Bridges PDF

BRIDGES
BRIDGES WITH FULL COVERAGE RETAINERS BRIDGES WITH PARTIAL COVERAGE RETAINERS
2001 REALITY Publishing Co. Vol. 15
Section 3 ~ The Techniques - Restorative Procedures
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3-52 Section 3 ~ The Techniques - Restorative Procedures
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BRIDGES WITH FULL COVERAGE RETAINERS

FEES:
Metal-free $3,182 ($2,200$4,500) Ceramometal $3,152 ($2,200$4,500)
RAVES
&R
ANTS
NO. OF APPOINTMENTS: 4 LENGTH OF TIME FOR APPOINTMENT

1st appointment: 6090 minutes 2nd appointment: 3060 minutes 3rd appointment: 4th appointment: 2040 minutes 1530 minutes
+ Strength and durability are well established in ceramometal

PER TOOTH:
+ Highly esthetic. (Photos 13, 17) + Can be provisionally cemented. (Photos 2730) + Fixed provisional allows refinement of ovate pontic receptor site. + Only choice for teeth with extensive caries and/or existing restorations. - Requires relatively aggressive tooth preparation. (Photos 12 & 13, 4042)
INSURANCE CODES
D6240 Pontic Porcelain fused to high noble metal D6241 Pontic Porcelain fused to predominantly base metal D6242 Pontic Porcelain fused to noble metal D6245 Pontic Porcelain/Ceramic D6250 Pontic Resin with high noble metal D6251 Pontic Resin with predominantly base metal D6252 Pontic Resin with noble metal D6720 Crown Resin with high noble metal D6721 Crown Resin with predominantly base metal D6722 Crown Resin with noble metal D6740 Crown Porcelain/Ceramic D6750 Crown Porcelain fused to high noble metal D6751 Crown Porcelain fused to predominantly base metal D6752 Crown Porcelain fused to noble metal
- Provisionalization is labor-intensive. - Parallelism sometimes difficult to achieve.
CLINICIANS: DENTISTRY BY M. MILLER IN-CERAM BY M. ROBERTS D.SIGN BY PAT TERRY PERIODONTICS BY M. MCGUIRE
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Bridges With Full Coverage Retainers
ALL-CERAMIC BRIDGE: RETREATMENT

Reason For Bridge: Opaque, Artificial-Appearing Ceramometal Bridge With Chronic Gingival Inflammation
Photo 1 Patient presented with unesthetic bridge and would not smile for pretreatment photos.
Photo 2 Ceramometal bridge from maxillary right first premolar to maxillary right lateral incisor is the main cause of the patients embarrassment. There is chronic inflammation in the gingiva investing the lateral incisor and the canine pontic is very gray.
Photos 3 & 4 Ceramometal bridge has been removed, the teeth were reprepared with full shoulder margins, and a properly contoured provisional bridge has resolved most of the inflammation. Note that the patient has a typically resorbed ridge in the area of the missing canine and is a prime candidate for a ridge augmentation. However, the patient declined to have the necessary surgery.
Photos 5 & 6 Two views of In-Ceram bridge. Even though the patient declined surgery for a ridge augmentation, a modified ovate pontic was prescribed. The modification of the pontic was to reduce its faciolingual dimension to conform to the resorbed ridge.
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Photo 7 Try-in of bridge shows incomplete seating and blanching of the ridge due to the convex tissue surface of the modified ovate pontic.
Photo 8 Tissue surface of the pontic is covered with indelible ink.
Photos 9 & 10 Ridge after the ink transfer from the pontic.
Photos 11 & 12 Ridge after minor socket preparation using electrosurgery.
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Photo 13 Completed bridge after cementation. Note the excellent tissue health.
Photo 14 Posttreatment smile view. Patient can now show teeth without embarrassment. This view also shows esthetics could have been improved by completing a tooth lengthening on the maxillary right lateral incisor.
Reason For Bridge: Opaque, Artificial-Appearing Ceramometal Bridge With Poor Pontic Ridge Contact
Photos 15 & 16 Patient presents after completing orthodontic treatment. Main treatment goal was to replace the unesthetic ceramometal bridge from the maxillary right central incisor to the maxillary left lateral incisor for shade purposes and inadequate ridge contact, but secondary goal was to lighten all the teeth in general. Since the patient needed a posterior reconstruction to replace defective restorations and refine the post-orthodontic occlusion, the decision was made to restore the remaining maxillary anteriors (those not involved with the bridge) with full coverage for uniformity.
Photo 17 Incisal view after ridge augmentation. Ridge is obviously inflamed due to patients inability to clean the tissue surface of the ridgelap pontic.
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Photos 18 & 19 Incisal and facial views after ovate pontic receptor site had been prepared with electrosurgery. Note that the faciolingual width of the pontic mimics that of the adjacent central incisor.
Photos 2022 Three different views of In-Ceram bridge. Note that the tissue surface of the pontic is convex both mesiodistally and faciolingually. The gingival embrasures are also filled with porcelain to eliminate the black triangles.
Photo 23 Initial placement of In-Ceram bridge with provisional cement shows almost perfect symmetry of pontic with adjacent central incisor retainer.
Photo 24 Smile view of provisionally-cemented bridge and individual crowns. The provisional cementation allows the patient to assess all aspects of new restorations prior to committing to definitive cementation. After four months, patient decided the restorations were too long and too bulky facially. However, length was determined by anterior guidance requirements.
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Photos 25 & 26 Two views of maxillary anterior restorations after recontouring. Despite functional requirements, patient insisted on recontouring.
Photos 2729 Patient presents for definitive cementation seven months after recontouring. Bridge is removed using a Richwil crown remover and a curved hemostat.
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Photo 30 Ovate pontic receptor site upon bridge removal. Note the absolute absence of inflammation despite the fact that the bridge was seated with the pontic applying substantial pressure to the ridge. This pressure is necessary to minimize food and plaque from accumulating under bridge and will not cause inflammation if the patient is conscientious with flossing the tissue surface of the pontic.
Photo 31 Maxillary restorations 512 years after definitive cementation. Note that the gingival crest around the left lateral incisor has receded slightly, revealing the dark root surface of the endodontically-treated tooth. Otherwise, the restorations are performing well.
Photo 32 Maxillary restorations 612 years after definitive cementation. The dark root surface on the facial of the left lateral incisor has been covered with a graft.
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CERAMOMETAL BRIDGE: RETREATMENT

Reason For Bridge: Failing Endodontics
Photos 3335 Patient presented with failing endodontics on maxillary left lateral incisor. Despite an apicoectomy, the tooth was declared hopeless by the endodontist. Treatment included extracting the tooth, performing both ridge preservation and augmentation procedures, and placing a fixed bridge in addition to new crowns for the other anterior teeth. Note that the right canine is a retained primary tooth.
Photos 36 & 37 Treatment began with removing the ceramometal crown on the left central incisor. Note that the tooth currently has a metal post and core. Due to patients main emphasis on strength over esthetics, it was decided not to remove the existing post and core. And, despite the fact that the facial views show the gingiva in what appears to be a chronic inflammatory state as evidenced by lack of stippling and a definite purplish color, the incisal view after crown removal shows the sulcular tissue to have a surprising lack of inflammation.
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Photos 38 & 39 Retraction cord is placed to protect the soft tissue before repreparation begins. Note the lack of an adequate shoulder on the facial to provide room for the metal coping, opaque, and porcelain.
Photos 4042 Preparations on both abutment teeth are complete. Note the lack of bleeding by protecting the gingiva with retraction cord. In addition, the lateral incisor is not extracted until the preparations on the abutment teeth are completed. Waiting to extract the tooth keeps the preparation debris out of the socket and gives more access to the tooth.
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Photos 4345 Completed ceramometal bridge (d.SIGN) and individual crowns. A ridge augmentation and graft were performed at the extraction site to recapture optimal contours and remove the discoloration that did not fade even after the tooth was extracted. And, despite porcelain margins and proper emergence profiles, it was not possible to recapture a healthy stippled effect on the gingiva.
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BRIDGES WITH FULL COVERAGE RETAINERS

The fixed bridge with full coverage retainers has been the mainstay of tooth replacement methods for many years. This is due to the fact that its retainers are none other than the very familiar full crown restoration that most dentists still hold near and dear to their hearts. You basically prepare the two abutments for full coverage, make sure they are more or less parallel, and, voila, you have a bridge. For cementation, the same rules apply as for a crown. Fill the retainers with cement, seat the bridge firmly, allow the cement to harden, clean the excess, and youre finished. While that scenario can certainly still be accomplished, the contemporary esthetic bridge has two new and specific design updates closing all gingival embrasures and ovate pontics. As discussed in both sections on CROWNS and all sections on VENEERS, open gingival embrasures are no longer tolerated by discriminating patients and clinicians. They are unnecessary for health purposes, collect food when eating, and are not esthetic. The same can be said about ovate pontics. None of the more conventional pontic designs have the benefits of an ovate. When done properly, an ovate pontic should look essentially the same as its dentate neighbors and keep food from accumulating on its tissue surface. Most ovate pontics require a ridge augmentation first, but it is still possible to do a modified version for patients who may decline to have the surgery (Photos 313). In our Editorial Team survey, 68% of anterior pontics were ovate, but only 38% of posterior pontics were of this design. reinforced, indirect resin has been used for bridges and shows promise. Nevertheless, in our survey, only 1% of the anterior bridges and 7% of the posterior bridges were fabricated with this material.
PRELIMINARY PROCEDURES
If the abutment teeth are misaligned teeth, parallelism may be difficult to accomplish without exposing the pulp. This possibility should be discussed with the patient before preparations are begun. Preliminary procedures such as intentional endodontics or pre-prosthetic orthodontics may be necessary to accomplish the goal of replacing a tooth in the most biologically-compatible and esthetically-pleasing manner.
BEFORE FIRST APPOINTMENT

Prior to the first appointment, the type of provisional that will be fabricated is determined. A direct intraoral provisional using a template made on a preoperative model of a diagnostic wax-up is certainly the most expedient and least expensive. However, a lab-fabricated shell made on a minimally prepared model typically gives the best results. Please see CROWNS - PROVISIONAL for complete information on their fabrication.
FIRST APPOINTMENT
STEP 1: Shade Selection (See 3-44) STEP 2: Check Existing Restorations (See 3-4)
WHAT ABOUT IMPLANTS?

While an implant-supported crown can certainly be done in many instances when a single tooth is missing, its advantages over a bridge tend to dissipate if the abutment teeth need crowns anyway. The decision to do an implant versus a bridge needs to be made by the patient after being given all the advantages and disadvantages of both procedures.
STEP 3: Preparations
The coronal 23 of the abutments is reduced 1.52.0mm. Depth cuts can be made with a round bur or diamond. Margins are usually full shoulders about 1.01.5mm deep in an axial direction and are initially placed to the gingival crest. Cord is then packed and the visible margins are extended 0.5mm subgingivally. Ceramometal margins are typically shoulders in visible areas and chamfers elsewhere, although you may also choose to prepare a 360 shoulder to eliminate any visible metal. A metal coping does not mandate that any of your margins must also be in metal. Even though it is optimal to align the teeth through selective preparation and/or resin augmentation prior to preparing multiple teeth, this step is not as critical with ceramometal as it is with metal-free bridges. This is due to the fact that the metal coping of each tooth can vary in thickness to equalize the thickness of the veneering porcelain. View the preparations from the incisal/occlusal direction using a mirror large enough to see all preparations without having to move it. Remove any undercuts, always keeping the pulp in mind.
MATERIAL SELECTION
Ceramometal is still the most reliable and time-tested bridge material and the favorite of the Editorial Team, as reported in our recent survey. For anterior bridges, ceramometal is the type of bridge fabricated 82% of the time, while for posterior bridges, that figure rises to 89%. Resin-to-metal has not captured the attention of the Editorial Team, with only 2%3% being fabricated with that combination of materials. However, metal-free ceramics with high strength cores have proven to be quite durable and highly esthetic, especially for anterior placement (Photos 13 & 32). More conventional ceramics have also been used for bridges, but using these highly esthetic materials means the risk of fracture is higher. For anterior use, 15% of the bridges provided by the Editorial Team were all-ceramic, while only 1% of the posterior bridges were all-ceramic. In addition, fiber-
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STEP 4: Prepare Ovate Pontic Receptor Site

(Photos 712, 18 & 19) Since your provisional bridge should have been fabricated with an ovate pontic, it will probably not seat due to the interference from the ridge, especially if the patient had an augmentation. Mark the tissue surface of the pontic with a disposable indelible ink stick and try to seat the bridge. This assumes you have a lab-fabricated provisional with shells to be relined as the retainers. If the shells themselves are not thicker than 1mm and you have reduced the teeth at least 1.5mm, then there should not be a binding of the shells on the preparations. If necessary, hollow grind the shells to be sure they are not preventing the provisional bridge from seating. The indelible ink will transfer to the ridge. Assuming the pontic on the provisional is in correct alignment, this ink spot indicates where the receptor site should be prepared. Using your instrument of choice (laser, electrosurgery, large round diamond), create a depression in the ridge. Repeat seating the provisional to re-mark the ridge and continue removing tissue until it seats completely, keeping in mind you still need to reline the shells. The pontic should now be in a socket, which will heal around the provisional. Treat the surgical site with your medicament of choice and dismiss the patient. Remember: Be conservative. Do not remove excessive tissue at this time. You can always remove more at a later date. In addition, the receptor site can be prepared when you seat the definitive bridge, especially if no ridge augmentation was done. However, it is more predictable to do it at the preparation appointment.
be too thin. If the provisional is too thin, the definitive retainers will also be too thin. The solution, of course, is to reprepare one or both abutments, reline the provisional, and check it again for thickness. This technique will insure that the definitive retainers will be the proper thickness. This is especially important with ceramics with high strength cores and ceramometal. If the veneering porcelain is too thin, the core or opaque over the coping will shine-through and the bridge will not be esthetic.
SECOND APPOINTMENT
(24 weeks after first appointment) Since tissue health is so important to the success of all restorations, especially when bonding them in place, the extra appointment with the inherent overhead of sterilization and chairtime is justified. This appointment also allows a re-evaluation of the provisional after the patient has had a chance to live with it for a while.
STEP 1: Check Tissue

Evaluate the post-preparation position of the gingival tissues. Make sure the tissue has reacted positively to the provisional and the margins of the preparations have not been exposed due to recession. If the tissue is healthy, you are ready to take the impression. If the tissue is inflamed, you must first ascertain the etiology of the inflammation and resolve the problem before proceeding to the impression. Inflammation may be the result of residual provisional cement that was not removed when the provisional was cemented or could be caused by illfitting margins on the retainers.
STEP 5: Provisional Restoration

Follow the directions for relining the retainer shells in CROWNS - PROVISIONAL. Once both retainers are relined, you may choose to customize the tissue surface of the pontic by sandblasting it, then adding chairside acrylic. This addition of acrylic is best done extraorally. Overbuild the pontic slightly, so when you reseat the bridge, the ridge will blanche slightly. If the provisional requires excessive seating pressure or the ridge overly blanches, then trim the tissue surface of the pontic. Polish the provisional and seat with a provisional cement.
STEP 2: Check Provisional

Ask the patient if he or she is happy with the appearance of the provisional. This is also time to assess whether the ovate pontic looks identical to its contralateral tooth. It should also be determined if any food or plaque is accumulating under the pontic. If any changes are desired, now is the time to do them. Once you and the patient are satisfied with the provisional, take an alginate impression so you can give the lab a model of the way that provisional looks in the mouth. This will give the lab guidance when building the definitive bridge. It is also prudent to take photos of the provisional in the mouth, both in a full smile and retracted.
STEP 6: Delay Impression

Even though the impression can be taken at the preparation appointment, it is prudent to delay it for several weeks to give you an opportunity to assess the reaction of the tissue to the procedure. This is especially important when you have prepared the receptor site for an ovate pontic. Another advantage to delaying the impression is the ability to modify the preparation as dictated by the provisional. For example, you may find that to achieve the best esthetics, you will need to flatten the facial surface of the provisional. However, once this is done, the provisional may
STEP 3: Remove Provisional And Reprepare

After administering local anesthesia (the previous steps were done unanesthetized so the provisional could be viewed in a natural smile), remove the provisional and check the margins for their position in relationship to the gingival crest. If the tissue has migrated and the margins are no longer in your preferred position, pack a single strand of
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nonmedicated cord only on the facial and visible sections of the proximal margins. Reprepare the margins and remove the cord to inspect their new position. You should also recheck the thickness of the provisional retainers. If their thicknesses are inadequate for the definitive retainers, additional tooth structure must be reduced. Once the provisional is removed, you can also check the receptor site. It should be well on its way to healing.
STEP 4: Take Impression (See 3-20) Repack medicated cord and take the impression. STEP 5: Reline Provisionals
If you reprepared the teeth at this appointment, the retainers will need to be relined or margins will need to be added. Please see CROWNS - PROVISIONAL for this technique.
STEP 6: Recement Provisional And Dismiss Patient

BETWEEN APPOINTMENTS
wheel such as a Busch Silent Stone. Repeat the procedure until the bridge seats completely. The margins on metal-free crowns should be very close to what we have come to expect from a well-fitting casting. Any gross marginal openings should have been discovered when trying the bridge on the unaltered solid model when it was returned from the lab. But, if a gross marginal opening is only discovered at this time, a return trip to the lab is indicated. In addition, other marginal problems need to be handled at this time. For example, even after all your precautions, the tissue may still have receded, leaving a margin supragingival. If it is visible and not esthetic, the tooth must be reprepared. A new impression is made, sent back to the lab, and provisional material is added to the provisional where the tooth was reprepared. Any overcontoured margins should be reduced with an abrasive wheel such as a Busch Silent Stone or with highspeed finishing diamonds and then polished before seating the bridge.
STEP 1: Lab Prescription (See 3-27) STEP 2: Check Bridge Returned From Lab (See 3-29)
THIRD APPOINTMENT
Use anesthesia if necessary. However, it is best to delay the administration of the anesthesia until after the try-in if at all possible. With the patient anesthetized, it is difficult to assess the effect of the bridge on the smile line.
NOTE: With metal-free retainers, even supragingival margins may be invisible if the ceramic material and resin cement are relatively translucent. Therefore, before you decide to send the bridge back to the lab merely because a retainer has an exposed margin, try-in the bridge with a try-in paste (see next step).
Once the margins have been checked and verified, have your assistant hold the bridge firmly in place and pass floss under the pontic. While it should be tight, it should not require excessive pressure, which will probably cause the patient to avoid flossing. An ovate pontic placed under pressure will only work if the patient flosses under it. Fortunately, provisional cementation will give you an opportunity to assess this aspect when the patient is not anesthetized.
STEP 1: Remove Provisional

Clean out the provisional cement so the provisional can be used in the next step and/or recemented if necessary.
STEP 2: Clean Teeth

Once the preparations are clean, reseat the provisional to keep the tissue from collapsing onto the margins of the retainer until you are ready to try-in the bridge.
STEP 4: Try-In Bridge For Color

In order to properly assess whether the shade will blend with the rest of the dentition, the bridge must be fully seated with enough stability to allow the patient to get out of the chair. If the bridge does not have enough inherent retention, use a small amount of a provisional cement or water-soluble tryin paste to stabilize it. Then, view the patient under different lighting conditions. Since the thickness of even a metal-free bridge usually does not allow for much color change at the chair, this try-in is mainly to verify that the shade corresponds to the one that was selected and to have the patient accept the result. It will also show you whether a supragingival margin will be visible or not. Use a water-soluble material such as glycerin or K-Y
STEP 3: Try-In Bridge For Fit

Seat the bridge. The pontic should blanche the tissue, but not with excessive pressure. If there is excessive pressure, you can either adjust the tissue surface of the pontic, remove more tissue from the ridge, or do a little of both. If the ridge has healed nicely and the socket looks to be nicely formed, then adjusting the bridge is the procedure of choice. Apply a very thin layer of PIP (pressure indicating paste) using a small brush. Seat the bridge and the brush strokes will disappear in the area of excessive pressure, similar to when seating and adjusting a denture. Adjust this area with a porcelain abrasive
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Jelly as translucent trial cement. If the shade is slightly off, use an appropriate shade of water-soluble, try-in paste from the resin cement system you are using to try to correct it. This procedure is not applicable to ceramics with high strength cores or ceramometal, which are opaque and do not allow shade modification by the cement. If changing the shade of the cement is not successful, photograph the bridge in the mouth next to the natural teeth you are trying to match and/or next to the selected shade tab to show the lab what you are seeing and return it to the lab for reshading or remake. For the patient to accept delays of this sort without becoming antagonistic, it is important that your provisional be as esthetic as possible and that the patient be properly informed prior to beginning the procedure that one or more trips back to the lab may be necessary to get the color just right. When the patient knows about this possibility from the beginning and understands how truly difficult it is to match shades on the first attempt, he or she will usually express very little objection to these types of delays.
A. Clean Bridge (See 3-9) B. Clean Preparations (See 3-7) C. Pack Cord Placing cord for provisional cementation is also not usually necessary, unless the tissue restricts access to the margins. D. Mix Cement and Seat Bridge Resin-based provisional cements have performed well for this purpose. E. Clean Excess Cement Allow cement to set completely before you remove the excess. For resin-based cements, light cure for 30 seconds on the facial and 30 seconds on the lingual before cleaning the excess.
STEP 8: Clean Bridge (See 3-9) STEP 9: Apply Silane (See 3-10)
This is not necessary for ceramometal bridges.
STEP 5: Try-In Bridge For Contour

It is advantageous to adjust the contours of the bridge prior to seating. After placing the bridge in the mouth, sit the patient upright in the chair. It may be necessary to use a tryin paste to stabilize the bridge prior to sitting the patient upright, since a dry bridge tends to lack retention. Both the patient and you should view the restoration in an upright position to evaluate his or her smile line, etc. Make modifications as needed for final approval and polish the modifications. It is possible to polish porcelain extraorally to the same high gloss as possible with glazing. This ability to polish porcelain negates the need to return the bridge to the lab.
STEP 10: Clean And Prepare Teeth For Bonding

(See 3-7) With ceramometal, you have your choice to either bond or more conventionally cement the restoration.
STEP 11: Etch Or Condition Preparations (See 3-8)

Treat the preparations according to the adhesive you are using. With ceramometal, this may not be necessary.
STEP 12: Apply Adhesive (See 3-9)

Follow the directions of the adhesive you are using. See DENTAL ADHESIVES for guidance. With ceramometal, this may not be necessary.
STEP 6: Check Occlusion

Have the patient carefully occlude to check the occlusion. But being careful is the main consideration with this procedure if the patient bites too hard, the bridge (even ceramometal) can fracture. It is advantageous to adjust the occlusion at this time, since polishing any adjusted areas is much easier extraorally than it is after the bridge has been bonded or cemented.
STEP 13: Mix Cement And Coat Inside Of Retainers

Your assistant mixes the dual cure resin cement and coats the inside of the retainers including the margins with a medium thick layer. For ceramics with high strength cores and for ceramometal, a self-cure cement such as Panavia 21 can achieve reasonably good adhesion and seems to be the cement of choice. For ceramometal, you can also use a resin ionomer or compomer cement.
STEP 7: Provisional Cementation

This is essential if you have created a receptor site for the ovate pontic, since you may have to remove the bridge to modify the pontic. Otherwise, skip this step and proceed to Step 8.
STEP 14: Seat The Bridge

Seat the bridge firmly. Be sure it is fully seated by checking one or two locations at the margins of the retainers with an explorer while holding it firmly in place. View from the incisal with a mirror to validate its correct alignment. If you are bonding the bridge, it is probably prudent to not have the
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patient occlude, as contamination from oral fluids could occur. Clean only the bulk excess of the cement at this time. With conventional cementation of a ceramometal bridge, the patient would typically occlude after it is seated.
STEP 15: Spot Cure

When bonding a metal-free bridge, hold it firmly in place if you are satisfied with its position. Your assistant then spotcures each retainer in the center of the facial surface for 1020 seconds using a small (23mm) light-curing tip. For thicker retainers, you may need to cure for 2030 seconds. Self-cure cements obviously do not require light-curing.
having to mix the base and catalyst again. It may be necessary to repack any of these areas with cord to gain proper access and moisture control. When filling a void, clean the area with a disinfectant, re-etch with phosphoric acid, apply adhesive, and then place the additional cement. If the void is large, use a restorative composite instead of resin cement.
STEP 21: Seal Margins (See 3-10) STEP 22: Check And Adjust Occlusion (See 3-11) STEP 23: Smooth And Polish Porcelain (See 3-12)
FOURTH APPOINTMENT
STEP 16: Remove Additional Excess Cement

After metal-free bridge retainers are tacked down by spot curing, you can more definitively remove all but a slight excess of cement off the retainers with a sable brush only leave a small amount at the margins to counteract any polymerization shrinkage of the cement. However, once the cement begins its chemical cure, stop removing the excess. If you try to remove more cement at this doughy stage, you can pull the cement out of small defects in the margins leaving voids. It is better to wait until the cement is rock hard and then remove the slight excess with a sharp hand instrument. Apply a thin layer of glycerin to the margins to prevent the formation of an air-inhibited layer. If you are using Panavia 21, apply Oxyguard II.
STEP 1: Check Occlusion

Be sure the bridge provides the proper anterior guidance and does not cause fremitus in centric occlusion.
STEP 2: Check Gingival Health (Photo 13)

This is a critical area. The health of the soft tissue is essential for a bridge to blend into the overall oral landscape without sticking out like a sore thumb. The tissue should typically be pink and stippled. If the gingiva was not healthy at the beginning of the procedure, the time to improve its health is either before starting the bridge (if this was initial placement) or during the period of time the provisional is in the mouth (and prior to the final impression). Assuming the bridge was placed in the presence of healthy gingiva, it should stay that way after their placement. If there are problems, a differential diagnosis must be made. This may range from the retainers being overcontoured in the gingival third (especially in the area of the emergence profile) to residual cement remaining in the sulcus. Since resin cement is more difficult to detect due to its more translucent color (compared to conventional cements), very careful tactile examination is necessary. Any roughness must be eliminated. If the roughness is residual cement, it can usually be removed with a hand instrument. However, if the roughness is due to a porcelain overhang, finishing diamonds in a highspeed handpiece or the Profin should be used to remove the overhang. In any event, tissue problems must be resolved for the bridge to be successful over the long term.
STEP 17: Cure Retainers

Each metal-free retainer should be cured one minute on the facial and one minute on the lingual. Two lights with large diameter tips help to speed up this curing. This does not apply if you are using Panavia 21.
STEP 18: Remove Cured Excess Cement

Remove excess cement from the bridge using scalpels and other composite carvers.
STEP 19: Remove Cord STEP 20: Check Margins

Check the margins with an explorer. If there is any residual excess cement that cannot be removed with a hand instrument or if you discover a porcelain overhang, contour these areas carefully using a finishing diamond or, proximally, use the Profin. For resin-based bridges, a #12 scalpel blade will usually remove proximal excess. If there are any small voids, fill these areas with a fresh mix of resin cement. If you are using dual cure cement that has a light-cured base component, you can probably just use it to fill a void instead of
STEP 3: Check Ridge Adjacent To Ovate Pontic

(Photo 23) With the bridge in place, pass floss under the pontic. If it is healthy, there should be no bleeding.
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STEP 4: Check Esthetics (Photo 2426) Evaluate the overall esthetics including shade, contour, texture, facial anatomy, smile line, etc. You obviously must please the patient, but it is your responsibility to guide the patient into making informed decisions on esthetics. Unless you provisionally cemented the bridge, your only option (other than remake) is recontouring. Minor problems with provisionally cemented bridges can be handled without removing them while major deficiencies such as being too short need to be corrected by returning the bridge to the lab. Due to this possibility, be sure to keep the provisional for reuse if necessary.
A. Apply Richwil Crown Remover An atraumatic bridge removal technique utilizes thermoplastic Richwil crown removers. Remove one Richwil from the plastic bag in which they are packaged and place in steaming hot water for two to three minutes. Remove the Richwil from the water with cotton pliers and place immediately over the incisal edges of the bridge to be removed. With moderate finger pressure, push the thermoplastic material over the facial and lingual surfaces of the retainers (Photos 2729). One crown remover can be used for one or two teeth. After pushing the material as far gingivally as possible (before it starts to cool and harden), rapidly harden it using an air/water spray for about 1015 seconds. B. Engage Richwil with Hemostat and Remove Bridge Using a curved hemostat, grab the Richwil, apply a slight torquing force, and remove the bridge (Photo 29). Be careful to keep the torquing force minimal excessive facial and lingual rocking movements can cause porcelain fractures. C. Clean Preparations and Bridge and Proceed with Cementation
NOTE: If you are ever in doubt about the length of the bridge, it is better to err on the side of making it slightly long. After the trial period, if the bridge is, indeed too long, you can merely shorten it very easily. However, if it is too short, you have no choice but to return it to the lab.
STEP 5: Definitive Cementation For Provisionally Cemented Crowns
Assuming both you and your patient agree that the provisionally cemented bridge is acceptable, it can be removed and recemented using a definitive cement. If adequate time does not remain in the appointment, the patient should be rescheduled.
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BRIDGES WITH PARTIAL COVERAGE RETAINERS

FEE: $2,619 ($1,500 $4,500)
Does not include veneer on pontic.
RAVES
PER TOOTH:
&R
ANTS
NO. OF APPOINTMENTS: 6 LENGTH OF TIME FOR APPOINTMENT

1st appointment: 1020 minutes 2nd appointment: 3060 minutes 3rd appointment: 3060 minutes 4th appointment: 4560 minutes 5th appointment: 6090 minutes 6th appointment: 1020 minutes
+ Conserves tooth structure (Photo 29). + Provisionalization is quick, easy, and inexpensive (Photo 54). + Can be done with or without veneer (Photos 36 40, 129 & 131). + Pontic can be sectioned and implant done in future if desired. + Supragingival margins are typical and simplify impression taking (Photo 29). + Highly esthetic (Photos 7274, 129).
INSURANCE CODES
D6245 Pontic Porcelain/ Ceramic D6548 Retainer Porcelain/Ceramic for resin bonded fixed prosthesis
- Removable provisional not comfortable for some patients. - Removable provisional does not allow refinement of ovate pontic receptor site as well as fixed. - Cannot be provisionally cemented. - Strength and durability are unproven.
COMMENTS
There is no insurance code for this type of bridge. We suggest using the ceramic codes listed above and adding a narrative that explains the bridge is actually resin-based.
- Not designed for teeth with extensive caries and/or existing restorations.
CLINICIANS: DENTISTRY BY M. MILLER BRIDGES AND VENEERS BY M. ROBERTS
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Bridges With Partial Coverage Retainers
ALL-RESIN BRIDGE: RETREATMENT

Reason For Bridge: Failed, Ceramometal Bridge
Photo 1 Patient with periodontally hopeless maxillary left central and lateral incisors was given options of full or partial coverage bridges, as well as implants. Due to the patients desire to preserve as much healthy tooth structure as possible and avoid the expense of implants, a partial coverage bridge was chosen.
Photos 2 & 3 Ridge has healed after extractions. Note the resorption. It would be very difficult to fabricate an esthetic bridge on a resorbed ridge such as this one.
3-70 Section 3 ~ The Techniques - Restorative Procedures 2001 REALITY Publishing Co. Vol. 15
Photos 4 & 5 Ceramometal bridge with conventional metal lingual wings. Note that porcelain was added to the distal of the canine retainer to close the space between the canine and first premolar.
Photo 6 Bridge pontic for central incisor is compared to extracted tooth, which was sent to the lab for shade matching purposes. When an extracted tooth is sent to the lab, it should be transported in water to prevent desiccation, which will lighten the tooth and give a false shade match.
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Photos 7 & 8 Ceramometal partial coverage bridge has been bonded. While the shade match is excellent, the opaque resin cement that was used to block out the graying effect of the metal lingual wings is visible in the facial embrasures between the central incisors and between the lateral incisor pontic and canine abutment. In addition, the gingival embrasures were not totally closed, causing black triangles to be visible.
Photos 912 After 11 years, patient presented again with the lingual wing retainer on the right central incisor having debonded. It was explained to the patient that an effort could be made to debond the canine retainer so the bridge could be salvaged and possibly rebonded, but damage to the canine itself was a possibility, however slight that risk may be. Patient elected to have the bridge removed by sectioning the canine retainer, followed by fabrication of a new metal-free bridge.
Photos 1315 New Sinfony/Vectris bridge in three views.
Photo 16 Old and new bridges compared for shade. The old bridge was sent to the lab for shade matching purposes, just as the natural extracted tooth was sent originally. Patient used the original flipper as the provisional.
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Photos 17 & 18 Full arch views of resin bridge show shade of pontics slightly lower in chroma, especially in the gingival third. In addition, the gingival length of the central incisor pontic is short when compared to that of the right central incisor abutment. These types of changes would be easy to do if the bridge was provisionally cemented and could be removed for modifications. Unfortunately, partial coverage bridges cannot be provisionally cemented and are even difficult at times to stabilize adequately for a thorough evaluation of the esthetics prior to bonding.
Photos 19 & 20 Close-up views show enamel-simulating texture in facial surfaces of pontics. In addition, gingival embrasures are totally closed and, due to the absence of metal, a transparent resin cement was used, eliminating the opaque cement problem of the original bridge.
Photos 21 & 22 Incisal views show stain already accumulating on retainers as a results of the patients smoking. In addition, plaque is not being removed from the gingival embrasures.
ALL-RESIN BRIDGES: RETREATMENT

Reason For Bridges: Unesthetic Ceramometal Bridges
Photos 23 & 24 Pretreatment views show bulky direct resin veneers were placed over abutment teeth to try to mask graying-out from the metal-based, partial coverage bridge.
Photos 2528 Close-up views after bridges and resin veneers were removed and ridge augmentations were completed.
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Photo 29 Preparations shown in middle third of lingual surfaces of abutment teeth. Ideal depth of preparations is 1.5mm.
Photo 30 Facial view of one of the resin bridges shows reinforcement fibers embedded in wings.
Photo 31 Ovate pontic receptor site has been prepared in very narrow space.
Photo 32 Attempt is made to seat bridge, but pontic is impinging on ridge.
Photos 33 & 34 Tissue surface of pontic is coated with pressure indicating paste.
Photo 35 Pressure indicating paste pinpoints where the pontic must be reduced.
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Photos 3640 Posttreatment views four years after initial placement. Note health of soft tissue and lack of graying-out effect. However, the gloss has been lost from the pontics and fibers have been exposed on the lingual.
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Reason For Bridge: Unesthetic and Dislodged Mandibular Ceramometal Bridge
Photos 41 & 42 Ceramometal partial coverage bridge has been dislodged and provisionally cemented. Patient prefers replacement with metal-free version.
Photo 43 Metal-free Targis99/Vectris bridge.
Photos 4446 Posttreatment views shows all-resin bridge is virtually undetectable from the incisal and lingual views, while the facial view shows its surface finish is nearly identical to the adjacent porcelain veneers.
ALL-RESIN BRIDGE
AND
SINGLE PORCELAIN VENEER: RETREATMENT
Reason For Bridge: Unesthetic Ceramometal Bridge
Photos 4751 Pretreatment views show graying-out of the abutments caused by ceramometal bridge. Also note that the left central incisor is longer and wider than right central incisor. Pontic is also in slight labioversion.
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Photos 52 & 53 Views after ridge augmentation.
Photo 54 Flipper was shortened gingivally by periodontist so it would not interfere with ridge augmentation.
Photos 55 & 56 Ridge immediately after the ovate pontic receptor site has been prepared.
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Photo 57 Additional acrylic has been added to the prosthetic tooth on the flipper to help form the ovate pontic receptor site.
Photos 58 & 59 Healed ovate pontic receptor site just a few weeks after preparation.
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Photos 6064 Caliper is used to measure edentulous area, adjacent teeth, and prosthetic tooth on flipper to decide whether to add to the right central incisor or left lateral incisor so that the pontic can be narrower.
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Photo 65 Composite was added to the mesial of the right central incisor to equalize the widths of both centrals.
Photo 66 Ovate pontic receptor site is completely healed one month after surgery.
Photo 67 All-resin bridge after bonding and cleaning the cement. Note the pontic has already been prepared for a porcelain veneer.
Photo 68 Cord is packed just apical to the veneer margin on the pontic. This cord will facilitate capturing a perfect impression.
Photo 69 Mylar strip has been placed under the pontic to protect the tissue during sandblasting.
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Photo 70 Adjacent teeth are masked with wax to protect them from sandblasting.
Photo 71 Pontic has been sandblasted and is ready to receive the veneer. Note that the Mylar strip under pontic was left in place during the cementation procedure to prevent resin cement from getting under the pontic.
Photos 7274 Posttreatment views show good symmetry between the maxillary central incisors and the elimination of the graying-out phenomenon by eliminating the metal in the frame.
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ALL-RESIN BRIDGE AND FOUR PORCELAIN VENEERS: INITIAL PLACEMENT

Reason For Bridge: Missing Central Incisor
Photo 75 Patient with missing left central incisor shows deficient ridge with concavity due to resorption instead of a root eminence.
Photo 76 Ridge after connective tissue augmentation. Note greatly increased faciolingual width.
Photos 77 & 78 Smile and retracted pretreatment views after ridge augmentation.
Photos 79 & 80 Close-up pretreatment views after ridge augmentation. Note that both right central incisor and left lateral incisor have large existing restorations. The optimal treatment for this patient would be a full coverage bridge. However, due to the defective crown on right canine, patient did not want any of his teeth reduced for full coverage retainers. Treatment plan was devised where the wings of bridge would cover the entire lingual surfaces of the abutment teeth, while the facial surfaces would be veneered.
3-85
Photos 81 & 82 Preparations completed both for the bridge and porcelain veneers. Since provisional veneers were not necessary, the teeth were prepared for veneers at the same time as they were prepared for the lingual wings to guide the lab in contouring the pontic, which was to be already prepared for a veneer. Note that restorations in abutments were replaced to insure their adequacy.
Photos 8388 Various views of the fiber-reinforced resin bridge both on and off the model. Note that pontic has already been prepared for a veneer, that the pontic is ovate in shape, and that the wings not only cover the entire lingual surfaces of the abutments but also wrap around the distal surface of the lateral incisor to simulate half of a crown.
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Photos 89 & 90 Bridge is tried in, but since the ovate pontic receptor site was prepared on the model before the mouth, the ridge is restricting the bridges complete seating.
Photo 91 Indelible marking stick is moistened in water to release the ink.
Photo 92 Tissue surface of pontic is marked with the indelible ink.
Photo 93 Tissue surface of the pontic after marking with indelible ink.
Photo 94 Bridge is pressed into ridge to transfer the ink.
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Photo 95 Indelible ink has been transferred to ridge. This is the area where the socket will be formed.
Photo 96 Electrosurgery is used to prepare the ovate pontic receptor site.
Photo 97 Ovate pontic receptor site after initial preparation.
Photo 98 Bridge is reseated to mark the ridge a second time.
Photos 99 & 100 Completed ovate pontic receptor site. Note how socket has been created to receive the ovoid-shaped pontic.
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Photo 101 Bridge is seated again after the ovate pontic receptor site has been completed. Note slight blanching in ridge, which insures a tight contact between the tissue surface of the pontic and the ridge. This tight contact almost completely eliminates food impaction and is more comfortable for patients.
Photos 102 & 103 Full seating of the bridge is evidenced by intimate fit of wings. Note the difference between the position of the wings in these views compared to that in Photo 90.
Photo 104 Bridge immediately after bonding.
Photo 105 Bridge after excess cement has been removed and the veneer preparations were re-defined.
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Photo 106 Incisal view showing complete lingual coverage of the teeth with the wings of the bridge.
Photos 107109 Facial preparations prior to bonding veneers. Note that the defective crown on right canine has already been replaced.
3-90
Photo 110 Resin pontic and restorations in other teeth are sandblasted to prepare them to receive their veneers.
Photo 111 Pontic and restorations after sandblasting. Note plastic strips between canines and lateral incisors protected the canines from the sandblasting.
Photo 112 Teeth and pontic are cleaned after sandblasting.
Photo 113 Teeth are etched. Pontic is covered with etchant to additionally decontaminate and acidify its surface.
Photo 114 Teeth and pontic after drying. Minimal dentin is exposed, so teeth were dried to achieve maximum bond strength to resin pontic.
Photo 115 Silane is applied to pontic, but will reduce bond strengths if allowed to overflow onto tooth structure.
3-91
Photo 116 Unfilled resin is applied to pontic as well as teeth.
Photo 117 Veneers are seated with light-cured resin cement.
Photo 118 Excess cement is cleaned with a sable brush.
Photo 119 Veneers immediately after cleaning the bulk of cement.
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Photos 120 124 Posttreatment views. Note how well the pontic fits into the ridge and appears to be real. Vibrant color is a characteristic of metal-free bridges.
3-93
ALL-RESIN BRIDGE AND EIGHT PORCELAIN VENEERS: INITIAL PLACEMENT

Reason For Bridge: Failed Endodontics
Photos 125 & 126 Pretreatment views of patient with internal resorption of maxillary right central incisor.
Photo 127 Right central incisor has been extracted and orthodontics to close anterior open bite has been completed.
Photo 128 Ridge augmentation has been completed.
Photo 129 Bridge has been bonded. With full contour pontic, patient does not have to be rushed to make decision concerning veneers.
Photo 130 Completed veneer preparations.
Photo 131 Completed porcelain veneers 212 years after seating. Note the natural contours of the right central incisor pontic that appears identical to the contralateral tooth.
Photo 132 Exposed reinforcement fiber on the lingual of lateral incisor. The exposed fiber should be removed with a highspeed diamond, followed by flowable composite to restore any resulting defect.
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BRIDGES WITH PARTIAL COVERAGE RETAINERS

Bridges with partial coverage retainers had been done for many years, with the main retentive device being pins. However, in 1973, Rochette first described a bridge with partial coverage retainers that was attached to teeth via enamel bonding. Thus the birth of the resin-bonded bridge (RBB). Rochettes new bridge had lingual wings of metal that had been perforated for retention. The resin cement, which was bonded to the abutments, formed a mechanical lock around these holes. In 1982, the Maryland Bridge was introduced by Thompson and Livaditis. Named after the dental school in which they taught, these two men modified the Rochette design by using solid wings, but electrochemically etched the metal for retention. Other retentive devices have been proposed over the years, but all of them used a metal framework with a ceramic-veneered pontic. Although these bridges were originally proposed as virtually no prep, it is now accepted that more conventional retentive devices such as boxes and grooves will be beneficial to the overall success of the restoration. In 1986, Ibsen and Strassler introduced the concept of a metal-free bridge, which used facial retention in the form of porcelain veneers. Around the same time, Golub described an all-resin bridge using silk fibers for reinforcement. Finally, in 1990, Materdomini and Yarovesky working with Nixon and Hornbrook, created a fiber-reinforced resin framework, while the pontic had a separate porcelain veneer. The framework and veneer were then luted simultaneously. The original Encore Bridge and modified versions remain the most popular designs today. The metal-free design eliminates the graying-out of the abutment teeth, which is a common feature of those bridges with metal wings (Photos 7 & 8, 23 & 24). While all these bridges are still resin-bonded, this luting mechanism also applies to bridges with full coverage retainers. Therefore, we have categorized bridges based on the configuration of the retainers.
If all anterior teeth are intact and esthetic, a classic Encore Bridge can be done, with the veneer being fabricated and luted simultaneously with the bridge. While this design is efficient and only requires two appointments, it tends to limit options for subsequent treatment. For example, the patient may want veneers but is unwilling to commit at the time the bridge is done. If you place a veneer on the pontic and then the patient decides to do all the veneers, then you would have to redo the veneer on the bridge to accomplish the perfect color match. If you know you will be doing veneers in conjunction with the bridge, you can prepare all the teeth for the veneers at the same time as the bridge preparations are done. This allows the lab to fabricate the bridge with a pontic that has already been reduced consistent with the veneer preparations and the veneers can be fabricated simultaneously with the bridge (extending the Encore Bridge two appointment protocol). However, if the bridge is not satisfactory and needs to be remade, having teeth already prepared for veneers can complicate treatment, especially if the veneer preparations required provisionals (Photos 75124). Fabricate the bridge with a full contour pontic. After luting the bridge, the pontic and any other teeth to be veneered are prepared, either at the same appointment that the bridge is cemented or at a subsequent one. This is the alternative with the most options: Pontic can remain all resin (Photos 2340). Pontic can be veneered singly (Photos 4774). Pontic can be veneered with other teeth (Photos 125132). With posterior teeth, inlays and onlays are the most common retainers.
MATERIAL SELECTION
The frameworks are typically fabricated using a fiber-reinforced, indirect resin. The fiber reinforcement can be integral within the material, such as Targis/Vectris and Sculpture/FibreKor, or it can be added with products such as Ribbond, Connect, GlasSpan, or Splint-It. One of the problems with fiber-reinforcement, however, is the fiber itself can be uncovered during the occlusal adjustment or through normal wear. Although these indirect resins are quite wear-resistant, the lab must bury the fibers deep enough in the wings (assuming you provided enough clearance) or normal wear will cause them to be exposed. In this case, you need to cover the fibers typically with a flowable composite after sandblasting (assuming there is enough interocclusal space) or use a highspeed diamond to create the interocclusal space. Exposed fibers do not seem to have a deleterious functional sequelae, but can cause the patient to remark that the bridge feels fuzzy (Photos 38 & 132).
WHAT ABOUT CONVENTIONAL BRIDGES OR IMPLANTS?

Bridges with partial coverage retainers can be used both anteriorly and posteriorly where the adjacent teeth are virtually intact. Although they can be done on teeth with existing restorations, a more conventional bridge with full coverage retainers will typically serve the patient better (Photos 75124). An implant-supported crown can also be done when a single tooth is missing. The decision to do an implant versus a bridge needs to be made by the patient after being given all the advantages and disadvantages of both procedures.
ALTERNATIVE DESIGNS
If a bridge with partial coverage retainers is chosen, the following alternatives are available:
3-95
SOFT TISSUE EFFECT

For a bridge of any type to appear natural, the pontic must have a soft tissue profile similar to the adjacent teeth. For this situation to occur, the pontic must be viewed as emerging from the tissue, just as a natural tooth does. To accomplish this goal, a receptor site must be prepared in the edentulous ridge and the pontic must be placed into this receptor site under pressure (Photos 5559 & 96-100).
Most patients choose the first option, since modifying a pre-extraction flipper can compensate for any errors in judgment when removing a tooth from a model.
FIRST APPOINTMENT
STEP 1: Shade Selection (See 3-44) STEP 2: Take Impressions And Bite Registration For Flipper
RIDGE AUGMENTATION
The edentulous ridge itself must be of adequate height and width. Unfortunately, the ridge typically atrophies when a tooth is removed or, if the tooth was congenitally missing, it may have never fully formed in the first place. To accommodate the pontic, the ridge must be augmented. There are numerous techniques to rebuild a deficient ridge. Some involve hard tissue replacement, but the more common and predictable procedure uses connective tissue. This procedure even allows you to create the illusion of a root eminence, although it may require more than one surgery to accomplish this goal (Photos 7579, 127 & 128).
STEP 1: Alter Working Model

Remove tooth to be extracted from the model. Dentist or lab can do this procedure.
STEP 2: Mount Models

Dentist or lab can do this procedure.
OVATE PONTIC
Once the ridge has been augmented, the receptor site is planned and the pontic is designed. The shape that is most conducive to maximize esthetics and comfort is ovate, which is ovoid or egg-shaped. Since this shape can be cleaned very readily using floss, it is also very hygienic. Once the receptor site, which is essentially a depression in the crest of the ridge, is prepared, the bridge is seated under pressure. This intimate contact not only helps mold the tissue to the pontic, but also keeps food from getting under the bridge. As long as the patient flosses under the bridge, the ridge will stay healthy (Photos 89103).
STEP 3: Send Case To Lab

Your prescription should ask for a provisional removable partial denture (flipper) with the denture tooth in perfect alignment and without any labial flange. Make sure the lab abuts the denture tooth tightly against the ridge. Unless there are multiple missing teeth, the flipper should be fabricated with wrought wire clasps wrapping around the distals of the second molars, so they will not interfere with the occlusion.
STEP 4: Receive Case From Lab

Check for proper fit of the flipper on a duplicate of the master model after the tooth was removed.
BEFORE FIRST APPOINTMENT

The typical patient requiring a bridge of this type is one who is about to lose an anterior tooth due to a failed endodontic procedure, fractured root, lost periodontal support, or idiopathic resorption (Photos 1, 125 & 126). Prior to the first appointment, the timing of the fabrication of the removable provisional partial denture (flipper) is determined. The flipper can be made from a model on which the tooth to be extracted has been removed or an impression immediately after extraction can be taken and the model from this impression can be used. In the first option, the patient will have the flipper inserted immediately after the extraction, so there is no time that the patient will be seen without the tooth. However, when a tooth is removed from a model, it is an estimate of how the mouth will appear after extraction. With taking the impression after the extraction, there is no guesswork. But the patient will have to exist for a day or two while the flipper is being made.
SECOND APPOINTMENT
STEP 1: Extract The Tooth (Photos 2 & 3, 127) This should be done as atraumatically as possible. Make every attempt to preserve the facial cortical plate of bone. STEP 2: Ridge Preservation
Filling the socket with an appropriate material such as hydroxylapatite, HTR, freeze-dried bone, etc. will help maintain the dimensional stability of the ridge.
CAUTION: Filling a socket with HA could negate future orthodontic treatment or implant placement in that area.
3-96
STEP 3: Insert The Flipper STEP 4: Refer Patient To Periodontist For Ridge Augmentation
This step assumes you extracted the tooth. Some generalists prefer to refer the patient for the extraction and ridge preservation procedure.
FOURTH APPOINTMENT
(Three weeks after preparing the ovate pontic receptor site)
STEP 1: Postoperative Check

Assess healing and the formation of the ovate pontic receptor site. If the socket has not matured sufficiently, reschedule the patient for another postoperative check in several weeks.
THIRD APPOINTMENT
(Six weeks after ridge augmentation)
STEP 1: Check Ridge

Assess healing and ridge contours. To proceed, the ridge should mimic that of adjacent teeth, including root eminences.
STEP 2: Modify Flipper (Photos 5457) Assuming the ridge is optimal in contour, the ovate pontic receptor site can now be created and then refined when the definitive bridge is luted or you can wait to prepare the entire ovate pontic receptor site when the definitive bridge is luted. With conventional bridges with full coverage retainers utilizing fixed provisionals, the ovate pontic receptor site is almost always prepared at this time, using the provisional bridge to help form it. However, the flipper used with this type of bridge is not as stable or predictable as a fixed provisional. If you choose to prepare the ovate pontic receptor site at this time, you would have to add tooth-colored acrylic to the tissue surface of the prosthetic tooth to create a length consistent with its contralateral analog. This prosthetic tooth is shorter since the periodontist will usually need to reduce the pontic in length gingivally to make room for the augmented tissue. Sandblast the tissue surface of the prosthetic tooth and add cold cure or dual cure acrylic until the length is optimal. Finish and polish. STEP 3: Prepare Ovate Pontic Receptor Site
(Photos 31, 55 & 56, 96100) Mark the tissue surface of the prosthetic tooth with a disposable indelible ink stick and try to seat the flipper. The indelible ink will transfer to the ridge. Assuming the prosthetic tooth on the flipper is in correct alignment, this ink spot indicates where the ovate pontic receptor site should be prepared. Using your instrument of choice (laser, electrosurgery, large round diamond), create a depression in the ridge. Repeat seating the flipper to re-mark the ridge and continue removing tissue until the flipper seats completely. The prosthetic tooth should now be in a socket, which will heal around the flipper. Treat the surgical site with your medicament of choice and dismiss the patient. Remember: Be conservative. Do not remove excessive tissue at this time. You can always remove more at a later date.
STEP 2: Prepare Abutments (Photo 29) Middle third of the lingual surface is the optimal area for the partial coverage wings. Using a depth-cutting diamond, prepare grooves in the middle of the lingual surfaces. These groves should be deep enough to provide for at least 1mm of clearance. Therefore, if you start out with an interocclusal distance of 0.5mm, then the depth of the grooves only has to be 0.5mm. However, 1.5mm of clearance is better and ensures the lab will have ample room to bury the reinforcement fibers. Enlarge the grooves in incisal and gingival directions. Try to stay at least 1mm gingival to the incisal edge and 1mm supragingival. Then prepare small, shallow potholes (about 0.5mm deep) at the axio-gingival rounded line angle. These holes are designed to augment bonded retention and provide a more positive stop than the rounded line angles when seating the bridge. STEP 3: Take Impression And Bite Registration
If you stayed supragingival, no retraction cord is necessary.
STEP 4: Provisional (Temporary) Restorations

Assuming you placed the potholes in the preparations, you can provisionalize quickly with a light-cured, flexible material such as E-Z Temp Onlay or Fermit-N. Otherwise, use Durelon.
STEP 1: Lab Prescription (See 3-27) STEP 2: Checking Bridge Returned From Lab
(See 3-29)
FIFTH APPOINTMENT
STEP 1: Remove Provisional Restorations

If flexible resin was used, merely obtain a purchase point and pop it out. For Durelon, you may need to use a sonic or ultrasonic scaler.
3-97
STEP 2: Clean Teeth STEP 3: Try-In Bridge For Fit (Photos 3235)
If the lab did not modify your the ovate pontic receptor site, the bridge should seat positively. The socket should blanch when you are applying the seating pressure, but this seating pressure should not be extreme. If the lab deepened the socket, you will have to repeat the process as when you originally prepared it. If your socket seems well formed, but the bridge does not seat, you may need to adjust the tissue surface of the pontic. Take pressure indicating paste and brush it over the tissue surface of the pontic. Just as you would relieve a denture, you do the same procedure with the bridge, using finishing discs. Once the bridge completely seats (dont overadjust the socket should still blanch), polish as you would any composite.
both wings. Clean only the bulk excess of the cement at this time.
STEP 14: Spot-Cure

When you are satisfied with the position of the bridge, hold the wings firmly in place. Your assistant then spot-cures each wing in the center of the lingual surface for 20 seconds using a small (2-3mm) light-curing tip.
STEP 15: Remove Additional Excess Cement

After the bridge is tacked down by spot curing, you can more definitively remove all but a slight excess of cement off the wings with a sable brush only leave a small amount at the margins to counteract any polymerization shrinkage of the cement.
STEP 16: Cure Cement

Each wing should be cured one minute on the facial and one minute on the lingual. Two lights with large diameter tips help to speed up this curing.
STEP 4: Try-In Bridge For Color

There is no adjustment. Either the shade is right or the case needs to go back to the lab for correction. Photograph the bridge in the mouth next to the natural teeth you are trying to match and/or next to the selected shade tab to show the lab what you are seeing and return the bridge to the lab for reshading or remake.
STEP 17: Remove Cured Excess Cement

Remove excess cement from the wings using scalpels and other composite carvers.
STEP 18: Check Margins (See 3-10) STEP 5: Try-In Bridge For Contour STEP 19: Check And Adjust Occlusion (See 3-11) STEP 6: Clean Bridge STEP 20: Smooth And Polish Adjusted Resin STEP 7: Sandblast Wings With CoJet (See 3-42) STEP 8: Apply Silane (See 3-10)
SIXTH APPOINTMENT
(See 3-14)
STEP 9: Clean And Prepare Teeth For Bonding

(See 3-7)
STEP 1: Postoperative Check

Assess healing and overall esthetics. Make decision on whether one or more veneers need to be done. If the decision is to proceed with veneers, prepare them as you would any conventional case, except the pontic needs to be sandblasted when preparing the rest of the teeth for bonding (Photos 70 & 71). Please see VENEERS - PORCELAIN & INDIRECT RESIN for details.
STEP 10: Etch Preparations (See 3-8) STEP 11: Apply Adhesive (See 3-9) STEP 12: Apply Resin Cement To Internal Surface Of Bridge Wings
Due to the thinness of the wings, a light-cured cement should be acceptable and will simplify the procedure.
STEP 13: Seat Bridge

Seat the bridge firmly. Be sure it is fully seated by checking one or two locations at the margins with an explorer while holding it firmly in place. View from the incisal with a mirror to validate its correct alignment. Do not have the patient occlude, as contamination from oral fluids could occur. In addition, since you have not yet adjusted the occlusion, having the patient occlude could move the bridge out of its correct position and could fracture one or

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BRIDGES

2001 REALITY Publishing Co. Vol. 15

Section 3 ~ The Techniques - Restorative Procedures

BRIDGES WITH FULL COVERAGE RETAINERS

NO. OF APPOINTMENTS: 4 LENGTH OF TIME FOR APPOINTMENT

+ Strength and durability are well established in ceramometal

- Provisionalization is labor-intensive. - Parallelism sometimes difficult to achieve.

2001 REALITY Publishing Co. Vol. 15

Section 3 ~ The Techniques - Restorative Procedures

Bridges With Full Coverage Retainers

ALL-CERAMIC BRIDGE: RETREATMENT

Section 3 ~ The Techniques - Restorative Procedures

2001 REALITY Publishing Co. Vol. 15

Bridges With Full Coverage Retainers

Photo 8 Tissue surface of the pontic is covered with indelible ink.

Photos 11 & 12 Ridge after minor socket preparation using electrosurgery.

2001 REALITY Publishing Co. Vol. 15

Section 3 ~ The Techniques - Restorative Procedures

Bridges With Full Coverage Retainers

Section 3 ~ The Techniques - Restorative Procedures

2001 REALITY Publishing Co. Vol. 15

Bridges With Full Coverage Retainers

2001 REALITY Publishing Co. Vol. 15

Section 3 ~ The Techniques - Restorative Procedures

Bridges With Full Coverage Retainers

Section 3 ~ The Techniques - Restorative Procedures

2001 REALITY Publishing Co. Vol. 15

Bridges With Full Coverage Retainers

2001 REALITY Publishing Co. Vol. 15

Section 3 ~ The Techniques - Restorative Procedures

Bridges With Full Coverage Retainers

CERAMOMETAL BRIDGE: RETREATMENT

Section 3 ~ The Techniques - Restorative Procedures

2001 REALITY Publishing Co. Vol. 15

Bridges With Full Coverage Retainers

2001 REALITY Publishing Co. Vol. 15

Section 3 ~ The Techniques - Restorative Procedures

Bridges With Full Coverage Retainers

Section 3 ~ The Techniques - Restorative Procedures

2001 REALITY Publishing Co. Vol. 15

BRIDGES WITH FULL COVERAGE RETAINERS

BEFORE FIRST APPOINTMENT

WHAT ABOUT IMPLANTS?

2001 REALITY Publishing Co. Vol. 15

Section 3 ~ The Techniques - Restorative Procedures

Bridges With Full Coverage Retainers

STEP 4: Prepare Ovate Pontic Receptor Site

STEP 1: Check Tissue

STEP 5: Provisional Restoration

STEP 2: Check Provisional

STEP 6: Delay Impression

STEP 3: Remove Provisional And Reprepare

Section 3 ~ The Techniques - Restorative Procedures

2001 REALITY Publishing Co. Vol. 15

Bridges With Full Coverage Retainers

STEP 6: Recement Provisional And Dismiss Patient

STEP 1: Remove Provisional

STEP 2: Clean Teeth

STEP 4: Try-In Bridge For Color

STEP 3: Try-In Bridge For Fit

2001 REALITY Publishing Co. Vol. 15

Section 3 ~ The Techniques - Restorative Procedures

Bridges With Full Coverage Retainers