e52 C HA P T E R 1 6 Rein-Bonded Splint and Bridge

16
Resin-Bonded Splints and Bridges
HARALD O. HEYMANN, ANDRÉ V. RITTER

M
obility of teeth has many causes, including traumatic With a coarse, lame-shaped diamond instrument, enamel on
injury to the face, advanced periodontal disease, habits both teeth at the proximal contact area is reduced to produce an
such as thumb sucking and tongue thrusting, and maloc- interdental space approximately 0.5 mm wide. his amount of
clusion. In addition, teeth often need stabilization and retention space enhances the strength of the splint by providing more bulk of
after orthodontic treatment. In the past, clinical procedures for composite material in the connector between teeth. Other enamel
the stabilization of teeth either involved extensive loss of the tooth areas of the tooth or teeth that need more contour are prepared by
structure or were poor in appearance. A conservative and esthetic roughening the surface with a coarse diamond instrument. Where
alternative has been made possible by using resin-bonded splints. no enamel is present, such as on the root surface, a mechanical
Certain criteria must be met when mobile teeth are splinted. lock is prepared with a No. 1 4 round bur in the dentin at the
Occlusal adjustment may be necessary initially. he splint should gingivoaxial line angle of the preparation. After the prepared
have a hygienic design so that the patient is able to maintain good tooth surfaces are acid etched, rinsed, and dried, a lightly frosted
oral hygiene. It also should allow further diagnostic procedures appearance should be observed on the etched enamel surfaces (see
and treatment, if necessary. he resin-bonded splinting technique Fig. 16.1B).
satisies these criteria. Light-cured composites are recommended he adhesive is applied, lightly blown with air, and polymerized.
for splinting because they aford extended working time for place- A hand instrument is used to place a small amount of composite
ment and contouring. material in the gingival area. Additional shaping with a No. 2
explorer reduces the amount of inishing necessary later. It is helpful
to add and cure composite in small increments, building from the
Periodontally Involved Teeth gingival aspect toward the incisal aspect. Finishing is accomplished
Loss of bone support allows movement of teeth, resulting in with round and lame-shaped carbide burs, ine diamonds, and
increased irritation to the supporting tissues and possible malpo- polishing disks and points. he retraction cord is removed and
sitioning of teeth. Stabilizing mobile teeth is a valuable treatment the occlusion is evaluated to assess centric contacts and functional
aid before, during, and after periodontal therapy. Splinting of teeth movements. Instructions on brushing and lossing are reviewed
aids in occlusal adjustment and tissue healing, thus allowing better with the patient. he result at 4 years is shown in Fig. 16.1C.
evaluation of the progression and prognosis of treatment. Splinting also can be used when the mandibular incisors are
A resin-bonded splint via the acid-etch technique is a conservative mobile because of severe bone loss. he same general steps are
and efective method of protecting teeth from further injury by followed as described earlier. If further reinforcement is deemed
stabilizing them in a favorable occlusal relationship. If the peri- necessary, however, a plasma-coated woven polyethylene strip such
odontal problem is complicated by missing teeth, a bridge as Ribbond (Ribbond Inc., Seattle, WA) can be used to strengthen
incorporating a splint design is indicated (see section Conservative the splint. Additionally, the use of lowable composites greatly
Bridges). facilitates the placement of interproximal composite connectors.
Fig. 16.2 illustrates a typical case. Following isolation with a
Techniques for Splinting Anterior Teeth rubber dam, small spaces (approximately 0.5 mm in width) are
In short-span segments subject to minimal occlusal forces, a relatively created between teeth with a lame-shaped diamond instrument
simple technique can be used for splinting periodontally involved to enable cross-sectionally strong composite connectors (see
teeth. Fig. 16.1A illustrates a maxillary lateral incisor that remains Fig. 16.2A–C).
mobile because of insuicient bone support even after occlusal Because a iber-reinforcing material will be used, the lingual
adjustment and elimination of a periodontal pocket. Esthetic surfaces to be bonded also should be lightly roughened with an
recontouring with composite augmentation can be accomplished oval diamond to enhance the resin bonds. All interproximal and
along with the splinting procedure. lingual surfaces to be bonded are etched for 15 seconds with a
Anesthesia generally is not required for a splinting procedure phosphoric acid-etching gel (see Fig. 16.2D), followed by thorough
when enamel covers the clinical crown. When root surfaces are rinsing and drying. Round wooden wedges can be used to stabilize
exposed and extreme sensitivity exists, however, local anesthesia is the mobile teeth and to help maintain an open gingival embrasure
necessary. Teeth are cleaned with a pumice slurry, and the shade form. To prevent any resin from sticking to the wooden wedges,
of light-cured composite is selected. A cotton roll and retraction a light coat of petroleum jelly can be placed on the wedges prior
cords are used for isolation in this instance. to positioning the wedges interproximally. Bonding agent is applied

e52
 CHAPTER 16 Rein-Bonded Splint and Bridge e53

A B C

• Fig. 16.1 Splinting and recontouring a mobile tooth using a light-cured composite. A, Maxillary right
lateral incisor is mobile from lack of bone support. B, Preparations completed and etched. C, Splinted
and recontoured tooth after 4 years.

A B

C D

E F

• Fig. 16.2 Splinting of mobile mandibular incisors reinforced with a plasma-coated, polyethylene-woven
strip (Ribbond; Ribbond Inc.). A and B, Facial and lingual preoperative views of mobile mandibular incisors
that need splinting. C, Preparation consists of roughening proximal surfaces and creating slight interdental
spaces to provide bulk to the connector areas of the composite splint. D, All interproximal and lingual
surfaces to be bonded are etched with a phosphoric acid gel. E, Teeth are stabilized with wooden wedges,
and a bonding agent is applied. F, Interproximal composite connectors are generated by injecting lowable
composite.
e54 C HA P T E R 1 6 Rein-Bonded Splint and Bridge

G H

I J
• Fig. 16.2, cont’d G, A iber-reinforcing strip is pressed into the uncured composite on lingual with
a gloved inger. H, The bonded strip is covered incrementally with lowable composite. I and J, Completed
iber-reinforced composite-bonded periodontal splint seen from facial and lingual views.

and cured to all etched surfaces (see Fig. 16.2E). he interproximal movement; however, stabilization of teeth is required, and the
composite connectors are then generated by injecting lowable unattractive spaces caused by undersized maxillary teeth need to
composite into these areas and shaped (if needed) with a No. 2 be closed (see Fig. 16.3B). A carefully planned appointment is
explorer (see Fig. 16.2F). A small amount of lowable composite required to accomplish the following: (1) Remove any fixed
is placed onto the lingual surfaces (but not cured) to receive the orthodontic appliance, (2) add composite to close the diastemas,
auxiliary splinting strip. An appropriate length of splinting material and (3) stabilize teeth with a twisted stainless steel wire and
(polyethylene-coated woven fabric) is cut and irst saturated with composite.
bonding agent. hen, by using a gloved inger, the strip is pressed
into uncured composite and cured initially into place (see Fig. Technique
16.2G). he bonded strip is then covered incrementally with After the orthodontic appliance is removed and routine procedures
lowable composite, resulting in a smooth lingual surface (see Fig. are followed for closing the diastemas (see Fig. 16.3C), the occlusion
16.2H). Facial and incisal embrasures are deined with inishing is examined carefully to determine the best position for locating
burs to enhance esthetics. After inishing procedures, the rubber the twisted wire because it will be placed only on the lingual
dam is removed and the occlusion is evaluated. he inal result is surfaces. A suicient length of twisted stainless steel wire (i.e.,
seen in Fig. 16.2I and J. 0.45 mm [0.0175 inch] in diameter) is adapted to the lingual
surface of anterior teeth. A stone cast is helpful for adapting the
Stabilization of Teeth After wire. he wire must rest against the lingual surfaces passively without
tension or interference with the occlusion. In the mouth, waxed
Orthodontic Treatment dental tape is used to position the wire against teeth and hold it
After orthodontic treatment, teeth may require stabilization with in place while the occlusal excursions are evaluated. he wire is
either ixed or removable appliances. he latter method allows attached only to the lingual fossa of each tooth. After the position
continued minor movements for the inal positioning of teeth. of the wire has been determined, it is removed and only the enamel
When this position is reached, it is better to stabilize teeth with in the fossae (not the marginal ridges or embrasures) is etched,
a ixed retainer. Removable retainers tend to irritate soft tissue. rinsed, and dried.
Also, they may be damaged, lost, or not worn, which usually leads Light-cured composite is best used for attaching the ixed wire
to undesired movement of teeth. splint. he wire is repositioned and held in place with dental tape,
Fig. 16.3A shows a patient with a removable orthodontic retainer. while a sparing amount of resin-bonding agent is applied and
Optimal positioning of teeth has been achieved by orthodontic lightly blown with air. After polymerization of the adhesive, a
 CHAPTER 16 Rein-Bonded Splint and Bridge e55

A B

C D

• Fig. 16.3 Stabilizing teeth after orthodontic treatment. A, Patient with existing removable retainer.
B, Residual spaces resulting from undersized teeth. C, Closure of spaces with composite additions is
completed. D, Orthodontic wire is held in position with dental tape and bonded into place with
composite.

A B

• Fig. 16.4 Splinting avulsed teeth. A, Patient with traumatically avulsed maxillary right incisors.
B, Completed splint stabilizes repositioned incisors.

small amount of composite material is placed to encompass the referral to an oral surgeon may be necessary. A partially avulsed
wire in each fossa and bond it to the enamel. he operator must tooth is repositioned digitally and may or may not need splinting.
be careful not to involve the proximal surfaces (see Fig. 16.3D). Traumatically avulsed teeth that are reimplanted immediately or
After polymerization of composite, the occlusion is evaluated and within 30 minutes have a good prognosis for being retained.1,2
adjusted, as needed, for proper centric contacts and functional After 30 minutes, the success rate declines rapidly. he avulsed
movements. tooth should be repositioned as soon as possible. In the interim,
his unique splint allows some physiologic movement of teeth, it should be placed in a moist environment such as saliva (i.e.,
yet it holds them in the correct position. he splint should remain held in the cheek or under the tongue), tooth-saver solution (i.e.,
in place for at least 6 months to ensure stabilization. Longer Hank balanced solution), milk, saline, or a wet towel. he replace-
retention may be necessary, depending on the individual situation ment of avulsed teeth has immediate psychologic value and
and recommendations of the orthodontist. maintains the natural space in the event that a ixed prosthesis is
required later.
Avuled or Partially Avuled Teeth Technique
Facial injuries often involve the hard and soft tissues of the mouth. he maxillary right incisors that were completely avulsed in an
he damage may range from lacerations of soft tissue to fractures accident (Fig. 16.4A) are repositioned immediately. After the teeth
of teeth and alveolar bone. Partial or complete avulsion of teeth are repositioned, radiographs reveal that no other complications
can occur. Maxillary central incisors are involved more often than exist. Isolation with cotton rolls or gauze is preferable to the use
are other teeth. A thorough clinical examination of soft tissue, of a rubber dam, which could cause malpositioning of the loose
lips, tongue, and cheeks should be made to locate lacerations and teeth. he occlusion should be evaluated to ensure that the teeth
embedded tooth fragments and debris. Radiographic examination are properly positioned.
is necessary to diagnose deeply embedded fragments or root he facial surfaces of the crowns are quickly cleaned with
fractures. hydrogen peroxide, rinsed, and dried by blotting with a gauze or
Treatment of soft tissue lacerations should include lavage, cotton roll or by lightly blowing with air. he dentist should avoid
conservative debridement, and suturing. Consultation with or blowing air into areas of avulsion or deep wounds to prevent air
e56 C HA P T E R 1 6 Rein-Bonded Splint and Bridge

emboli. If a crown is fractured, deeply exposed dentin may need Conservative bridges are especially indicated for young patients
to be protected with a liner or base material. A twisted orthodontic because the teeth usually have large pulp chambers and short
wire (0.49 mm [0.0195 inch]) must be long enough to cover the clinical crowns. Many older patients with gingival recession and
facial (or lingual) surfaces of enough teeth to stabilize the loose mobile teeth are prime candidates because splinting can be incor-
teeth. he wire is adapted and the ends rounded to prevent irritation porated with the bridge. More speciic indications and clinical
to soft tissue. In an emergency, a disinfected paper clip can be procedures for each of the four types of bridges are presented in
used as a temporary splint. the following sections.
No preparation of the enamel surface is necessary other than
that provided by acid etching. he middle third of the facial surfaces Natural Tooth Pontic
are etched, rinsed, and dried of all visible moisture. Drying should
be accomplished by blotting with a gauze or cotton roll and a he crowns of natural teeth (primarily incisors) often can be used
light stream of air. Self-cured or light-cured composite may be as acid-etched, resin-bonded pontics. Considerations for this type
used. he wire is positioned and held lightly in place, and the of treatment include the following: (1) Periodontally involved teeth
ends are attached with composite material (see Fig. 16.4B). Light warrant extraction, (2) teeth have fractured roots, (3) teeth are
pressure is applied to the repositioned teeth as the facial surfaces unsuccessfully reimplanted after avulsion, and (4) root canal
are bonded to the wire in succession. Care is exercised not to allow treatment has been unsuccessful. However lost, the immediate
composite to low into the proximal areas. When the teeth are replacement of a natural anterior tooth has great psychologic value
stabilized, any fractured areas can be conservatively repaired by for most patients, although the procedure may be temporary. Natural
the acid-etch, resin-bond technique. Finishing is accomplished by tooth pontics also can be placed as interim restorations until an
a lame-shaped carbide inishing bur and abrasive disks. he extraction site heals if conditions require a conventional bridge or
occlusion is evaluated carefully to ensure that no premature contacts an implant.
exist. Certain prerequisites must exist to ensure a successful result:
he patient is advised to maintain gentle care of the involved (1) he extracted tooth and abutments must be in reasonably good
teeth. Antibiotic therapy may be required if the alveolar bone is condition, especially the pontic, because it may become brittle
fractured or signiicant soft tissue damage has occurred. Tetanus and more susceptible to fracture; (2) the abutment teeth should
shots or boosters are advised, if indicated by the nature of the be fairly stable; and (3) the pontic must not participate in heavy
accident; the patient’s physician should be contacted about this. centric or functional occlusion. Because of this third restriction,
Appointments are made for follow-up examinations on a weekly canines and posterior teeth are not usually good candidates for
basis for the irst month. he patient is warned about symptoms this procedure. If the adjacent teeth are mobile, it is frequently
of pulpal necrosis and advised to call if a problem develops. If necessary to secure them by splinting with composite (see the
root canal therapy is required, it is better accomplished with the section on Techniques for Splinting Anterior Teeth).
splint in position.
Removal of the splint is accomplished in 4 to 8 weeks provided Technique
that recall visits have shown normal pulp test results and the teeth A maxillary right central incisor must be extracted for periodontal
are asymptomatic. he wire is sectioned, and the resin material is reasons (Fig. 16.5A and B). Before the tooth is extracted, a small
removed with a lame-shaped, carbide inishing bur at high speed round bur is used to place a shallow identifying mark on the facial
with air-water spray and a light, intermittent application. Abrasive surface to indicate the level of the gingival crest. If the tooth to
disks are used to polish the teeth to a high luster. be extracted is well positioned in the dental arch, a PVS bite registra-
tion or putty impression material can be used to generate an index
Conervative Bridge to reposition the natural tooth pontic in the correct preextraction
position. After extraction, a 5-cm by 5-cm (2-inch by 2-inch)
In selected cases, conservative bridges can be made by bonding a sponge is held in the space with pressure for hemorrhage control.
pontic to the adjacent natural teeth. hese conservative bridges By using a separating disk or a diamond instrument, the extracted
are classiied according to the type of pontic: (1) natural tooth tooth is transversely cut a few millimeters apical to the identiication
pontic, (2) denture tooth pontic, (3) porcelain-fused-to-metal pontic mark. When pontic length is determined, shrinkage of the healing
or all-metal pontic with metal retainers, and (4) all-porcelain pontic. tissue underlying the pontic tip must be anticipated. he root end
Although the four types difer in the degree of permanency, they is discarded.
share a major advantage—conservation of the natural tooth If the pulp canal and chamber have completely calciied, the
structure. In addition, they can be viable alternatives to conventional next procedure is shaping and polishing the apical end of the
ixed bridges in circumstances where age, expense, and clinical natural tooth pontic as described in the following paragraphs. If
impracticality are considerations. the chamber is calciied as disclosed on the radiograph and the
Because of the conservative preparation and bonded nature of canal is nearly calciied, the canal is opened from the apical end
all of these bridge types, retention is never as strong as in the case by using a small round bur or diamond to the extent of the canal.
of a conventional bridge. As part of informed consent, patients he operator should be as conservative of the tooth structure as
should be told of the risk, although remote, of swallowing or possible and yet provide access for subsequent injection of the
aspirating bonded bridges that are dislodged. To reduce the risk composite material to ill the canal. A large chamber and canal
of dislodgment, patients should be cautioned not to bite hard are instrumented and debrided using conventional endodontic
foods or objects with bonded bridge pontics. procedures with access from the apical end (see Fig. 16.5C). Access
he ideal site for a conservative bridge is where the edentulous is provided for subsequent injection of composite. Removal of the
space is no wider than one or two teeth. Other considerations pulpal tissue in this manner prevents discoloration of the tooth
include bite relation, oral hygiene, periodontal condition, and caused by degeneration products. Traditional lingual access for
extent of caries, defects, and restorations in the abutment teeth. instrumentation is avoided to prevent weakening the pontic. After
 CHAPTER 16 Rein-Bonded Splint and Bridge e57

A B C

D E F

• Fig. 16.5 Resin-bonded maxillary natural tooth pontic. A, Preoperative photograph before extraction
of periodontally involved maxillary right central incisor. B, Extraction site immediately after the removal of
an incisor. C, Enlarged apical opening ready to be illed with composite. The pontic tip has been contoured
to an ovate design. D, The abutment teeth are isolated, roughened, and acid etched. E, Immediate
postoperative photograph of natural tooth pontic bonded in place. F, Resin-bonded natural tooth pontic
with healed residual ridge 6 weeks later.

these procedures, the canal (and chamber, if present) is illed and

closed with composite.
After composite has been fully polymerized, the apical end is
contoured to produce a bullet-shaped ovate design (see Fig. 16.5C).
his design provides adaptation of the pontic tip to the residual
ridge, and yet it allows the tissue side of the pontic tip to be cleaned
with dental loss. It is also the most esthetic pontic tip design
that can be used. While being contoured, the tip is occasionally
evaluated by trying the pontic in the space. In the maxillary arch,
passive contact between the pontic tip and the healed residual ridge
is considered ideal for maximal phonetic and esthetic potential. In
the mandibular arch (where esthetics is not generally a problem),
the pontic tip is best shaped into the same bullet-shaped design
but positioned as a hygienic pontic type that does not contact A B
tissue (Fig. 16.6A). he pontic tip is smoothed and polished
using a proper sequence of abrasive disks or polishing points.
• Fig. 16.6 Pontic tip design. A, Hygienic-type pontic with ovate or
A polished pontic tip not only is easier to clean but also retains bullet-shaped tip. B, Modiied ridge lap-type pontic with slight concavity
less plaque. conforming to residual ridge.
Usually, a rubber dam is needed for isolation of the region to
prevent seepage of blood and saliva. Isolation using cotton rolls
and gingival retraction cords is acceptable if the hemorrhage has
been controlled. Any caries lesions or faulty proximal restorations Light-cured composite is preferred for bonding natural tooth
on involved proximal surfaces of the pontic and the abutments pontics because the extended working time allows the operator to
are restored with light-cured composite (preferably the same material contour the connectors before polymerization. First, the adhesive
to be used subsequently for the bridge connectors) by using modiied is applied to the etched surfaces of the pontic and lightly blown
preparation designs. It is recommended that the resulting restored with air to remove the excess. hen it is polymerized by application
surfaces be undercontoured rather than overcontoured to facilitate of light, and the pontic is set aside (ready for bonding in the
positioning of the natural tooth pontic. mouth). Next, the adhesive is applied to the etched surfaces of
Next, the involved proximal surfaces on the abutment teeth the abutment teeth and cured. A small amount of composite material
and the pontic are roughened with a coarse, lame-shaped diamond is placed on the proximal contact areas of the natural tooth pontic,
instrument. Spaces of approximately 0.5 mm should exist between and the pontic is inserted carefully in the proper position in the
the pontic and the abutment teeth because stronger connectors mouth. he composite is shaped around the contact areas with
are provided by the additional bulk of the composite material. an explorer tip. After inal veriication that the pontic position is
Now, the operator should acid-etch, rinse, and dry all the prepared correct, composite is polymerized with light. Next, additional
(i.e., roughened) surfaces (see Fig. 16.5D). composite is applied in the proximal areas (more material is added
e58 C HA P T E R 1 6 Rein-Bonded Splint and Bridge

on the lingual than on the facial surface), contoured, and cured. best accomplished with acrylic burs and a Burlew wheel in a straight
Adequate gingival embrasures must be provided to facilitate lossing handpiece. he tissue side of the pontic should be contoured to
and ensure gingival health. After suicient material has been added a modiied ridge lap coniguration that is convex mesiodistally and
and polymerized, the embrasure areas should be shaped and slightly concave faciolingually (see Fig. 16.6B). his type of design
smoothed with carbide inishing burs or ine diamonds and polishing not only allows the pontic tip to adapt to the residual ridge, but
disks or points. he rubber dam is removed, and the occlusion is it also allows for efective cleaning with dental loss. After it is
evaluated for centric contacts and functional movements. Heavy contoured, the pontic tip should be smoothed and highly polished
contacts on the pontic or the connector areas must be adjusted. with pumice and an acrylic-polishing agent (see Fig. 16.8D).
he inished bridge immediately after bonding is illustrated in Fig. Because composite does not normally bond to acrylic resin,
16.5E. he patient should return in 4 to 6 weeks for evaluation provisions must be made to facilitate a strong connection between
of the relationship of the pontic tip to the tissue. Passive contact the pontic and the adjacent teeth. One provision may be completed
should exist between the pontic tip and the underlying tissue to in the laboratory by preparing large Class III conventional prepara-
prevent ulceration. If tissue ulceration is present, the pontic must tions in the pontic that mechanically retain the composite material.
be removed, recontoured, and rebonded. he inished bridge and he outline of the preparations must be large enough to provide
healed residual ridge are shown in Fig. 16.5F. adequate surface area of the composite restoration for bonding to
As stated earlier, abutment teeth that are mobile often can be the adjacent teeth (see Fig. 16.8E–G). An appropriately sized round
splinted with composite to aford stability to periodontally involved bur (No. 2 or No. 4) is used to cut each preparation to a depth
teeth. he abutments are isolated, roughened, and acid etched of approximately 1.5 mm and extend the outline approximately
(Fig. 16.7A). Because esthetics is not as crucial, a hygienic pontic 0.5 mm past the contact areas into the gingival, incisal, and facial
tip is recommended for mandibular incisors (see Fig. 16.6A). he embrasures. Even more extension should be made into the lingual
inished bridge splint is illustrated in Fig. 16.7B. embrasure to provide for bulk of composite material in the connector
areas. he lingual extensions should not be connected because this
unnecessary step would unduly weaken the pontic. Mechanical
Denture Tooth Pontic undercuts are placed at the incisoaxial and gingivoaxial line angles
An acrylic resin denture tooth can be used as a pontic for the with a No. 1 2 bur to lock the composite material (to be inserted
replacement of missing maxillary or mandibular incisors by using later in the technique) mechanically in the acrylic resin pontic (see
the resin-bonding technique (Fig. 16.8A–H). Although this type Fig. 16.8G and H).
of bridge is sometimes used as an interim prosthesis and is called At the next appointment, the pontic is tried in place to conirm
a temporary bridge, it can be a viable alternative to a conventional that the shade and contours are correct. Approximately 0.5 mm
bridge and may last for years in some circumstances. As with the of space should exist between each proximal “contact” and the
natural tooth pontic, the major contraindications to this type of abutment tooth. he pontic is cleaned with acetone to remove
resin-bonded bridge are abutment teeth that have extensive caries, dust and debris. Retention of the pontic by undercuts, as previously
restorations, or mobility or a pontic area that is subjected to heavy described, also can be augmented by a second provision—the
occlusal forces. In the illustrated example, the permanent maxillary conditioning of the proximal aspects of the pontic with two
right lateral incisor is missing and the adjacent teeth are in favorable applications of ethyl acetate, a polymer softener. A thin layer is
condition and position (see Fig. 16.8A). Further examination reveals applied in the Class III preparations and on the cavosurface areas
an ideal situation for a conservative bridge that uses a denture and allowed to dry for 5 minutes. his process is repeated to ensure
tooth pontic. optimal bonding. he preparations are illed with the same light-
cured composite material expected to be used for bonding the
Technique pontic in place. he composite should be applied and cured in
Although the entire procedure can be completed at chairside in the retentive areas before the remainder of the preparation is illed.
one appointment, considerable time can be saved by an indirect his step ensures complete polymerization. After the entire prepara-
technique. During the irst appointment, the shade (see Fig. 16.8) tion is illed, it should be polymerized again with the light source.
and mold of the denture tooth are selected, and impressions are It is better to leave the contact areas slightly undercontoured for
made. In the laboratory, stone casts are poured, and the ridge area the pontic to it easily between the abutment teeth. he pontic is
is relieved slightly and marked with a soft lead pencil. As the pontic set aside in a safe place for some time.
is trial positioned, the pencil markings rub of onto its tip to Isolation of the abutment teeth should be accomplished with
facilitate contouring of this area (see Fig. 16.8C). Contouring is cotton rolls and retraction cords (rather than with a rubber dam)

A B

• Fig. 16.7 Resin-bonded mandibular bridge splint using natural tooth pontic. A, The anterior segment
is splinted with composite, and the abutment teeth are isolated, roughened, and etched. B, Natural tooth
pontic is bonded in place.
 CHAPTER 16 Rein-Bonded Splint and Bridge e59

A B C
a

D E F G

H I

• Fig. 16.8 Resin-bonded denture tooth pontic. A, Preoperative photograph shows a missing maxillary
lateral incisor. B, Shade and mold selection. C, Positioning pontic on working model while contouring.
D, Contoured and polished pontic (lingual view). E–G, Outline form of Class III preparations: facial (E),
lingual (F), and proximal (G) views. H, Cross section of denture tooth (longitudinal section) in plane ab as
seen in G showing the mechanical retention form incisally and gingivally as prepared with a No. 12 bur.
I, Denture tooth pontic is bonded in place with composite.

to relate the pontic better to the residual ridge area. Any caries or inishing procedures. he facial, incisal, and gingival embrasures
old restorations in the adjoining proximal areas of the abutment should be deined with a lame-shaped inishing bur or ine diamond
teeth should be removed at this time, and any indicated liners and polished with appropriate disks or points. he lingual aspect
should be applied. he proximal surfaces of the abutment teeth of the bridge is contoured with a round inishing bur without
are roughened with a coarse lame-shaped diamond instrument. deining lingual embrasures because this could weaken the con-
his step is followed by acid etching, rinsing, and drying. he nectors. he retraction cords are removed from the gingival crevice.
adhesive is applied, lightly blown with air, and cured. Tooth Articulating paper is used to mark the occlusion, and any ofensive
preparations, if present, are restored with the same composite contacts are removed. he inal restoration is shown in Fig. 16.8I.
material. Care is taken not to overcontour the restoration or
restorations. Porcelain-Fued-to-Metal Pontic or All-Metal
he pontic is evaluated by positioning it temporarily in the
edentulous space. If adjustments are made, the surfaces should be Pontic With Metal Retainer
cleaned with acetone. Next, a small amount of composite is wiped A stronger and more permanent type of acid-etched, resin-bonded
onto the contact areas (mesial and distal) of the pontic, and the bridge is possible by use of a cast-metal framework.3,4 In anterior
pontic is placed into the proper position between the abutment areas where esthetics is a consideration, the design of the bridge
teeth. An explorer tip is helpful in placing the material evenly includes a porcelain-fused-to-metal (PFM) pontic with metal winged
around the contact area. Care must be taken to place the pontic retainers extending mesially and distally for attachment to the
so that it lightly touches the ridge, but does not cause tissue proximal and lingual surfaces of the abutment teeth. In posterior
blanching. he composite material used to position the pontic is areas where esthetics is not a critical factor, the bridge can have
polymerized. It is helpful to add and cure the additional composite either a PFM or an all-metal pontic. he technique is more
in small increments to obtain the correct contour and minimize complicated and time consuming than the previously described
e60 C HA P T E R 1 6 Rein-Bonded Splint and Bridge

methods because it requires some initial tooth preparation, an diameter of 1.5 mm on the tooth side. Each hole is countersunk
impression, laboratory procedures, and a second appointment for so that the widest diameter is toward the outside of the retainer.
etching and bonding. Compared with conventional bridges, resin- When the bridge is bonded with a resin cement, it is mechanically
bonded bridges of this type ofer ive distinct advantages: locked in place by microscopic undercuts in the etched enamel
1. Anesthesia is usually not required. and the countersunk holes in the retainer (Fig. 16.10A).
2. he tooth structure is conserved (i.e., no dentin involvement). he advantages of this design include the following:
3. Gingival tissues are not irritated because margins usually are • It is easy to see the retentive perforations in the metal.
not placed subgingivally. • If the bridge must be removed or replaced, the bonding medium
4. An esthetically pleasing result can be obtained more easily. can be cut away in the perforations to facilitate easy removal.
5. he cost is lower because less chair time is required, and labora- • No metal etching is required.
tory fees are lower as well. he disadvantages of this design include the following:
Ideally, this type of conservative bridge is used for short spans • he perforations, if improperly sized or spaced, could weaken
in the anterior or posterior areas with sound abutment teeth in the retainers.
good alignment. he most favorable occlusal relationship exists • he exposed resin cement is subject to wear.
where little or no centric contact and only light functional contact • It is not possible to place perforations in proximal or rest areas.
are present. However, teeth can be prepared and the bridge A second type of cast-metal framework, commonly known as
framework designed to withstand moderately heavy occlusal forces. the Maryland bridge, is reported to have improved bonding strength
Orthodontics may be required to improve tooth alignment. he (see Fig. 16.9B).3,5 Instead of perforations, the tooth side of the
bridge also can be extended to splint adjacent periodontally involved metal framework is electrolytically or chemically etched, which
teeth. Surgical crown-lengthening procedures sometimes are produces microscopic undercuts (see Fig. 16.9C). he bridge is
indicated for teeth with short clinical crowns. attached with a self-cured, resin-bonding medium that locks into
Although minimal, some preparation of the enamel of the the microscopic undercuts of the etched retainer and the etched
abutment teeth is mandatory in the retainer area of the bridge to enamel (see Fig. 16.10B). It can be used for anterior and posterior
(1) provide a deinite path of insertion or seating or both, (2) bridges. Although this design has been reported to be stronger, it
enhance retention and resistance forms, (3) allow for the thickness is more technique sensitive because the retainers may not be properly
of the metal retainers, and (4) provide physiologic contour to the etched or may be contaminated before cementation. Because the
inal restoration. he importance of the tooth preparation design retentive features cannot be seen with the unaided eye, the etched
cannot be overemphasized. he success of these types of bridges metal surfaces must be examined under a microscope to verify
depends on the preparation design. he bridges must be indepen- proper etching (minimum magniication).
dently retentive by design and cannot rely solely on resin bonding More recently, Maryland bridges have been fabricated with no
for retention. Preparation design for these types of bridges is similar electrolytic etching of the surface and chemically bonded to the
to that for a cast three quarter crown; however, it is restricted to tooth after a process called silicoating or with a 4-META or
enamel. phosphate ester–containing, resin-bonding medium.6,7 Resin
he preparation for each abutment varies, depending on the materials containing 4-META or other resin monomers are capable
individual tooth position and anatomy. Approximately the same of strongly bonding to metal surfaces.8,9 Surface roughening with
amount of surface area should be covered on each abutment tooth. microetching (i.e., sandblasting) is commonly used in conjunction
In some situations, recontouring of the adjacent and opposing teeth with these adhesive cements. hese types of Maryland bridges are
may be indicated. he details of the preparations are described later. referred to as adhesion bridges and difer only in the means of
Two primary types of resin-bonded bridges with metal retainers retention. he design of adhesion bridges is the same for this
currently exist: (1) Rochette and (2) Maryland.3,4 Each type has alternative Maryland bridge design. Successes and failures have
advantages and disadvantages. The Rochette type uses small been observed with both bonded bridge designs. Because the
countersunk perforations in the retainer sections for retention and procedures are technique sensitive, every step must be followed
is best suited for anterior bridges (Fig. 16.9A).4 Care must be carefully.
exercised in placing the perforations to prevent weakening the
framework. Perforations that are too large or too closely spaced Maxillary Anterior Bridge
invite failure of the metal retainer by fracture. he perforations In Fig. 16.11A, a maxillary lateral incisor is congenitally missing
should be approximately 1.5 to 2 mm apart and have a maximum and the teeth on either side are sound. he occlusion is favorable,

A B C

• Fig. 16.9 Acid-etched, resin-bonded metal bridges. A, Rochette type. B, Maryland type. C, Scanning
electron micrograph of etched metal surface. (Courtesy Dr. John Sturdevant.)
 CHAPTER 16 Rein-Bonded Splint and Bridge e61

the partial denture as a temporary prosthesis. A small amount of

self-curing acrylic resin is added to the mesial and distal portions
ae ae of the removable partial denture tooth to maintain proximal
mp
relationships.

Laboratory Phae
he impression, bite registration, patient information, and instruc-
tions are sent to the dental laboratory. A perforated retention
design (i.e., Rochette) is speciied in this instance, although the
other types could be used. he bridge is fabricated in the laboratory
(porcelain contoured but unglazed, and perforations prepared in
p
the retainers).

Try-in Stage
During the initial try-in, the bridge is examined for proper shade,
contour, tissue compatibility, marginal it, and occlusion. Adjust-
ments are made, and the bridge is returned to the laboratory for
A B corrections (if needed), glazing, and polishing of the metal
• Fig. 16.10 Cross-sectional diagram of two types of resin-bonded framework. Fig. 16.11F and G show the completed bridge from
bridges. A, In addition to acid-etching prepared enamel surfaces (ae), the facial and lingual views.
Rochette type uses small countersunk perforations (p) in the retainer
section. B, In the Maryland type, the tooth side of the framework is either Bonding Step
etched to produce microscopic pores (mp) or bonded with no etching he steps in bonding require an exacting coordination between
with an adhesive cement. the dentist and the assistant. All of the equipment and materials
needed for isolation, etching, and bonding must be kept ready at
the beginning of the appointment: prophylaxis angle handpiece,
and no periodontal problems are present (see Fig. 16.11B). he pumice slurry, self-curing resin cement kit with all accessories,
patient has been wearing a removable partial denture that is plastic hand instrument, polyester strip, and cotton rolls. Alter-
undesirable. Radiographs and study casts are made to complete natively, rubber dam isolation can be used; it is particularly recom-
the diagnosis and to facilitate preparation design. he outline of mended for the placement of posterior bonded bridges.
the proposed preparation is penciled on the cast to cover as much he abutment teeth are cleaned with pumice slurry, rinsed,
enamel surface as possible for maximal bonding area but with the dried, and isolated with cotton rolls. If the cervical area of the
following two stipulations: (1) he lingual portions are extended retainer is subgingival, the dentist inserts a retraction cord in the
neither subgingivally nor too far incisally, and (2) the proximal gingival crevice to displace the tissue and prevent seepage. he
portions are not extended facially of the contact areas but enough bridge should be carefully tried in place to review the path of
to allow preparation of retention grooves (see Fig. 16.11C and E). insertion and to verify the it. On removal, the bridge is placed
Before tooth preparation, the dentist cleans the teeth, selects in a convenient location near where the resin-bonding medium
the shade of the pontic, and marks the occlusion with articulating will be mixed.
paper to evaluate centric contacts and functional movements. If he dentist artfully applies the etching gel for 30 seconds to
adjustment or recontouring of the abutment teeth is indicated, the prepared enamel and slightly past the margins. he acid must
it should be accomplished at this time. When a base metal alloy not be allowed to low onto the unprepared proximal areas of the
rather than a high gold alloy is used for the bridge framework, abutment or adjacent teeth. After rinsing, the teeth are dried of
less tooth structure is removed because the metal retainers all visible moisture (see Fig. 16.11H). If a lightly frosted surface
can be made thinner. Base metal alloys have superior tensile is not present, the etching procedure is repeated. A clean, dry
strength. surface is absolutely essential. he slightest amount of saliva
contaminates the etched enamel and necessitates an additional 10
Preparation seconds of etching, followed by rinsing and drying. A rubber dam
Several depth cuts (0.3–0.5 mm) are made in the enamel with a is preferred for isolation; however, cotton rolls and gingival retraction
small, round, coarse diamond instrument (1–1.5 mm in diameter). cord provide adequate isolation in selected areas where salivary
he depth cuts are joined with the same instrument or a round low can be controlled.
diamond instrument (see Fig. 16.11D). A large surface area (i.e., he manufacturer’s instructions for the bonding procedure
outline form) is desirable to obtain maximum bonding and strength should be read and followed. Usually, equal parts of the resin
of the bridge. A shallow groove is cut in the enamel of each proximal cement (i.e., base and catalyst) are placed on one mixing pad, and
portion of the preparations with a small, tapered, cylindrical equal parts of the adhesive (i.e., base and catalyst) are placed on
diamond instrument to establish a path of draw in an incisal another mixing pad. he operator mixes the adhesive with a small
direction. his feature provides a deinite path of insertion and foam sponge or brush and quickly paints a thin layer on the tooth
positional stability for the prosthesis during try-in and bonding side of the bridge and then onto the etched enamel. While the
(see Fig. 16.11E). In addition, the retention of the bridge is operator uses the air syringe to blow the excess adhesive of the
improved because a shear force is required to unseat the bridge. bridge and then the enamel, the assistant mixes the resin cement
Fig. 16.1E illustrates this groove on the working cut. and places a thin layer on the tooth side of the bridge retainers.
he dentist makes an elastomeric impression of the completed he bridge is positioned on the abutment teeth and held in place
preparations and a bite registration. he patient continues to wear with a polyester strip over the lingual surface. he retainers are
e62 C HA P T E R 1 6 Rein-Bonded Splint and Bridge

A B C

D E F

G H I

J K

• Fig. 16.11 Resin-bonded, porcelain-fused-to-metal maxillary anterior bridge. A, Congenitally missing

maxillary lateral incisor. B, Occlusion marked with articulating paper. C, Model with outline of preparations.
D, Preparing the lingual surface with a diamond instrument. E, The working cast shows the proximal
groove prepared (a second groove is on mesial of canine) to establish path of insertion for prosthesis and
provide positional stability and increase the retention form. F and G, Completed Rochette-type bridge
from the facial (F) and lingual (G) views. H, Teeth isolated with a gingival-retraction cord and cotton rolls.
Preparations are etched and ready for bonding. I, Holding the bridge in place during polymerization.
Bonded bridge: facial view (J) and lingual view in mirror (K).

seated and held irmly in place with the index ingers positioned more resin is mixed and added. Additions bond to the previously
on the strip over the lingual retainers, and the thumbs are held placed resin cement without additional surface treatment. he
on the facial aspect of the abutment teeth to equalize the pressure dentist removes excess resin along the lingual margins with a
(see Fig. 16.11I). he amount of resin cement at the facial and discoid-cleoid hand instrument, evaluates the occlusion, and makes
gingival embrasures is quickly inspected. Sometimes, the assistant any necessary adjustment. Contouring and polishing are accom-
may need to add more cement or remove excess unpolymerized plished in the usual manner with carbide inishing burs, ine
resin with an explorer or plastic instrument. Priority is given to diamonds, hand instruments, and disks. A completed Rochette-type
the gingival embrasure because later correction is more diicult bridge is shown in Fig. 16.11J and K, as viewed from the facial
in this area. and lingual aspects. When the bridge is complete, the patient is
instructed on how to use a loss threader and dental loss to clean
Finihing Procedure under the pontic and around the abutment teeth. Another example
After the resin cement has hardened, the dentist removes the of an anterior resin-bonded bridge replacing both maxillary central
polyester strip and inspects the lingual area. If voids are present, incisors is shown in Fig. 16.12.
 CHAPTER 16 Rein-Bonded Splint and Bridge e63

A B

• Fig. 16.12 A and B, Anterior resin-bonded bridge with multiple pontics. Before and after views of a
porcelain-fused-to-metal, resin-bonded bridge replacing both maxillary central incisors.

A B C

D E F

• Fig. 16.13 Resin-bonded mandibular anterior porcelain-fused-to-metal bridge and splint. A, The
patient is wearing ill-itting removable acrylic partial denture. B, Edentulous space resulting from missing
mandibular central incisors. C, Laboratory model with preparations outlined. D, Lingual view of completed
prosthesis (Rochette type with multiple countersunk perforations). E, Facial view of completed prosthesis.
F, Lingual view of prosthesis bonded in place with composite. The anterior segment is stabilized by the
splinting effect of the bridge retainers. G, Facial view of porcelain-fused-to-metal pontics bonded in place.

Mandibular Anterior Splint-and-Bridge Combination he preparations for the splint-and-bridge combination consist
An indication for a conservative bridge that incorporates a splint of removing approximately 0.3 mm of enamel on the lingual aspect
design of the PFM framework is illustrated in Fig. 16.13. he of the lateral incisors and canines (as outlined on the laboratory
patient’s mandibular central incisors were extracted because of cast) and preparing proximal retention grooves (see Fig. 16.13C).
advanced periodontal disease. he weak lateral incisors are stabilized he perforated design of the winged retainers was the Rochette
by including the canines in a splint-and-bridge design. hese teeth type for ease of replacement or repair (see Fig. 16.13D and E).
are caries free and have no restorations. An ill-itting, removable he splint bridge is bonded by the method previously described
partial denture was uncomfortable and did not support the adjacent (see Fig. 16.13F and G). he gingival aspect of the pontic is
teeth (see Fig. 16.13A and B). free of tissue contact and has suicient space for cleaning. A
e64 C HA P T E R 1 6 Rein-Bonded Splint and Bridge

A B C

D E F

G H

• Fig. 16.14 Conservative mandibular posterior bridge with a combination metal and porcelain pontic.
(A, G, and H are mirror views.) A, Missing mandibular irst molar with occlusion identiied by marks from
articulating paper. B, Study model surveyed and outlines of the preparation marked with pencil. C, Prepa-
ration of axial surfaces with coarse, cylindrical, diamond instrument. D, Laboratory model with margins
outlined. E, Completed bridge on cast ready for try-in. Note the centric contacts on metal to minimize
wear of the opposing teeth. F, Teeth cleaned, isolated, and etched. G, Occlusal view of bonded bridge.
H, Facial view of the bonded bridge.

similar splint also can be achieved with a Maryland bridge the patient’s teeth have suicient crown length to avoid subgingival
design. margination.

Mandibular Posterior Bridge With Preparation

Metal-and-Porcelain Pontic Prophylaxis, shade selection, and any needed occlusal adjustment
In Fig. 16.14A, a missing mandibular irst molar needs to be are accomplished before the preparations are begun. As with the
replaced to maintain proper occlusal contacts and to preserve the anterior teeth, some preparation is necessary to provide draw, to
integrity of the arch. A clinical examination with radiographs increase retention and resistance forms, and to provide bulk to
conirms that the abutment teeth are in good alignment and are the retainers for strength without overcontouring. Preparation is
sound, and that the occlusion is favorable. Conservative amalgam minimal and involves only enamel. Using the surveyed penciled
restorations have been inserted to correct the occlusal issures on cast as a reference, the dentist prepares the patient’s teeth with a
the abutment teeth. Impressions and a bite registration are made coarse, tapered, rounded-end diamond instrument (see Fig. 16.14C).
for study casts. An acid-etched, resin-bonded, cast-metal bridge he occlusal rests are prepared with a round diamond instrument.
(Maryland type), including a porcelain pontic with metal, occlusal, An elastomeric impression and a bite registration are made for
and centric stops, provides for optimal occlusal wear resistance laboratory use.
and an acceptable esthetic result.
he dentist uses a surveyor to determine the most favorable Laboratory Phae
path of draw and marks the outline of the retainer area with a he dentist includes a sketch of the bridge design with the laboratory
pencil (see Fig. 16.14B). he occlusal rest areas provide rigidity instructions. he nonperforated, etched metal design (Maryland)
and resistance form to vertical forces, and the extensions on the is speciied in this instance because the “wings” are very thin, and
facial and lingual surfaces provide a “wrap-around” design for other areas of the bridge are inaccessible for placing perforations.
added retention and resistance against lateral forces. In this example, It is helpful to the technician if the margins of the preparation
 CHAPTER 16 Rein-Bonded Splint and Bridge e65

are marked with an indelible pencil (see Fig. 16.14D). Before any for mixing and applying the bonding materials to teeth and the
glazing of porcelain or polishing of framework or etching of metal, bridge. he preparations must be clean and dry to ensure proper
the bridge is returned to the dentist for the try-in stage (see Fig. bonding. When the bridge is in place, a polyester strip is placed
16.14E). over the pontic, and inger pressure is used to secure the bridge
until polymerization is complete. After removal of the excess resin,
Try-in Stage the occlusion is evaluated. he occlusal and facial views are esthetic
he dentist seats the bridge and evaluates for proper it, occlusion, with only the centric contacts in metal (see Fig. 16.14G and H).
and color matching. After adjustments are made, the bridge is Another example of a posterior, resin-bonded, Maryland-type bridge
returned to the laboratory for corrections, inal glazing, polishing is shown in Fig. 16.15.
of the metal framework, and etching or other metal treatment
procedures. he etched metal must be examined under a microscope Maxillary Bridge With Porcelain-Fused-to-Metal Pontic
to ensure that proper etching of the metal has occurred. Fig. 16.16A illustrates a space resulting from the extraction of a
maxillary second premolar. As with the mandibular bridge, resistance
Bonding Step to lateral forces must be provided by the design of the preparations
Care must be exercised in handling the bridge because the etched and resulting prosthesis. Because esthetics is more critical in the
area can be contaminated easily. he bridge should not be tried maxillary arch, however, the wrap-around design used in the
in place (again) until teeth are isolated, and enamel has been etched mandibular arch cannot be employed to as great an extent, especially
(see Fig. 16.14F). Rubber dam isolation is preferable when bonding in the area adjacent to the facial aspect of the pontic. Proximal
mandibular resin-bonded bridges. Cotton roll isolation can be grooves are prepared (in enamel) in the same occlusogingival orienta-
used with retraction cords if a rubber dam cannot be placed. Being tion as the path of draw to provide additional resistance form to
careful not to touch or contaminate the etched metal, try-in of lateral forces. he lingual extensions and occlusal rests are prepared
the bridge is done to verify it and path of draw. Everything must as described for the mandibular bridge (see Fig. 16.16B and C).
be “ready to go” as the manufacturer’s instructions are followed For retention, perforations in the retainer (e.g., Rochette design)

A B

• Fig. 16.15 A and B, Maryland-type, resin-bonded posterior bridge. A missing mandibular right irst
molar is conservatively replaced by a porcelain-fused-to-metal, resin-bonded bridge.

A B C

D E F

• Fig. 16.16 Maxillary posterior resin-bonded bridge with porcelain-fused-to-metal pontic. A, Preopera-
tive photograph (mirror view) of a missing maxillary second premolar. B and C, Outlined inal tooth prepa-
rations: occlusal (B) and lingual (C) views. D, Completed prosthesis. E, Etched preparations isolated and
ready for bonding. F, Porcelain-fused-to-metal bridge bonded in place.
e66 C HA P T E R 1 6 Rein-Bonded Splint and Bridge

A B C

• Fig. 16.17 Resin-bonded mandibular posterior all-metal bridge. A, Edentulous space resulting from
loss of irst molar and distal migration of second premolar. B and C, All-metal bridge with electrolytically
etched retainers (Maryland type) bonded in place: occlusal view (B) and lingual view (C). Note non–tissue-
contacting, hygienic-type pontic. (Courtesy Dr. William Sulik.)

are used in addition to acid etching the preparations. Perforations enamel surfaces that are intact or contain very small composite
are placed in the accessible lingual extensions. his design aids in restorations. Second, the abutment teeth should be stable with
removing the bridge if replacement becomes necessary (see Fig. little mobility present. If the abutment teeth are mobile, it is
16.16D). he etched preparations, which are ready for bonding, frequently necessary to secure them as well by splinting with
are illustrated in Fig. 16.16E. he completed bonded bridge is composite to adjacent teeth before placement of the bonded pontic
shown in Fig. 16.16F. (see section Techniques for Splinting Anterior Teeth). hird, the
pontic must not be placed in a position that would subject it to
Mandibular Posterior Bridge With Metal Pontic heavy centric or functional occlusal contacts. Because of these
Fig. 16.17A illustrates a space between the mandibular premolars occlusion concerns, canines and posterior teeth are not usually
resulting from extraction of the permanent irst molar at an early good candidates for these types of resin-bonded bridges.
age and subsequent distal migration of the second premolar. Because
esthetics was not a factor, an all-metal bridge (e.g., Maryland type) Technique
with a hygienically designed pontic was used. he steps are identical Fig. 16.18A and B illustrates a typical case of congenitally missing
to the steps for the mandibular posterior bridge with a PFM pontic lateral incisors in which tooth contours contraindicated the use
(as discussed earlier). he bridge, after several years of service, is of resin-retained bridges with metal retainers. Central incisors are
shown in Fig. 16.17B and C. very translucent, and the mesial contours of canines are deicient
(see Fig. 16.18C and E). After assessing centric and functional
occlusions, it was determined that all-porcelain pontics could be
All-Porcelain Pontic placed without subjecting them to heavy occlusal forces. At the
Improvements in dental porcelains along with the capacity to etch irst appointment, the involved abutments are cleaned with lour
and bond strongly to porcelain surfaces have made all-porcelain of pumice and an accurate shade selection is made, noting any
pontics a viable alternative to pontics with metal winged retainers desired color gradients or characterizations.
(e.g., Maryland and Rochette bridges).10,11 Although all-porcelain No preparation of the teeth is recommended unless the proximal
pontics are not as strong as pontics with metal retainers, far superior surfaces of the abutment teeth adjacent to the edentulous space
esthetic results can be achieved because no metal substructure or are markedly convex. In such cases, slight lattening of the proximal
framework is present. All-porcelain pontics often can be used when surfaces with a diamond instrument facilitates closer adaptation
tooth anatomy precludes or restricts the preparation and placement of the pontic to the abutment teeth, increasing strength of the
of a metal winged pontic. Long, pointed canines with proximal connectors. Otherwise, no retentive features are recommended for
surfaces exhibiting little occlusogingival height often lack adequate the preparation in the abutment teeth; the connector areas are
areas for the placement of retention grooves. Anterior teeth that entirely made of composite.
are notably thin faciolingually also are not good candidates for Bridge connectors composed of porcelain are subject to eventual
metal, resin-bonded bridge retainers and often are esthetic failures fatigue fracture, after which repair is made more diicult. Studies
because of metal showing through the tooth. In both instances, show that “veneer bridges” (i.e., all-porcelain pontics retained by
custom-fabricated, etched porcelain pontics frequently can provide adjacent etched porcelain veneers) in particular are the weakest
an esthetic, functional alternative. design of all and should be avoided.11 hese types of bridges not
All-porcelain pontics are particularly indicated in adolescents only provide little bond strength to the pontic but also needlessly
and young adults, in whom virgin, unrestored teeth are often cover adjacent, healthy facial tooth surfaces. All-porcelain pontics
encountered. Because teeth are not extensively prepared, this (composite used for bonding to the abutment teeth) are similar
procedure is almost entirely reversible. his is a major beneit in to extracted natural tooth pontics in this regard. hose that have
young patients, where all-porcelain pontics can be placed as interim connector areas consisting of the design feature allow for easy
restorations until implants or a more permanent prosthesis can be repair and replacement of the composite connector should a fracture
placed at an older age. Because of their limited strength, all-porcelain in this area be encountered.
pontics should be considered provisional in nature, similar to the If high-strength ceramics that are totally immune to crack
natural tooth pontic and the acrylic denture tooth pontic. propagation and cohesive fracture are developed, retentive features
Similar to the natural tooth and denture tooth pontics, certain prepared in the adjacent abutment teeth may be desired. hese
prerequisites must be met to ensure a successful result. First, the features, prepared in enamel, would consist of proximal grooves
abutment teeth must be in reasonably good condition with proximal or boxes, depending on the faciolingual dimension of the proximal
 CHAPTER 16 Rein-Bonded Splint and Bridge e67

A B

C D

E F

G H

• Fig. 16.18 All-porcelain pontics. A and B, Patient with congenitally missing lateral incisors. C and D,
Right side before and after treatment. E and F, Left side before and after placement of all-porcelain pontic.
G, Lingual view of completed bridges. H, Facial view of all-porcelain pontics.
e68 C HA P T E R 1 6 Rein-Bonded Splint and Bridge

surfaces. In the absence of such totally fracture-resistant ceramics, is recommended, however, so that optimal gingival pressure can
however, all-porcelain pontics are best placed with composite be maintained for best tissue adaptation. he dentist shapes the
connectors for ease of repair and replacement. excess composite extruding from the connector areas around the
An elastomeric impression is made, and a working cast is gener- contact areas with an explorer tip or small plugger end of a composite
ated from it. A modiied ridge lap pontic tip design as previously instrument. After inal veriication that the pontic position is correct,
described (see Fig. 16.6B) is recommended. An occlusal bite registra- the composite is polymerized with light for a minimum of 40 to
tion should be made and forwarded to the laboratory so that the 60 seconds each from facial and lingual directions (for a total of
occlusal relationship can be considered during fabrication of all- 80–120 seconds).
porcelain pontics. he proximal surfaces of the pontics are etched Additional composite is applied in the proximal areas (more
with hydroluoric acid. he area etched must include all areas material is added on the lingual surface than on the facial surface),
anticipated for bonding to the composite-bonding medium. he contoured, and polymerized. Adequate gingival embrasures must
etched proximal surfaces should extend just beyond the lingual be maintained to facilitate lossing and ensure good gingival health.
line angles so that additional composite can be placed in the lingual After suicient material has been added and polymerized, the dentist
embrasure areas for additional connector strength. shapes and smooths the embrasure areas with carbide inishing burs,
At the subsequent appointment, teeth are isolated with cotton ine diamonds, and polishing disks. Facial embrasures are deined
rolls. A 5-cm by 5-cm (2-inch by 2-inch) cotton gauze is placed for esthetics, but lingual embrasures are closed with composite to
across the back of the patient’s mouth to act as a protective shield strengthen the connectors (see Fig. 16.18D, F, and G).
should the pontic be inadvertently dropped. A rubber dam is not he dentist evaluates the occlusion centric contacts and functional
recommended for this procedure because it precludes accurate movements. Heavy contacts on the pontic or the connector areas
assessment of the adaptation of the pontic tip to the residual ridge. must be adjusted. he inished bridges (immediately after bonding)
Before the teeth dehydrate, the position of each pontic is tested are illustrated in Fig. 16.18D and F–H. As with all resin-bonded
in the edentulous space to assess the shade and relationship of the bridges, patients must be advised to avoid biting into hard foods
pontic tip to the residual ridge. he pontic tip should contact the or objects to reduce the risk for dislodgment. Also, as noted earlier,
residual ridge passively with no blanching of the underlying tissue the patient must be advised as part of informed consent that
evident. Spaces of approximately 0.3 to 0.5 mm should exist between although the chances are remote, the potential for dislodgment
the pontic and the abutment teeth because stronger connectors and the risk of swallowing or aspirating the pontic do exist. his
are provided by the additional bulk of composite material. Care possibility exists for all resin-bonded bridges, and patients must
must be taken not to allow contamination of the etched pontic be warned of this hazard even though the risk is minimal.
from saliva to occur during the try-in phase. If saliva contamination
occurs, the etched proximal surfaces of the pontic must be cleaned Reference
thoroughly with alcohol and dried. After try-in, all etched proximal
surfaces of the porcelain pontics are primed with a suitable silane- 1. Andreasen JO: he efect of pulp extirpation or root canal treatment
coupling agent (see the manufacturer’s instructions for the speciic on periodontal healing after replantation of permanent incisors in
technique). he pontics are now ready for bonding. monkeys. J Endod 7:245, 1981.
he involved proximal enamel surfaces of the abutment teeth 2. O’Riorden MW, Ralstrom CS, Doerr SE: Treatment of avulsed
are roughened with a coarse, lame-shaped diamond instrument. permanent teeth: An update. J Am Dent Assoc 105:1028, 1982.
hereafter, all of the prepared (i.e., roughened) enamel surfaces 3. Livaditis G: Cast metal resin-bonded retainers for posterior tooth. J
should be acid etched, rinsed, and dried. Care must be taken to Am Dent Assoc 101:926, 1980.
4. Rochette AL: Attachment of a splint to enamel of lower anterior
maintain clean, dry, uncontaminated etched surfaces until the
teeth. J Prosthet Dent 30:418, 1973.
pontic is positioned and bonded. he abutment teeth are now 5. Livaditis G, hompson VP: Etched castings: an improved retentive
ready for bonding. mechanism for resin-bonded retainers. J Prosthet Dent 47:52, 1982.
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