Textbooks on Fixed Prosthodontics still recommend multiple abutments as a means of tying in the prosthesis. Double abutments are also described as a means of increasing the retention of the prosthesis.

Their use on these grounds is mistaken.

Fixed bridges are much more at risk of failure due to inadequate resistance, i.e. being twisted or torqued off the abutment teeth. Thus, double abutments increase retention but decrease resistance, thereby increasing the risk of failure of the bridge through loss of cementation of the secondary retainer as the primary abutment becomes a fulcrum. There is also no evidence that the use of a second abutment will protect a weakened one.

Periodontal support and Double Abutting

The older literature states that double abutting is often used to overcome both unfavorable crown/root ratios and long span retention. The secondary abutment must have a similar carrying capacity to the primary abutment and the retainers on these secondary abutments must be as retentive as the primary abutment preparation.
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RETAINERS
Thus, double abutments are out of favor in modern crown and bridge design, (Foster 1991, Ibbetson et al. 1999,) and posterior bridge units tend to be stress-broken to permit some vertical movement in the posterior section of the bridge. This stress breaking applies to both maxillary and mandibular posterior bridges. Because of the curvature of the dental arch, anterior bridges tend to be rigidly constructed. Arch Position of the Teeth. When the pontic(s) lies outside the inter-abutment axis as in the replacement of maxillary anterior teeth, the pontic(s) will act as a lever arm producing torque to the bridge. This is a common problem in replacing all four maxillary incisor teeth with an FPD, and is most pronounced in the arch that is pointed in the anterior region. To offset this problem it was suggested that additional retention be gained in the opposite direction from the lever arm at a distance from the inter-abutment axis equal to the length of the lever arm; by double abutting.
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RETAINERS
It used to be thought that double abutting was necessary in these cases, but modern design only singularly abuts in most cases, unless the arch curvature is excessive. Two of the problems with double abutting are 1. the difficulty with oral hygiene caused by the interproximal connector and 2. the problems of parallelism of the multiple abutment teeth. It is further suggested that stressstress-breaking is unnecessary in anterior bridges because anterior bridges receive less stress than posterior bridges.
Markley K., J Prosthet Dent.1951,1:416Dent.1951,1:416-423.

These bridges had excellent success with an average lifespan in excess of 10.6 years. Walton J et al. 1986

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Connectors Retainers
CLASSIFICATION: Crown type
: Full crowns : Partial crowns- must at least be three quarter crowns. Onlays and inlays have insufficient retention, (or do they ???) : Maryland retainers
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To stress-break or not to stress-break, that is the question!! What about all ceramic bridges? Maxillary FPDs Obviously they cant Anterior : fixed be stress broken so I do Posterior : fixed-free not feel a use for them Mandibular FPDs: More on all-ceramic Anterior : Fixed bridges later. Posterior : Fixed-free i.e. Fixed at the posterior connector and stress broken at the anterior connector. Now, it is becoming more common to stress break ALL POSTERIOR BRIDGES.
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in the posterior mouth.

CONNECTORS
The occlusal forces applied to a fixed partial denture (FPD) are transmitted to the supporting structures through the pontic, the connectors, and the retainers.

CONNECTORS
Remember that connectors are that portion of the bridge that unites the retainers and the pontics. They are of two types, rigid connectors and non-rigid connectors (NRCs). Rigid connector could be made by casting, soldering, and welding. The cast connectors should be properly shaped in wax patterns. The soldered connectors are made by fusion of an intermediate metal alloy to the previously made castings. These days, the one piece casting goes a long way towards overcoming rigid connector failure in bridgework. The connector that permits limited movement between the otherwise rigid members of the FPDs, is the Non- Rigid Connector or NCR . The NRC could be made by an incorporation of prefabricated precision inserts, by use of a custom-milling machine or by use of the prefabricated plastic patterns. Ref. Pissiotis AL, Michalakis KX. An esthetic and hygienic approach to the use of intracoronal attachments as interlocks in fixed prosthodontics. J Prosthet Dent 1998;79:347-9
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Variables that may influence the longevity of a bridge and its abutments include the occlusion, span length, bone loss, and the quality of periodontium.
The excessive flexing of the long-span FPD, which varies with the length of the span cubed, can lead to material failure of the prosthesis or to an unfavorable tissue/bone response.

Biomechanical factors such as occlusal overload, leverage, torque, and flexing, induce abnormal stress concentration in an FPD.
This stress concentration is found in the connectors of the bridge and in the cervical dentin area near the edentulous ridge. This factor plays an important role in the potential for failure, particularly in long-span bridge.
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NON-RIGID CONNECTORS.
The indications for the use of the NRC in fixed prosthodontics are : 1. The existence of a Pier abutment , which promotes a fulcrum-like situation that can cause the weakest of the terminal abutments to fail and may also cause intrusion of the pier abutment. But should Pier Abutments be used at all considering their high failure rate ??? (Ziada

et al. 1998.)
2. The existence of a malaligned abutment , where parallelling preparations might result in excessive tooth preparation and devitalisation. Such situations can be solved through the use of intracoronal attachments as connectors. 3. The presence of mobile teeth , which need to be splinted together with the fixed prosthesis. In such situations, it is not practical to cement a splinting type restoration with numerous teeth involved. Through the use of interlocks, smaller segments can be cemented with the splinting effect provided by the interlocks.

4. Long span FPDs: which can distort due to shrinkage and pull of porcelain on thin sections of framework and thus affect the fitting of the prosthesis on the teeth. Again, should long span bridges be favored considering their failure rate and considering the success rate of implants ??? 5. In situations where a questionable distal abutment exists and fabrication of the fixed partial denture is considered to be the best interim treatment, the use of the NRC may solve the problem of not having to repeat the restoration of the remaining abutment(s) after final failure of the questionable abutment. 6. It could also be used with osseointegrated implants.

So, the NRCs are mainly used to reduce stress on the abutment and to accommodate malaligned FPD abutments.
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The four types of NRCs are the

1. Dovetail (key-keyway) or (Tenon-Mortise) connectors. 2. Loop connectors. 3. Split connectors. 4. Cross pin and wing connectors. Align the path of the keyway to that of the mesial abutment. A deep wax box is carved into the distal of the wax pattern for the incorporation of a keyway, which in turn requires an intracoronal preparation of adequate depth and a parallel path of insertion. Ref: Badwalk PV, Pakhan AJ. Non-rigid connectors in Fixed

CONNECTORS
Sutherland et al. (1980) suggested that a rigid bridge resolves more of its stress internally before the remaining stress can reach the bone, and it has been found that the greatest stress concentrations in a rigid bridge occur in the connectors. With a nonnon-rigid design, the stress may be directed through the abutment teeth to the supporting bone rather than being concentrated in the connector itself. This means that the prosthetic material and the luting cement in a rigid design must withstand much greater stress than in the nonnon-rigid design.

Prosthodontics: current concepts. J Indian Dent Assoc. 2005;5:2,99-102 Banjaree S. et al Non-rigid connectors- the wand to reduce stresses on the abutment teeth. Contemp Clin Dent 2011,2:351.
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CONNECTORS
Another problem that exists in the posterior mouth is the inequality of the abutment tooth size. In a bridge replacing a first molar for example, the smaller abutment (second premolar) may develop a thicker pericemental cushion following frequent stress, as a compensating measure for this stress. As a result, weaker abutments may move more than the larger sturdier abutment. This results in large lever strains on the weaker abutment which tends to shear the luting bond. However, when a stressstress-breaker is used on the smaller abutment, it will tend to dissipate much of the leverage force. StressStress -breakers can also be required in long long-span bridges as satisfactory tooth alignment becomes more difficult to achieve. Even in shortshort-span bridges with divergent abutment teeth, abutment preparations do not have to be parallel to each other. Each preparations can be designed to MAXIMIZE individual retention, independent of a common path of insertion.
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Connectors
The use of stress-breakers also tends to break up bridge length to more manageable portions and makes subsequent repair/replacement easier.

Fixed-fixed Rigid connectors

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Fixed Free Stress broken connectors.

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Connectors

P P P

Stress-breakers
SEVEN UNIT BRIDGE BROKEN INTO MANAGEABLE UNITS. Precision, semi-precision type attachment
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Rest and seat

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EXAMPLES OF NON-RIGID OR STRESS BROKEN POSTERIOR BRIDGES.

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THE PIER ABUTMENT. Unfortunately, the pier abutment is a real problem in FPD design. The highest stress values were located at connectors and cervical regions of abutment teeth, especially at the pier abutment. Diagram shows the pier abutment acting as a fulcrum in bridge loading. It is suggested that a NRC in the distal of the abutment and the mesial of the pontic will help dissipate stress in the pier abutment. Ref.: Oruc S et al. Stress analysis of effects of NRC on FPDs with pier abutments. J Prosthet Dent 2008;99:3,185-192

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PIER ABUTMENTS
Ref: Shillingburg/Hobo/Whitsett. Fundamentals of Fixed Prosthodontics, Second Edition pages 25-29.

PIER ABUTMENT These movements of measurable magnitude and in divergent directions can create stresses in a long span prosthesis, which will be transferred to the abutments.
Because of the great length through which movement occurs, the independent direction and magnitude of movements of the abutment teeth, and the tendency of the pier abutment to act as a fulcrum; considerable stress will be generated in the abutment teeth.

instances, an edentulous space will occur on both sides of a tooth, creating a lone, freestanding pier abutment. Physiologic tooth movement, arch position of the abutments, and the retentive capacity of the retainers make rigid, soldered five unit bridges a less than ideal plan of treatment. Studies in tooth movement have shown that the buccolingual movement ranges from 56 microns, and intrusion is 28 microns. Teeth in different segments of the arch move in different directions. Because of the curvature of the arch, the movement of an anterior tooth in a faciolingual direction occurs at a much greater angle when compared to the buccolingual movement of a molar.
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In many

The use of a non-rigid connector can lessen these hazards.

In spite of an apparent accurate fit of the bridge, the movement allowed by this type of connector is enough to prevent the middle abutment from serving as a fulcrum in a buccolingual or occclusocervical direction. The non-rigid connector is a broken-stress mechanical union of retainer and pontic, instead of the usual rigid joint. The keyway of the connector should be placed within the normal distal contours of the middle abutment and the key should be placed on the mesial side of the first molar pontic.

The nonrigid connector is also a solution to the problem of the tilted FPD abutment. 12/03/13

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THE REPLACEMENT OF A MISSING CANINE. The canine tooth is often the keystone of the Dental Arch and a very difficult tooth to replace using a bridge. The adjacent teeth are very poor in terms of the amount of retention and support that they can offer and the canine is often subject to enormous stresses in lateral excursions particularly in canine guided occlusions. If the canine is to be replaced with a bridge, the occlusal scheme should be redesigned to provide group function, NEVER a CANINE PROTECTED OCCLUSION. Canine replacement is best done by using

Mandibular FPDs
3 unit FPD replacing a lower 6

an implant.

There is a very good article by Hemmings and Harrington, 2004, that describes the treatment options for the edentulous space , to-gather with reasons for the choice of the replacement recommended. It is well worth a read. Hemmings K and Harrington Z. Replacement of missing teeth with fixed 12/03/13 prostheses. Dent Update;2004,31:137-1241.

Tilted 2nd molar

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Over-erupted opposing molar

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3 unit FPD replacing a lower 6

1. A 3 unit FPD replacing a lower 6

Remember that I would stress-break ALL posterior bridges.

CROWN OR RE-SHAPE THE OCCLUSAL SURFACE of the over erupted opposing molar

BRIDGE CONSTRUCTED WITHOUT ATTENTION TO THE OCCLUSAL PLANE

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Level the occlusal plane

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3 unit FPD replacing a lower 6

Provide Anterior guidance

GROUP FUNCTION

1: Organise the occlusion

: Even out the occlusal plane : Remove tooth prematurities to CR : Provide anterior guidance, preferably cuspid protection

ICP

2: Fabricate the mandibular FPD

with a NRC.

RESHAPE CUSPID- CUSPID PROTECTED

3: Institute a Post-op OHI and maintenance program

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2. Mandibular FPDs The heavily tilted molar

Mandibular FPDs
1. Prepare 2 full crowns for FPD
THE TEEPEE PREPARATION.

1: Elective RCT 2: Recontour mesial lower 7 3: Methods of retention

: crown lengthening : retentive devices (grooves, boxes etc) are indispensible

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1: Possible pulp exposure 2: Poor retention 3: Difficult path of insertion

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Mandibular FPDs
2. Prepare 2 full crowns after placing a telescopic crown on lower second molar

Mandibular FPDs
3. Prepare partial crown for distal abutment
1: Poor retention 2: High failure rate

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High failure rate

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Mandibular FPDs Mandibular FPDs

4. Orthodontically upright lower 7
THE BEST APPROACH BUT we must consider:

5. Use fixed-free design (a NCR.)

1:Abutments prepared separately
thereby Maximizing retention on each preparation.

: no pulp exposure 1: Cost 2: Time

THE SECOND BEST TREATMENT APPROACH.
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2: 2 separate paths of insertion 3: NRC counteracts mandibular flexure

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Mandibular FPDs Summary

1: Occlusal Control: Reorganize occlusion to cuspid protected if possible

2: FPD

: 2 abutments only and avoid long spans. : no double abutments : full crown preparations with boxes etc. particularly in posterior bridges. : fixed at distal end : stress broken at mesial end : supra or equi-gingival abutment margins : hygienic pontic in the posterior arch : avoid non-vital teeth and pier abutments

BADLY DESIGNED HYGIENIC PONTICS

Different materials in occlusal contact.

3: Pre and post-op oral hygiene instruction

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TWO ANTERIOR THREE UNIT BRIDGES NOTE THE LENGTHENED AND RESHAPED MAXILLARY AND MANDIBULAR CUSPIDS TO CREATE CUSPID DISCLUSION.

EXTENSIVE BONE AND SOFT TISSUE LOSS.

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Implant: Single tooth in particular with virgin teeth

as potential abutments

Spring cantilever Bridge had the longest success rate

(25 + yrs) in one study but was dismissed because it belonged to another

era.

Boy, where does that put me !!!!

Maryland bridge
The days of DENTAL GLUE ??

There is absolutely reams written on these bridges in the literature

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MARYLAND BRIDGE

MARYLAND BRIDGE FAILURE

CAN PROSTHODONTICS GET ANY MORE INTERESTING THAN THIS ???

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BRIDGE FAILURES
Failure in bridgework is difficult to forecast. Different studies draw conflicting conclusions. Average lifespan of fixed restorations are anywhere between 10-21 years plus. Success probably depends on adequate diagnosis, caries control, as well as radiographic, clinical and laboratory QUALITY control procedures and oral hygiene. Bridges with 3 or more abutments have a greater chance of failure than those with only 2 abutments. Bridges with 2 or more pontics have a similar lower survival rate. (See next slide.) Ref. 1. Walton T. A survey of crown and fixed partial denture failures:length of service and reasons for replacement. J Prosthet Dent. 1986;56:416-421. 2. Scurria. Meta-analysis of fixed partial denture survival:prostheses and abutments. J Prosthet Dent. 1998;79:459464. 3. Holm C. et al. Longevity and quality of FPDs:a retrospective study of restorations 30, 20 and 10 years after insertion. Int J Prosthodont. 2003;16:283-289.
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Ref: Foster LV Relationship between failure and design in conventional bridgework. J Oral Rehabil. 1991,18:6,491-495
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Some recent findings: The overall survival estimation for Short-span FDPs was statistically MUCH better than for Long-span FDPs at year 20. The use of an RCT abutment becomes more significant in fixed prosthetic restorations with 4 or more units.
De Backer et al. Int J Prosthodont 2008;21:7585.

BRIDGE FAILURES
It must be remembered that the length of service of a fixed partial denture is not only dependent on the number of years in service, but of specific procedures and routine recall appointments that can increase the length of service of the restoration. Ref. Libby G. Longevity of fixed partial dentures. J Prosthet Dent. 1997;78,2127-31. Here are some of Libbys suggested procedures to improve the length of service of a fixed partial denture: Pretreatment periapical radiographs of all abutment teeth. Removal of all pre-existing restorations and bases, unless placed by you. Use of high content gold alloys. Shoulder preparation as finish lines. Margins placed at or coronal to the gingival crest
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There was no statistically significant difference in the long-term survival of 3-unit FDPs on vital abutments versus those with at least 1 RCT abutment. For FDPs with more than 3 units and Cantilevered-FDPs, the use of a post-and-core abutment led to significantly more failures.
De Backer et al. Int J Prosthodont 2007;20:229234

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Bridge failures
Metal cervical collars on preparations if possible. Metal occlusal surfaces Post cementation radiograph. Dental hygiene follow-ups. Avoid root filled teeth and pier abutments. Avoid anterior bridges in general except the six unit anterior bridge off two suitable canines,

Non-Metallic or All-Ceramic Bridges

During the past 3 decades, dentists have been placing non-metallic bridges made of all ceramic materials (They have been constructed of many different types of materials, including: feldspathic porcelain, leucite-reinforced glass ceramic, aluminum oxide, lithium disilicate, and, most recently, zirconium oxide. The feldspathic bridges (1983) were not very strong and were prone to fracture in both the anterior and posterior regions of the mouth. It was not until pressed leucite-reinforced ceramic (1993) began to be used for anterior bridges that any degree of success was attained.
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Finally, a little data on all-ceramic non-metal bridges.

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Other stronger ceramics have been tried as frameworks, such as aluminum oxide, and a newer material called lithium disilicate (1998) (pressed or CAD/CAM), but studies have shown that these had a higher failure rate than when zirconia was used. Zirconia crowns (2003) and bridges are the newest addition to the clinicians choices for a non-metallic restoration . Sailer 2007, recently completed a study of 57 three- to five-unit posterior zirconia bridges in 45 subjects where CAD/CAM frameworks were veneered with porcelain and cemented with resin cement. At the 5-year recall, only 33 of the bridges were left and 12 of those needed to be replaced. Marginal gaps were found in almost 60% of the cases with secondary caries. Only 3% of the frameworks fractured, but 15.2% of the bridges had fracturing of the surface porcelain.
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Chipping of the veneered porcelain has been a common problem with zirconia frameworks. Swain 2009, has reported that the unstable chipping of the veneering porcelain could be caused by the difference in the thermo-elastic properties between the zirconia frameworks and the veneering material. Two-year results in an ongoing clinical study by Clinicians Report 2008, comparing PFM bridges with those made from a zirconia framework revealed "external ceramic fractures were five times more prevalent with ceramic formulations used on zirconia versus those used on metal." This study also showed that 48% of the bridges had chips, 45% had surface degradation, 7% had cracks, and 1% had delamination. Unlike PFM, there has been little research done with the zirconia/porcelain combination
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Many articles are now appearing in various journals studying all aspects of zirconia crowns and bridges, such as: bond strengths to different types of zirconia, the effect of various surface treatmentsincluding hydrochloric acidon the bond strength between the zirconia and the veneering porcelain, as well as preparation design, which has been recommended by Beyer et al. 2008, to be a shoulder. References.
1.Swain MV. Unstable cracking (chipping) of veneer porcelain on allceramic dental crowns and bridges. Acta Biomater,2009;5:1668-1677. 2.Christensen GJ. Clinicians report (on line) 2008;1(11) 3.Beyer F. et al. Effect of preparation design on the fracture resistance of zirconia crown copings. Dent Mater J 2008;27:362-367. 4.Small BW. Fixed partial dentures. Inside Dentistry,2011;7:4. 5. Sailer I. et al. Five year clinical results of zirconia framework for posterior FPDs. Int J Prosthodont.2007;20:383-388.
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AN INTERESTING BRIDGE CASE (1999) PRESENTED TO 55 POST-GRADUATE DENTISTS IN THE UK. 65% RESPONDED TO THE QUESTIONS ASKED. THE RESPONSES WERE BOTH INTERESTING AND ENLIGHTENING OR SHOULD THAT BE FRIGHTENING, PARTICULARLY FOR ME AS AN ACADEMIC.

THANK YOU SO MUCH FOR YOUR ATTENTION.

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THE FINAL BRIDGE DESIGN IS BATHED IN CONTROVERSY AS FAR AS I AM CONCERNED.

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WE WILL ONLY CONCENTRATE ON 1. 2. CHOICE OF ABUTMENT TEETH NUMBER OF PONTICS 3. TYPES OF RETAINERS 4. TYPES OF CONNECTORS 5. OPPOSING TEETH CONSIDERATIONS
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