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Keith E.

Thayer, DOS, MS'


Vincent D. Williams, DOS, MS"
Ana M. Diai-Arnold,

Acid-Etched, Resin Bonded


Cast Metal Prostheses:
A Retrospective Study of 5to 15-Year-Old Restorations

DDS, M S ' "

Daniel B. Boyer, DOS, MS, PhD"*


College of Dentistry
University of Iowa
Iowa City, Iowa 52242

Eighty-five resin bonded prostheses were evaluated in a


retrospective study over a 15-year period. All had been in
function for at least 4.5 years. Multifactorial variables were
studied to ascertain their effect on debonding and the health
of the oral tissues. The results showed; (1) the caries rate of
the retainer teeth was 6%, (2) the mean gingival indices for the
prostheses were significantly higher {P > .0001) than those of
the remaining dentition, (3) 61% of the restorations had not
debonded (if failure resulfing from trauma was not included,
the incidence of debonding dropped to 19%], and (4) all
patients liked their prosfheses. InlI Prosthodont 1993;6:264-269.

Materials and Methods

his study is the third in a series of retrospective

studies conducted by these investigators on


T
resin bonded prostheses and reports observations

Figbty-five anterior and posterior resin bonded


prostbeses of both etched metal and perforated
design were evaluated. All restorations were originally placed between 1975 and 198.5 and had been in
service for at least 4.5 years. Of the 85 prostheses,
53 had been placed for female and 32 for male
patients. Dental students made46oftheprostheses
and 39 were made by faculty or residents. Sixty-four
percent of the prostbeses were placed in patients
under 50 years of age. The age distribution of the
prostheses is sbown in Table 1.
Three dentists completed the clinical examinations using the same criteria that were used in the
10-year retrospective study.- A mouth mirror, explorer, and periodontal probe were used in the
examination. Irreversible hydrocolloid impressions
for casts and 35-mm slides were made for all
patients.
Tbe 35-mm slides were studied for proper esthetic concerns such as condition of the edentulous ridge, pontic shade, and incisal bluing. Incisal
bluing is a term that is used to describe color
cbange of tbe retainer tooth due to metal showing
through a translucent incisal third of the crown.

at the 15th year. A 7-year study' followed by a 10year study- were previously completed. This study
comprised 85 resin bonded prostheses, of which 23
had been examined and evaluated in all three studies, 43 had been examined in the 10- and 15-year
studies, and 19 were first evaluated in tbe 15-year
study. Numerous articles bave been written on this
type of fixed restoration,=-'^ but few have evaluated
long-term clinical performance. The purpose of
this study was to evaluate the efficacy of the resin
bonded prostheses in the sample population and
record the complications attending this treatment.

'Professor,
"Professor,
'"Associate
""Professor,

Department of Prosthodontics.
Department of Family Dentistry.
Professor, Department of Family Dentistry.
Department of Operative Dentistry.

Reprint requests: Or Thayer.


Presented at the lADR 69th General SessionlAADH 20th Annual
Session, 18 April, 1991, Acaputco, Mexico.

The International lourral of Prosihodoniics

264

Volume 6, N i ; - " - -

Thaye

Acid.Etched, Resin Bonded Cast Melal Proslfieses

Figs la and Ib Six-unit mandibular prosthesis with perforated retention, no caries, gingivitis, prosthesis Gi ^ 1.0, piaque present on
the iinguai surfaces of ail retainers, and resin tiash tound on three retainers. The unit was reiuted twice, had a slight washout ol
pertorations, no incisai bluing, and the retainers and pontics were in occlusion in both centric and eccentric excursions.
Table 1
by Year
Age (yl

Percent

4-5
5-6
6-7
7-8
8-9

10
21
17
12
6
3
8
4
1
3

11.3
24.7
20.0
14,1

9-10
10-11
11-12
12-13
13-14

thenumberandsizeof perforafionsin tbe retainers


were recorded. Perforations were evaluated for dissolution of the luting material. The marginal integrity of tbe retainers was also evaluated. All retainers
were evaluated for debonding using finger pressure and an explorer. Pontic design was recorded as
either conical, ridge lap, nonconfacting, or complete ridge lap. Occlusion for each restoration was
evaluated by recording centric and eccentric contacts of pontics and retainers during mandibular
movement.

Age Distribution of the Prostheses Grouped

7.1
3.5
9,4
4,7
1,2
3,5

Cumuiative
percent
11.8
36.5
56,5
70.6
77 6
81.2
90.6
95,3
96,5
100.0

In the absence of the examining dentist, eacb


patient was asked: HI how they liked the restoration; {2) if there were any problems with cleaning;
(3) if they were happy with tbe esthetics; and (4) if
there were any other problems witb the prosthesis.
Distribution of pontics and retainers was such that
74% of tbe restorations had two retainers, 78% bad
one pontic, 5% had three retainers, 16% had four
retainers, and 1% had six retainers; 18 of the restorations had two pontics and 1 bad four. The prosthesis
with four pontics was placed on a 74-year-old
woman and bad been in service for 7 years and 8
months. The restoration with six retainers was on a
50-year-old woman. The patient had completed
adult orthodontics and had one pontic in an orthodonticaliy created space witb the mandibular anterior teeth splinted from canine fo canine as a fixed
orthodontic retainer. The restoration had been in
service for 13 years and 1 month (Figs la and Ib),

Mean age ol prosthesis = 7.3 years.

This is caused by eitber using a nonopaquing iuting


cement or microleakage of tbe perforated retainer
causing a dark oxide layer on the internal surface of
the retainer casting,
Periodontai healtb was determined by evaluating
the general gingival index as described by Loe and
Silness'" as well as tbe gingival index of retainer
feeth. Tissue color, edematous conditions, and
health of tbe edentulous tissue in the pontic area
were recorded. Probing deptbs were recorded as
specified in tbe general gingival index determination system. Tbe probing depths, plaque, and resin
flash on all retainer teeth were recorded as well.
Retainer design was described relative fo surface
area, retention metbod (etched metal or perforated), circumference of posterior retainers in degrees, and number of occiusai rests. Retainer dimensions were measured witb a periodontal probe
mesiodistally and occlusogingivally or incisogingivally and tbe numbers multiplied to estimate
the surface area. In Rocbette design restorations.

6 . Numbers, 1993

Fifty-five of the restorations were placed in the


anterior region, while 11 were posterior restorations; 19 had both anterior and posterior retainers
and/or pontics. Only one of the posterior restorations was placed before 1980. The other 10 were
placed between January 1980 and January 1984,
Thirty of fhe restorations were placed in the mandible and 55 were placed in the maxillae.

263

lournai o Prosthodonlic

Acid-Etthed, Resm Bonded Casi Mlai Prosthe

Thayer cl al

Figs 2a and 2b Tbree-unif maxillary anterior prostbesis witb perforated refention. Tbis unit bas been in function for 13.3 years and was
reluted atter 6.5 years. Ttie prostbesis Gl = 2.5 with no probing deptbs > 3 mm. There was gingivitis; however, no canes was found.
There was sligbt wasbout ot the resin composite in tbe perforations and slight mesial bluing or disooloration in the mcisal tbird ol the
crowns. Tbe restoration was in occlusion in both centric and eccentric excursions.

A ridge lap or modified ridge lap pontic design


was used for 71 of the restorations; ti pontics were
conical and 1 was a complete ridge lap.

Prostheses Materials and Design


The classification affecting debonding variables
was submitted to the statistical tests of ANOVA, chisquare, and Fisher's exact test. Student's test was
used to determine the variables affecting debonding (mean number of perforations, mean area of
retainers, mean probing depth, mean age of patients, and mean age when first bonded).
Forty of the restorations were of the perforated
design and 41 of the etched metal design. The
remaining four prostheses had previously debonded and perforations had been made in the
metal prior to rebonding.
Seven different luting agents had been used with
these restorations: 53% were luted with Comspan
(LD Caulk Co, Milford, DF); 19% with Adaptic (Johnson and Johnson, Fast Windsor, NJ); 17% with Conclude (.M Dental Products Div, St Paul, MN); and 7%
with Concise (3M). Simulate (Kerr Mfg, Romulus,
Ml), Caulk Exp (LD Caulk), and Kerr (Kerr Mfg) resin
bonded prosthesis cements were each used with
one patient. There was no record of the lype of
luting agents used on 11 of the 85 restorationsVarious alloys were used in the fabrication of the
restorations; 19 were of Biobond (Dentsply, York,
PA); 6 were of Cameo (Jelenko Dental Health
Products, Armonk, NY); and 7 were of Kexillium ill
(Jeneric Cold Co, Wallingford, CT). Unknown nonprecious metals accounted for 44 of the restorations and the metal for9was unknown. The restorations were fabricated by various commercial dental
laboratories.
The majority of the perforated design prostheses
(25 of 44) had a hole size diameter of a no. 2 round
bur, 12 had a hole size of a no. 1/2 bur, 6 were of a
no, 1 bur size, and 1 was no. 4 bur size.

The Internalional lojrnai of Prosthodonti<

Results
Harti Tissue Findings

Hard tissue examinations showed a very low incidence of caries, as in Figs 2a and 2b; 84% of the
prostheses were caries free, 9% had one lesion, and
7% had two to four lesions. There were only five
retainer teeth (6%) with carious lesions, some of
which were decalcified enamei or white spot lesions. Two of the patients exhibited generalized
caries with a total of 14 lesions identified. As reported in the two previous studies,'- caries continues to appear to be a minor problem.
The incidence of resin flash continues to remain

Table 2 Gingival Index*


Area

Mean

Oral Cavity
Resin tDonded
prosthesis
Conventional
prosthesis

99
99

0,9
0.7

0.5
0.5

O-2.0
0-2.2

0.9

0.4

0.5-1.4

Oral Cavity
Resin bonded
prostbesis
Conventional
prostbesis

85
85

0.3
0.6

0.3
0.5

0-0-8
0-2.5

1.3

0.6

0.5-2.0

SD

Range

10-year study

15-year study

266

Thayer et al

Table 3

Acid-Etched, Resin Bonded Casi Melal Prostheses

Literature Review of Debonds of Resin Bonded Prostheses

Authors
Kuike 8 Drennon*
Den eh y 8 Howe'
Shaw 8 Tay'
Berge ndai et aP
Eshleman et al=
Ekstrand'
Williams et al=
Thompson & Wood'"
Tanaka et ai'
Van der Veen et al"
Priest & Donate II i"
Williams et al=
Creugers et a l "
Olin et a l "

1977
1979
1982
1983
1984
1984
1984
1986
1986
1987
1988
1989
1990
1990

Observation
period (mo)

No,
prostheses

No,
debonded

24
36
44
59
36
36
84
41
36
12
23
120
60
84

20
30
46
100
39
120
63
180230
64
58
90
203
96

2
3
9
29
6
22
10
6
10
10

20
10
20
29
15
18
16
22
3
156
17,2
20
22
11

20t
47
11

Retainers
fTrauma not included.

somewhat high, with 32% of the restorations exhibiting excess resin at the gingival margins. This finding suggests that all clinicians should carefully examine gingival margins for resin flash, as it blends in
exceedingly well with tooth and root structure.
However, of M surfaces with resin flash on 26 prostheses, only four surfaces on four prostheses exhibited crevicular probing depths greater than 3 mm.

Table 4 Age of Prostheses When First Debonded

Soft Tissue Findings

%at

%at

%at

Age (y]

7-year study

10-year study

15-year study

0-1
1-2
2-3
3-4
4-5
5-6
6-7

33
29
12
9
9

9-10

50
10
0
20
10
10
0
-

>10

30
9
15
6
12
6
6
3
3
6
3

7-8
8-9

The clinical record showed that 69% of the patients had an initial periodontal problem (gingivitis
orperiodontitis),asin Figs2aand2b, Thirty percent
of the prostheses had crevicular depths greater
than 3 mm as measured by the periodontal probe.
However, of 808 probing depths evaluated on retainer teeth, only 63 recordings were greater than 3
mm. The greatest probing depth recorded was 9
mm. Plaque continues to be a problem in fixed
partial dentures, as 73% of the retainer teeth had
plaque on one or more surfaces. The residual ridge
was healthy in 90% of the prostheses studied. No
attempt was made to correlate pontic design with
tissue health of the residual ridge except to record
the area as either healthy or inflamed. Only one
patient had a complete ridge lap pontic, and this
area was evaluated as inflamed.
Table 2 presents a comparison of the mean gingival indices (GIs]* of the oral cavities, retainers of
resin bonded prostheses, and conventional prostheses of both the 10- and 15-year studies. The
mean CIs of the resin bonded prostheses and the
conventional prostheses were significantly higher
than the mean Ci of the oral cavities in the 15-year
study (paired test, P = ,0001).

3,1993

0
9

0
Q
0
0

Debonding
Debonding occurred in a total of 33 restorations
(39%), with 3 restorations (4%) debonding as a
result of trauma. Only 16% had to be remade over
a 15-year period; 4 because of porcelain fracture
(5%) and 9 because of other causes (11%) including
metal failure. If the prostheses that were remade or
debonded following trauma are eliminated from
the data, the debond rate is 19%, similar to that
reported in the literature (Table 3). There was no
significant difference (P - ,394) in debond rates
for etched vs perforated retainer designs adjusted
forage.
The age of the prostheses when first debonded is
shown for all three studies in Table 4, The mean age
of the restorations at debonding was 3,7 years for
those in the 15-year study (range 0.04 to 10.6 years).
The area of the retainer influenced debonding of

267

The Inlernational Iournal ot Prosthodontics

Acid-Elched, Resin Bonded Cast Metal Prosthe

Thayer et

Table 5 Comparison of Prostheses in 7-, 10-, and


15-Year Studies (n = 23)
Findings
Caries
Plaque
Crevicular depth
> 3 mm
Resin composite
wear
Biuing

% at
7-yearstudy

% at
10-yearstudy

Table 6

Number of Times Prosthesis was Reluted

No, of
prostheses

% at
15-yearstudy

Times
reluted

% of total
61.2
22.4
10.6
1.2
1.2
1.3
2.4

0
57
17
44
4

metal, luting agent, number of retainers, number


of pontics, loss of resin composite in perforations,
perforation size, nature of occlusion centric or
eccentric), initial periodontal problems, and probing depths greater than 3 mm.
At the end of the 15-year study 61% of the prostheses had not debonded and 22% had to be rebonded only once. A comparison of the 23 restorations evaluated in the 7-, 10-, and 15-year studies is
given in Table 5. It was found that there was an
increase in the incidence of plaque from 57% to
87%, in resin composite wear from 44% to 74%, and
in incisai bluing from 4% to 35%. Caries and probing depths greater than 3 mm had a slight increase
in incidence. Table 6 indicates the number of times
prostheses were reluted.
Subjective findings showed that 100% of patients
liked their restorations. However, 17% of the patients expressed problems with oral hygiene, 37%
expressed problems with shade or color, and
8% had a fear of debonding of the fixed partial
denture.

the prostheses. The mean area of the retainers that


debonded (37.6 mm- was significantly smaller |i
test, P = ,0421] than that of retainers that did not
debond (44.9 mm'].
The number of perforations in Rochette prostheses also affected debonding. The mean number
of holes in retainers that debonded (7.3) was significantly less than that of retainers that did not debond (9.0) (f test, P = .04%). Larger retainers had a
larger number of holes, so this was probably why
the number of holes was associafed with less debonding. Marginal washout of the cement influenced debonding. Prostheses that debonded had
higher degrees of marginal washout (chi-square,
P = .032). The debonding resulting from the variable marginal washout was tested using chi-square
and Fisher's exact test (1 tail, 2 tail) and was found to
be significant (P = .05). The washout was measured
on the debonded prostheses, however, and may
only indicate that the reluted prostheses did not fit
as well as ones that had not been reluted. A previous study- showed no significant difference (chisquare, P = .05] on the relationship of marginal
washout to debonding.

Discussion
The gender of the patients was related to debonding of the prostheses. Debonding occurred
more frequently in men than in women (chisquare, P = .036]. Olin et al'= obtained similar
results. This result might be attributed to the
stronger force of mastication in men."
Poor resistance form of prostheses (less than 180
degrees in circumference) may have played a role in
debonding. Seventy-five percent of the debonds of
perforated retainers occurred with seven restorations that were less than 180 degrees in circumference and 31 % occurred with 16 etched retainers that
were less than 180 degrees in circumference. Of the
latter, three restorations needed to be remade.

Hard tissue disease (caries) does not appear to be


a problem with resin bonded prostheses. Three
successive studies by the same authors over a 15year period (Table 5] show that the retainer teeth
have a very low rate of caries even though the
plaque occurrence and CI of the prostbeses are
higher than that of the oral cavity Cl (Table 2). This
may result from resin banded prosthesis preparations being in enamel, whereas conventional prostheses are prepared in dentin. Also, the interface
between resin bonded prostheses is different than
conventional prostheses in that resin composite
tags penetrate the enamel providing a micromechanical retentive seal between the prosthesis and
the enamel. Conventional prostheses with dentinal
preparation must provide excellent retention, resistance form, and proper luting agents to prevent
caries. However, this may be too simplistic a ration-

The following variables did not significantly influence debonding (chi-square, a = ,05); age of patient, year of prosthesis attachment, prosthesis
location (anterior vs posterior], placement in maxillary vs mandibular arch, laboratory used, type of

lojrnalof Piosthodontii

268

Volume 6, N

Thayer et al

Acid-Eichcd, Resin Bonded Cast Metal Prostheses

ale when so many variables exist in the oral cavity, ie,


patient oral hygiene compliance and procedures.
That resin bonded prostheses are tolerated well
by the periodontal tissues is shown by the fact that
probing depths greater tban 3 mm increased only
6% in the 7-, 10-, and 15-year studies (Table 5). Also,
resin flasb occurred 32% of the time on tbe retainers but only four surfaces on four prostheses bad
probing depths greater than 3 mm. Even though the
CIs of resin bonded and conventional prostbeses
were significantly higher in the 15-year study compared to the 10-year study where no cbange was
noticed (Table 2), it should be noted that the difference in gingival indices was very small. This difference could have resulted from interrater validity, as
three different operators conducted the study and
may have used different periodontal probing pressures. Even with the increase in plaque noticed in
the three successive studies (Table 5) and an incidence of resin flash of 32%, only 8% of retainer
teeth had probing depths greater than 3 mm.
Proper design and tootb preparation affected debonding rates of resin bonded prostheses. Tbe area
of the retainer and tbe number of perforations
significantly influenced debonding. Tbis is to be
expected, as a decreased surface area would have
less area for either mechanical or micromechanical
retention of the prostbesis. Marginal washout at
the margin interface with the enamel did affect
debonding. This may have resulted from rebonded
prostheses being included in tbe study and tbe
possibility of deforming the framework of a loose
prosthesis during removal. Of tbe occurrences of
debonding, 22% had to be rebonded only once
(Table 6). There were debonds in 75% of the perforated retainers and 31% of tbe etched retainers
when tootb preparation and design called forencirciement of the tootb crown of less tban 180 degrees. This would suggest that proper design and
tooth preparation are essential for a successful
prognosis of the resin bonded prostbesis.
Summary
The results of this 15-year retrospective study
continue to validate the results of the previous
studies.'- Caries on retainer teeth was very iow, the
periodontium did not show a greater incidence of
periodontal disease, very few prostheses needed to
be remade, and the debond rate was acceptable.
The investigators continue to believe that the
resin bonded cast prosthesis, when properly designed and placed in correctly selected patients, is
an excellent restoration and may be the restoration
of choice for a particular situation on a specific
patient.

Conclusions
This retrospective study reviewed 85 resinretained prostheses 15 years after placement of
these restorations. Based on the conditions of the
study and the manner in which the evaluations were
made, the following conclusions may be drawn:
1. The caries rate of resin bonded prostheses is
very low.
2. Resin bonded prostheses do not contribute to
periodontal disease.
3. Proper prosthesis design and tooth preparation do affect debonding rates of resin bonded
prostheses.
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The International Journal ol Prosthodontic