Natural tooth pontic fixed partial denture usingresin composite-reinforced giass fibersMahesh Chauhan, BDS'

This article describes the rationaie and method of using giass libers reinforced with resin composite as anexternal framework to reuse a patient's own naturai anterior tooth as a pontic, after extraction,(Quintessence Int 2004:35:549-553)

Key words: fiber-reinforced composite, natural tooth pontic, periodontal splinting, resin-bonded fixedpartial denfure

CLINICAL RELEVANCE: A natural tcofh pcnfic fixed par-tial denture using fiber reinforced composite offers a con-servative, cost-effective, noninvasive, esthetic, functional,and durable solution for replacing a single anterior tooth.

Conservation, natural preservation, minimum inva-sion, esthetics, and cost are some of the important

factors that are considered when replacing a missingtooth, as well as prosthesis biocompatibility and oralhygiene maintenance.

Glass fibers reinforced with resin composite can beused as a bonded external framework to support a pa-tient's own natural anterior tooth that is due for extrac-tion, Tbe extracted tootb, after root sectioning, serves asa "natural tooth pontic," while glass-fiber bonding simul-taneously splints periodontafly weak abutment teeth.

'Private Practice, New Delfii, India,

ReprinI requests: Dr Matiesh Chauhan, Mother Dental Impiant Ciinic,18 Ansaii Road, Darya Gar), New Daltii 110002, India, E-mail:rr_ctiaijtian_in@yahoo,coni

Bunocore' described a simple method of increasingthe adhesion of acrylic restoration materials to enamelsurfaces. Since then, an adhesive revolution hasevolved. Today, adhesive dental procedures have wide-spread usage. Restorative composites have been exten-sively used to restore defects in teeth or as tooth orprosthesis veneering materials.

Hypermobile teeth with reduced hard and soft tissuesupport benefit by splinting them together^ and by tbeelimination and treatment of the disease and etiologicfactor. Hypermobile teeth bave been stabilized using anumber of different material combinations such asresin composites,^'' wire and wire mesh, '* amalgam-emhedded wire," woven polyethylene ribbon,* andpreimpregnated glass-lib er-composite combinations,'

A number of research ers'"-'" bave also used fiberand composite combinations not only to splint mobileteetb, hut also on a temporary, intermediate, or long-term basis for replacing a single missing anteriortootb.

This article presents general guidelines, indications,contraindications, materials required, and a completetechnique to replace a patient's own natural extractedanterior tooth and reuse it as a pontic by bonding ifwith adjacent teeth.

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Fig 1 Right maxillary cennal incisor ot a 43-year-oid male, duefor extraction because ot advanced periodontal disease.

Fig 2 Tooth in Fig 1 snürtly alter extraction. Periodontal surgerywas also pertormed on remaining teeth. 3-0 siik sutures are inplace.

RATIONALE

Fiber-reinforced composites consist of fiber materialheld together by a resinous matrix. A resin-fiber com-bination offers good flexure strengtb and very bigbfiexure modulus values, which are more favorablefhan those for dental resins alone.^' Fiber-reinforcedcomposites exhibit different mechanical properties indifierent fiber configurations or weaves. In unidirec-fional fiber composites, all glass fibers are parallel toeacb other, and properties are highest in the directionparallel to the fibers and lowest in the direction per-pendicular to the fibers.^^-^' A woven configuration isable to take load from different directions.

METHOD AND MATERIALS

Tbe cbairside procedure primarily uses three compo-nents to secure the natural tooth pontic to abutmentteetb: (1) A woven glass-fiber material (Fiber-Splint,Polydentia), which serves as an external frameworkfor the fixed partial denture; (2) a fourth-generationbonding agent {Scotchbond Multipurpose Plus, 3MEspe) for bonding the Fiber-Splint and composite toteetb; and fJJ a restorative resin composite (Cbarismaand Flowline, Heraeus Kulzer) for reinforcement ofFiber-Splint.

Light curing was done using halogen light-curingunits having intensities above 400 mW/cm^. Usualcomposite finishing and polishing procedures werefollowed.

CASE SELECTION AND GENERAL GUIDELINES

Case selecfion criteria indicating usage of a naturaltooth as a pontic bonded with fiber-reinforced com-posite, were the following: (1) patients desiring tohave natural tooth back in place wben it is due for ex-

traction; (2) patients wanting a minimally invasiveprocedure; (3) patients desiring fasf and immediafe fix-ation in an esthetically important area; (4) support foradjacent abufment teeth, which have an unpredictablelong-term prognosis; (5) fixation of an avulsed tooth;and (6) cost-effective replacement.

Contraindications for the procedure were the fol-lowing: (1) inferfering parafunctional habits; (2) shortclinical crowns for bond adhesion; (3) inadequate oc-ciusal clearance space for reinforced fiber bonding; (4jinability to maintain isolafion of tbe field during bond-ing procedures; and (5) primary dentition.

Technique

Initial evaluation. The tooth to be removed wifbin thearch is evaluated for alignment, esthetic compromise,and its ability to be acid etcbed (Fig 1).

Customizing the extracted natural tooth. The rootis marked and sectioned as required (Fig 2). Either abullet shape or a modified ridge-lap sbape is given tothe cervical area. After sectioning, the newly createdapical opening of tbe pulp canal is cleaned, enlargedsligbtly (Fig 3), and sealed witb resin composite. Tbeextracted natural tooth is referred to as a natural toothpontic (NTP).

Fiber strip measuremenL The required length ofglass-fiber strip is measured with a periodontal probeor dead-soft matrix strip. Using the matrix strip as anindex, fhe required length of glass-fiber strip is cutwith serrated scissors, placed on a clean surface, andcovered to prevent contaminafion.

Tooth preparation for bonding. The lingual sur-faces of the abutment teeth to be bonded and tbe NTPare cleaned with abrasive containing nonfluoridepaste, propbylaxes jet, or microsand blaster.

Stabilizing the pontic. Occiusal evaluation is car-ried out, so as to position the tooth in such a way fhatit bears minimum forces. In many cases, tbe NTP willeasily be held in place by tight contact between the

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Fig 3 Foilowing pulp ciiamber cleansing, the aocess hoie isfilied with composite.

Fig 4 After root cutting and tiiiing ot the access hoie, the centraiincisor is positioned to its desired iocation and ready for bondingprocedure.

Fig 5 A wire being used as a temporary holding device lor thenatural tooth pontic. on a patient

Fig 6 Model of the desirea lingual adaptation cf a Fiber-Splint

proximal surfaces of abutment teetb (Fig 4). The NTPcan also be held in place with the help of a temporaryholding device, such as a wire (Fig 5), The wire is tem-porarily attached to the labial side of the abutmentteeth and tooth ponfic with flowable composite, with-out acid etching and without bonding agent, so that itcan be easily removed once the definitive bonding onthe palatal side bas been eompleted.

Bonding steps. After isolation, wooden wedgesmay be placed in fbe cervical interdental area to limitthe resin from flowing tbere, as it is desirable to keepthis area open for oral hygiene, Ahernatively, addi-tional heavy-bodied silicon material may be used toblock out tbe gingival embrasures.

The abutment teetb and the NTP are then acid-etched on tbe lingual side and proximal areas, washed,dab dried, and then primed to facilitate better penetra-tion of the bonding agent. After evaporating excessprimer with an air syringe, bonding agent is applied tothe lingual and proximal surfaces of the NTP andabutment teeth.

The premeasured glass-fiber strip is soaked com-pletely in the bonding agent and closely adapted to thelingual surfaces of the NTP and abutment teeth (Fig 6).

Adapting closely to the lingual side and holding thefiher strip in the interproximal area gives additionalsurface area contact, and strength to the whole struc-ttire. This ean he done with a fine explorer, which holdsand keeps the glass-fiber strip closely adapted in theproximal area while the assistant light cures it. Com-posite placement instruments made of clear transparentpolycarbonate (Hilite, Polydentia) are very helpful inthe close adaptation of glass-fiber strips onto tbepalatal side, as tbese allow ligbt to pass tbrougb tbem.

Polymerization of tbe fiber strip sbould be done ina step-wise fashion, closely adapfing the fiber strip tothe lingual side of each tooth and polymerizing onesegment at a time. When the teeth are irregular, thestrip should follow the lingual contours of the arch.

When the entire strip has heen adapted and bonded,additional strips should be cut to size, soaked in bond-ing agent, and bonded, without disturbing isolationand without contamination. This maintains tbe in-tegrity of the outer oxygen-inhibited layer, allowing ad-ditional strips to be bonded. Up to six fiber strips maybe bonded on one another, or alternatively, a single,presfitched, six-layered material, such as Fiber-SplintML (Polydentia), might be used.

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Fig 7 The natural tooth oontic fixed partial denture after comple-tion cf the bonding procedure and suture removal (On the oppos-ing mandibular a(ch, tive implants have been placed].

Fig 8 Eighteen-monlh tcllcw-up. The natural tooth pontic is es-thetically acceptable and functionally stable despite patient'shabit of chewing "paan" regularly (Paan Is an Indian mcuth fresh-ener made of betel leaves, betel nuts, cardamcm, lime, and othernatural/artificial flavors. It may also contarn tobacco). Note heavystaining ot porcelain teeth and pcrceiain wear on mandibular firstpremolar.

After all the layers have been bonded together andlight cured sequentially, a layer of particulate resincomposite is used on the lingual/palatal surface overthe glass-fiber strips, to coat them completely. Thisprovides additional strength and a smooth polishedsurface,

A hybrid/flowable composite is used as additionalfortification in the interdental areas. In cases wherethere is diastema between teeth, using a slightly darkershade of hybrid composite in the interdental area onthe labial gives illusion of natural embrasures.Additionally, composite staining can be done usinglight-cured color liquids to give a more natural"stained" look, if the patient so desires.

Finishing and polishing. After all the bonding atidpolymerization processes are completed, the wholefiber strip surface should be covered with a layer ofcomposite, leaving no fibers exposed, so that it issmooth and able to be polished.

Occlusal interferences should be checked and cor-rected. Finishing and polishing procedures are carriedout in a progressive way as with all composites (Fig 7).Finally, the patient should be instructed in keepinghis/her "newly reacquired" tooth clean and plaquefree (Fig 8).

Clinical success

The author has treated 21 patients over 6 years usingthe techniques described in this article. Two patientshad the NTP debond. This was probably due to unre-solved parafunctional habits. In both the cases, theNTP was easily rebonded for continued successful es-thetics and function.

CONCLUSiON

The described tecbnique of using a patient's own nat-ural tooth as pontic in a resin composite-reinforcedglass-fiber framework is a conservative, esthetic, cost-effective, and practical alternative to the conventionalmetal-ceramic fixed partial denture. A natural toothpontic is also capable of giving long-term service.However, the procedure is highly operator dependentand demands appropriate case selection and precisetechnique.

REFERENCES

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2. Serio FG, Clinical rationale for tooth stabilization andsplinting. Dent Clin North Am 1999;43:l-6,

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4. Rochette AL. Attachment of a splint to enamel of lower an-terior teeth, I Prosthet Dent 1973;30:413-418.

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8. Strassler HE, Lopresti J, Scherer W, Rudo D. Clinical evalu-ation of a woven polyethylene ribbon used for splinting.Esthet Dent Update 1995;6:80-S4.

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