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Prosthodontics

Authors: Dr. Manesh Lahori, Dr. Manpreet Kaur, Dr. Charan Singh

Introduction

Treatment planning for a case of generalized chronic periodontitis that has resulted in pathological migration and diastema formation in maxillary and mandibular anterior is challenging. The periodontally weakened teeth often drift to a position that is esthetically unpleasant as well as functionally unstable. The altered forces acting on teeth worsen the migration. Many of these patients want the correction of diastema and an esthetically pleasant look but are not ready to sacrifice the periodontally hopeless teeth. The ultimate goal of successful management of mobile teeth is to restore function and comfort by establishing a stable occlusion that promotes tooth retention and the maintenance of periodontal health. Tooth loss in the anterior region is a very traumatic experience to the patient. Their primary concern is the compromised facial esthetics that accompanies tooth extraction. Immediate esthetic replacement of the tooth will be required, and this can be in the form of temporary, semi-permanent or permanent treatment modalities. Patients always desire secure, fixed tooth replacement prosthesis.

Fig. 1 Pre operative view on smiling Fig. 2 Pre operative intraoral view
Fig. 1 Pre operative view on smiling Fig. 2 Pre operative intraoral view
 
Fig. 3a,b Diagnostic casts showing rotated and supra-erupted central incisor tooth.
  Fig. 2 Pre operative intraoral view
Fig. 3a,b Diagnostic casts showing rotated and supra-erupted central incisor tooth.
FIBER REINFORCED SPLINT:

Previous attempts at chairside tooth replacement involved the use of pontics derived from extracted teeth, acrylic resin denture teeth with or without lingual wire reinforcements and resin composites. A new class of materials designed for reinforcing dental resins has been introduced. These products are fiber reinforcing ropes, braids, ribbons, and bundled fibers. These fibers upon embedding into the resin provide for an increase in physical properties and more durable tooth stabilization. There have been case reports documenting the use of natural tooth pontic along with fiber reinforced composite.

4a,b Central incisor sliced from the diagnostic cast. 4a,b Central incisor sliced from the diagnostic cast.
4a,b Central incisor sliced from the diagnostic cast.

The use of gas plasma treated woven polyethylene fabric to reinforce composite resin has been tried and found to be effective. We have described a case in which a periodontally hopeless tooth was extracted, and the edentulous space replaced using the crown of the extracted tooth and splinted to the neighboring teeth with fiber reinforced composite resin. This treatment modality has the advantage of being flexible to include any other teeth that may be lost in future unlike the splinting using fixed partial denture (FPD) and has been reported in earlier studies. It improves the comfort level of the patient by stabilizing the mobile teeth.

4a,b Central incisor sliced from the diagnostic cast. 4a,b Central incisor sliced from the diagnostic cast.
Fig.5 Atraumatic extraction of central incisor Fig.6 Extracted Incisor
Case Report

A 64-year-old female patient reported with a chief complaint of unaesthetic, rotated, supraerupted and grade III mobile maxillary left central incisor. It was planned to extract the tooth for replacement according to patient’s main concern. Adjacent teeth showed recession, bone loss, but patient was unwilling to consider extraction at the present stage.

Fig 7. Preparation of groove of 0.75 mm depth.
Fig 8. Acid etching for 15 seconds
Fig 7. Preparation of groove of 0.75 mm depth. Fig 8. Acid etching for 15 seconds
Treatment plan

The patient was advised to undergo supra and subgingival scaling and was reviewed 2 weeks later. Response of the tissues to periodontal therapy after scaling was good. There was good compliance with the oral hygiene instructions.

Fig 9. Application of bonding agent followed by light curing Fig 10. Extracted central incisor is secured with fibre.
Fig 9. Application of bonding agent followed by light curing Fig 10. Extracted central incisor is secured with fibre.

The maxillary left central incisor was having hopeless periodontal prognosis and needed extraction. Various treatment options available were removable partial denture (RPD), FPD or splinting with natural teeth pontic. The abutment teeth available were periodontally weak. RPD with supporting clasps on the abutment teeth would have made them weaker. An FPD using two abutments on either side was a viable treatment option. It was not acceptable to the patient due to high expense involved. Splinting of the maxillary left central incisor using fiber splint and using the extracted natural tooth as pontic in the splint was considered. This option had the advantage of stabilizing periodontally weak abutments. The patient found the treatment plan appealing because of the comparative low cost and possibility of having a fixed prosthesis in one appointment.

Treatment

Diagnostic impressions were made at the first appointment and mounted on the articulator. On the articulator, the upper left central incisor was cut at the cervical portion using a disc. The proximal splicing of the tooth was done as diagnostic preparation and placed in the edentulous area to evaluate the fit and esthetics of the tooth.

Fig 11. Postoperative intraoral view
Fig 11. Postoperative intraoral view

On second appointment, the maxillary left central incisor was extracted atraumatically under local anesthesia. The extracted tooth was scaled and polished thoroughly to remove all the deposits on them and kept in betadiene. The extracted tooth was trimmed so as to rest passively on the edentulous ridge in maxillary central incisor area. The tooth was sealed with composite in apical area. The tooth was prepared by making a groove of 0.75 mm depth in the lingual middle 1/3rd area with a round abrasive point and arranged on the edentulous ridge of the study model. The pontic was passively touching the edentulous ridge and had no incisal contact point with opposing teeth. The adjacent teeth were marked and grooved to a depth of 0.75 mm in the middle third of lingual aspect with round abrasive point.

maxillary lateral incisors, right central incisor and canines were acid etched for 15 s. After application of bonding agent and curing with LED curing unit, flowable composite was placed in the lingual groove area.

The fiber splint was immersed in the flowable composite and cured one tooth at a time. The trimmed natural tooth pontic was attached to the fiber splint.

covered with composite resin and cured, taking care to see that the ends of the fiber are covered. This was followed by a thorough finishing and polishing of the restoration with enhance polishing system.

eliminate any occlusal contact on the splint. The patient was trained to use an interdental brush to keep the splinted teeth clean. She was put on supportive periodontal therapy, that is, maintenance recall schedule.

Fig 12a, 12b. Patient’s preoperative and postoperative smile view
Fig 12a, 12b. Patient’s preoperative and postoperative smile view
Fig 12a, 12b. Patient’s preoperative and postoperative smile view Fig 12a, 12b. Patient’s preoperative and postoperative smile view
Discussion

Tooth splinting may be indicated for individual mobile teeth as well as for an entire dentition in cases where FPD and implant therapy is not a viable alternative. These can be successfully managed by retaining the tooth through more conservative methods like splinting. The overall objective of splinting is to create an environment where the tooth movement can be contained within physiological limits, thereby improving patient comfort and the restoration of function. Provisional splints are indicated for a limited time period. They will provide information as to whether teeth stabilization will have benefits before planning comprehensive treatment. Examples include ligature wires, nightguards, and interim fixed prosthesis, composite resin splints (with or without wire and fiber support). Definitive splints are placed only after completion of periodontal therapy and achievement of occlusal stability. They are intended to increase functional stability and improve esthetics on a long term basis.

When a periodontally compromised tooth in the visible or esthetic zone is planned for

extraction, the primary concern of the patient is of esthetics. There are various options which can be given to the patient like acrylic RPDs or the extracted natural teeth can be used as a pontic. The acrylic RPDs are bulky and uncomfortable to the patient. Prefabricated denture teeth can be used as a pontic when bonded to the adjacent teeth. They present challenges with regard to color matching, size and shape matching. They may require substantial modifications to achieve an acceptable appearance. Implant supported prostheses may not be the best option due to severe generalized soft and hard tissue loss.

Using the natural tooth as a pontic offers the benefits of being the right shape, size, and color. Moreover, the patient gets an added boost on seeing his own tooth being used instead of an artificial one. These natural tooth pontics can be splinted to the adjacent teeth by composite resins, with or without wire reinforcement. Fibre used hereis Interlig by Angelus, Brazil is a braided, intertwined glass fiber impregnated with dental resin. The use of a light cure fibre leads to very low friction coefficient, high wear resistance, and high impact strength. It is woven into a ribbon for dental application.

The reinforcing capacity of fibers is dependent on their adhesion to the resin, orientation of the fibers and their impregnation with the resin. The advantages of fiber reinforced composite material for periodontal splinting include:

  1. Ease of application with minimal tooth preparation.
  2. Low to moderate cost as compared to fixed prostheses.
  3. Can easily be removed when splinting is no longer considered necessary.
  4. Easily repaired in case of failure through re-bonding and re-application of material.
  5. Ease of accommodation of oral hygiene practices by the patient.

The most common type of failure seen is the exposure of the ends of the fiber and debonding of the fiber from the tooth. This is especially seen when we are replacing many teeth and stabilizing with fiber. The lingual grooving to a depth of 0.75 mm on the abutment teeth and the pontics enable the fiber to be placed perfectly within the tooth surface without any protruding area. Placing a flowable composite and then embedding the fiber in that helps the integration of the resin with the fiber. Trimming the pontic teeth is important so that there is no pressure on the edentulous ridge, and oral hygiene maintenance can be done by the patient. It must be emphasized to the patient to avoid heavy biting pressure on the splinted teeth. All eccentric movements should be recorded and relieved. In case of accidental trauma to that area and loss of the pontic, the option of using an artificial denture tooth can be used. Long-term follow-up is essential to evaluate the fiber reinforced resin splint as an alternative to the conventional partial denture or the fixed prostheses.

Conclusion

Tooth mobility alone does not necessarily indicate the existence of an underlying pathologic condition. The etiology of the mobility should be established first. Following this, splinting of teeth to improve the periodontal stability can be done. The teeth can be splinted using provisional or definitive modalities, and the diastema occurring can be managed using denture teeth or patients own extracted teeth. Using a natural tooth pontic is an excellent, acceptable treatment option for situations in which anterior teeth need to be removed and reflects the dentist’s concern for the patient’s compromised facial esthetics. Using a fiber-reinforced composite resin as a splint is a conservative, esthetic and cost effective method for replacement of mobile or missing anterior. It can be adapted for use with patient’s own natural mobile tooth which is extracted and used as pontic or it can be used with artificial denture teeth which act as pontics.

References
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