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Use of an alternative pontic foundation technique for a fiber-reinforced composite fixed partial denture: A clinical report
Use of an alternative pontic foundation technique for a fiber-reinforced composite fixed partial denture: A clinical report Emrah Ayna, DDS, PhD,a and Sema Celenk, DDS, PhDb Department of Prosthodontics and Pediatric Dentistry, Faculty of Dentistry, Dicle University, Diyarbakir, Turkey This article describes the treatment of a patient for whom a fiber-composite laminate dowel and core and polyethylene fiber were used as a conservative alternative to provide a dowel-and-core and fixed partial denture foundation. The treatment plan included removing the existing restoration on the maxillary right first molar, placing a fiber-reinforced resin dowel and core for retention and reinforcement of the maxillary first premolar, and fabricating a definitive restoration using polyethylene fiber to reinforce the fixed partial denture. (J Prosthet Dent 2005;93:412-5.)
T
he teeth adjacent to the area where a single tooth is missing may have surface restorations or carious lesions that involve 1 to 3 tooth surfaces. In these situations, a missing tooth may be restored using a conservative resin-bonded inlay as an abutment for a fixed partial denture (FPD).1 During the last 2 decades, there has been increased use of fiber-reinforced FPDs as an attractive alternative to conventional metal FPDs for replacing missing teeth.2,3,4 The ceramic optimized polymer (ceromer)/fiber-reinforced composite system consists of a load-bearing fiber framework and a veneering composite with highly filled ceramic particles. While the clinical success of this type of restoration warrants long-term evaluation of its predictability, this system has demonstrated good results in certain situations. Clinical studies of fiber-reinforced restorations have shown a relatively high success rate over a short evaluation period.4 Recently, plasma-treated polyethylene fibers have been embedded in resin composites to reinforce the materials used for splinting periodontally involved teeth, replacing missing teeth, and restoration.5-10 In a recent clinical report, Eskitascioglu and Belli11 indicated that it was possible to fabricate a dowel-andcore system conservatively, using an adhesive restorative material and a reinforced bondable ribbon (Ribbond; Ribbond Inc, Seattle, Wash). This article describes the treatment of a patient for whom a fiber-composite laminate dowel and core and polyethylene fiber were used as a conservative alternative to provide a dowel-and-core and FPD foundation.
CLINICAL REPORT A 28-year-old woman, missing the maxillary right second premolar and having received endodontic treatment for the maxillary first premolar with an excessive Presented at the 9th Congress of the Balkan Stomatological Society, Ohrid, Macedonia, May 2004. a Assistant Professor. b Assistant Professor.
412 THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. Initial clinical presentation.
loss of tooth structure, was referred to the Dicle University Faculty of Dentistry, Department of Prosthodontics, Diyarbakir, Turkey. On examination (Fig. 1), the patient had good periodontal health and a satisfactorily endodontically treated maxillary right first premolar. In addition, an amalgam restoration on the mesio-occlusal surface of the maxillary right first molar was noted. The patient had a stable maximum intercuspation position, normal vertical and horizontal overlap, and canine-protected occlusion. The treatment plan included removing the existing restoration on the maxillary right first molar, placing a fiber-reinforced resin dowel and core (Ribbond; Ribbond Inc) for retention and reinforcement of the maxillary first premolar, and fabricating a definitive restoration with polyethylene fiber (Ribbond Inc) to reinforce the FPD. This approach was relatively less invasive and permitted other alternative treatments in the future. Additionally, it was economical and timesaving compared to fabrication of a conventional FPD. First, a vinyl polysiloxane (VPS) impression (Lastic Xtra; Kettenbach, Eschenburg Germany) was made of the maxillary teeth, and an irreversible hydrocolloid impression (Cavex CA 37; Cavex, Haarlem, Holland) was VOLUME 93 NUMBER 5
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Fig. 2. Pontic placed on impression material.
Fig. 3. VPS index.
Fig. 4. View of maxillary right first molar and first premolar after amalgam restoration was removed and pulp chamber and coronal portion of root canal were cleaned.
Fig. 5. Ribbon placed after index was positioned.
Fig. 6. Occlusal view of definitive restoration.
Fig. 7. Buccal view of definitive restoration.
made of the mandibular teeth. The diagnostic casts were poured with Type IV dental stone (Giludur; Fachbereich Dental, Ludwigshath, Germany). An artifi-
cial maxillary second premolar (MajorDent; Major Prodotti Dentari, Moncalieri, Italy) was used as a simulated pontic. The pontic was adjusted to the adjacent
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and opposing teeth. The VPS impression was injected onto the cast, and the pontic was placed in the planned position (Fig. 2). The maxillary and mandibular diagnostic casts were hand articulated. The pontic was removed when the impression material polymerized (Fig. 3). This impression served as an index of the relationship of the inferior surface of the pontic to the residual ridge. The existing amalgam restoration on the maxillary right first molar was removed, and an inlay preparation was made (Fig. 4). The pulp chamber and coronal portion of the root canal of the maxillary right first premolar were cleaned and irrigated with water and dried with paper points. The width of the reinforcement fiber was determined, and a 2-mm width was selected. The prepared dowel space was measured with a periodontal probe. The distance from the axial groove of the inlay preparation of the maxillary right first molar to the root canal of the maxillary right first premolar was determined. This measurement was tripled to determine the length of fiber needed. Two pieces of fiber were then cut with special scissors (Ribbond Shears; Ribbond). The fiber pieces were then coated with a dualpolymerizing resin composite (Liner Bond II V; Kuraray, Tokyo, Japan) and placed in a light-protective container. The internal surfaces of the root canal and pulp chamber were treated with the primer of the same system (Liner Bond II V, primer A and B mixture; Kuraray) for 30 seconds and dried with a gentle air stream for 15 seconds. A dual-polymerizing dentin bonding agent (Liner Bond II V, bond A and B mixture; Kuraray) was applied to the internal surfaces of the canal and pulp chamber and thinned with a brush. A highly filled, dual-polymerizing hybrid resin (Panavia-F; Kuraray) was injected into the canal space. One piece of the reinforcement fiber, which had been coated with bonding agent, was folded and packed into the canal space as tightly as possible using an endodontic plugger. A second piece was packed into the canal space perpendicular to the first piece. The excess resin was removed, and the free ends of the fiber were extended to the inlay preparation of the maxillary first molar after the index had been placed on the edentulous area. The resin-soaked ribbon was applied using an incremental technique (Fig. 5). As many, and as directionally varied, fiber-reinforced ribbons as could be reasonably placed were used to create a strong, resilient, and retentive substructure.6,10 The bulk of the crown of the pontic and maxillary first premolar and the inlay restoration of the maxillary first molar were formed using a layer of a hybrid resin (Clearfil AP-X; Kuraray). The index was removed after the resin restoration had polymerized for at least 2 minutes with a polymerizing unit (Polofil Lux; VOCO, Caxhaven, Germany). The restoration was shaped and polished with contouring and polishing discs (Sof Lex; 3M ESPE, St. Paul, Minn) (Fig. 6), and 414
AYNA AND CELENK
using the index to provide a good reproduction of the morphology of the pontic and proximal gingival embrasure (Fig. 7). At the 12-month clinical and radiographic recall examination, no problems with the restoration were identified.
DISCUSSION This clinical report describes a conservative, esthetic fiber-reinforced composite FPD foundation using a direct technique that incorporates a bondable ribbon. There have been recent reports describing use of reinforcement fibers for inlay-retained FPDs, dowels and cores, and composite pontics fabricated using a direct technique.5,7,10 Although this approach was initially intended as an interim method of anterior tooth replacement, its inherent advantages and relative noninvasiveness suggest that it may be considered as a definitive alternative in certain situations. However, the limitations of the technique require that patients be carefully selected. Short spans, not exceeding 8 to 10 mm, are recommended.5 Functional stresses and occlusal loading of the pontic tooth should be minimal, and the supporting abutment teeth must be structurally sound enough to serve as retainers for the reinforced-fiber matrix. Traditional metal-ceramic FPDs or implants are undoubtedly stronger, clinically proven, and reliable and should, therefore, remain the first consideration in discussions with the patient.5 Adaptation of the pontic surface to the ridge is a problem with directly applied fiber-reinforced fixed partial restorations.5 This problem was overcome by reproducing the pontic surface in contact with the residual ridge. There are several advantages with this technique. First, the procedure can be completed in 1 appointment and, apart from the fiber-mesh material, requires no unusual materials or instrumentation. Second, because this approach is relatively less invasive, it permits the patient the option of other, more traditional tooth replacement methods in the future. Third, it is more economic than conventional restorations. Adjustments to the design, esthetic details, and occlusal and softtissue relationships may be performed immediately, or in a minimum of time, during recall appointments.1-5,7
SUMMARY This article describes a conservative alternative preparation for a pontic of a direct fiber-reinforced composite FPD foundation. The treatment plan included removing the existing restoration on the maxillary right first molar, placing a fiber-reinforced resin dowel-andcore for retention and reinforcement of the maxillary first premolar, and fabricating a definitive restoration with polyethylene fiber to reinforce the inlay and dowel-and-core–retained FPD. VOLUME 93 NUMBER 5
AYNA AND CELENK
REFERENCES 1. Gohring TN, Mormann WH, Lutz F. Clinical and scanning electron microscopic evaluation of fiber-reinforced inlay fixed partial dentures: preliminary results after one year. J Prosthet Dent 1999;82:662-8. 2. Iglesia-Puig MA, Arellono-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. 3. Vallittu PK, Sevelius C. Resin-bonded, glass fiber-reinforced composite fixed partial dentures: a clinical study. J Prosthet Dent 2000;84:413-8. 4. Song HY, Yi YJ, Cho LR, Park DY. Effects of two preparation designs and pontic distance on bending and fracture strength of fiber-reinforced composite inlay fixed partial dentures. J Prosthet Dent 2003;90:347-53. 5. Rose E, Frucht S, Jonas IE. Clinical comparison of a multistranded wire and a direct-bonded polyethylene ribbon-reinforced resin composite used for lingual retention. Quintessence Int 2002;33:579-83. 6. van Wijlen P. A modified technique for direct, fibre-reinforced, resinbonded bridges: clinical case reports. J Can Dent Assoc 2000;66:367-71. 7. Eskitascioglu G, Belli S, Kalkan M. Evaluation of two post core systems using two different methods (fracture strength test and a finite elemental stress analysis). J Endodon 2002;28:629-33. 8. Ahlstrand WM, Finger WJ. Direct and indirect fiber-reinforced fixed partial dentures: case reports. Quintessence Int 2002;33:359-65. 9. Newman MP, Yaman P, Dennison J, Rafter M, Billy E. Fracture resistance of endodontically treated teeth restored with composite posts. J Prosthet Dent 2003;89:360-7.
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10. Behr M, Rosentritt M, Ledwinsky E, Handel G. Fracture resistance and marginal adaptation of conventionally cemented fiber-reinforced composite three unit FPDs. Int J Prosthodont 2002;15:467-72. 11. Eskitascioglu G, Belli S. Use of bondable reinforcement fiber postand-core buildup in an endodontically treated tooth: a case report. Quintessence Int 2002;33:549-51. Reprint requests to: DR EMRAH AYNA DEPARTMENT OF PROSTHODONTICS FACULTY OF DENTISTRY DICLE UNIVERSITY DIYARBAKıR TURKEY FAX: 90-412-248-8100 E-MAIL: [email protected] or [email protected] 0022-3913/$30.00 Copyright Ó 2005 by The Editorial Council of The Journal of Prosthetic Dentistry.
doi:10.1016/j.prosdent.2005.03.004
415
T
he teeth adjacent to the area where a single tooth is missing may have surface restorations or carious lesions that involve 1 to 3 tooth surfaces. In these situations, a missing tooth may be restored using a conservative resin-bonded inlay as an abutment for a fixed partial denture (FPD).1 During the last 2 decades, there has been increased use of fiber-reinforced FPDs as an attractive alternative to conventional metal FPDs for replacing missing teeth.2,3,4 The ceramic optimized polymer (ceromer)/fiber-reinforced composite system consists of a load-bearing fiber framework and a veneering composite with highly filled ceramic particles. While the clinical success of this type of restoration warrants long-term evaluation of its predictability, this system has demonstrated good results in certain situations. Clinical studies of fiber-reinforced restorations have shown a relatively high success rate over a short evaluation period.4 Recently, plasma-treated polyethylene fibers have been embedded in resin composites to reinforce the materials used for splinting periodontally involved teeth, replacing missing teeth, and restoration.5-10 In a recent clinical report, Eskitascioglu and Belli11 indicated that it was possible to fabricate a dowel-andcore system conservatively, using an adhesive restorative material and a reinforced bondable ribbon (Ribbond; Ribbond Inc, Seattle, Wash). This article describes the treatment of a patient for whom a fiber-composite laminate dowel and core and polyethylene fiber were used as a conservative alternative to provide a dowel-and-core and FPD foundation.
CLINICAL REPORT A 28-year-old woman, missing the maxillary right second premolar and having received endodontic treatment for the maxillary first premolar with an excessive Presented at the 9th Congress of the Balkan Stomatological Society, Ohrid, Macedonia, May 2004. a Assistant Professor. b Assistant Professor.
412 THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. Initial clinical presentation.
loss of tooth structure, was referred to the Dicle University Faculty of Dentistry, Department of Prosthodontics, Diyarbakir, Turkey. On examination (Fig. 1), the patient had good periodontal health and a satisfactorily endodontically treated maxillary right first premolar. In addition, an amalgam restoration on the mesio-occlusal surface of the maxillary right first molar was noted. The patient had a stable maximum intercuspation position, normal vertical and horizontal overlap, and canine-protected occlusion. The treatment plan included removing the existing restoration on the maxillary right first molar, placing a fiber-reinforced resin dowel and core (Ribbond; Ribbond Inc) for retention and reinforcement of the maxillary first premolar, and fabricating a definitive restoration with polyethylene fiber (Ribbond Inc) to reinforce the FPD. This approach was relatively less invasive and permitted other alternative treatments in the future. Additionally, it was economical and timesaving compared to fabrication of a conventional FPD. First, a vinyl polysiloxane (VPS) impression (Lastic Xtra; Kettenbach, Eschenburg Germany) was made of the maxillary teeth, and an irreversible hydrocolloid impression (Cavex CA 37; Cavex, Haarlem, Holland) was VOLUME 93 NUMBER 5
AYNA AND CELENK
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 2. Pontic placed on impression material.
Fig. 3. VPS index.
Fig. 4. View of maxillary right first molar and first premolar after amalgam restoration was removed and pulp chamber and coronal portion of root canal were cleaned.
Fig. 5. Ribbon placed after index was positioned.
Fig. 6. Occlusal view of definitive restoration.
Fig. 7. Buccal view of definitive restoration.
made of the mandibular teeth. The diagnostic casts were poured with Type IV dental stone (Giludur; Fachbereich Dental, Ludwigshath, Germany). An artifi-
cial maxillary second premolar (MajorDent; Major Prodotti Dentari, Moncalieri, Italy) was used as a simulated pontic. The pontic was adjusted to the adjacent
MAY 2005
413
THE JOURNAL OF PROSTHETIC DENTISTRY
and opposing teeth. The VPS impression was injected onto the cast, and the pontic was placed in the planned position (Fig. 2). The maxillary and mandibular diagnostic casts were hand articulated. The pontic was removed when the impression material polymerized (Fig. 3). This impression served as an index of the relationship of the inferior surface of the pontic to the residual ridge. The existing amalgam restoration on the maxillary right first molar was removed, and an inlay preparation was made (Fig. 4). The pulp chamber and coronal portion of the root canal of the maxillary right first premolar were cleaned and irrigated with water and dried with paper points. The width of the reinforcement fiber was determined, and a 2-mm width was selected. The prepared dowel space was measured with a periodontal probe. The distance from the axial groove of the inlay preparation of the maxillary right first molar to the root canal of the maxillary right first premolar was determined. This measurement was tripled to determine the length of fiber needed. Two pieces of fiber were then cut with special scissors (Ribbond Shears; Ribbond). The fiber pieces were then coated with a dualpolymerizing resin composite (Liner Bond II V; Kuraray, Tokyo, Japan) and placed in a light-protective container. The internal surfaces of the root canal and pulp chamber were treated with the primer of the same system (Liner Bond II V, primer A and B mixture; Kuraray) for 30 seconds and dried with a gentle air stream for 15 seconds. A dual-polymerizing dentin bonding agent (Liner Bond II V, bond A and B mixture; Kuraray) was applied to the internal surfaces of the canal and pulp chamber and thinned with a brush. A highly filled, dual-polymerizing hybrid resin (Panavia-F; Kuraray) was injected into the canal space. One piece of the reinforcement fiber, which had been coated with bonding agent, was folded and packed into the canal space as tightly as possible using an endodontic plugger. A second piece was packed into the canal space perpendicular to the first piece. The excess resin was removed, and the free ends of the fiber were extended to the inlay preparation of the maxillary first molar after the index had been placed on the edentulous area. The resin-soaked ribbon was applied using an incremental technique (Fig. 5). As many, and as directionally varied, fiber-reinforced ribbons as could be reasonably placed were used to create a strong, resilient, and retentive substructure.6,10 The bulk of the crown of the pontic and maxillary first premolar and the inlay restoration of the maxillary first molar were formed using a layer of a hybrid resin (Clearfil AP-X; Kuraray). The index was removed after the resin restoration had polymerized for at least 2 minutes with a polymerizing unit (Polofil Lux; VOCO, Caxhaven, Germany). The restoration was shaped and polished with contouring and polishing discs (Sof Lex; 3M ESPE, St. Paul, Minn) (Fig. 6), and 414
AYNA AND CELENK
using the index to provide a good reproduction of the morphology of the pontic and proximal gingival embrasure (Fig. 7). At the 12-month clinical and radiographic recall examination, no problems with the restoration were identified.
DISCUSSION This clinical report describes a conservative, esthetic fiber-reinforced composite FPD foundation using a direct technique that incorporates a bondable ribbon. There have been recent reports describing use of reinforcement fibers for inlay-retained FPDs, dowels and cores, and composite pontics fabricated using a direct technique.5,7,10 Although this approach was initially intended as an interim method of anterior tooth replacement, its inherent advantages and relative noninvasiveness suggest that it may be considered as a definitive alternative in certain situations. However, the limitations of the technique require that patients be carefully selected. Short spans, not exceeding 8 to 10 mm, are recommended.5 Functional stresses and occlusal loading of the pontic tooth should be minimal, and the supporting abutment teeth must be structurally sound enough to serve as retainers for the reinforced-fiber matrix. Traditional metal-ceramic FPDs or implants are undoubtedly stronger, clinically proven, and reliable and should, therefore, remain the first consideration in discussions with the patient.5 Adaptation of the pontic surface to the ridge is a problem with directly applied fiber-reinforced fixed partial restorations.5 This problem was overcome by reproducing the pontic surface in contact with the residual ridge. There are several advantages with this technique. First, the procedure can be completed in 1 appointment and, apart from the fiber-mesh material, requires no unusual materials or instrumentation. Second, because this approach is relatively less invasive, it permits the patient the option of other, more traditional tooth replacement methods in the future. Third, it is more economic than conventional restorations. Adjustments to the design, esthetic details, and occlusal and softtissue relationships may be performed immediately, or in a minimum of time, during recall appointments.1-5,7
SUMMARY This article describes a conservative alternative preparation for a pontic of a direct fiber-reinforced composite FPD foundation. The treatment plan included removing the existing restoration on the maxillary right first molar, placing a fiber-reinforced resin dowel-andcore for retention and reinforcement of the maxillary first premolar, and fabricating a definitive restoration with polyethylene fiber to reinforce the inlay and dowel-and-core–retained FPD. VOLUME 93 NUMBER 5
AYNA AND CELENK
REFERENCES 1. Gohring TN, Mormann WH, Lutz F. Clinical and scanning electron microscopic evaluation of fiber-reinforced inlay fixed partial dentures: preliminary results after one year. J Prosthet Dent 1999;82:662-8. 2. Iglesia-Puig MA, Arellono-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. 3. Vallittu PK, Sevelius C. Resin-bonded, glass fiber-reinforced composite fixed partial dentures: a clinical study. J Prosthet Dent 2000;84:413-8. 4. Song HY, Yi YJ, Cho LR, Park DY. Effects of two preparation designs and pontic distance on bending and fracture strength of fiber-reinforced composite inlay fixed partial dentures. J Prosthet Dent 2003;90:347-53. 5. Rose E, Frucht S, Jonas IE. Clinical comparison of a multistranded wire and a direct-bonded polyethylene ribbon-reinforced resin composite used for lingual retention. Quintessence Int 2002;33:579-83. 6. van Wijlen P. A modified technique for direct, fibre-reinforced, resinbonded bridges: clinical case reports. J Can Dent Assoc 2000;66:367-71. 7. Eskitascioglu G, Belli S, Kalkan M. Evaluation of two post core systems using two different methods (fracture strength test and a finite elemental stress analysis). J Endodon 2002;28:629-33. 8. Ahlstrand WM, Finger WJ. Direct and indirect fiber-reinforced fixed partial dentures: case reports. Quintessence Int 2002;33:359-65. 9. Newman MP, Yaman P, Dennison J, Rafter M, Billy E. Fracture resistance of endodontically treated teeth restored with composite posts. J Prosthet Dent 2003;89:360-7.
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THE JOURNAL OF PROSTHETIC DENTISTRY
10. Behr M, Rosentritt M, Ledwinsky E, Handel G. Fracture resistance and marginal adaptation of conventionally cemented fiber-reinforced composite three unit FPDs. Int J Prosthodont 2002;15:467-72. 11. Eskitascioglu G, Belli S. Use of bondable reinforcement fiber postand-core buildup in an endodontically treated tooth: a case report. Quintessence Int 2002;33:549-51. Reprint requests to: DR EMRAH AYNA DEPARTMENT OF PROSTHODONTICS FACULTY OF DENTISTRY DICLE UNIVERSITY DIYARBAKıR TURKEY FAX: 90-412-248-8100 E-MAIL: [email protected] or [email protected] 0022-3913/$30.00 Copyright Ó 2005 by The Editorial Council of The Journal of Prosthetic Dentistry.
doi:10.1016/j.prosdent.2005.03.004
415