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Resin Bonded Bridges: Techniques For Success: K. A. Durey, P. J. Nixon, S. Robinson and M. F. W.-Y. Chan
Resin Bonded Bridges: Techniques For Success: K. A. Durey, P. J. Nixon, S. Robinson and M. F. W.-Y. Chan
PRACTICE
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% success 6 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
Specialist Registrar in Restorative Dentistry, 2,4Con-
1*
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
iii) Aesthetics
The aesthetics of a RBB are determined by
the retainer wing, the porcelain work and
a b
how the soft tissues are managed. Metal
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 com-
mon 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.
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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