Success with Resin Bonded Bridges (aka Adhesive Bridges or formerly Maryland) - PDP132

[@babitha007]

Very detailed talk with appropriate questions and answers

[@protrusive]

thank you doc!

[@rashedala-uddin9012]

Superb podcast. RBBs - love them.

[@velism]

Such a great podcast! Looking for Dr. Salman’s webinar on RBB that he mentioned towards the end. I understand that it was live but I wonder if the recording is somewhere online?

[@oohitsjc]

Great informative video, thank you both! Do you recommend seat preparations on 6s?

[@protrusive]

I have seen it work, it is good to cover the occlusal on 6s and sometimes this may be from seat prep

[@ZACY1234]

Hey Jaz! Another great episode with a lot of gems!! I have some questions: 1. In the case of immediate RBB--> How do we control bleeding after extraction so that we have a clean bonding environment? 2. where can I find the Mathias Kern paper? Do you mind sharing the title please? 3. What's the minimum soft tissue thickness to have before using the thermacut burs to shape the site for the ovate pontic?

[@protrusive]

Hi Dem! Thank you. 1. I use PTFE over the socket 2. pubmed.ncbi.nlm.nih.gov/28688950/ 3. As long as you leave 1.5mm soft tissue overlying the bone, you're good. So I like to have 3mm (or more) to play with.

[@ZACY1234]

@@protrusive perfect answer!! Thank you very much!! Take care:)

[@KevinRapkochFishing]

Hi, i have a congenitally missing #10. After braces, my orthodontist placed a maryland bridge when i was 17, and it lasted until it finally broke off at 37 (20 years). My roots are too close together, so my dentist and I opted for a new Maryland Bridge. It was placed last week, but it feels "loose". It's a porcelain bridge (the wings appear to be same material as the tooth), and its bulky. There are two wings, and every morning I wake up, it feels like the bridge is sitting slightly differently (just a feeling, not visually if that makes sense); and there is a loose feeling to it (it's not noticeably loose if I try to wiggle it), but something definitely seems off. My dentist thinks its fine. Any thoughts? Thank you in advance! 🙂✌️

[@danielshaw4716]

Great info, thanks! What are your thoughts on a bonded bridge to replace a missing lower central incisor? Is it enough to use a single wing bonded to the lateral? Thanks in advance!

[@protrusive]

Yes absolutely - have done this a lot and also is the situation in MY mouth! Sometimes its beneficial to go fixed-fixed if single RBB is too fiddly in this region or a degree of perio splinting or ortho retention is desired

[@juicer52]

Thank you for the excellent presentation. My former professor, Dr. Livaditis, was involved in the original Maryland bridge design. Dr. Livaditis is a proponent of the method of chemically treating the base metal prior to cementation versus the electrochemical method. Do you have a preference? I believe there are procedural steps based on metal composition, beryllium versus non-beryllium content.

[@protrusive]

Hi Doc! Thank you so much for your comment. Indeed, the electrochemical etching method is obsolete and the use of beryllium containing alloys has been abandoned due to safety concerns. Contemporary RBBs are base metal such as cobalt-chrome and abrasive blasting and metal priming is the accepted adhesive protocol that the latest literature has shown to be predictable. Hope that helps and thanks again for tuning in!

[@michelleflynn5667]

I have had a bridge for 20 years and a crown on my left incisor front tooth, (beside the bridge) due to breaking my tooth in the playground at he age of 9. Recently the crown fell out. I have an option to have an implant or cantilever bridge which would involve to remove the current bridge and replace it with a new one adding another tooth - hence the cantilever bridge. What would you recommend implant or cantilever bridge ? Which material would you recommend zirconium oxide or the traditional alloy metals with porcelain ?

[@protrusive]

There are so many factors to consider and the best person to advise is your dentist (whilst you described your case well, there are so many unknown unknowns here that your Dentist will know eg. your gum condition, medicines you take and your bite).

[@break1722]

had an adhesive bridge by NHS 18 years ago, still going strong! if it ever fell out, how much would it cost to have it re-attached?

[@Taraloveswayne]

How many missing teeth do you have? I wonder if you can have a Maryland for 3 missing teeth.

[@break1722]

@@Taraloveswayne I have just one, but yes you can have multiple in a row, I would highly recommended it. Lasts a lifetime, and can simply be re-glued in the unlikely scenario it ever falls out

[@break1722]

@@Taraloveswayne Also mine only has a wing on one side, so it’s only attached to one tooth next to it. I would imagine it would be indestructible if attached to both adjacent teeth, with two wings

[@juicer52]

When treating a missing lower lateral, bonding off the cuspid, is it advisable to create any mechanical retention like a distal (and mesial) groove within the cuspid's enamel which could serve to prevent rotation on seating as well as a stop if not wanting to show incisal metal. If aesthetically feasible, the mesial groove could insure the .7mm minimum connector. I am trying to bring local clinician up to speed in treating me. As your talk suggests, many practitioners shy away from RBBs. Many thanks for keeping the technique and materials current.

[@protrusive]

according to the best available evidence, grooves did not improve success rate. Not necessary but I'm not against it entirely- seldom do grooves

[@nickybonnici6732]

Hi Dr.Gulati first of all thank you for your amazing podcasts. Love learning new things and keeping up to date. I have a case coming up in a few days in which we opted to use a RBB to replace 12 with a mesial cantilever from 13. The pt is around 55 years old, with an unrestored canine with good enamel and no parafunction. Given his occlusion at Maximal intercuspal position, if no preparation is done, he'd definitely bite down on the 0.7mm wing. Can I still rely on the Dahl effect in someone his age or is it preferable in our younger patients? If not what sort of preparation would you advise? Thanks

[@protrusive]

I would look at the opposing, could you adjust/round off/'equilibrate' 0.5mm of a cusp tip to create space? And maybe a very light prep in to the abutment

[@nickybonnici6732]

@protrusive thank you for your reply. Yes, I'll see how to opposing arch makes contact and adjust accordingly

[@michelleflynn5667]

@protrusive Thank you for your prompt reply. Actually it's the upper front/incisor (no 8 ) not lower. As previously mentioned there had been a crown there before which lasted 30 years and it had been root canal treated. The neighbouring teeth no. 7, 6, & 5 there is a bridge so I have been given the option to remove it and place another bridge this time a cantilever bridge to fill the gap of no.8, I had the root extracted 3 moths ago. If it was you would you go for the cantilever bridge or implant now that you know it's the upper jaw ?

[@juicer52]

Originally, non-precious was the metal of choice due to its properties when relying on etching. Is that still the case in the day of Panavia V5 which relies on sandblasting or is semi-precious preferable when considering potential metal allergies? Many labs shy away from non-precious..

[@protrusive]

nowadays it's cobalt chrome (not nickel chrome) and works well sand blasted and with Panavia V5

[@bettyboop1524]

I've recently been told that my #30 has a fracture found with x-ray. So far I have not been given any options besides "implant". The cost is not something that I can handle. Doing my own research I have been wondering about a Maryland Bridge - haven't asked my dentist about it yet. It is so frustrating that I don't get any options besides extraction and implant (US). Thank you for this video.

[@protrusive]

thanks for commenting. generally for #30 it's not recommended as a general rule

[@rakeebamowjood]

What are the calipers youll use?

[@babitha007]

Would love to know what Cement was used by your principal in olden days for Maryland bridges

[@protrusive]

fairly sure it was Panavia which has been around since early 80s

[@trippssey]

Have you bonded bridges to teeth that had fake materials such as a chipped tooth that was rebuilt? (Front tooth was chipped in childhood and lower half is fake, the tooth next to it is now missing.) Also, any tips for finding dentists who are passionate about these options? And when interviewing dentists on this, what questions should be asked or what should be looked for? Are there healthier resins or materials or an ultimate ideal scenario? Hope that makes sense. Thank you.

[@protrusive]

Thanks for commenting - I don't have the capacity to serve the public as well as Dentists - but seeing as your questions have some learning points for Dentists: Unrestored teeth with good quantity and quality of enamel will make the most successful abutments for RBBs. Small restorations might be accepted as a compromise but everything else must be going in your favour.

[@Yaaae92]

I lost my first premolar (right upper jaw) last year and chipped half of my second premolar (right upper jaw). I don’t want dental implants what do you suggest?

[@protrusive]

Hi - this channel does not give direct advice to public, sorry about that. Please do find a Dentist near you that you trust and they will look after you. Thanks

[@velism]

Would you extend the retainer all the way down to the gingival margin even if you have had some recession and now there is exposed dentine gingivally?

[@protrusive]

good Q - assuming a good surface area of enamel - I would stick just to enamel and not get on to root dentine IF the abutment is small and enamel surface area is small, I would question this abutment for suitability for RBB

[@velism]

Thanks Jaz

[@michelleflynn5667]

@protrusive Thank you very much for your reply. I have seen a restorative dentist and an implantologist I been given the go ahead to either option a cantilever bridge or an implant that's why I'm quandary which option to take ? I am not on any medications. I have a very high bite but apparently either option is possible. Re. the implant I would need to undergo a small bone graft which is why I am hesitant , what would you advise?

[@protrusive]

With the limited information, if it was my own tooth I would have a bridge (providing its already crowned and not root canal treated). I'm not the biggest fan of implants to replace narrow lower incisors. But that's just my opinion

[@JacquelineSanders-q8p]

Hi! I have some questions about the "less prep" approach. I am almost done with the RBB Master Class and I just sent my first case for a Zirconia RBB to the lab. My lab contacted me saying that they will not fabricate a Zirconia RBB without cingulum or finger rests due to lack of retention. They have asked me to switch my material choice to composite.... and the evidence for this material is not promising. My lab literally refused to fabricate the RBB from zirconia. Do you or does anyone in the states have a lab they use for this approach? Is there a way I could just tell my lab to fabricate as directed? Thanks - Jacquie

[@LoLFilmStudios]

They’re not the ones to reject anything because it is your responsibility. Find another lab but make sure you know what you’re doing. Lab workers know a little but not as much as they think.

[@boguszwegner5464]

​ @protrusive Hi Jaz! I see many metal-based one wing RBB's here and there to replace 12 or 22 (second upper incisors). What do you think about full zirconia rbb in that cases. In case if first incisor and canine are both in good condition - which one should be preffered to bond the wing. And one more question with premorals - what do you think about using full zirconia fixed-fixed rbbs with making them bit lower than biting surface to reduce clench forces on pontic.

[@protrusive]

Check out the papers by M Kern - amazing success rates for replacing laterals for Zirconia RBBs!

[@protrusive]

@boguszwegner5464 as for Central vs Canine - more often the central will give more surface area - however the canine has a surved palatal anatomy which provides strength.

[@protrusive]

as for posterior cases with zirconia it seems to be less predictable with high risk if framework fracture. these RBBs are more for beauty than for function

[@rajivkar]

Will this work to replace canines

[@DINOTUBE73]

Can this be done to replace two upper insciors? I really need a response doc. Im loosing two front teeth and feel down rn as i don't have Money for implants and don't want to have metal in my jaw.

[@protrusive]

it can but there are a lot of ifs and buts and a lot depends on the bite and the condition of the abutment teeth. If my life dependent on it I would say 'No' But in the right scenarios it can work.

[@DINOTUBE73]

Thanks for the response

[@disha3558]

I lost my first upper premolar can i opt for cantilever maryland bridge using my second upper premolar?

[@protrusive]

If the stars align perfectly, then yes, but it's dependent on so many factors. It must be understood that these bridges are not designed to chew on, they are for smiling.

[@juicer52]

what type metal are you using for the Maryland Bridge?

[@protrusive]

non precious metal (specifically nowadays cobalt chrome)

[@juicer52]

​@@protrusive 1 local lab uses rexilium III which contains nickel chrome beryllium but acid etch (HFl?) and no sand blasting. I like your simple method with consideration for the lab tech's life span. BTW I gave our Panavia rep links to your YT videos and suggest they put you on their payroll.

[@protrusive]

​@@juicer52thanks doc!!!

[@jamesmaher8595]

Before I watch yopur video does your preparatory work on the two adjoining teeth damage their enamel in any way please?

[@protrusive]

in a word: hardly (if you do it NON or MINIMAL prep)

[@carlymc876]

Can this be done on #12??

[@protrusive]

yes! if you have a virgin #13 with good enamel surface area - you can have the wing cover palatally and the palatal half of the occlusal surface. Metal should be 0.7mm thick so may need to create some occlusal space by preparing the #13 and maybe even a cusp tip of the opposing

[@Taz4u12k4]

Ive had this done 5 years ago in my molar it quit a big tooth bonded with the metal wing, it functions just like a normal tooth the only issue i have had with it food getting stuck into it from time to time and the teeth its bonded too is slightly darkish in colour however it being on the bottom tooth it hardly visable and it seems like it will last a long time i was considering gettin an implant as thats the best option however i dont have any issue and its hardly noticable

[@sbommana6489]

Can they be done on tooth#9

[@protrusive]

as an abutment? Yes, for sure. As a pontic - way less common and needs A LOT of favourable conditions to make it work

[@sbommana6489]

@@protrusive so if as Pontic, what other options are better if implant and other invasive methods to be avoided. Thanks

[@protrusive]

@s Bommana 1. a partial denture 2. any other type of bridgework (but same limitations) - other than an implant everything else is just a variation of the above

[@sbommana6489]

@@protrusive Thanks for answering, I can’t have implant as space is issue and bridge may spoil good teeth, is composite resin or ribbond really work to create a bridge ? Sorry for so many follow up questions.

[@protrusive]

@s Bommana I understand. Ribbons and all are great but they are still a type of bridge. Everything is possible but all treatment modalities have compromises involved. I wish you well with your care

[@hazeltwycross2946]

Hi Jaz. Very glad to find your podcast. Could you please comment if you think sandblasting with cojet is a necessary step for a long lasting zirconia maryland or just aluminium blast and MDP? How many cases have you seen with zirc go past 10 years?

[@protrusive]

Hi Doc! Sorry for the delayed reply. Sandblasting with aluminium oxide is just fine, you don't need cojet. My older zirconia RBB cases are 5 year old at the moment - this is when I started using zirconia slowly. I still do a lot of metal ones. I see the 25 and 30 year old RBBs my predecessor did regularly (many that have never debonded, and a few that were recemented every 8 years or so) - I must recommend you read the findings by M Kern on their longevity which is showing very high success rates at 10 years: pubmed.ncbi.nlm.nih.gov/28688950/

[@michelleflynn5667]

Ps. There isn't a root canal where the bridge is no 7,6 & 5

[@protrusive]

sorry Michelle I feel uncomfortable giving dental advice online without a consultation. I do however wish you all the best with your care. My top advice is to trust the judgement and recommendation from your dentist. If no one has given you a clear recommendation , ask for it.

[@michelleflynn5667]

@@protrusive

[@michelleflynn5667]

Thank you.