Journal of Oral Rehabilitation, 1990, Volume 17, pages 131-136

A clinical evaluation of conventional bridgework

G.S.p. CHEUNG, A. DIMMER, R. MELLOR and M. GALE Department of
Conservative Dentistry, Faculty of Dentistry, University of Hong Kong, Hong Kong :

Summary
The present study evaluated the incidence and causes of failure of conventional
bridgework provided in the Prince Philip Dental Hospital, Hong Kong. Any bridge
that utilized resin-bonded (Maryland) retainers was excluded from this study. All
patients with bridges fitted between 1981 and 1987 were recalled for review, and 143
patients attended, a response rate of 77%. A total of 169 bridges were examined, their
mean length of service being 35 months. Thirty-five bridges were deemed to have
failed. The most frequent cause was endodontic, followed by loss of retention, then
persistent pain and sensitivity. Failures of endodontic origin affected mostly anterior
bridges, which could be attributed to the over-sized pulp of anterior teeth and the
amount of tooth reduction required for the ceramometal retainer. AH of the bridges
that failed because of endodontic problems had had ceramometal retainers. Taking
posterior bridges alone, the failure rate was 4.4% per year. From the evidence of this
study, the replacement of the maxillary canine with a cantilever bridge appears to be
contra-indicated.

Introduction
The longevity of amalgam restorations has been reported extensively (Elderton, 1976;
Maryniuk, 1984). However, information related to longevity of cast restorations is not
as adequate for analysis as it is for amalgam alloys (Maryniuk, 1984). Even less
information on fixed bridgework is available because it is made much less frequently
compared to amalgam or single-unit cast restorations. This makes the collection of
bridge failure rate a time-consuming and difficult process. Although long-term
longitudinal records are available in all dental offices, they are not readily available
for analysis because of logistical problems.
The Prince Philip Dental Hospital was opened in 1981. It is the teaching hospital
for the Faculty of Dentistry of the University of Hong Kong. Most dental treatment is
provided by dental students under supervision, and a small proportion is carried out
by registered dentists or lecturers working on the premises. The personal and treat-
ment records of every patient who attends the hospital are entered on a computer,
and thus data are readily available. The purpose of this study was to examine the fixed
conventional bridges provided in the Prince Philip Dental Hospital and to evaluate
the causes of failure in this type of restoration.

Correspondence: Dr. S.P. Cheung, Department of Conservative Dentistry, The Prince Philip Dental
Hospital, 34 Hospital Road, Hong Kong.

131
132 G.S.P. Cheung et a l . -:. r,..- "^ • • - . • • : • --::•-:-'••.•:..-:•#. ,-;;'• "^ •;-;AM.\

Materials and methods

A list of patients who were provided with one or more fixed conventional bridges
between 1981 and 1987 was obtained by searching the computerized hospital records.
The written records of these patients were consulted and any bridgework that utilized
resin-bonded (Maryland) attachments on any abutments was excluded from this study.
A total of 184 patients satisfying the requirements for inclusion in this study were
identified. They were invited to return for a review appointment during the month of
M y or September 1988.
A special form was designed for use in the assessment. The clinical examination
comprised a dental check-up and an assessment of the bridgework, followed by
radiographic examination of all abutments. Factors evaluated included design, position
and status of the bridge, condition of abutments, and their periodontal and pulpal
status. For the purpose of this study a bridge was deemed to be a failure if any of the
following was found.
(i) The bridge required recementing or had to be remade.
(ii) The abutments had become non-vital and/or root filled after cementation of
the bridge.
(iii) There was fracture of the retainer, pontic, or abutment.
(iv) Caries was present in the abutment tooth.
The collected data were recorded using a Sperry Univac computer and later
analysed. Where further treatment was deemed necessary, this was arranged following
the review.

Results
One hundred and forty-three patients attended for the review, a response rate of
77%. A total of 169 bridges, involving 340 abutments and replacment of 200 units of
teeth, were examined. These included 50 abutments which were non-vital and root-
treated before the provision of bridgework. The patients ranged from 18 to 71 years of
age, averaging 39 years. The mean length of service of the bridges was 35 months. The
newest one was fitted 7 months before the review and the oldest bridge had been
present for 55 months.
The design and distribution of the bridges are summarized in Table 1. Over half of
the bridges replaced posterior teeth. Another 37% replaced anterior teeth. The
replacement of a canine accounted for a small proportion, 6.5%, of all bridges fitted.
Irrespective of location, the fixed—fixed design was the most common (about 77%).
The fixed—movable design was less frequently used, in general. More fixed—movable
than cantilever bridges were fitted in the posterior segments, while the converse was
true in the anterior part of the mouth (Table 1).
A total of thirty-five bridges, or 20.7% of all bridges fitted, failed (Table 2). The
failure rate was 7.1% per year, calculated according to Roberts (1970). The average
life span of these bridges was 2 years, ranging from 2 to 50 months. The most frequent
cause of failure was endodontic. That is, the abutments became non-vital and had to
be or had been endodontically treated. This accounted for 57% of all failures in this
group of patients. Loss of retention causing the bridge to be recemented or remade
occurred in seven bridges, i.e. one-fifth of the total number of failures. Five bridges
were removed because of persistent pain and sensitivity in the abutments after cemen-
tation. The symptoms subsided after replacement of these bridges. Fractured porcelain,
abutment fracture and root resorption led to the failure of one bridge each. A small
 Conventional bridgework 133
Table 1. Breakdown of bridges examined

Anterior Posterior Replacing canine Total (%)

Fixed-fixed 49 74 7 130 (76-9)

Fixed-movable • • • 3 20 • • • -
1 24 (14-2)
Cantilever 11 1 3 15 (8-9)
Total (%) : 63 (37-3) 95 (56-2) 11 (6-5) - 169 (100)

Table 2. Amount of failures, average service of 35 months

Cause of failure No. of bridges (% of all failures)

Endodontic 20 ( 57-1)
Loss of retention 7 ( 20-0)
Pain and sensitivity 5 ( 14-3)
Porcelain fracture 1 ( 2-9)
Fracture of abutment 1 ( 2-9)
Root resorption 1 ( 2-9)
Total 35 (100.1)

secondary carious lesion was found on the abutment of one bridge that had failed
because of a concurrent endodontic problem.
The three major causes of failure were further analysed according to the location
of the bridgework (Table 3). Strikingly, endodontic failures affected mostly the upper
anterior bridges. Loss of retention occurred mainly on upper anterior and lower
posterior segments, while persistent post-operative pain and sensitivity caused more
failures in posterior than in anterior bridges.

Discussion
The present study was a clinical survey on the prevalence of failure of conventional
bridges provided in the Prince Philip Dental Hospital. Most patients were quite willing
to attend, and a very high response rate of 77% was achieved. Of the forty-one
patients who failed their appointments, seven returned some time after the study and
the bridges were found to be intact and functional. These bridges were, however, not
included in the calculation of success/failure rate. Seventeen patients had moved to a
new address and could not be contacted. The other 17 patients did not attend, for no
obvious reason. In the combined group of thirty-four patients not examined, there
were thirty-two fixed-fixed, two fixed-movable and six cantilever bridges, of which
seventeen replaced the anterior, twenty-one replaced the posterior and two replaced a
canine tooth. Except for the small numbers of fixed-movable bridges, the proportion of
the bridges according to their location and design was similar to that shown in Table 1.
It seems unlikely that this group of non-respondents would affect the present result
because of the relatively small number in this group of patients. The successful bridges
in the seven late respondents would offset any unfavourable change in the result
obtained, if not improve it.
This study was designed to be a cross-sectional survey in which all patients fitted
with one or more fixed prostheses were recalled. In this respect, it differed from the
134 G.S. P. Cheung etal

Table 3. Distribution of the three major causes of failure

Endodontic Loss of , Pain Bridges made

retention

Upper antenor 13 4 1 59
Upper replacing canine 1 0 .• .•• • . .-. 9

Upper posterior 1 34
Lower anterior 1
a0 •. .-^^ -2.

0
. •

4
Lower replacing canine 0 0 0 - 2
Lower posterior 4 3 2 61
Total (%) 20 (11-8) 7(4.1) 5(3) 169(100)

studies of other workers which examined patients who presented with unserviceable
bridgework (Schwartz et al, 1970; Walton, Gardner & Agar, 1986). In this latter type
of study, the subjects were self-selected and the failure rate could not be assessed. In
the present study, approximately one in five bridges failed after 3 years of service. The
collective failure rate calculated was 7-1% per year, the projected average life span
being 7-0 years. The high incidence of failures was attributed to the exceptionally high
failure rate of the anterior bridgework (Table 4). Taking the posterior bridges alone,
the failure rate was 4.4% per year, a figure that is comparable with many studies of
the same kind (Roberts, 1970; Reuter & Brose, 1984).
Most failures were endodontic in origin. Twenty out of the thirty-five failed
bridges had either or both of their abutments devitalized, necessitating root canal
therapy. Operational trauma, undiagnosed pre-operative pulpal condition, chemical
irritation caused by the cementing medium, marginal leakage, or occlusal trauma after
bridge cementation might have contributed to the pulpal death. The first reason stated
is the most likely (Karlsson, 1986). The deeper and the more extensive the tooth
reduction, the higher the chance of overheating and microscopic exposure of the pulp
during the operative procedures. Anterior teeth are particularly vulnerable because of
their large pulp size and the amount of tooth reduction required for a ceramometal
retainer. This was reflected by the observation in the present study that 70% of the
failures of endodontic origin were in the anterior segments. In fact, all of the abutment
teeth that failed endodontically had had ceramometal retainers. The fact that some
anterior teeth used as abutments had previously large composite restorations and
possibly a compromised pulp before preparation may also have contributed to the
problem.
The incidence of post-cementation pain and sensitivity in the abutment teeth was
higher in posterior than in anterior bridges. This might be explained by the amount of

Table 4. Failure rates of bridges at different locations

Location No. of No. of Average months Failure rate

bridges failures of service (% per year)

Anterior 63 20 35-6 10-7

Posterior 95 12 34-8 4.4
Replacing canine 11 3 33-8 9-7
ALL 169 35 35-1 7-1
 Conventional bridgework 135
occlusal loading on the posterior teeth and the possible introduction of occlusal
interferences. Irritation due to the cementing medium might also play a role. Four out
of the five bridges that were removed due to post-cementation pain were luted with
glass ionomer cements. Although histopathological studies suggest that glass ionomer,
when used as a restorative, does not evoke any greater pulpal response than zinc
phosphate or polycarboxylate cement (Heys et al., 1987), post-operative sensitivity
was reported in some fixed crown and bridge restorations in which glass ionomer
cements were used as luting agents (Council of Dental Materials, Instruments and
Equipment, 1984). The patients reported no symptoms after the bridges were removed
and replaced.
Debonding occurred in seven (4-1%) of the bridges examined and was limited to
the upper anterior and lower posterior segments. Occlusal interferences appear to
have been the major factor in the debonding of these retainers, which were endo-
dontically treated and restored with posts and cores, and this finding is in general
agreement with that of Karlsson (1986).
There were three cantilever bridges replacing canines (Table 1). Two of them
replacing upper canines failed technically, the reasons being fractured porcelain and
fracture of the abutment tooth. It appears that either the bridge or the natural tooth
substance yielded to the heavy occlusal loads on the* maxillary canine pontic during
function. Replacement of canines, of the upper arch in particular, with a cantilever
bridge is not recommended.
Of all bridges examined, recurrent caries was detected in only one abutment of
one bridge. This is not in accordance with other studies, which generally concluded
that caries was the single most frequent cause for failure (Kantorowicz, 1968; Schwartz
et al., 1970; Walton et al., 1986). However, it must be remembered that Hong Kong
has had water fiuoridation since 1961, and the bridges surveyed in this study were a
maximum of four and a half years old. The rate of secondary caries incidence may be
offset by the average short-term service of the bridges and the extremely low DMFT
rate of the area, approximately 1-8 in the adult dentition in Hong Kong (Joint FDI/
WHO Working Group, 1985).

Conclusion
The longevity and causes of failure of conventional bridgework provided in the Prince
Philip Dental Hospital were evaluated. Fifty-seven per cent of all failures were
endodontic in origin, of which the majority were with anterior bridges. Debonding
occurred in 4-1% of the bridges examined. The failure rate was 4-4% per year for
posterior bridgework. Anterior bridges failed relatively more frequently, which could
be attributed to the over-sized pulp and the large amount of tooth reduction for
ceramometal retainers in the anterior teeth used as abutments. The increased use of
resin-bonded retainers is expected to reduce the incidence of pulpal death in the
abutments of anterior bridges.

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Manuscript accepted 28 April 1989