In the first part of this series on repairing an existing bridge (“Repair, Don’t Replace – Part 1”), a case was presented where a patient fractured the facial ceramic of a maxillary central incisor on a 6-unit porcelain fused to metal bridge. The facial fracture was stress related and did not involve the exposure of the underlying metal substructure. A successful repair was made by creating a veneer preparation into the ceramic and placing a new porcelain veneer on top of the affected surface.
Now, what happens if the ceramic fracture is substantially larger and involves the exposure of the underlying metal framework? The following case will demonstrate how, in some circumstances, the remaining porcelain can be removed from the metal and a “saddle crown” can be fabricated and cemented over the existing bridge.
A patient presented with a porcelain fracture on an anterior multiple-unit fixed bridge (Fig. 1). The fracture involved the entire facial surface of tooth #7 and exposed the metal framework at the disto-incisal angle. When viewed from the lingual aspect (Fig. 2), the fracture extends down to the porcelain-metal junction of the mostly metallic lingual surface. Because of the occlusal forces placed on this tooth in both protrusive and lateral excursions, it was decided to prepare the remaining porcelain down to the metal understructure and create a “saddle crown” to repair the defect.
Figure 1: A preoperative view of tooth #7, part of a multiple-unit fixed bridge that has sustained a porcelain fracture on the facial surface.
Figure 2: An incisal view of the fractured abutment showing a porcelain fracture down to metal on the disto-incisal angle.
The saddle crown consists of a facial and lingual surface only. These surfaces are only joined proximally incisal to the solder joint of the existing bridge. The preparation is designed to create negative space for this “telescopic” structure without compromising the structural integrity of the bridgework below.
A round-ended, tapered, coarse diamond is used to prepare the remaining porcelain and metal. Care must be taken not to score the adjacent proximal ceramic surfaces during the preparation phase (Figs. 3, 4). Also, be careful not to create undercuts when preparing the cervical areas of the preparation. In this case, it was a challenge to create sufficient space on the lingual surface without prepping away some of the existing metal framework. This should be kept to an absolute minimum to avoid compromising the strength of the existing bridge.
Figure 3: The fractured unit has been prepared using rotary diamond instrumentation down to the metal understructure, then polished with a fine diamond and rubber polishing abrasives. Care was taken not to disturb the porcelain on the adjacent teeth and the metal covering the damaged unit, especially the interproximal metal bridge connectors.
Figure 4: Lingual view showing the surface after preparation. The original bridge had metal lingual surfaces, so preparation was made into the metal to create space for the “saddle crown” on the functional surface. Some of the metal was removed to tooth structure, but care was taken not to remove so much as to compromise the integrity of the original bridge.
Figure 5 shows the incisal clearance created for the saddle crown as the patient closes into centric occlusion. This clearance is checked in protrusive and lateral excursions as well, to make sure adequate space has been provided. The preparation is polished with a round-ended 30 micron finishing diamond, followed by rubber polishing abrasives to smooth the cut metal substructure and porcelain.
Figure 5: This view shows the space created for incisal reduction as the patient closes to centric occlusion. 1.5 mm of space is needed in all functional movements.
Figure 6: Retraction cords in place on the facial and lingual surfaces prior to the registration of the master impression.
Next, a retraction cord (Ultrapak® [Ultradent; South Jordan, Utah]) is placed on the facial and lingual marginal areas of the preparation (Figs. 6, 7). A two-cord technique is used, first placing a #00 cord, then a #1 on top of it. After a few minutes, the top cord is removed, leaving the #00 in the sulcus (Fig. 8). The master impression is then made using a syringeable light-bodied and heavy-bodied vinyl polysiloxane impression material (Honigum [DMG America; Englewood, N.J.]) (Fig. 9).
Figure 7: Facial view of the gingival retraction cords in place.
Figure 8: The #00 cord is left in place after removal of the #1 cord, leaving an obvious sulcus prior to injection of the light-bodied impression material.
A provisional restoration is then fabricated using a bis-acrylic provisional material (Luxatemp® [DMG America]) and is cemented with polycarboxylate cement (Fig. 10). Digital photographs are provided to the ceramist to aid in characterization.
Figure 9: The impression is made using a polyvinyl siloxane impression material. Note the margin is captured, as well as approximately 0.5 mm of tooth or root surface apical to the prepared margin. This will ensure an accurate fit of the saddle crown.
Figure 10: A provisional restoration is fabricated from a preoperative impression taken prior to preparation of the fractured unit. Flowable composite resin was used to fill in the fracture prior to taking the impression, so that the provisional restoration would have the correct contours.
Figure 11 is a facial view of the saddle crown on the laboratory cast model. An incisal view of the master cast shows the preparation design that basically strips the porcelain down to the metal substructure on the facial and lingual, and is “tied in” with a continuous mesial and distal proximal finish line on the metal connectors of the preexisting bridge (Fig. 12). A proximal view of the completed restoration highlights the “saddle” design (Fig. 13). Interproximal margins are in metal and are located incisal to the metal connectors of the understructure. The lingual surface of the restoration is made in metal to match the preexisting bridge and limit the amount of lingual reduction (Fig. 14).
Figure 11: The fabricated saddle crown on the master laboratory model, shown from the facial aspect.
Figure 12: Incisal view of the preparation as seen on the master laboratory model.
Figure 13: The saddle crown shown from the proximal view.
Figure 14: The saddle crown on the master laboratory model from the lingual aspect.
The completed saddle crown is tried in after removal of the provisional restoration (Fig. 15). After verification of fit and checking occlusion with articulating paper, the restoration is ready for cementation. In this case, resin-modified glass ionomer cement was used (Fig. 16). A 4-META-type cement is also good to cement metal to metal if retention is less than ideal. The cement is mixed according to the manufacturer’s instructions (Fig. 17) and pushed into place on the preparation (Fig. 18). It is recommended to hold the restoration in place until the cement is completely set, as hydraulic pressure can in some cases push the restoration incisally as the cement sets.
Figure 15: After removal of the provisional restoration, the saddle crown is tried in and the fit is evaluated.
Figure 16: A resin ionomer cement (RelyX™ Luting Cement [3M™ ESPE™; St. Paul, Minn.]) is dispensed prior to mixing.
Figure 17: The mixed cement is placed into the saddle crown.
Figure 18: The saddle crown is held in place while the cement is allowed to set.
Figure 19 is a lingual view of the cemented restoration. The metal lingual surface of the saddle crown fits the adjacent metal margin of the bridge like an inlay. Figure 20 is a facial view of the completed saddle crown. Compare this to Figure 21, which is a facial view of the previous bridge prior to the fracture.
Figure 19: A lingual view of the cemented saddle crown.
Figure 20: A view of the completed saddle crown on tooth #7 from the facial aspect.
Figure 21: A view of tooth #7 prior to the fracture. Compare this to Figure 20, which is the same view of the repaired bridge using a saddle crown. A beautiful, esthetic and functional match was made without having to remake the entire bridge.
The esthetics of a repair made using a saddle crown makes it an excellent alternative to replacing the entire multi-unit restoration.
The esthetics of a repair made using a saddle crown makes it an excellent alternative to replacing the entire multiunit restoration. This solution works well in anterior and posterior regions for pontics as well as abutments.