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Intermediate fiberglass splints
Johan Frislcopp, D.D.S.,* and Leif Blomlof, D.D.S.** Karolinska Institutet, School of Dentistry, Huddinge, Sweden, and County Council of Stockholm, Stockholm, Sweden
lrior to prosthetic rehabilitation, a temporary treatment is often needed. The effects of endodontic and periodontal treatment can seldom be evaluated immediately. Sometimes an observation period of 1 year or more is necessary, and temporary treatments may be hard to maintain in function during such a long time. Some patients, therefore, need temporary prosthetic treatment that can function for a long time, prior to definite prosthetic rehabilitation. These temporary crowns or fixed partial dentures of long duration may be considered as intermediate prosthetics. They may be designed in many different ways to stabilize mobile teeth and to replace lost teeth. Acrylic resin splints have been made as onlays or inlays. Inlays are less bulky than onlays but require cavity preparation. ’ 2 A conventional temporary fixed partial denture requires even more preparation of the abutment teeth. Splinting mobile teeth with composite resin material has been performed by a number of investigators.3-5 Because many fractures of the splinting material have been reported with this technique,4s5 efforts have been made to reinforce the composite resin. Steel wires or different kinds of metal mesh have been used.“’ However, the union between metal and composite resin is purely mechanical, which makes the reinforcement questionable.’ By use of fiber material, such as polyester yarn or fiberglass, the interface between resin and reinforcement is increased and the strength of the splint or fixed partial denture may thus be enhanced.‘,” The purpose of this article is to present a simple method for making fiberglass-reinforced splints and fixed partial dentures for intermediate use.
MATERIAL
AND METHODS
Eighteen intermediate fixed partial dentures were made for 18 patients with advanced periodontitis. The fixed partial dentures usually involved six teeth, but in
*Departmentof Oral Pathology. **Departmentof Periodontology
334
Fig. 1. Maxillary anterior teeth of a patient with advanced periodontitis prior to treatment.
Fig. 2. Rubber (dam is applied removed.
and old
fillings
a few patients only three or four teeth were used. They were placed in both maxillary and mandibular jaws; molars were not used as abutment teeth. The teeth were scaled and polished prior to etching with acid in all patients. Fillings with material noncompatible with Bowen’s resin were replaced with composite resin material. To avoid contamination with saliva, a rubber dam was always used (Figs. 1 to 3). The splints and. fixed partial dentures were made of fiberglass bonded together and to the involved teeth
MARCH
1984
VOLUME
51
NUMBER
3
Fig. 3. New fillings place.
of composite resin material in
Fig. 5. Cut end of a flat band of fiberglass.
Fig. 4. Fiberglass roving. Flat bands are suitable for reinforcement of self-curing resin. with self-curing BIS-GMA resin. Strings of fiberglass were obtained from fiberglass roving. The individual fibers had a diameter of 11 pm (Figs. 4 and 5). The self-curing resin contained no filler material (Concise Enamel Bond, 3M Co., Minneapolis, Minn.). Involved teeth were treated as recommended by the manufacturer, with the etching solutions provided with the resin. Artificial acrylic resin teeth (Myerson, Cambridge, Mass.) were used as pontics in two caseswhere the patients’ own teeth were not suitable or available. Lingual and buccal indexes of the involved teeth were made of thermoplastic impression material (Kerr green, Kerr/Sybron, Romulus, Mich.) (Fig. 6). The teeth were etched, dried, and painted with resin. Fiberglass was cut to the length of the intermediate fixed partial denture, soaked with resin, and placed on the lingual index, which was then replaced and pressed
THE JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 6. Lingual and facial indexes are made of thermoplastic material. onto the teeth for approximately 1 minute (Fig. 7). This procedure was repeated twice. Three layers of treated fiberglass were usually used. On the buccal side, fiberglass was cut to fit the interproximal areas only. The buccal fibers were also soaked in resin but were placed in the interproximal spaces and squeezed in place with the buccal index (Fig. 8). In two patients, Kevlar fiber (Du Pont and Co., Wilmington, Del.) was used on the lingual side in the first two layers with one covering layer of fiberglass. The splint was finished with diamonds and pumice into the desired hygienic design (Fig. 9). Finally, a thin layer of resin (Adaptic Glaze, Johnson and Johnson, East Windsor, N.J.) was applied to give a smooth surface.
335
FRISKOPP
Fis. 7. Teeth are etched, dried, and painted with resin. Fiberglass is soaked in resin and placed on lingual index, which is squeezed onto teeth.
AND
BLOMLOF
Fig. 9. Finished intermediate restoration.
SPLINTING
MATERIA
TOWARO THE SPLINT SPLlNTlNC
MATERIA
Fig. 8. Facial indexes covering facial/interproximal fiberglass. RESULTS Fiberglass-reinforced fixed partial dentures and splints produced with the index method described here have been used since 1978. Sixteen patients have used them for 1 year or more without fractures. Five layers of fiberglass, three layers lingually and two buccally approximately 20 mg/cm of total weight, seemed strong enough. However, during finishing, some fiberglass was removed. The two fixed partial dentures on which Kevlar was used as reinforcing material did not fracture. However, grinding off resin and fiberglass exposed the Kevlar of the deeper layers. These fibers did not wear off as fast as the resin and left a rugged surface that was not comfortable to the patient. In two patients where pontics were used, fractures involving the pontic occurred. The fiberglass lingual to
336
Fig. 10. Occlusive forces in anterior regions. the artificial teeth was intact, but the bond between the acrylic resin pontic and the splint was fractured. Endodontic treatment was completed without fractures in two patients through the use of fibergkiss material. Scaling and/or periodontal surgery was possible in all 18 patients after the intermediate restorations were placed. Access to root surfaces was as good with an intermediate fixed partial denture as with a permanent construction. Oral hygiene was good in all patients receiving these reconstructions.
MARCH
1984
VOLUME
51
NUMBER
3
INTERMEDIATE
FIBERGLASS
SPLINTS
The esthetic appearance pleased most of the patients. They were also comforted by the stabilization of the excessively mobile teeth.
DISCUSSION AND CONCLUSIONS Fiberglass has previously been used in dental practice to reinforce self-curing resin. The method presented here is essentially a modification of a previous technique. lo In that technique fiberglass was applied and kept in place with forceps and explorers. With the aid of the index used in the present modification, the fibers can be more densely packed and thus allow a more favorable fiberglass-to-resin ratio. The strength of the construction is determined by the number of fibers, not by the thickness per se. The increased strength of the material makes the use of thinner splints possible, which thus minimizes occlusal interference. Considering the experience from a previous investigation” and the present study, the following conclusions can be made. Fractures occurred in the maxillary arch when the fiber material was placed lingually only. In the mandibular arch, however, the lingual position of the splints was satisfactory. The strength of the construction was markedly increased when fiber material was placed on the facial side as well. In the mandibular anterior teeth, forces are directed lingually/apically toward the splint; in the maxillary anterior teeth, the forces are directed labially/apically away from the splint (Fig. 10). Therefore, it seems possible to exclude facial fiberglass in the mandibular anterior region. The acrylic resin in the artificial teeth used as pontics does not bind chemically to BIS-GMA resin. The mechanical retention, by tindercuts prepared in the teeth, is not strong enough. A number of pontics made of composite resin material have been serving well for 1 year. The binding between different materials seems to be the problem rather than the strength of each material. When the acid-etch technique is used, it is essential to avoid contamination of the newly etched and dried surfaces with saliva, moisture, grease, and so forth.” Material used to reinforce self-curing resins should be inert to salivary environment. Metals, except noble ones, may corrode when exposed to saliva by the action of the patient grinding off some of the covering resin. Fibers like glass, Kevlar, and carbon are very resistant to saliva.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
The tensile strength of Kevlar was satisfactory even in thin applications. Wearing characteristics were not compatible to those of the resin, which may cause discomfort when the fiber material is exposed. When Kevlar is desired as the splinting material, occlusal wear must be considered. Intermediate fixed partial dentures made with the index method are produced as rapidly as temporary fixed partial dentures but last longer. They make it possible to evaluate endodontic and periodontal treatment during periods of 1 year or more and thus give a reliable foundation for the final prosthetic treatment. REFERENCES 1
2.
3.
4.
5.
6.
7. 8. 9.
10. 11.
Sorrin, S.: The use of fixed and removable splints in the practice of periodontia. Am J Orthod Oral Surg 31:354, 1945. Obin, J. N., and Arvins, A. N.: The use of self-curing resin splints for the temporary stabilization of mobile teeth due to periodontal involvement. J Am Dent Assoc 42:320, 1951. Poison, A. M., and Billen, J. R.: Temporary splinting of teeth using ultraviolet light-polymerized bonding material. J Am Dent Assoc 89:1137, 1974. Midda, M.: The Use of the Acid-etch Technique in Periodontal Splinting. Proceedings of an International Symposium on the Acid Etch Technique. St. Paul, 1975, North Central Publishing Co. Vogel, R. I.: The use of self-polymerizing resin with enamel etchant for temporary stabilization. J Periodontol 47:69, 1976. Klassman, B., and Zucker, H. W.: Combination wire composite resins intracoronal splinting rationale and technique. J Periodontol 42481, 1976. Blomliif, L., Friskopp, J., and Sijder, P-b.: Fixation av tander med emaljbindningsteknik. Tandlzkartidningen 69:530, 1977. Rosenberg, S.: A method for stabilization of periodontally involved teeth. J Periodontol 51:469, 1980. Schmid, M. O., Lutz, F., and Imfeld, T.: A reinforced intracoronal composite resin splint. J Periodontol 50:441, 1979. Friskopp, J., Blomlb;f, L., and Slider, P-ii.: Fiberglass splints. J Periodontol 50:193, 1979. Young, K. G., Hussey, M., Gillespie, F. C., and Stephen, K. W.: In vitro studies of physical factors affecting adhesion of fissure sealant to enamel. Proceedings of an International Symposium on the Acid Etch Technique. St. Paul, 1975, North Central Publishing Co.
Reprint requests to: DR. JOHAN FRISKOPP KAROLINSKA INSTITIJTET SCHOOL OF DENTISTRY
Box 4064 HUDDINCE SWEDEN
141 04
337
lrior to prosthetic rehabilitation, a temporary treatment is often needed. The effects of endodontic and periodontal treatment can seldom be evaluated immediately. Sometimes an observation period of 1 year or more is necessary, and temporary treatments may be hard to maintain in function during such a long time. Some patients, therefore, need temporary prosthetic treatment that can function for a long time, prior to definite prosthetic rehabilitation. These temporary crowns or fixed partial dentures of long duration may be considered as intermediate prosthetics. They may be designed in many different ways to stabilize mobile teeth and to replace lost teeth. Acrylic resin splints have been made as onlays or inlays. Inlays are less bulky than onlays but require cavity preparation. ’ 2 A conventional temporary fixed partial denture requires even more preparation of the abutment teeth. Splinting mobile teeth with composite resin material has been performed by a number of investigators.3-5 Because many fractures of the splinting material have been reported with this technique,4s5 efforts have been made to reinforce the composite resin. Steel wires or different kinds of metal mesh have been used.“’ However, the union between metal and composite resin is purely mechanical, which makes the reinforcement questionable.’ By use of fiber material, such as polyester yarn or fiberglass, the interface between resin and reinforcement is increased and the strength of the splint or fixed partial denture may thus be enhanced.‘,” The purpose of this article is to present a simple method for making fiberglass-reinforced splints and fixed partial dentures for intermediate use.
MATERIAL
AND METHODS
Eighteen intermediate fixed partial dentures were made for 18 patients with advanced periodontitis. The fixed partial dentures usually involved six teeth, but in
*Departmentof Oral Pathology. **Departmentof Periodontology
334
Fig. 1. Maxillary anterior teeth of a patient with advanced periodontitis prior to treatment.
Fig. 2. Rubber (dam is applied removed.
and old
fillings
a few patients only three or four teeth were used. They were placed in both maxillary and mandibular jaws; molars were not used as abutment teeth. The teeth were scaled and polished prior to etching with acid in all patients. Fillings with material noncompatible with Bowen’s resin were replaced with composite resin material. To avoid contamination with saliva, a rubber dam was always used (Figs. 1 to 3). The splints and. fixed partial dentures were made of fiberglass bonded together and to the involved teeth
MARCH
1984
VOLUME
51
NUMBER
3
Fig. 3. New fillings place.
of composite resin material in
Fig. 5. Cut end of a flat band of fiberglass.
Fig. 4. Fiberglass roving. Flat bands are suitable for reinforcement of self-curing resin. with self-curing BIS-GMA resin. Strings of fiberglass were obtained from fiberglass roving. The individual fibers had a diameter of 11 pm (Figs. 4 and 5). The self-curing resin contained no filler material (Concise Enamel Bond, 3M Co., Minneapolis, Minn.). Involved teeth were treated as recommended by the manufacturer, with the etching solutions provided with the resin. Artificial acrylic resin teeth (Myerson, Cambridge, Mass.) were used as pontics in two caseswhere the patients’ own teeth were not suitable or available. Lingual and buccal indexes of the involved teeth were made of thermoplastic impression material (Kerr green, Kerr/Sybron, Romulus, Mich.) (Fig. 6). The teeth were etched, dried, and painted with resin. Fiberglass was cut to the length of the intermediate fixed partial denture, soaked with resin, and placed on the lingual index, which was then replaced and pressed
THE JOURNAL
OF PROSTHETIC
DENTISTRY
Fig. 6. Lingual and facial indexes are made of thermoplastic material. onto the teeth for approximately 1 minute (Fig. 7). This procedure was repeated twice. Three layers of treated fiberglass were usually used. On the buccal side, fiberglass was cut to fit the interproximal areas only. The buccal fibers were also soaked in resin but were placed in the interproximal spaces and squeezed in place with the buccal index (Fig. 8). In two patients, Kevlar fiber (Du Pont and Co., Wilmington, Del.) was used on the lingual side in the first two layers with one covering layer of fiberglass. The splint was finished with diamonds and pumice into the desired hygienic design (Fig. 9). Finally, a thin layer of resin (Adaptic Glaze, Johnson and Johnson, East Windsor, N.J.) was applied to give a smooth surface.
335
FRISKOPP
Fis. 7. Teeth are etched, dried, and painted with resin. Fiberglass is soaked in resin and placed on lingual index, which is squeezed onto teeth.
AND
BLOMLOF
Fig. 9. Finished intermediate restoration.
SPLINTING
MATERIA
TOWARO THE SPLINT SPLlNTlNC
MATERIA
Fig. 8. Facial indexes covering facial/interproximal fiberglass. RESULTS Fiberglass-reinforced fixed partial dentures and splints produced with the index method described here have been used since 1978. Sixteen patients have used them for 1 year or more without fractures. Five layers of fiberglass, three layers lingually and two buccally approximately 20 mg/cm of total weight, seemed strong enough. However, during finishing, some fiberglass was removed. The two fixed partial dentures on which Kevlar was used as reinforcing material did not fracture. However, grinding off resin and fiberglass exposed the Kevlar of the deeper layers. These fibers did not wear off as fast as the resin and left a rugged surface that was not comfortable to the patient. In two patients where pontics were used, fractures involving the pontic occurred. The fiberglass lingual to
336
Fig. 10. Occlusive forces in anterior regions. the artificial teeth was intact, but the bond between the acrylic resin pontic and the splint was fractured. Endodontic treatment was completed without fractures in two patients through the use of fibergkiss material. Scaling and/or periodontal surgery was possible in all 18 patients after the intermediate restorations were placed. Access to root surfaces was as good with an intermediate fixed partial denture as with a permanent construction. Oral hygiene was good in all patients receiving these reconstructions.
MARCH
1984
VOLUME
51
NUMBER
3
INTERMEDIATE
FIBERGLASS
SPLINTS
The esthetic appearance pleased most of the patients. They were also comforted by the stabilization of the excessively mobile teeth.
DISCUSSION AND CONCLUSIONS Fiberglass has previously been used in dental practice to reinforce self-curing resin. The method presented here is essentially a modification of a previous technique. lo In that technique fiberglass was applied and kept in place with forceps and explorers. With the aid of the index used in the present modification, the fibers can be more densely packed and thus allow a more favorable fiberglass-to-resin ratio. The strength of the construction is determined by the number of fibers, not by the thickness per se. The increased strength of the material makes the use of thinner splints possible, which thus minimizes occlusal interference. Considering the experience from a previous investigation” and the present study, the following conclusions can be made. Fractures occurred in the maxillary arch when the fiber material was placed lingually only. In the mandibular arch, however, the lingual position of the splints was satisfactory. The strength of the construction was markedly increased when fiber material was placed on the facial side as well. In the mandibular anterior teeth, forces are directed lingually/apically toward the splint; in the maxillary anterior teeth, the forces are directed labially/apically away from the splint (Fig. 10). Therefore, it seems possible to exclude facial fiberglass in the mandibular anterior region. The acrylic resin in the artificial teeth used as pontics does not bind chemically to BIS-GMA resin. The mechanical retention, by tindercuts prepared in the teeth, is not strong enough. A number of pontics made of composite resin material have been serving well for 1 year. The binding between different materials seems to be the problem rather than the strength of each material. When the acid-etch technique is used, it is essential to avoid contamination of the newly etched and dried surfaces with saliva, moisture, grease, and so forth.” Material used to reinforce self-curing resins should be inert to salivary environment. Metals, except noble ones, may corrode when exposed to saliva by the action of the patient grinding off some of the covering resin. Fibers like glass, Kevlar, and carbon are very resistant to saliva.
THE JOURNAL
OF PROSTHETIC
DENTISTRY
The tensile strength of Kevlar was satisfactory even in thin applications. Wearing characteristics were not compatible to those of the resin, which may cause discomfort when the fiber material is exposed. When Kevlar is desired as the splinting material, occlusal wear must be considered. Intermediate fixed partial dentures made with the index method are produced as rapidly as temporary fixed partial dentures but last longer. They make it possible to evaluate endodontic and periodontal treatment during periods of 1 year or more and thus give a reliable foundation for the final prosthetic treatment. REFERENCES 1
2.
3.
4.
5.
6.
7. 8. 9.
10. 11.
Sorrin, S.: The use of fixed and removable splints in the practice of periodontia. Am J Orthod Oral Surg 31:354, 1945. Obin, J. N., and Arvins, A. N.: The use of self-curing resin splints for the temporary stabilization of mobile teeth due to periodontal involvement. J Am Dent Assoc 42:320, 1951. Poison, A. M., and Billen, J. R.: Temporary splinting of teeth using ultraviolet light-polymerized bonding material. J Am Dent Assoc 89:1137, 1974. Midda, M.: The Use of the Acid-etch Technique in Periodontal Splinting. Proceedings of an International Symposium on the Acid Etch Technique. St. Paul, 1975, North Central Publishing Co. Vogel, R. I.: The use of self-polymerizing resin with enamel etchant for temporary stabilization. J Periodontol 47:69, 1976. Klassman, B., and Zucker, H. W.: Combination wire composite resins intracoronal splinting rationale and technique. J Periodontol 42481, 1976. Blomliif, L., Friskopp, J., and Sijder, P-b.: Fixation av tander med emaljbindningsteknik. Tandlzkartidningen 69:530, 1977. Rosenberg, S.: A method for stabilization of periodontally involved teeth. J Periodontol 51:469, 1980. Schmid, M. O., Lutz, F., and Imfeld, T.: A reinforced intracoronal composite resin splint. J Periodontol 50:441, 1979. Friskopp, J., Blomlb;f, L., and Slider, P-ii.: Fiberglass splints. J Periodontol 50:193, 1979. Young, K. G., Hussey, M., Gillespie, F. C., and Stephen, K. W.: In vitro studies of physical factors affecting adhesion of fissure sealant to enamel. Proceedings of an International Symposium on the Acid Etch Technique. St. Paul, 1975, North Central Publishing Co.
Reprint requests to: DR. JOHAN FRISKOPP KAROLINSKA INSTITIJTET SCHOOL OF DENTISTRY
Box 4064 HUDDINCE SWEDEN
141 04
337