Direct Replacement of Anterior Tooth with Fiber-Reinforced Composite and Natural Tooth Pontic

Direct Replacement of Anterior Tooth with Fiber-Reinforced Composite and Natural Tooth Pontic: A Case Report

Abstract

The fiber-reinforced composite (FRC) bridges can be an excellent alternative to conventional prosthetic techniques since it is a conservative, fast and cost effective treatment method.

Properties of FRC, such as strength, desirable esthetic characteristics, ease of use, adaptability of various shapes, and potential for direct bonding to tooth structure make it suitable for various applications (Hyeon Kim et al, 2014)
The anterior permanent extracted tooth can be directly bonded to the adjacent teeth with the FRC. ⁸

This non invasive provisional method leads to exact repositioning of the coronal part of the anterior extracted tooth in its original intraoral three-dimensional position. ⁸
The purpose of this article was to present a clinical case of a single anterior tooth replacement by means of fiber- reinforced composite and natural tooth pontic.

Key Words

Case report, Fiber-reinforced composite, anterior tooth replacement, esthetic, function

Introduction

Every day, dentists are exposed to various and complex esthetic, functional and restorative challenges.

Following traumatic loss of the anterior tooth, it is important that an immediate replacement is provided in order to avoid esthetic, masticatory and phonetic difficulties, and to maintain the edentulous space (Smriti Bhargava et al. 2011)

A wide range of treatment options can be proposed as solutions for the replacement of a traumatically missing anterior permanent incisor.

Some authors consider that implants are the treatment of choice in this clinical situation, since they enable a more conservative approach. Of course, they are indicated when general and local conditions are favorable. ^{9, 11}

However, the need for surgical procedures and its high cost may reduce its accessibility for some patients (Hyeon Kim et al. 2014). In addition, we should not ignore the patient anxiety and fear about this surgical process. ⁹

The missing incisor can be replaced with conventional porcelain-fused-to-metal or all ceramic bridge or even with resin-bonded fixed partial denture (Maryland Bridge). ^{10, 11}
The disadvantages of these treatment options: invasive reduction of healthy tooth structure (conventional bridge), non esthetic aspect of the metal framework, dental reduction (grooves…) and lack of longevity (partial denture) and sometimes compromised esthetics. ^{10, 11}

Over the last few years, the development of an innovative treatment using fiber-reinforced composite (FRC) has been reported to replace a single anterior tooth. It offers the possibility of fabricating resin-bonded, esthetically good and metal-free tooth restorations. ^{3, 7, 9}

In some studies, even the missing posterior teeth can be replaced by means of prefabricated FRC technique. ⁵ The development of the FRC materials and technologies may also allow alternatives for directly made molar replacements (Sufyan Garoushi et al. 2012).

Using the natural tooth as a pontic offers the benefits of being the right size, shape, and color. Moreover, the positive psychological value to the patient in using his or her natural tooth is an added benefit (Smriti Bhargava et al. 2011).

The current article describes a clinical case treated with a FRC bridge, which was fabricated using the natural tooth as a pontic for immediate replacement of a central permanent incisor in a teenage patient.

Clinical significance

The use of FRC restoration as a novel concept for immediate replacement of missing anterior tooth can provide minimally invasive and esthetically promising clinical result.

Case report

A 13-year-old patient who lost a maxillary central incisor due to trauma reported to the Dental Department for replacement of the same. On discussion, for this adolescent patient, non-invasive transitory prosthetic solutions are indicated. The replacement was performed using FRC Bridge because of its conservative nature, the favorable occlusal conditions, esthetic result, and preserving tooth substance.

This treatment is an ideal and esthetic option for patients who need a provisional fixed prosthesis before a definitive treatment is chosen (between a classical prosthetic and the implant one).

The treatment was accomplished in a one-visit appointment.

Fig 1: Intra-oral preoperative labial view, showing the missing central maxillary incisor

Fig 2: The tooth was immersed in saline solution, and then scaled from the remaining soft tissue

Fig 3: Decoronation of the tooth, removal of the pulp tissue and the apical end of the root was formed into an ovate pontic design with finishing diamond burs. The pulp space was restored with light cure composite.

Fig 4: Fitting of the crown

Fig 5: Palatal view

Fig 6: Conservative box preparations are prepared (limited to enamel), Dimensions: 1.5 to 2 mm long, 1.5 to 2 mm wide, and 2 mm deep the proximal aspects of the abutment two teeth

Fig 7: Premeasured FRC material was cut with the Ribbond cutter

Fig 8: The adhesive bonding agent was applied to all the prepared tooth structure according to the manufacturer’s guidelines

Fig 9: The adhesive bonding agent was applied to all the prepared tooth structure according to the manufacturer’s guidelines

Fig 10

Fig 11: Premeasured FRC was immersed into the specified bonding agent and flowable composite for 15 minutes. Then, it was passed through the tunnel with clear cotton pliers

Fig 12: The pontic was placed into the predetermined position and the fibers were condensed through the resin composite

Fig 13: The adhesive was polymerized for 20 seconds

Fig 14: A tunnel was prepared across the pontic from one proximal side to another with round burs at the predetermined level

Fig 15: The Box preparations on the two abutment teeth were etched (37% phosphoric acid gel, 30 seconds), rinsed and gently air-dried

Fig 16: Measuring of the surface of the pontic from one side to another

Fig 17: Immediate final resto

Fig 18: Palatal view of the final restoration. The Occlusion was carefully adjusted, especially the anterior guidance using articulating paper

Fig 19: Frontal view

We recommended to the patient to keep a good hygiene and maintain the FRC restoration free from dental plaque. ¹

Fig 20: 3 months following up restoration

Discussion

The replacement of a traumatically missing permanent anterior maxillary tooth can be performed by different treatment options. ^{6, 11}

The missing tooth can be replaced with conventional 3-unit bridge or even with resin- bonded fixed partial denture (Maryland Bridge) or a single implant. ^{10, 11}

A traditional 3-unit bridge (porcelain-fused-to-metal or all ceramic) is a viable solution (Gerard J et al. 2001). However, this treatment leads to excessive reduction of the structure of the abutment two teeth and high risk of pulp exposure. ^{1, 10, 11}

Referring to the study of Garoushi S et al. 2011, the conventional fixed partial denture was not indicated in our clinical case due to the young age of the patient.

The resin-bonded fixed partial denture (Maryland Bridge) has some disadvantages as the non-esthetic aspect of the metal framework and the necessity of preparation of the dental grooves. ¹¹

It is also considered that partial removable dentures can be exposed to fracture and can irritate the palatal mucosa when used for a long period. ⁸

Dental implant can be a suitable solution for the replacement of the missing central maxillary incisor but it is considered as an expensive, invasive treatment and we should not ignore the anxiety and fear of the patient about the surgical procedure. ^{1, 9, 10, 11} Systemic problems may also contraindicate surgery (H Kermanshah et al. 2010).

In our case report and referring to other studies, the young age of the patient was a clear contraindication for an implant therapy. ⁴

Over the last few years, the development of fiber reinforced composite (FRC) has given the dental profession the possibility of fabricating adhesive, aesthetic, and metal-free dental replacements (Kaur Inderjeet et al. 2011).

The FRC prosthesis are considered as an innovative and conservative alternative treatment to conventional fixed bridges or partial dentures and even to implants. ²

Compared to traditional prosthetic options, a fiber-reinforced composite bridge is generally less costly (Amir Chafaie et al. 2004)

The thin filaments that are incorporated to a base resin offer an excellent fracture resistance, fatigue strength, improved flexural and tensile strength. ²

While clinical performance is the final determinant of success, flexure is still the most widely reported mechanical property (H Kermanshah et al. 2010).

The FRC restorations can be performed directly or indirectly with an artificial acrylic tooth, a direct build up by composite resin or with the crown of the expulsed tooth. ¹¹

The primary type of failures identified were either bulk fracture at the connector or the pontic area, debonding of the veneering composite or fiber exposure (H Kermanshah et al. 2010).

In the literature, some authors do not recommend the use of composite materials for definitive restoration because of the risk of the increased wear, accumulation of dental plaque and unstable esthetic clinical result. ¹

In our clinical case, all these risks are diminished since we used the natural crown as a pontic. Thus, we avoided complicated laboratory procedure. ⁸

In the study of Hyeon Kim et al. 2014, the extracted tooth presented no esthetic problems, but the pontic was build up with composite because of the difference of the shape of the adjacent teeth and presence of malalignement of the anterior teeth.

The biggest advantage of using the natural crown of the patient as a pontic for the FRC Bridge is the better patient acceptance and tolerance of the tooth loss. Added to that the better shape, color, size and alignement of this natural pontic. ⁸

The preparations (grooves) of the two abutment teeth were minimal and confined to enamel, it was a non-invasive approach. ²

In this case report, the immediate restoration of the missing central permanent maxillary incisor by means of FRC using the natural tooth as a pontic offered promising esthetic result and psychological acceptance from the patient.

The technique is practical, economically feasible, requires limited laboratory support and materials, and can be accomplished in a single appointment (Smriti Bhargava et al. 2011).

In the visit of control (three months after restoration), the clinical evaluation showed successful result, no evidence of problems and the teenage patient maintained a good oral hygiene as it was recommended before. He was satisfied with the final restoration.

It should be emphasized that FRC prosthesis cannot be a long-term treatment; it is a provisional treatment before conventional fixed prostheses or implant therapy.

Garoushi S et al. in (2011, 2012) showed that there is a lack of long-term clinical research of FRC prostheses. Moreover, those longitudinal studies reported general failure rates between 5% and 16% over periods up to 4-5 years.

Conclusion

The replacement of the missing anterior maxillary incisor is an esthetic and functional challenge. The growing desire of patients for esthetic and metal free restorations led to an innovative, conservative, simple and cost-effective approach using FRC prostheses. The success of this technique depends on different factors such as the use of high quality materials and the correct clinical indication of this technique.

References

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by Dr. Mayada Jemâa, Pr. Bassem Khattech (Military Principal Hospital of Instruction, Tunis, Tunisia), Dr. Nouha Mghirbi,
Pr. Hayet Hajjami, Pr. Sonia Zouiten, Pr. Abdellatif Boughzala (Hospital Farhat Hached, Sousse, Tunisia)