Resin bonded bridges

Resin bonded bridge is a fixed bridge bonds to the lingual and proximal surface of the
abutments. It is considered a minimally invasive option for replacing missing teeth.

Development of resin-bonded bridge

• Bonded pontics
The earliest resin-bonded prostheses were extracted natural teeth or acrylic teeth used as
pontics that were bonded to the proximal and lingual surfaces of abutment teeth with
composite resin. The composite resin connectors were brittle and required supporting wire or a
stainless steel mesh framework. These bonded pontics were limited to short anterior spans and
had a limited lifetime, with degradation of the composite resin bond to the wire or mesh and
subsequent fracture.

• Cast perforated resin-bonded bridge

In 1973, Rochette introduced the concept of bonding metal to teeth by using flared
perforations of the metal casting to provide mechanical retention. The restorations were
bonded with a heavily filled composite resin as a luting medium.

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The perforated bridge retainers presents the following limitations:
1. Weakening of the metal retainer by the perforations
2. Exposure to wear of the resin at the perforations
3. Limited adhesion of the metal provided by the perforations

• Etched-cast resin-bonded (maryland bridge)

A technique for the electrolytic etching of cast base metal retainers was developed at the
University of Maryland.
A two-phase alloy is designed which can be deeply etched using an electrolytic cell. The main
requirements are that the phase which is to be dissolved has the more electropositive
potential, but not by so much that galvanic corrosion becomes a problem in service.

Electrochemical Etching Apparatus; consisted of a variable low voltage direct current, rheostat,
ammeter and current meter. Insulated copper wire was used as an anode to which the bridge is
attached, another insulated wire having a stainless steel rod at its tip was used as cathode and
placed 1.5 cm away from the anode. The electrolytic solution consisted of 10 % sulfuric acid
mixed in methanol in the ratio of 9:1 respectively. The surface of alloy sample that was to be
etched was carefully dipped into the solution taking care only to etch the required exposed
surface. Specimens were attached to the anode.
Etched-cast retainers have definite advantages over cast-perforated restorations:
1. Retention is improved because the resin-to-etched metal bond can be substantially
stronger than the resin-to-etched enamel.
2. The retainers can be thinner yet still resist flexing.
3. The oral surface of the cast retainers is highly polished and resists plaque accumulation.

Disadvantages of electrolytic etching:

1. The technique is time consuming
2. Extremely technique sensitive
Electrolytic etching of base metal alloys proved to be critically dependent on attention to
details in the laboratory in accordance with alloy composition. Proper etching requires
evaluation of the alloy surface with a scanning electron microscope.

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Lack of attention to detail can result in electropolishing or surface contamination. Highly
variable results have been reported from dental laboratories in which the same alloy is etched.
3. Limited to specific alloys (non-precious)
4. Bond strength severely degrade by time in a moist environment
5. Subject to failure by inadvertent contamination

These methods were followed by simplified techniques, chemical etching, or gel etching. They
all yield similar results, provided that the technique is optimized for a specific alloy.

Development of resin cements

During the course of this work, the need for a composite resin with a low film thickness for
luting the casting became apparent. This led to the first generation of resin cements, which
allowed micromechanical bonding into the undercuts in the metal casting created by etching
and simultaneously provided adequate strength and allowed complete seating of the cast
retainers. Comspan (Dentsply Caulk), the first of these cements, was moderately filled (60% by
weight) with a film thickness of approximately 20 μm. Such cements do not adhere chemically
to the metal.

Newer generations of adhesive composite resin cements are now available. Theses cements
contains adhesion promotors like 10-methacryloxydecyl dihydrogen phosphate (MDP) and 6-(4-
vinylbenzyl-n-propyl) amino-1,3,5-trizaine-2,4-dithiol) (VBATDT) have the ability to produce
chemical bonding with metals.

The favorable findings for direct adhesion to base metal have rendered alloy etching and
macroscopic retention mechanisms obsolete. This simplifies the laboratory and clinical
procedures for placement of resin-bonded FDPs. Particle abrasion have now completely
supplanted metal etching as retention mechanisms.
The combination of metal electrolytic etching, followed by application of an adhesive cement
does not improve the tensile bond to the alloy, and its strength is actually slightly lower than

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that of the bond obtained with adhesive cement to base metal alloys abraded with airborne
particles (sandblasted).

Framework design
Contemporary designs of resin-bonded bridges requires considerable tooth preparation, in an
effort to minimize failures. They do not preserve as much tooth structure as did their
predecessors; nevertheless, they are still limited to enamel and conform to conservative design
principles.
The goals of the design is:
1. Cover as much enamel surface as possible, as long as occlusion, esthetics, or periodontal
health is not compromised. This can be achieved by:
a. Creating occlusal clearance
b. Lowering the lingual and proximal height of contour.
2. Direct any loading parallel to long axis of abutments. This can be achieved by:
a. Placing occlusal rests, cingulum rests and lingual grooves.
3. Obtain vertical path of insertion (in an occluso-gingival direction). This can be achieved
by:
a. Engaging the proximal surfaces. It is accepted that 180° wraparound retainers
constitute the ideal design, but this must be balanced with the demand for
aesthetics.
b. Well-placed and precise grooves on abutment teeth.
4. Minimize inter-abutment forces.
Resin bonded bridges with multiple abutments are more likely to debond due to the
differential movement of abutment teeth, especially where occlusal contact involves the
natural tooth surface. Minimizing inter-abutment forces can be achieved by using single
abutment cantilever design.

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 Cantilevered designs have significant advantages:
a. The preparation is simplified.
b. The problems associated with the occlusion and differing mobilities of abutment teeth,
which tend to place excessive stresses on the cement and retentive features, are
avoided. Cantilevered resin-bonded FDPs work well on mobile teeth.
c. If a cantilevered resin-bonded FDP with a single abutment becomes loose, it falls out of
the mouth. The dentist can then reassess the situation in terms of occlusion, retentive
features, and cementation. A much more difficult situation is if a resin-bonded FDP
becomes loose at one end. Many patients return to the dentist only when caries are
established under the loose abutment. A cantilevered resin-bonded FDP either is
cemented or falls out. The risk to the patient of caries under a loose retainer is
eliminated.
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. If a fixed-fixed design is required, contact in excursive movements and
intercuspation should be on the retainer only.

5. Obtain a rigid framework. Any flexing of the metal bridge retainer exerts stress on the
cement lute that eventually leads to fatigue failure. Base metal alloys are highly rigid
and therefore can be used in thin section without risk of flexing, making them ideally
suited for use in RBB retainers. A 0.7 mm is the minimal dimension should be stipulated
in the technical prescription.

Abutment selection:

Abutment should have adequate bone support & coronal structure with adequate enamel for
bonding.

 If teeth are restored, fillings should be replaced with fresh composite restorations, which
will bond more favorably to the resin cement enhancing retention of the bridge.

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Preparation of the abutment teeth

Anterior teeth:

 Occlusal clearance of minimum 0.7 mm is required for the thickness of the base metal
retainer.
 Resistance to displacement in inciso-gingival direction is achieved either by cingulum rest of
lingual surface grooves.
Lingual grooves are better option in young patients where the teeth are not well
erupted yet. The grooves look like railroad tracks, and they do not need to be parallel.
However, the depth and width are critical for clinical success. They should be 0.75 mm
wide, 1 mm deep, and approximately 5 mm long. They should be started with a new
1/2 round tungsten carbide bur (0.5 mm in diameter) in a high speed handpiece, and
then the sides and base should be squared with a new small, tapered fissured (No.
168) bur. The diameter of the tip of this bur is also 0.5 mm. Always use new tungsten
carbide burs because they blunt quickly when cutting enamel.

 Resistance to lingual displacement can be achieved by extending the preparation onto both
the mesial and distal surfaces to allow for casting wraparound or by interproximal groovs.
o A groove is placed on the interproximal surface next to the pontic space. This groove
extends vertically from the gingival margin and exits on the lingual side of the incisal
edge. The groove is shaped with a No. 168 bur. The length of this groove can vary
considerably, depending on the size of the interproximal surface. The position of this
groove is usually more lingual to avoid involving or undermining the incisal enamel.
The size and shape of the grooves are critical for retention. Large grooves are less
effective. All grooves should be narrow and have flat parallel sides. They are placed
with burs of very narrow diameter.
o Additional grooves can be added preferably at the other proximal surface just lingual
to the contact area.

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Posterior teeth:
 A spoon-shaped occlusal rest seat, similar to that described for a partial removable dental
prosthesis, is placed in the proximal marginal ridge area of the abutments adjacent to the
edentulous space. An additional rest seat may be placed on the opposite side of the tooth.
The rest is an important retention feature and simultaneously provides resistance to both
occlusal and lateral force.
 Proximal and lingual axial surfaces are reduced to lower their height of contour to
approximately 1 mm from the crest of the free gingiva.
 The proximal surfaces are prepared so that parallelism results without undercuts .
 In the interproximal area, a gingival chamfer margin is not desirable; a knife-edge margin is
better for avoiding enamel penetration.
 Occlusally, the framework should be extended high on the cuspal slope, well beyond the
actual area of enamel recontouring (provided that it does not interfere with the occlusion).
 Resistance to lingual displacement is more easily managed in the posterior region of the
mouth. A single path of placement should exist. The alloy framework should be designed to
engage at least 180 degrees of tooth structure when viewed from the occlusal aspect. This
proximal wrap enables the restoration to resist lateral loading by engaging the underlying
tooth structure and is assisted in this regard by grooves in the proximal surface just lingual
to the buccal line angle. Moving a properly designed resin-bonded FDP in any direction
except parallel to its path of placement should not be possible, nor should it be possible to
displace any tooth to the buccal aspect from the framework.

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 In general, preparation differences between maxillary and mandibular molar teeth exist
only on the lingual surfaces. The lingual wall of the mandibular tooth may be prepared in a
single plane. The lingual surface of the maxillary molars requires a two-plane reduction
because of occlusal function and the curvature of these functional cusps in the occlusal two
thirds. However, the mandibular lingual retainer may be carried over the lingual cusps to
augment resistance and retention form, which is particularly helpful on short clinical crowns
of mesially and lingually inclined molars.

Despite the importance of tooth preparation to provide mechanical resistance & retention,
there are situations where RBB can be made with no preparation at all. It is not desirable to
make any irreversible damage to abutments when RBB is planned as a short-term interim
restoration (for example if it would be replaced with implant).
On the other hand, more extensive preparation can be justified when teeth are restored.
Preparation may be developed into restorations to produce longitudinal grooves, occlusal rests
and boxes on posterior teeth, and into access cavity restoration on anterior teeth. This helps to
promote axial loading and creates resistance form.

Extension of retainer wing

into existing palatal access
cavity to improve resistance
and retention form.

Impression:

Make an accurate impression. Marginal fit is as crucial for a resin-bonded restoration as for
a conventional FDP. Bond strengths are reduced with thick resin layers.
Provisional restoration:
Provide temporary occlusal stops. Significant supraocclusion of the abutment teeth can
occur rapidly, particularly in younger patients and in patients with reduced periodontal
support. This can be avoided on anterior teeth by placement of a small amount of
composite resin on the opposing mandibular teeth. This is rarely needed for posterior teeth
unless significant onlays are planned for the abutment (in which case small composite resin
stops can be bonded to the enamel. The resin is removed just before placement of the
resin-bonded FDP.

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Try in and cementation:

 Evaluate the restoration clinically; when the fit is satisfactory, characterize and glaze it. The
use of opaque resin cement is necessary to prevent metal from graying the abutment teeth.
Depending on the opacity of the resin and tooth translucency, the value of the abutment
may be increased. Evaluation for anterior teeth should involve a try-in paste for proper
characterization of the pontic. Any try-in paste remaining on the pontic will be eliminated
during the glaze firing. After this is completed, the restoration can be polished. Regular
finishing compound is suitable.
 Clean the fitting surface with a particle-abrasion unit, using aluminum oxide (50 µm at a
minimum of 0.3 MPa [40-psi] pressure); rinse thoroughly with water, and dry. If the
restoration is evaluated again, particle abrasion should be repeated just before bonding.

A Technical tip:
A locating tag or seating lug should be extended over the incisal edge of anterior teeth to
help to locate the retainer correctly and resist cervical displacement of the retainer during
cementation. It should be removed with a bur after cementation and the metal polished as
needed.

A locating tag or seating lug

should be extended over
the incisal edge

Bonding the Restoration:

As for any adhesive luting system, the manufacturer’s instructions must be closely followed to
maximize the cemented restoration’s physical properties.
1. Clean the teeth with pumice and water.
2. Isolate them with the rubber dam.
3. Etch with 37% phosphoric acid for 30 seconds. Rinse, dry thoroughly, and check for
frosted appearance on tooth structure.
4. Apply the cement (both opaque and tooth-colored if it is an anterior retainer) to the
inner surface of the casting, and completely seat the restoration. Proper seating should
be verified visually and by running an explorer over the margins.

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 5. Firm pressure should be exerted on the restoration while excess uncured resin is
removed with a brush or pledget.
6. The restoration should be held in place until the resin has polymerized. Any residual
excess can be removed with a sharp hand instrument.

Occlusion:
The occlusion is adjusted so that there is a centric stop on the pontic and no other contacts on
the pontic in all excursive movements. It is important that the pontic is not involved in guidance
during mandibular excursive movements. If this is unachievable, guidance should be shared
with other natural teeth.
Postoperative care
All resin-bonded restorations should be inspected at the regular recall examinations. Because
debonding or partial debonding can occur without complete loss of the prosthesis, visual
examination and gentle pressure with an explorer should be performed to confirm such a
complication. Because debonding is most commonly associated with biting or chewing hard
food, patients should be warned about this danger. If the patient perceives any changes in the
restoration, he or she should seek early attention. Early diagnosis and treatment of a partially
debonded FDP can prevent significant caries. The restoration can usually be rebonded
successfully. The bonding surface should be cleaned with airborne particle abrasion and the
enamel surface refreshed by careful removal of the remaining resin with rotary instruments,
followed by etching. If a prosthesis debonds more than once, reevaluating the preparation and
remaking the prosthesis are probably necessary. Attention to periodontal health is crucial
because this retainer design has the potential to accumulate excess plaque as a result of lingual
overcontouring and the gingival extent of the margins. The patient should be taught
appropriate plaque-control measures. Calculus removal is recommended with hand
instruments over ultrasonic scalers to reduce the risk of debonding.
Aesthetic aspect
Metal connectors may shine-through translucent incisors causing them to appear grey. It was
reported that the metal of the retainer was the most common reason for patient dissatisfaction
with their RBB.
Greying can be reduced by:
o The use of opaque cement
o Ending the metal retainer 2 mm away from the incisal edge, where the enamel becomes
relatively more translucent.
o The use of ceramic retainers;
High-strength ceramics, particularly zirconia, have been used as retainers for resin-bonded
FDPs. These restorations exhibit better esthetics than do metal retainers, which can

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 discolor, particularly with thin abutment teeth. Good medium-term clinical performance
has been demonstrated.
Advantages of resin-bonded bridge:
 Minimal removal of tooth structure
 Minimal potential for pulpal trauma
 Anesthesia not usually required
 Supragingival preparation
 Easy impression making
 Interim restoration not usually required
 Reduced chair time
 Reduced patient expense
 Rebonding possible

Disadvantages of resin-bonded bridge:

 Reduced restoration longevity
 Enamel modifications: required
 Space correction: difficult
 Good alignment of abutment teeth: required
 Esthetics compromised on posterior teeth

Indications of resin-bonded bridge:

 Replacement of missing anterior teeth in children and adolescents
 Short edentulous span
 Unrestored abutments
 Single posterior tooth replacement
o Specific requirements:
 Significant clinical crown length
 Sufficient enamel to be etched for retention
 Excellent moisture control

Contraindications of resin-bonded bridge:

 Parafunctional habits
 Long edentulous span
 Restored or damaged abutments
 Compromised enamel
 Significant pontic width discrepancy
 Deep vertical overlap
 Nickel allergy

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