The one-appointment direct bridge

No crowns, no impressions, no models, no lab-bill and you probably have everything you need right there in your operatory

The benefits of a one-appointment prosthesis over a traditional lab-processed bridge are fairly obvious -

• Patient cost can be dramatically reduced, bringing treatment within the means of even your low-income patients.

• The dentist can make a reasonable return on his “economy” restorations by eliminating the lab bill and costs involved in temporization.

• And, obviously, a one-appointment bridge is more convenient for the patient, because it slashes one or even two appointments from the treatment plan.

In fact, Sirona has found a nice market for its $90,000 CAD-CAM machines making just this proposal.

Over the years, Parkell Today has described a number of more economical approaches to the one-appointment bridge. Several dentists have discussed using a Mach-2^® instant model and a reinforcing material like Ribbond_^® to create a chairside indirect bridge. Once it’s fabricated, the bridge is then bonded into the mouth as usual. One article even showed how to replace a lost tooth with an acrylic denture tooth Metabonded to the proximal teeth!

About 25 years ago I developed my own approach to one-appointment anterior bridges. Since my practice was located in Atlanta at the time, I dubbed it the “Georgia Bridge”. It offers all the advantages of other one-appointment techniques ... plus a couple more. Since it’s a direct technique (not indirect), there’s no need for impressions ... and no need for models. And in my immodest opinion the cosmetic results are better.

And though I can’t know for sure, I suspect the Georgia Bridge offers one more advantage: a longer history of clinical success.

Over the decades I’ve built more than 1000 of the bridges, and I’ve found them extremely predictable. Far more so than Maryland Bridges (which incidentally don’t look as good, cost more and require twice as many appointments.) In my practice, most Georgia Bridges have lasted at least 5 years. And a few have lasted as long as 22 years.

In fact, for some situations the Georgia Bridge has become my restoration of choice. But more about case-selection in a minute.

The technique is easy for any dentist experienced in bonding. The example I’m using here to demonstrate the technique shows replacement of an upper central incisor. However, if you’re doing the technique for the first time, I suggest you begin with a lateral or lower central.

The Georgia Bridge - Step-by-step

A beautiful young lady (age 20) with a limited income presented wearing a very unattractive flipper replacement for #9. She aspired to be a model, and recognized what a liability her restoration was (figure 1).

When I explained the Georgia Bridge, she jumped at the opportunity to improve her appearance.

1) Using a chamfer diamond, I made semicircular preparations on the labial and lingual of both proximal teeth (figure 2).

2) Then, using the same diamond, I cut 3 horizontal grooves in the labial and lingual enamel (figure 3). The depth of these grooves was about 1mm. The preparation, (both semi-circle and horizontal grooves) should extend about 1/3 of the way around the labial and lingual anatomy.

Note: The preparation is very important to the strength and longevity of the bridge. One research study has suggested that cutting enamel before etching affords a 25% stronger bond than etching alone. In addition to making the surface more “bondable”, the notches provide additional surface area plus mechanical resistance to vertical forces.

Figure 4 shows the final preparation prior to etching.

3) The prepared surfaces of both teeth were etched with 37% phosphoric acid for 30 secs, then thoroughly rinsed and dried.

4) The abutments were rebuilt to their original contour (figure 5). Nowadays I use a flowable as my first step to assure good wetting, but flowables weren’t available when this case was done.

5) I built the bridge structure using a heavily-filled small-particle composite. This provided the resistance to load and stiffness I needed to span the gap. (You can use whatever strong posterior composite you’re comfortable with.)

To ensure that contraction forces from the curing composite did not disturb the bond to the abutments, I added and cured the composite in 3 or 4 very small steps (figure 6). The gap in the pontic was just 1/2 mm wide when I added the final composite (figure 6).

I suspect you’re wondering whether composite alone, without internal reinforcement provided by a bar, wire or ribbon, can really withstand occlusion? ABSOLUTELY ... POSITIVELY ... provided you cure the resin in small increments. In all my years using the system, the incidence of fracture has been less than 10%. (Incidentally, when it occurs, the fracture is always at the bonded surface - not within the composite.)

6) To improve the esthetics and create an ultra-smooth surface, I laminated the labial and gingival surfaces with Epic®-TMPT composite. This microfilled composite doesn’t offer the strength necessary to serve as the body of the bridge, but its translucency and long-lasting, glossy finish creates an extremely vital effect. Though it’s not a flowable, as it warms in the mouth, Epic conforms nicely to the underlying surface - a good feature when you’re laminating the substructure.

I enjoy custom color-matching, so I often mix four or more shades to get the precise color I want.

7) I polished and adjusted the occlusion in the mouth.

By the way, this patient subsequently had a successful modeling career in Atlanta and New York.

So when should a dentist consider a Georgia Bridge?

When I lecture about the Georgia Bridge, most dentists immediately recognize how useful it could be for transitional cases where you don’t want to invest too much time, effort or money restoring a mouth that’s headed downhill. However, in my opinion reserving it for transitional cases would be a shameful waste.

Here are just a few of the instances where I suggest you consider a Georgia Bridge.

1.) When the patient can’t afford traditional options, and you don’t like cosmetics, function or constant servicing of acrylic flippers. (For example, the case we just discussed.)

2.) When the patient loses an anterior tooth and immediate replacement is necessary. (See the “Bridal Bridge” below.)

3.) When the patient is in periodontal therapy and you’re waiting to see if additional teeth will be lost. It also helps stabilize those mobile teeth. (Okay, you could consider this “transitional.”)

4.) When you’re using very thin lower anteriors as abutments, and you’re concerned that a conventional C&B preparation may cause pulpal damage or leave so little structure remaining that they may be prone to snapping. Here, the Georgia Bridge isn’t an alternative. It’s my first choice.

Where wouldn’t you use this approach?

For one thing, you wouldn’t use it for posterior loads. The Georgia Bridge is for anterior single tooth replacement.

And even in the anterior, patients who are determined bruxers or who suffer posterior collapse have issues that must be resolved before a Georgia Bridge could be considered.

Most patients think a Georgia Bridge looks just fine. But if the patient wants the best esthetics possible, nothing can compete with the work of a master ceramist.