IN BRIEF

PRACTICE

13
● The indications for the management of worn teeth, in occlusal management, and following
molar endodontics
● Design and tooth preparation for anterior and posterior teeth
● Clinical procedures, including management of existing restorations and bonding
● Problems with aesthetics and temporisation
● Maintenance and, where necessary, rebonding

Crowns and other extra-coronal restorations:

Resin-bonded metal restorations
A. W. G. Walls1 F. S. A. Nohl2 and R. W. Wassell3

Resin-bonded metal restorations is the final part of the series. Cast metal restorations which rely on adhesion for attachment
to teeth are attractive because of their potential to be much more conservative of tooth structure than conventional crowns
which rely on preparation features providing macromechanical resistance and retention.

The past 25 years have witnessed great strides

CROWNS AND EXTRA-CORONAL in the development of adhesive dentistry.
RESTORATIONS: Many would say that our day-to-day practice
1. Changing patterns and has been influenced more fundamentally by
the need for quality these advances than by any other recent dental
2. Materials considerations innovation.
3. Pre-operative One of the advances is the introduction of
assessment resin-bonded metal restorations (RBMR). Anteri-
4. Endodontic orly, the RBMR resembles a retentive wing of a
considerations resin-bonded minimal preparation bridge. Pos-
5. Jaw registration and teriorly, the RBMR (sometimes termed a shim)
articulator selection resembles a conventional metal onlay but usual-
Fig. 1 Occlusal view of anterior palatal resin-bonded
6. Aesthetic control ly without box forms or other mechanical means metal restorations
7. Cores for teeth with of providing retention. Sometimes however,
vital pulps where pre-existing restorations have been
8. Preparations for full replaced as part of the RBMR, the distinction
veneer crowns between onlay and shim becomes blurred; the
9. Provisional restorations only differentiation being the means of cemen-
10. Impression materials and tation which has evolved from the technology
technique developed for resin-bonded bridgework.
11. Try-in and cementation The need to remove tooth substance to
of crowns achieve mechanical resistance and retention of
12. Porcelain veneers worn teeth for conventional crowns would seem
particularly counterproductive: RBMR can offer
13. Resin bonded metal
restorations conservative solutions in this situation. A num-
ber of case reports and two surveys1,2 have
1Professor of Restorative Dentistry,
3Senior Lecturer in Restorative Dentistry,
appeared documenting and supporting the use of
Department of Restorative Dentistry, The RBMR on the palatal aspects of worn maxillary
Fig. 2 Posterior resin-bonded metal restoration
School of Dental Sciences, Framlington anterior teeth (Fig. 1). The use of RBMR on the
Place, Newcastle upon Tyne NE2 4BW occlusal surfaces of posteriors has also been
2Consultant in Restorative Dentistry, The
Dental Hospital, Richardson Road,
described (Fig. 2).2–4 However, there are no well- was first demonstrated clinically by Rochette in
Newcastle upon Tyne NE2 4SZ controlled clinical studies of the long-term suc- 1973.7 His periodontal splint was made of cast
*Correspondence to: Prof A. W. G. Walls, cess of RBMR in comparison with conventional gold and retained macromechanically by com-
Department of Restorative Dentistry, The restorations. Other uses have included produc- posite resin extruded through countersunk per-
Dental School, University of Newcastle
upon Tyne, Newcastle upon Tyne NE2 4BW tion of rests for the support of partial dentures5 forations in the metalwork. Tooth surfaces were
E-mail: [email protected] and restorations to alter the morphology of etched with acid to provide micromechanical
occlusal holding and guiding surfaces of retention for composite resin cement. The major
Refereed Paper
© British Dental Journal 2002; 193:
canines.6 breakthrough was that other than etching no
135–142 The ability to bond cast metal alloys to teeth destructive tooth preparation was required.

BRITISH DENTAL JOURNAL VOLUME 193 NO. 3 AUGUST 10 2002 135

PRACTICE

As the adhesive minimal preparation bridge preparation has been carried out prior to place-
became commonplace, methods of modifying ment means that cumulative insults to the pulp
base metal alloys were developed to improve are likely to be less than when conventional
adhesion of the retainers to tooth substance via a restorations have been placed (assuming that the
resin-based cement. One technique was to incor- bonding process to dentine is not damaging to
porate irregularities into the fitting surface of the pulp!).
the retainers during pattern formation, which Central to the provision of RBMR are tech-
were subsequently reproduced in metal; these niques to create occlusal space for the restora-
took the form of voids left after the wash out of tion; suffice it to say that non-preparation tech-
salt crystals, spheres or meshwork, but had the niques, such as the Dahl approach,11 involving
disadvantage that castings were bulky and the controlled axial movement of teeth are attrac-
laboratory technique was exacting. Microscopic tive. In this approach teeth are built-up to cause
etch patterns in the fitting surface of bridge their intrusion and the supra-eruption of others
retainers greatly increase the surface area for taken out of occlusion. This topic is summarised
contact with luting agents and can be produced in Part 3 of this series. However, it is worth
by electrolytic corrosion in an acidic environ- emphasising that the build-up must result in
ment. Again this approach was technique sensi- axial loading. Non-axial loading, resulting from
tive but could produce reliable attachment a deflective contact or interference on the build-
between metals and resin.8 Base metal retainers up, can cause problems such as pain and tooth
can also be air abraded with alumina particles mobility.
that as well as increasing the surface area may
enhance the bond with some cements by chemi- In occlusal management
cal interactions.9 RBMRs are made in the laboratory using the lost
Lesser demands on rigidity with single unit wax casting technique. In conjunction with the
restorations enabled the use of precious metal dental technician, the dentist has good control
alloys (type III gold [ADA classification]) rather over form of occlusal surfaces of RBMRs, which
than the nickel based alloys used in adhesive can be used therefore to create occlusal stops
bridgework. This gives advantages in casting and guiding surfaces with a high degree of pre-
accuracy, ease of adjustment and finishing, the cision. RBMRs are particularly helpful when
potential for reduced wear of opposing teeth and such teeth are unrestored and where the alterna-
perhaps of appearance. Several precious metal tive of conventional crowns would be unaccept-
surface treatments have been documented. ably destructive.
These include tin plating,9 heat treatment of A drawback of the technique is that the new
high copper content gold alloys,10 air abrasion guidance surfaces cannot be tested using provi-
of the cast metal surface,2,10 and the Silicoater.11 sional restorations as with conventional crowns.
Air abraded base metal luted to etched enamel Guidance surfaces therefore need to be carefully
using two chemically active cements gave high- formed with the use of a semi-adjustable articu-
er bond strengths in-vitro than precious metal lator and the dentist must accept that some
alloy/surface treatment combinations.9 Howev- adjustment may be required after the RBMRs
er, tin plating or heat treating air abraded pre- have been cemented.
cious metal alloys gave enhanced bond
strengths in-vitro compared with this alloy air Following molar endodontics
abraded alone.10 Clinically, air abraded nickel- Many posterior teeth which have been root
chromium anterior RBMRs cemented with treated are at risk of fracture and will benefit
Panavia Ex gave a survival probability of 0.74 at from a protective cusp covering cast
56 months,1 and air-abraded gold RBMRs (ante- restoration.13 A RBMR with occlusal coverage
rior and posterior), also cemented with Panavia can provide a conservative restoration for a
Ex, were associated with a survival probability tooth already compromised by the need for
of 89% at 60 months.2 However it cannot be endodontic access.
assumed that because a metal surface treatment
works with one cement that it will necessarily be TECHNIQUES
effective with others.
Choice of metal
INDICATIONS If facilities do not exist to heat treat or tin plate
gold after try-in, it may be more sensible to use
In the management of worn teeth air abraded nickel-chromium, accepting that its
RBMR can protect worn and vulnerable tooth shade may look less harmonious in the oral
surfaces from the effects of further wear by environment than yellow gold.
forming a barrier against mechanical and chem-
ical insults. Design and tooth preparation: anterior teeth
Any technique, which could delay entry into Very thin portions of unsupported buccal enam-
a restorative spiral necessitating ever enlarging el remaining on some worn maxillary anterior
restorations with endodontic implications, is to teeth are highly vulnerable to damage on a stone
be welcomed. Although RBMR are susceptible to master cast resulting in a casting which will not
debonding, marginal recurrent caries and mar- fit the tooth. Such enamel should be removed
ginal lute wear, the fact that little if any tooth prior to making the impression and defects

136 BRITISH DENTAL JOURNAL VOLUME 193 NO. 3 AUGUST 10 2002

 PRACTICE

waxed-up on the master cast before building up Table I Precautions for intra-oral air abrasion
patterns for RBMR (Fig. 3). After cementation,
composite resin can be packed against the RBMR Alumina particles are hazardous if inhaled, can scratch glass (eg spectacle lenses) and can leave patients
feeling like they have a mouthful of sand. To avoid these problems:
to replace lost buccal enamel. The latter tech-
1. Use rubber dam where possible.
nique can also be used to restore pre-existing
buccal tooth defects. No other tooth preparation 2. Pack-off area around tooth with wrung out wet paper towels (alumina will stick to towel — not
rebound).
is required for anterior palatal RBMR.
3. Cover patient’s whole face including spectacles, with wet paper towels. Fold to allow patient to
breathe from beneath towel.
4. Dentist and nurse must wear masks and eye protection.
5. Use high volume aspiration.

Whereas conventional crowns are designed

so that non-axial forces tend to put the cement
layer in compression (non-adhesive cements are
best able to resist compression), RBMR rely sub-
stantially on their adhesive luting agent to resist
tensile and shearing forces. Axial preparation is
useful in as much as it will facilitate accurate
orientation on the tooth during bonding. Such a
Fig. 3 Enamel defects waxed up on master cast prior to preparation would have an axial reduction of
constructing restorations
approximately 0.5 mm depth extending down
the axial surfaces by one millimetre or so, termi-
To optimise adhesion, the maximum possible nating on a chamfer margin (Fig. 5). Axial
palatal tooth surface should be covered by the preparation will also give the advantage of
RBMR. Type III gold should probably be a mini- increasing the surface area for bonding to etched
mum of approximately 0.5 mm thick though it enamel. To what extent axial preparation will
may be reasonable to use nickel-chromium in help resist peel and shear forces is currently
thinner section because it is more rigid. It is nec- unclear.
essary to incorporate features that aid accurate
location during seating of the RBMR. A layer of
metal overlying the whole of the incisal edge of
anterior teeth facilitates accurate seating and
following careful thinning can often be left in
place without affecting appearance significantly
(Fig. 4). In function, the latter feature should also
reduce the likelihood that opposing tooth con-
tacts will act directly on the cement layer to
cause shear failure.

Fig. 5 Preparation form for posterior

resin-bonded metal restoration

Managing existing restorations

RBMR rely primarily on adhesion to enamel for
retention. Existing restorations which account
for a large proportion of the surface area avail-
able for adhesion but also extend beyond the
periphery of the RBMR are not be ideally suited
to restoration using this technique. The critical
factor is to finish the margin of the restoration
Fig. 4 Appearance of metal incisal coverage because of on enamel if at all possible.
anterior palatal resin-bonded metal restorations
Anterior teeth
Design and tooth preparation – posterior teeth Restorations deemed to be in need of replace-
The occlusal part of the restoration must be able ment involving the labial surface of anterior
to withstand functional forces and, in the teeth can be managed in several ways:
absence of evidence to the contrary, dimensions
for gold alloy RBMR should follow those recom- 1. Replace prior to impressions. However by the
mended for conventional cusp covering crowns time the RBMR is cemented the surface will
(see Part 6). As with anterior RBMRs it may be be waterlogged and may only offer sub-opti-
possible to reduce these dimensions when using mal bonding to chemically active cements.
nickel-chromium because it is more rigid. Use of an intra-oral air abrasion device on
Occlusal preparation should only be performed the plastic restoration may be beneficial.
where the treatment plan indicates that occlusal 2. Remove prior to cementation of RBMR and
space for the restoration is required (see Part 3). pack fresh composite against either the trial

BRITISH DENTAL JOURNAL VOLUME 193 NO. 3 AUGUST 10 2002 137

PRACTICE

seated or cemented RBMR. Placement of Records

composite against the cemented RBMR can Impressions for the laboratory fabrication of
make the job of shade matching easier than RBMR should meet the same quality criteria as
when replacement is carried out prior to for conventional crowns (see Part 10 of this
impressions because opaquers and appropri- series). Anterior palatal wear often spares a rim
ate shades of composite can be used over the of enamel in the proximity of the gingival
metal. crevice which should be captured by the impres-
sion as it may enhance adhesion significantly. It
Posterior teeth is helpful to use a gingival retraction technique
Some caution is required in relation to existing to achieve this.
restorations that will be completely covered by Fabrication can be carried out by investing
the RBMR, as they may not offer as great a bond and casting a pattern which has been lifted
to chemically active cements as etched enamel. from the master cast or by forming the pattern
Much will therefore depend on the area of enam- for the restoration on refractory material
el available for bonding. Strategies to manage which is itself incorporated within invest-
existing restorations, which will be completely ment.
covered by the RBMR, would include:
Bonding
1. Leaving the restoration undisturbed. In this
Although occlusal adjustments are more easily
case it may be best to assume that the old
polished if carried out before the RBMR is
restoration offers no additional retention.
attached to the tooth, stabilising the restoration
An example for this approach would be a
sufficiently to analyse occlusal contacts can be
small sound restoration surrounded by a
difficult. A small amount of paraffin jelly
good periphery of enamel.
smeared onto the fitting surface of the RBMR
2. Air abrading the surface of existing restora-
can provide some retention but needs to be
tions with the aim of providing microme-
removed completely before bonding.
chanical retention for the resin cement
The fitting surface should ideally be air
(Table 1).
abraded and steam or ultrasonically cleaned
3. Replacement of an existing amalgam
before cementation. Gold alloy RBMR are heat
restoration with GIC to facilitate bonding.
treated at this stage. A brief cycle in a porce-
4. Removal of whole or part of the restoration
lain oven is required (400°C for 4 minutes in
with the aim of providing a retentive intra-
air). Despite the colour of the oxidised alloy, no
coronal feature on the fit surface of the
further polishing should be carried out until
RBMR and exposing tooth structure for
after the restoration has been cemented as to
bonding. The resulting preparation will
attempt this risks contaminating the all-
resemble that for a conventionally cemented
important oxide layer developed in the heat
onlay incorporating box forms, bevels and
treatment (Fig. 6).
flares.14 However, removal of old restora-
In the past there has been concern that the
tions may be associated with unnecessary
quality of bonding of the chemically active
damage to the tooth and where necessary
cements advocated for RBMR may be affected
undercuts should be blocked out with glass
by the presence of eugenol.15 However another
ionomer cement.
study16 indicates that eugenol containing tem-
porary cements have no adverse effect on the
shear bond strength of a dual-curing luting
cement to enamel although there may be an
effect if a composite core is used.
Several chemically active cements are avail-
able to bond RBMR: the same cement as would
be chosen for adhesive bridgework. Manufac-
turers instructions for handling the chosen
chemically active cement must be followed
closely: it is the responsibility of the dentist to
Fig. 6 Appearance of heat-treated
gold just after cementation ensure that this is so. Rubber dam is mandatory.
Floss ligatures can assist retraction of rubber at
the gingival margins of maxillary anterior
teeth (Fig. 7). Soft wax on the end of an instru-
ment can be helpful to carry the RBMR to the
tooth but great care must be taken not to smear
wax onto the fitting surfaces.
After attaching a RBMR to the tooth,
removal of excess cement, occlusal adjust-
ments and polishing can be achieved with hand
scalers and a sequence of rotary instruments
(Table 2). Care must be taken not to overheat
Fig. 7 Floss ligatures to facilitate the restoration or the resin cement will be soft-
isolation with rubber dam ened and the RBMR dislodged.

138 BRITISH DENTAL JOURNAL VOLUME 193 NO. 3 AUGUST 10 2002

 PRACTICE

Table 2 Suggested sequence of instruments for

removal of excess set cement at periphery of
resin-bonded metal restorations
Hand scalers
Fine and very fine high speed diamond burs
Rubber points
Polishing cup and prophy paste
Fig. 8 Recurrent erosion at the
periphery of resin-bonded metal
PROBLEMS restorations in situ

Appearance
Maxillary anterior teeth, which have been
thinned by wear on their palatal aspects, may
transmit light easily. RBMR luted to the palatal
aspects of these teeth may cause a grey coloura-
tion that can be unacceptable and is more likely
if non-opaque cement is used. On the other
hand, opaque cements may help disguise metal
but can also cause a lightening in shade. At the
initial assessment it is wise to assess possible
Fig. 9 Partially de-bonded adhesive
shade change caused by a RBMR and its cement.
metal splint
White modelling clay applied to the palatal
aspect of the thin tooth can mimic the effect of
opaque cement. Tin foil burnished onto the to declare itself by debonding than a conven-
palatal surfaces of teeth to be restored can indi- tionally retained crown which may stay in place
cate the effect of grey nickel chromium or dark long enough for the consequences of leakage to
oxidised gold in combination with non-opaque take effect. Analysis of the cause of failure for a
cement. RBMR may indicate that an attempt should be
Showing metal is aesthetically acceptable to made to re-attach it after appropriate cleansing
some patients but simply not for others! Yellow and surface treatments. All traces of old cement
gold can look more harmonious in the oral envi- should be removed from the RBMR, which
ronment than nickel-chromium. A useful tech- should then be handled and treated as new. An
nique is to use an air abrader to reduce the air abrasion device, abrasive discs and ultrasonic
reflectance of the polished RBMR. In our experi- scalers are useful in removing cement from the
ence the surface produced by air abrasion also tooth surface. A round diamond bur can be used
picks up ink of occlusal marking tape more easi- without water in a turbine or speed increasing
ly than metal left highly polished.17 A chairside handpiece. The powdery white surface of the
air abrader for intra-oral use is a ideal for this instrumented cement can easily be distinguished
purpose but needs to be used with care (Table 1). from the glossy appearance of instrumented
The advantages of RBMR should be fully enamel. Occasionally etching tooth surface can
explained to the patient: the informed patient help to establish whether or not cement remains:
may accept this compromise in appearance. areas not appearing frosty are either dentine or
residual cement. It is important to remove the
Temporisation of RBMR resin-infiltrated layer in both enamel and den-
In many cases temporary restorations are tine and hence facilitate bonding. Cement
unnecessary but as with porcelain labial veneers removal must be carried out carefully or changes
retention can be a problem. These aspects are in tooth shape or fit surface of the RBMR will
addressed in the ninth article in this series. result in an increase in lute thickness. Inevitably,
It is a significant disadvantage that RBMR repeated attempts at reattachment are increas-
cannot be reliably attached to teeth for a trial ingly likely to fail as the lute thickness rises.
period using temporary cement. Glass ionomer RBMRs linked rigidly together to act as a
cement (GIC) may afford easy retrieval (or post-orthodontic retainer or periodontal splint,
unplanned loss) in some situations but in others carry the risk that one or more retainers may
acts as a final cement! debond leaving the restoration as a whole
attached without causing any initial symptoms.
MAINTENANCE If this happens caries can progress unchecked
Erosion can cause loss of tooth tissue at the beneath decemented elements with disastrous
periphery of a RBMR (Fig. 8). This problem may results (Fig. 9). Adhesive splints need careful fol-
occur as a result of not identifying or not con- low-up: patients must be instructed to seek
trolling the aetiology of the patient’s presenting attention if they think a tooth has become
tooth wear. Repair with an adhesive filling mate- debonded. It is often necessary to remove the
rial may however be straightforward, although whole restoration and attempt to re-bond it. A
concern has been raised about the ability of the sharp tap to a straight chisel whose blade is posi-
repairing material to bond to the metal casting. tioned at the lute space is often sufficient to dis-
A RBMR whose lute has failed is more likely lodge the cemented portions of an adhesive

BRITISH DENTAL JOURNAL VOLUME 193 NO. 3 AUGUST 10 2002 141

PRACTICE

splint. Occasionally it is possible to accept the 7. Rochette A L. Attachment of a splint to enamel of lower
anterior teeth. J Prosthet Dent 1973; 30: 418-423.
compromise of removing a decemented retainer 8. Livaditis G J, Thompson V P, Etched castings: an improved
if this is at the end of the restoration. Linking mechanism for resin bonded retainers. J Prosthet Dent 1982;
RBMR should be avoided wherever possible. 47: 52-58.
9. Dixon D L, Breeding L C, Hughie M L, Brown J S. Comparison
of shear bond strengths of two resin luting systems for a
CONCLUSIONS base and a high noble metal alloy bonded to enamel.
RBMR rely for their attachment on chemically J Prosthet Dent 1994; 72: 457-461.
active cements. The choice is between precious 10. Eder A, Wickens J. Surface treatment of gold alloys for resin
adhesion. Quintessence Int 1996; 27: 35-40.
metal and base metal alloys with various surface 11. Hansson O. The Silicoater technique for resin-bonded
treatments to enhance adhesion with the prostheses: clinical and laboratory procedures. Quintessence
cement. RBMR have the potential to be very Int 1989; 20: 85-99.
conservative of tooth tissue but are technique 12. Dahl B L, Krogstad O, Karlsen K. An alternative treatment in
cases with advanced localised attrition. J Oral Rehabil 1975:
sensitive. To date few clinical studies exist 2: 209-214.
examining their success. 13. Sorensen J A, Martinoff J T. Intracoronal reinforcement and
coronal coverage: a study of endodontically treated teeth.
1. Nohl F S, King P A, Harley K E, Ibbetson R J. Retrospective J Prosthet Dent 1984; 51: 780-784.
survey of resin-retained cast-metal veneers for the 14. Shillingburg H T, Hobo S, Whitsett L D, Brackett S E.
treatment of anterior palatal tooth wear. Quintessence Int Fundamentals of fixed prosthodontics. 3rd ed. pp171-180.
1997; 28: 7-14. Chicago: Quintessence, 1997.
2. Chana H, Kelleher M, Briggs P, Hooper R.J. Clinical evaluation 15. Paul S J, Scharer P. Effect of provisional cements on the bond
of resin-bonded gold alloy veneers. J Prosthet Dent 2000; strength of various adhesive systems on dentine. J Oral
83: 294-300. Rehabilitation 1997; 24: 8-14.
3. Foreman P C. Resin-bonded acid-etched onlays in two cases 16. Jung M, Gnass C, Senger S. Effect of eugenol-containing
of gross attrition. Rest Dent 1988; 15: 150-153. temporary cements on bond strength of composite to
4. Harley K E, Ibbetson R J. Dental Anomalies- Are adhesive enamel. OperDent 1998; 23: 63-68.
castings the solution? Br Dent J 1993; 174: 15-22. 17. Kelleher M G, Setchell D J. An investigation of marking
5. Lyon H E. Resin-bonded etched-metal rest seats. J Prosthet materials used in occlusal adjustment. Br Dent J 1984; 156:
Dent 1985; 53: 366-368. 96-102.
6. Thayer K E, Doukoudakis A. Acid-etch canine riser occlusal
treatment. J Prosthet Dent 1981; 46: 149-152.

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