FROM the ARCHIVES

The One-Appointment Direct Bridge

By John Savage D.D.S.

o 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 its 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 its a direct
technique (not indirect), theres no need
for impressions... and no need for models.
And in my immodest opinion the cosmetic
results are better.
And though I cant know for sure, I
suspect the Georgia Bridge offers one
more advantage: a longer history of
clinical success.

Over the decades Ive built more than

1000 of the bridges, and Ive found them
extremely predictable. Far more so than
Maryland Bridges (which incidentally
dont 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 Im
using here to demonstrate the technique
shows replacement of an upper central
incisor. However, if youre doing the
technique for the first time, I suggest you
begin with a lateral or lower central.

The Georgia Bridge

Stepbystep

ABOUT the AUTHOR:

Dr. John Savage is

living proof that you
can have a successful
practice anywhere.
He practices dentistry
in a one-chair office in
Ebro Florida ... on the
banks of the Choctawhatchee River, at
the end of a dirt road, 19 miles from
the nearest traffic light. He lectures on
dental cosmetics, money management and personal fulfillment.

these grooves were about 1mm. The

preparation, (both semi-circle and
horizontal grooves) should extend
about 1/3 of the way around the labial
and lingual anatomy.
Fig. 2

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 (Fig. 1).
Fig. 1

(Fig. 1) The patient presented

missing #9.

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 (Fig. 2).
2) Then, using the same diamond, I cut
3 horizontal grooves in the labial and
lingual enamel (Fig. 3). The depth of

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Fig. 3

(Fig. 2) I prepped the proximal area

plus semicircular areas on the facial
and lingual of #8 and #10. (Fig. 3)
Using the same bur, I cut horizontal
grooves in both preps.

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.
1

(Fig. 4) shows the final preparation prior

to etching.
Fig. 4

Fig. 7

Fig. 5

(Fig. 4) The finished preparation before

etching. (Fig. 5) Before beginning to span the
gap, I carefully built and cured the abutting
composite on both teeth.

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 (Fig. 5). Nowadays
I use a flowable as my first step to
assure good wetting, but flowables
werent 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 youre 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 (Fig. 6). The gap in the
pontic was just 1/2 mm wide when I
added the final composite (Fig. 6).
I suspect youre 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 doesnt 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 its not
a flowable, as it warms in the mouth,
2

Fig. 6

(Fig. 6) Then I built out the span incrementally,

curing each addition thoroughly before
proceeding. (Fig. 7) The finished substructure,
after Id added and cured 6 layers of composite (3 from each side.)

Epic conforms nicely to the underlying

surface - a good feature when youre
laminating the substructure.
I enjoy custom color-matching, so I
often mix four or more shades to get
the precise color I want.

1) When the patient cant afford

traditional options, and you dont 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.)
Fig. 11

Fig. 12

Fig. 8

(Fig. 12) So she got to my

office at 5:00. By 5:30, Id
very carefully extracted
the root.
Fig. 13

(Fig. 8) Only then did I begin creating

the tooth anatomy.

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.
Fig. 9

(Fig. 11) The Bridal Bridge.

Thursday afternoon I
received a call from a
very upset young lady.
She was getting married
on Saturday and had just
fractured #9 at the
gumline! (There was
potential here for
some memorable
wedding pictures!)

Fig. 10

(Fig. 9) A 75-year-old colleague whod attended one of my lectures, lost a lower central incisor and came to me for a Georgia
Bridge. (Fig. 10) The patient was delighted
with the results.

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 dont want to invest too much
time, effort or money restoring a mouth
thats 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.

(Fig. 13) She returned on

Friday at 1:00 pm for her
direct Georgia Bridge.
Wedding saved! She
even sent me some wedding pictures.

3) When the patient is in periodontal

therapy and youre waiting to see
if additional teeth will be lost. It
also helps stabilize those mobile
teeth. (Okay, you could consider
this transitional.)
4) When youre using very thin lower
anteriors as abutments, and youre
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 isnt an
alternative. Its my first choice.
Where wouldnt you use this approach?
For one thing, you wouldnt 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.

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