CASE REPORT

Australian Dental Journal 2005;50:(2):114-118

Indirect resin-bonded fibre-reinforced composite anterior bridge: A case report

A Husein,* T Berekally*

Abstract In recent years fibre-reinforced resin composites (FRCs) have gained increasing acceptance in mainstream prosthodontics as viable alternatives to alloy-based restorations. A combination of good aesthetics and fracture toughness validates their use in a diverse range of clinical applications. In this case report an indirect resin-bonded fibre-reinforced composite anterior bridge incorporating a novel design is described. At 24-months recall the prosthesis was problem free and the patient was very happy with the treatment outcome. While definitive long-term data about their clinical performance is scarce, fibre-reinforced resin composite prostheses appear to have a worthwhile role in the conservative treatment of short edentulous spaces.
Key words: Fibre-reinforced resin composite, resinbonded, case report. Abbreviations and acronyms: FRC = fiber-reinforced resin composite. (Accepted for publication 31 August 2004.)

INTRODUCTION Fibre-reinforced composites have numerous industrial and aerospace applications because they are light, strong and non-flammable. However, with respect to clinical dentistry they are relative newcomers into the spectrum of prosthodontic treatment options.1 Their dental origins can be traced back to earlier experiments investigating the reinforcement of acrylic denture bases with carbon fibre.2-4 Over the years these materials have evolved to the extent that they can be used for both direct and indirect restorations5 including in more recent times implant supported prostheses.5-7 The durability of fibre-reinforced resin composites is collectively related to: 1) the individual properties of the fibres and resin matrix; 2) impregnation of fibres

with resin; 3) adhesion of fibres to matrix; 4) volume of fibres in the composite matrix; 5) the orientation of the fibres and; 6) location of fibres in the prosthesis construction.8 Moreover their alloy-free composition has distinct aesthetic advantages. Several clinical studies have reported a range of problems that may occur with ceramo-metal resinbonded prostheses, namely, the potential for alloy hypersensitivity, corrosion, health hazards to laboratory personnel, abutment tooth greying, retainer fracture and partial or total loss of attachment from bridge abutments.9-11 Base metal bridge frames, whilst strong and durable in thin cross sections, are also very stiff as a result of their high elastic modulus. This property may contribute to the partial loss of attachment observed in fixed multiple abutmentsupported prostheses.12 Accordingly, a trend has emerged in the utilization of cantilever single abutment supported bridges to offset the possibility of partial debonding and its sequelae.12,13 In the authors opinion, FRC bridges may be better able to dissipate functional loads as a result of their lower elastic modulus compared to alloy-based restorations and on this premise fixed FRC bridges may have a superior retention rate in the long-term. The inherent strength of fibre-reinforced resin composites coupled with the excellent aesthetics afforded by an alloy-free composition formed the basis for choosing the bridge design described in this case report. CASE REPORT A 49 year old male was referred to the Specialist Services Clinic of the Adelaide Dental Hospital for the replacement of two missing upper anterior teeth that were lost as a result of a motorcycle accident. This traumatic event also rendered him a paraplegic. The patient had been wearing a cobalt-chrome partial upper prosthesis but his plea was to have a fixed replacement for the missing incisors, in the form of a bridge or implant-supported single crowns. He also enquired about the possibility of veneers to mask out the discoloration and surface defects on 12, 21 and 23.
Australian Dental Journal 2005;50:2.

*Dental School, Faculty of Health Sciences, The University of Adelaide, South Australia.
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Fig 1. Extra-oral preoperative anterior view. Fig 4. Survey line on 21 indicating labial bulge.

Fig 2. Intra-oral preoperative labial view.

The treatment options considered included a ceramometal fixed-fixed bridge, a fixed-fixed resin-bonded ceramo-metal Maryland bridge with a cantilever 11 pontic, a direct FRC bridge or two implant-supported single crowns. The last option whilst desirable and feasible was rejected on financial grounds and the first option was not pursued because of its invasive nature. Following some further discussion with the patient, a conservative resin-bonded bridge design became the preferred option to restore the edentulous spaces and porcelain laminate veneers to mask out the aesthetic anomalies associated with 12 and 21. After further examination of the diagnostic models the authors pondered whether an indirect fibre-reinforced composite bridge could be fabricated whereby 12, 21 and 23 could all be used as abutments to support a single bridge frame. The orientation of 12 and 21 precluded the use of a palatal bonded retainer on the latter. Hence the idea arose as to whether a labial facing on the 21 could be utilized as both a bridge retainer and a masking restoration. The maxillary model was surveyed and a wax mock-up of the bridge design was constructed to see if the prosthesis could in fact be

Fig 3. Extra-oral view of maxillary model.

On examination no extra-oral abnormalities were detected. His lip line via a reserved smile exposed about 75 per cent of the upper anterior tooth crowns (Fig 1). Intra-orally the soft tissues were sound and his oral care was very good. Further examination revealed an Angles Class II Divison 2 incisor tendency (Fig 2). The 21 was mildly retroclined and the 12 slightly rotated towards the labial. This difference in angulation between incisors is illustrated in Fig 3.
Australian Dental Journal 2005;50:2.

Fig 5. Diagnostic wax up of bridge labial view.

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Fig 6. Diagnostic wax up of bridge palatal view.

Fig 8. Palatal view FRC bridge on master model.

placed over all three intended bridge abutments. Figure 4 illustrates a labial bulge apical to the blue survey line on the 21 which if recontoured would allow placement of the bridge as a single span entity. A diagnostic wax-up of the proposed bridge was carried out after the appropriate bench top recontouring of 21. It appeared that a one-piece prosthesis was possible. The design consisted of a labial veneer on 21, a lingual retainer on 12 and pontics to restore the 11 and 22 spaces. Figure 5 and 6 illustrates labial and palatal views of the wax up of the diagnostic model. At the second appointment the patient was shown the trial wax up of the intended bridge. After viewing the wax bridge and being shown the minimal amount of tooth reduction involved he was happy to proceed with treatment. Abutment tooth 21 was prepared for a labial veneer with incisal-palatal overlap as described by Garber et al.14 Proximal reduction was performed on 12, 21 and 23 to create guide planes for path of insertion. The chamfer margin was extended onto the labial of 23 to mask out stains on this tooth with a bridge retainer extension. The abutment tooth margins for 12 were prepared similar to those described for resin-bonded cast alloy bridges incorporating gingival and proximal chamfer finish lines and a cingulum rest.15 A two-phase polyvinylsiloxane impression (Imprint II 3M/Espe, St Paul, Minnesota, USA) was taken of the

abutment teeth. Gingival retraction was unnecessary since the abutment tooth margins were supragingival on both labial and palatal aspects. A temporary resin composite provisional bridge was fabricated using Protemp-Garant, (3M/Espe) and cemented with a dualcuring temporary resin cement Temp Bond Clear (SDS/Kerr, Orange, California, USA). The FRC bridge was constructed using Sinfony resin (3M/Espe) with a cold gas plasma-coated high molecular weight polyethylene ribbon, Connect (SDS/Kerr) incorporated as the fibre-reinforcement of the bridge frame. Figure 7 and 8 illustrates the laboratory-fabricated prosthesis.

Fig 9. Anterior view with bridge in place.

Fig 7. Labial view of FRC bridge on master model.

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Fig 10. Intra-oral view of cemented bridge.

Australian Dental Journal 2005;50:2.

fracture resistance, marginal integrity, gingival tolerance and effect on opposing tooth surfaces certainly warrant ongoing long-term investigation. CONCLUSIONS The treatment described in this case report appears suitable as a conservative alternative to the more traditional prosthodontic strategies such as removable partial dentures, ceramo-metal bridges and implantsupported crowns. In concert with their alloy-based counterparts, fixed-fixed indirect resin-bonded fibrereinforced resin composite may also have a role to play in the array of treatment options for the replacement of single teeth in young patients as a lead up to implant therapy at a later age. Moreover they are indicated for the elderly and disabled patients for whom complex dentistry is either impractical or out of reach on a cost basis. Furthermore, the metal-free composition of these restorations has clear benefits for patients who have known hypersensitivity reactions to dental alloys. ACKNOWLEDGEMENTS The authors would like to thank the Board of Management of the South Australian Dental Service for their approval to publish this case report. In accordance with client confidentiality protocols consent was obtained from the patient for the inclusion in this article of personal health information held by the South Australian Dental Service. REFERENCES
1. Rosenstiel SF, Land MF, Fujimoto J. Contemporary Fixed Prosthodontics. 3rd edn. St Louis: Mosby, 2001:697-706. 2. Schreiber CK. Polymethylmethacrylate reinforced with carbon fibres. Br Dent J 1971;130:29-30. 3. Manley TR, Bowman AJ, Cook M. Polymethylmethacrylate (PMMA) denture bases reinforced with carbon fibres. Br Dent J 1979;146:25-29. 4. Ekstrand K, Ruyter IE, Wallendorf H. Carbon/graphite fiber reinforced poly(methylmethacrylate): Properties under dry and wet conditions. J Biomed Mat Res 1987;21:1065-1080. 5. Freilich MA, Meiers JC, Duncan JP, Goldberg AJ. Fibrereinforced Composites in Clinical Dentistry. Chicago: Quintessence Publishing Co Inc, 2000. 6. Ruyter IE, Ekstrand K, Bjrk N. Development of carbon/graphite fiber reinforced poly(methylmethacrylate) suitable for implantfixed dental bridges. Dent Mat 1986;2:6-9. 7. Bjrk N, Ekstrand K, Ruyter RE. Implant-fixed dental bridges from carbon graphite reinforced poly(methylmethacrylate) prostheses. A longitudinal multicenter study. Clin Oral Impl Res 1995;6:246-253. 8. Vallittu PK. Strength and Interfacial Adhesion. In: Vallittu PK, ed. The Second International Symposium of Fibre Reinforced Plastics in Dentistry. Finland: University of Trk, 2002:2-28. 9. Culy G, Tyas M. Direct resin-bonded, fibre-reinforced anterior bridges: a clinical report. Aust Dent J 1998;43:1-4. 10. Berekally TL, Smales RJ. A retrospective clinical evaluation of resin-bonded bridges inserted in the Adelaide Dental Hospital. Aust Dent J 1993;38:85-96. 11. Creugers N, De Kanter R, vant Hof M. Long-term survival data from a clinical trial on resin-bonded bridges. J Dent 1997;25:239-242. 12. Botelho M, Nor L, Kwong H, Kuen B. Two-unit cantilevered resin-bonded fixed partial dentures a retrospective preliminary clinical investigation. Int J Prosthodont 2000;13:25-28.
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Fig 11. Intra-oral palatal view of cemented bridge.

At the third appointment the FRC bridge was tried in. After minor occlusal adjustments the patient was very pleased with the appearance and fit of the bridge. After air abrasion with Rocatec Soft (3M/Espe), the fitting surfaces of the bridge retainers were coated with a silane bonding agent, Ceramic Primer (SDS/Kerr) and a dual-curing resin cement, Panavia-F (Kuraray Medical Inc, Osaka, Japan) was used to lute the prosthesis in place. Post insertion views of the bridge are shown in Fig 9-11. DISCUSSION Fibre-reinforced composite bridges can be fabricated directly chairside and via the dental laboratory. The former technique has the benefit of an immediate result. However, in order to optimize aesthetics and bridge form a lot of chairside time is involved. In addition, the direct method of incrementally building up a large span restoration has inherent problems including resin depth of cure, adequacy of light curing, incorporation of porosities, pontic contour, surface polish of the pontic fitting surface and adequate coverage of the fibre component of the bridge. In this particular case the indirect method of fabrication was chosen because the resulting prosthesis, in the authors experience, has superior aesthetics, surface polish, colour stability and durability in comparison to the direct bridge. Indeed, at a 24-month recall the patient was very pleased with the treatment outcome on the basis that the bridge was aesthetic, comfortable, functional and retentive. While short-term studies of indirect resin-bonded FRC bridges indicate that their clinical performance appears promising16-18 there is a paucity in the long-term evidence-based data that is so desirable in order to substantiate their viability when discussing treatment options with the patient. In a recent pilot study19 investigating the survival rates of glass fiber-reinforced composite fixed partial dentures the author cites a mean survival time for these restorations at 55 months. Interestingly in this study, as with the case in this report, the multiple unit prostheses examined employed a variety of abutment tooth preparation designs. Indeed, properties such as wear rate, colour stability,
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13. Chan A, Barnes I. A prospective study of cantilever resin-bonded bridges: an initial report. Aust Dent J 2000;45:31-36. 14. Garber DA, Goldstein RE, Feinman RA. Porcelain Laminate Veneers. Chicago: Quintessence Publishing Co Inc, 1988. 15. Flood AM. Resin bonded prostheses: clinical guidelines. Aust Dent J 1989;34:209-218. 16. Freilich M, Meiers J, Duncan J, Eckrote K, Goldberg A. Clinical evaluation of fiber-reinforced fixed bridges. J Am Dent Assoc 2002;133:1524-1534. 17. Vallittu PK. Prosthodontic treatment with a glass fibre-reinforced resin-bonded fixed partial denture: A clinical report. J Prosthet Dent 1999;82:132-135. 18. Vallittu PK, Sevelius C. Resin-bonded, glass fibre-reinforced composite fixed partial denture: a clinical study. J Prosthet Dent 2000;84:413-418.

19. Vallittu PK. Survival rates of resin-bonded glass fiber-reinforced composite fixed partial dentures with a mean follow-up of 42 months: a pilot study. J Prosthet Dent 2004;91:241-246.

Address for correspondence/reprints: Dr Tom Berekally Adelaide Dental Hospital Frome Road Adelaide, South Australia 5000 Email: tom.berekally@adelaide.edu.au

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