5/20/2014

The Direct Composite Bridge: Still a Unique Solution for Some Clinical Situations

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The Direct Composite Bridge: Still a Unique Solution for Some Clinical
Situations
WrittenbyRobertLowe,DDS
Thursday,10May201208:56

CEArticles
DentalMaterials
DentalMedicine
Diagnosis
DigitalImpression
Technology
Endodontics
Ergonomics
ForensicDentistry
GeriatricDentistry
Hygiene
Implants
Impressions
InfectionControl
Interdisciplinary
Dentistry
Interview
Laboratory
Management
Materials
Microdentistry
NewDirections
PracticeManagement
Restorative
OralCancerScreening
Occlusion

I
NTRODUCTION
Oftentimes,whenpresentedwithasingletoothedentulousspace,we"automatically"thinkofeithera3unitfixedpartialdenture
(bridge),oranimplantandcrown.Yet,therearestillsomesituationsthatarebesttreatedwithdirectresin.

Manyyearsago,Iwasintroducedtoadirectresinbridgetechniquecalled"theGeorgiaBridge,"asdemonstratedina1986lectureby
Dr.JohnSavagefromAtlanta.Dr.Savagedescribeda"freehanded"bondingtechniquetousedirectcompositeresinasapontic,
utilizingadhesivedentistryandundercutsintheenamelsurfaceoftheabutmentteethtohelpretainthis"pontic"betweenthe
edentulousspan.Facialandproximalsurfacesoftheabutmentteethwerepreparedminimally,asiffordirectlabialveneers.
Horizontalgroveswerethenmadeinthesesurfacesforauxiliaryretentionoftherestorativematerial.Next,a"compositebridge"was
fabricatedusinglightcuredresinacrosstheedentulousareabetweentheabutmentteeth.

Dr.SavagedescribedthisGeorgiaBridgeas"thebridgeofchoice"whenreplacingsingleanteriormissingteethwhen:(1)thepatient
couldnotaffordaconventionalfixedbridge,(2)thepatientdidnotwishtoprepare"virgin"abutmentteethrequiredforafixedbridge
replacement,(3)theedentulousridgewasinadequateforplacementofanimplant,and(4)thepatientchosenottohaveanimplant
placed.

SincethetimethattheoriginalarticleontheGeorgiaBridgewaswritten,manyadvancesinadhesivedentaltechnologyand
compositeresinshaveoccurredthatmakethistechniqueevenabetterlongtermsolutionforsomeoftheaforementionedclinical
situations.ThisarticlewillfeatureamodificationoftheGeorgiaBridgetechniqueusingamoderncompositeresintoclosean
edentulousspaceleftbytheextractionofamandibularincisor.
CASEREPORT
DiagnosisandTreatmentPlanning
A76yearoldfemalepatientpresentedwithamissingmandibularleftlateralincisorthathadbeenrecentlyextractedbecauseof
severerootcariesonthedistalsurfacethathadmadethetoothunrestorable(Figure1).

Uponclinicalandradiographicexamination,itwasnotedthattherewasnotenoughremainingboneinthelabiallingualdirectionto
consideranimplant.Also,theteethadjacenttotheedentulousspace,asidefromhavingsomecrestalboneloss,wereunrestored.
Thecrowntorootratioandmesiodistalrootdiameteratthegingivalcrestofthemandibularleftcentralincisorwerenotfavorabledue
tothealveolarboneloss,makingitaquestionableabutmentforafixedpartialdenture.Theotherrestorative"choice,"asingletooth
removable"flipper"appliance,wouldhavebeenapoorsolutionduetotheamountofplastictoreplace"onemissingtooth"andthe
probablelackofpatientcompliancetowearsuchanappliancelongterm.Itwasdecidedthatthemostconservativeapproachforthis
patientwouldbeto"suspend"aponticbetweentheabutmentteethusingadhesivetechnologyandfiberreinforcement.

Sincetheponticwouldbelayeredinasimilarfashiontothewayaceramistwouldmakeabridge,theplanwastouseanopacious
dentinasthefirstlayerreplicatingtheinternaldentinstructureofthenaturaltooth.Next,the"universal"VITAshadewouldbelayered
overtheinitialmaterialtorecreatethe"bulk"oftheremainingdentin.Finally,anincisalshadewouldbeusedtorecreatetranslucency
intheincisalthirdofthetoothandcompletetheincisaledge.
MaterialSelection
Auniversalnanocompositeresin(Kalore[GCAmerica])waschosenasamaterialthatwouldbewellsuitedforthistask.Inrecent
years,advancesincompositeresintechnologyhavebeenlargelyonthefillersidechangesinparticlesize,particleshape,orfiller
typetotrytomaximizetheaestheticpotentialofthematerialwhilemaintainingthephysicalpropertiesnecessarytoenablethe
materialtowithstandthestressesofmasticatoryforcesintheoralenvironment.WithKalore,themanufacturerreportsaninnovationin
monomertechnology.ADuPontmonomer(DX511)isused,whichhasalongrigidcorewithflexiblearms.Itisbelieved,withthisnew
monomerformulation,thatthepolymerizationshrinkagechallengemaybesolvedbyremovingtheshorterchainmethacrylatematrix,
providingthepotentialforreducingsuchclinicalchallengesasmarginalgapformation,microleakage,stain,andsecondarycaries

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OralMedicine

The Direct Composite Bridge: Still a Unique Solution for Some Clinical Situations
whileenhancingaestheticsandwearresistance.

OralSystemic
connection
Orthodontics
PediatricDentistry
Periodontics
Pharmacology
PainManagement

igure1.Afacialpreoperativeview
F
ofa76yearoldfemalepatientwho
presentedwithamissingleft
mandibularlateralincisor.

igure2.Thisisaphotoofthe
F
KaloreShadeGuide(GCAmerica).
Itsuniquedesignallowsfor
individualshadeselectionin3
differentopacities,andgivesthe
"recipe"forlayeringtocreatethe
"VitaSpectum"ofshadesfordifficult
anteriorshadematches.

igure3.Theshadesofthe
F
nanocompositeresin(Kalore[GC
America])werechosenforthis
patient'srestoration.

igure4.Thisphotodemonstrates
F
thedifferenceinthe"new"Kalore
Unitip(top)fromtheoriginaldesign
(bottom).Notethedifferenceinthe
sizeofthetipopeningthatallowsfor
easierextrusionofthe
nanocompositematerial.

Prevention
Prosthodontics
Psychology
Radiography
PostandCore
Technique
Regulatory
Restorative
BiteRegistrationTechnique
ImpressionMaterials
InterproximalContact
Technique
Photography
MinimallyInvasiveDentistry
MidRestorative

SleepDisorders
SportsDentistry
TechnoClinical
Technology

Kalorealsohasauniqueshadingsystemthatoffersopaque,universal,andtranslucentshadingthatprovidesthedentistthe
opportunityto"stack"acompositeresininthesamefashionasalabtechniciantocreateinternalbeautyandlifelikeaesthetics.Most
ofthetime,theuniversalshadealonewillprovideexcellentshadeblendingwithnaturaltoothstructure.Thesimplifiedshadesystem
offersthedentistthe"recipe"toproducebeautifullyaestheticanteriorrestorationsforexample,inClassIVsituations,neutralizingthe
darknessoftheoralcavitypresentsachallengeforeventhemostexperiencedclinician.

Figure2showstheshadeguideofcorrespondinghuesandopacitiesrequiredtorecreate"nature'sblueprint"incompositeresin.
Notealsothatthereare3cervicalshades:cervical(CV),cervicaldark(CVD),andcervicaltranslucent(CVT).Inthiscase,these
shadeswillbehelpfultorecreatetheexposedrootstructureseenontheadjacentnaturalteeth(Figure3).

Inaddition,foreaseofuse,themanufacturerrecentlyimprovedtheextrusionofthisnoncompositematerialbyslightlyincreasingthe
sizeoftheunitip(Figure4)andslightlydecreasingthefillercontent.Thecombinedeffectisimprovedflow.Thistinydecreaseinfiller
contentalsohadnoeffectonotherphysicalproperties.

TechniqueoftheWeek
TreatmentPlanning
Viewpoint

ClinicalProtocol
Afterthepatienthadbeengivenlocalanesthesia,horizontalgrooveswerepreparedintothelingualsurfacesoftheabutmentteeth,
teethNos.22and24(Figure5).Thesegrooveswereplacedjustincisaltothecingulumareasofthelingualsurface,atadepthof
about1.0to1.5mm.Next,aselfetchingadhesive(GaenialBond[GCAmerica])wasappliedtothepreparedsurfaces,boththe
enamelanddentin,andleftundisturbedfor10seconds(Figures6and7).Afterairthinningandevaporationofthesolvent,the
adhesivewaslightcuredfor20seconds(Figure8).Apieceof1.0mmdiameterfiberglassribbon(Connect[Kerr])wascutandfitinto
theslotsonthelingualsurfacesspanningacrosstheedentulousarea.Thisribbonshouldfitperfectlyintotheslot,notbeingtoolong
thatthefibersaredoubledupandcompletelyobliteratingthespace,ornotsoshortthatthereisnotenoughlengthtotheribbonto
providemechanicalrigidity.Oncethefitwasverified,aflowablecompositeresin(GaenialUniversalFlo[GCAmerica])wasplaced
intotheslotto"wet"theinternalsurfaceofthepreparationstheribbonwasplacedusingacottonforceps,tofulldepth,andthenthe
ribbonwascompletelycoveredwithGaenialBondtothecavosurfacemargins(Figures9and10).Next,theflowablecompositewas
lightcuredfor20seconds(Figure11).

igure5.Alingualviewshowsthe
F
abutmentteeththatwereprepared

igure6.GaenialBond(GC
F
America),aseventhgenerationself

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The Direct Composite Bridge: Still a Unique Solution for Some Clinical Situations
withaslotcutinthelingualsurfaces etchingbondingagent,was
tocontaintheimbeddedfiber

dispensedintoadisposable

reinforcementtoprovidethe

mixingwell.

"framework"tofreehandthe
nanocompositeresinponticinthe
edentulousspace.

igure7.Thebondingagentwas
F
appliedtoallpreparedsurfaces
usingamicrobrush.

igure8.Thebondingagentwas
F
thenlightcuredfor20seconds.

igure9.Theflowablecomposite
F
resin(GaenialUniversalFlo)with
anapplicatortipappliedtotheend
ofthesyringethelong,narrow
cannulamakespreciseplacement
veryeasy.

igure10.GaenialUniversalFlo
F
wassyringedintothepreparationsin
athincoat.Thefiberreinforcement
wasplacedintothefloorofthe
preparations,andtheywerethen
filledwithflowablecompositetothe
cavosurfacemarginsandlight
cured.

igure11.Next,theflowable
F
Figure12.Thisfacialviewshowsthe

compositewasplacedonthe
compositereinforcedfiberglass
stabilizedfiberglassfiber(Connect reinforcementinplace.
[Kerr])towetthesurfacebetween
theteethwithcompositeresin.Itwas
thenlightcuredfor20seconds.

igure13.KaloreAO3wasusedto
F
beginbuildingaponticonthefiber
betweentheabutmentteeth.

igure14.Aplasticinstrument
F
(GoldsteinFlexi
thinMini4[Hu
Friedy])wasusedforshapingA3.5
asthebasedentinforthepontic.
KaloreCV(B5)wasusedtosimulate
arootformsimilartotheadjacent
teeth.

Oncethefiberwasanchoredinplace,anadditionallayerofflowablecompositewasplacedtocompletelycovertheexposedfiber

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The Direct Composite Bridge: Still a Unique Solution for Some Clinical Situations
andeffectively"splint"theabutmentteethtogether(Figure12).Thenextstepwastobeginto"sculptatooth"onthefiber.Thefirstlayer
oftheponticwassculptedandcureddirectlytothefiberusingKaloreA3opaquecomposite(Figure13).Noticeabout2mmofspace
wasleftincisallyforadditionofanincisalshadelater.Also,spacewasleftinthecervicalareaforsimulationoftherootsurfacewith
cervicalshades.

Oncecompleted,thecervicalareawassculptedwithKaloreCV,whileuniversalshadeA3.5wasaddedtobuildfacialcontourtothe
initialopaqueincrementgivingthe"illusion"ofdepth(Figure14).AGoldsteinFlexithinMini4(HuFriedy)wasthenusedtosculptthe
nanocompositeresin.Afinesablebrush(KeystoneNo.4Flat[PattersonDental])wasusedtoaddtextureandrefinecontour(Figure
15).TheincisaledgewasaddedusingKaloreDarkTranslucent(DT)(Figure16),blendedwiththesablebrush,andthenlightcured
for20seconds.

Finalcontourwasaccomplishedusingan8flutedcompositefinishingdiamond(ETNo.9[BrasselerUSA]),followedbyflexiblediscs
(Optidisc[Kerr]).Notethe"backside"ofthedischastheabrasiveonitsoitcanbeflexedacrosstheproximalfaciallineanglesto
create"reflectiveangles"andpropertriangularformforthefacialsurfaceofthismandibularincisor(Figure17).Thepolishingphaseis
statedusingarubberabrasivepolishingdisc(JiffyPolishers[UltradentProducts])(Figure18).Theedgeoftherubberdiscwas
orientedvertically,thenmovedacrossthefacialsurfaceofthecompositeinthehorizontaldirectiontocreatesurfacetextureand
createnaturalluster.Thefinallusteronthesurfaceoftherestorationwascreatedusingapolishingcupwithimpregnatedbristles
(Occlubrush[Kerr])(Figure19).

Figures20to23arefinishedviewsofthecompleteddirectcompositebridgereplacingtoothNo.23.Insomecases,theclinicianmay
wanttouseagingivacoloredcompositeifso,onecoulduseGradiaGum(GCAmerica).

igure15.Asablebrush(Keystone
F
No.4Flat[PattersonDental])was
usedtocreatesurfacetextureand
refineanatomicform.

igure16.KaloreDTwasusedto
F
createincisaltranslucency.

igure17.Afterinitialcontouring
F
withan8flutedcarbidecomposite
finishingbur,contouringwas
completedusingabrasivediscs
(Optidisc[Kerr]).

igure18.Ayellowdisc(JiffyDisc
F
[UltradentProducts])wasthenused
topolishthelabialsurface,andto
refinethereflectiveanglesand
surfacetexture.

igure19.Apolishingcupwith
F
impregnatedbristles(Occlubrush
[Kerr])wasusedasthefinal
instrumenttocreatesurface
lusterandshine.

igure20.Facialviewofthe
F
completedfiberreinforceddirect
nanocompositeresinbridge.

Figure21.Patientsmilingwiththe

Figure22.Onemonthpostoperative

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The Direct Composite Bridge: Still a Unique Solution for Some Clinical Situations
completeddirectcompositebridge.

photoofthedirectcompositebridge.

Notethenaturalappearanceofthe

Notethebeautyofthenatural

restoration,ascomparedtothe

aestheticsthatwascreated.

patient'snaturalteeth.

igure23.Acloseupviewfromthe
F
facialaspectofthedirectcomposite
pontic.Thecervicalshadecreateda
naturalappearingrootformthat
simulatedthepatient'snaturalteeth.
CONCLUSION
Atechniquehasbeendemonstratedusingadirectuniversalnanocompositeresintoconstructafiberreinforced3unitfixedbridge.It
isimportanttoconsiderthedirectresinrestorativeoptionforasingletoothedentulismwhenclinicalandeconomicalcircumstances
precludeanimplantorfixedpartialdentureasatreatmentchoice.Thedirectcompositebridgecanbeaveryaestheticand
functioningdentalrestorationwhenusedintheappropriateclinicalcircumstance.Itisimportanttoalsorememberthatifthisappliance
shouldeverrequirerepairorreplacement,itismucheasiertodosincethesubstrateiscompositeratherthanporcelain.Forthe
clinicalpatientpresentedinthisarticle,asformanylikeher,thedirectcompositebridgewillsatisfyherrestorativeneedforyearsto
come!
Dr.LowegraduatedmagnacumlaudefromLoyolaUniversitySchoolofDentistryin1982andservedthereasanassistantprofessor
inoperativedentistryuntilitsclosurein1993.SinceJanuaryof2000,hehasbeeninprivatepracticeinCharlotte,NC.Hereceived
FellowshipsintheAGD,InternationalCollegeofDentists,AcademyofDentistryInternational,andAmericanCollegeofDentists,and
receivedthe2004GordonChristensenOutstandingLecturersAward.In2005,hewasawardedDiplomatestatusontheAmerican
BoardofAestheticDentistry.Helecturesinternationally,publishesonaestheticandrestorativedentistry,andisaclinicalevaluatorof
materialsandproducts.Hecanbereachedat(704)4503321orviaemailatboblowedds@aol.com.

Disclosure:Dr.LowelecturesforKerrandGCAmerica.
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cameacrossthearticlesearchingwhatcompositeponticmeant.awesomeworksir.remarkablygood.
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