CLINICAL ARTICLE

“CLINICAL SUCCESS IN RESIN BONDED BRIDGES”

Fahim Vohra1 M Pros RCS, M ClinDent, MFDS, BDS.

Haroon Rashid2 MDSc, BDS

Resin bonded bridges offer a conservative approach to the restoration of edentulous spaces than conventional
bridgework. However, since their introduction, the main concern regarding resin bonding bridge work has been
increased debonding rates and inferior longevity. Increasing published scientific reports have shown success rates
of seven to nine years provided that vital success factors are respected. Clinical success in resin bonded bridgework
is dependent on identification of high risk cases, appropriate assessment, optimum bridge design, maximum tooth
coverage and meticulous clinical technique. This paper will examine design principles vital in the success of resin
bonded bridgework and present two clinical cases.
KEYWORDS: resin bonded bridge, clinical success, de-bonding, bridge design, case selection
How to cite this article: Vohra F, Rashid H. Clinical Success In Resin Bonded Bridges. J Pak Dent Assoc
2013;22(2):147-153.

INTRODUCTION & stability along with plaque retention remain with them
and they may not be the treatment of choice for most

T ooth replacement is a common dental need warranting

special considerations. Teeth may be missing due
to a number of factors which include trauma, congenital
conditions, caries, periodontal disease, restoration
requirements and failed dental treatments. The common
options available for management of missing teeth include
conventional fixed partial dentures, dental implants,
removable dentures, no replacement and resin bonded
fixed partial dentures.
Conventional fixed partial dentures are irreversible
options of tooth replacement and require tooth preparation.
Preparation sequence when followed requires extensive
reduction of the abutments which compromises the vitality
of the pulp tissue1. Plaque accumulation, inflammation
and gingivitis are also reported to occur in teeth restored
with conventional crowns & bridges2. Removable partial
dentures (RPD) restore function and aesthetics to an extent
and are cost effective, however problems of poor retention
1. HOD & Assistant Professor, Department of
Prosthodontics, Ziauddin College Of Dentistry. Ziauddin
University
2. Assistant Professor, Department of Prosthodontics,
Ziauddin College Of Dentistry, Ziauddin University
Correspondence: Dr Fahim Vohra
<fahimvohra@yahoo.com> Cell: 0305-9224353
individuals. Whilst removable prosthesis becomes loose
and unstable with time, dental implants can provide support
for both removable and fixed prosthesis which are both
aesthetic and durable. However; implants require clinical
expertise, circumferential bone, long-term maintenance,
increased expense and cannot be placed in growing
individuals and patients with medical contraindications.
Dentists may hesitate to provide resin bonded metal
restorations because of the fear that the restorations might
fail. However, dental literature has a number of studies
outlining the improved clinical performance of resin bonded
bridges. These restorations have shown survival rates that
are acceptable in view of minimally invasive techniques3,4.
Creugers et. al., 19915 reported 75% survival rates for the
anterior RBBs over a period of 7.5 years. Long term median
survival rates of 7 years and 10 months were reported by
Djemal et.al 6 and similar success rates were also reported
by Hussey & linden7. Boyer et. al.8 also demonstrated that
resin bonded bridges can provide predictable long term
clinical service . RBBs are considered useful alternatives
to conventional crowns and bridges but debonding has
been considered as main disadvantage of these restorations9.
However if sufficient coverage over the abutment teeth is
provided, proper case selection is done and the occlusal
considerations are understood during their fabrication,
these restorations offer good clinical performance whilst
being conservative.

147 JPDA Vol. 22 No. 02 Apr-June 2013

 Vohra F, Rashid H.
There is no standard registered body to give a number of
RBB’s fabricated or fitted in Pakistan. After an online
search of journal database in Pakistan
(www.pakmedinet.com), we were unable to find published
statistical facts related to the percentage of usage of RBB’s
in teaching institutes or private practices in Pakistan. This
makes it impossible to factually comment on the clinical
use of these restorations and in some way reflects the
inferior understanding and under usage of these indirect
restorations. This paper will present the factors vital in
clinical success of RBBs and two cases to demonstrate
their clinical application and treatment sequence.
FACTORS VITAL FOR CLINICAL SUCCESS OF
RESIN BONDED BRIDGES
The clinical success in the provision of resin bonded
bridges is multifactorial and these are discussed as follows.
a) Case Selection
Patients with para-functional habits can cause excessive
occlusal loading and increased demands on the cement
lute. Similarly, short clinical crowns in patients with tooth
surface loss, microdontia and hypodontia, teeth which are
heavily restored, and with abnormalities of enamel or with
exposed dentine surface reduce the amount of enamel for
adhesive bonding. Due to rapid developments in bonding
to enamel and dentine, techniques and materials, the above
mentioned conditions are although not absolute
contraindications for Resin Bonded Bridges but extra
precautions should be taken in the designing of connectors
and retainers, and bonding techniques. Patients should also
be consented and those with parafunctional habits provided
with an hard acrylic splint for night time wear.
b) Bridge and Connector design
There are three possible designs of a bridge based on
retainer type and connectors.
• Cantilever RBB
• Fixed-fixed RBB
• Hybrid bridge
Tay and Shaw10 in the year 1982 suggested that where
single missing anterior teeth were being replaced with
adhesive (Rochette) bridges then single unit cantilever
worked best. However in a study6 of 832 resin retained
bridges and splints, the median survival for fixed-fixed
designs was 7.8yrs whereas the median survival for
cantilever designs was 9.8yrs.
The movement allowed within the periodontal ligament
JPDA Vol. 22 No. 02 Apr-June 2013 148
Clinical Success In Resin Bonded Bridges
space of the abutment tooth together with the attached
bridge is responsible for the improved performance of
cantilever resin bonded bridges compared to fixed-fixed
RBB. In a fixed-fixed resin bonded design the opportunity
for such free movement is lost as the abutment teeth are
splinted together by the rigid framework. As a result of
this differential abutment movement, if one retainer
debonds, the bridge will still remain in situ and the carious
destruction of tooth tissue may go undetected for some
time. However, using a single retainer eliminates the
problem of partial decementation as the bond failure is
instantaneously obvious. This may also be seen as a
disadvantage because of dramatic failure.
However, it is suggested5 that it is too simplistic to
assume that longevity is automatically associated with
cantilever design. It was proposed6 that the increased
success associated with cantilever bridges is related to
their selection in relatively ‘safe’ situations i.e. where
occlusal demands are modest and the stability of the
abutment is predictable. However the ambitious use of
cantilevers simply to avoid a fixed-fixed alternative is
cautioned. In situations where the span is of such a length
that an abutment is needed at each end, or where the
occlusion is more complicated and excursive movements
on pontics cannot be avoided, or where tooth stability
following orthodontic movement is required then a fixed-
fixed design is indicated. A vital factor in decreasing the
risk failure is also to eliminate sliding contacts across the
tooth- retainer junction as this could result in tensile forces
between the tooth and retainer, increasing the risk of failure.
A conventional fixed movable-bridge has a rigid
connector usually at the distal end of the pontic, and a
movable connector on the mesial abutment tooth. It is
thought that the fixed-movable design exerts a ‘stress-
breaking’ effect, reducing the demands on the minor retainer
and allowing the abutments to retain a degree of independent
axial mobility. In reality whether this happens or not has
yet to be proven and there are no studies that demonstrate
increased longevity when utilising a fixed-moveable design.
With regard to resin bonded bridgework the use of fixed-
movable designs should be limited to hybrid bridges.
c) Retainer design & coverage
Resin bonding a cast framework was originally described
by Rochette11 and employed as a periodontal splint. This
was based on macro mechanical retention. Howe and
Denehy12 adapted this concept for a resin bonded bridge
with perforated retaining wings. Such restorations have
become known as Rochette bridges. Livaditis and
Thompson13 superseded this design with an improved
 Vohra F, Rashid H.
retentive mechanism for retainer retention; the etched
casting. This design became known as the Maryland bridge
after the institute in which the research was carried out.
The retainer should cover as much of the crown of the
abutment teeth as possible without compromising aesthetics
or oral hygiene. Maximal coverage increases the surface
area for bonding and so increases retention. Increasing the
height of the adhesive wing increases both retention and
resistance form. Furthermore, wrapping around as much
as possible with extension into the pontic area and the
tooth’s other proximal surface, therefore enhancing retention
and resistance form.
Retainers should be thick enough to ensure that they
are sufficiently rigid to resist flexion. Flexion of retainers
may cause failure of the cement bond. It has been
recommended that for nickel chromium a thickness of at
least 0.7mm is required14.
d) Framework alloy:
The Ideal Properties for metals alloys in case of resin
bonded bridges are optimum modulus of elasticity, accuracy
of casting, bonding to ceramic, bonding to resin cements,
biocompatibility and acceptable aesthetics. Nickel
chromium is preferred over type IV gold as it shows greater
bond to resin cements15, is less expensive and increased in
rigidity.
e) Occlusal management
Management of the occlusion is important in the success
of cantilever bridges. A careful occlusal analysis is required
to avoid heavy contact on the pontic especially in excursive
movements which could cause bond failure or tooth rotation.
In situations where occlusion is more complicated and
excursive movements on pontics cannot be avoided then
a fixed-fixed design is indicated.
Adhesive retainers generally require at least 0.7mm of
space between abutment teeth and their antagonists, if
resistance of the framework to flexure is to be adequate.
Often it is necessary to create space for the framework.
There are a number of ways of creating space.
• Preparation of the abutment
• Adjustments of the antagonists
• Relative axial toot movement
f) Tooth preparation
Initial trends in resin bonded bridges were of non
preparation. However due to perceptions of increased de-
bonding, preparation of teeth with slots and grooves in
enamel have increased. Preparation results in sensitivity,
caries with undetected de-bonding, difficulty in
temporization, makes removal of bridges difficult and
renders the process irreversible. The very concept of resin
149
Clinical Success In Resin Bonded Bridges
bonded bridges is conservation of tooth structure, which
is lost with tooth preparation. It is established that interfacial
bond strength of resin cements to enamel is far greater
than dentine16, as a result dentine exposure needs to be
avoided during tooth preparation. Use of proximal grooves
(1 to 3 mm), is becoming come practice17 for better retention
and resistance form of preparations. Other preparation
features include rest seats for a seating stop and resistance
to displacement, parallel proximal surface preparation or
guide planes to increase connector height and develop path
of insertion, palatal or lingual reduction for space of metal
retainer and axial reduction supragingival margins allowing
for 180° wrap around of the retainer to abutment tooth.
However, there is no evidence to suggest that tooth
preparation provides greater success rates6 and to date no
comparable data is available. Therefore, a balance needs
to be established between decreased risk of de-bonding
and caries development in case of undetected partial failure.
g) Pontic design
Initially, investigators thought that the pontic material
may have been an important factor in the aetiology of
inflammatory changes beneath bridge pontics. In a further
investigation18 the plaque retaining capacity of four dental
materials was assessed. They found that the plaque retaining
capacity of porcelain and acrylic was significantly different
to type III gold and ceramo-metal. Therefore, porcelain
and acrylic were easier to clean though all could be cleaned
in time. In addition to that, pontic surfaces should be a
smooth as possible to prevent them from being plaque
retentive19.
The most important features of pontic design are
therefore related to its cleansability. Poor cleansibility
around pontics can lead to plaque accumulation and hence
soft tissue inflammation. Proper oral hygiene instruction
to the patient and the cleansability of pontics is more
important than the choice of material. Therefore, pontics
should have passive tissue contact with a convex, smooth
fit surface and adequate embrasure space to facilitate
cleaning.
h) Periodontal considerations
The periodontal health of the remaining teeth should
always be optimum before bridgework is commenced and
this should be maintained after the bridge is constructed.
Aspects of bridge design that have implications for the
periodontium need to be considered, which include
overcontouring, undercontouring, surface finish, cleansable
embrasures, optimum marginal fit, adequate cement lute
finish and polish, a favourable pontic-soft tissue contact
and ideal proximal contact points. An over contoured
JPDA Vol. 22 No. 02 Apr-June 2013
 Vohra F, Rashid H.
restoration may cause plaque accumulation and gingival
inflammation and the margins should be placed
supragingivally1,20,21.
Good periodontal health is dependent on the patient’s
ability to control plaque, and restorations should provide
optimum access for oral hygiene. Overcontoured
restorations in the embrasure region leave insufficient
room to accommodate an oral hygiene aid. In case of teeth
with poor periodontal support when using relative axial
tooth movement, splaying of abutment teeth may occur
rather than intrusion or compensatory eruption of the
remaining teeth. Teeth with active periodontal inflammation
(gingivitis, periodontitis) render the prosthodontic treatment
almost impossible due to presence of increased fluids and
bleeding during tooth preparation, impression taking and
restoration fit.
i) Aetiology Of Tooth Loss
The cause of tooth loss or absence can be an important
factor in successful function of resin bonded bridges. The
causes resulting in a need of RBB can be hypodontia,
extraction due to orthodontic reasons, trauma, caries and
its sequelae and periodontal disease. Patients with
hypodontia have deficient enamel for adhesive bonding.
Garnett et al4 (2006) in a follow up study of 79 RBB’s
over a period of eleven years reported 41.1% debonding
rate. Increase failure rates have been reported5 for trauma
patients due to increased dentine exposure and short clinical
crowns of abutment teeth. Saddles with increased bone
loss due to periodontal disease result in taller and longer
pontics. This could present the potential for greater non-
axial forces on the restoration, however, taller abutments
also allow for increased dimensions of connectors. Teeth
lost due to and dentition affected by periodontal disease
show differential micr-movement. This could further result
in partial de-bonding at one or more abutments with greater
individual tooth mobility.
j) Fit of framework
A poorly fitting restoration results in plaque
accumulation which creates the potential for gingivitis,
periodontitis, marginal leakage, secondary caries, partial
debond of bridge and complete decementation. Therefore
it is pivotal that the framework is as accurate a fit to the
abutment tooth surface as possible. As the thickness of
the cement lute increases above the optimum, the bond
strength decreases22. In a further study, Chana et al23 showed
that bridges constructed using a refractory die technique
produce more accurate castings than those where the pattern
was lifted off the cast prior to investing.
k) Cementations procedure
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Clinical Success In Resin Bonded Bridges
Preparation of the retainer surface should be carried
out immediately before cementation using 50um alumina
in a sandblaster. Sandblasting helps to increase surface
area, form micromechanical undercuts and remove the
oxide layer from the metal surface. Following this, the
metal should be steam cleaned to ensure it is free from
alumina or metal deposits. Resin cements are the material
of choice and the cementation protocol for each product
should be strictly adhered. Metal alloy resin primers are
also used in some cement systems (Panavia- Ex, Kuraray
Co., Ltd., Osaka, Japan) to couple the adhesion of resin
cement to metal. Isolation with a rubber dam is essential
for the success of all enamel and dentine bonding
procedures.
CLINICAL CASES
Both the cases presented below were initially screened
by a senior clinician and referred to the prosthetic
department clinic for restoration of spaces with fixed
prosthesis. The patients were treated within four clinical
appointments involving Initial assessment and treatment
planning, tooth preparation and final impression, try-in
and cementation and lastly follow-up. Initial assessment
involved history taking, intra and extra oral examination,
radiographic records, alginate impressions, facebow and
interocclusal record. In the laboratory, casts were prepared
and articulated on a semi-adjustable articulator (Denar)
and assessed for abutment position, angulation, mesio-
distal and inter-occlusal saddle space, tissue loss at the
saddle (bucco-lingual and vertical) and verification of
intra-oral findings (Occlusion). Following which a
diagnostic wax-up was performed in order to assess and
plan for the type, design and contours of the planned
restoration. Also custom trays were requested to be ready
at the next clinical visit. Second clinical appointment
involved treatment plan discussion, mouth preparation,
final impression ( Dual phase, single stage
polyvinylsiloxane; PVS in custom tray), inter-occlusal
record and shade and mould discussion and decision. Third
clinical visit included prior to sand-blasting try-in and
adjustments, sandblasting and cementation. In both cases
cementation was carried out using; Panavia-Ex, dual
polymerized resin based cement under rubber dam. Follow-
up appointment involved patient’s feedback, assessment
of occlusion, function, aesthetics and patient adherence to
plaque control.
Clinical case A: (Figures 1 & 2) was a 15 year old
female with missing bilateral mandibular premolars due
 Vohra F, Rashid H.
Fig 2: Postoperative image,
after fit of fixed-fixed resin
Fig 1: Preoperative mandible
bonded bridges
with missing premolar teeth
to hypodontia. The history revealed that the patient had
orthodontic treatment and was at the stage of wearing a
full-time retainer. The patient was medically fit and well
with no known allergies and abnormalities. On intra-oral
assessment, the mesio-distal saddle space was for a single
unit premolar tooth bilaterally. There was no active disease
in relation to soft and hard oral tissues and the direct
restoration present ( class V composite on tooth number
36 and 46) were deemed as optimum on clinical and
radiographic evaluation. The occlusion was class-I with
canine guidance bilaterally and absence of posterior
interference. The spaces were restored with contemporary
resin bonded bridges to preserve the sound abutment teeth
as implants were contraindicated due to continued growth.
After completion of diagnostics the only tooth preparation
carried out was at the proximal surfaces of abutment teeth
for guide planes. No tooth preparation was deemed essential
for occlusal surface of molars and lingual of the canines
(abutment teeth) due to presence of space after orthodontic
treatment. The design involved coverage of lingual surfaces
of canine and molar including 1/4th of the lingual-occlusal
surface as a seating lug. The cementation was done under
rubber dam with Panavia- Ex (Kuraray Co., Ltd., Osaka,
Japan). The cement lute margins were finished and polished
using shofu rubber wheels followed by diamond polishing
paste on rubber cups using a slow speed motor.
Clinical case B: (Figures 3, 4 and 5) illustrates the
Fig 3: Preoperative image Fig 4: Postoperative image
showing buccal view of missing showing buccal view of
maxillary first premolar restored maxillary first
premolar space with resin
bonded bridge
151
Clinical Success In Resin Bonded Bridges
Fig 5: Postoperative
occlusal view of resin
bonded bridge restoring
maxillary first premolar
provision of resin bonded bridge for replacement of lost
maxillary left first premolar. Tooth was lost due to refractory
infection and bone loss as a consequence of an endo-perio
lesion. The mesial abutment ( canine) was un-restored
and vital and the distal abutment (second premolar) was
also vital with an adequate, moderate sized class I occlusal
amalgam. Resin bonded bridge with palatal and partial
occlusal coverage retainers was the treatment of choice
and was chosen with mutual consent. To obtain a minimum
of 4mm of connector height the distal proximal surface of
canine and mesial of premolar received minimal preparation
for guide planes. The interocclusal space on the palatal
canine surface was created by using relative axial tooth
movement as described by Dahl24. The inter-occlusal space
created was 0.7mm ( the thickness of the retainer) and
space closure was complete in 16 weeks with full arch
contacts.
In the period during which axial tooth movement took
place, patient was reviewed every two weeks for carrying
occlusal adjustments.
Both patients were delighted with the outcome of
treatment and are reviewed every six months for detection
of prosthesis related issues specifically, partial de-bonding.
DISCUSSION
The intention of this article is to present the vital factors
in success of resin bonded bridges along with a couple of
clinical cases to elaborate on some clinical issues
encountered during treatment. In both the cases the spaces
were restored with RBB’s primarily due to conservation
of dentition and tooth structure. Also the relative
contraindications for this treatment modality (parafuntional
activity, high caries risk, heavily restored abutments, long
span or heavy occlusal loads) were within physiologic
limits. In case B, the presence of class I amalgam restoration
did not compromise the adhesive bonding of retainer, as
there was enough enamel at the mesial marginal ridge and
beyond.
A fixed–fixed RBB was the design of choice, reason
JPDA Vol. 22 No. 02 Apr-June 2013
 Vohra F, Rashid H.
being multifactorial. Firstly, cantilever RRB’s, although
reported to have higher success rates6 are mostly in case
of anterior saddle areas. Secondly, minimal preparation
results in reduced tooth reduction than anticipated in cases
of two abutment retained fixed-fixed design. RRB’s are
retained primarily by adhesive bond strength along with
the mechanical guide planes. Bond strength is directly
proportional to the amount of surface area available for
enamel bonding. In both cases the complete lingual surface
of posterior teeth along with the lingual proximal surfaces
were bonding substrates, resulting in 180° enwrapment.
In addition, a mesial occlusal marginal ridge rest seat was
also utilized to act as a seating stop. Furthermore, complete
lingual surfaces of canines in both cases were also bonding
substrates. This not just increased the retention, but also
resistance form of the metal framework6,14.
Preparation of teeth is not always necessary to create
space for retainers, as space in occlusion may be present
as shown in clinical case A (lingual surface of canine). As
metal can be finished knife edge, no distinct preparation
margins were prepared. The metal framework was designed
to be 1mm short of lingual and proximal gingival margins
for ease of cementation and cleansability for the patient.
Space creation at the palatal surface of maxillary canine
abutment was done using relative axial tooth movment24.
Relative axial tooth movement occurs when a localised
appliance or restoration is placed in supra-occlusion, the
occlusion re-establishes full arch contacts over a period
of time. This method has been used for creation of
interocclusal space in cases of tooth wear in combination
with dento-alveolar compensation resulting in loss of
prosthesis space. In a retrospective evaluation25 of the
outcome and factors relating to the creation of localised
inter-occlusal space, space was created with the use of an
interim prosthesis that was generally a cemented cobalt
chromium appliance. 50 appliances were reviewed in the
study and the success rate was 96%.
Adhesive bond of a cemented RRB involves two
substrates (metal and tooth enamel) resulting in two
interface. On one side, resin cement interacts with the
conditioned tooth enamel, resulting in a highly predictable
bond. On the other side the metal retainer is surface treated,
mechanically by the use of sandblasting with alumina
particles and chemically using bi-functional metal primers
(Panavia- Ex, Kuraray Co., Ltd., Osaka, Japan) enhancing
bond strength26 and increasing survival rates of bonded
metal restoration 27,28. Significantly higher bond strengths
have been reported for silicoating procedures, which
involves sandblasting metal retainers with silica coated
JPDA Vol. 22 No. 02 Apr-June 2013 152
Clinical Success In Resin Bonded Bridges
alumina particles resulting in enhanced bond strengths29.
CONCLUSION
Resin Retained bridge is a viable treatment option for
replacement of one to two missing teeth in anterior or
posterior regions of the mouth and should always be
included in the treatment options for indirect restorations.
These restorations have lower survival rates in comparison
to conventional restorations, however they are, conservative
of tooth structure, cost-effective, not needing local
anaesthesia administration and reversible in nature with
minimal or no tooth damage on debond. Its longevity is
supported by increased enamel for adhesive resin bonding,
non mobile abutments, lack of parafunction, rational bridge
design, appropriate alloy selection, maximum enamel
retainer coverage, adequate connector height and meticulous
clinical technique.
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