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Replacement of a maxillary central incisor using a polyethylene fiber-reinforced composite resin fixed partial denture: A clinical report
Replacement of a maxillary central incisor using a polyethylene fiberreinforced composite resin fixed partial denture: A clinical report Sebnem Begum Turker, DDS, PhD,a and Isil Damla Sener, DDSb Marmara University Faculty of Dentistry, Istanbul, Turkey Fiber-reinforced composite resin (FRC) restorations generally consist of a composite resin veneer supported by a fiber-reinforced composite resin substructure and prepared chairside to be used when the patient needs a short-term solution. It is an esthetic, conservative treatment alternative and allows for future options. This article describes the use of a polyethylene fiber-reinforced composite resin fixed partial denture (PFRCFPD) with a ceramic pontic for the replacement of a missing central incisor due to trauma. (J Prosthet Dent 2008;100:254-258) Resin-bonded fixed partial dentures (RBFPDs) bonded to natural teeth and acrylic resin pontics are a treatment alternative for the replacement of missing teeth when a conservative tooth preparation is needed.1 Conventional metal ceramic complete-coverage fixed partial dentures (FPDs) provide maximum strength, and all-ceramic conventional FPDs are metal-free and esthetically more pleasing; however, the attraction of the resin-bonded FPD is that it allows for a more conservative tooth preparation.2-4 A strong and stable resin bond to the ceramic is required for the clinical application of RBFPDs.5 No tooth preparation, or minimal preparation, to produce space for pontic fabrication is needed for the replacement of missing teeth with fiber-reinforced composite resin FPDs with optimal esthetics. Resin-bonded FPDs with a single pontic have been reported to have a 5-year survival rate of 61%.6 A common problem with metal ceramic resin-bonded FPDs has been the gray color of the incisal third of the abutment teeth due to the cast-metal lingual retainers.7 Careful patient selection, adequate planning of the design, precise preparation, correct choice of materials, and bonding techniques are important factors for the dura-
bility and success of fiber-reinforced composite resin fixed partial denture (FRCFPD) restorations.8 The polyethylene fibers can be treated to enhance the adhesion between the polyethylene and resin with electrical plasma treatment, which etches the surface so that it can be bonded mechanically to the resin.9,10 After many years of clinical research involving numerous types of reinforcing elements and pontics, such as metal bars, wires, and screens,11-14 the best reinforcing agents are considered to be nonwoven bundle filaments of 10- to 20-µm-diameter high-density polyethylene or polypropylene fibers combined with custom-made composite resin pontics.10 High-strength reinforcement ribbon (Connect; Kerr Hawe SA, Bioggio, Switzerland) is an ultrastrength polyethylene fiber that can be used to provide increased levels of strength to single-tooth stressbearing restorations, provisional composite resin and acrylic resin crowns and fixed partial dentures, orthodontic retainers, periodontal splints, dentures, and occlusal guards, and can also be used for repair and reinforcement.15,16 In vitro studies have shown that fiber-reinforced composite resin (FRC) materials exhibit flexure strength that is greater than or comparable to
metal alloys, but have a lower flexural modulus.16,17 Clinical use and research have shown that fiber-reinforced inlays, resin-bonded FPDs, and fixed complete dentures supported by multiple implants in edentulous jaw can be used satisfactorily both for shortand long-term treatment of missing teeth.16-19 For FRC restorations, functional stresses and occlusal loading of the pontic should be minimized, vertical and horizontal overlap should not be greater than 3 mm,20 and the supporting abutment teeth must be structurally vital and intact to serve as abutments for the fiber-reinforced matrix.21 All-ceramic crowns and ceramic veneers, such as IPS Empress (IPS Empress System; Ivoclar Vivadent, Schaan, Liechtenstein) or In-Ceram (Vita Zahnfabrik, Bad Säckingen, Germany), have excellent esthetics, primarily in anterior regions.22,23 IPS Empress 2 (Ivoclar Vivadent) is a popular ceramic system developed in 1998 that improved upon the crystalline content of IPS Empress.24 Conventional luting cements used in metal ceramic FPDs are not capable of forming a microretentive or specific bond to the prepared enamel and dentin structure and the restorative material.25 The adhesive strength of ceramic restorations to tooth struc-
Assistant Professor, Department of Prosthodontics. Research Assistant, Department of Prosthodontics.
a
b
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October 2008 ture can be improved by treatment with a silane coupling agent to the adherent surface of restorations.26-29 Investigations of surface conditioning with a combination of hydrofluoric acid etching and silane application also have reported favorable bond strengths between composite resin and ceramic.3,30,31 This clinical report describes a treatment alternative for the replacement of a maxillary central incisor with a polyethylene fiber-reinforced composite resin fixed partial denture (PFRCFPD).
CLINICAL REPORT A 26-year-old white woman with a missing right central incisor was referred for prosthetic treatment to the Marmara University School of Dentistry. The chief complaint of the patient was esthetic (Fig. 1). The clinical and radiographic examinations revealed that the patient had approximately 3 mm of vertical and horizontal overlap, a stable maximum intercuspation position, canine protected occlusion, and adequate periodontal health and root support without any residual ridge deficiency. An implantsupported crown, resin-bonded fixed partial denture, conventional fixed partial denture, and a PFRCFPD with an IPS Empress 2 (Ivoclar Vivadent) or composite resin pontic were the treatment options presented to the patient for replacement of the missing incisor. The patient expressed a preference for a PFRCFPD with an IPS Empress 2 pontic rather than an implant-supported prosthesis, because no surgical procedure was needed, the time to insertion would be relatively short, and the outcome would be more esthetic compared to a conventional metalceramic FPD. Furthermore, minimal tooth preparation was needed for this viable restoration option. Preliminary impressions were made conventionally with irreversible hydrocolloid material (Alginate; Chromatic Conforme EN, Grassina, Italy). An initial diagnostic waxing was accomplished on a diagnostic
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cast (Fig. 2) and evaluated intraorally, using the vacuum-formed matrix to demonstrate to the patient the definitive appearance of the restoration. At this stage, it was observed that the maxillary right lateral incisor needed additional proximal margin preparation to produce space for the pontic to provide symmetry.4 A second waxing was prepared after performing the proximal tooth preparation. The patient was satisfied with the definitive waxing. A vacuum shell matrix (ProForm; Dental Resources, Maple Lake, Minn) was prepared to fabricate the composite resin (Tetric Ceram; Ivoclar Vivadent) provisional pontic. The provisional pontic was polymerized incrementally in the vacuum shell matrix and, after removal from the matrix, was polished (9405.204, 9436F.204; Komet/Gebr Brasseler GmbH, Lemgo, Germany). The polished provisional pontic was maintained in position by bonding it to the abutment teeth.
A complete arch impression was made with a silicone impression material (Speedex; Coltène/Whaledent, Inc, Cuyahoga Falls, Ohio), and the shade was determined (Chromascop; Ivoclar Vivadent). The IPS Empress 2 (Ivoclar Vivadent) pontic was fabricated with a palatal groove, 2 mm deep and 1 mm long (Fig. 3). The horizontal overlap duplicated the original condition of the patient.32 The esthetic appearance of the IPS Empress 2 crown and the path of insertion were evaluated at the trial insertion appointment, and the patient approved the appearance. The palatal groove, at least three quarters of the mesiodistal width of the abutment teeth, was prepared on the palatal surfaces of the right maxillary lateral and left maxillary central incisors using a round diamond rotary cutting instrument (G+K Mahnhardt Dental, Thurmansbang, Germany) with the same dimensions and at the same lev-
1 Missing right central incisor prior to treatment.
2 Initial diagnostic waxing.
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3 All-ceramic pontic with palatal slot.
4 Slots prepared at palatal surface of abutments.
A
B
5 A, Palatal surface of definitive PFRCFPD. B, Facial view of definitive prosthesis. el as the IPS Empress 2 pontic (2 mm deep and 1 mm long) (Fig. 4).12 The grooved surface of the crown and the mesial and distal proximal area were etched with 5% hydrofluoric acid (IPS Ceramic Etching Gel; Ivoclar Vivadent) for 20 seconds. Then a silane coupling agent (Monobond-S; Ivoclar Vivadent) was applied for 60 seconds. The abutment groove surfaces and the mesio-proximal surface of the right maxillary lateral and disto-proximal surface of the left maxillary central incisor were etched with 37% phosphoric acid (Total Etch; Ivoclar Vivadent) for 30 seconds. The preparations were rinsed with water and thoroughly dried. Following the manufacturer’s guidelines, Syntac Primer (Ivoclar Vivadent) and Syntac Adhesive (Ivoclar Vivadent) were applied. A bonding agent (Heliobond; Ivoclar Vivadent) was applied by brush on both the prepared abutment area and the prepared surface of the
crown. The excess bonding agent was removed with the tip of the brush. The distance between the grooves was measured and a piece of fiber ribbon (Connect; Kerr Hawe SA), with the same dimensions as the space between the grooves, was cut and embedded in mixed resin cement. The polyethylene fiber ribbon was placed along the grooves. The fiber-resin combination was carefully placed into the grooves using titanium nitridecoated instruments (Brilliant Esthetic Line Composite Instrument; Coltène/ Whaledent, Inc), the proximal embrasures were cleaned, and cementation was performed immediately by using high-viscosity resin cement (Variolink II; Ivoclar Vivadent). Excess cement was removed with a brush and dental floss. The restorations were polymerized for 40 seconds with a wide-tipped prismatic light-polymerizing unit (Optilux VCL 401, at 420 mW/cm2; Kerr Corp, Orange, Calif ) from the buccal
The Journal of Prosthetic Dentistry
and palatal surfaces of both abutment teeth and from the lingual and vestibular surfaces of the IPS Empress crown restoration for a total of 280 seconds. Additional composite resin (Tetric Ceram; Ivoclar Vivadent) was applied to blend the FRC contours. The occlusion was evaluated with articulating paper (Hanel Articulating Paper; Coltène/Whaledent, Inc), the premature contacts were eliminated, and the definitive restoration was polished (9405.204, 9436F.204; Komet/Gebr Brasseler GmbH) (Fig. 5). Over the 27-month period following cementation of the PFRCFPD, the patient was examined 9 times. Evaluation of the restorations at these visits indicated that there was no plaque accumulation on the fiber-composite resin combination, and no caries was observed on the abutment teeth. Additionally, the patient reported no functional or esthetic problems.
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October 2008 DISCUSSION This clinical report describes the replacement of a central incisor with an esthetic and conservative PFRCFPD with an IPS Empress 2 pontic resulting in success over a short-term follow-up. The esthetics of the FRCFPD were shown to be considerably better than the esthetics of FPDs with metal frameworks, as determined visually by other investigators.1 Although this technique was used for an interim method of anterior tooth replacement, its conservative preparation and reported success suggest that it may be considered as a definitive alternative in certain situations. Fabrication of a direct composite resin pontic is effectively accomplished in a single visit, but it is difficult to provide characterization and to obtain a smooth surface at the pontic area, and it has been determined that the longevity of the FPD is threatened by the wear of the particulate veneering composite resin occlusal surface.1 Because of the unpredictability of bonding acrylic resin to composite resin, an acrylic resin denture tooth is not recommended for use as a pontic for any prosthesis other than a provisional partial denture.1 The development of dentin adhesive systems has also led to simpler and minimally invasive preparations.8,25 Adhesive resin cements are composite resins that have a decreased proportion of filler, with an organic polymer matrix of bis-GMA and UDMA, an inorganic filler, bonding agent, initiators, and pigments.23 Newly introduced resin luting agents have higher proportions of filler.23 The combination of the resin luting agent and bonding systems is one of the most important factors for retention of these restorations.33 Until clinical success of the less invasive FPDs is determined, the use of small cavity preparations for the fiber framework with the optional combination of the palatal (lingual) bonding wing is recommended.1 The preparation, an occlusal rest seat,
Turker and Sener
helps to direct masticatory forces and diminishes the debonding stress of the bonding wing.1 In the present clinical report, small preparations, such as slots, provide space for the fiber framework to completely support the pontic element. While luting the restoration, 2 interfaces are formed: the first between the porcelain and the luting composite resin, and a second between the luting composite resin and the enamel and/ or dentin. This luting involves several steps to obtain optimal adhesion.5,8 Etching the intaglio surface of a crown or an extracoronal restoration with hydrofluoric acid followed by the application of a silane is a well known and recommended method to increase bond strength.5 For IPS Empress 2, the hydrofluoric acid (HF) attacks the glassy phase of the glass ceramic, dissolving the surface to the depth of a few micrometers, and, consequently, lithium disilicate crystals protrude from the glassy matrix.24 Without an intermediate medium, and due to the lack of chemical interaction between composite resin and ceramic, the bond depends on the mechanical retentive features of the ceramic surface. Silane has been a medium of choice to provide chemical interaction between dental composite resins and dental ceramics, resulting in a strong bond between the materials.28,29 The modified FRC technique described is simple and easy. It is an affordable and fast solution for patients who reject more invasive treatment. Further studies are needed to evaluate the long-term usefulness of a polyethylene fiber-reinforced composite resin fixed partial denture (PFRCFPD) with an all-ceramic pontic.
SUMMARY This report describes the clinical procedures involved in the fabrication of a PFRCFPD with an all-ceramic pontic, which provided a conservative solution for the restoration of anterior missing teeth.
REFERENCES 1. Vallittu PK, Sevelius C. Resin-bonded, glass fiber-reinforced composite fixed partial dentures: a clinical study. J Prosthet Dent 2000;84:413-8. 2. Corrente G, Vergnano L, Re S, Cardaropoli D, Abundo R. Resin bonded fixed partial dentures and splints in periodontally compromised patients: a 10-year followup. Int J Periodontics Restorative Dent 2000;20:628-36. 3. Ozcan M. The use of chairside silica coating for different dental applications: a clinical report. J Prosthet Dent 2002;87:469-72. 4. Turker SB, Guvenli SY, Arikan A. Replacement of two mandibular central incisors using a zirconium resin-bonded fixed partial denture: a clinical report. J Prosthet Dent 2005;94:499-503. 5. Ozcan M, Akkaya A. New approach to bonding all-ceramic adhesive fixed partial dentures: a clinical report. J Prosthet Dent 2002;88:252-4. 6. Pröbster B, Henrich GM. 11-year follow-up study of resin-bonded fixed partial dentures. Int J Prosthodont 1997;10:259-68. 7. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications in fixed prosthodontics. J Prosthet Dent 2003;90:31-41. 8. Iglesia-Puig MA, Arellano-Cabornero A. Inlay fixed partial denture as a conservative approach for restoring posterior missing teeth: a clinical report. J Prosthet Dent 2003;89:443-5. 9. Jagger DC, Harrison A, Jandt KD. The reinforcement of dentures. J Oral Rehabil 1999;26:185-94. 10.Ellakwa AE, Shortall AC, Shehata MK, Marquis PM. The influence of fibre placement and position on the efficiency of reinforcement of fibre reinforced composite bridgework. J Oral Rehabil 2001;28:785-91. 11.Ladizesky NH, Ho CF, Chow TW. Reinforcement of complete denture bases with continuous high performance polyethylene fibers. J Prosthet Dent 1992;68:934-9. 12.Belvedere PC. Single-sitting, fiber-reinforced fixed bridges for the missing lateral or central incisors in adolescent patients. Dent Clin North Am 1998;42:665-82. 13.Vallittu PK. Prosthodontic treatment with a glass fiber-reinforced resin-bonded fixed partial denture: a clinical report. J Prosthet Dent 1999;82:132-5. 14.Freilich MA, Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical dentistry. Chicago: Quintessence; 2000. p. 18-46. 15.Rudo DN, Karbhari VM. Physical behaviors of fiber reinforcement as applied to tooth stabilization. Dent Clin North Am 1999;43:7-35. 16.Freilich MA, Duncan JP, Alarcon EK, Eckrote KA, Goldberg AJ. The design and fabrication of fiber-reinforced implant prostheses. J Prosthet Dent 2002;88:449-54. 17.Anusavice KJ. Phillips’ science of dental materials. 11th ed. St.Louis: Elsevier; 2003. p. 563-620.
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Volume 100 Issue 4 18.Freilich MA, Meiers JC, Duncan JP, Eckrote KA, Goldberg AJ. Clinical evaluation of fiber-reinforced fixed bridges. J Am Dent Assoc 2002;133:1524-34. 19.Freilich MA, Duncan JP, Meiers JC, Goldberg AJ. Preimpregnated, fiber-reinforced prostheses. Part I. Basic rationale and complete-coverage and intracoronal fixed partial denture designs. Quintessence Int 1998;29:689-96. 20.Ricketts RM. Provocations and perceptions in craniofacial orthopedics: dental science and facial art/parts 1 and 2. Vol. 1. Denver: Rocky Mountain Orthodontics; 1990. p. 702-3. 21.Rose E, Frucht S, Jonas IE. Clinical comparison of a multistranded wire and a directbonded polyethylene ribbon-reinforced resin composite used for lingual retention. Quintessence Int 2002;33:579-83. 22.Rosentritt M, Behr M, Lang R, Handel G. Experimental design of FPD made of allceramics and fibre-reinforced composite. Dent Mater 2000;16:159-65.
23.Ferracane JL. Materials in dentistry: principles and applications. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2001. p. 74-82. 24.Pisani-Proenca J, Erhardt MC, Valandro LF, Gutierrez-Aceves G, Bolanos-Carmona MV, Del Castillo-Salmeron R, et al. Influence of ceramic surface conditioning and resin cements on microtensile bond strength to a glass ceramic. J Prosthet Dent 2004;96:412-7. 25.Edelhoff D, Spiekermann H, Yildirim M. Metal-free inlay-retained fixed partial dentures. Quintessence Int 2001;32:269-81. 26.Hooshmand T, van Noort R, Keshvad A. Bond durability of the resin-bonded and silane treated ceramic surface. Dent Mater 2002;18;179-88. 27.Della Bona A, Anusavice KJ, Hood JA. Effect of ceramic surface treatment on tensile bond strength to a resin cement. Int J Prosthodont 2002;15;248-53. 28.Shen C, Oh WS, Williams JR. Effect of post-silanization drying on the bond strength of composite to ceramic. J Prosthet Dent 2004;91:453-8.
29.Hayakawa T, Horie K, Aida M, Kanaya H, Kobayashi T, Murata Y. The influence of surface conditions and silane agents on the bond of resin to dental porcelain. Dent Mater 1992;8:238-40. 30.Bailey JH. Porcelain-to-composite bond strengths using four organosilane materials. J Prosthet Dent 1989;61:174-7. 31.Llobell A, Nicholls JI, Kois JC, Daly CH. Fatigue life of porcelain repair systems. Int J Prosthodont 1992;5:205-13. 32.Chiche GJ, Pinault A. Esthetics of anterior fixed prosthodontics. Chicago: Quintessence; 1994. p. 115-42. 33.O’Brien WJ. Dental materials and their selection. 3rd ed. Chicago: Quintessence; 2002. p. 132-55. Corresponding author: Dr Sebnem Begum Turker Marmara University Faculty of Dentistry Buyuk Ciftlik Sok. No: 6 34365 Nisantasi Istanbul TURKEY Fax: +902122465247 E-mail: [email protected] Copyright © 2008 by the Editorial Council for The Journal of Prosthetic Dentistry.
Noteworthy Abstracts of the Current Literature Clinical evaluation of all-ceramic onlays: A 4-year retrospective study Naeselius K, Arnelund CF, Molin MK. Int J Prosthodont 2008;21:40-4. Purpose: The aim of the present study was to evaluate the clinical outcome of extensive Empress onlays retained with resin-bonded cement. Materials and Methods: One hundred thirty extensive ceramic onlays were placed in premolar and molar regions in 91 patients treated by 2 general practitioners between 1997 and 2000. Seventy-seven percent of the constructions were luted with chemically cured resin composite cement and 23% were luted with dual-cured resin cement. Fifty-nine patients with 81 restorations were clinically evaluated independently by 2 calibrated examiners using the California Dental Association protocol. The mean time in function for all restorations at examination was 49 months. Results: Seventy-five (93%) onlays were still in function after 4 years. Six onlays (7.3%) failed; 1 had lost retention as a result of caries, and 5 had fractured. All failures were in molar regions. Conclusions: Ceramic onlay therapy is an acceptable treatment alternative over a 4-year period, but further long-term data are necessary before this treatment should be considered for general dental practice. Reprinted with permission of Quintessence Publishing.
The Journal of Prosthetic Dentistry
Turker and Sener
bility and success of fiber-reinforced composite resin fixed partial denture (FRCFPD) restorations.8 The polyethylene fibers can be treated to enhance the adhesion between the polyethylene and resin with electrical plasma treatment, which etches the surface so that it can be bonded mechanically to the resin.9,10 After many years of clinical research involving numerous types of reinforcing elements and pontics, such as metal bars, wires, and screens,11-14 the best reinforcing agents are considered to be nonwoven bundle filaments of 10- to 20-µm-diameter high-density polyethylene or polypropylene fibers combined with custom-made composite resin pontics.10 High-strength reinforcement ribbon (Connect; Kerr Hawe SA, Bioggio, Switzerland) is an ultrastrength polyethylene fiber that can be used to provide increased levels of strength to single-tooth stressbearing restorations, provisional composite resin and acrylic resin crowns and fixed partial dentures, orthodontic retainers, periodontal splints, dentures, and occlusal guards, and can also be used for repair and reinforcement.15,16 In vitro studies have shown that fiber-reinforced composite resin (FRC) materials exhibit flexure strength that is greater than or comparable to
metal alloys, but have a lower flexural modulus.16,17 Clinical use and research have shown that fiber-reinforced inlays, resin-bonded FPDs, and fixed complete dentures supported by multiple implants in edentulous jaw can be used satisfactorily both for shortand long-term treatment of missing teeth.16-19 For FRC restorations, functional stresses and occlusal loading of the pontic should be minimized, vertical and horizontal overlap should not be greater than 3 mm,20 and the supporting abutment teeth must be structurally vital and intact to serve as abutments for the fiber-reinforced matrix.21 All-ceramic crowns and ceramic veneers, such as IPS Empress (IPS Empress System; Ivoclar Vivadent, Schaan, Liechtenstein) or In-Ceram (Vita Zahnfabrik, Bad Säckingen, Germany), have excellent esthetics, primarily in anterior regions.22,23 IPS Empress 2 (Ivoclar Vivadent) is a popular ceramic system developed in 1998 that improved upon the crystalline content of IPS Empress.24 Conventional luting cements used in metal ceramic FPDs are not capable of forming a microretentive or specific bond to the prepared enamel and dentin structure and the restorative material.25 The adhesive strength of ceramic restorations to tooth struc-
Assistant Professor, Department of Prosthodontics. Research Assistant, Department of Prosthodontics.
a
b
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October 2008 ture can be improved by treatment with a silane coupling agent to the adherent surface of restorations.26-29 Investigations of surface conditioning with a combination of hydrofluoric acid etching and silane application also have reported favorable bond strengths between composite resin and ceramic.3,30,31 This clinical report describes a treatment alternative for the replacement of a maxillary central incisor with a polyethylene fiber-reinforced composite resin fixed partial denture (PFRCFPD).
CLINICAL REPORT A 26-year-old white woman with a missing right central incisor was referred for prosthetic treatment to the Marmara University School of Dentistry. The chief complaint of the patient was esthetic (Fig. 1). The clinical and radiographic examinations revealed that the patient had approximately 3 mm of vertical and horizontal overlap, a stable maximum intercuspation position, canine protected occlusion, and adequate periodontal health and root support without any residual ridge deficiency. An implantsupported crown, resin-bonded fixed partial denture, conventional fixed partial denture, and a PFRCFPD with an IPS Empress 2 (Ivoclar Vivadent) or composite resin pontic were the treatment options presented to the patient for replacement of the missing incisor. The patient expressed a preference for a PFRCFPD with an IPS Empress 2 pontic rather than an implant-supported prosthesis, because no surgical procedure was needed, the time to insertion would be relatively short, and the outcome would be more esthetic compared to a conventional metalceramic FPD. Furthermore, minimal tooth preparation was needed for this viable restoration option. Preliminary impressions were made conventionally with irreversible hydrocolloid material (Alginate; Chromatic Conforme EN, Grassina, Italy). An initial diagnostic waxing was accomplished on a diagnostic
Turker and Sener
cast (Fig. 2) and evaluated intraorally, using the vacuum-formed matrix to demonstrate to the patient the definitive appearance of the restoration. At this stage, it was observed that the maxillary right lateral incisor needed additional proximal margin preparation to produce space for the pontic to provide symmetry.4 A second waxing was prepared after performing the proximal tooth preparation. The patient was satisfied with the definitive waxing. A vacuum shell matrix (ProForm; Dental Resources, Maple Lake, Minn) was prepared to fabricate the composite resin (Tetric Ceram; Ivoclar Vivadent) provisional pontic. The provisional pontic was polymerized incrementally in the vacuum shell matrix and, after removal from the matrix, was polished (9405.204, 9436F.204; Komet/Gebr Brasseler GmbH, Lemgo, Germany). The polished provisional pontic was maintained in position by bonding it to the abutment teeth.
A complete arch impression was made with a silicone impression material (Speedex; Coltène/Whaledent, Inc, Cuyahoga Falls, Ohio), and the shade was determined (Chromascop; Ivoclar Vivadent). The IPS Empress 2 (Ivoclar Vivadent) pontic was fabricated with a palatal groove, 2 mm deep and 1 mm long (Fig. 3). The horizontal overlap duplicated the original condition of the patient.32 The esthetic appearance of the IPS Empress 2 crown and the path of insertion were evaluated at the trial insertion appointment, and the patient approved the appearance. The palatal groove, at least three quarters of the mesiodistal width of the abutment teeth, was prepared on the palatal surfaces of the right maxillary lateral and left maxillary central incisors using a round diamond rotary cutting instrument (G+K Mahnhardt Dental, Thurmansbang, Germany) with the same dimensions and at the same lev-
1 Missing right central incisor prior to treatment.
2 Initial diagnostic waxing.
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3 All-ceramic pontic with palatal slot.
4 Slots prepared at palatal surface of abutments.
A
B
5 A, Palatal surface of definitive PFRCFPD. B, Facial view of definitive prosthesis. el as the IPS Empress 2 pontic (2 mm deep and 1 mm long) (Fig. 4).12 The grooved surface of the crown and the mesial and distal proximal area were etched with 5% hydrofluoric acid (IPS Ceramic Etching Gel; Ivoclar Vivadent) for 20 seconds. Then a silane coupling agent (Monobond-S; Ivoclar Vivadent) was applied for 60 seconds. The abutment groove surfaces and the mesio-proximal surface of the right maxillary lateral and disto-proximal surface of the left maxillary central incisor were etched with 37% phosphoric acid (Total Etch; Ivoclar Vivadent) for 30 seconds. The preparations were rinsed with water and thoroughly dried. Following the manufacturer’s guidelines, Syntac Primer (Ivoclar Vivadent) and Syntac Adhesive (Ivoclar Vivadent) were applied. A bonding agent (Heliobond; Ivoclar Vivadent) was applied by brush on both the prepared abutment area and the prepared surface of the
crown. The excess bonding agent was removed with the tip of the brush. The distance between the grooves was measured and a piece of fiber ribbon (Connect; Kerr Hawe SA), with the same dimensions as the space between the grooves, was cut and embedded in mixed resin cement. The polyethylene fiber ribbon was placed along the grooves. The fiber-resin combination was carefully placed into the grooves using titanium nitridecoated instruments (Brilliant Esthetic Line Composite Instrument; Coltène/ Whaledent, Inc), the proximal embrasures were cleaned, and cementation was performed immediately by using high-viscosity resin cement (Variolink II; Ivoclar Vivadent). Excess cement was removed with a brush and dental floss. The restorations were polymerized for 40 seconds with a wide-tipped prismatic light-polymerizing unit (Optilux VCL 401, at 420 mW/cm2; Kerr Corp, Orange, Calif ) from the buccal
The Journal of Prosthetic Dentistry
and palatal surfaces of both abutment teeth and from the lingual and vestibular surfaces of the IPS Empress crown restoration for a total of 280 seconds. Additional composite resin (Tetric Ceram; Ivoclar Vivadent) was applied to blend the FRC contours. The occlusion was evaluated with articulating paper (Hanel Articulating Paper; Coltène/Whaledent, Inc), the premature contacts were eliminated, and the definitive restoration was polished (9405.204, 9436F.204; Komet/Gebr Brasseler GmbH) (Fig. 5). Over the 27-month period following cementation of the PFRCFPD, the patient was examined 9 times. Evaluation of the restorations at these visits indicated that there was no plaque accumulation on the fiber-composite resin combination, and no caries was observed on the abutment teeth. Additionally, the patient reported no functional or esthetic problems.
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257
October 2008 DISCUSSION This clinical report describes the replacement of a central incisor with an esthetic and conservative PFRCFPD with an IPS Empress 2 pontic resulting in success over a short-term follow-up. The esthetics of the FRCFPD were shown to be considerably better than the esthetics of FPDs with metal frameworks, as determined visually by other investigators.1 Although this technique was used for an interim method of anterior tooth replacement, its conservative preparation and reported success suggest that it may be considered as a definitive alternative in certain situations. Fabrication of a direct composite resin pontic is effectively accomplished in a single visit, but it is difficult to provide characterization and to obtain a smooth surface at the pontic area, and it has been determined that the longevity of the FPD is threatened by the wear of the particulate veneering composite resin occlusal surface.1 Because of the unpredictability of bonding acrylic resin to composite resin, an acrylic resin denture tooth is not recommended for use as a pontic for any prosthesis other than a provisional partial denture.1 The development of dentin adhesive systems has also led to simpler and minimally invasive preparations.8,25 Adhesive resin cements are composite resins that have a decreased proportion of filler, with an organic polymer matrix of bis-GMA and UDMA, an inorganic filler, bonding agent, initiators, and pigments.23 Newly introduced resin luting agents have higher proportions of filler.23 The combination of the resin luting agent and bonding systems is one of the most important factors for retention of these restorations.33 Until clinical success of the less invasive FPDs is determined, the use of small cavity preparations for the fiber framework with the optional combination of the palatal (lingual) bonding wing is recommended.1 The preparation, an occlusal rest seat,
Turker and Sener
helps to direct masticatory forces and diminishes the debonding stress of the bonding wing.1 In the present clinical report, small preparations, such as slots, provide space for the fiber framework to completely support the pontic element. While luting the restoration, 2 interfaces are formed: the first between the porcelain and the luting composite resin, and a second between the luting composite resin and the enamel and/ or dentin. This luting involves several steps to obtain optimal adhesion.5,8 Etching the intaglio surface of a crown or an extracoronal restoration with hydrofluoric acid followed by the application of a silane is a well known and recommended method to increase bond strength.5 For IPS Empress 2, the hydrofluoric acid (HF) attacks the glassy phase of the glass ceramic, dissolving the surface to the depth of a few micrometers, and, consequently, lithium disilicate crystals protrude from the glassy matrix.24 Without an intermediate medium, and due to the lack of chemical interaction between composite resin and ceramic, the bond depends on the mechanical retentive features of the ceramic surface. Silane has been a medium of choice to provide chemical interaction between dental composite resins and dental ceramics, resulting in a strong bond between the materials.28,29 The modified FRC technique described is simple and easy. It is an affordable and fast solution for patients who reject more invasive treatment. Further studies are needed to evaluate the long-term usefulness of a polyethylene fiber-reinforced composite resin fixed partial denture (PFRCFPD) with an all-ceramic pontic.
SUMMARY This report describes the clinical procedures involved in the fabrication of a PFRCFPD with an all-ceramic pontic, which provided a conservative solution for the restoration of anterior missing teeth.
REFERENCES 1. Vallittu PK, Sevelius C. Resin-bonded, glass fiber-reinforced composite fixed partial dentures: a clinical study. J Prosthet Dent 2000;84:413-8. 2. Corrente G, Vergnano L, Re S, Cardaropoli D, Abundo R. Resin bonded fixed partial dentures and splints in periodontally compromised patients: a 10-year followup. Int J Periodontics Restorative Dent 2000;20:628-36. 3. Ozcan M. The use of chairside silica coating for different dental applications: a clinical report. J Prosthet Dent 2002;87:469-72. 4. Turker SB, Guvenli SY, Arikan A. Replacement of two mandibular central incisors using a zirconium resin-bonded fixed partial denture: a clinical report. J Prosthet Dent 2005;94:499-503. 5. Ozcan M, Akkaya A. New approach to bonding all-ceramic adhesive fixed partial dentures: a clinical report. J Prosthet Dent 2002;88:252-4. 6. Pröbster B, Henrich GM. 11-year follow-up study of resin-bonded fixed partial dentures. Int J Prosthodont 1997;10:259-68. 7. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications in fixed prosthodontics. J Prosthet Dent 2003;90:31-41. 8. Iglesia-Puig MA, Arellano-Cabornero A. Inlay fixed partial denture as a conservative approach for restoring posterior missing teeth: a clinical report. J Prosthet Dent 2003;89:443-5. 9. Jagger DC, Harrison A, Jandt KD. The reinforcement of dentures. J Oral Rehabil 1999;26:185-94. 10.Ellakwa AE, Shortall AC, Shehata MK, Marquis PM. The influence of fibre placement and position on the efficiency of reinforcement of fibre reinforced composite bridgework. J Oral Rehabil 2001;28:785-91. 11.Ladizesky NH, Ho CF, Chow TW. Reinforcement of complete denture bases with continuous high performance polyethylene fibers. J Prosthet Dent 1992;68:934-9. 12.Belvedere PC. Single-sitting, fiber-reinforced fixed bridges for the missing lateral or central incisors in adolescent patients. Dent Clin North Am 1998;42:665-82. 13.Vallittu PK. Prosthodontic treatment with a glass fiber-reinforced resin-bonded fixed partial denture: a clinical report. J Prosthet Dent 1999;82:132-5. 14.Freilich MA, Meiers JC, Duncan JP, Goldberg AJ. Fiber-reinforced composites in clinical dentistry. Chicago: Quintessence; 2000. p. 18-46. 15.Rudo DN, Karbhari VM. Physical behaviors of fiber reinforcement as applied to tooth stabilization. Dent Clin North Am 1999;43:7-35. 16.Freilich MA, Duncan JP, Alarcon EK, Eckrote KA, Goldberg AJ. The design and fabrication of fiber-reinforced implant prostheses. J Prosthet Dent 2002;88:449-54. 17.Anusavice KJ. Phillips’ science of dental materials. 11th ed. St.Louis: Elsevier; 2003. p. 563-620.
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Volume 100 Issue 4 18.Freilich MA, Meiers JC, Duncan JP, Eckrote KA, Goldberg AJ. Clinical evaluation of fiber-reinforced fixed bridges. J Am Dent Assoc 2002;133:1524-34. 19.Freilich MA, Duncan JP, Meiers JC, Goldberg AJ. Preimpregnated, fiber-reinforced prostheses. Part I. Basic rationale and complete-coverage and intracoronal fixed partial denture designs. Quintessence Int 1998;29:689-96. 20.Ricketts RM. Provocations and perceptions in craniofacial orthopedics: dental science and facial art/parts 1 and 2. Vol. 1. Denver: Rocky Mountain Orthodontics; 1990. p. 702-3. 21.Rose E, Frucht S, Jonas IE. Clinical comparison of a multistranded wire and a directbonded polyethylene ribbon-reinforced resin composite used for lingual retention. Quintessence Int 2002;33:579-83. 22.Rosentritt M, Behr M, Lang R, Handel G. Experimental design of FPD made of allceramics and fibre-reinforced composite. Dent Mater 2000;16:159-65.
23.Ferracane JL. Materials in dentistry: principles and applications. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 2001. p. 74-82. 24.Pisani-Proenca J, Erhardt MC, Valandro LF, Gutierrez-Aceves G, Bolanos-Carmona MV, Del Castillo-Salmeron R, et al. Influence of ceramic surface conditioning and resin cements on microtensile bond strength to a glass ceramic. J Prosthet Dent 2004;96:412-7. 25.Edelhoff D, Spiekermann H, Yildirim M. Metal-free inlay-retained fixed partial dentures. Quintessence Int 2001;32:269-81. 26.Hooshmand T, van Noort R, Keshvad A. Bond durability of the resin-bonded and silane treated ceramic surface. Dent Mater 2002;18;179-88. 27.Della Bona A, Anusavice KJ, Hood JA. Effect of ceramic surface treatment on tensile bond strength to a resin cement. Int J Prosthodont 2002;15;248-53. 28.Shen C, Oh WS, Williams JR. Effect of post-silanization drying on the bond strength of composite to ceramic. J Prosthet Dent 2004;91:453-8.
29.Hayakawa T, Horie K, Aida M, Kanaya H, Kobayashi T, Murata Y. The influence of surface conditions and silane agents on the bond of resin to dental porcelain. Dent Mater 1992;8:238-40. 30.Bailey JH. Porcelain-to-composite bond strengths using four organosilane materials. J Prosthet Dent 1989;61:174-7. 31.Llobell A, Nicholls JI, Kois JC, Daly CH. Fatigue life of porcelain repair systems. Int J Prosthodont 1992;5:205-13. 32.Chiche GJ, Pinault A. Esthetics of anterior fixed prosthodontics. Chicago: Quintessence; 1994. p. 115-42. 33.O’Brien WJ. Dental materials and their selection. 3rd ed. Chicago: Quintessence; 2002. p. 132-55. Corresponding author: Dr Sebnem Begum Turker Marmara University Faculty of Dentistry Buyuk Ciftlik Sok. No: 6 34365 Nisantasi Istanbul TURKEY Fax: +902122465247 E-mail: [email protected] Copyright © 2008 by the Editorial Council for The Journal of Prosthetic Dentistry.
Noteworthy Abstracts of the Current Literature Clinical evaluation of all-ceramic onlays: A 4-year retrospective study Naeselius K, Arnelund CF, Molin MK. Int J Prosthodont 2008;21:40-4. Purpose: The aim of the present study was to evaluate the clinical outcome of extensive Empress onlays retained with resin-bonded cement. Materials and Methods: One hundred thirty extensive ceramic onlays were placed in premolar and molar regions in 91 patients treated by 2 general practitioners between 1997 and 2000. Seventy-seven percent of the constructions were luted with chemically cured resin composite cement and 23% were luted with dual-cured resin cement. Fifty-nine patients with 81 restorations were clinically evaluated independently by 2 calibrated examiners using the California Dental Association protocol. The mean time in function for all restorations at examination was 49 months. Results: Seventy-five (93%) onlays were still in function after 4 years. Six onlays (7.3%) failed; 1 had lost retention as a result of caries, and 5 had fractured. All failures were in molar regions. Conclusions: Ceramic onlay therapy is an acceptable treatment alternative over a 4-year period, but further long-term data are necessary before this treatment should be considered for general dental practice. Reprinted with permission of Quintessence Publishing.
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