The Direct Composite Bridge_ Still a Unique Solution for Some Clinical Situations
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5/20/2014 The Direct Composite Bridge: Still a Unique Solution for Some Clinical Situations http://www.dentistrytoday.com/restorative/7320-the-direct-composite-bridge-still-a-unique-solution-for-some-clinical-situations 1/6 The Direct Composite Bridge: Still a Unique Solution for Some Clinical Situations Written by Robert Lowe, DDS Thursday, 10 May 2012 08:56 INTRODUCTION Often times, when presented with a single tooth edentulous space, we "automatically" think of either a 3unit fixed partial denture (bridge), or an implant and crown. Yet, there are still some situations that are best treated with direct resin. Many years ago, I was introduced to a direct resin bridge technique called "the Georgia Bridge," as demonstrated in a 1986 lecture by Dr. John Savage from Atlanta. Dr. Savage described a "freehanded" bonding technique to use direct composite resin as a pontic, utilizing adhesive dentistry and undercuts in the enamel surface of the abutment teeth to help retain this "pontic" between the edentulous span. Facial and proximal surfaces of the abutment teeth were prepared minimally, as if for direct labial veneers. Horizontal groves were then made in these surfaces for auxiliary retention of the restorative material. Next, a "composite bridge" was fabricated using lightcured resin across the edentulous area between the abutment teeth. Dr. Savage described this Georgia Bridge as "the bridge of choice" when replacing single anterior missing teeth when: (1) the patient could not afford a conventional fixed bridge, (2) the patient did not wish to prepare "virgin" abutment teeth required for a fixed bridge replacement, (3) the edentulous ridge was inadequate for placement of an implant, and (4) the patient chose not to have an implant placed. Since the time that the original article on the Georgia Bridge was written, many advances in adhesive dental technology and composite resins have occurred that make this technique even a better longterm solution for some of the aforementioned clinical situations. This article will feature a modification of the Georgia Bridge technique using a modern composite resin to close an edentulous space left by the extraction of a mandibular incisor. CASE REPORT Diagnosis and Treatment Planning A 76yearold female patient presented with a missing mandibular left lateral incisor that had been recently extracted because of severe root caries on the distal surface that had made the tooth unrestorable (Figure 1). Upon clinical and radiographic examination, it was noted that there was not enough remaining bone in the labiallingual direction to consider an implant. Also, the teeth adjacent to the edentulous space, aside from having some crestal bone loss, were unrestored. The crowntoroot ratio and mesiodistal root diameter at the gingival crest of the mandibular left central incisor were not favorable due to the alveolar bone loss, making it a questionable abutment for a fixed partial denture. The other restorative "choice," a singletooth removable "flipper" appliance, would have been a poor solution due to the amount of plastic to replace "one missing tooth"; and the probable lack of patient compliance to wear such an appliance long term. It was decided that the most conservative approach for this patient would be to "suspend" a pontic between the abutment teeth using adhesive technology and fiber reinforcement. Since the pontic would be layered in a similar fashion to the way a ceramist would make a bridge, the plan was to use an opacious dentin as the first layer replicating the internal dentin structure of the natural tooth. Next, the "universal" VITA shade would be layered over the initial material to recreate the "bulk" of the remaining dentin. Finally, an incisal shade would be used to recreate translucency in the incisal third of the tooth and complete the incisal edge. Material Selection A universal nanocomposite resin (Kalore [GC America]) was chosen as a material that would be wellsuited for this task. In recent years, advances in composite resin technology have been largely on the filler side—changes in particle size, particle shape, or filler type—to try to maximize the aesthetic potential of the material while maintaining the physical properties necessary to enable the material to withstand the stresses of masticatory forces in the oral environment. With Kalore, the manufacturer reports an innovation in monomer technology. A DuPont monomer (DX511) is used, which has a long rigid core with flexible arms. It is believed, with this new monomer formulation, that the polymerization shrinkage challenge may be solved by removing the shorter chain methacrylate matrix, providing the potential for reducing such clinical challenges as marginal gap formation, microleakage, stain, and secondary caries 29 Search... Articles Aesthetics Clinical Update CE Articles Dental Materials Dental Medicine Diagnosis Digital Impression Technology Endodontics Ergonomics Forensic Dentistry Geriatric Dentistry Hygiene Implants Impressions Infection Control Interdisciplinary Dentistry Interview Laboratory Management Materials Microdentistry New Directions Practice Management Restorative Oral Cancer Screening Occlusion Home Leaders News Articles Products Videos Online CE Meetings FREEinfo Buyers Guide
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Transcript of The Direct Composite Bridge_ Still a Unique Solution for Some Clinical Situations
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5/20/2014 The Direct Composite Bridge: Still a Unique Solution for Some Clinical Situations
http://www.dentistrytoday.com/restorative/7320-the-direct-composite-bridge-still-a-unique-solution-for-some-clinical-situations 1/6
The Direct Composite Bridge: Still a Unique Solution for Some ClinicalSituationsWrittenbyRobertLowe,DDSThursday,10May201208:56
INTRODUCTIONOftentimes,whenpresentedwithasingletoothedentulousspace,we"automatically"thinkofeithera3unitfixedpartialdenture(bridge),oranimplantandcrown.Yet,therearestillsomesituationsthatarebesttreatedwithdirectresin.Manyyearsago,Iwasintroducedtoadirectresinbridgetechniquecalled"theGeorgiaBridge,"asdemonstratedina1986lecturebyDr.JohnSavagefromAtlanta.Dr.Savagedescribeda"freehanded"bondingtechniquetousedirectcompositeresinasapontic,utilizingadhesivedentistryandundercutsintheenamelsurfaceoftheabutmentteethtohelpretainthis"pontic"betweentheedentulousspan.Facialandproximalsurfacesoftheabutmentteethwerepreparedminimally,asiffordirectlabialveneers.Horizontalgroveswerethenmadeinthesesurfacesforauxiliaryretentionoftherestorativematerial.Next,a"compositebridge"wasfabricatedusinglightcuredresinacrosstheedentulousareabetweentheabutmentteeth.Dr.SavagedescribedthisGeorgiaBridgeas"thebridgeofchoice"whenreplacingsingleanteriormissingteethwhen:(1)thepatientcouldnotaffordaconventionalfixedbridge,(2)thepatientdidnotwishtoprepare"virgin"abutmentteethrequiredforafixedbridgereplacement,(3)theedentulousridgewasinadequateforplacementofanimplant,and(4)thepatientchosenottohaveanimplantplaced.SincethetimethattheoriginalarticleontheGeorgiaBridgewaswritten,manyadvancesinadhesivedentaltechnologyandcompositeresinshaveoccurredthatmakethistechniqueevenabetterlongtermsolutionforsomeoftheaforementionedclinicalsituations.ThisarticlewillfeatureamodificationoftheGeorgiaBridgetechniqueusingamoderncompositeresintocloseanedentulousspaceleftbytheextractionofamandibularincisor.
CASEREPORTDiagnosisandTreatmentPlanningA76yearoldfemalepatientpresentedwithamissingmandibularleftlateralincisorthathadbeenrecentlyextractedbecauseofsevererootcariesonthedistalsurfacethathadmadethetoothunrestorable(Figure1).Uponclinicalandradiographicexamination,itwasnotedthattherewasnotenoughremainingboneinthelabiallingualdirectiontoconsideranimplant.Also,theteethadjacenttotheedentulousspace,asidefromhavingsomecrestalboneloss,wereunrestored.Thecrowntorootratioandmesiodistalrootdiameteratthegingivalcrestofthemandibularleftcentralincisorwerenotfavorableduetothealveolarboneloss,makingitaquestionableabutmentforafixedpartialdenture.Theotherrestorative"choice,"asingletoothremovable"flipper"appliance,wouldhavebeenapoorsolutionduetotheamountofplastictoreplace"onemissingtooth"andtheprobablelackofpatientcompliancetowearsuchanappliancelongterm.Itwasdecidedthatthemostconservativeapproachforthispatientwouldbeto"suspend"aponticbetweentheabutmentteethusingadhesivetechnologyandfiberreinforcement.Sincetheponticwouldbelayeredinasimilarfashiontothewayaceramistwouldmakeabridge,theplanwastouseanopaciousdentinasthefirstlayerreplicatingtheinternaldentinstructureofthenaturaltooth.Next,the"universal"VITAshadewouldbelayeredovertheinitialmaterialtorecreatethe"bulk"oftheremainingdentin.Finally,anincisalshadewouldbeusedtorecreatetranslucencyintheincisalthirdofthetoothandcompletetheincisaledge.
MaterialSelectionAuniversalnanocompositeresin(Kalore[GCAmerica])waschosenasamaterialthatwouldbewellsuitedforthistask.Inrecentyears,advancesincompositeresintechnologyhavebeenlargelyonthefillersidechangesinparticlesize,particleshape,orfillertypetotrytomaximizetheaestheticpotentialofthematerialwhilemaintainingthephysicalpropertiesnecessarytoenablethematerialtowithstandthestressesofmasticatoryforcesintheoralenvironment.WithKalore,themanufacturerreportsaninnovationinmonomertechnology.ADuPontmonomer(DX511)isused,whichhasalongrigidcorewithflexiblearms.Itisbelieved,withthisnewmonomerformulation,thatthepolymerizationshrinkagechallengemaybesolvedbyremovingtheshorterchainmethacrylatematrix,providingthepotentialforreducingsuchclinicalchallengesasmarginalgapformation,microleakage,stain,andsecondarycaries
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5/20/2014 The Direct Composite Bridge: Still a Unique Solution for Some Clinical Situations
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whileenhancingaestheticsandwearresistance.
Figure1.Afacialpreoperativeviewofa76yearoldfemalepatientwhopresentedwithamissingleftmandibularlateralincisor.
Figure2.ThisisaphotooftheKaloreShadeGuide(GCAmerica).Itsuniquedesignallowsforindividualshadeselectionin3differentopacities,andgivesthe"recipe"forlayeringtocreatethe"VitaSpectum"ofshadesfordifficultanteriorshadematches.
Figure3.Theshadesofthenanocompositeresin(Kalore[GCAmerica])werechosenforthispatient'srestoration.
Figure4.Thisphotodemonstratesthedifferenceinthe"new"KaloreUnitip(top)fromtheoriginaldesign(bottom).Notethedifferenceinthesizeofthetipopeningthatallowsforeasierextrusionofthenanocompositematerial.
Kalorealsohasauniqueshadingsystemthatoffersopaque,universal,andtranslucentshadingthatprovidesthedentisttheopportunityto"stack"acompositeresininthesamefashionasalabtechniciantocreateinternalbeautyandlifelikeaesthetics.Mostofthetime,theuniversalshadealonewillprovideexcellentshadeblendingwithnaturaltoothstructure.Thesimplifiedshadesystemoffersthedentistthe"recipe"toproducebeautifullyaestheticanteriorrestorationsforexample,inClassIVsituations,neutralizingthedarknessoftheoralcavitypresentsachallengeforeventhemostexperiencedclinician.Figure2showstheshadeguideofcorrespondinghuesandopacitiesrequiredtorecreate"nature'sblueprint"incompositeresin.Notealsothatthereare3cervicalshades:cervical(CV),cervicaldark(CVD),andcervicaltranslucent(CVT).Inthiscase,theseshadeswillbehelpfultorecreatetheexposedrootstructureseenontheadjacentnaturalteeth(Figure3).Inaddition,foreaseofuse,themanufacturerrecentlyimprovedtheextrusionofthisnoncompositematerialbyslightlyincreasingthesizeoftheunitip(Figure4)andslightlydecreasingthefillercontent.Thecombinedeffectisimprovedflow.Thistinydecreaseinfillercontentalsohadnoeffectonotherphysicalproperties.
ClinicalProtocolAfterthepatienthadbeengivenlocalanesthesia,horizontalgrooveswerepreparedintothelingualsurfacesoftheabutmentteeth,teethNos.22and24(Figure5).Thesegrooveswereplacedjustincisaltothecingulumareasofthelingualsurface,atadepthofabout1.0to1.5mm.Next,aselfetchingadhesive(GaenialBond[GCAmerica])wasappliedtothepreparedsurfaces,boththeenamelanddentin,andleftundisturbedfor10seconds(Figures6and7).Afterairthinningandevaporationofthesolvent,theadhesivewaslightcuredfor20seconds(Figure8).Apieceof1.0mmdiameterfiberglassribbon(Connect[Kerr])wascutandfitintotheslotsonthelingualsurfacesspanningacrosstheedentulousarea.Thisribbonshouldfitperfectlyintotheslot,notbeingtoolongthatthefibersaredoubledupandcompletelyobliteratingthespace,ornotsoshortthatthereisnotenoughlengthtotheribbontoprovidemechanicalrigidity.Oncethefitwasverified,aflowablecompositeresin(GaenialUniversalFlo[GCAmerica])wasplacedintotheslotto"wet"theinternalsurfaceofthepreparationstheribbonwasplacedusingacottonforceps,tofulldepth,andthentheribbonwascompletelycoveredwithGaenialBondtothecavosurfacemargins(Figures9and10).Next,theflowablecompositewaslightcuredfor20seconds(Figure11).
Figure5.Alingualviewshowstheabutmentteeththatwereprepared
Figure6.GaenialBond(GCAmerica),aseventhgenerationself
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5/20/2014 The Direct Composite Bridge: Still a Unique Solution for Some Clinical Situations
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withaslotcutinthelingualsurfacestocontaintheimbeddedfiberreinforcementtoprovidethe"framework"tofreehandthenanocompositeresinponticintheedentulousspace.
etchingbondingagent,wasdispensedintoadisposablemixingwell.
Figure7.Thebondingagentwasappliedtoallpreparedsurfacesusingamicrobrush.
Figure8.Thebondingagentwasthenlightcuredfor20seconds.
Figure9.Theflowablecompositeresin(GaenialUniversalFlo)withanapplicatortipappliedtotheendofthesyringethelong,narrowcannulamakespreciseplacementveryeasy.
Figure10.GaenialUniversalFlowassyringedintothepreparationsinathincoat.Thefiberreinforcementwasplacedintothefloorofthepreparations,andtheywerethenfilledwithflowablecompositetothecavosurfacemarginsandlightcured.
Figure11.Next,theflowablecompositewasplacedonthestabilizedfiberglassfiber(Connect[Kerr])towetthesurfacebetweentheteethwithcompositeresin.Itwasthenlightcuredfor20seconds.
Figure12.Thisfacialviewshowsthecompositereinforcedfiberglassreinforcementinplace.
Figure13.KaloreAO3wasusedtobeginbuildingaponticonthefiberbetweentheabutmentteeth.
Figure14.Aplasticinstrument(GoldsteinFlexithinMini4[HuFriedy])wasusedforshapingA3.5asthebasedentinforthepontic.KaloreCV(B5)wasusedtosimulatearootformsimilartotheadjacentteeth.
Oncethefiberwasanchoredinplace,anadditionallayerofflowablecompositewasplacedtocompletelycovertheexposedfiber
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5/20/2014 The Direct Composite Bridge: Still a Unique Solution for Some Clinical Situations
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andeffectively"splint"theabutmentteethtogether(Figure12).Thenextstepwastobeginto"sculptatooth"onthefiber.ThefirstlayeroftheponticwassculptedandcureddirectlytothefiberusingKaloreA3opaquecomposite(Figure13).Noticeabout2mmofspacewasleftincisallyforadditionofanincisalshadelater.Also,spacewasleftinthecervicalareaforsimulationoftherootsurfacewithcervicalshades.
Oncecompleted,thecervicalareawassculptedwithKaloreCV,whileuniversalshadeA3.5wasaddedtobuildfacialcontourtotheinitialopaqueincrementgivingthe"illusion"ofdepth(Figure14).AGoldsteinFlexithinMini4(HuFriedy)wasthenusedtosculptthenanocompositeresin.Afinesablebrush(KeystoneNo.4Flat[PattersonDental])wasusedtoaddtextureandrefinecontour(Figure15).TheincisaledgewasaddedusingKaloreDarkTranslucent(DT)(Figure16),blendedwiththesablebrush,andthenlightcuredfor20seconds.Finalcontourwasaccomplishedusingan8flutedcompositefinishingdiamond(ETNo.9[BrasselerUSA]),followedbyflexiblediscs(Optidisc[Kerr]).Notethe"backside"ofthedischastheabrasiveonitsoitcanbeflexedacrosstheproximalfaciallineanglestocreate"reflectiveangles"andpropertriangularformforthefacialsurfaceofthismandibularincisor(Figure17).Thepolishingphaseisstatedusingarubberabrasivepolishingdisc(JiffyPolishers[UltradentProducts])(Figure18).Theedgeoftherubberdiscwasorientedvertically,thenmovedacrossthefacialsurfaceofthecompositeinthehorizontaldirectiontocreatesurfacetextureandcreatenaturalluster.Thefinallusteronthesurfaceoftherestorationwascreatedusingapolishingcupwithimpregnatedbristles(Occlubrush[Kerr])(Figure19).Figures20to23arefinishedviewsofthecompleteddirectcompositebridgereplacingtoothNo.23.Insomecases,theclinicianmaywanttouseagingivacoloredcompositeifso,onecoulduseGradiaGum(GCAmerica).
Figure15.Asablebrush(KeystoneNo.4Flat[PattersonDental])wasusedtocreatesurfacetextureandrefineanatomicform.
Figure16.KaloreDTwasusedtocreateincisaltranslucency.
Figure17.Afterinitialcontouringwithan8flutedcarbidecompositefinishingbur,contouringwascompletedusingabrasivediscs(Optidisc[Kerr]).
Figure18.Ayellowdisc(JiffyDisc[UltradentProducts])wasthenusedtopolishthelabialsurface,andtorefinethereflectiveanglesandsurfacetexture.
Figure19.Apolishingcupwithimpregnatedbristles(Occlubrush[Kerr])wasusedasthefinalinstrumenttocreatesurfacelusterandshine.
Figure20.Facialviewofthecompletedfiberreinforceddirectnanocompositeresinbridge.
Figure21.Patientsmilingwiththe Figure22.Onemonthpostoperative
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5/20/2014 The Direct Composite Bridge: Still a Unique Solution for Some Clinical Situations
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completeddirectcompositebridge.Notethenaturalappearanceoftherestoration,ascomparedtothepatient'snaturalteeth.
photoofthedirectcompositebridge.Notethebeautyofthenaturalaestheticsthatwascreated.
Figure23.Acloseupviewfromthefacialaspectofthedirectcompositepontic.Thecervicalshadecreatedanaturalappearingrootformthatsimulatedthepatient'snaturalteeth.
CONCLUSIONAtechniquehasbeendemonstratedusingadirectuniversalnanocompositeresintoconstructafiberreinforced3unitfixedbridge.Itisimportanttoconsiderthedirectresinrestorativeoptionforasingletoothedentulismwhenclinicalandeconomicalcircumstancesprecludeanimplantorfixedpartialdentureasatreatmentchoice.Thedirectcompositebridgecanbeaveryaestheticandfunctioningdentalrestorationwhenusedintheappropriateclinicalcircumstance.Itisimportanttoalsorememberthatifthisapplianceshouldeverrequirerepairorreplacement,itismucheasiertodosincethesubstrateiscompositeratherthanporcelain.Fortheclinicalpatientpresentedinthisarticle,asformanylikeher,thedirectcompositebridgewillsatisfyherrestorativeneedforyearstocome!
Dr.LowegraduatedmagnacumlaudefromLoyolaUniversitySchoolofDentistryin1982andservedthereasanassistantprofessorinoperativedentistryuntilitsclosurein1993.SinceJanuaryof2000,hehasbeeninprivatepracticeinCharlotte,NC.HereceivedFellowshipsintheAGD,InternationalCollegeofDentists,AcademyofDentistryInternational,andAmericanCollegeofDentists,andreceivedthe2004GordonChristensenOutstandingLecturersAward.In2005,hewasawardedDiplomatestatusontheAmericanBoardofAestheticDentistry.Helecturesinternationally,publishesonaestheticandrestorativedentistry,andisaclinicalevaluatorofmaterialsandproducts.Hecanbereachedat(704)[email protected].
Disclosure:Dr.LowelecturesforKerrandGCAmerica.
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