Resin Retained Fixed Partial Dentures

Introduction
Conventional procedures for the preparation of abutment teeth often
involve major removal of tooth structure. If coverage is necessary for
cosmetic purposes because of caries or pre-existing restorations, this removal
of structure is acceptable. However, when the abutment is sound,
conventional full coverage procedures seem quite radical. ore conservative
procedures, such as partial veneer crowns or pin-retained, present limitations
in esthetics and retention. any patients object to these drawbac!s and
consequently choose removable partial dentures which may not to be used.
"ecent innovations in the acid-etch technique have led to new
alternative to traditional treatment for esthetic and restorative procedure.
Review of Literature
#. $en %tolpa &'()*+ described a adhesive technique for fixed partial dentures
by using aluminium foil and acrylic resin teeth stabili,ed by adapting foil
reinforced with acrylic resin to form a matrix. He made Class III cavity
preparation, on mesial surfaces of acrylic resin teeth and on distal surfaces of
abutment teeth. - fresh mix of composite resin applied to the abutment teeth
and Class III cavity preparation of the pontic.
.onald /. Howe and 0erald 1. .enehy &'())+ they described a technique
which permits the fabrication and attachment of an anterior fixed partial
denture without tooth preparation. 2he fixed partial denture is attached to the
'
lingual surfaces of the abutment teeth utili,ing a composite resin and acid
etch enamel.
Comment 3 since the frame has to be thic! enough to prevent flexibility that
may adversely affect the porcelain pontic, a potential for occlusal
interference exists.
.an 4athanson and 5ambi, oin &'(67+ they described a technique for
replacement of single anterior tooth. -n artificial composite resin tooth
reinforced with orthodontic perforated metal pads is used as a pontic and is
bonded directly to proximal and lingual surfaces of time adjustment teeth
using composite resin and acid etching.
0.#. 8ivaditis and 9.:. 2hompson &'(6;+ described a technique for a
retentive mechanism that etches the inner side of the cast fixed partial
denture framewor!s. 2hey etched metal ceramometal restoration with 7-*4
nitric acid was then bonded to the enamel surface utili,ing the technique for
acid etching enamel. 2hey suggested that improved resin bonded retainers
provide innovative conservative and viable alternatives to traditional fixed
prosthodontics.
#. "obert 1. %hleman, :eter C. oon, "obert /, $ranes &'(6<+ during a =;
month period, =( anterior fixed partial dentures were bonded on =) patterns.
-ll used the perforated metal retainer design, from the study they concluded
that minimal tooth preparation enhances the bond strength and can provide
occlusal clearances. 2he most common clinical failure is the bond to the
enamel which suggested that retainer design should cover the largest possible
surface without placing margins in inaccessible areas.
;
0erald $orrac! &'(6<+ the vertical path of insertion is developed so that the
restoration will not be displaced during function. 2he force is distributed
through wrap around design that includes substantial enamel coverage. 2his
provides the greatest surface area for bonding and a vertical path of insertion.
He also suggested that the surface to be etched should be cleaned with
an air abrasive with *7>m particle si,e aluminium oxide after etching the
blac! alloy surface must be removed by placing the casting in '6?
hydrochloric acid and in ultrasonic cleanser for '7 to '* minutes.
#effery 8. Hudgins, :eter C. oon and /lorian #. 5nap &'(6*+ they placed ;)
particle roughned resin bond /.:... during @ month period. /rom the study
they concluded that particle roughned metal retainer possesses sufficient
mechanical bond strength for resin bonded system. 2he wea! lin! in metal to
etched enamel resin bonded system was the resinAetched enamel interface.
2hey adviced to cover as much surface as feasible when resin bonded
retention etched to enamel.
2hey also suggested the advantages of particle roughened resin bonded
technique over the etched metal resin bonded procedure as follows3
'+ 2he time consuming and technique sensitive electrochemical etching of
the framewor! is eliminated which decreases treatment time by the
appointment since the framewor! is eliminated, which decreases
treatment time by one appointment. %ince the framewor! try in is
obviated.
;+ Combination of retentive surface is minimi,ed.
=
=+ "etentive surface is more easily evaluated.
<+ 2he advantages of the etched metal resin bonded framewor! technique
over the particle roughened resin bonded procedure are3 '+ :attern
fabrication and investment are less technique, sensitive and ;+ smoother
margins are achieved between the metal retainer and tooth structure.
2imothy $rady, -sterious .oc!ouda!is and %tephen 2. "asmussen &'(6*+
they compared the retention of the etched metal retainers and perforated
metal retainer, metal dis!s bonded to prepared tooth specimens and stored in
saline solution for ;7 days were measured for shear strength. 2he etched
dis!s were capable of withstanding more than four time the brea!ing load of
the perforated disc!s. 2hey concluded that etched retainers are superior to the
perforated retainers.
-sterios .ou!ouda!is, $ernard Cohen and -ndreas 2soutsos &'(6)+
described a method for etching metal alloys containing beryllium silicon,
boron and all nic!el base alloys in following ways3
'+ $last the metal surfaces to be etched with aluminium oxide.
;+ -pply a drop of the met-etchgel &containing aqua regia solution+ on
metal surfaces and spread with a plastic instrument.
=+ :lace the framewor! in warm oven at '*7B/ for = minutes.
<+ "emove the framewor! from the oven and rinse off the gel with tap
water. 2he met-etchgel is reapplied for ) to '7 minutes or until the gel
<
becomes greenish colour for revarification that the metal has been
etched properly.
*+ "inse the gel with tap water. If the etched surfaces have a dar! oxide
film, clean with an '6? solution of hydrochloric acid.
@+ 2hen clean the restoration with distilled water in an ultrasonic cleaner
for * minutes.
2he advantages of using this method of chemically etching are3
'+ 2his conservative procedure can be performed in two clinical sessions.
;+ 2he etching of the framewor! can be effectively controlled by the
dentist or laboratory technician and
=+ If the metal framewor! is dislodged it can be cleaned, etched and
reattached during the same appointment.
Comment 3 Can not etch gold alloys and those with high palladium content.
ohsen 2eleghani, 5arl /. 8einfelder and -!ram . 2aleghani &'(6)+ they
conducted a study to determine the effectiveness of small undercuts in mesh
patterns on the retention of resin luting agents compared with conventional
etching techniques. 2he results of the study demonstrated that the cast mesh
surface can serve as an alternative to chemical or electrolyte etching. -nother
advantage is the dentists ability to determine the appropriate surface
conditioning of the metal.
*
0./. :riest and H.-. .onatelli &'(66+ they evaluated <) patients receiving *6
resin bonded fixed partial dentures for ; to *' month periods &perforated
electrolytically and chemical etched retainers+ during the evaluation period,
'7 prosthesis became dislodged, six restorations were successfully rebounded
and four were remade. %ix anterior and four posterior restorations were
dislodged. Cne restoration containing more than one pontic was dislodged.
2hey made the following conclusion. $ased on retention rates demonstrate in
the study the resin bonded fixed partial denture are indicated as definite
prosthesis. Chemically etched prosthesis offer better retention than
electrolytically etched or perforated prosthesis. Compromises no established
design parameters adversely affect retention, particularly when bonded
enamel is minimal or resistance form is inadequate. :rosthesis location does
not appear to affect retention. .ifferences seem to exist in retentive strengths
of cementing agents.
#.". 1shleman. C.1. #anus and C.". #ones &'(66+ they suggested designs for
"$/:.Ds that provide the best possibly combination of auxiliary retention
and resistance features and resin to enamel bond strength a also suggested
use of data provided by %hillinberg and 0race on average enamel thic!ness
to as a guide for developing optimal preparations within the confines of the
enamel layers.
Maxillary Anterior Tooth Preparation
2he maxillary anterior teeth present a unique problem in "$/:.
design on many anterior teeth, a large percentage of available bonding
surface is also involved in centric and excursive contacts with mandibular
teeth. Consequently, the thic!ness of the lingual enamel plate of the abutment
@
teeth limits the amount of occlusal clearance for the "$/:. retainers that
can be obtained by preparing only these teeth. 2he available thic!ness of
enamel is further reduced when the abutment teeth have wear facets.
-dditional clearance may be obtained by reducing the incisal edges of the
mandibular teeth. 2his option is not always viable, however especially when
the incisal edges also exhibit wear. -lthough etched metal retainers can be
made as thin as 7.;mm the particle roughened retainers should be atleast
7.*mm thic!. -dditional, it has been shown that photoelastic stresses are
reduced when the retainer castings are 7.@mm thic!.
1namel thic!ness on the lingual surfaces of six maxillary anterior
teeth is consistently less than 7.*mm at gingival surface. Centric contact =
mm or less from the cementoenamel junction will require reduction of
opposing dentition to provide adequate &7.*mm+ clearance of particle
roughened retainers to leave enamel on the maxillary abutments for bending
the prosthesis patients who have Class II occlusal relationships with a deep
hori,ontal overlap may be more difficult to treat with a resin bonded
prosthesis in the maxillary region than patients with either a Class I or Class
II occlusion.
2he cervical finishing line of retainer should be either 'mm incisal to
the cementoenamel junction or no more than '.@mm incisal to the free
gingival margin. $ecause available enamel thic!ness at this site is
approximately 7.;(mm, no more than a light chamfer finishing should be
used. In most instances the casting thic!ness will exceed the amount of
enamel removed. 2herefore, for an optimal periodontal response, the
finishing line should always be placed incisal to the free gingival margin.
)
2he finishing line on the proximal surface adjacent to the edentulous
space should be placed as far facially as practical without lengthening outline
from the tooth. - shallow groove 7.*mm in depth should be placed slightly
lingual to the labial termination of proximal reduction. 2he tooth structure
lingual to the groove should be prepared in flat plane terminology cervically
in a !nife edge finishing line 'mm from free gingival margin. 2he proximal
slices on adjacent teeth should have on occlusal divergence in the range of
approximately @ degrees to '* degrees. 2he incisal finishing line should be
lightly chamfered and placed as near to the incisal edge as esthetic
considerations will permit.
2he principles of preparation for mandibular anterior teeth are similar
to these for maxillary anterior teeth, with awareness that lingual enamel
thic!ness for mandibular teeth are from '' to *7? less than those in
comparable parts of their maxillary counterparts. -s the cingulum of
mandibular anterior teeth is usually poorly developed, a positive cingulum
rest seat may be provided to assure correct positioning during bonding.
Posterior tooth preparation
2he enamel thic!ness varies from '.<6mm in the thic!est part of
marginal ridge to 7.@6mm near the cementoenamel junction. Enless the
abutment teeth are severely tipped in relation to each other, the proximal
slices should be at least ;.* to =mm in an occlusogingival dimension. 2he
proximal slices should have an occlusal divergence of approximately @ to '*
degrees. - positive rest seat should be prepared in each marginal ridge
adjacent to the edentulous space. 2he lingual surfaces of mandibular
6
posterior teeth are usually prepared in a single plane, terminating cervically
with a !nife edge or light chamfer finishing line.
#ohn C. $urgess and #ames 0. cCartney &'(6(+ they compared the load
required to dislodge acid etched resin bonded castings from various tooth
preparations li!e casting with grooves, one half groove, pins and the labial
extensions. 2hey confirmed the effectiveness of tooth preparation designs to
increase the resistance to lingual displacement of resin-bonded increase the
resistance to lingual displacement of resin bonded retainers. 2he most
effective proportions involved distinct proximal grooves or labial extension.
:reparations without facial correspond grooves or a single pinhole were
significantly less retentive.
9incent .. Filliams, 5eith e. 2hayer, 0erald 1. .enely, .aniel $. :oyer,
they evaluated ninety-nine anterior and posterior cast metal resin bonded
prosthesis from a '7 year period. 2he results of '7 years retrospective study
showed that3 '+ Caries rate on retainer teeth was minor, ;+ 2he periodontium
did not show a greater incidence of periodontal disease and few prosthesis
needed to remade.
.H. 1l %herif, -. 1l essey and .4. Haithoul &'(('+ they evaluated the
effects on retention of three metal surface textures 3 electrochemically etched,
air abraded and particle roughned and four resin luting materials &compson,
conclude, microfill pontic, panavia 1x+ by measuring the magnitude of the
force require for the removal of resin bonded fixed partial denture retainers.
2he result of study indicate that a retainer surfaces prepared by air abrading
with ;*7> aluminium oxide were superior in retention than other and :anavia
1x material could successfully retain the /:.Ds.
(
/ran!lin 0arcia 0odoy, .avid -. 5aiser, Filliam /.:. alone and 0regory
Hubbard &'(('+ compared the shear bond strength of :anavia 1x and
Compson opaque adhesive resins with electrolytically etched or sandblasted
rexillium and litecast $ alloys. 2hey found that panavia resin recorded a
greater bond strength than compson resin with etched and sandblasted
"exillium III metal. 2he results of metal etching did not differ from
sandblasting using both panavia and compson resin with sandblasting using
both panavia and compson resins with rexillium III metal. %andblasting
produced a superior bond strength compared with metal etching using
panavia resin with litecast $ metal. etal etching created a greater bond
strength than sandblasting using compspan resin with litecast $ metal.
.r. 4.:. :atil and 0.C. "eddy, they concluded that the stress distribution
patterns by fung bridge is quite favourable with less distructive forces on
alveolar bone and there are chances of fracture of bridge post at the pontic
abutment interface under much heavier application of load.
Types of Resin bonded fixed partial denture designs
'+ "ochette
;+ aryland
=+ %oc!well
<+ 9irgenia
*+ /ung
'+ "ochette type
- 2he "ochette type uses small perforation in the retainer
sections for retention and is best suited for anterior bridges.
'7
- Care must be exercised in placing the perforations to prevent
wea!ening the framewor!. :erforations that are too large or too
closed spaced will invite failure of the metal retainer by fracture.
- 2he perforations should be approximately 'mm apart and have
a maximum diameter of '.*mm on tooth side.
- 1ach hole is countersun! so that the widest diameter is toward
the outside of the retainer.
- Fhen the bridge is bonded with a luting resin, it is
mechanically loc!ed in place by microscopic undercuts in the
etched enamel and the countersun! holes in the retainer.
-dvantages of this design are follows3
'+ It is easy to see the retentive perforations in the metal.
;+ If the bridge must be replaced, the composite resin can be cut away in
the perforations to aid in the removal process.
=+ 4o metal etching is required.
.isadvantages are as follows3
'+ 2he perforations would wea!en the retainers if improperly si,ed or
spaced.
;+ 2he exposed resin is subjected to wear.
=+ It is not possible to place perforation in proximal or rest areas.
''
Maryland type
- It is reported to have improved bonding strength.
- Instead of perforations, the tooth si,e of the framewor! is
electrolytically etched, which produces microscopic undercuts.
- 2he bridge is attached with a resin luting agent that loc!s into
microscopic undercuts of both the etched retainer and the
etched enamel.
- It can be used for both anterior and posterior bridges.
- -lthough this design has been reported stronger, it is more
technique sensitive because the retainers may not be properly
etched or may be contaminated before cementation. $ecause
the retentive features cannot be seen with the unaided eye of
the etched surface must be examined with a microscopic to
verify proper etching &minimum magnification G@7+.
Sockwell Type
- It incorporates both perforations and etching of metal.
- 2he perforated type can be etched on the tooth side of metal
retainer to provide microscope undercuts. /or added retention.
2his is especially important in areas where perforations cannot
be placed.
';
- 2he etched metal type can be improved by adding perforations
to provide both types of retention.
Virginia Type
- oon and Hudgins et al produced particle roughened retainers
by incorporating salt crystals into the retainer patterns to
produce roughness on the inner surfaces.
- 2his method is also !nown as lost salt technique.
- 2his framewor! is outlined on the die with a wax pencil and the
area to be bonded is coated first with model spray and then
with lubricant.
- %ieved cubic salt crystal &4aCl+, ranging in si,e from '<( to
;*7>m are sprin!led over the outlined area.
- 2he retainer patterns are fabricated from resin leaving 7.* to
'.7mm wide, crystal free margin amount the outlined area.
- Fhen the resin has polymeri,ed, the patterns are removed from
the cast, cleaned with a solvent and then placed in water in an
ultrasonic cleaner to dissolve the salt crystas.
- 2his leaves cubic avoids in the surface that are reproduced in
the cast retainer producing retention for the fixed partial
dentures.
'=
- %ubsequent investigation showed that retainer fabricated by this
technique could be =7? to '*7? more retentive than retainers
prepared by the electrochemical technique, depending on the
resin used.
Fung Bridge Introduced by Fung 1998
- It consists of prefabricated pontic with channel inside it.
- 2he channel permits the placement of bridge post.
Advantage!
- inimum tooth reduction.
- "educed appointments and less chair time.
- 1sthetically pleasant.
- 4o expensive equipment.
"iadvantage
- 8ongevity is questionable.
- "equires occlusal adjustments.
Indication!
- %ingle tooth replacement.
#ontra indication: - 2eeth with large pulp chambers.
- %tep by step procedure.
'. 2ry in of fung bridge pontic.
;. :reparation of loc!ing slots on proximal aspect of
abutment tooth on edentulous side.
'<
=. 2ry in of bridge post and adjustment of bridge post.
<. Cementation with resin cement.
*. Ccclusal adjustments.
Advantage o$ %ein Bonded Fi&ed 'artial "enture(
2here are many reasons for the almost instant popularity of etched
metal retainer technique. 2hey can all be accounted for, however, by the fact
that the etched metal approach answers nearly all the objections that patient,
dentists and laboratory technicians have to the conventional crowns and
bridge.
1) Mini*al +na*el %eduction
- Cne of the most popular features of the etched metal retainers
is the conservative preparation that they require.
- 2he amount of enamel that must be removed in preparing a
direct bonded bridge is minimal, until recently this conservative
preparation has been more than just simply on advantage H it
has literally been design requirement.
,) -o pulpal involve*ent
- $ecause tooth reduction in the etched enamel retainer
technique is minimal there is obviously no pulpal irritation as a
result of preparation. - benefit to all age groups this feature is
particularly important for younger patients.
'*
- Infact only the conservative nature of these preparations and
complete lac! of pulpal involvement allow use to place a
permanent prosthesis in mouth of patients whose pulp would
otherwise be too close to the surface to withstand the normal
rigers of conventional crown and bridge.
- 1ven in more mature elder patients the etched metal retainer
technique avoids any ris! of sensitivity by eliminating
penetration in to dentinal tissue during preparation.
.) Mini*al periodontal involve*ent
- -ll tooth preparation and the final placement of direct bonded
retainers ta!e place above the gingiva. 2he supragingival
placement of the gingival border of the retainer is practically
guaranteed by this technique.
- In addition to their supragingival placement, all of the gingival
borders of the prosthesis are cast to a !nife edge. 2hese two
features permits easy periodontal maintenance.
/) Si*pli$ied i*preion
- $ecause the finished prosthesis remains supragingival there is
no need to extend the impression subgingivally. 2his eliminates
gingival retraction while the impression is made. 2here is no
need for gingival surgery. 2here is also no need to pac! a
retraction and also it eliminates one of the more vexing aspects
of the conventional crown and bridge procedures.
'@
0) -o analgeia
- 2he very conservative nature of the preparation requirements
which allow us to finish the preparations entirely within the
borders of the enamel structure, completely precludes the
necessity for any local analgesia. 2his is certainly a benefit to
the dentists, who save the time in providing regional or local
anesthesia and patients to appropriate that their dentistry can be
performed without the need of needle.
1) Si*pli$ied and Accurate et2etic
- 1sthetically, a direct bonded retainer is generally an
improvement over a conventional bridge for several reasons.
- /irst the abutment tooth remains intact.
- 2here is lac! of metal colour along the facial aspect the
abutment.
- 2he framewor! do not cover the facial aspect of abutment.
3) Forgiving clinical tec2ni4ue
- any of the difficulties encountered in conventional crown or
bridge are avoided in the cast alloy direct bonded retainer
technique. /or example, there are only three cardinal principles
that must be observed. :rovided that these minimal
requirements are met, the techniques themselves are quite
forgiving parallelism, for instance is a concept of very little
value for the direct bonded retainer. 2he placement of finishing
')
time is not nearly as critical for the direct bonded retainer as it
is for a conventional crown or bridge. 2here is no fear of pulpal
encroachment. -ll in all the clinical phase of procedure is much
less demanding than with conventional crown and bridge.
8) Forgiving laboratory tec2ni4ue
- 2here is no need for instance, of waxing and finishing the
retainer to a perfect, precise finish line. 2here is infact, often no
real finish line at all.
- 2here are no problems created by ditching the dies because
there is no need for ditching.
- 2here are no problems arising from adulterating the master
model by trimming away the area that is estimated to represent
the gingival tissue.
- Individual dies are not made for each abutment, because all
dies are usually left together on the model as a single unit. 2he
advantage is that there is no possibly of slight discrepancies in
their placement when the individual dies are returned to the
model.
- .ifficulties with soldering are eliminated because these
framewor!s are cast as a unit.
'6
- -ll these things considered, the laboratory technique for a
direct bonded retainer is both easier and more forgiving than
that required for a conventional crown or bridge.
9) 5e ti*e re4uired $or all procedure
- 2he clinical procedure for direct bonded retainers is usually
less time consuming than that for a conventional bridge.
Esually the saving of time amounts to *7? or more.
- In addition to saving time during the preparation and
impression, direct bonded retainers usually eliminate the need
for tempori,ation. 2he two major reasons for tempori,ation
with conventional crown or bridge are maintaining the
relationship between the abutment and protecting the denuded
dentinal surface. 4either of these reasons are found with the
direct bonded retainer.
- Esually the preparation for direct bonded retainer do not
change the contact points on adjoining teeth nor do they
substantially change in either the interproximal or occlusal
relationships, there is no reason to expect a sudden shifting of
the abutment teeth. 2he preparation of the teeth. 2he
preparation of the teeth for a direct bonded bridge is so minor
that the abutment teeth do not need further protection. 2here is
infact no denuded after preparation.
'(
16) %everibility o$ procedure
- $ecause the preparations for a direct bonded retainer are so
minimal the procedure is virtually reversible.
- -ccordingly, the reversibility of the procedure gave early
investigations the confidence to begin using direct retainers
clinically.
- If at any time the direct bonded retainer itself should become a
problem, the retainer could simply be removed and the patient
is bac! to where he started.
''+ -dvantage of composite resin as luting agent. -lthough the
insolubility of composite resin cement is only one of its many assets
because this feature allows for wide latitude in the construction of the
appliance within broad limitations when one uses those cements, there is
no longer such a thing as an open margin.
';+ 8ower cost
- 2o many patients the greatest single benefit of the direct
bonded retainer is the reduced cost of this appliance.
"iadvantage!
2he list of possible disadvantages as associated with direct bonded
retainers are as3
'. 2he longevity of some of the restorations is not yet !nown.
;7
;. :laque accumulation.
=. $ul!y contours.
<. "estricted to single tooth replacement.
Indication!
- 2he indications for direct bonded techniques are very much the
same as for a conventional crown and bridge with a few
additional considerations.
- 2he direct bonded technique should be used in preference to a
conventional crown and bridge whenever the conservative
nature of the technique would be an advantage.
1) %eplace*ent o$ *iing teet2(
- :erhaps the most dramatic application of the direct bonded
techniques is the replacement of missing teeth. $efore the
direct bonded techniques were developed in order to replace a
missing tooth, a dentist would either fabricate a removable
prosthesis or he would wrea! great destruction on the
abutments, in order to secure a permanently cemented
replacement.
- 4ow not only can missing teeth be replaced with a relatively
simple technique, but in many circumstances it is the only
possible technique.
;'
- /or a young patient, for instance there is not fixed conventional
counter part to the direct bonded techniques.
,) 'eriodontal plinting
- 2he more conventional periodontal splints have been extremely
difficult to maintain in the mouth.
- 2he strength and thinness of the direct bonded cast retainers do
ma!es the job easier not present a periodontal handicap.
- In this regard they have been as successful as the hori,ontal and
vertical pin splits, both parallel and non parallel variety.
- 2he direct retainer are not only easier to apply but they have all
other advantage that have been already be listed.
.) 'ot7ort2odontic Splinting
- .irect bonded cast retainer have also been used for post
orthodontic retention.
- Fhere indicated, they can replace such traditional removable
retainers as the Hawley retainer.
- .irect bonded cast retainer have the esthetic advantage of not
being visible as are most.
;;
- 2he direct retainer only becomes the post orthodontic retainer
of choice for those cases in which retention is expected to be
permanent or of an extremely long duration.
<+ Combinations with removal prosthodontics. 2he direct bonded
techniques have been used to splint wea! terminal abutments to stronger
adjacent teeth for reinforcement. In addition, they have been used to bond
stress brea!ers, cast rest seats, semi precision attachments and precision
attachments to the abutments for removable prosthodontic appliances.
*+ -djusting occlusion
- .irect bonded retainers have been used in many forms for
adjusting the occlusal table.
- Cne simple appliance used in occlusal rehabilitation is a metal
bac!ing for the lingual canines which is intended to create new
cuspid guidance.
- %ome times the framewor! of an etched metal appliance is
designed so that it can be bonded to rebuild the occlusal surface
of teeth that have been tilted in such a way so that a portion of
their occlusal table is not functioning. Cn occasion, the occlusal
portion of the alloy has been coated with porcelain for an
improved appearance.
- /or post temporomandibular joint therapy, individual wafers of
porcelain fused to bondable alloy have been fabricated to cover
the occlusal surface of existing posterior occlusal surfaces. 2he
;=
result is a permanent 2# prosthetic appliance that has been
achieved at a significantly greater saving of time, tooth and
money than with conventional approach.
1) Strengt2ening natural teet2
- Cast alloys bac!ings have been used to strengthen incipient
fractures of incisors.
#ontraindication!
:resently there are only three contraindications for the direct bonded
techniques3
'+ 2he first is if a patient shows any sensitive to the materials used for
the techniques, including any metal contained in the alloy, sensitivities
to the bonding or fusing materials would also preclude the use of these
techniques.
- Esually a metal sensitivity can be avoided through careful
selection of alloy to be used. %ensitivities to bonding or fusing
material can be avoided as variety of available materials often
ma!es it possible for a dentist to avoid the altergen while still
using the direct bonded technique.
;+ 2he second contraindication for the use of direct bonded retainer
techniques is insufficient enamel on the abutment teeth for proper
bonding or enamel that does not have caries existing restorations
;<
sufficient strength to withstand the forces that will be applied.
&Incisors with thin faciolingual dimension abraded teeth+.
=+ .eep vertical overbite.
#linical #onideration $or t2e direct bonded retainer!
2here are several design considerations that must be !ept in mind
when planning a restoration using any of the cast alloy direct bonded
techniques.
2he three cardinal requirements are all quite obvious3
'+ 2he framewor! must be strong enough to withstand the forces that
will be applied to it.
;+ 2he teeth themselves must be strong enough to withstand the
pressures that will be applied to them when the retainer is in place.
=+ a!ing each tooth retentive, it has been referred as the secret of
successful design in direct bonded retainers. 2his is to say that no
tooth should be able to brea! free of the retainer after cementation.
2his is a requirement for every tooth to be used as abutment.
Factor in cat retention!
'+ %urface area3 In etched metal framewor!s, the total retention of the
case is directly proportional to the surface area that is bonded.
;*
;+ "esistance to torquing3 the most important consideration in designing
the shape of metal framewor! is that it should be able to resist all the
occlusal and torquing forces. Composite cement is exceptionally
strong except for cleavage and peel. .ue to the rigidity of the metal
peel is not generally involved with the etched metal restorations.
Cleavage is however, is a problem with composite cement that applies
here. 2he greatest wea!ness of the etched metal technique is found
when the cement must withstand cleavage forces. If the case is
designed so that it is not the cement but the metal framewor! that
withstand the cleavage forcesI the cement can easily provide retention
against all remaining forces.
- 1ven for teeth that are slightly periodontally involved the
design of the metal framewor! is extremely important in
providing positive resistance against torquing of teeth away
from splint in the facial direction.
- $uccal wraps3 :erhaps the easiest way to create positive
resistance to torque is to provide the restoration with a single
path of insertion that is approximately parallel to the long axis
of the teeth. 2his resistance is generally provided for by the
inclusion of buccal wraps. 2he buccal wrap is simply an
extension of metal around the buccal surface of the tooth that it
resists any movement of the tooth in buccal direction.
- "etentive slots surprisingly there is a problem with buccal
wraps when the teeth exhibit extensive excessive spacing. Here
the difficulty is that the wraps can be usually obstrusive
;@
because the interproximal surfaces of teeth are also visible. In
such cases, as well as those involving crowding it is necessary
to provide positive resistance to torquing by creating a single
path of insertion for splint. 2his is usually can accomplished by
placing small vertical slots in the interproximal surfaces of the
teeth to be splinted.
- Ccclusal rests3 the greatest forces on the teeth in normal
occlusion are occlusal forces. 2he forces a pontic in a vertical
direction can be considerable and as the surface area of the
pontics increase, the total amount of force that must be resisted
by framewor! increases rapidly. 2he inclusion of a positive
occlusal rest of some sort, which allows the metal framewor! to
resist these forces eases the stress on cement bond.
- 2hic!ness of metal 3 -nother important consideration in the
framewor! is the minimum thic!ness that is required.
- 7.=mm is ideal thic!ness for every portion of framewor!.
- -ctually 7.=mm is the minimum thic!ness required on metal
where it is covered with porcelain in order to produce sufficient
rigidity to prevent fracture of the overlying porcelain.
- 2he areas within the pontic and in areas connecting the pontic
greater strength is necessary and the minimum thic!ness should
be '.7mm. another such area is where the framewor! passes a
proximal line angle, the minimum recommended thic!ness is
7.@mm.
;)
- Cn other hand, the in such areas as the point where the
opposing tooth occludes on the lingual plate of an anterior
retainer, the major requirement of the metal is more abrasion
resistance than strength. 2he non precious metals are so hard
that the thic!ness required at the occlusal contact point is only
7.'mm.
In fabrication of resin retained fixed partial dentures, attention i.e.
detail in all three phases is necessary for predictable success3
'+ :reparation of abutment teeth.
;+ .esign of restoration
=+ $onding of restoration.
'+ :reparation of abutment teeth3 Fhether anterior or posterior teeth are
prepared common principles dictate tooth preparation design.
- - distinct path of insertion must be established, proximal
undercuts must be removed, rest seats to provide resistance
form and a definite and distinct margin must be prepared.
- 2he amount of reduction is less because the enamel must not be
penetrated. If necessary the opposing teeth can be recontoured
to increase interocclusal clearance. It is essential that there
should be sufficient enamel area for successful bonding and
that the metal retainers encompass enough tooth structure to
resist lateral displacement.
;6
Bur election
- 0ingival margins and circumferential preparation are easily
accomplished with a chamfer or round tipped diamond.
- Ccclusal and incisal rest seats can be prepared with a diamond
or carbide inverted cone burs.
- -dditional retentive features such as slots, grooves or pinholes
can be made with a tapered fissure carbide.
Step7by7tep procedure
'+ 8eave the margins about 'mm for the incisal or occlusal edge and
'mm supragingival if possible.
- .efinite lingual ledges will provide resistance form for the
retainers and assist in positive seating during cementation.
Fherever possible to enhance resistance more than half the
circumference of the tooth should be prepared.
;+ a!e an accurate impression H arginal fit is a critical for a resin
retained restoration as for a conventional /.:...
=+ /abricate a proximal restoration with autopolymeri,ing acrylic resin.
;(
Anterior toot2 preparation and $ra*e work deign
- In designing an anterior prosthesis the largest possible surface
area of enamel should be used that will not result in
compromise of the esthetics of the abutment teeth.
- 2he retentive retainers &wings+ should extend on one tooth
mesially and distally if a single tooth is replaced.
- If a combination of tooth replacement and splinting is used the
framewor! may cover a larger number of teeth.
- 2he gingival margin should be designed so that a slight
supragingival chamfer exists that definite the gingival
extension of the preparation.
- -ny undercut enamel is removed at this time.
- 2he chamfer finish line may also extend incisally through the
distal marginal ridge area.
- 2he finish line on the proximal surface adjacent to the
edentulous space should be placed as for facially as is practical.
-butments should have parallel proximal surfaces.
- -n optional slot, 7.*mm in depth, prepared with a tapered
carbide bur, may be placed slightly lingual to the labial
termination of the proximal reduction.
=7
- 2he occlusion is assessed to ensure at least 7.*mm of
interocclusal clearance for the metal retainers in the intercuspal
position and throughout the lateral and protrusive excursive
pathways. If inadequate clearance exists, selective
enameloplasty is performed.
- Cccasionally additional clearance can be obtained through
reduction of opposing teeth. In presence of wear or attrition on
incisal edges, however, this is not advised.
- - distinct rest seat is then placed in the cingulum area of
abutment tooth. 2his may consist of ledges similar to those
incorporated in a pin ledge preparation or it can be a notch or
flat plane perpendicular to the long axis of the tooth.
- 2he objective is to provide resistance to gingival displacement
and to add rigidity to the casting.
- "est seats are prepared with an inverted cone bur to facilitate
internal refinement.
- 2he framewor! is extended labially past the proximal contact
point to prevent torquing forces from dislodging the prosthesis
to the lingual.
- 2o optimi,e esthetics the proximal wrap in the anterior region
may be achieved in part through using the metal ceramic
pontic.
='
- :reparation of mandibular anterior teeth is similar to that for
the maxillary incisors. 8ingual enamel thic!ness is '' to *7
percent less than for maxillary teeth and consequently tooth
preparation must be more conservative, combinations of
periodontal splinting and tooth replacement is commonly used
in the mandibular anterior region.
'oterior toot2 preparation and $ra*ework deign
- 2he basic framewor! for the posterior resin retained /.:...
consists of three major components. 2he occlusal rest &for
resistance to gingival displacement+ the retentive surface &for
resistance to occlusal displacement+ and the proximal wrap &for
resistance to torquing forces+.
- - spoon shaped occlusal rest seat is placed in the proximal
marginal ridge area of the abutments adjacent to the edentulous
space. -n additional rest seat may be placed on the opposite
side of the tooth.
- 2o resist occlusal displacement, the restoration is designed to
maximi,e the bonding area without unnecessarily
compromising periodontal health or esthetics.
- :roximal and lingual walls are reduced to lower their height of
contour to approximately 'mm from the crest of the force
gingiva. 2he proximal wall are prepared so that parallelism
results without undercuts.
=;
- 2he bonding area can be increased through extension onto the
occlusal surface provided it does not interfere with the
occlusion. 0enerally a !nife edge type of margin is
recommended.
- "esistance to lingual displacement is more easily managed in
the posterior region of the mouth. - single path of insertion
should exist.
- 2he alloy framewor! should be designed to engage at least '67
degrees of tooth structure when viewed from the occlusal. 2his
proximal wrap allows the restoration to resist lateral loading by
engaging the underlying tooth structure. It should not be
possible to remove a properly designed resin bonded /.:... in
any direction but parallel to its path of insertion.
- In general, the preparation differs between maxillary and
mandibular molar teeth on the lingual surface only.
- 2he lingual wall of maxillary tooth may be prepared in a single
plane and the palatal surface of maxillary molars dictates a two
plane reduction due to taper of these centric cusps in the
occlusal two thirds and occlusal function.
Cccassionally a combination prosthesis can be used. 2his type of
/.:... includes a resin bonded retainer on one of the abutment teeth and a
conventional cast restoration on the other.
==
%ein to *etal bonding!
- In the original design "ochette made six perforations with a
waxing instrument, thus providing mechanical undercuts for
the resin cements.
- - perforated design has a disadvantge of exposing the resin to
oral fluids, which may lead to problems of abrasion of the resin
or microlea!age at the resin metal interface.
- - non perforated design avoids this potential problem and can
be highly polished, resulting in improved oral hygiene.
- :resently non perforated retainers are recommended.
Metal rein can be clai$ied a eit2er
IJ echanical or IIJ Chemical
:rimarily mechanical bonding is subdivided into3
'+ icro mechanical retention which uses etching to create microscopic
porosities and
;+ acro mechanical retention H which relies on visible undercuts
usually with a mesh or pitted metal.
Chemical bonding generally employs tin plating of metal framewor!
and specific resin adhesives for metal and enamel.
=<
+lectrolytic etc2ing!
In this procedure microscopic porosity is created in the fitting surface
of a nic!el chromium framewor! by different electrolytic etching.
- 2he fabrication technique was developed at the university of
aryland of school dentistry and hence the prosthesis
sometimes referred as the Karyland bridgeL.
Procedure
- Clean the fitting surface of metal restoration with an air
abrasion unit with aluminium oxide.
- Cover the polished surfaces with wax and attach the prosthesis
to an electrolytic etching unit following the manufacturers
instructions.
- - typical etching cycle will be = minutes in '7? H;%C
<
with a
current of =77 milliamper per square centimeter of casting
surface.
- Clean the etched surface ultrasonically in '6? Hcl and then
wash and air dry it.
- 2he etched surface must not be handled after this stage.
=*
#2e*ical etc2ing
Procedure:
- - gel consisting of nitric and hydrochloric acid is applied to the
internal surface of the metal framewor! for approximately ;*
minutes.
- -s electrolytic etching is extremely sensitive, many authors
believe that chemical etching provides more reliable results due
to procedural simplicity.
Macrocopic retention
In non perforated retainer, porosity cast in the pattern itself rather than
subsequently obtained by etching.
2his is done in variety of ways3
- Cne techniques uses a special pattern to form a meshwor! on
the fitting surface and the external lingual surface is waxed to
give a smooth finish that can be highly polished.
- -n alternative technique uses water soluble salt crystals
sprin!led onto the die and incorporated into the wax pattern.
2he crystals are dissolved away before investing.
- -n advantage of both these techniques is that any alloy can be
selected, where as with electrolytic or chemical etching the
alloy usually must be nic!el chromium.
=@
- -dditionally, tryin and bonding of the prosthesis can be
accomplished at the same appointment.
- 2hese surfaces are not li!ely to be damaged during handling as
are the very fragile etched metal surfaces.
- .isadvantages of the technique include difficulty on adapting
the mesh to create a closely fitting metal framewor! and a
potentially thic!er metal framewor! than can be obtained with
a etched metal retainer.
- -lso, the rate of microlea!age along the cast mesh composite
resin interface is significantly greater than along an etched
metal resin inteface.
Procedure:
'+ Cutline the mesh framewor!, trim it to the preparation margins and
adapt it to the master cast.
;+ .evelop the lingual contours, wax the pontic and cutbac! and sprue
the finished pattern as usual.
=+ %oa! the cast in cold water to help release the pattern invest it
normally.
<+ Cast the framewor! and prepare the veneering surface in the
conventional way.
=)
*+ $uildup porcelain, polish the casting and clean the fitting surface with
an air abrasion unit.
@+ 2he restoration is ready for tryin prior to bonding.
Tin plate!
2in plating is recently introduced procedure that can improve the
strength of adhesive cement to most metals. :recious alloys can be plated
with tin and used as framewor!s. /or resin retained /.:...s. 2in forms
organic complexes with several specific adhesive resin cements that result in
significantly greater bond strength.
Bonding Agent
Composite resins play an important role in the bonding of the metal
framewor! to etch enamel.
'+ /illwed $is0- composite resin &$isphenol - glycidal+.
;+ 210.- &2riethylene glycel dimethacrylate.
=+ <12- &< methacrylyloxethyl trimellitate anhydrite+.
<+ E.1- &Erethane dimethacrylate+.
'+ /illed $is0- composite resin 3 - phosphate ester added to the
monomer allows chemical bonding to both the metal and the etched
tooth enamel. 2he powder contains approximately )*? quart, filler
and is almost insoluble in oral fluids. 2he material shows excellent
bond strength to non noble metals and tin plated noble metals. It will
no set in presence of oxygen. 2o ensure a complete cure the
=6
manufacturers provides a polyethylene glycol gel, which should be
placed over margins of restoration. 2his creates oxygen barrier and
can be washed away after the material has set.
Procedure :
'+ Clean the teeth with pumice and water isolate them with the rubber
dam and chemically prepare them.
Currently =)? phosphoric acid is used to etch the enamel and
is applied for =7 to @7 seconds.
;+ :lace the cement on external surface of the prosthesis and completely
seat the restoration.
=+ /orm pressure should be exerted on the restoration while excess
uncured resin is removed prior to the material completely setting.
<+ 2he restoration should be held in place until resin has polymeri,ed.
=(
Summary !onclusion
"esin bonded fixed partial dentures after the following significant
advantages to the dentist and the patient in properly selected clinical
situations3
'+ 2ooth preparation is reduced to a minimum.
;+ 2he procedure is reversible.
=+ %oft tissue management is simplified.
<+ 2here is less problem with color matching and
*+ "educed cast and simplicity give high patient acceptability.
2here are two disadvantages3
'+ $onding procedures are more difficult and time consuming than
conventional luting techniques.
;+ Ccclusal adjustment at the tryin of the restoration is more difficult
because of the lac! of a retentive crowns tooth relationship.
Cne of the basic principles of tooth preparation for fixed
prosthodontics is conservation of tooth structure. 2his is the primary
advantage of resin retained fixed partial dentures and a careful patient
selection is an important factor in predetermination of clinical success.
-ll factors considered, it seems that the use of the cast metal resin
bonded fixed partial denture should be encouraged where sound abutment
teeth exist and only one or two teeth are missing.
<7
References
'+ -sterios .ou!oda!is, $enard Cohen and -ndreas 2soutsos 3 - new
chemical method for etching metal framewor!s of the acid etched
prosthesis. #. :rosthet. .ent., *6 &<+ 3 <;'-<;=, '(6).
;+ .onald /. Howe and 0erald 1. .enehy 3 -nterior fixed partial denture
utili,ing the acid etch technique and a cast metal frame wor!. #.
:rosthet. .ent., =) &'+ 3 ;6-=', '()).
=+ .an 4athanson and 5ambi, oin 3 etal reinforced anterior tooth
replacement using acid-etch composite resin technique. #. :rosthet.
.ent., <= &<+, <76-<';, '(67.
<+ /ran!lin 0arcia 0odoy, .avid -. 5aiser, Filliam /.:. alone and
0regory Hubbard 3 %hear bond strength of two resin adhesives for acid-
etched metal prosthesis. #. :rosthet. .ent., @* &@+ 3 )6)-)6(, '(('.
*+ 0.#. 8ivaditis and 9.:. 2hompson 3 1tched castings 3 -n improved
retentive mechanism for resin bonded retainers. #. :rosthet. .ent., <)
&'+ 3 *;-*6, '(6;.
@+ 0erald $arroc! 3 "ecent advances in etched cast restorations. #.
:rosthet. .ent., *; &*+ 3 @'(-@;@, '(6<.
)+ 0./. :riest and 4.-. .onatelli 3 - four year clinical evaluation of
resin bonded fixed partial dentures. #. :rosthet. .ent., *( &*+ 3 *<;-*<@,
'(66.
<'
6+ #. "obert 1shleman, :eter C. oon, "obert /., $ranes 3 Clinical
evaluation of cast metal resin bonded anterior fixed partial dentures. #.
:rosthet. .ent., *' &@+, )@'-)@<, '(6<.
(+ #effrey 8. Hudgens, :eter C. oon, and /lorian #. 5nap 3 :article
roughned resin bonded retainers. #. :rosthet. .ent., *= &<+ 3 <)'-<)@,
'(6*.
'7+ #. $en %tolpa 3 -n adhesive technique for small anterior fixed partial
dentures. #. :rosthet. .ent., =< 3 *'=-*'(, '()*.
''+ #.". 1shlemon, C.1. #anus and C.". #ones 3 2ooth preparation designs
for resin bonded fixed partial dentures related to enamel thic!ness. #.
:rosthet. .ent., @7 &'+ 3 '6-;;, '(66.
';+ #ohn C. $urges and #ames 0. cCartney 3 -nterior retainer design for
resin bonded acid etched fixed partial dentures. #. :rosthet. .ent., @' 3
<==-<=@, '(6(.
'=+ .H. 1l %herif, -.1l-essay and .4. Halhoul 3 2he effects of alloy
surface treatments and resins on the retention of resin bonded retainers.
#. :rosthet. .ent., @* &@+ 3 )6;-)6@, '(('.
'<+ .r. 4.:. :atil and 0.C. "eddy 3 - finite element analysis of stress
distribution pattern underneath the alveolar bone in response to vertical
and oblique loads H :aper read before I.- C.- conference ;777 at
.elhi.
<;
'*+ "esensteil, 8and and /ujimoto 3 Contemporary fixed prosthesis.
%econd edition.
'@+ %hellinburg, Hobo, Fhitsut, #acobi and $rac!ett 3 /undamental of
fixed prosthodontics.
')+ %turdvent 3 2he art and science of operative dentistry. =<*-=<@.
'6+ %imonsen. 2homson A $orrac! 3 1tched cast restoration H clinical and
laboratory techniques. Munitessence :ublishing Co., '(6(.
'(+ 2ylman 3 /ixed prosthodontics.
;7+ 2imothy $rady, -stenious .ou!oda!is and %tephen 2. "asmusten 3 -
comparison between perforated and etched metal resin bonded
retainers. #. :rosthet. .ent., *< &=+ 3 =@'-=@<, '(6*.
;'+ Ginent .. Filliams, 5eith 1. 2hayer, 0erald 1. .enely, .aniel $.
$oyer 3 Cast metal resin bonded prosthesis H '7 year retrospective
study.
<=