Resin-bonded fixed partial dentures; Metals to Ceramics

- a literature review.
Review
Sudhakara V Maller , Karthik. K. S. , Udita S Maller
1 2 3
1
Ksr Institute Of Dental Science And Research, Tiruchengode.
2
- Senior Lecturer Department Of Prosthodontics,
Ksr Institute Of Dental Science And Research, Tiruchengode.
3
- Professor, Ksr Institute Of Dental Science And Research,
Tiruchengode.
Address for correspondance :
Sudhakara V Maller,
Department Of Prosthodontics
KSR Institute Of Dental Science And Research,
KSR Kalvinagar, Tiruchengode,
Namakkal Dist- 637215.
Phone Number: 9443051313.
E- Mail Id: drmallers@in.com

- Professor & Head Of The Department Of Prosthodontics,
ABSTRACT
Purpose: Resin-bonded fixed partial dentures (RBFPD) have been in
our profession for over 40 years. The aim of this work was to provide
some background about their evolution.
Materials and Methods: Publications listed in the Pubmed were taken
as references for this review.
Results: The typical design of RBFPDs is characterized by a high degree
of conservation of tooth structure of abutments compared with
designs of conventional fixed prostheses. This review captures the
developments in preparation design and bonding techniques as well as
better understanding of the appropriate type of metal alloy to be used
and the best preparation method for enhanced bonding. Use of all-
ceramic systems for resin bonded fixed partial dentures is also
included.
Conclusion: RBFPDs should be considered viable treatment options for
those clinical situations that are best suited for their use. Preparation
design, cement type, and casting alloy, all-ceramic types suitable as
well as surface treatment are among the most important factors that
influence longevity of RBFPDs.
Keywords: Resin cements, Ceramics, Fixed partial dentures.
Introduction:
The introduction of enamel acid etching and
resin bonding by Dr Buonocore in 1955 marked the
(
beginning of a new era of adhesive dentistry . Not
only did this have a significant impact on tooth
restoration techniques, but it also opened the door for
new applications in preventive dentistry, orthodontics,
periodontics, and prosthodontics. Initially, the
technique made it possible to bond resin composite
restorations to enamel of anterior teeth; hence,
restoration of fractured incisors became a simple task.
Later, bonding applications were extended to the
posterior teeth. Furthermore, modifications were
made to render other direct restorative materials,
including amalgam, bondable to tooth structure, with
benefits ranging from enhanced marginal seal to
12,14
strengthening of remaining tooth structure . In
preventive dentistry the introduction of fissure sealing
techniques was a significant milestone, while in
orthodontics the introduction of bondable brackets to
replace bands was an important enhancement to
(9)
fixed appliance type of treatment .
In 1973 Dr Rochette of France introduced the
idea of bonding a cast metal bar to the lingual
surfaces of periodontally involved anterior teeth for
9,12,14)
splinting purposes using the acid-etch technique and
9,13
an unfilled resin cement . The cast metal splint had
perforations made with sloping walls to permit
attachment to the resin cement through mechanical
interlocking. This idea was applied by Howe and
Denehy in 1977 to a specially designed partial
denture to the enamel of abutment teeth in the
anterior segments of the mouth. This earliest design of
resin-bonded fixed partial dentures (RBFPD) was later
referred to as the Rochette bridge, and Howe and
Denehy were conservative in their expectations of the
longevity of such a prosthesis, considering it to be only
provisional.
Since that time, a number of significant
modifications to this original design have improved its
longevity in the oral environment, and currently
RBFPDs are considered by many to be a viable
alternative to conventional fixed partial dentures
(FPD).
Current advancements involve the inclusion of
all-ceramic systems to eliminate the metal frame work
and reduce the disadvantage of metal inclusion
mainly the unaesthetic metal appearance in the
17,20
proximal areas .
JIADS VOL -1Issue 1 Jan-March,2010 |22|
The aim of this article is to review the
significant developments and modifications to
RBFPDs since their introduction to the profession in the
late 1970s and to describe their preparation designs
for replacement of Single missing anterior and
posterior teeth. Advancements in the design and
approach with the advent of all-ceramic systems have
20
been discussed .
Treatment of the Fit Surface of the Casting:
The original design of RBFPDs suggested by Howe
and Denehy was indicated for replacement of single
missing anterior teeth with minimal preparation of the
abutment teeth. Livaditis suggested a modification to
the original RBFPD design to include preparation of
guide planes through reduction of lingual and
proximal surfaces and preparation of occlusal rest
seats to resist tissue ward displacement of the
prosthesis. However, the Rochette RBFPDs were
associated with a considerable number of clinical
failures, in part because the retention area of the wing
surface to which the resin cement attaches was limited
to the perforations only and not the whole wing
surface, and because of occasional fracture of the
wings, which were weakened by the perforations and
could not sustain long-term repeated loading of
mastication forces. This led Livaditis and Thompson to
develop a method for treatment of the metal surface
to render it retentive without resorting to the retentive
perforations. This involved electrolytic etching of a
non precious metal alloy to create microscopic
surface roughness through selective dissolution of the
9,10
most corrosion-sensitive phases in the metal .
However, electrolytic etching has some
disadvantages. It requires the use of special
laboratory equipment, and the quality of etching is
dependent on a number of factors that include the
type of casting alloy, type of acid etchant, acid
concentration, etching time, and electric current
density. Because of the variability of surface areas
among retainer wings and the difficulty of measuring
them, inaccurate setting of the electric current density
may result in inferior etching quality (underetching or
overetching), and hence may lead to early
detachment of the prosthesis. Quality control by the
clinician is also a problem, as the produced surface
roughness cannot be assessed by the naked eye; a
microscope is necessary for verification of the quality
9
of etching .
Because of the above shortcomings of
electrolytic etching, other alternative techniques were
developed. These ranged from chemical etching with
different acids to incorporation of retentive devices in
the retainer wing to provide macroscopic roughness.
Ot her advocat ed t he use of l ost sal t
technique(Virginia bridges) with NaCl salts, and use
of cast nylon mesh inclusion was also applied to
improve the surface area for binding, while the
addition of macroscopic retentive devices resulted in
adequate bond strength in most cases, these devices
never gained clinical popularity because some
resulted in over contouring of the lingual surfaces of
the abutment teeth with potential for subsequent peri-
odontal problems, and others led to compromised fit
of the casting. Chemical etching, on the other hand,
resulted in adequate bond strength but was reported
to be dependent on the etching gel temperature and
10
on the number of applications .
Micro-etching of the fit surface of the casting
with aluminum oxide powder was then suggested,
and studies that tested its effectiveness reported
positive results. Advantages of micro-etching include
the fact that it does not require expensive equipment
to perform and the change in the appearance of the
surface is visible to the naked eye. A clinical trial study
that followed these reports found no significant
difference in survival rates between RBFPDs that were
electrolytically etched and those that were
9
microetched .
Another method for preparation of the metal
surface for bonding is silicoating. This involves the
fusion of a thin layer of silica, about 0.5 m, to the
alloy fit surface. At cementation, this layer of silica
reacts chemically with a silane coupling agent that is
applied before the resin cement. A number of studies
indicated that the bond strength between a silicoated
non-precious alloy and resin cement was similar to
the bond to a micro-etched surface of the same alloy.
However, this method of surface treatment typically
requires the use of a silicoater, which is a relatively
expensive piece of equipment, and unless
cementation is performed immediately after coating,
9,18
it may adversely affect bond strength .
For the use of all-ceramic systems, both glass-
ceramics and high-strength oxide ceramics can be
used to produce optical properties similar to those
observed in natural teeth. For the ceramic bonding a
new approach for modifying zirconia surfaces
(tentatively named NobelBond; Nobel Biocare AB)
2,17,20
was introduced .
Bonding Systems:
The f i r st r esi n composi t e cement
manufactured for use with RBFPDs was Comspan
Resin-bonded fixed partial dentures; Metals to Ceramics Sudhakara Maller, Karthik & Udita Maller
JIADS VOL -1Issue 1 Jan-March,2010 |23|
(Dentsply/Caulk). This was based on a bis-GMA
formula, and over the years it became synonymous
with RBFPDs. In spite of its continued use for a number
of years, this cement only attached to the etched metal
surface through engaging the micro-roughness,
without any kind of chemical bonding with the casting
alloy. To enhance the bond between the casting and
the resin cement, other resin cements that were
capable of chemical bonding to the surface of
nonprecious metal alloys were later formulated.
Super-Bond C&B (Sun Medical), which is capable of
chemical bonding to base metal alloys, was in-
troduced to the profession in 1981. This had the
component 4-methacryl oxyethyl tri mel l i tate
anhydride (4-META), and a significant improvement
in the bond strength of a nickel-chromium alloy to the
resin cement was achieved with this type of chemical
compared with plain cement. However, oxidation of
the fit surface is necessary to enhance the effect of this
chemical bond, as the 4-META reacts more readily
with the oxide film than with the nonoxidized alloy
surface.
Another resin cement that has a special
formulation capable of chemical bonding to oxides of
nickel, chromium, and cobalt is Panavia EX (Kuraray),
which was first introduced to the profession in 1984. It
is based on a bis-GMA resin and contains a chemical-
known as MDP (10-methacryloxydecyl dihydrogen
phosphate).
RBFPD frame works fabricated with densely
sintered oxide ceramics rely exclusively on adhesive
cementation for retention. However, chemical
bonding associated with mechanical interlocking is
necessary to obtain a strong, durable, and reliable
resin bond to ceramics. Recently, a new approach for
modifying zirconia surfaces (tentatively named
NobelBond; Nobel Biocare AB) was introduced. The
new modified surface is purported to have a unique
adhesive surface replete with intricate micro-
porosities. The modified zirconia surface does not
require further post-manufacture surface treatment,
being ready for adhesive cementation as is. It has
been suggested that the combination of zirconia
mechanical properties with the new adhesive surface
would be advantageous for the fabrication of RBFPD
17,20
framework .
Prosthesis Design:
The original Rochette RBFPD was indicated for
replacement of missing single anterior teeth with
minimal or no reduction of the abutment teeth.
Suggestions to modify the design were made by
Livaditis to include proximal reduction to provide for a
path of insertion. Lingual reduction was indicated for
posterior teeth with occlusal rest seat preparations in
the abutments so that the casting could resist tissue-
ward displacement. Reduction of the abutments re-
duces the problem of overcontouring, which may lead
to periodontal problems. According to Livaditis
RBFPDs consists of lingual and proximal segments as
well as occlusal rests. The proximal segments act as
connectors for the pontic and contribute to the bucco-
lingual bracing of the abutments, while the lingual
segments increase the surface area available for
bonding and add to dissipation of laterally directed
1,10
forces . This design applies to a solid framework in
which surface treatment of the fit surface produces
micro-roughness for micromechanical attachment.
Placement of vertical grooves in the mesial and distal
surfaces of the abutments was suggested to further
enhance resistance to lateral displacement.
An alternative means for retention in retainers
with existing restorations was suggested in the form of
inlays that replace the existing restorations and
9,18.
eliminate the need for the lingual segments (wings)
For all-ceramic restoration with resin
bonding, a dual retainer as opposed to the cantilever
framework design was suggested for high-strength
17,20
all-ceramic RBFPD's .
Factors that Affect RBFPD Longevity:
Apart from the design of the prosthesis and
the type of cement used with it, there seems to be a
number of other factors that can influence the long-
term success of RBFPDs. Patient selection is an
important factor in the survival of RBFPDs. While
mastication forces have been documented to be
greater in males than in females some clinical trial
studies found gender to have no significant effect on
longevity of RBFPDs. However, other studies attributed
a higher debonding rate to the greater force of
mastication of male recipients. Another controversial
issue is age. While some studies associated a higher
rate of debonding with young age (less than 30 years

old), others found no relationship between the age of
recipients and rate of debonding. Para-functional
habits such as bruxism have been reported to be
associated with a higher rate of debonding,
The use of RBFPDs should be limited to single-
tooth replacement, as multiple pontics were associ-
ated with a higher rate of failure. More failures were
also associated with the use of 3 or more abutment
teeth for support of RBFPDs. While the use of more
than 2 abutments provides increased surface area for
Resin-bonded fixed partial dentures; Metals to Ceramics Sudhakara Maller, Karthik & Udita Maller
JIADS VOL -1Issue 1 Jan-March,2010 |24|
bonding, differential movement of the abutments
results in shear peel forces and greater stresses in the
bonding area, which lead to early failure. Location of
the prosthesis in the mouth is thought to be an
influential factor in predicting longevity, while some
studies found this factor to be of no significance in
longevity of RBFPDs, other studies reported contrary
observations. In one study, mandibular RBFPDs failed
at a rate that was twice as high as that of maxillary
ones, and another study indicated that mandibular
posterior RBFPDs were associated with the poorest
prognosis.
A number of reasons were given for the higher
rate of debonding in mandibular posterior RBFPDs,
including a discrepancy in height between maxillary
and mandibular posterior teeth in favor of the
maxilla, which results in an increased area for
bonding. In some situations, rubber dam isolation
can be more effective in the maxilla than in the
mandible, leading to improved bonding conditions at
the insertion appointment. Rubber dam use in general
is an important factor in ensuring optimum bonding,
and as a result can influence long-term success.
Neglecting to use a rubber dam can lead to early
debonding. In addition to the above reasons, the
trajectory of the forces of mastication seems to work
more in favor of prostheses placed in the maxilla than
those in the mandible with RBFPDs. Anterior RBFPDs
were reported to be more long lasting than posterior
20
ones .
The type of metal alloy used for fabrication of
the RBFPD can have an effect on its longevity. Castings
made of nickel-chromium or cobalt-chromium alloys
are preferred to gold-based alloys. A casting made of
gold-based alloy has a lower modulus of elasticity
and has to be relatively thicker for adequate strength
and rigidity. In addition, bonding of the resin cement
to the surface of a casting made of a gold-based alloy
is typically inferior and may not sustain long-term
stresses in the oral environment.
CONCLUSIONS:
1. Since their introduction, RBFPDs have undergone
significant developments that involve preparation
design, treatment of the fit surface, and adhesive
cement.
2. Current preparation designs are relatively more in-
volved than the original ones. Proximal and lingual
reductions are integral parts of the preparation in
addition to providing resistance to vertical and
horizontal displacing forces.
3. Microetching with aluminum oxide powder offers '
a simple, consistent, and effective method for treat-
ment of the fit surface of the casting to produce the
microroughness necessary for effective bonding.
4. Resin cements recommended for use with RBFPDs
have formulations that enable additional chemical
bonding to the surface of the casting to further
enhance bond strength.
5. Factors other than desi gn and cement that
affect the l ongevi ty of RBFPDs i ncl ude l ength
of the edentul ous space, l ocati on i n the
mouth, para-functi onal habi ts, and type of
casti ng al l oy.
6. There is evidence in recently published clinical trial
studies that performance of RBFPDs has improved
significantly. Their use in carefully selected cases
following appropriate preparation designs and
cementation procedures can result in long-lasting
restorations
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