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Enamel-bonded immediate tooth replacement
Enamel-bonded replacement Bernard Newurk,
Rakow,
D.D.S.,*
immediate and Ernest
I. Light,
tooth
D.D.S.**
N. J.
A
significant problem which faces the orthodontist from time to time is that of the patient who suffers the sudden loss of an anterior tooth. All too often, it seems, this occurs just as highly favorable orthodontic treatment is being concluded. Most often the course of such a situation is traumatic evulsion or injury requiring extraction of the tooth. Regardless of the cause, it is an emergency situation and calls for immediate treatment. It is necessary for the lost tooth to be replaced to maintain arch form as well as to provide esthetic and psychological support to the patient. Often after active orthodontic treatment stabilizing appliances are worn for a period of time. At this stage immediate tooth replacement is necessary to support a functional retainer and prevent collapse of the case. With the loss of an anterior tooth, its temporary replacement is often accomplished by banding the adjacent teeth to support a pontic. The cosmetic result of such an appliance is highly undesirable. Should the patient be using a removable prosthesis, such as a Hawley retainer, a replacement can be added to it. This automatically limits its potential activity and requires the patient to be wedded to it, even if its use had previously been necessary only during the evening hours. In addition, the effect of a tissue-bearing prosthesis that is in constant contact with the soft interproximal tissues frequently results in a gingivitis and a loss of supporting bone structure. Also, the fastidious person has an ongoing problem maintaining good oral hygiene, especially if meals are taken in public restaurants. The discomfort experienced from entrapped particles of food and the taste and odor of the end products of putrefaction are a constant challenge. Among the many potential uses of the enamel-bonding technique, the luting or bonding’-” of single and multiple4 pontics has proved clinically successful. In vitro studies have corroborated these findings by ascertaining that the applied forces required to dislodge an anterior pontic is far greater than the forces normally experienced in mastication.” This method of immediate replacement of a missing anterior tooth thus can now be included as an alternative procedure in applicable cases. It has the advantage of being placed as soon as a dry field can be maintained following elimination of the tooth, and it is a chairside procedure, it is a reversible technique, it does From the Department of Operative Jersey Dental School. *Associate Professor. **Professor and Chairman.
Dentistry,
College
of Medicine
0002-9416/78/100430+05$00.50/0
and Dentistry
of New Jersey,
New
&?I 1978 The C. V. Mosby Co.
Volume 74 Number 4
Enamel-bonded
immediate
tooth replacement
431
F&J. 1. A, Furiously f&ctured devitafized, discokxed tooth with soWissue abscess discernible over the labial gingiva resulting from two longitudinal root fractures. 8, Longitudinal root fracture as seen following extraction. C, Immediate replacement, following extraction, by enamel bonding of an acryfic denture tooth to the adjacent teeth.
Fig. 2. A, Hawley retainer remains functional following replacement of the left centrai incisor. B, Labial view shows gingival recession 3 weeks following immediate replacement with an acrylic artificial tooth.
not interfere with any functional retainers, it can be replaced if it should fail, it can be accomplished painlessly and without elimination of any surrounding tooth structure, it is sanitary, and it is esthetic. The insertion of a prosthesis with such attributes should be positively considered to effectively restore a patient to emotional stability following the sudden loss of a tooth and permit the orthodontist to continue treatment without interruption. The accompanying illustrations show the treatment of a fractured, markedly discolored upper right central incisor in a 17-year-old girl. The recommending dentist had indicated that it was a devitalized tooth which had been treated many years ago. He had suggested to the patient that a labial surface veneer overlay, using the enamel bonding technique, could effectively restore the harmonious color relationship with the adjacent teeth and restore the anatomic contour. At the appointed visit the patient presented with a large labial swelling extending from the free margin of the gingiva about 6 mm. apically (Fig. 1, A). The patient waS aware of the condition, which elicited no pain. She revealed that it first became apparent about 36 hours previously. Upon probing of the gingivolingual tooth surface, a loose segment of tooth was noted. Roentgenograms revealed a longitudinal fracture extending to the apex and a periapical abscess. The patient was therefore informed that the tooth would have to be extracted.
Am. .I. Orthml. October 1978
432
Rtrkm,
Fig. 3. gingival Tin foil view of
A, Proximal view reveals marked gingival recession 3 weeks following extraction. B, To restore contact, a mortise form preparation was placed into the gingival ridge lap of the acrylic tooth. was burnished over the gingiva prior to the insertion of composite filling restorative. C, Labial repaired ridge. Lap restoring gingival adaptation precludes food stagnation.
trrul
Light
AS is understandable, the loss of an anterior tooth, especially in a young girl, is a traumatic experience and its immediate replacement is fundamental in placating the patient’s distress. To further complicate the case, the patient was wearing a Hawley retainer at night following the recent completion of orthodontic treatment. We therefore elected to use the enamel-bonding technique to lute a pontic to the adjacent teeth following removal of the fractured tooth. This is now an accepted procedure which other clinicians have also used to replace one to four pontics, although not necessarily as an immediate prosthesis. The treatment was performed at the New Jersey Dental School and the patient was referred to the Oral Surgery Department for extraction of the incisor (Fig. 1, B). Approximately 90 minutes later, following the initial clotting and with the cessation of bleeding from the socket, the adjacent teeth were prepared for enamel bonding by thorough cleaning, washing, drying, etching, flushing, and drying. An acrylic denture tooth was contoured to fit in the open socket, the proximal surfaces were prepared with mortise-form preparations, and the lingual surface of the pontic was also reduced so that its relation to the gingival tissues would be open and sanitary. Using the Concise acid-etch system,” the artificial tooth was then luted to the adjacent teeth (Fig. 1, C). The Hawley retainer was inserted to determine whether it was still functional (Fig. 2, A). The interproximal excess ‘3M
Company,
Dental
Products
Division,
St. Paul,
Minn
Enamel-bon,
Fig. 4. A, Proximal view of restored ridge. Lap reveals close proximity restored relationship of tooth to sofl tissue once again is accomplished objectives of the Hawley retainer.
th replacement
of tooth to soft without disturbing
433
tissue. B, The the functional
was then reduced, contoured, and glazed. The patient was seen the next day. Recovery was uneventful and without discomfort from the prosthesis. At the next visit, 3 weeks following the initial treatment, the gingiva had receded considerably as expected (Figs. 2, B and 3, A), but this was of no concern to the patient as her lip line almost totally concealed the defect. Nevertheless, we decided to “repair” the deficiency. A mortise-form preparation was developed within the ridge lap of the acrylic tooth, the area was cleaned and isolated with cotton rolls, and the gingiva was covered with tinfoil. This was burnished to remove the wrinkles (Fig. 3, B) and Concise restorative composite* was then inserted into the preparation and surrounding voids. By adroitly contouring the material before its initial polymerization, a minimal of finishing was required. The removal of the tinfoil followed and a sulci disc? was used to finish the surface (Figs. 3, C and 4, A and B). The ability to maintain the ridge lap in contact with the receding tissue, at the chair, with no discomfort, is another advantage of this procedure. The acid-etch technique of bonding a pontic between two adjacent teeth is now an accepted routine. The potential applications for its uses, however, have not been fully documented. As in this case, patients completing active orthodontic treatment often meet with some mishap resulting in the loss of a tooth. Immediate replacement is most important to assuage the psyche and preclude interference from treatment with appliances that are already placed and functioning. This dual advantage to the orthodontist should be a major consideration in recommending treatment until a permanent prosthesis is indicated. The favorable factors, however, are not limited to these entities, for there are many more which should be considered in selected cases. Another important benefit, which has not as yet been noted, is that the orthodontist would not be dependent upon the restorative dentist to render treatment, should the latter’s service not be available in an emergency. The armamentarium, exclusive of an acrylic denture tooth, is already available for all orthodontists now bonding brackets to teeth. If improvisation requires the orthodontist to “‘3M Company, -i-J. F. Jelenko
Dental Products Division, & Co.. Inc.. New Rochelle,
St. Paul, Minn N. Y. 10801.
Am. J. Orthod. October 1978
treat such cases, even a resin tooth may be fashioned in the office. A translucent crown form filled with a resin restorative can serve for emergency purposes after the crown form’s shell has been stripped away. Thus, when the exigency arises, the orthodontist, by using the same techniques and materials used for bonding brackets, would be in possession of those skills required to replace a tooth immediately for the benefit of the patient. REFERENCES I. Ward, G. T., and Woolridge, E. D., Jr.: Some clinical applications of adhesives in restorative dentistry. In Moskowitz, H. D., Ward, G. T., and Woolridge, E. D.: Dental adhesive materials symposium, Nov. 8 and 9, 1973, Washington, D. C., U. S. Dept. H. E. W. pp. 267-281. 2. Ibsen, R. L.: One-appointment technic using an adhesive composite, Dent. Survey 49: 30-32, 1973. 3. Rakow, B., and Light, E. I.: Enamel bonding of pontics with accessory anchorage, J. N. J. Dent. Assoc., pp. 15-17, winter, 1978. 4. Rakow, B., and Light, E. I.: Temporary resin-bonded fixed multiple tooth prosthesis, N. Y. State Dent. J.
42: 79, 1976. 5. Lambert, P. M., Moore, D. L., and Elletson, H. E.: In vitro retentive strength of fixed bridges with acrylic pontics and an ultraviolet light-polymerized resin, J. Am. Dent. Assoc. 92: 740,
100 Brrj+w St. (07103)
constructed 1976.
Rakow,
D.D.S.,*
immediate and Ernest
I. Light,
tooth
D.D.S.**
N. J.
A
significant problem which faces the orthodontist from time to time is that of the patient who suffers the sudden loss of an anterior tooth. All too often, it seems, this occurs just as highly favorable orthodontic treatment is being concluded. Most often the course of such a situation is traumatic evulsion or injury requiring extraction of the tooth. Regardless of the cause, it is an emergency situation and calls for immediate treatment. It is necessary for the lost tooth to be replaced to maintain arch form as well as to provide esthetic and psychological support to the patient. Often after active orthodontic treatment stabilizing appliances are worn for a period of time. At this stage immediate tooth replacement is necessary to support a functional retainer and prevent collapse of the case. With the loss of an anterior tooth, its temporary replacement is often accomplished by banding the adjacent teeth to support a pontic. The cosmetic result of such an appliance is highly undesirable. Should the patient be using a removable prosthesis, such as a Hawley retainer, a replacement can be added to it. This automatically limits its potential activity and requires the patient to be wedded to it, even if its use had previously been necessary only during the evening hours. In addition, the effect of a tissue-bearing prosthesis that is in constant contact with the soft interproximal tissues frequently results in a gingivitis and a loss of supporting bone structure. Also, the fastidious person has an ongoing problem maintaining good oral hygiene, especially if meals are taken in public restaurants. The discomfort experienced from entrapped particles of food and the taste and odor of the end products of putrefaction are a constant challenge. Among the many potential uses of the enamel-bonding technique, the luting or bonding’-” of single and multiple4 pontics has proved clinically successful. In vitro studies have corroborated these findings by ascertaining that the applied forces required to dislodge an anterior pontic is far greater than the forces normally experienced in mastication.” This method of immediate replacement of a missing anterior tooth thus can now be included as an alternative procedure in applicable cases. It has the advantage of being placed as soon as a dry field can be maintained following elimination of the tooth, and it is a chairside procedure, it is a reversible technique, it does From the Department of Operative Jersey Dental School. *Associate Professor. **Professor and Chairman.
Dentistry,
College
of Medicine
0002-9416/78/100430+05$00.50/0
and Dentistry
of New Jersey,
New
&?I 1978 The C. V. Mosby Co.
Volume 74 Number 4
Enamel-bonded
immediate
tooth replacement
431
F&J. 1. A, Furiously f&ctured devitafized, discokxed tooth with soWissue abscess discernible over the labial gingiva resulting from two longitudinal root fractures. 8, Longitudinal root fracture as seen following extraction. C, Immediate replacement, following extraction, by enamel bonding of an acryfic denture tooth to the adjacent teeth.
Fig. 2. A, Hawley retainer remains functional following replacement of the left centrai incisor. B, Labial view shows gingival recession 3 weeks following immediate replacement with an acrylic artificial tooth.
not interfere with any functional retainers, it can be replaced if it should fail, it can be accomplished painlessly and without elimination of any surrounding tooth structure, it is sanitary, and it is esthetic. The insertion of a prosthesis with such attributes should be positively considered to effectively restore a patient to emotional stability following the sudden loss of a tooth and permit the orthodontist to continue treatment without interruption. The accompanying illustrations show the treatment of a fractured, markedly discolored upper right central incisor in a 17-year-old girl. The recommending dentist had indicated that it was a devitalized tooth which had been treated many years ago. He had suggested to the patient that a labial surface veneer overlay, using the enamel bonding technique, could effectively restore the harmonious color relationship with the adjacent teeth and restore the anatomic contour. At the appointed visit the patient presented with a large labial swelling extending from the free margin of the gingiva about 6 mm. apically (Fig. 1, A). The patient waS aware of the condition, which elicited no pain. She revealed that it first became apparent about 36 hours previously. Upon probing of the gingivolingual tooth surface, a loose segment of tooth was noted. Roentgenograms revealed a longitudinal fracture extending to the apex and a periapical abscess. The patient was therefore informed that the tooth would have to be extracted.
Am. .I. Orthml. October 1978
432
Rtrkm,
Fig. 3. gingival Tin foil view of
A, Proximal view reveals marked gingival recession 3 weeks following extraction. B, To restore contact, a mortise form preparation was placed into the gingival ridge lap of the acrylic tooth. was burnished over the gingiva prior to the insertion of composite filling restorative. C, Labial repaired ridge. Lap restoring gingival adaptation precludes food stagnation.
trrul
Light
AS is understandable, the loss of an anterior tooth, especially in a young girl, is a traumatic experience and its immediate replacement is fundamental in placating the patient’s distress. To further complicate the case, the patient was wearing a Hawley retainer at night following the recent completion of orthodontic treatment. We therefore elected to use the enamel-bonding technique to lute a pontic to the adjacent teeth following removal of the fractured tooth. This is now an accepted procedure which other clinicians have also used to replace one to four pontics, although not necessarily as an immediate prosthesis. The treatment was performed at the New Jersey Dental School and the patient was referred to the Oral Surgery Department for extraction of the incisor (Fig. 1, B). Approximately 90 minutes later, following the initial clotting and with the cessation of bleeding from the socket, the adjacent teeth were prepared for enamel bonding by thorough cleaning, washing, drying, etching, flushing, and drying. An acrylic denture tooth was contoured to fit in the open socket, the proximal surfaces were prepared with mortise-form preparations, and the lingual surface of the pontic was also reduced so that its relation to the gingival tissues would be open and sanitary. Using the Concise acid-etch system,” the artificial tooth was then luted to the adjacent teeth (Fig. 1, C). The Hawley retainer was inserted to determine whether it was still functional (Fig. 2, A). The interproximal excess ‘3M
Company,
Dental
Products
Division,
St. Paul,
Minn
Enamel-bon,
Fig. 4. A, Proximal view of restored ridge. Lap reveals close proximity restored relationship of tooth to sofl tissue once again is accomplished objectives of the Hawley retainer.
th replacement
of tooth to soft without disturbing
433
tissue. B, The the functional
was then reduced, contoured, and glazed. The patient was seen the next day. Recovery was uneventful and without discomfort from the prosthesis. At the next visit, 3 weeks following the initial treatment, the gingiva had receded considerably as expected (Figs. 2, B and 3, A), but this was of no concern to the patient as her lip line almost totally concealed the defect. Nevertheless, we decided to “repair” the deficiency. A mortise-form preparation was developed within the ridge lap of the acrylic tooth, the area was cleaned and isolated with cotton rolls, and the gingiva was covered with tinfoil. This was burnished to remove the wrinkles (Fig. 3, B) and Concise restorative composite* was then inserted into the preparation and surrounding voids. By adroitly contouring the material before its initial polymerization, a minimal of finishing was required. The removal of the tinfoil followed and a sulci disc? was used to finish the surface (Figs. 3, C and 4, A and B). The ability to maintain the ridge lap in contact with the receding tissue, at the chair, with no discomfort, is another advantage of this procedure. The acid-etch technique of bonding a pontic between two adjacent teeth is now an accepted routine. The potential applications for its uses, however, have not been fully documented. As in this case, patients completing active orthodontic treatment often meet with some mishap resulting in the loss of a tooth. Immediate replacement is most important to assuage the psyche and preclude interference from treatment with appliances that are already placed and functioning. This dual advantage to the orthodontist should be a major consideration in recommending treatment until a permanent prosthesis is indicated. The favorable factors, however, are not limited to these entities, for there are many more which should be considered in selected cases. Another important benefit, which has not as yet been noted, is that the orthodontist would not be dependent upon the restorative dentist to render treatment, should the latter’s service not be available in an emergency. The armamentarium, exclusive of an acrylic denture tooth, is already available for all orthodontists now bonding brackets to teeth. If improvisation requires the orthodontist to “‘3M Company, -i-J. F. Jelenko
Dental Products Division, & Co.. Inc.. New Rochelle,
St. Paul, Minn N. Y. 10801.
Am. J. Orthod. October 1978
treat such cases, even a resin tooth may be fashioned in the office. A translucent crown form filled with a resin restorative can serve for emergency purposes after the crown form’s shell has been stripped away. Thus, when the exigency arises, the orthodontist, by using the same techniques and materials used for bonding brackets, would be in possession of those skills required to replace a tooth immediately for the benefit of the patient. REFERENCES I. Ward, G. T., and Woolridge, E. D., Jr.: Some clinical applications of adhesives in restorative dentistry. In Moskowitz, H. D., Ward, G. T., and Woolridge, E. D.: Dental adhesive materials symposium, Nov. 8 and 9, 1973, Washington, D. C., U. S. Dept. H. E. W. pp. 267-281. 2. Ibsen, R. L.: One-appointment technic using an adhesive composite, Dent. Survey 49: 30-32, 1973. 3. Rakow, B., and Light, E. I.: Enamel bonding of pontics with accessory anchorage, J. N. J. Dent. Assoc., pp. 15-17, winter, 1978. 4. Rakow, B., and Light, E. I.: Temporary resin-bonded fixed multiple tooth prosthesis, N. Y. State Dent. J.
42: 79, 1976. 5. Lambert, P. M., Moore, D. L., and Elletson, H. E.: In vitro retentive strength of fixed bridges with acrylic pontics and an ultraviolet light-polymerized resin, J. Am. Dent. Assoc. 92: 740,
100 Brrj+w St. (07103)
constructed 1976.