Permanent Maryland bridge

Maryland bridge

Maryland bridge is a common prosthesis for patients that are too young or don’t have the bone for dental implants.  Often they are done when a person is missing a lateral incisor.  The lateral incisor is the small tooth right next to the center one.  This is genetic, very common and it runs in families, so blame mom and dad!!

Photos of a maryland bridge

What are the marlyand bridge options?

The are several variations of the maryland bridge out there.  Materials that we use are either metal, porcelain, or composite.  The porcelain we use is usually zirconia or pure emax, both of these have pluses and minuses.  I would recommend going with whatever your dentist recommends, provided they can show you before and after pictures of their own work that you find acceptable.  My opinion on technique and material questions is that the best material in the world isn’t the best in the hands of someone that hasn’t used it before or doesn’t like it.

There are only three major design decisions to make and you should ask your dentist what they prefer.

The questions to ask are

  • One wing or two?  We have had several one wings rotate so there does exist some complications with the single wing.  These were done shortly after braces when the teeth were still settling and we believe that had something to do with it.
  • Will you use metal or ceramic for the substructure support?
  • Will the cosmetic part be made out of composite or ceramic?

Porcelain fuse to metal Maryland bridge (PFM Maryland bridges)

This is what the vast majority of dentists use for their Maryland bridges.  The material and technique is time tested and both labs and dentists are all familiar with it.

Emax maryland bridges

These are becoming more common but require more thickness to be strong enough.  The ones that can be found online are in our opinion too bulky and unaesthetic.

Zirconia maryland bridges

These can be very good but one must worry about how well you are bonding to the tooth structure with zirconia.  Some are creating methods to allow for porcelain to bond to the tooth and still utilizing the strength of the zirconia.  This is accomplished through either holes in the zirconia that the lab fills with porcelain or porcelain circumferentially around the zirconia.

Composite Maryland bridge

A composite Maryland bridge is not very useful for most people. I only use if someone can not afford anything but the cheapest possible option. Even then I will only use it on someone that is very old and will likely not need it much longer. Usually it is a patient that is thinking of just leaving the space and doesn’t care very much. This patient often makes one of the funnier jokes I hear from very old patients, ” Honey, at my age I don’t even buy green bananas.”

Image of Composite Maryland bridge

If you are reading about Maryland bridges you are not going to be getting something this cheap.

Image composite Maryland bridge

Bad photo for a composite Maryland bridge, not that a good photo would do it any justice. This is not a high esthetic option.

Issues that make a maryland bridge more challenging

There are several things about you that can make a maryland bridge hard to do well.

First off is how hard are you on your teeth?  Grinders, clenchers, people that have hard diets will pop these off on a regular basis.  No one will be happy.

Where is your smile line?  That means how much gum tissue do you show when you smile?  If the answer is none, then the esthetics of where the tooth needs to look like it’s coming out of the gums is not that important.  If you have a gummy smile it is going to be a challenge to get it to look natural.  The best method will include some type of temporary to train the gum tissue.

The final issue is the amount of tissue and bone you have to work with.  If there isn’t much tissue or bone then the dentist can’t make it look like it’s coming out of the gums naturally.  Many people with little bone will have an indention in that area and it will never look natural without doing some sort of gum graft before the maryland bridge is made.  The other issue with these indented areas is the tooth always looks darker as the lip casts a shadow on it because it sinks in more in that area.

Marlyand bridge before and after pictures

This is an example of two Maryland bridges that we did on a young girl.  We are using a modified version of the traditional Maryland bridge in which we use only 1 wing.  This method allows to only reduce the back side of one tooth instead of two.  In this particular case these are her final restorations that she will have for as long as she can keep them.

Images of before and after Maryland bridge.

Laser gum treatment for maryland bridges

It makes a big esthetic difference if you can train or treat the tissue before delivery of final maryland bridge.  Ideally the final result looks like the tooth is coming out of the gums, not sitting on top of the gums.  If you have very little bone and/or tissue width this may not be possible or be very challenging anyway.

Maryland bridge information for dentist and lab

Connecting the maryland bridge to a cuspid and incisor is more likely to cause adhesion failure at the incisor.  This adhesion failure can lead to decay if not detected.  Best methd for the one wing is to connect it to the canine.   Keep the prep in enamel with a Yamahita design.  Use non-precious metal, like Rexillium III, sandblast it and bond with MDP containing material like Panavia.      Keep the metal supraginigval due to metal sensitivity.  Do not let the lab electrolytically etch the non-precious metal, you can just blast it with aluminum oxide before bonding it. Don’t wash off the residual sand, simply apply your MDP containing resin.

Panavia 21 to porcelain fused to metal Maryland bridge

Maryland bridge to base metal

  1. Sandblast 2-3 seconds per cm2. (30-50 micron alumina)
  2. Air dry
  3. Mix A and B for 35 seconds
  4. Place A and B on tooth for 60 seconds
  5. Air dry
  6. 1 full turn and mix cement 20-30 seconds
  7. Seat restoration with finger pressure for 60 seconds
  8. Place Oxyguard II for 3 minutes
  9. Clean up excess with scaler or explorer

What is a Yamashita prep design?

Yamashita adhesion bridges use intra-enamel grooves on mesial and distal.  I heard about it on this dentaltown thread.  In that thread it said Botelho et al. has a study showing the Yamashita prep design, but I looked at the study and found that is not the case.  Here is what the study says, “As this study was retrospective, it was not possible to describe the biomechanical variables of the prostheses, such as thickness of retainer and use of grooves, pins, or cingulum rests, and these variables were therefore not controlled.”  Frankly, I can not find a great description or picture of it anywhere.

Despite that the prep design that I use has 2 retention spots and 1 retention groove. It forms a smiley face and my lab said it makes her happy so I like it.

Photo of a maryland bridge prep design.

Smiley face maryland bridge prep design for added retention. The benefits of this design are debatable and as I look at this I feel the shape of the retention grooves should be inverted.

What is the Maryland bridge dental code?

The dental code for a Maryland bridge is actually going to be 2 or 3 dental codes depending on if we use 2 or 1 wing. The wing or retainer is dental code D6545 for metal and D6548 for porcelain, so think emax or zirconia. The pontic tooth is dental code D6242 for noble metal and D6245 for porcelain.

SmartMaryland bridge from Uwe

I like the look of this one too.

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39 Responses to “Permanent Maryland bridge”

  1. Susan SchlossFebruary 26, 2018 at 11:05 pm #

    Hello. I have #7 and #10 congentially missing. I had a Maryland bridge that my dentist in Bozeman Montana put in 30 years ago. I cannot believe it lasted that long! Anyway, I need a replacement Maryland Bridge and I was wonderinf if you could refer me to a dentist in Billings Montana that does these. Seems like everyone wants to do a traditional bridge and I just do not want to grind down perfectly good front teeth.

    • Bauer BryanFebruary 26, 2018 at 11:33 pm #

      Any dentist can do it just tell them you want a Maryland and you won’t do a bridge. Unless you have decay or large fillings on the teeth, someone will do it. I don’t know anyone near you, sorry!

  2. BevMarch 9, 2018 at 12:34 am #

    Hello, I live in Pittsburgh, PA and would like to have the Maryland Bridge. Do you know of any Dentist in my area that would do this type of bridge? Thank you.

    • Bauer BryanMarch 10, 2018 at 11:35 pm #

      Any dentist can do one. Some do better looking ones but it’s not that tough.

  3. Julie ZMarch 28, 2018 at 6:12 pm #

    Hello, my teeth 7 and 10, have been missing since birth and I’ve had a MD bridge for nearly 30 years with no problem. I’m 55 and have taken good care to be gentle and superfloss often. Also, tooth 8 has had a root canal (from a fall when I was a teen) and some internal bleaching because of darkening. It has also shifted back so that 9 appears to stick out in front, shadowing 8. Combined with the metal of the bridge, 8 is even darker, as are 6 and 11. My dentist insists that using a white or ceramic MD bridge is a bad option because it will crack and break, even though my current bridge has never cracked, she said it’s because it’s metal. She insists that implants are the far better option but the idea of having invasive surgery plus probably grafting is not appealing. I still haven’t met with an oral surgeon but would like to know how my situation does with implants instead of a newer MD bridge made of non-metal?

    • Bauer BryanMarch 28, 2018 at 9:57 pm #

      Your dentist is right. Implants are better IF you have the bone. Nothing wrong with bridges or doing a new Maryland but it won’t last as long – usually much less than the first one.

  4. JudiMay 9, 2018 at 6:46 pm #

    I am so impressed with your website and how thorough you are! This, however, is the cause for much disappointment that I am in California and can’t use you to fulfill my dentistry needs. 🙁
    I do want to thank you for providing such clear information, so that I am better equipped to make good decisions and advocate for myself, and my family, in an informed way.

    • Bauer BryanMay 9, 2018 at 11:08 pm #

      Thank you! Good luck to you!

  5. HannaMay 15, 2018 at 5:46 pm #

    Hi,
    I am looking at getting Emax Marlyand Bridges for #7 and #10. I am having a hard time with my insurance. How would you recommend the billing department coding the Emax Maryland Bridges? Right now they are using D6548 each tooth #6-11.
    Thanks!

    • Bauer BryanMay 15, 2018 at 6:46 pm #

      That’s because insurance companies suck and will do everything possible not to pay on anything. That is the right code. I quit playing games with insurance companies, I go straight to the state insurance commission and file a complaint when they pull these stall tactics. However, the pontic 7 and 10 should be either 6242 or 6245. That may be why insurance won’t pay.

  6. JLAugust 15, 2018 at 5:41 pm #

    Any ideas on how to code this?

    #4 is PFM D6750
    #5 is PFM Pontic D6240
    we want to include an additional wing that bonds to the lingual of #6
    How would you code that additional wing from #5-6?

    • Bauer BryanAugust 15, 2018 at 10:27 pm #

      The wing or retainer is dental code D6545 for metal and D6548 for porcelain. I assume you are using metal wing in this case though so D6545

  7. Janice DeFondaSeptember 17, 2018 at 12:20 pm #

    Hello Dr. Bauer, I live in Syracuse, NY and had a Maryland Bridge to replace a front tooth that got knocked out as a teen and then reinserted into my gum because it was undamamged root and all. As I grew, the tooth did not, so, my dentist replaced it with this bridge. I’ve had it for over 30 years. My concern is one of the supporting teeth now has a decay spot and my dentist does not know anything about these bridges or how to address this. What would you recommend?
    Thank- you for responding!

    • Bauer BryanSeptember 17, 2018 at 3:23 pm #

      If you are under 70 I would strongly consider an implant at this point. A second Maryland will not last as long as the first for many reasons.

  8. HolleOctober 4, 2018 at 2:29 am #

    My daughter (three years old) fell and cracked her upper front left tooth. Unfortunately, I had to get it removed today and now I’m not sure what to do but I do not want her to go years without a tooth. What would you recommend?

    • Bauer BryanOctober 4, 2018 at 3:35 am #

      I’m sorry to hear that. Usually kids just have to go without. I’m going to ask our pediatric dentist is she knows of any tricks or treatments.

  9. HolleOctober 4, 2018 at 8:49 am #

    Thank you!

    • Bauer BryanOctober 5, 2018 at 4:31 am #

      I think the office spoke with you about doing a special kind of space maintainer with a tooth on it. Sounds like that is your best solution.

  10. AnonymousDecember 1, 2018 at 10:10 am #

    Hi Dr. Bauer Bryan,
    I recently fractured my root canal tooth #7 about 2mm to 3mm below the gum line but tooth still hanging there by some flesh. After reading your article, I was wondering if I can save money by using my existing tooth #7 as a pontic for the Bonded Maryland Bridge? If this is possible, I assume I just had to have the dentist trim the top part of my natural tooth #7 to the gum line and put fillings in the hole. Also, is it necessary to put fillings on the root side of tooth #7 below the gum line to prevent it from decaying or does the gum tissue eventually closes up the hole by itself over time?? I don’t want to extract my tooth until the day of my dental implant (maybe 5 years from now) so bone won’t contract inside the socket. Thanks for your opinion.

    Mark.

  11. Greg SchneiderDecember 7, 2018 at 11:54 pm #

    Hello Dr. Bauer,

    I just had a Maryland bridge put in for my number 9 tooth the only two teeth that make contact now are my bottom two teeth with the back of the bridge. My dentist keeps telling me it’s fine don’t worry about it but it doesn’t feel right and I’m thinking I’m going to end up damaging the bottom teeth. The molars no longer make contact. Any thoughts?

    • Bauer BryanDecember 10, 2018 at 5:14 pm #

      Get another opinion. That does not sound right.

  12. TrishDecember 10, 2018 at 1:40 am #

    I have had q Maryland bridge for over 30 yrs it has finally just came in cemented from my other teeth how much would a dentist charge me to re cement it in is all I need…

    • Bauer BryanDecember 10, 2018 at 5:13 pm #

      Few hundred at most. Some come uncemented due to decay and thus can not be recemented. The dentist will tell you that.

  13. Lois BamfordFebruary 18, 2019 at 11:14 pm #

    My original Maryland bridge lasted for 25 years. When it finally came out , my dentist replaced it with a new Maryland bridge but the problem is the new Maryland bridge keeps coming out. My dentist tells me the cement is the issue. In the last year, he has recemented it back in place three times. This last time, he used a bonding agent plus the cement and felt this would solve the problem. It didn’t. Any suggestions or recommendations?

    • Bauer BryanFebruary 18, 2019 at 11:31 pm #

      At some point you both have to agree it’s not working anymore and take a different route. Many reasons why this could be, but my experience is just because something worked in the mouth for decades doesn’t mean it will ever work again. I’m guessing there was decay or something that changed since the old one. Sometimes that’s all it takes to make it impossible to repeat.

  14. Greg SchneiderFebruary 18, 2019 at 11:40 pm #

    There may be a problem with the appliance itself. I had the same issue and the dentist sent it back with a new mold for a better fit and it fixed
    problem. I’m not a dentist but that’s just my personal experience

  15. nat comberFebruary 27, 2019 at 7:25 pm #

    I need a replacement maryland bridge. The original lasted 10 years and then another 10 years after being re-glued.
    My dentist is unwilling to replace it with another two wing bridge saying that there is an issue with them and decay occurring behind a loose wing.
    She wants to fit one with just one wing which, to me, seems a lot weaker. I’d appreciate your advice.
    The tooth is an incisor next to a canine. I’m 52 – I figure i only need another 2 or three 10 year bridges

    • Bauer BryanMarch 6, 2019 at 3:44 am #

      Please dispel the idea that just because the first one lasted x years so will the next one. In general future ones last considerably less time because the thing they are attached to (your teeth) is in worse shape. One wing or two both work but can have issues. The risk of two is that often one wing detaches long before the second and decay can form under. The risks of one are the tooth can rotate and it is less stable. There is no perfect answer but if you have not had decay after 20 years I would strongly consider rebonding it again.

  16. LillianMarch 16, 2019 at 3:01 am #

    I have a 20 year old Marland bridge and the metal is getting thin in one spot.
    Is there any way to fix that area?

    • Bauer BryanMarch 17, 2019 at 6:35 pm #

      No. Even thin metal should last a long long time.

  17. AmberMarch 20, 2019 at 6:46 pm #

    Hi I have just had a Maryland bridge put in to replace the gap I have from a missing tooth in the bottom front of my mouth. I’m only 30 and elsewise have good teeth. I am however upset that I was told I would have a resin back so it’s not noticeable. When he went to put it in he said they needed to make it metal, now although I love the tooth, the two surrounding teeth look Grey from the metal at the back showing through. Is there any way to fix this? Thank you

    • Bauer BryanMarch 20, 2019 at 7:17 pm #

      No way to fix. Some people’s teeth are more translucent than others and this shows through, especially on lower teeth of younger people like you. I’ve had this happen. I can’t remember if I just replaced it or if we ended up using a really opaque cement to fix it.

  18. DaveJune 25, 2019 at 5:14 pm #

    Hi, I have a Maryland bridge upper right lateral. The bridge has two wings attached to the adjacent teeth. One of the wings has come loose. Is it possible to re-cement the loose side without breaking the bridge or should I leave it until both sides are loose?

    • Bauer BryanJune 26, 2019 at 4:33 am #

      I usually just leave it be until comes off. Which can take years

  19. RobinJuly 2, 2019 at 4:55 am #

    Hello,
    I have two Maryland bridges for lateral incisors. They have metal wings and I’ve had them for almost 20yrs. One of them has been re-bonded several times. The last time it was re-bonded, the dentist made a small chip in the pontic, so now it looks like I have a poppyseed inbetween my teeth. The pontics also no longer match my natural tooth color very well, and I’m not a fan of the dark metal. Do you think it’s a good idea to get new Marylands with zirconia (or another white colored) wings?

    • Bauer BryanJuly 2, 2019 at 10:17 pm #

      It is a possibility. I would recommend doing whatever your dentist thinks is best. Any differences in material choices are not as critical as the dentist’s experience with the materials. All of these things are technique sensitive so best to go with whatever your dentist is best at.

  20. Barry IsdanerJuly 15, 2019 at 4:18 pm #

    I am a dentist. I made two Maryland bridges for a young patient replacing #7,10. The left side bridge fit perfectly and has been cemented in place with no problems. However, the right side continues to come out after cementation. The lab suggested a prep on each abutment. How would you prepare the lingual surfaces of #6,8 to improve retention and can resin cements be used that I use for crowns and bridges or must I use Panavia or Metabond for retention?

    • Bauer BryanJuly 17, 2019 at 1:26 pm #

      Yes a resin cement should work. Clean the lingual surface with pumice or roughen with diamond, etch, bond, then follow instruction of your resin cement for bonding to metal. They usually want something with MDP on the metal. Microetch the metal add MDP then bond then ready to bond with your resin cement is likely the protocol. The resin cement needs to be dual cure or you will not get cure in the middle with a metal wing FYI. I prep a smiley face in the teeth. I microetch metal then use z prime then bond cure then DC resin cement. Cements and bonds should come with instructions but I think panavia is best. I put up a photo of the prep design but basically the eyes are a 330 dot and then a small smile with same bur.

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