Natural Tooth Pontic in Periodontally Compromised Tooth
Content
Int J Dent Case Reports 2011; 1(3): 20-24 © IJDCR 2011. All rights reserved www.ijdcr.com CAS E REPORT NATURAL TOOTH PONTIC IN PERIODONTALLY COMPROMIS ED TOOTH Maryam Moezizadeh 1 1
Associate Professor, Department of Operat ive Dentistry, School of Dentistry, Shaheed Beheshti University of Medical Sciences, Tehran - Iran Address for Correspondence Dr. Maryam Moezizadeh, DDS, M SC Flat no. 8; Door no. 287, Bu ilding 280 Dolat Ave., Pasdaran Street, Tehran - Iran Telephone number: 0098-21-88 77 84 85 Fax No. : 0098-21-88 77 85 84 E mail: [email protected]
ABSTRACT This article describes the replacement of periodontically co mpro mised tooth by natural tooth pontic technique using resin composite and fiber.
Following extraction and root resection of the maxillary central incisor, the pulp
chamber was cleaned of any pulp tissue and filled with co mposite resin follo wing wh ich it was acid etched and bonded to adjacent teeth and reinforced with pre- imp regnated rein fiber in order to increase the retention of the tooth pontic. Key words: fiber reinforced co mposites; fiber position and orientation; fracture resistance
Moezizadeh
Natural Tooth Pontic
INTRODUCTION:
CLINICAL TECHNIQUE:
Tooth loss in esthetic zone because of trauma, periodontal disease , failed endodontic therapy and root resorption is very challenging for dentist and need immediate treat ment(1,2) .
A 40 years old wo man with malposed anterior maxillary right central incisor presented in dental clin ic. (Fig .1)
Most of the patients demand immediate treat ment because they usually suffer fro m psychological trauma and their social life gets affected by compro mised esthetic (3, 4). Use of dental imp lant as restoring and replacement of missing tooth is the first and the best option for such situations, but high cost of imp lant prevents use of it and as a result less expensive treatment options should be considered. Fixed partial denture like bridge can also be used but it requires preparing of adjacent teeth and using them as abutments to support pontic and it is not a very conservative type of restoration because there is always chance of loss of adjacent prepared teeth by caries or periodontal disease. Another method for replacement of missing tooth is removable partial denture which is not acceptable by many patients.
Figure 1 After radiographic and clinical examination of patient it was revealed that she is suffering fro m periodontal disease and had a periodontal surgery few years ago. The tooth was moved from its original position and started proclining labially and it had become so severe that had severely compro mised patient’s esthetic in such a way that she avoided smiling because of unpleasant appearance. The first option recommended to her was extraction of malpopsed central incisor and replacement of it with imp lant, but because of high cost of implant she rejected that option and natural tooth pontic for replacement of missing area was reco mmended wh ich was accepted by patient.
Since the introduction of adhesive dentistry and many improvements wh ich are achieved in this field, the acid etch bridge technique has been introduced in which a fiber reinforced co mposite or even patient’s own natural tooth in cases where crown portion of tooth is intact and sound can be used(5). Use of patient’s own tooth as a pontic and bonding it to adjacent teeth is more conservative and less time consuming compared to other techniques and since such patients suffer fro m severe psychological trauma due to loss of tooth in esthetic zone, this technique is of great use because it brings the patient’s smile back to his or her face and more than patient’s tooth, his confidence will be restored (1, 2).
The diseased tooth was extracted carefully without any trauma to the tooth. One week t ime was given for healing of g ingiva, then the root of tooth was resected 2 mm below cemento enamel junction with a 556 bur (SS White Burs), access was opened and inside pulp chamber was cleaned fro m any pulp tissue and filled with bonded composite resin .(Fig .2)
A natural tooth pontic offers the benefits of being the right size, shape and color. When the crown of the tooth is in good condition, it can be temporarily bonded easily to the adjacent teeth with light-cured restorative material (2, 6). This paper describes clin ical steps of natural tooth pontic as a restorative option for replacement of ext racted periodontal compro mised central incisor.
The gingival aspect of the tooth was smoothened and shaped to be rounded. A modified ridge lap shape was given to cervical area to facilitate cleaning and appearance of emerging profile. The pontic was also cleaned with pu mice, washed and dried.
21 Int J Dent Case Reports
Nov 2011, Vol.1, No. 3
Moezizadeh
Natural Tooth Pontic
A preimpregnated fiber was cut for connecting the pontic tooth to adjacent teeth. To measure the length of fiber needed, a piece of dental floss was placed on the facial surfaces of the teeth, extending fro m the left maxillary central incisor to right maxillary lateral incisor .The pontic was positioned carefully and a drop of flowable co mposite was placed on mesial and distal aspects of pontic to stabilize its position correctly and prevent any movement during placement of fiber. Since patient had open bite and no contact was present between upper and lo wer teeth, no preparations were made on pontic and adjacent teeth as groove or class III p reparation and there was enough space for placing fiber and composite over it. After positioning the fiber on pontic and adjacent teeth composite was placed over fiber and light cured for 40 seconds. (Fig .4-6)
Figure 2 Adjacent teeth were also cleaned with slurry of pumice and dried, then acid etched with 35% phosphoric acid and unfilled bonding agent ( Margin Bond) was applied on them using micro brush and light cured for 20 seconds using light curing LED unit for 20 seconds , at the same time the pontic tooth was immersed into 37 percent phosphoric acid for 30 seconds , washed, dried, and unfilled bonding agent was applied and light cured using LED light curing unit for 20 seconds from all the aspects.(Fig . 3)
Figure 4 Since the teeth are now joined together, it is important that the patient have demonstrated how to clean under pontic and the gingival embrasure areas between the teeth using superfloss. The patient was shown how to use a proximal b rush to clean the embrasure areas.
Figure 3
22 Int J Dent Case Reports
Nov 2011, Vol.1, No. 3
Moezizadeh
Natural Tooth Pontic
DISCUSS ION:
Figure 5
Replacement of missing anterior tooth using a natural tooth pontic technique is an intermediary restoration and may not be used as permanent restoration for long term. Th is technique can not be used for every patient and some important factors should be considered before performing such restorations which among them are: patient’s bite, interfering parafunctional habits, inadequate occlusal clearance space for reinforced fiber or orthodontic wirecomposite resin bonding, inability to maintain isolation of field during bonding procedures, primary dentition and high esthetic expectations of patient, but this technique also has some advantages like:good aesthetic results, preservation of natural crown structure, no laboratory work required, reduced psychological impact on the patient, this technique is reversible and allows other restorative options to be evaluated, micro-resiliency of pontic allo ws stimu lation of underlying t issue and avoids excessive post-extraction ridge resorption(5,7-9).
It is worthy to mention that few years ago mandibular central incisors of same patient were ext racted due to periodontal disease and the same teeth used as natural teeth pontics and replaced the missing site. The same above mentioned technique was used by the same operator few years ago wh ich is still retained in patient mouth and functioning properly. (Fig. 7)
Figure 6 CONCLUS ION: Natural tooth pontic can be used as interim restoration for replacement of missing anterior tooth. This technique is simp le, less time consuming, provides good esthetic and function. However, this procedure is highly operator-dependent and demands appropriate case selection and precise technique. Appropriate patient education and instruction to clean the gingival embrasures and avoid having heavy bite is very crit ical and important. Figure 7
23 Int J Dent Case Reports
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Moezizadeh
Natural Tooth Pontic
REFERENCES 1-
2-
3-
4-
5-
Parolia, A., Shenoy, K. M., Tho mas, M. S. and Mohan, M. Use of a natural tooth crown as a pontic fo llo wing cervical root fracture: a case report. Aus End J. 2010; 36: 35–38. 6- Lambert J. Stu mpel . The natural tooth pontic; Simplified. CDA.J .2004; 32: 257260. 7- Ashley M, Holden V. An immed iate adhesive bridge using the natural tooth. Br Dent J 1998; 184: 18–20. 8- Edelhoff D, Spiekermann H, Yildirim M. A review of esthetic pontic design options. Quintessence Int 2002; 33: 736–46. 9- Walsh LJ, Liew VP. The natural tooth pontic – a compro mise treat ment for periodontally involved anterior teeth. Aus Dent J 1990; 35: 405–8.
Kermanshah H, Motevasselian F .Immed iate tooth replacement using fiber-reinfo rced composite and natural tooth pontic. Oper Dent. 2010 ; 35: 238-245. James L., Kretzschma R. The natural tooth pontic A temporary solution fo r a d ifficult esthetic situation JADA. 2001; 132: 15521553. Lee GTR. Ut ilization of a natural tooth in acid-etch bridging. J Dent Child. 1988; 55:201-204. Livaditis GJ , Thompson VP. Etched castings: an imp roved retentive mechanism for resin-bonded retainers. J Prosthet Dent. 1982; 47:52-58.
24 Int J Dent Case Reports
Nov 2011, Vol.1, No. 3
Associate Professor, Department of Operat ive Dentistry, School of Dentistry, Shaheed Beheshti University of Medical Sciences, Tehran - Iran Address for Correspondence Dr. Maryam Moezizadeh, DDS, M SC Flat no. 8; Door no. 287, Bu ilding 280 Dolat Ave., Pasdaran Street, Tehran - Iran Telephone number: 0098-21-88 77 84 85 Fax No. : 0098-21-88 77 85 84 E mail: [email protected]
ABSTRACT This article describes the replacement of periodontically co mpro mised tooth by natural tooth pontic technique using resin composite and fiber.
Following extraction and root resection of the maxillary central incisor, the pulp
chamber was cleaned of any pulp tissue and filled with co mposite resin follo wing wh ich it was acid etched and bonded to adjacent teeth and reinforced with pre- imp regnated rein fiber in order to increase the retention of the tooth pontic. Key words: fiber reinforced co mposites; fiber position and orientation; fracture resistance
Moezizadeh
Natural Tooth Pontic
INTRODUCTION:
CLINICAL TECHNIQUE:
Tooth loss in esthetic zone because of trauma, periodontal disease , failed endodontic therapy and root resorption is very challenging for dentist and need immediate treat ment(1,2) .
A 40 years old wo man with malposed anterior maxillary right central incisor presented in dental clin ic. (Fig .1)
Most of the patients demand immediate treat ment because they usually suffer fro m psychological trauma and their social life gets affected by compro mised esthetic (3, 4). Use of dental imp lant as restoring and replacement of missing tooth is the first and the best option for such situations, but high cost of imp lant prevents use of it and as a result less expensive treatment options should be considered. Fixed partial denture like bridge can also be used but it requires preparing of adjacent teeth and using them as abutments to support pontic and it is not a very conservative type of restoration because there is always chance of loss of adjacent prepared teeth by caries or periodontal disease. Another method for replacement of missing tooth is removable partial denture which is not acceptable by many patients.
Figure 1 After radiographic and clinical examination of patient it was revealed that she is suffering fro m periodontal disease and had a periodontal surgery few years ago. The tooth was moved from its original position and started proclining labially and it had become so severe that had severely compro mised patient’s esthetic in such a way that she avoided smiling because of unpleasant appearance. The first option recommended to her was extraction of malpopsed central incisor and replacement of it with imp lant, but because of high cost of implant she rejected that option and natural tooth pontic for replacement of missing area was reco mmended wh ich was accepted by patient.
Since the introduction of adhesive dentistry and many improvements wh ich are achieved in this field, the acid etch bridge technique has been introduced in which a fiber reinforced co mposite or even patient’s own natural tooth in cases where crown portion of tooth is intact and sound can be used(5). Use of patient’s own tooth as a pontic and bonding it to adjacent teeth is more conservative and less time consuming compared to other techniques and since such patients suffer fro m severe psychological trauma due to loss of tooth in esthetic zone, this technique is of great use because it brings the patient’s smile back to his or her face and more than patient’s tooth, his confidence will be restored (1, 2).
The diseased tooth was extracted carefully without any trauma to the tooth. One week t ime was given for healing of g ingiva, then the root of tooth was resected 2 mm below cemento enamel junction with a 556 bur (SS White Burs), access was opened and inside pulp chamber was cleaned fro m any pulp tissue and filled with bonded composite resin .(Fig .2)
A natural tooth pontic offers the benefits of being the right size, shape and color. When the crown of the tooth is in good condition, it can be temporarily bonded easily to the adjacent teeth with light-cured restorative material (2, 6). This paper describes clin ical steps of natural tooth pontic as a restorative option for replacement of ext racted periodontal compro mised central incisor.
The gingival aspect of the tooth was smoothened and shaped to be rounded. A modified ridge lap shape was given to cervical area to facilitate cleaning and appearance of emerging profile. The pontic was also cleaned with pu mice, washed and dried.
21 Int J Dent Case Reports
Nov 2011, Vol.1, No. 3
Moezizadeh
Natural Tooth Pontic
A preimpregnated fiber was cut for connecting the pontic tooth to adjacent teeth. To measure the length of fiber needed, a piece of dental floss was placed on the facial surfaces of the teeth, extending fro m the left maxillary central incisor to right maxillary lateral incisor .The pontic was positioned carefully and a drop of flowable co mposite was placed on mesial and distal aspects of pontic to stabilize its position correctly and prevent any movement during placement of fiber. Since patient had open bite and no contact was present between upper and lo wer teeth, no preparations were made on pontic and adjacent teeth as groove or class III p reparation and there was enough space for placing fiber and composite over it. After positioning the fiber on pontic and adjacent teeth composite was placed over fiber and light cured for 40 seconds. (Fig .4-6)
Figure 2 Adjacent teeth were also cleaned with slurry of pumice and dried, then acid etched with 35% phosphoric acid and unfilled bonding agent ( Margin Bond) was applied on them using micro brush and light cured for 20 seconds using light curing LED unit for 20 seconds , at the same time the pontic tooth was immersed into 37 percent phosphoric acid for 30 seconds , washed, dried, and unfilled bonding agent was applied and light cured using LED light curing unit for 20 seconds from all the aspects.(Fig . 3)
Figure 4 Since the teeth are now joined together, it is important that the patient have demonstrated how to clean under pontic and the gingival embrasure areas between the teeth using superfloss. The patient was shown how to use a proximal b rush to clean the embrasure areas.
Figure 3
22 Int J Dent Case Reports
Nov 2011, Vol.1, No. 3
Moezizadeh
Natural Tooth Pontic
DISCUSS ION:
Figure 5
Replacement of missing anterior tooth using a natural tooth pontic technique is an intermediary restoration and may not be used as permanent restoration for long term. Th is technique can not be used for every patient and some important factors should be considered before performing such restorations which among them are: patient’s bite, interfering parafunctional habits, inadequate occlusal clearance space for reinforced fiber or orthodontic wirecomposite resin bonding, inability to maintain isolation of field during bonding procedures, primary dentition and high esthetic expectations of patient, but this technique also has some advantages like:good aesthetic results, preservation of natural crown structure, no laboratory work required, reduced psychological impact on the patient, this technique is reversible and allows other restorative options to be evaluated, micro-resiliency of pontic allo ws stimu lation of underlying t issue and avoids excessive post-extraction ridge resorption(5,7-9).
It is worthy to mention that few years ago mandibular central incisors of same patient were ext racted due to periodontal disease and the same teeth used as natural teeth pontics and replaced the missing site. The same above mentioned technique was used by the same operator few years ago wh ich is still retained in patient mouth and functioning properly. (Fig. 7)
Figure 6 CONCLUS ION: Natural tooth pontic can be used as interim restoration for replacement of missing anterior tooth. This technique is simp le, less time consuming, provides good esthetic and function. However, this procedure is highly operator-dependent and demands appropriate case selection and precise technique. Appropriate patient education and instruction to clean the gingival embrasures and avoid having heavy bite is very crit ical and important. Figure 7
23 Int J Dent Case Reports
Nov 2011, Vol.1, No. 3
Moezizadeh
Natural Tooth Pontic
REFERENCES 1-
2-
3-
4-
5-
Parolia, A., Shenoy, K. M., Tho mas, M. S. and Mohan, M. Use of a natural tooth crown as a pontic fo llo wing cervical root fracture: a case report. Aus End J. 2010; 36: 35–38. 6- Lambert J. Stu mpel . The natural tooth pontic; Simplified. CDA.J .2004; 32: 257260. 7- Ashley M, Holden V. An immed iate adhesive bridge using the natural tooth. Br Dent J 1998; 184: 18–20. 8- Edelhoff D, Spiekermann H, Yildirim M. A review of esthetic pontic design options. Quintessence Int 2002; 33: 736–46. 9- Walsh LJ, Liew VP. The natural tooth pontic – a compro mise treat ment for periodontally involved anterior teeth. Aus Dent J 1990; 35: 405–8.
Kermanshah H, Motevasselian F .Immed iate tooth replacement using fiber-reinfo rced composite and natural tooth pontic. Oper Dent. 2010 ; 35: 238-245. James L., Kretzschma R. The natural tooth pontic A temporary solution fo r a d ifficult esthetic situation JADA. 2001; 132: 15521553. Lee GTR. Ut ilization of a natural tooth in acid-etch bridging. J Dent Child. 1988; 55:201-204. Livaditis GJ , Thompson VP. Etched castings: an imp roved retentive mechanism for resin-bonded retainers. J Prosthet Dent. 1982; 47:52-58.
24 Int J Dent Case Reports
Nov 2011, Vol.1, No. 3
