JPOR-300; No.

of Pages 5

journal of prosthodontic research xxx (2015) xxx–xxx

Available online at www.sciencedirect.com

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journal homepage: www.elsevier.com/locate/jpor

Case Report

A fixed movable resin-bonded fixed dental

prosthesis – A 16 years clinical report

Michael G. Botelho BDS, MSc (Lond), PhD (Wits), AdvDipProsthodont (HK),

MRDRCSEd, FRACDS*, Walter Y.H. Lam BDS, MDS (Pros),
AdvDipProsthodont, FRACDS, MFDSRCSEd, MFDSRCPSG, MProsRCSEd
Oral Rehabilitation, Faculty of Dentistry, The University of Hong Kong, Hong Kong, China

article info abstract

Article history: Patients: This report describes the case of a 48-year-old female patient who initially received
Received 27 July 2015 a 4-unit fixed-fixed (FF) resin-bonded fixed dental prosthesis (RBFDP) for replacement of
Received in revised form mandibular left second premolar and first molar. Twenty-one months later, debond of the
23 September 2015 RBFDP was found at one of retainers. A new fixed-movable RBFDPs with a modified non-rigid
Accepted 19 October 2015 connector as well as increased resistance form features was placed and successfully
Available online xxx retained at the 16-year clinical review.
Discussion: RBFDPs are a conservative tooth replacement option that requires minimum
Keywords: tooth preparation and retention by a resin cement to etched enamel. However debonding is
Resin bonded fixed partial denture the most frequently seen complication and has been attributed to the relative movement
Non-rigid connector between abutment teeth during function that stress the bonding interface. This case report
Survival highlights the use of modified non-rigid connector which allows relative movement be-
tween abutment teeth and therefore a reduced stress on the bonding interface.
Conclusion: It is proposed that the use of modified non-rigid connectors that allow indepen-
dent movement between the abutment teeth during function was responsible for the long
term clinical success of fixed-movable RBFDPs.
# 2015 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.

prostheses. However, the present literature still appears to

1. Introduction
Evidence based information continues to accumulate on ways
to improve the design of resin bonded fixed dental prostheses
(RBFDPs). Aspects of tooth preparation [1–3], framework
extension [4,5], and the use of two-unit cantilevered designs
[6–18] have significantly improved clinical retention of these
support the observation that the greater the number of units in
the resin-bonded fixed dental prosthesis (RBFDP), the higher
the debonding rate [7,12,19–21].
The failure of fixed-fixed RBFDPs, in particular long-span
(four or more units) may be interconnected as to why two-unit
cantilevered prostheses are clinically retentive. Complex
interabutment stresses occur during function, parafunction

* Corresponding author at: Oral Rehabilitation, Faculty of Dentistry, The University of Hong Kong, 34 Hospital Road, Prince Philip Dental
Hospital, Sai Ying Pun, Hong Kong Special Administrative Region. Tel.: +852 2859 0412; fax: +852 2858 6114.
E-mail address: botelho@hku.hk (M.G. Botelho).
http://dx.doi.org/10.1016/j.jpor.2015.10.003
1883-1958/# 2015 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.

Please cite this article in press as: Botelho MG, Lam WYH. A fixed movable resin-bonded fixed dental prosthesis – A 16 years clinical report. J
Prosthodont Res (2015), http://dx.doi.org/10.1016/j.jpor.2015.10.003
JPOR-300; No. of Pages 5

2 journal of prosthodontic research xxx (2015) xxx–xxx

and possible mandibular flexure [22] between rigidly retained

abutments. These stresses will challenge the retainer rigidity
and the resin-bonded interface that may lead to clinical
decementation. Such adverse interabutment stresses are not
possible with two-unit cantilevered RBFDPs. It is this differ-
ence between fixed-fixed RBFDPs and the free standing nature
of simple cantilevered RBFDPs that is said to be responsible for
the success of two-unit RBFDPs [10,13,23].
There are a small number of patient reports in the dental
literature where RBFDPs utilizing non-rigid connectors have
been used. From these, it is interesting to note that papers
give the reason for use of a fixed-movable design because the
abutments had different periodontal support or tooth mobility
and because of this it was of concern that in these situations Fig. 1 – Mandibular arch showing edentulous spaces and
there may actually be an increase in the stress on the tooth abutments after preparation.
cemented retainers and therefore an increased probability for
debonding [24–26]. This paper presents a clinical report that
shows increased clinical retention with a modified non-rigid
connector. The fundamental design principles for long-span
fixed-movable RBFDPs hinges on maximizing the resistance
form of both the tooth preparation and the retainer as well as
using a modified non-rigid connector that allows free
movement between the abutment teeth in the horizontal
and vertical planes to minimize interabutment stresses on the
abutments [27].

2. Outline of the case

A 48-year-old woman complained of reduced masticatory

ability and requested for replacement of her missing mandib-
ular right first molar and mandibular left second premolar and
first molar (Fig. 1). She refused implant surgery and it was
decided to restore these missing teeth with two RBFDPs.
Periodontal and radiological examination revealed good bone
support for the potential abutment teeth and fixed-fixed
design was chosen with extensive wraparound on the
abutment teeth for both RBFDPs.
Abutment teeth preparation generally follows the estab-
lished principle for RBFDPs. The height of contour of the
abutment teeth was lowered with regard to the path of
insertion and a smooth knife-edge margin no closer than
1 mm above gum margin were prepared with a tungsten
carbide 170 bur (Hi Di; Ash, Surrey, UK). On the molar
abutments, a D-shaped groove following the fissure was
prepared with a No. 1 round diamond bur (Hi Di; Ash, Surrey,
UK) to allow the ends of the retainer to be joined thereby
increasing the retainer rigidity. One millimetre occlusal
clearance was required for the occlusal bar, confirmed by
the use of occlusal indicator wax (Kerr Dental, Orange,
California, US).
The tooth preparation was checked by taking an alginate
impression and a cast of the tooth abutments poured in Snap-
Stone (Whip-Mix, Louisville, Kentucky, US) to survey and
confirm the path of insertion and the height of contour of both
abutment teeth (Fig. 2). After refining the tooth preparation,
the working impression was taken in an additional silicone
(Imprint; 3M, St. Paul, Minneapolis) and poured firstly in
vacuum mixed Dentstone KD (British Gypsum, Newark, UK)
and kept for checking the fitting of cast RBFDP. The working
Fig. 2 – Sectional Snap Stone cast surveyed to ensure
maximum retainer extension for the chosen path of
insertion.
model was then poured in DVP investment die material (Whip
Mix, Louisville, Kentucky, US) and casting wax sheet of 0.8 mm
thickness (Dentarum; Pforzheim, Germany) was laid down on
it to ensure a minimum thickness. Plastodent inlay wax
(Degussa Dental, Hanau, Germany) was used to finish the full
extent of the retainer and pontic contour of the framework
(Fig. 3). The pattern on the investment model was cast in
Optimum nickel chrome alloy (Matech Inc., Sylmar, California,
US) and Omega porcelain (Vita, Bad Sackingen, Germany) was
used to build up the pontic (Fig. 4).
Two RBFDPs were sandblasted with 50 mm aluminium oxide
powder at a pressure of 520 kPa and then luted with Panavia 21
resin cement (Kuraray Co., Osaka, Japan) to pumice-cleaned
acid-etched enamel following manufacturer’s instruction and
under rubber dam isolation. The patient was then examined
one month later with no significant findings. Twenty-one
months later at a clinical review it was noticed that the
mandibular left four-unit RBFDP had partially debonded on
the molar (Fig. 5). This was initially surprising given the
apparently greater resistance form of the framework and tooth
preparation as compared to the premolar. However, closer
examination revealed a non-working side occlusal interference
on the buccal cusp (Fig. 5) of the molar that may have
contributed to the debonding. Initial occlusal contacts on tooth

Please cite this article in press as: Botelho MG, Lam WYH. A fixed movable resin-bonded fixed dental prosthesis – A 16 years clinical report. J
Prosthodont Res (2015), http://dx.doi.org/10.1016/j.jpor.2015.10.003
JPOR-300; No. of Pages 5
journal of prosthodontic research xxx (2015) xxx–xxx
Fig. 3 – Wax sheets of 0.8 mm thickness are adapted to the
abutments of the investment models and sealed down
and extended with blue inlay wax.
Fig. 4 – The finished four-unit fixed-fixed RBFPD prior to
cementation.
Fig. 5 – After 21 months of clinical use, the fixed-fixed
RBFPD was observed to have debonded on the major
retainer. A sickle scaler was used to diagnose the debond
by lifting up the major retainer. Note a non-working side
occlusal interference on the disto-buccal cusp (arrow).
tissue rather than retainer have been attributed to increasing
the chance of debonding of RBFDPs in vivo [4].
The mandibular left four-unit RBFDP was removed and the
residual cement on the abutment teeth was removed with a
Please cite this article in press as: Botelho MG, Lam WYH. A fixed movable resin-bonded fixed dental prosthesis – A 16 years clinical report. J
Prosthodont Res (2015), http://dx.doi.org/10.1016/j.jpor.2015.10.003
3
Fig. 6 – The minor retainer was cast with a customized
tapering box shaped matrix into which DuraLay (Reliance)
pattern resin was applied. The major retainer and pontic
was waxed up and cast in nickel chrome after which the
matrix and patrix were adjusted to ensure independent
between the major and minor retainer.
Fig. 7 – The long-span fixed-movable RBFPD after 16 years
of clinical use and no debond.
multi-fluted finishing bur (Midwest, Des Plaines, Illinois, US).
An improved prosthesis was planned for the edentulous space
with a non-rigid connector that allows minor independent
movement between the major and minor retainers. The major
retainer carrying pontic teeth and a matrix part of the non-
rigid joint was supported by the molar with better resistance
and retention form and the minor retainer carrying an extra-
coronal patrix of the joint was supported by the premolar.
Minor intra-enamel tooth preparation was performed on the
molar abutment to accommodate the increased wraparound
to 3608 and a working impression was taken. No dentine was
exposed and no attempt was made to cover the wear facets.
The minor retainer was fabricated with a burn-out patrix
(MS Attachment; Dentsply, York, Pennsylvania, US) on the
distal surface of the minor retainer and was waxed-up on an
investment cast. The patrix was fabricated with DuraLay
pattern resin (Reliance Dental Mfg Co, Wort, Illinois, US) onto
the cast matrix (Fig. 6.). The wax pattern for the major retainer
and pontic was then laid down and then invested and cast in
Optimum nickel chrome alloy. After casting, the retainers
were seated on the working model and the matrix and patrix
JPOR-300; No. of Pages 5
4 journal of prosthodontic research xxx (2015) xxx–xxx
of the non-rigid connector adjusted to ensure that indepen-
dent movement between the two abutments would be
possible, in particular pitching movements so that stress
would not be concentrated by the tooth-cement interface. The
improved prosthesis was luted with Panavia 21 (Kuraray Co.,
Osaka, Japan) onto etched enamel and has been successfully
functioning for 16 years with no debond showing the
durability of this design with a modified non-rigid connector
(Fig. 7).
3. Discussion
Based on longevity data for prosthetic treatment planning,
Pjetursson and Lang suggested full coverage fixed dental
prostheses (FDPs) and implant supported prostheses as the
preferred options for replacement of missing teeth [28].
However, the biological cost of full coverage FDPs on abutment
teeth is significant [29] and in addition patients may refuse even
free implant surgery [30]. Furthermore, while Pjetursson and
Lang considered that resin-bonded fixed partial dentures
(RBFDPs) ‘‘second option’’ based on a single study of 9.1 years
follow up of 51 RBFDPs with a variety of prosthesis designs,
many clinical studies demonstrated 2-unit cantilevered RBFDPs
are a durable prostheses [6–18]. Ideally RBFDPs should be
bonded to enamel where the bond strength is higher however,
dentine may be exposed during RBFDP tooth preparation and
the use of a dentine bonding agent is appropriate.
With any restorative failure it is prudent to consider the
causation and how to improve on the replacement prosthesis
to prevent a similar occurrence. In this case, the failed fixed-
fixed RBPFD was redesigned with two key design changes, a
non-rigid connector and increased abutment and retainer
resistance form. While the extension of the framework on the
molar abutment would have added retention and resistance
form to the prosthesis, the non-working side contacts were
not controlled by the new preparation and coverage with the
framework so as to be conservative to tooth tissue. If the molar
abutment had an adjacent tooth, a decision of break open the
proximal contact would be considered for longer span RBFDPs
[27]. It would appear that the modified nature of the non-rigid
connector, allowing independent movement of the abutments
has been contributory to the success of the prosthesis in an
edentulous span of up to 17 mm. If a debond were to occur on
the load bearing major retainer, re-luting would be possible
thereby giving greater restoration survival. While short-term
survival of modified non-rigid connectors is promising [31],
further studies are required to confirm the hypothesis of the
beneficial use of modified non-rigid connectors for short and
long span RBFDPs.
4. Conclusion
This paper describes the successful replacement of a partially
debonded fixed-fixed RBFDP 21 months after cementation with
a fixed-movable design that was retentive and functioning for
over 16 years. Modified non-rigid connectors that allow
movement between the abutments in long-span RBFDPs reduce
adverse loads and stresses at the restoration–cement–enamel
Please cite this article in press as: Botelho MG, Lam WYH. A fixed movable resin-bonded fixed dental prosthesis – A 16 years clinical report. J
Prosthodont Res (2015), http://dx.doi.org/10.1016/j.jpor.2015.10.003
interface providing greater retention and improved clinical
prognosis.
Conflict of interest
The authors have no conflict of interest to declare.
Acknowledgments
The author would like to express appreciation for the technical
support provided by the staff of the dental technology unit, in
particular Mr. KB Wong, The Prince Philip Dental Hospital in
Hong Kong.
references
[1] Simon JF, Gartrell RG, Grogono A. Improved retention of
acid-etched fixed partial dentures: a longitudinal study. J
Prosthet Dent 1992;68:611–5.
[2] Rammelsberg P, Pospiech P, Gernet W. Clinical factors
affecting adhesive fixed partial dentures: a 6-year study. J
Prosthet Dent 1993;70:300–7.
[3] Barrack G, Bretz WA. A long-term prospective study of the
etched-cast restoration. Int J Prosthodont 1993;6:428–34.
[4] Creugers NH, Snoek PA, van ‘t Hof MA, Kayser AF. Clinical
performance of resin-bonded bridges: a 5-year prospective
study. II. The influence of patient-dependent variables. J
Oral Rehabil 1989;16:521–7.
[5] Crispin BJ. A longitudinal clinical study of bonded fixed
partial dentures: the first 5 years. J Prosthet Dent
1991;66:336–42.
[6] Hussey DL, Pagni C, Linden GJ. Performance of 400 adhesive
bridges fitted in a restorative dentistry department. J Dent
1991;19:221–5.
[7] Dunne SM, Millar BJ. A longitudinal study of the clinical
performance of resin bonded bridges and splints. Br Dent J
1993;174:405–11.
[8] Gilmour AS, Ali A. Clinical performance of resin-retained
fixed partial dentures bonded with a chemically active
luting cement. J Prosthet Dent 1995;73:569–73.
[9] Hussey DL, Linden GJ. The clinical performance of
cantilevered resin-bonded bridgework. J Dent 1996;24:251–6.
[10] Briggs P, Dunne S, Bishop K. The single unit, single retainer,
cantilever resin-bonded bridge. Br Dent J 1996;181:373–9.
[11] Brabant. Indication and design: the key to successful resin-
bonded fixed partial dentures. In: Degrange M, Roulet J-F,
editors. Minimally invasive restorations with bonding.
Chicago: Quintessence Pub. Co.; 1997. p. 201–10.
[12] Djemal S, Setchell D, King P, Wickens J. Long-term survival
characteristics of 832 resin-retained bridges and splints
provided in a post-graduate teaching hospital between 1978
and 1993. J Oral Rehabil 1999;26:302–20.
[13] Botelho MG, Nor LC, Kwong HW, Kuen BS. Two-unit
cantilevered resin-bonded fixed partial dentures – a
retrospective, preliminary clinical investigation. Int J
Prosthodont 2000;13:25–8.
[14] Chan AW, Barnes IE. A prospective study of cantilever
resin-bonded bridges: an initial report. Aust Dent J
2000;45:31–6.
[15] Lam WY, Botelho MG, McGrath CP. Longevity of implant
crowns and 2-unit cantilevered resin-bonded bridges. Clin
Oral Implants Res 2013;24:1369–74.
JPOR-300; No. of Pages 5
journal of prosthodontic research xxx (2015) xxx–xxx
[16] Botelho MG, Ma X, Cheung GJ, Law RK, Tai MT, Lam WY.
Long-term clinical evaluation of 211 two-unit cantilevered
resin-bonded fixed partial dentures. J Dent 2014;42:
778–84.
[17] Botelho MG, Chan AW, Leung NC, Lam WY. Long-term
evaluation of cantilevered versus fixed-fixed resin-bonded
fixed partial dentures for missing maxillary incisors. J Dent
2014 [submitted for publication].
[18] Kern M, Sasse M. Ten-year survival of anterior all-ceramic
resin-bonded fixed dental prostheses. J Adhes Dent
2011;13:407–10.
[19] Marinello CP, Kerschbaum T, Heinenberg B, Hinz R, Peters
S, Pfeiffer P, et al. First experiences with resin-bonded
bridges and splints – a cross-sectional retrospective study,
Part II. J Oral Rehabil 1988;15:223–35.
[20] Olin PS, Hill EM, Donahue JL. Clinical evaluation of resin-
bonded bridges: a retrospective study. Quintessence Int
1991;22:873–7.
[21] Hosseini A. Clinical evaluation of resin-bonded prostheses:
Rochette technique. Quintessence Int 1994;25:567–71.
[22] Fischman BM. The influence of fixed splints on mandibular
flexure. J Prosthet Dent 1976;35:643–7.
[23] Wong TL, Botelho MG. The fatigue bond strength of fixed-
fixed versus cantilever resin-bonded partial fixed dental
prostheses. J Prosthet Dent 2014;111:136–41.
Please cite this article in press as: Botelho MG, Lam WYH. A fixed movable resin-bonded fixed dental prosthesis – A 16 years clinical report. J
Prosthodont Res (2015), http://dx.doi.org/10.1016/j.jpor.2015.10.003
5
[24] Plainfield S, Wood V, Podesta R. A stress-relieved resin-
bonded fixed partial denture. J Prosthet Dent 1989;61:291–3.
[25] Dummer PM, Gidden JR. Two-part resin bonded cast metal
bridges for use when abutment teeth have unequal
effective root surface areas. Restor Dent 1990;6:9–14.
[26] Pollock GR. Case report: the use of a resin retained bridge
with movable joint. Eur J Prosthodont Restor Dent
1996;4:35–8.
[27] Botelho MG. Improved design of long-span resin-bonded
fixed partial dentures: three case reports. Quintessence Int
2003;34:167–71.
[28] Pjetursson BE, Lang NP. Prosthetic treatment planning on
the basis of scientific evidence. J Oral Rehabil
2008;35(Suppl. 1):72–9.
[29] Tan K, Pjetursson BE, Lang NP, Chan ES. A systematic
review of the survival and complication rates of fixed
partial dentures (FPDs) after an observation period of at
least 5 years. Clin Oral Implants Res 2004;15:654–66.
[30] Ellis JS, Levine A, Bedos C, Mojon P, Rosberger Z, Feine J,
et al. Refusal of implant supported mandibular
overdentures by elderly patients. Gerodontology
2011;28:62–8.
[31] Botelho MG, Dyson JE. Long-span, fixed-movable, resin-
bonded fixed partial dentures: a retrospective, preliminary
clinical investigation. Int J Prosthodont 2005;18:371–6.