the carolina bridge: a novel interim all-porcelain bonded ... · interim prosthesis for adolescent...

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*Professor, Department of Operative Dentistry, UNC School of Dentistry, Chapel Hill, NC, USA

The Carolina Bridge: A Novel Interim All-Porcelain Bonded Prosthesis

HARALD O. HEYMANN, DDS, MED*

ABSTRACTNumerous bonded bridge designs have been advocated over the years for the temporary or per-manent replacement of missing teeth. Both metal and all-porcelain designs of bonded bridgeshave been advocated, with varying degrees of success. However, all of these designs involve somedegree of tooth preparation, making them irreversible in nature. The Carolina bridge, a novel all-porcelain bonded pontic, requires no significant tooth preparation, making it an outstandingoption as an interim prosthesis. The key to success is the availability of adequate surface areainterproximally to ensure optimally strong resin composite connectors.

CLINICAL SIGNIFICANCEThis article describes the indications, contraindications, and clinical technique for the placementof an ultraconservative all-porcelain bonded bridge for the interim replacement of single incisors.

(J Esthet Restor Dent 18:81–92, 2006)

DOI 10.2310/6130.2006.00014

With the advent of adhesivedentistry, many approaches

have been advocated for the con-servative replacement of missinganterior teeth. A myriad of bondedbridge designs have been intro-duced over the years. An early ver-sion of a bonded bridge was theRochette-type bridge.1,2 Thisdesign uses countersunk holes inthe metal retaining wings for reten-tion of the bridge to the lingualsurfaces of the adjacent teeth via aresin composite cement.

Subsequently, Maryland bridgeswere introduced that also incorpo-rated metal retaining wings.3,4

Etched metal surfaces afford strongmicromechanical bonds of themetal retaining wings to the adja-cent abutment teeth. Soon there-after, another version of theMaryland bridge, the adhesionbridge, was introduced and hasbeen widely used.5,6 This designrelies upon various surface treat-ments (eg, sandblasting, silicoating)of the metal wings along withchemically adhesive cement formu-lations (eg, 4-META) to facilitatestrong resin-to-tooth bonds.

Additionally, tooth-colored versionsof the Maryland bridge have beenadvocated. An early form of this

type of bridge was the all-porcelainveneer bridge.7–9 This design usedfacial or lingual porcelain veneersbonded to adjacent abutment teethto retain a porcelain pontic. How-ever, this type of bridge was foundto afford poor resistance to fractureand unnecessarily covered other-wise intact, healthy tooth structureon abutment teeth.10,11

More recently, other tooth-coloredbonded bridges made fromprocessed resin or high-strengthceramics have been advocated. Avariant of this type of processedresin bonded bridge, the Encorebridge (da Vinci Dental Studios,

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Woodland Hills, CA, USA), consistsof a pontic used in conjunctionwith a facially bonded porcelainveneer.12,13 Tooth-colored Mary-land bridges also have been notedin the literature made from In-Ceram (Vita Zahnfabrik, BadSäckingen, Germany).14–16 How-ever, owing to the fact thatprocessed resin possesses littlepotential for chemical adhesion,surface treatments, such as sand-blasting, must be used to achievemechanical adhesion to abutmentteeth. Similarly, mechanical adhe-sion is difficult to attain with In-Ceram; however, silicoating doesseem to improve adhesion with In-Ceram to some degree. Regardless,the incorporation of proximalgrooves is recommended toimprove macromechanical retentionof this bridge design.16

All of these bridge types have beenused with varying degrees of suc-cess, and when properly made,some can provide excellent bondstrengths. However, all of thesebridge designs share one significantdisadvantage: they all require somedegree of tooth preparation and, assuch, are irreversible in nature.

More conservative options for ante-rior bonded bridges also have beenintroduced over the years that, bycontrast to the bridges noted above,do not require any appreciabletooth preparation. These includebonded denture tooth bridges,

extracted natural tooth pontics, and custom resin composite pon-tics.17–19 All of these bonded bridgedesigns are exceptionally conserva-tive and rely on resin compositeconnectors between the pontic andthe abutment teeth for retention. Ofcourse, a favorable occlusion andsufficient surface area on the adja-cent abutment teeth must be pre-sent to ensure optimal success withthese conservative bridge types.Also, because these types of bondedbridges do not provide the bondstrengths of conventional bridgesand probably are not as strong asporcelain-fused-to-metal Maryland-type bridges, they are typicallyadvocated as interim or provi-sional restorations.

Despite the more provisional natureof these bridges, they have beenwidely used with success for thereplacement of single missingincisors in patients for whom amore permanent prosthesis is nei-ther practical nor affordable. Thisis particularly true for extractednatural tooth pontics. In manycases involving elderly patients withcompromised periodontal or med-ical health or limited financialmeans, extracted natural tooth pon-tics afford a practical and beneficialalternative to more traditional pros-theses. Moreover, owing to the sim-plicity with which the resincomposite connectors can beplaced, these bridges are easy torepair and maintain.


The purpose of this article is toreview an alternative approach forthe replacement of single missingincisors using a custom-fabricatedall-porcelain bonded pontic, theCarolina bridge. This name wascoined by Drake Precision DentalLab of Charlotte, NC, USA, in the late 1990s. First used by theauthor in 1987, this simple designconsists of a custom-made all-porcelain pontic with an etchedproximal surface that is bonded to the adjacent abutment teethusing resin composite connectors(Figure 1).20

The primary qualities of this type of bonded bridge include ease ofplacement, esthetic vitality (nometal substructure), ease of connec-tor repair, and a totally reversiblenature. As with all bonded bridges,the primary keys to success includethe availability of adequate surfacearea for bonding, favorable occlu-sion, and periodontally sound andstable abutment teeth.

I N D I C A T I O N S

Patients best suited for an all-porcelain bonded Carolina bridgeare young adolescents with missingmaxillary incisors. Adolescentpatients with congenitally missingmaxillary lateral incisors are fre-quently ideal candidates (Figure 2).

Although the best long-term solu-tion frequently is the placement of

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a dental implant, patient age oftenprecludes this option in adoles-cents. Heretofore the onlyreversible option for interim incisor

Both options are not very hygienic,with tissue inflammation and papil-lary hyperplasia being commonresultant sequelae.

replacement in adolescent patientshas been a “flipper-type” tempo-rary prosthesis or a denture toothattached to a Hawley retainer.

A B

C D

E F

G

Figure 1. A, Patient with congenitally missingmaxillary lateral incisors. B, Bilateral, all-porcelain bonded bridges replace the missinglateral incisors. C and D, Right side, viewedbefore and after placement of a bondedbridge. E and F, Left side, viewed before andafter placement of a bonded bridge. G, Lin-gual view of bilateral bonded bridges. Notethat lingual embrasures are left undefined forthe strength of the connector.



In these cases, an all-porcelainbonded pontic is an excellentinterim prosthesis because of itstotally reversible nature. UnlikeMaryland-type bridges and otherbonded bridges involving somedegree of tooth preparation, the all-porcelain bonded pontic, or Car-olina bridge, requires no significanttooth preparation, making itentirely reversible. The abutmentteeth can be returned to their origi-nal virgin condition simply throughremoval of the bonded pontic andthe resin composite connectors.Subsequent treatment with animplant is not precluded.

As noted above, this alternative isparticularly well suited as aninterim prosthesis for adolescentpatients with congenitally missinglateral incisors. However, whereindicated, the Carolina bridge alsocan be used as a restorative alterna-tive in cases for which a more per-manent fixed prosthesis is neitherpractical nor affordable owing tothe patient’s age, medical condition,or economic status (Figures 3 and4). Additionally, patients with miss-ing lateral incisors and in whom the

remaining edentulous space is toosmall for an implant often areexcellent candidates for an all-porcelain bonded pontic of thistype. By slightly lapping the adja-cent teeth, an esthetically accept-able prosthesis can be obtained.

Ideally, patients should exhibit anocclusal relationship with little ver-tical overlap. Clearly, patients whoexhibit an end-to-end or slightopen-bite anterior occlusal relation-ship are well suited for this type ofbridge. Adolescent, post–orthodon-tic treatment patients often fall intothis ideal category.

In all cases, patients must be cau-tioned as part of informed consentthat the Carolina bridge does notpossess the strength of a conven-tional prosthesis and therefore mustbe used with caution to prevent dis-lodgment. However, properly done,this type of bonded all-porcelainpontic can provide an excellentinterim esthetic alternative.

C O N T R A I N D I C A T I O N S

Carolina bridges are not indicatedfor the replacement of posterior

teeth or canines because of thedegree of occlusal stress encoun-tered in these areas. Additionally,patients exhibiting a deep-bite ante-rior occlusal relationship and/orevidence of bruxism or clenchinginvolving the anticipated area to betreated are contraindicated.

Most importantly, abutment teethmust exhibit sufficient incisogingi-val height to ensure adequate sur-face area for bonding. Short teethare contraindicated as abutments.The absolute key to success is theavailability of adequate surface areafor bonding. This fact cannot beoveremphasized. Accordingly, theabutment teeth must be sufficientlylong to provide the surface areaneeded for successful bonding.

In most cases, a minimum inciso-gingival height of 5 mm is neededalong the proximal surface to ensureadequate bonding. To achieve thisrequisite condition it is sometimesnecessary to expose more of theclinical crown through a surgicalcrown lengthening procedure. Inadolescent patients, this type of pro-cedure is generally not undertaken

A B

Figure 2. A, Patient with congenitally missing maxillary lateral incisors. B, Bilateral, all-porcelainbonded bridges replace the missing lateral incisors.

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until approximately age 15 years. Aneed for crown lengthening of abut-ment teeth is not uncommonly seenin young patients who have recentlycompleted orthodontic treatmentand whose teeth exhibit a buildupof redundant or hyperplastic tissuealong proximal surfaces.

Patients also must possess soundabutment teeth with small or noproximal restorations and with nocrowns. Teeth with large Class IIIor IV restorations are contraindi-cated as abutment teeth, as areteeth with crowns. Abutment teethalso must be sound periodontally,with little mobility.

A D V A N T A G E S O F T H E

C A R O L I N A B R I D G E

Carolina bridges offer many advan-tages over metal “winged” pontic-type bridges. Properly done,Maryland-type bridges (and adhe-sion bridges) can serve as superbconservative prostheses for replace-ment of posterior missing teethbecause, generally, sufficient surfacearea is available for the incorpora-tion of a number of retention fea-tures. These include occlusal rests,inlay components, wrap-aroundretainer designs, and internally pre-pared slots or grooves. In a well-designed posterior Marylandbridge, the design of the prosthesis

effectively protects the bond, oftenrendering a highly successful result.

However, when used for replace-ment of missing anterior teeth,Maryland-type bridges experiencemore problems owing to the limitedamount of proximal surface area inwhich to incorporate adequateretention features, such as proximalgrooves. Certainly, success can beachieved with anterior Marylandbridges in some cases, but the poten-tial for problems is much greater.

The design of the Carolina bridgeavoids many of the problems asso-ciated with Maryland bridges,

A B

Figure 4. A, Patient with a traumatically missing maxillary central incisor. B, An all-porcelainbonded bridge replaces the missing central incisor.

Figure 3. A, Elderly patient with a missing maxillary lateral incisor. B, Porcelain pontic viewed on a model with a polyvinyl-siloxane index. C, Lingual view of a pontic on a model. D, All-porcelain bonded bridge viewed after placement. Note the longincisogingival length of connectors, which are essential to success.

A B C D



including adhesion bridges. First, asnoted earlier, no definitive prepara-tion of the adjacent abutment teethis required, making this approachtotally reversible. Second, the all-porcelain Carolina bridge is highlyesthetic owing to the absence of ametal substructure. Esthetic vitalityfrom optimal light penetration issuperb. By contrast, Marylandbridges are notoriously unestheticbecause of the graying potentialcreated by the metal wings, particu-larly in translucent abutment teeth.Moreover, the metal framework inthe pontic area of an anteriorMaryland bridge often limits thethickness of porcelain needed toachieve excellent esthetic vitality.

Also, all-porcelain pontics, such asthe Carolina bridge, often can beused when tooth anatomy precludesor restricts the preparation andplacement of a Maryland-typebridge. For example, long, pointedcanines with proximal surfacesexhibiting little incisogingivalheight often lack adequate surfacearea for the placement of retentiongrooves (see Figure 1E and F). Also,anterior teeth that are notably thinfaciolingually often still can betreated with an all-porcelain Car-olina bridge in many cases in whicha Maryland bridge would be anesthetic failure.

Third, the proximal resin compositeretaining connectors of all-porcelainCarolina bridges are easily repaired.

By contrast, if one wing of a Maryland bridge becomes loose, it is most difficult to remove thebridge without damage to the pros-thesis or the abutment tooth. Worseyet, if the loose wing goes unde-tected, caries can develop thatrequires more extensive restorationof the abutment tooth, often pre-cluding re-treatment with a newMaryland bridge. In another worst-case scenario, if food impactionoccurs between the loose metalretaining wing and the underlyingtooth, the tooth can actually be displaced facially, requiring ortho-dontic correction. All of these problems are avoided with the all-porcelain Carolina bridge.

C L I N I C A L T E C H N I Q U E

In the case used to illustrate thistechnique, an adolescent patient,age 14 years, presented with a missing maxillary right lateralincisor (Figure 5A). The patient lost the clinical crown owing totrauma. It was determined by ateam consisting of a periodontist,an orthodontist, an endodontist,and a restorative dentist that a den-tal implant ultimately will be thebest treatment once the patientreaches maturity. To best preservethe bony site for subsequentimplant placement, it was decidedto orthodontically submerge theendodontically treated root. A Carolina bridge was selected as the best interim prosthesis. Theocclusal relationship is favorable,

and sufficient crown length of theabutment teeth exists.

At the first appointment, shadeselection is determined, taking carethat the teeth are not allowed todehydrate prior to this assessment.An elastomeric impression is madeof the anterior segment from whicha working cast is generated. Animpression of the opposing arch ismade, as well as a bite registration.

An all-porcelain pontic is fabricatedof feldspathic porcelain by the labo-ratory (Figure 5B). Feldspathicporcelain is preferred to otherceramic materials because of the easewith which it can be effectivelyetched with hydrofluoric acid. Amodified ridge lap pontic tip designis used for the Carolina bridge. Theproximal surfaces of the pontic areetched with hydrofluoric acid toafford a highly retentive surface foradhesive bonding.21,22 It is importantthat all surfaces to be bonded andincluded in the resin composite con-nector area are effectively etched. Itis recommended that the surfaces tobe etched extend the full length ofthe proximal surfaces incisogingi-vally and extend onto the lingualsurface of the pontic at least to theposition of the lingual line angle toensure sufficient surface area forbonding. A positioning stent or indexis fabricated from polyvinylsiloxaneto facilitate positioning and bondingof the Carolina bridge at the deliv-ery appointment (see Figure 5B).

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At the second appointment, theinvolved abutment teeth are firstcleaned with flour of pumice in aprophy cup administered at slowspeed using a prophy angle hand-piece. The teeth are then thoroughlyrinsed, and the area is isolated withbilateral cotton rolls. A 2 × 2–inchgauze is placed across the patient’smouth to prevent swallowing oraspiration of the pontic during try-in and cementation. Care must betaken not to allow the teeth to dehy-drate prior to shade assessment.

The pontic is carefully trial posi-tioned to assess the accuracy of theshade and the adaptation of thepontic to the residual ridge (Figure5C). Once the accuracy of theshade and fit has been verifiedintraorally, the pontic is readied forcementation. If any contaminationof the etched proximal surfaces ofthe porcelain pontic occurs duringtry-in, these surfaces should becleaned by applying phosphoricacid briefly (a few seconds), fol-lowed by thorough rinsing and dry-ing of the pontic. A silane couplingagent is placed on the etched proxi-mal surfaces of the porcelain ponticto improve the bond strength.

Preparation of the abutment teethconsists simply of light rougheningof the proximal surfaces with acoarse, flame-shaped diamondstone (Figure 5D). Rougheningremoves the outer fluoride-richlayer of enamel that is more imper-

vious to acid-etching and increasesthe surface area for bonding,thereby improving the bondstrength of the resin connector tothe enamel surfaces of the abutmentteeth. The enamel of the proximalsurfaces is acid etched using a 30 to35% phosphoric acid etching gelfor a minimum of 15 seconds (Fig-ure 5E). Once etched, the proximalsurfaces must be kept clean and dryto ensure optimal bonding.

At this point, the pontic is ready forbonding into the edentulous space.Adhesive resin is placed on theetched surfaces of the abutment teethand porcelain pontic and is curedfor 20 seconds (Figure 5F and G). A small amount of resin compositeis applied to the proximal surfacesof the pontic (Figure 5H). A hybridresin composite is recommended forthe strength of the connectors. Toprevent premature curing of the resincomposite connectors during posi-tioning, it is recommended that theoperatory light be turned awayslightly to avert direct illuminationduring the bonding sequence.

Using the polyvinylsiloxane index,the pontic is positioned in the eden-tulous space. Excess resin compos-ite is removed with a resincomposite instrument or anexplorer (Figure 5I). The facialembrasures are defined, and thegingival embrasures are shaped toensure that they are open to allowaccess for cleaning. The lingual

embrasures are not defined butrather are bulked to strengthen theresin composite connector. Theresin composite in each interproxi-mal connector area is cured with alight source directed from bothfacial and lingual directions for aminimum time of 20 seconds eachto ensure complete maximal poly-merization (Figure 5J). Additionalresin composite is added and curedin any areas deemed deficient incontour. As noted earlier, the lin-gual contour of each resin compos-ite connector should be continuousmesiodistally from the line angle ofeach abutment tooth across to therespective line angles of the porce-lain pontic to maximize the cross-sectional diameter of the connectorsand achieve optimal strength.

The final contours of the resin composite connectors are achievedusing appropriate finishing burs. Aseries of abrasive points and cupsare used to finish and polish theresin composite connectors. Theocclusion is checked and adjustedto ensure that only minimal centricor functional contact is present.

The patient is instructed in properoral hygiene techniques, includingthe correct use of a floss threader toaccess the underside of the pontic(Figure 5K). The patient (and/or thepatient’s parents) is once againreminded to avoid biting hard foodsor objects to prevent fracture of con-nector areas. Also, as for all bonded



bridges, it is an important part ofinformed consent that the patient(and/or the patient’s parents) oncemore be informed of the possibilityof swallowing or aspiration of thepontic if it were totally dislodged.

This consent should be given in writ-ing, with a signature of acknowledg-ment obtained from the patient orthe patient’s parent if the patient is aminor. The completed Carolinabridge is seen in Figure 5L and M.

R E P A I R O F T H E R E S I N

C O M P O S I T E C O N N E C T O R

Although infrequently, patients willoccasionally present with a frac-tured resin composite connector.Usually, a fracture of a resin com-

C D

E F G

Figure 5. A, Patient with a traumatically missing maxillary central incisor. B, Porcelain ponticviewed on a model with a polyvinylsiloxane index. C, Pontic being tried in place prior to bond-ing. Note protective gauze in place. D, Light roughening of the enamel proximal surfaces of theabutment teeth with a coarse diamond. E, Acid-etching of the involved proximal surfaces withphosphoric acid. F and G, A light-cured resin bonding agent is applied to both the proximal sur-faces of the abutment teeth and the pontic and cured prior to bonding of the pontic. (continuedon next page)

A B

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posite connector occurs when apatient inadvertently bites on ahard food or object. It is very rarethat both connectors would frac-ture even from this type of insult.Almost always, patients are imme-

diately aware if a resin compositeconnector fractures.

As seen in Figure 6, a patient pre-sented with a fractured resin com-posite connector that resulted from

biting a hard candy. The first stepin repair of the resin compositeconnector is to use an ultrathin,tapered diamond instrument toremove the existing resin compositefrom the abutment tooth and the

H I

J K

L M

Figure 5 (continued). H, Resin composite is applied to the proximal surfaces of the pontic inpreparation for bonding. I and J, The porcelain pontic is positioned using a PVS index, and theresin composite connectors are shaped and light-cured. K, The patient is instructed regarding theproper use of a floss threader to facilitate regular cleaning of the area. L and M, Lingual andfacial views of the completed all-porcelain bonded pontic.



porcelain pontic (see Figure 6A). Ifneeded for adequate access, alwaysopen the connector at the expenseof the porcelain pontic. Neverremove tooth structure to gainaccess for repair of the resin com-posite connector. The remnants ofthe resin composite connector mustbe removed to expose porcelain onthe pontic and enamel on the abut-ment tooth to allow proper etchingand bonding.

Once the connector area is free ofresin composite remnants and theinterproximal area is open, a rubberdam is placed using the open con-tact for access (see Figure 6B). Toensure an optimal gingival seal dur-ing etching and bonding, the rubberdam is ligated. A Mylar strip is con-toured and placed interproximally

to protect the enamel surfaces of theabutment tooth during etching pro-cedures of the porcelain pontic. Theproximal surfaces of the porcelainpontic are etched using a 9.6%buffered hydrofluoric acid gelapplied for 2 minutes or as recom-mended by the manufacturer. Caremust be taken to extend applicationof the etching gel just beyond thelingual line angle of the pontic toachieve sufficient surface area forbonding of the resin composite con-nector. Following the timed applica-tion of the porcelain etchant, thesurfaces are thoroughly rinsed withwater for 5 to 10 seconds. Theetched porcelain surfaces are thor-oughly dried. A lightly frostedappearance should be evident.While maintaining isolation of thenatural tooth abutment with a

Mylar strip, a silane coupling agentcan be applied and dried accordingto the manufacturer’s instructions.

Following etching of the porcelainsurfaces, the enamel surfaces of theabutment tooth are acid etchedwith a 30 to 35% phosphoric acidetching gel for a minimum of15 seconds. Thereafter, the enamelsurfaces are rinsed for 5 to 10 sec-onds with a steady stream of water,followed by air drying. Adhesiveresin is placed on the etched sur-faces of the porcelain pontic andthe abutment tooth and is cured for20 seconds. An appropriate shadeof resin composite is inserted intothe connector area and shapedusing an explorer or resin compos-ite instrument, as noted previously(see Figure 6C).

A

D

CB

Figure 6. A and B, A fractured resin composite connector is removed with an ultra-slim, flame-shaped diamond instrument, exposing enamel and porcelain proximalsurfaces. C, After proper etching of proximal surfaces (porcelain with 9.6% bufferedhydrofluoric acid and enamel with 35% phosphoric acid), a new resin compositeconnector is generated. D, Immediate postoperative view of a repaired all-porcelainbonded bridge. Note the dehydration line consistent with the isolation level of the rubber dam.

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The final contours of the resin com-posite connectors are achievedusing suitable finishing burs. Aseries of abrasive points and cupsare used to finish and polish theresin composite connectors. Theocclusion should be assessed toensure that no heavy centric orfunctional contact exists on thenewly placed resin composite con-nector. Again, the patient should bereminded to avoid biting hardfoods or objects. The final resultcan be seen in Figure 6D.

Resin composite connectors willperiodically need surfacing, replace-ment, or repair owing to staining,wear, or fracture (Figure 7). How-ever, unlike other types of bondedbridges that are inherently invasive,Carolina bridges use simple com-posite connectors that can be easilyrepaired. Additional strengtheningof connector areas can be achievedthrough the use of a fiber reinforc-ing material, such as RibbondTHM (Ribbond, Inc., Seattle, WA,USA), if the occlusion allows. How-ever, additional reinforcement ofthis type is rarely needed if propercase selection has occurred and suf-ficiently large connectors have beenachieved for optimal strength.

S U M M A R Y

The Carolina bridge is a novel all-porcelain bonded prosthesis thatcan serve as an outstanding interimprosthesis for the replacement ofsingle anterior incisors. As notedrepeatedly, the absolute key to suc-

cess is the availability of adequatesurface area for bonding.

D I S C L O S U R E A N D

A C K N O W L E D G M E N T

The author does not have any finan-cial interest in the companies whosematerials are discussed in this article.

The author wishes to acknowledgethe outstanding work of Mr. DanielMaterdomini of da Vinci DentalStudios and Mr. Andre Theberge ofDrake Precision Dental Lab fortheir technical expertise in the fab-rication of these prostheses.

R E F E R E N C E S

1. Rochette AL. Attachment of a splint toenamel of lower anterior teeth. J ProsthetDent 1973;30:418.

2. Heymann HO. Resin-retained bridges: theporcelain-fused-to-metal winged pontic.Gen Dent 1984;32:203–8.

3. Livaditis G. Cast metal resin-bondedretainers for posterior tooth. J Am DentAssoc 1980;101:926.

4. Livaditis G, Thompson VP. Etched cast-ings: an improved retentive mechanism forresin-bonded retainers. J Prosthet Dent1982;47:52.

5. Hansson O. The silicoater technique forresin-bonded prostheses: clinical and labo-ratory procedures. Quintessence Int1989;20:85–99.

6. Matsumura H, Nakabayashi N. Adhesive4-META/MMA-TBB opaque resin withpoly (methyl methacrylate)-coated tita-nium dioxide. J Dent Res 1988;67:29–32.

7. Ibsen RL, Strassler HE. An innovativemethod for fixed anterior tooth replace-ment utilizing porcelain veneers. Quintes-sence Int 1986;17:455–9.

8. Schaffer JL. All-porcelain anterior fixedpartial denture: a preliminary report. J Prosthet Dent 1988;59:669–71.

9. Denissen HW, Gardner FB, Wijnhoff GF,et al. All porcelain anterior veneer bridges.J Esthet Dent 1990;2:22–7.

10. Moore DL, Demke R, Eick JD, Sigler TJ.Retentive strength of anterior etchedporcelain bridges attached with resin com-posite resin: an in vitro comparison ofattachment techniques. Quintessence Int1989;20:629–36.

11. Denissen HW, Wijnhoff GF, Veldhuis AA,Kalk W. Five-year study of all porcelainveneer fixed partial dentures. J ProsthetDent 1993;69:464–8.

12. Hornbrook DS. Anterior tooth replace-ment using a two-component resin-bondedbridge. Compend Contin Educ Dent1993;14:52–9.

13. Leal FR, Cobb DS, Denehy GE, MargeasRC. A conservative aesthetic solution for a single anterior edentulous space: casereport and one-year follow-up. PractProced Aesthet Dent 2001;13:635–41.

14. Kern M, Knode H, Strubb JR. The all-porcelain, resin-bonded bridge. Quintes-sence Int 1991;22:257–62.

15. Trushkowsky RD. Replacement of con-genitally missing lateral incisors withceramic resin-bonded fixed partial den-tures. J Prosthet Dent 1995;73:12–6.

16. Pospiech P, Rammelsberg P, Unsold F. Anew design for all-ceramic resin-bondedfixed partial dentures. Quintessence Int1996;27:753–8.

Figure 7. Typical all-porcelain bondedbridge replacing a maxillary right cen-tral incisor seen after 4 years, 2 monthsof service. Stained areas of the resincomposite connector typically requireresurfacing or replacement.



17. Antonson DE. Immediate temporarybridge using an extracted tooth. Dent Surv1980;56:22–5.

18. Heymann HO. Resin-retained bridges: thenatural tooth pontic. Gen Dent1983;31:479–82.

19. Heymann HO. Resin-retained bridges: theacrylic denture tooth pontic. Gen Dent1984;32:113–7.

20. Heymann HO. Additional conservativeesthetic procedures. In: Roberson TM, editor. The art and science of operativedentistry. 4th ed. St. Louis: CV Mosby Co;2001. p. 592–649.

21. Calamia JR. Etched porcelain facialveneers: a new treatment modality basedon scientific and clinical evidence. N Y JDent 1983;53:255–9.

22. Stangel I, Nathanson D, Hsu CS. Shearstrength of the composite bond to etchedporcelain. J Dent Res 1987;66:1460–5.

Reprint requests: Harald O. Heymann,DDS, Med, Department of Operative Den-tistry, UNC School of Dentistry, 302 BrauerHall, Chapel Hill, NC, USA 27599-7450; e-mail: [email protected]©2006 Blackwell Publishing, Inc.

*Professor and chair, Department of General Dentistry, MUSC College of Dental Medicine, Charleston, SC, USA

COMMENTARY

THE CAROLINA BRIDGE: A NOVEL INTERIM ALL-PORCELAIN BONDED PROSTHESIS

W. Dan Sneed, DMD, MAT, MHS*

Adhesives have certainly changed the way we practice dentistry. Macromechanical resistance and retentive features havehistorically been a hallmark of quality restorative dentistry. Even today, it is certainly wise to incorporate mechanicaldesign along with adhesives. This article, however, presents a very viable alternative to the traditional grooves, pins, andslots to retain a single-tooth pontic.

The author begins with a thorough review of the pertinent literature. He describes the various methods of fabricatingconservative, single-tooth, fixed partial dentures, and most of these require some significant preparation of the abut-ment teeth. The author is intimately aware of his options, as well as the advantages and disadvantages of each. Withthat understanding, he then proposes a truly adhesive bridge that is totally reversible. At first read, this approach mayseem futile. Many dentists have tried “gluing” pontics between two abutment teeth only to see them quickly fail. Thedifference here is the dentist’s clear understanding of the indications for and the limitations of this technique. There isalso an understanding of occlusion and material and adhesive dynamics.

For this procedure, the author selects only patients who meet a defined set of criteria, and those patients understandwhat to expect. Then feldspathic porcelain is used because it, unlike some other ceramics, can be etched with hydroflu-oric acid. The application of a silane then ensures that the adhesive interface is stronger than the cohesive strength ofeither the porcelain or the composite.1–3 The enamel is lightly abraded with a diamond to enhance an already tenaciousenamel bond.4 A hybrid composite is selected because of its strength. The connector areas must be of a certain widthand length, and again and again, the author makes informed judgments.

The true message of this article is not just another technique but a process of problem solving based on knowledge andjudgment. If we all approached restorative dentistry this way, with an informed patient and a knowledgeable dentist,surprises would be few and far between and success would be routine.

REFERENCES

1. Guler AU, Yilmaz F, Ural C, Guler E. Evaluation of 24-hour shear bond strength of resin composite to porcelain according to surfacetreatment. Int J Prosthodont 2005;18:156–60.

2. Knight JS, Homes JR, Bradford H, Lawson C. Shear bond strength of composite bonded to porcelain using porcelain repair systems. Am JDent 2003;16:252–4.

3. Barghi N. To silanate or not to silanate: making a clinical decision. Compend Contin Educ Dent 2000;21:659–62.4. Schneider PM, Messer LB, Douglas WH. The effect of surface reduction in vitro on the bonding of composite resin to permanent human

enamel. J Dent Res 1981;60:895–900.

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