ISSN: 2320-5407 Int. J. Adv. Res.

11(04), 1072-1081

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/16762

DOI URL: http://dx.doi.org/10.21474/IJAR01/16762

RESEARCH ARTICLE
AESTHETIC REHABILITATION OF SEVERE ANTERIOR ALVEOLAR RIDGE DEFECT WITH
ANDREW’S BRIDGE-A CASE SERIES

Dr. Gopika K.K, Dr. Gayathri P.M, Dr. Ayana Shalimon and Dr. Harsha Kumar K.
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Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Loss of variable amount of soft and hard tissueis often an inevitable
Received: 28 February 2023 consequence of missing teeth.Prosthetic rehabilitation of large anterior
Final Accepted: 31 March 2023 alveolar ridge defects is often a challenge to the clinician. 1 Such defects
Published: April 2023 require not just the replacement of teeth, but also closure of defective
area so as to achieve proper speech and aesthetics. Fixed removable
Key words:-
Andrew’s Bridge, Fixed- Removable partial dentures are indicated for patients with extensive tissue loss and
System, Anterior Ridge when the alignment of opposing arches creates difficulties for
placement of conventional partial denture. Andrews’s bridge is a type
of fixed removable prosthesis indicated in patients with severe ridge
defects. This type of prosthesis successfully replaces missing teeth
along with complete closure of defect, restoring speech and aesthetics. 2

Copy Right, IJAR, 2023,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
Andrew’s bridge is a fixed partial denture-removable partial denture system.It was introduced by Dr James Andrews
of Amite, Louisiana, USA in 1965. Andrews bridge system incorporates a fixed component and a removable pontic
component.Fixed component consists of porcelain fused to metal ceramic retainers on the abutment teeth joined by a
bar.3The removable pontic component consists of removable partial denture having attachments or sleeves to fit on
the bar. Andrews bridge system is indicated in patients where a greater degree of the residual ridge has been lost due
to trauma,congenital defects or other pathological process.

This functionally fixed prosthesis has the advantage of flexibility in arranging the removable partial denture teeth
with minimum extension along with better retention and stability. The occlusal forces are directed more along the
long axis of the abutment teeth.This technique successfully replaces the missing teeth along with complete closure
of the defect and restores phonetics and aesthetics. The removable part of this system can be easily removed and
reattached by the patient. Thus, it enables the patient to maintain hygiene around the abutments and under the bar.

This article describes three case reports having multiple missing anterior teeth along with ridge defects. These
defects were restored successfully by using fixed-removable Andrew’s bridge system.

Case Report-1
A 36-year-old male patient presented to the department of prosthodontics with a chief complaint of missing
maxillary and mandibular anterior teeth. Patient had a history of road traffic accident 1 year back. Intra oral
examination revealed missing teeth in relation to12,21,22,31,32.Ellis class 2 fracture in relation to 21 and extrusion
in relation to 11.

Corresponding Author:- Dr. Gopika K.K

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Patient had undergone root canal treatment irt 11,21 and alveoloplasty in relation to31,41 region. There was a bony
defect irt mandibular anterior region (Siebert’s class IIIdefect) Personal history revealed chronic smoking and
tobacco chewing habits.Treatment options for the maxillary arch included implant supported FDP, conventional
FDPand conventionalRPD.Treatment options for the mandibular arch included implant supported FDP with
autogenous bone graft and a fixed-removable partial denture.

The patient was informed about the various treatment options. Implant supported fixed dental prosthesis treatment
option was not considered because the patient is a chronic smoker. Healso did not prefer surgical treatment for
prosthetic rehabilitation of missing teeth. On further discussion with patient, he preferred a conventionalfixed partial
denture for the maxillary arch and a fixed-removable prosthesis for the mandibular arch.

Procedure
1.Complete oral prophylaxis
2.Diagnostic impressions were made with irreversible hydrocolloid impression material and poured in type iii dental
stone.
3.Tooth preparation on 11,13,21 to rehabilitate maxillary anterior region (figure:2)followed by provisionalisation
with tooth coloured acrylicresin.
4.Zirconia fixed dental prosthesis was cemented with glass ionomer luting cement. (Figure:3)
5.Preparation done on 33,43 to receive PFM crowns for fabricating Andrew’s bridge in relation to mandibular
anterior region.

Final impression was made with two stage putty wash technique using polyvinyl siloxane impression material and
the impression has been sent to laboratory for fabrication of fixed component of Andrew’s bridge system.

Provisional acrylic crowns were cemented irt 33,43 with intermediate restorative material.
6.In the laboratory, wax patterns were fabricated on the prepared abutment teeth (33,43) and were connected using
prefabricated castable plastic bar attachment. To facilitate maintenance of oral hygiene by the patient, 2-3 mm
clearance wasmade between the bar and the crest of the alveolar ridge. Then the entire assembly was casted in
chrome cobalt alloy.
7. The finished and polished metal framework was tried in the patient’s mouth to verify proper fit and clearance
between the bar and underlying soft tissues.
8.Shade selection was done for the ceramic teeth. Ceramic layering was done on the retainers 33,43.
9. The next step was the fabrication of the removable part of Andrew’s bridge system. The missing teeth 31,32,41,42
were arranged on the wax occlusal rim placed over the metal framework which was fabricated on to the edentulous
area of the cast. Subsequently, try in of the removable partial denture (RPD) unitwas done for aesthetic approval by
the patient. The replacement teeth along with the wax baseisflasked,dewaxed and cured using heat cure acrylic resin
10.The fixed part of the prosthetic assembly (retainers joined by the bar) was then cemented in the patient’s mouth
with type I GIC luting agent.The removable component of the Andrews bridge which is havinga snug fit on the
metallic component is placed in position.
11. The patient was trained to insert and remove the RPDsnuggly fitting over the fixed component of
Andrew’sbridge. Proper oral hygiene (including the use of interdental brush) instructions were given to the patient.
The patient was scheduled for follow-up visits after 1 week, 3and 6 months.
12.On evaluation over 6 months,it was found that the patient very well adapted and was comfortable with the
prosthesis.The patient was also satisfied with the restoration of function and aesthetics.

Figure 1:- Pre-operative extraoral view.

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Figure 2:- Pre-operative intraoral view.

Figure 3:- Tooth preparation on11,13,21.

Figure 4:- Zirconia FPD in relation to 11,13,21.

Figure 5:- Fixed component of Andrews bridgeIntraorview.

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Figure 6:- Fixed component of Andrews bridge -Intra oral view.

Figure 7:- Removable component of Andrew’s bridge -wax trial.

Figure 8:- OT Cap in the intaglio surface of removable component of Andrew’s bridge.

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Figure 9:- Post-operative intraoral view.

Figure 10:- Post operative extra oral view.

Case report 2
A 56-year-old male patient reported to the Department of Prosthodontics and Crown and Bridge, GDC, Trivandrum
with the chief complaint of missing lower front teeth. (Fig 11) The teeth were lost many years back due to trauma as
reported by patient. Patient had an interim RPD but was not using it as he was not satisfied with the function. On
examination, a large defect was present in the alveolar region extending from 33 to 43 which can be classified as
Siebert’s class III. (Fig 12) The patient was provided various treatment options available like removable partial
denture, fixed partial denture, implant with graft and fixed removable prosthesis. Patient was not very supportive
regarding removable partial denture and implant prosthesis. Thus, the patient was explained about the advantages,
disadvantages treatment duration and importance of oral hygiene measures while using Andrews Bridge prosthesis.
Patient agreed to go with Andrews fixed removable prosthesis.

Procedure:-1
Diagnostic impressions were made using alginate impression material. Mandibular left and right canines were used
as abutments. Tooth preparation was done with 33 and 43 to receive PFM retainers and impression was made in
Polyvinyl siloxane impression material. (Figure13). The bar was fabricated in the wax pattern and casted along with
these copings. The finished and polished metal framework was tried in the patient’s mouth for proper fit and
clearance between the bar attachment and underlying soft tissues was checked.(Figure 14). The missing teeth were
arranged on wax occlusal rim fabricated on to the edentulous area of the cast and tried for aesthetic approval by the
patient. (Figure 15). The removable part of the Andrews Bridge was then fabricated using heat cured
polymethylmethacrylate resin. Metal copings were then veneered with ceramic and the whole restoration was
finished and polished.

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The fixed component of the Andrews system was cemented over the prepared teeth. After one hour, a removable
component was inserted and occlusal adjustments were carried out.(Figure 16) Recall appointment was given after
the first day and then after a week. The patient was happy with the aesthetics and functions of the prosthesis and was
advised for regular recall visits.

Figure 11:- Preoperative extra oral view.

Figure 12: Intraoral pre-operative view

Figure 13:- Tooth preparation of 33 and 43 and Putty light body impression.

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Figure 14:- Metal framework trial.

Figure 15:- Wax try in.

Figure 16:- Post operative extraoral view.

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Case Report 3:
A 40-year-old male patient reported to department of prosthodontics with a chief complaint of missing mandibular
central and lateral incisors (31,32,41,42) which were extracted five years back due to mobility after a road traffic
accident. On examination it was observed that mandibular canines were supraerupted and there was a Sieberts Class
III defect of the edentulous region (Figure 17).There was severe bone loss with loss of lower lip support. The defect
required a prosthesis which could restore not only the missing teeth but also a large area of supporting structures.
The case was planned for esthetic rehabilitation using Andrews bridge with a bar retainer and a clip attachment for
better esthetics and hygiene. A precision fit metal sleeve inserts retentively on the bar.

Both the mandibular left and right canines were endodontically treated and tooth preparation was done on canines to
receive a metal ceramic crown and a bar connecting the two abutment crowns. A polyvinyl siloxane impression was
made. This whole assembly was then cast into a chromium-cobalt alloy. The prepared and polished metal frame over
the canines, attached to a ribbed metal bar, was tried in the patient's mouth to ensure proper fit and clearance
between the bar attachment and the underlying soft tissue (Figure 18, 19).Metal copings were then veneered with
ceramic and the whole restoration was finished and polished. The missing teeth were arranged on the wax occlusal
rim and aesthetics was evaluated in patient (Figure 20). The removable part of Andrew's bridge was then made of
heat cure polymethyl methacrylate resin. Plastic clip and metal housing were placed on to the cast bar and acrylic
resin was packed (Figure 21).The fixed component of the Andrews system was cemented to the prepared teeth. After
1 hour, the removable component was inserted and occlusal adjustment was performed (Figure 22). The patient was
instructed about the maintenance of the prosthesis and was trained to insert and remove the removable part of
Andrews bridge. Patient was recalled after the first day and one week later of delivery. This ribbed bar with plastic
clip incorporated in the metal sleeve increase the surface area of contact and ensures good friction fit between the
walls of bar and sleeve which enhances the retention of prosthesis.

Figure 17:- Pre operative intra oral view.

Figure 18:- Metal Try in of Andrews bridge framework after tooth preparation.

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Figure 19:- Try in of fixed component.

Figure 20:- Teeth setting trial.

Figure 21:- Ribbed bar and intaglio surface of removable component with metal sleeve and nylon clip.

Figure 22:- Post-operative intraoral view.

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Discussion:-
Restoration or rehabilitation of multiple missing teeth with severe bone loss is done on a routine basis with
removable partial denture treatment. Mostly in Siebert’s class III ridge defect presenting inadequate height and
width, removable prosthesis can be used. But these removable prostheses are less retentive, less stable and have poor
comfort as compared to fixed prosthesis. Due to this reason, patients prefer fixed prosthesis. But the treatment with
fixed prosthesis will have poor long-term prognosis. In such situations, Andrew’s bridge system is one of the
preferred treatment modalities.

Andrews Bridge system incorporates a removable partial denture of gingival coloured acrylic resin and acrylic
denture teeth for the missing dentition. This removable component clips over a bar which connects the Porcelain
Fused to Metal (PFM) retainer over the abutment teeth. 4There are various retentive systems used for Andrew’s
bridge like bar and sleeve attachment, magnets, ball attachment etc.In bar and sleeve attachment,two types of bars
are used, a single bar to use anteriorly and a twin bar for posteriors. These bars are available in three lengths of three
different curvatures. Each curve is a segment of a circle and the combinations allow adaptation to most clinical
situations. Since the bar formed part of the arc of a circle, it simplifies reconstruction should a patient lose or
damage the removable section. For any given situation, Andrews recommended using the bar with the greatest
possible curvature, thereby providing a maximum length and hence more frictional surface and greater wear
resistance. It also resulted in a more critical path of insertion that reduced the chance of accidental dislodgement of
the prosthesis. As with any bar retained prosthesis the design of the preparation must allow for adequate bulk of
metal close to the gingival margin. All types of bar prostheses require a common path of insertion for the fixed
section of the restoration, unless an auxiliary system has been incorporated. A shoulder or chamfer preparation
adjacent to the bar is recommended, for this will contribute to the strength of the crown margins which are prone to
damage under load. For the fabrication of this bar, wax patterns were made for all the prepared teeth and a wax
custom bar running over edentulous deficit ridge was connected to this prepared wax patterns. 5In two of the cases
described here, ball type of extra coronal attachment was incorporated into the custom bar. This ball attachment was
designed to engage the OT cap in the intaglio surface of the removable component of the fixed removable
prostheses. In the third case, bar and sleeve system was used.

The advantages of the Andrews Bridge system are reported widely in literature such as improved aesthetics, better
adaptability and phonetics. It is both comfortable and economical for patients. There is no lingual extension as in the
case of removable partial dentures. Soft tissue response is also better due to less soft tissue impingement. This type
of prosthesis is more retentive and stable with minimal extension. The system avoids unwanted leverage forces to
the abutment teeth by acting as a stress breaker. Moreover, reconstruction is simpler if the patient loses or damages
the removable section. The disadvantages of this system include the need to frequently remove the prosthesis for
cleaning and associated loss of retention of the attachment.

Conclusion:-
A patient with several missing teeth along with ridge defect in the anterior aesthetic region poses a greater challenge
for prosthodontic rehabilitation. Andrews Bridge is an effective and economical treatment modality for patients with
pronounced ridge defects. It also possessesexcellent properties of both fixed and removable prosthesis which can
provide best aesthetic results.The patients treated with the Andrews bar system in this case series were routinely
followed up and the patients were found to be comfortable with the prosthesis without any complaints.

Reference:-
1. Bhapkar. Andrew’s Bridge System: An Esthetic Option.
2. Gopi A, Sahoo NK. Andrews Bridge: A fixed removable prosthesis. Journal of Pierre Fauchard Academy
(India Section). 2016;30.
3. R C. Prosthodontic Rehabilitation of a Cleft Patient with Andrews Bridge: A Case Report.
4. Prosthodontic Rehabilitation of Anterior Bony Defect with Fixed Removable Bridge System: – A Claspless
Approach. J Oral Biol 2016
5. Soni R, Yadav H, Kumar V. Andrew’s bridge system: A boon for huge ridge defect in aesthetic zone. J
Oral Biol Craniofac Res. 2020;10: 138–40.

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