|Year : 2014 | Volume
| Issue : 1 | Page : 43-46
Natural tooth pontic with splinting of periodontally weakened teeth using fiber-reinforced composite resin
Gauri Srinidhi1, Srinidhi Surya Raghavendra2
1 Periodontist, Private Practice, Karvenagar, Pune, Maharashtra, India
2 Department of Conservative Dentistry and Endodontics, Sinhgad Dental College, Pune, Maharashtra, India
|Date of Web Publication||6-May-2015|
Dr. Srinidhi Surya Raghavendra
Department of Conservative Dentistry and Endodontics, Sinhgad Dental College and Hospital, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
Replacement of missing anterior teeth due to periodontal reasons is challenging due to the poor support of abutment teeth. This prevents the use of fixed partial dentures (FPDs). Fiber-reinforced splinting provides a viable alternative to the dentist while choosing a treatment plan in replacing missing anterior teeth in periodontally compromised patients as opposed to conventional modalities like FPDs or removable partial dentures. Replacing missing teeth using either patient's own tooth or a denture tooth as pontic can be done by splinting adjacent teeth with fiber reinforced composite. The splinting has an additional advantage of stabilizing adjacent mobile teeth. This case report details the case selection, procedure with follow-up of a case where the natural extracted tooth of the patient was used as pontic to replace a missing anterior tooth. The splinting was done with fiber reinforced composite resin. Fiber-reinforced composite resin splinting of patient's extracted natural tooth is economical, fast, and easy to use chairside technique with the added benefit of periodontal stabilization.
Keywords: Fiber reinforced composite resin, natural tooth pontic, splinting, tooth mobility
|How to cite this article:|
Srinidhi G, Raghavendra SS. Natural tooth pontic with splinting of periodontally weakened teeth using fiber-reinforced composite resin. J Dent Allied Sci 2014;3:43-6
|How to cite this URL:|
Srinidhi G, Raghavendra SS. Natural tooth pontic with splinting of periodontally weakened teeth using fiber-reinforced composite resin. J Dent Allied Sci [serial online] 2014 [cited 2019 Jan 16];3:43-6. Available from: http://www.jdas.in/text.asp?2014/3/1/43/156531
| Introduction|| |
Treatment planning for a case of generalized chronic periodontitis that has resulted in pathological migration and diastema formation in maxillary and mandibular anterior is challenging. The periodontally weakened teeth often drift to a position that is esthetically unpleasant as well as functionally unstable. The altered forces acting on teeth worsen the migration. Many of these patients want the correction of diastema and an esthetically pleasant look but are not ready to sacrifice the periodontally hopeless teeth. The ultimate goal of successful management of mobile teeth is to restore function and comfort by establishing a stable occlusion that promotes tooth retention and the maintenance of periodontal health.
Tooth loss in the anterior region is a very traumatic experience to the patient. Their primary concern is the compromised facial esthetics that accompanies tooth extraction. Immediate esthetic replacement of the tooth will be required, and this can be in the form of temporary, semi-permanent or permanent treatment modalities. Patients always desire secure, fixed tooth replacement prosthesis.
Previous attempts at chairside tooth replacement involved the use of pontics derived from extracted teeth, acrylic resin denture teeth with or without lingual wire reinforcements and resin composites.  A new class of materials designed for reinforcing dental resins has been introduced. These products are fiber reinforcing ropes, braids, ribbons, and bundled fibers. These fibers upon embedding into the resin provide for an increase in physical properties and more durable tooth stabilization.
There have been case reports documenting the use of natural tooth pontic along with fiber reinforced composite.  Placement of an immediate and indirect periodontal, prosthetic splint has been reported frequently. The use of gas plasma treated woven polyethylene fabric to reinforce composite resin , has been tried and found to be effective.
We have described a case in which a periodontally hopeless tooth was extracted, and the edentulous space replaced using the crown of the extracted tooth and splinted to the neighboring teeth with fiber reinforced composite resin. This treatment modality has the advantage of being flexible to include any other teeth that may be lost in future unlike the splinting using fixed partial denture (FPD) and has been reported in earlier studies. , It improves the comfort level of the patient by stabilizing the mobile teeth.
| Case Report|| |
A 58-year-old female patient reported with a painful and grade III mobile mandibular right central incisor. The tooth had to undergo extraction for pain relief and infection control. However, replacement was patient's main concern. Adjacent teeth showed severe recession, severe bone loss, and variable degrees of mobility but patient was unwilling to consider extraction at the present stage.
The patient was advised to undergo supra and subgingival scaling and was reviewed 2 weeks later. Response of the tissues to periodontal therapy after scaling was good. There was good compliance with the oral hygiene instructions. The mandibular right central incisor was having hopeless periodontal prognosis and needed extraction.
Various treatment options available were removable partial denture (RPD), FPD or splinting with natural teeth pontic. The abutment teeth available were periodontally weak. RPD with supporting clasps on the abutment teeth would have made them weaker. An FPD using two abutments on either side was a viable treatment option. It was not acceptable to the patient due to high expense involved.
Splinting of the mandibular anterior using fiber splint and the inclusion of the extracted natural tooth as pontic in the splint was considered. This option had the advantage of stabilizing periodontally weak abutments. It also was flexible to allow any other treatment needed in future (like endodontic/periodontic/extraction) for questionable abutments. The patient found the treatment plan appealing because of the comparative low cost and possibility of having a fixed prosthesis.
The mandibular right central incisor was extracted under local anesthesia. The extraction was uneventful. The extracted tooth was scaled and polished thoroughly to remove all the deposits on them. After healing of extraction socket, impressions were made and study models prepared. The extracted tooth was trimmed so as to rest passively on the edentulous ridge in mandibular central incisor area. The tooth was endodontically instrumented from the apical area and sealed with composite. The tooth was prepared by making a groove of 0.75 mm depth in the lingual mid 1/3 rd area with a round abrasive point (BR 40, Mani, Japan) and arranged on the edentulous ridge of the study model. The pontic was passively touching the edentulous ridge and had no incisal contact point with opposing teeth. The adjacent teeth were marked and grooved to a depth of 0.75 mm in the middle third of lingual aspect with round abrasive point (BR 40, Mani, Japan) [Figure 1].
Lingual surfaces of mandibular laterals and canines were acid etched (Dentsply, USA) for 15 s [Figure 2]. After application of bonding agent (Prime and Bond NT, Dentsply, USA) and curing with LED curing unit (Apoza, Taiwan), flowable composite (Charisma, Kulzer) was placed in the lingual groove area. The fiber splint (Interlig, Angelus, Brazil) was immersed in the flowable composite and cured one tooth at a time [Figure 3]. The other teeth were covered with foil to prevent premature polymerization. The trimmed natural tooth pontic was attached to the fiber splint, taking care to see that the fiber splint was placed in the prepared groove [Figure 4]. The fiber splint was covered with composite resin and cured, taking care to see that the ends of the fiber are covered. This was followed by a thorough finishing and polishing of the restoration [Figure 5]. Care was taken to eliminate any occlusal contact on the splint. The patient was trained to use an interdental brush to keep the splinted teeth clean. She was put on supportive periodontal therapy, that is, maintenance recall schedule.
| Discussion|| |
Tooth splinting may be indicated for individual mobile teeth as well as for an entire dentition in cases where extraction and implant therapy is not a viable alternative. These can be successfully managed by retaining the tooth through more conservative methods like splinting. The overall objective of splinting is to create an environment where the tooth movement can be contained within physiological limits, thereby improving patient comfort and the restoration of function.
Provisional splints are indicated for a limited time period. They will provide information as to whether teeth stabilization will have benefits before planning comprehensive treatment. Examples include ligature wires, nightguards, and interim fixed prosthesis, composite resin splints (with or without wire and fiber support). Definitive splints are placed only after completion of periodontal therapy and achievement of occlusal stability. They are intended to increase functional stability and improve esthetics on a long term basis. 
When a periodontally compromised tooth in the visible or esthetic zone is planned for extraction, the primary concern of the patient is of esthetics. There are various options which can be given to the patient like acrylic RPDs or the extracted natural teeth can be used as a pontic. The acrylic RPDs are bulky and uncomfortable to the patient. Prefabricated denture teeth can be used as a pontic when bonded to the adjacent teeth. They present challenges with regard to color matching, size and shape matching. They may require substantial modifications to achieve an acceptable appearance. Implant supported prostheses may not be the best option due to severe localized soft and hard tissue loss. 
Using the natural tooth as a pontic offers the benefits of being the right shape, size, and color. Moreover, the patient gets an added boost on seeing his own tooth being used instead of an artificial one. These natural tooth pontics can be splinted to the adjacent teeth by composite resins, with or without wire reinforcement.  One of the alternatives of splinting is with the use of fiber reinforced composites. The most popular fiber types are ultra-high molecular weight polyethylene (UHMWPE) and glass fibers.
The use of a UHMWPE leads to very low friction coefficient, high wear resistance, and high impact strength. It is woven into a ribbon for dental application. The polyethylene reinforcement fiber has a flexible white mesh appearance and is treated with cold plasma gas in order to increase its reactivity and wetting ability. This enables chemical and physical interactions with composite resins.  Interlig by Angelus, Brazil used here is a braided, intertwined glass fiber impregnated with dental resin.
The reinforcing capacity of fibers is dependent on their adhesion to the resin, orientation of the fibers and their impregnation with the resin. The advantages of fiber reinforced composite material for periodontal splinting include:
- Ease of application with minimal tooth preparation.
- Low to moderate cost as compared to fixed prostheses.
- Can easily be removed when splinting is no longer considered necessary.
- Easily repaired in case of failure through re-bonding and re-application of material.
- Ease of accommodation of oral hygiene practices by the patient. ,
The most common type of failure seen is the exposure of the ends of the fiber and debonding of the fiber from the tooth. This is especially seen when we are replacing many teeth and stabilizing with fiber. The lingual grooving to a depth of 0.75 mm on the abutment teeth and the pontics enable the fiber to be placed perfectly within the tooth surface without any protruding area. Placing a flowable composite and then embedding the fiber in that helps the integration of the resin with the fiber. This is due to the gas plasma treatment done to the fiber. Trimming the pontic teeth is important so that there is no pressure on the edentulous ridge, and oral hygiene maintenance can be done by the patient.
It must be emphasized to the patient to avoid heavy biting pressure on the splinted teeth. All eccentric movements should be recorded and relieved. In case of accidental trauma to that area and loss of the pontic, the option of using an artificial denture tooth can be used. Long-term follow-up is essential to evaluate the fiber reinforced resin splint as an alternative to the conventional partial denture or the fixed prostheses.
| Conclusion|| |
Tooth mobility alone does not necessarily indicate the existence of an underlying pathologic condition. The etiology of the mobility should be established first. Following this, splinting of teeth to improve the periodontal stability can be done. The teeth can be splinted using provisional or definitive modalities, and the diastema occurring can be managed using denture teeth or patients' own extracted teeth. Using a natural tooth pontic is an excellent, acceptable treatment option for situations in which anterior teeth need to be removed and reflects the dentist's concern for the patient's compromised facial esthetics. Using a fiber-reinforced composite resin as a splint is a conservative, esthetic and cost effective method for replacement of mobile or missing anterior. It can be adapted for use with patient's own natural mobile tooth which is extracted and used as pontic or it can be used with artificial denture teeth which act as pontics.
| References|| |
Kermanshah H, Motevasselian F. Immediate tooth replacement using fiber-reinforced composite and natural tooth pontic. Oper Dent 2010;35:238-45.
Chauhan M. Natural tooth pontic fixed partial denture using resin composite-reinforced glass fibers. Quintessence Int 2004;35:549-53.
Kini V, Patil SM, Jagtap R. Bonded reinforcing materials for esthetic anterior periodontal tooth stabilization: A case report. Int J Dent Clin 2011;3:90-1.
Miller TE. A new material for periodontal splinting and orthodontic retention. Compend Contin Educ Dent 1993;14:800-12.
Bernal G, Carvajal JC, Muñoz-Viveros CA. A review of the clinical management of mobile teeth. J Contemp Dent Pract 2002;3:10-22.
Danan M, Degrange M, Vaïdeanu T, Brion M. Immediate replacement of a maxillary central incisor associated with severe facial bone loss: Use of Bio-Oss collagen - Case report. Int J Periodontics Restorative Dent 2003;23:491-7.
Kretzschmar JL. The natural tooth pontic: A temporary solution for a difficult esthetic situation. J Am Dent Assoc 2001;132:1552-3.
Gaspar Junior Ade A, Lopes MW, Gaspar Gda S, Braz R. Comparative study of flexural strength and elasticity modulus in two types of direct fiber-reinforced systems. Braz Oral Res 2009;23:236-40.
Strassler HE, Garber DA. Anterior esthetic considerations when splinting teeth. Dent Clin North Am 1999;43:167-78, vii.
Syme SE, Fried JL. Maintaining the oral health of splinted teeth. Dent Clin North Am 1999;43:179-96.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]