Precise Placement of Single-Retainer Resin-Bonded Fixed

Dental Prostheses with an Innovative Splint Design

Michael Stimmelmayr, Priv. Doz. Dr. med. dent.,1,2 Martin Stangl, Dr. med dent,1
Judith Kremzow-Stangl, Dr. med dent,1 Gerald Krennmair, Prof. Dr. med dent.,3 Florian Beuer, Prof. Dr.
med. dent.,4 Daniel Edelhoff, Prof. Dr. med. dent.,3 & Jan-Frederik Güth, Priv. Doz. Dr. med. dent.2
1
Private Practice for Oral Surgery, Cham, Germany
2
Department of Prosthodontics, University of Munich, Germany
3
University of Vienna, Dental School, Wien, Austria
4
Department of Prosthodontics and Gerontostomtology, University of Berlin, Germany

The article is associated with the American College of Prosthodontists’ journal-based continuing education program. It is accompanied
by an online continuing education activity worth 1 credit. Please visit www.wileyhealthlearning.com/jopr to complete the activity and
earn credit.

Keywords
Insertion splint; resin-bonded fixed dental
prostheses; single-retainer fixed dental
prostheses.
Correspondence
Michael Stimmelmayr, Priv. Doz. Dr. med
dent, Josef-Heilingbrunnerstr.2, 93413 Cham,
Germany.
E-mail: michael.stimmelmayr@med.uni-
muenchen.de.
The authors deny any conflicts of interest.
Abstract
Single-retainer resin-bonded fixed dental prostheses (RBFDPs) are difficult to position
due to the pressure of soft tissue at the pontic area and the single-retainer design. This
clinical report describes an innovative technique for the insertion of single-retainer
RBFDPs. An incisal inserting splint is used to position the RBFDPs reliably. With the
help of grooves in the buccal and incisal area of the splint, the precise positioning of
the splint on the adjacent teeth and the RBFDP can be controlled. Also, a hole in the
retainer wing region of the splint gives access for pressure application on the wing
during the bonding process. With the aid of this method, 25 single-retainer FBFDPs
were inserted in the correct position in a case series. The splint described here allows
the precise insertion of single-retainer RBFDPs and simplifies delivery.

Accepted August 23, 2016

doi: 10.1111/jopr.12562

Replacing a missing single incisor is an esthetic challenge for
the restorative team of the dental laboratory technician and clin-
ician. Initially, different treatment options, such as a removable
prosthesis, a fixed dental prosthesis (FDP), or an implant re-
construction need to be considered, and a decision needs to be
reached. When no surgery is possible, and adjacent teeth are
free of caries and fillings, resin-bonded FDPs (RBFDPs) rep-
resent a minimally invasive treatment alternative in the esthetic
zone. Often, patients also prefer conservative and less invasive
procedures.1-3
Metal-ceramic RBFDPs using metal frameworks with two
palatal metal wings for retention have unfavorable effects on
the translucency and color of the abutment teeth. Furthermore,
the classic two-retainer design sometimes shows complications
by a debonding of one of the retainer wings. While the restora-
tion is still in place, caries develop under the debonded wing.
After converting to a single-retainer design by cutting off the
debonded retainer wing, some of these RBFDPs remain suc-
cessful in function. All-ceramic RBFDPs with two wings some-
times show fractures within the proximal connector of one re-
tainer and the pontic. To keep the restorations in function, the
same procedure as described for the metal-ceramic restorations
is followed. Clinically, single-retainer all-ceramic RBFDPs
made from glass-infiltrated alumina ceramic show even higher
survival rates than the classic two-retainer RBFDPs made from
alumina ceramic. Recently published 10-year RBFDP survival
data show that the single-retainer resin-bonded FDP with a
94% survival rate outmatch the two-retainer resin-bonded FDP
with a survival rate of 67%.4,5 One reason might be a higher
torsional load for the two-retainer RBFDPs. Today, in the an-
terior region, single-retainer all-ceramic RBFDPs represent the
state-of-the-art in resin-bonded prosthodontics.3,5,6
For the retainer wing, an enamel-bordered lingual veneer-
preparation with a fine cervical chamfer, a fine incisal finish-
ing shoulder, a groove on the cingulum, and a small proximal
box preparation on the pontic side (approximately 2 mm ×
2 mm × 0.5 mm) is suggested.4,6,7 All sharp edges should be
smoothed. Air-abrasion at a moderate pressure (ࣘ1 bar) and

Journal of Prosthodontics 26 (2017) 359–363 

C 2016 by the American College of Prosthodontists 359
Placement of RBFDPs
the use of phosphate monomer containing primers and/or lut-
ing resins feature long-term durable bonding to glass-infiltrated
alumina and zirconia ceramic under oral conditions.7-9 For the
framework, zirconia seems to be the most suitable material. The
minimum thickness of the retainer wing has been described as
between 0.5 and 0.7 mm.5
During the insertion of RBFDPs, the precise positioning is
limited by displacement of the pontic because of the pressure of
the soft tissue at the pontic area. To fulfill esthetic requirements,
the pontic should be designed as an ovate pontic design. To
guarantee adequate oral hygiene, an oval configuration for the
pontic is also suggested. This requires a certain kind of pressure
on the RBFDPs during insertion. Another problem is the use of a
rubber dam, which also complicates the insertion by additional
coating of the gingiva at the pontic area.
Case description and results
A female patient, aged 17 years, presented with aplasia of the
upper right and left maxillary lateral incisors (Fig 1). After
completion of orthodontic treatment to open both gaps, the
patient was referred for prosthetic replacement of teeth 12 and
22 (FDI tooth numbering system) with RBFDPs as a long-term
interim solution.
Dental and periodontal statuses, as well as the occlusal rela-
tionship, were checked. The patient had a class I occlusion
in centric relation by missing occlusal contact of both ca-
nines, showing no temporomandibular joint problems. Gen-
erally, single-retainer RBFDPs for the replacement of lateral
incisors can be supported either on the central incisor or on
the canine. As there was no static occlusal contact on both ca-
nines and strong contacts on the maxillary central incisors, the
retainer wings were placed on the canines to keep the prepara-
tion minimally invasive. In addition, a canine guidance could
be established. Actually, central incisors are recommended for
bonding the retainers, because the anatomic shape of central
incisors allows a greater vertical connecter zone and a larger
surface for retainer wing formation. There is also an esthetic
reason because the palatal tooth surface of the central incisor,
and consequently, the retainer wing, is less visual compared
with the palatal surface of a maxillary canine.5 The height of
the interdental connector must be as large as possible.10
The retainer wing preparation consisted of a light palatinal
cove preparation 1 mm supragingival, a small proximal box
preparation (2×2×0.5 mm3 ) proximal to the pontic side, in-
cluding a distal parallel pin ledge preparation and a palatal
veneer preparation with a fine incisal finishing shoulder. All
sharp edges were smoothed. An impression was taken using
regular-body polyether impression material (Impregum; 3M
ESPE, Seefeld, Germany) and sent to the laboratory.
The zirconia frameworks were designed and milled out of
pre-sintered zirconia blocks (Kuraray Noritake Dental Inc.,
Tokyo, Japan) using a computer aided design (CAD)/computer
aided manufacturing (CAM) system (exocad, Darmstadt,
Germany and Dental Concept; Zubler, Ulm, Germany). After
sintering in a special furnace (Austromat 624; Dekema,
Freilassing, Germany), a glass matrix was fired at 1000°C on
the bonding areas of the retainer wings (vitreous application) to
facilitate future adhesive insertion (DCM hotbond zirconnect;
360 Journal of Prosthodontics 26 (2017) 359–363 
Stimmelmayr et al
Dental Balance GmbH, Potsdam, Germany). The thickness
of the glass phase was approximately 12 µm according to
the manufacturer.11 Then, the frameworks were veneered
at 910°C with veneering porcelain (Creation ZI-CT; Willi
Geller Creation, Breckerfeld, Germany). On the plaster master
cast, the pontic areas were slightly reduced to create an oval
configuration of the pontics. After finishing, an incisal inserting
splint was fabricated on the master cast by using a flowable
light-curing composite resin (Ceramill Gel; Amann Girbach
GmbH, Pforzheim, Germany). First, the cast was hardened
(Gradia Die Hardener; GC, Leuven, Belgium) and separated
(Gradia Die Separater; GC). The flowable resin was applied in
three steps to the mesial adjacent tooth, the FDP, and the distal
adjacent tooth. These three parts were connected to one splint
to reduce the overall shrinkage of the resin. Finally, the splints
were trimmed, and the grooves were drilled.
To insert the RBFDPs in an accurate position, it is necessary
that the FDPs fit exactly in the splint and the splint on the
adjacent teeth. Also, this fit must be controllable during the
luting process. Therefore, buccal, incisal, or palatal grooves
were made in the splint in the area of the adjacent teeth and
sometimes in the area of the pontics of the RBFDPs to control
the precise positioning of the splint. No visible space should
occur between the splint and the teeth on the incisal, buccal, and
palatal surfaces. To get access for pressure application on the
retainer wings during insertion (for example, with a flat packer)
a palatal hole in both canine regions was created (Fig 2).
Retraction cords were placed in the area of the preparation
boundaries, a rubber dam was placed from teeth 14 to 24, and
the fit of the RBFDPs and the splint was tested (Fig 3). The
restorations were cleaned with 97% isopropyl alcohol. Due to
the vitrification, no air abrasion with alumina particles was nec-
essary before the luting process. Instead, the bonding areas of
the retainers were etched with 5% hydrofluoric acid (IPS ce-
ramic etching gel; Ivoclar Vivadent, Schaan, Liechtenstein) for
40 seconds, rinsed with water spray, and air dried. To protect the
surface of the pontic and the proximal veneering ceramic from
the acid, those areas were previously covered with an adhesive
tape. Then, an adhesive (Monobond Plus; Ivoclar Vivadent)
was applied for 60 seconds on the bonding surfaces of the re-
tainer wings, air dried, and placed in the splint. The abutment
teeth were cleaned with pumice, subsequently sprayed with wa-
ter, and air dried. The enamel was etched with 37% phosphoric
acid (Total Etch; Ivoclar Vivadent) for 40 seconds, cleaned with
water spray, and then air dried. The splint was separated with
insulating varnish (Microfilm; Kerr Corp. Orange, CA), and the
RBFDP placed in the splint. The luting resin (Variolink II dual
curing; Ivoclar Vivadent) was applied on the retainer wing of
the RBFDP, already fixed in the splint. Following the insertion,
the splint with the RBFDP was placed on the adjacent teeth,
and the fit of the splint was controlled by the grooves. During
insertion of the restorations, pressure was applied from the in-
cisal and palatal direction on the splint. Additionally, the hole
in the splint enabled extra pressure on the retainer wing using a
flat packer (Fig 4). After excess resin was removed from the ac-
cessible areas with a small brush, an oxygen barrier gel (Liquid
Strip; Ivoclar Vivadent) was applied onto the margins and the
resin light cured for 40 seconds from the buccal, incisal, and
palatal side (Bluephase 20i; Ivoclar Vivadent). Subsequently,
C 2016 by the American College of Prosthodontists
Stimmelmayr et al
Figure 1 Missing lateral incisors in a 17-year-old female patient after
orthodontic treatment.
Figure 2 Insertion splints with bucco-incisal grooves and holes in the
wing areas.
Figure 3 Try-in of the RBFDPs after rubber dam placement.
Journal of Prosthodontics 26 (2017) 359–363 
C 2016 by the American College of Prosthodontists
Placement of RBFDPs
Figure 4 Deliveries of the RBFDPs.
Figure 5 Final esthetic results with two RBFDPS for replacement of
teeth 12 and 22—buccal view.
Figure 6 Final esthetic results with two RBFDPS for replacement of
teeth 12 and 22—occlusal view.
the splint was removed, an oxygen barrier gel was again applied
on all margins, and light cured again for 40 seconds from the
buccal, incisal, and palatal side. After complete polymeriza-
tion, the excess composite resin was removed, occlusion was
controlled, and the patient received oral hygiene instructions
(Figs 5 and 6).
To provide protection for the restoration and to avoid rotation
of anchor teeth, a maxillary night guard with front and canine
tooth guidance was produced and delivered. The patient was
advised to use it during the night.
361
Placement of RBFDPs
Discussion
Particularly in young patients with large pulp chambers, a full-
crown preparation or preparation for complete veneer retainers
can lead to loss of tooth vitality. Therefore, a minimal prepa-
ration should be chosen as an alternative for younger patients.
In addition, the use of conventional FDPs and splinting teeth
should be avoided as long as growth is not completed.1,2 By
splinting of teeth with FDPs during vertical growth of the jaw,
normal tooth eruption can be disturbed, which can result in
infraocclusion.
Clinical long-term studies on bonded zirconia restorations
are scarce. Data from 2014 showed that air abrasion at a
moderate pressure and phosphate monomer containing primers
and/or luting resins provide long-term durable bonding to
zirconia and glass-infiltrated alumina ceramic under oral
conditions.9 An older clinical study evaluated clinical factors
affecting adhesive FDPs with metal frameworks (Co-Cr alloy)
over 6 years. The metal-to-cement interface was the most vul-
nerable clinical area, irrespective of the location of the bonded
FDPs (anterior or posterior quadrant). Tooth preparations that
included parallel channels and grooves had a substantially re-
duced risk of failure, while the method of retainer conditioning
(air-abrasion/acid etching/silane-coating) was not clinically
relevant to the success rate of retentively (tooth) prepared
adhesive FDPs.12 In a published laboratory study on adhesion
of zirconia, vitreous application and etching with hydrofluoric
acid presented increased surface roughness and showed the
highest bond strength results. The results also confirmed
that the approach of coating the surface-conditioned zirconia
ceramic with a vitreous material increased the initial shear
bond strength to resin cement.13 In another study, the treatment
of zirconia surfaces with a layer of low-fusing porcelain
significantly increased the bond strength of a dual-cure luting
agent to the ceramic surface. In combination with hydrofluoric
acid, they showed bond strength values statistically superior to
those of groups that used conventional air abrasion with 50 or
110 µm aluminum oxide. It was also shown that the use of a
silane-coupling agent does not influence the bond strength of
resin to zirconia-based ceramics.14 When zirconia is bonded to
dentin, the weakest interface is between the resin cement and
dentin. The resin cement/zirconia ceramic interface was less
susceptible to failures, owing to the zirconia ceramic surface
treatments.15 An analysis showed that bond strengths of the
luting cement tested on the dental ceramics following surface
conditioning methods varied according to ceramic type.
Hydrofluoric acid gel was effective mostly on the ceramics
that had a glassy matrix in their structures. Roughening the
ceramic surfaces with air-particle abrasion provided higher
bond strengths for high-alumina ceramics, and the values
increased significantly after silica coating/silanization.16
Bonding procedures for RBFDPs are highly technically
sensitive and represent a challenge for practitioners. In the
literature, the use of a rubber dam is always recommended.7
The use of rubber dam for delivery of RBFDPs is not easily
possible in every case. It depends on the scallop of the gingiva
and the design and pressure of the pontic to the gingiva.
Therefore, a try-in of the RBFDP has to be done before and
after placement of the rubber dam. If the RBFDP cannot placed
362 Journal of Prosthodontics 26 (2017) 359–363 
Stimmelmayr et al
properly with rubber dam because of the interference of the
gingiva, the rubber dam has to be cut out in the pontic area and
fixed at the palate and in the vestibule with sutures or glue (e.g.,
Histoacryl). Alternatively the rubber dam could be removed,
and the delivery could be done under relative drainage.
Some recently published data concerning the influence of the
operatory field isolation technique on direct dental restorations
showed that the use of a rubber dam did not influence the
longevity of restorations.17-19 With the classic two-retainer
design, the use of a rubber dam during the insertion of RBFDPs
does not pose a limitation, because the insertion axis with two
abutment teeth can be clearly found; therefore, an inserting
splint is not necessary. The handling of restorations with a
single-retainer design is completely different. Locating the
insertion axis is hindered by displacement of the soft tissue at
the pontic area. The use of a rubber dam also complicates the
insertion by covering the gingiva in this region. In this case, it
can be helpful to use an incisal inserting splint to find the correct
position of the RBFDP. The idea of using an incisal splint for
correct positioning of the RBFDP was already mentioned in
a previous article by Sasse and Kern.5 However, the described
splint had neither grooves to control precise positioning nor an
access for pressure application on the retainer wing.
To stabilize the RBFDP in the splint, proper fixation must be
achieved. Hence, the insertion splint covers the retainer wing
nearly completely, which complicates the excess removal of
the luting cement. Because of the laminary palatal and incisal
coverage, the overflow of the resin takes place in the palatal
cervical and buccal connecting area. At those accessible areas,
the excess resin can be removed with a small brush. The residual
excess resin has to be removed after complete polymerization
and removal of the splint. This can take some more time and
effort; however, the perfect fit of the RBFDP is more decisive.
To obtain greater access to the margins, the splint had to cover
the FDPs only partially. This would be an advantage for the
removal of the resin, but could lead to an imperfect delivery of
the RBFDP.
On the one hand, splint fabrication takes some time in the
dental laboratory and incurs additional costs. On the other hand,
it facilitates the luting procedure. If the delivery of the RBFDP
fails because of displacement of the restoration, it would be
much more time-consuming and costly to recement, or even
renew, the RBFDP compared with the fabrication of an inserting
splint in the dental laboratory.
Conclusions
An incisal inserting splint with grooves on the bucco-incisal
side and a hole on the palatal side of the retainer wing for
pressure application is a very helpful instrument for inserting
single-retainer RBFDPs. For practitioners, it is a considerable
facilitator during insertion.
Acknowledgment
We thank Michael Zangl, C.D.T., for designing and fabricating
the splints and the RBFDPs.
C 2016 by the American College of Prosthodontists
Stimmelmayr et al
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