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5/20/2014 The Direct Composite Bridge: Still a Unique Solution for Some Clinical Situations

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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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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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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



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



DEEPTHIPR (26.06.2013(09:46:12))

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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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