esthetic rehabilitation of anterior primary teeth using polyethylene with two different approaches

327JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Oct - Dec 2011 | Issue 4 | Vol 29 |

Case RepoRt

Esthetic rehabilitation of anterior primary teeth using polyethylene fiber with two different approaches

Jain M1, Singla S, Bhushan BAK1, Kumar S2, Bhushan A1 Department of Pedodontics and Preventive Dentistry, People’s Dental Academy, Bhanpur, Bhopal, 1Department of Pedodontics and Preventive Dentistry 2Department of Oral and Maxillofacial Surgery, M.N. D.A.V Dental College and Hospital, Tatul, Solan, Himachal Pradesh, India

Correspondence: Dr. Mansi Jain, W/o Dr. Sanjay Soni, Kailash View, Buria, District Yamunanagar, Haryana, India. E-mail: [email protected]

Website: www.jisppd.com

DOI: 10.4103/0970-4388.86381

PMID: **********

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Abstract

An acceptable treatment approach for early childhood caries in the past may not necessarily be the best treatment option for our young patients today. Technological advances in dental materials and the approach to their use need to be considered, and the introduction of new adhesive systems, restorative materials, and the approach toward treating these teeth has yielded convincing results. Two such clinical case reports where polyethylene fibers were used as intra-canal posts and to splint the pontic fabricated with polyethylene fibers reinforced composite are reported.

Key words

Composite pontic, maxillary incisors, polyethylene fibers, strip crowns

Introduction

Early childhood caries is a serious public health problem in disadvantaged communities, in both the developing and industrialized countries, where malnutrition is common. Maintenance of primary dentition in a healthy condition is important for the well-being of the child as far as proper masticatory, esthetics, phonetics, space maintenance, and prevention of aberrant habits are concerned.

The esthetic restoration of severely mutilated anterior primary teeth has been for long a challenge to a pediatric dentist, not only because of the available materials and techniques, but also from the point of view of pediatric patients, who are usually among the youngest and least manageable group. Inadequate esthetic options in addition to the severity of the condition have prompted extraction in most of the cases, in spite of the treatment being not convincing both to the parents as well as the clinicians.

Even though treatment modalities for esthetic restoration of anterior primary teeth range from placement of stainless steel crowns to ceramo – based metal crowns, the use of a composite strip crown has been preferred and has performed well in spite of its limitations, due to the type of material and size of the lesion, which may affect its stability, retention, and marginal adaptation.[1] In extreme forms, extraction can be an alternative followed by a removable or fixed appliance.

Anterior primary teeth, when grossly decayed, lack a coronal structure, leading to decreased support and adhesion for a composite crown. Hence, use of a resin-based composite reinforced with polyethylene fibers is preferred and the technique is referred to as the ‘short post technique,’ which requires root canal treatment and a short composite post.[2,3]

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Jain, et al.: Esthetic rehabilitation of anterior primary teeth

328 JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Oct - Dec 2011 | Issue 4 | Vol 29 |

In restorative dentistry, a relatively new technique of etching the enamel surface and bonding composite artificial teeth directly to the adjacent natural teeth reinforced with high density fibers, without metal frameworks, has yielded remarkable results. The advantage of minimal tooth preparation, little or no tissue removal and low laboratory cost has drawn extensive attention.

This article presents two case reports where fiber composite resin, reinforced with polyethylene fibers, is utilized to restore mutilated and extracted primary anterior teeth.

Case Reports

Case 1Parents with a four-year-old girl, reported to the Department of Pediatric and Preventive Dentistry with the chief complaint of poor facial appearance due to discolored and worn out front teeth. On examination multiple carious lesions with root stumps of 52, 53, 61, and 62 were observed [Figure 1]. The root stumps were found to be firm, with less than 2 mm of the crown above the gingival margin being intact. Radiographic examination revealed no signs of exfoliation, with normal development of a permanent successor. Endodontic treatment and esthetic rehabilitation of the mutilated incisors were considered in phase 1 and phase II, respectively.

Step-wise treatment was carried out as mentioned herewith:• Pulpectomyfollowedbyobturationof 52,53,61and

62 [Figure 2]• Removalof 2mmof thecoronalportionof theroot

filling [Figure 3]• Coronalstructuresandpulpchamberwereetched

and conditioned• Polyethylenefibersconditionedwithbondingagent,

placed in the slot of the root canal, were stabilized with composite material [Figure 4]

• Polyethylene fibers, 2 – 3mm in length, weremaintained above the crown to reinforce the coronal structure

• Dentalmorphologywas restored and completefunction attained with strip crowns [Figures 5 and 6]

Clinical and radiographic examination after one, three, and six months revealed the presence of

Figure 1: Multiple carious lesions [Pre-operative]

Figure 2: Radiograph showing endodontic management

Figure 3: Slot preparation for laying down of polyethylene fibers

an intact crown and the absence of periapical pathology, confirming the efficacy of the combined technique.



Figure 4: Polyethylene fibers stabilized in slots with composite Figure 5: Trial fit of strip crowns

Figure 6: Morphology restored with strip crowns [Post-operative] Figure 7: Grossly decayed 51, 61, and 52 and fenestration i.r.t 62

Figure 8: Occlusal viewFigure 9: Radiograph showing endodontic management of the affected incisors

Case 2A four-and-a-half-year-old boy reported to the Department of Pediatric and Preventive Dentistry with a chief complaint of decayed teeth. On examination 51,

61, and 52 were grossly carious, to the extent that only 2 – 3 mm of the crown structure above the gingival margin was intact, with the presence of fenestration



Figure 10: Trial fit of strip crowns Figure 11: Pontic preparation

Figure 12: Cured composite pontic Figure 13: Splinting of pontic

Figure 14: Occlusal view [Post-operative]

i.r.t 62 [Figures 7 and 8]. Radiographic examination revealed the presence of a fully formed root without any signs of early resorption of 51, 61, and 52.

The management was carried out in two phases:Phase I - Rehabilitation of 51, 61, and 52 with endodontic treatment followed by extraction of 62 [Figure 9].Phase II - Esthetic rehabilitation of the mutilated incisors by,• Drilling thecanalsat least1–2mm, tocreatea

coronal space for the composite• Etching the incisors, and before the trial, fit

strip crowns were bonded followed by occlusion adjustment on removal of the strip crowns [Figure 10]

• Stripcrownbestsuitedfor62wasselectedforthepreparation of the pontic

• Additional strengthwas attained by passing afiber splint from the center of the strip crown [Figure 11]

• Crownalongwithsplintwasloadedwithcomposite,cured outside the oral cavity before splinting



to 61 and 63 with the help of composite resin [Figures 12 – 14].

Morphology along with complete functional recovery was restored with placement of strip crowns and composite pontic for 62. Periodic recall at every three months revealed the absence of any discoloration, secondary caries, or change in gingival and periapical conditions, confirming the efficacy of the used technique.

Discussion

Despite the decline in overall caries prevalence, its incidence continues to be as high as 18% in two to four-year-old and 52% in six to eight-year-old children Kaste et al.[4]

In the restoration of the anterior teeth, esthetics and mechanical resistance to fracture are of great importance for obtaining a long-lasting result, which can be attained through reinforcement of the resinous matrix with fibers.[5] Polyethylene fibers are preferred as they improve the impact strength, modulus of elasticity, and flexural strength, and are almost invisible in the resinous matrix, in contrast to glass fibers, which fail to stick to the resinous matrix and carbon and Kevlar fibers, which interferes with the esthetics.[6]

The morphology and histology of primary teeth present a lesser surface for bonding, a pulp chamber that is relatively large, and enamel that is inheritantly difficult to etch, due to its aprismatic nature.[7] Thus, the destruction of the tooth structure frequently involves the entire crown, leaving just the root dentine for bonding of the restorative material, thereby increasing the failure rate.[8]

The above-mentioned adopted technique, in spite of being simple and quick, achieved excellent cosmetic results.

In view of the physiological resorption that occurs in primary dentition, innovations for short retentive posts are needed, unlike the post and core used in adult dentition.[9] A combined technique of glass fiber post and composite, with final morphology achieved with strip crowns, was found to be a simple and efficient technique with excellent esthetic and functional results, which was in accordance with the technique described by Webber and co-workers.[10]

Occurrence of a homogeneous mechanical and chemical bonding of a fiber core post, with a flowable composite, forms a unit where both components are bonded firmly to reinforce the tooth, Sidoli et al.[11] As post retention is an important factor with little or no coronal dentin (Cohen et al.),[12] the fiber core exhibiting Young’s modulus of elasticity approximating to that of the tooth decreases the stress concentration and increases the longevity of the restoration.

In case II, as an effective alternative, a fixed functional space maintainer was used for restoring 62, which was a single visit procedure, biocompatible, esthetically acceptable, patient friendly, and needing no reliance on any compliance or laboratory service, in contrast to a conventional removable acrylic plate Artun.[9,13,14]

Use of ultra-high molecular weight polyethylene fiber in the fabrication of a fixed space maintainer and a space maintainer with an artificial tooth has yielded promising results (Karaman et al.)[14,15]

Mandibular lateral incisor and canine interferences during parafunctional mandibular movements or a physiological forward mandibular shift need attention. These can be overcome by restoring crowns slightly shorter, with labial proclination, (Judd).[2]

In the techniques discussed, the etchant used was an aqueous phosphoric ester solution, which removed the smear layer, etched the enamel, and demineralized the dentine to form a hybridized layer for bonding to the dentine along with a micro-mechanical bonding with the enamel.[16,17] Another factor that added to the success of these techniques was the use of a bonding agent that increased the resistance of the core to the torsional forces (Cohen et al.)[18,19]

In view of the cases discussed herein, it can be concluded that intervention using polyethylene fiber posts to support composite strip crowns on severely mutilated primary anterior teeth may be a valuable clinical procedure.

Conclusions

Early loss of the anterior primary teeth may lead to psychological disturbances and affect the child’s self-esteem and socialization during the important phase of development. Teeth lost in the anterior region infrequently require space maintenance, but demand rehabilitation from a psychological point of view, as



How to cite this article: Jain M, Singla S, Bhushan B, Kumar S, Bhushan A. Esthetic rehabilitation of anterior primary teeth using polyethylene fiber with two different approaches. J Indian Soc Pedod Prev Dent 2011;29:327-32.

Source of Support: Nil, Conflict of Interest: None declared.

many a time, children suffer without being vocal about it. Technological advances in dental materials and new approaches in their use, such as polyethylene fibers used to reinforce the composite strip crown, have yielded convincing results in various studies and also in our cases. Further similar studies with increased follow-up time and newer hybrid composites are required to establish the superiority of the polyethylene fibers in comparison to other fiber core posts, which are under trial at present.

References

1. Lambrechts F,Willems G,Vanherle G, Braem M. Esthetic limits of light cured composite resin in anterior teeth. Int Dent J 1990;40:149-58.

2. Judd PL, Kenny DJ, Johnston DH, Yacobi R. Composite resin short-post technique for primary anterior teeth. J Am Dent Assoc1990;120:553-5.

3. Pithan S, Vieira Rde S,Chain MC. Tensile bond strength of intracanal posts in primary anterior teeth: An in vitro study. J ClinPediatr Dent 2002;27:35-40.

4. KasteLM, Selwitz RH, Oldakowski RJ, Brunelle JA, Winn DM, Brown LJ. Coronal caries in the primary and permanent dentition of children and adolescents 1-17 years of age: United states 1998-91. J Dent Res1996;75 Spec No:631-41.

5. Fidel SR, Sassone L, Alvares GR, Guimaraes RP, Fidel RA. Use of glass fiber post and composite resin in vertical fractures tooth. DentTraumatol 2006;22:337-9.

6. Vitale MC, Caprioglio C, Martignone A, Marchesi U, Botticelli AR. Combined technique with polyethylene fibers and composite resins in restoration of traumatized anterior teeth. DentTraumatol2004;20:172-7.

7. Mortada A,King NM. A simplified technique for the restoration of severely mutilated primary anterior teeth. J ClinPediatr Dent 2004;28:187-92.

8. Papathanasiou AG, Curzon ME, Fairpo CG. The influence of

restorative material on the survival rate of the restorations in primary molars.Pediatr Dent1994;16:282-8.

9. Kapur A, Chawla HS, Goyal A, Gaube K. An esthetic point of view in very young children. J ClinPediatr Dent 2005;30:99-103.

10. Webber DL, Epstein NB, Wong JW, Tsamtsouris A. A method of restoring primary anterior teeth with the aid of a celluloid crown from and composite resins. Pediatr Dent 1979;1:244-6.

11. Sidoli GE, King PA, Setchell DJ. An in vitro evaluation of a carbon fiber-based post and core system. J Prosthet Dent 1997;78:5-9.

12. Cohen BI, Pagnillo MK, Deutsch AS, Musikant BL. Fracture strength of three core restorative materials supported with or without a prefabricated split-shank post. J Prosthet Dent 1997;78:560-5.

13. Kırzıoglu Z, Erturk MS. Success of reinforced fiber material space maintainers.J Dent Child (Chic)2004;71:158-62.

14. Artun J, Marstrander PB. Clinical efficiency of two different types of direct bonded space maintainers. ASDC J Dent Child 1983;50:197-204.

15. Karaman AI, Kir N, Belli S. Four applications of reinforced polyethylene fiber material in ortodontic practice.Am J OrthodDentofacialOrthop2002;121:650-4.

16. Christensen GJ. Self-etching primers are here. JAm Dent Assoc 2001;132:1041-3.

17. Tay FR, Pashely DH. Aggressiveness of contemporary self etching systems. I: Depth of penetration beyond dentin smear layers. Dent Mater 2001;17:296-308.

18. Cohen BI, Pagnillo MK, Musikant BL, Deutsch AS, Cofrancesco G. Pilot study of the effects of three bonding systems on the torsional resistance of a titanium-reinforced composite core. J Prosthet Dent 1999;82:277-80.

19. Sharaf AA. The application of fiber core posts in restoring badly destroyed primary incisors. J ClinPediatr Dent 2002;26:217-24.

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esthetic rehabilitation of anterior primary teeth using polyethylene with two different approaches

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