W hen called upon by to replace a missing tooth on apatient who has an abhorrence to a removableprosthesis, dentists have historically only had a few

options: fixed partial dentures (bridges) and implants. Bothpresent considerable advantages over no treatment (tx), yetnecessarily imply considerable commitment on the part of thepatient.

First, a willingness to allow relatively extensive treatment isnecessary. Even the most conservative bonded modalities requireimpressions and a laboratory phase, also provisionalization or awillingness to “go without” while the prosthesis is fabricated;more conventional bridges and implant dentistry sometimes evenrequiring preliminary analyses, pre-prosthetic surgical tx, wax-ups, and/or try-ins in addition to impressions and some time.

Second, there are financial considerations. All the work involvedin providing a patient with an excellent replacement tooth hasattendant costs. Offering a third-party financial program, such asCare Credit, often increases the patient’s willingness to moveforward with the tx plan.

Third, there is a commitment to comprehensive tx of theircurrent dental condition. This can be most daunting to dentists,especially in a patient with little or no appreciation for theirdiagnoses and prognosis. The ultimate course of tx hinges upon apatient who can trust the doctor to provide for them what is intheir best interest. Frequently, these initial contacts with a patient,

in addressing their most pressing concerns,can evolve in to a relationship wherein thepatient finally comes to a point that allowshim or her to give the dentist both his trustand financial approval.

For a patient who has lost a tooth, and whoadditionally may not have a good prognosisfor adjacent teeth, making a commitment tosuch considerable time, effort and monetaryoutlay may be difficult to swallow. Even ifthey are willing to spend some time andmoney, our list of options has been short interms of what we as dentists can offer thepatient. Usually we tell them about atransitional removable partial denture (a“flipper”) and attempt, through education,to steer them towards ultimatelyconsidering comprehensive evaluation andtx planning of their entire dental condition,in the hope that one day they might choosethat course of tx over an ipso facto

commitment to complete edentulism. But, for the patient whofinds a flipper distasteful or unacceptable, we have simply beenforced to take a stance wherein we, as practitioners, appear to besaying, “it’s my way or the highway,” offering the definitive routewith all its attendant commitments. Not an enviable position forcaregivers, particularly ones who are constantly swimmingupstream in a battle against patient phobias, mediamisinformation and general ignorance about dentistry!

Recent application of sound engineering and metallurgical

TOWNIE CLINICAL PRESENTATION

BY: Marshall White, DMDOfficial DentalTown Townie

Photo #1: The EastFlex components. On the left is the EF-100 suitable for molarsand larger spans. In the center is the EF-60 used for the Monodont bridge in thiscase. On the right is the ‘Tie-Bow’ component, used for intra-coronal splinting.

Photo #2: Pre-op view of the lower anterior, after removalof the failed composite splint and gross scaling.

32 DentalTown Magazine February 2002

How to use the Monodont as a cost-effective alternative bridgeStainless steel minimally invasive component system has multiple single tooth applications

principles has produced a modality that,though it may serve only a segment of thepartially edentulous patient population,creates an opportunity for dentists topresent a long-term fixed transitionalprosthetic option to patients who aremissing a tooth. Another option howeverdoes exist that allows a patient to steer amiddle course in fulfilling their currentdesire for a fixed prosthesis while makingno compromises to their future, moredefinitive, tx.

Monodont, a patented stainless steelcomponent manufactured by EastFlexCorporation (available exclusively throughBenco Dental–www.benco.com) permitsthe fabrication of a fixed, single toothprosthesis using a premium denture toothbonded intra-coronally to the two teethadjacent to the space. The componentuses techniques currently ubiquitous indental offices and labs throughout theindustrialized world. In addition toobtaining U.S. patents, EastFlex (a smallstartup founded by a couple of dentist-inventors) recently obtained FDARegistration for this component as a ClassI Dental Device, as well as for a similarlydesigned component for use inperiodontal splinting.

Presentation of the CaseA 48-year old male presented with a chiefcomplaint of “loose bottom front teeth.”He currently had a full maxillary dentureand bilateral mandibular fixed prosthesesin gold to replace the mandibular firstmolars, abutted on the second molars andsecond bicuspids. Originally there wereacrylic facings on the bridges, nowvirtually worn away. This tx had beenprovided some 25 years earlier, the patienthaving only sought intermittentpreventive care, as he “had no need foranything more and nothing ever hurt.”The mandibular canines and incisors hadno restorations. Oral health was fair togood, though the patient stated apreference for toothpicks over floss.

Clinical and radiographic examinationrevealed ADA Type II-III periodontitis,with generalized bone loss, most severe inthe incisors. Teeth #’s 23, 25, and 26 hadCl. 2 mobility, #24 had Cl. 3. No carieswere evident. OCS was negative save for

mild leukoplakia on the floor of themouth and a nodule on the anteriordorsum of the tongue, both of whichproved to be negative through an OralCDx Brush Biopsy. TMJ’s were bothnormal and symptomatic.

Despite our desire to provide a reline orrefabrication of the maxillary denture, thepatient was quite comfortable in its fit, itsappearance and his ability to chew. Herefused consent to replace or reline it.

After discussion and many questions, aplan was presented to initially includeRPC and provisional periodontal splintingof teeth #’s 22-27 in accordance with thepatient’s wishes. The ultimate solution tobe a conventional fixed prosthesis #’s 22-27. Gross debridement of calculus andsplinting of #’s 22-27 was performed inone visit and following a review of currentOHI, the patient re-appointed for RPC.We also discussed the failure of his oldbridges, the need to address theuntenability of the lower incisors andseveral other options. The patientcontinually expressed his absolute desireto avoid a lower removable prosthesis.

As is so often the case, this patient hadwork scheduling problems that requiredthe cancellation of appointments toundergo tx of his periodontitis. Thesplinting having been performed and his

chief complaint resolved, he relates withcandor that he felt little need for more txanyway.

Our next meeting came as he presentedsome year-and-a-half later. He related thata month or so earlier tooth number 24had popped loose from the splint andavulsed. We again discussed his options,now limited to the choices of a “flipper,”or definitive anterior tx with a fixedprosthesis including the canines asabutments. The patient finally admittedthat the cost of definitive tx was a realobstacle for him. He indicated he wouldbe more than willing to take advantage offinancing options available at our office,and for now preferred something fixed buttransitional.

An alternative fixed transitional modalitywas presented to him, involving use of aBioform IPN denture tooth fromDentsply TruByte in addition to the use ofa EastFlex pontic-support-component toreplace #24 (a “Monodont” bridge).EastFlex intracornonal periodontal splintcomponents were used to facilitateconservative intracoronal splinting of #’s

February 2002 DentalTown Magazine 33

Photo #3: Tie-Bow splintingcomponents have been placed andbonded at non-pontine contact pointsfrom #’s 22-27; preps of #23 and#25 to receive Monodont bridge.

Photo #4: The Monodont bridge hasbeen oriented and tacked in placewith Build-It FR.

TOWNIE CLINICAL PRESENTATION

22-27 (“Tie-Bows”). This would be about 25% the cost ofdefinitive tx (e.g.: a conventional fixed prosthesis used to replaceall the periodontally compromised lower incisors with the caninesas abutments.) After discussion of the fact that the transitionalmodality would be merely a way to transition him ultimately intoa) the more definitive tx (b) conventional fixed bridge, (c) aremovable partial denture, or (d) edentulism, the patient chosethis transitional option. Study models were made and the patientscheduled for this course of tx.

A denture tooth was ordered in a shade and mould to fit his spaceand an appropriate EastFlex component chosen. The lower studymodel was prepped to approximate the location of thepreparations on the canines and incisors to receive the prosthesisas well as the Tie-Bow intra-coronal splinting components. Thebridge component was sandblasted and the bifid wings tacked inplace on the model with wax. After adjustment and modificationof the lingual of the IPN tooth to fit over and around thecomponent and in a manner wherein the tooth would be properlypositioned between teeth #’s 23 & 25, the tooth was bonded tothe component with Pro-Tech U-Bar and removed from themodel for finishing. Eastflex maintains that the use of Pro-Tech U-Bar is critical to success and the strength of the prosthesis. Please notethat in this instance, the tooth was set with its incisal edge about1.5 mm higher than those of #’s 23 & 25, thus allowing itsreduction in the mouth for aesthetics and occlusion at placement.Subtleties of shape and contour were performed with acrylic bursto confirm an excellent fit within the space, normal-appearingembrasures and good inferior contact with the gingiva thusensuring acceptable phonetic function. The exposed bifid wingsof the bridge, and the splinting components in their entirety, weremicro-etched, cleaned and primed with Alloy Primer(www.jmoritausa.com) Now we were ready to go to the mouth.

The patient refused anaesthesia as was his habit, preparations wereplaced in the approximate spots determined on the study modelusing an hourglass-shaped Two-Striper diamond bur #1250, andthe bridge and splinting components tried in. The preparationsare most retentive when they have walls that converge lingually,much as was once taught when using non-bonded restoratives to

restore lingual-accessed Cl. III lesions and to a depth of 1.5-3.0mm as appropriate. The incisal and gingival margins of thepreparations for the bridge were placed at distances measuredfrom the incisal edges of their respective abutment teeth with acommon periodontal probe and taken from the study model. Thebridge was tried in as necessary to allow fine-tuning of thepreparations for correct placement. This was not necessary for thesplinting components, as they were placed at the contact points of

Monodont bridge technique

Photo #5: The Monodont bridge from the facial, prior toadjustments.

34 DentalTown Magazine February 2002

Photo #6: Facial view of prosthesis, after finishing.

continued page 36

adjacent teeth. Alternatively, a thin suck-down shim may bemade over the study model and used as a stint to locate the spotson the abutments at preparation.

Clearfil SE bond (Kuraray) was placed as directed on the cleanedand isolated preparations and cured. A small amount of Flow-ItALC (www.jeneric.com/dental) was placed upon the facial wallsof each of the preparations for the splinting components ONLYand these components then carried to the teeth and manipulatedinto place using an explorer. Once these splinting componentswere correctly positioned, they were briefly cured to tack them inplace. The components were then individually covered withFlow-It ALC and the preparations filled. Following confirmationunder loupes of the correct shape of each splinted embrasure forboth aesthetics and cleansability using an explorer and floss asneeded, the non-slumping Flow-It ALC was cured completelyfrom lingual then facial aspects. This was repeated for eachembrasure.

Finally, a small amount of dual-cured tooth colored Build-It FR(www.jeneric.com/dental/) was placed upon the facial walls of thepreparations for the bridge. Once placed in proper position thesewere briefly cured to tack in the bridge. Using loupes and againwith utmost care to facilitate aesthetic and cleansable embrasures,the bifid wings of the bridge were covered with Build-It FR andfully light-cured from lingual, incisal and facial aspects.

All embrasures were adjusted and finished under loupes usingfinishing burs, strips and diamonds as necessary, the incisal edgeof the pontic #24 was reduced and occlusion adjusted so as toallow very light contact of the pontic with opposing dentition,and the composite and denture tooth polished as needed.

DiscussionNow in the midst of an economic downturn, the ability to offera less-expensive, yet fixed alternative to conventional toothreplacement can be an adjunct to any dental practice. A newmodality, the Monodont bridge, provides a viable long-termtransitional prosthesis for patients who either desire to delay theinevitable, or who postpone more conventional fixed prostheticoptions due to monetary concerns. For a person who is properlyinformed as to its intermediate longevity, it is a modality that isboth straightforward and easily mastered, yet is surprisinglydurable, highly aesthetic and well-accepted by patients. DT

The Monodont system can be found at: Keller Laboratories,Inc. 1-800-325-3056 and Lord's Dental Studio, Inc. 1-800-821-0859.

Marshall White, DMD is a wet-gloved dentist to the commonman. In 1995, after a decade of solo and associateshippractice, he founded Optimal Dental Care, Ltd., focusingupon using the most conservative, long-lived and patient-friendly techniques. An avid nightly participant on themessage boards at www.DentalTown.com, Dr. White is a self-described "Simple Country Dentist" and a tireless advocate ofscientifically-based clinical practice. An aficionado of boththe written and spoken word, he resides on 5 acres of woodedbliss in rural Licking County, Ohio, with his wife Jennifer, their twoyoung sons and a veritable menagerie of dogs, cats and wildfauna. Dr. White welcomes any and all communication andmay be reached at (740) 344-1200, or by email atdrwhite@optimaldental.com.

Photo #8: Close up of relaxed smile.

Photo #7:Lingual view,finishedMonodont. Tooth #24 will require an extraction, due to caries beneath the

bony crest, and a communication between the canal and pdlspace. There exists a diastema between #24 and #25 of about4-5mm. Patient refuses an implant. Is it possible to Cantilever#24 off #23? associateboy, Official Townie

This situation is custom made for a Monodont procedure. ACantilever bridge won't work. Check out www.eastflex.comand click on "Monodont How To" icon or email our very ownDr. Marshall White who is becoming an expert in his ownright on this procedure.drmjlans, Official Townie

In the right situation an anterior Cantilever does work. If youare unsure and the patient insists that an implant isout of the question, a transitional partial is anotheroption. Fistula, Official Townie

Is the main use for a low-cost bridge alternative? How is this

Townies talk about otherMonodont applications

Monodont bridge technique

36 DentalTown Magazine February 2002

TOWNIE CLINICAL PRESENTATION

coded and reimbursed? Use normaldenture teeth? What about bonding of theacrylic to the tooth?rcyoungdds, Official Townie

Sand blasting and jet acrylic bonding of adenture tooth provides a pontic that canwithstand 1200 psi. Many Mondodontistsuse the direct buildup with some sort ofGMA resin. This provides an evenstronger bond. Due to glycidal knottingby the chronium static charge on freshlyetched steel. These Monodonts are madeof biocompatible stainless steel that ismalleable. It can be bent 180 deg. Smalllower anteriors are best done using thedirect method. Preps are best kept in thecontact areas. They hold up to normal useand wear and tear. Above 1200 psi theywill pop out. They are much easier torepair than MD bridges. They can bemodified easier too.daniel, Official Townie

Your description sounds like the diastemawill cause the post-extraction spacebetween #'s 23 & 25 to be quite a bitwider than say the current width of #25?

If so, and you want to re-create thatdiastema by doing a Cantilever bridge, I'dsure consider using both #'s 22 & 23 todouble abut. I think that if you'rescrupulous about your occlusion youcould get away with a single-abutmentscenario off # 23, but preventing rotationof that abutment may be the real challengelong-term due to mesial drift/crowdingphenomena. If that diastema's been thereforever, it may not be a problem, butdouble-abutting will pretty much assurebetter stability with respect to that issue.

Also, the diameter of these lower incisorsis narrowest at the cervix in a mesio-distaldimension, and any single-abuttedCantilever bridge is what I like to call a"perfect tooth fracturing device." Donewith a re-creation of that diastema, there isno mesial contact to help give the bridgeresistance form to incisive forces. If I'mmisreading the size of that space, and it isactually very close in width to #25, then aMonodont is definitely an option. Thebeauty of this option is its use as aconservative, yet fixed modality, and one

with neither the financial nor timecommitment necessary for a conventionalmodality. Its design is simple, yet itsphysics are elegant.

Yes, it is useful to think of this modality asa lower cost alternative to a conventionalfixed prosthesis, but there are alsoapplications when abutment teeth havequestionable prognoses and a patientabsolutely refuses something removable.In scenarios, where for monetary,emotional, or any number of other ficklereasons a patient refuses to move forwardwith more definitive treatment, yet ISwilling to spend some money and whilstdemanding some kind of a transitionalmodality to afford them a fixed solution toa single space. Hmm, transitional?EastFlex maintains there are a lot of thesein great shape and functioning after 6+years...correct me if I'm wrong, but Ibelieve that's better than the weighted-

mean lifespan of an amalgam. marshall_white_dmd,Official Townie

MESSAGE BOARDS

February 2002 DentalTown Magazine 37