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Table of Contents   
ORIGINAL RESEARCH  
Year : 2012  |  Volume : 23  |  Issue : 1  |  Page : 59-63
Immediate natural tooth pontic: A viable yet temporary prosthetic solution: A patient reported outcome


1 Unit of Prosthodontics, Oral Health Sciences Centre, PGIMER, Chandigarh, India
2 Department of Periodontics, HSJ Institute of Dental Sciences and Hospital, Panjab University, Chandigarh, India

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Date of Submission08-Apr-2011
Date of Decision27-Jun-2011
Date of Acceptance27-Sep-2011
Date of Web Publication26-Jul-2012
 

   Abstract 

Introduction: In patients with hopeless prognosis of the anterior teeth there is still a strong desire to save them for the sake of esthetics. If not grossly carious, broken down or discolored the extracted tooth after suitable modifications can be placed back in its original site by splinting it to the adjacent stable teeth.
Materials and Methods: Fifteen patients (10 males, 5 females) in the age range of 40-65 years with pathologically migrated, unsalvageable teeth were treated by splinting the extracted teeth immediately with the stable adjacent teeth. After 12 weeks, all the patients were explained various treatment options available for replacement of the lost teeth. The patients were asked to fill out a simple closed ended questionnaire citing the various difficulties encountered during this transitional period, selection of further treatment modalities and the reasons for their choice. The feedback obtained was then analyzed statistically.
Results: Hundred percent of patients were happy with the esthetics; however, 60% of them were dissatisfied with the function that it provided. The primary problem being apprehension of splint fracture and difficulty while incising and the data was found to be statistically significant (P=0.01**). All patients demanded a permanent treatment option following this with a fixed prosthesis. None of the patients were interested in the implant supported prosthesis due to cost, treatment time involved, and need for surgery.
Conclusion: The concept of immediate pontic placement is surely a viable treatment option and promises an excellent transient esthetic solution for a lost tooth as well as enables good preparation of the extraction site for future prosthetic replacement.

Keywords: Fixed prosthesis, immediate dentures, implants, natural tooth pontic, splinting

How to cite this article:
Bhandari S, Chaturvedi R. Immediate natural tooth pontic: A viable yet temporary prosthetic solution: A patient reported outcome. Indian J Dent Res 2012;23:59-63

How to cite this URL:
Bhandari S, Chaturvedi R. Immediate natural tooth pontic: A viable yet temporary prosthetic solution: A patient reported outcome. Indian J Dent Res [serial online] 2012 [cited 2018 Oct 19];23:59-63. Available from: http://www.ijdr.in/text.asp?2012/23/1/59/99040
All patients strongly desire to postpone the extraction of their natural teeth especially teeth in the esthetic zone irrespective of their status. Anterior teeth affected with severe periodontitis in the presence of excessive occlusal forces migrate pathologically with an associated development of gingival recession and bone loss creating a situation where in they are unsalvageable [Figure 1]. [1] Extraction of these teeth mainly leads to esthetic and phonetic difficulties and a functional disability to some extent. Irrespective of the permanent treatment options available, patients usually refuse delayed replacement and desire an immediate alternative solution in the post-extraction phase with the primary aim to restore the esthetics. Removable temporary partial dentures made from denture base resin in the immediate post extraction phase are un-esthetic due to presence of clasps needed for retention, [2] bulky, non functional and discomforting to the patient and might even impede the healing process and jeopardize the periodontal health of the remaining dentition. [3],[4] The option of placement of immediate implants following extraction may be given to the patient in cases with no residual infection in the socket and presence of adequate bone and soft tissue for coverage.
Figure 1: Intraoral view of the left mandibular incisorss periodontally involved, pathologically migrated and with hopeless prognosis

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Natural tooth pontic (NTP) suitably modified and bonded to adjacent teeth enables proper healing in the area without compromising the anterior esthetic demands of the patient. NTP offers excellent color, shape, and size match and thus enhances the psychological and social acceptability of the patient with a minimal cost involved. [5] A variety of periodontal splint materials such as the multi-flex orthodontic wires, steel meshes, glass or fiber splint etc. can be used to splint the pontic to the adjacent stable abutments via composite resin. [6],[7],[8] This case series presents the use of unsalvageable natural teeth; both single and multiple as pontics and splinting them using a multi-flex wire and flowable composite. This treatment modality achieved good esthetic and fair functional results over a period of time.


   Materials and Methdos Top


The cases that are indicated for this procedure were carefully identified keeping in mind the following inclusion criteria:

  • Patient desires for immediate esthetic restoration of the lost tooth/teeth.
  • Teeth; single or multiple in the anterior esthetic zone with severe periodontitis which are not salvageable following any form of periodontal therapy.
  • Adequate periodontal support of the adjacent teeth.
  • Absence of any form of para-functional habits such as bruxism, clenching, clamping etc.
  • Adequate occlusal clearance for placement of material used for splinting.


Exclusion criteria:

Three or more periodontally weak adjacent teeth.

Non motivated patients.

Fifteen patients (10 males and 5 females) with age range between 40-65 years with the above mentioned inclusion criteria were evaluated and assessed for placement of natural tooth pontics. Informed consent was obtained from each patient prior to administering the treatment. The procedure was divided into three simple stages.

  • Extraction of the periodontally mobile teeth.

    The teeth were extracted with minimal tissue trauma and following extraction the socket was gently packed with sterile wet gauze to control bleeding till the pontic was modified to be placed back.
  • Preparation of the extracted teeth The extracted tooth was scaled/cleaned off all its attachments with ultrasonic scaler (EMS Minipiezon, Electromedical systems SA, Nyon, Switzerland). The root of the tooth was then reduced using Airotor (NSK, Japan) so as to achieve a suitable length of the tooth in comparison to the adjoining teeth in the oral cavity. All pulpal remnants of the extracted tooth were removed by making an access through the root and the orifice was sealed using composite resin (Z250, 3M ESPE, St Paul, MN, USA). Light cure composite resin was used to contour the apex to an ovate pontic design [Figure 2] and finishing of the apex was done by polishing rubber points (Ivoclar-Vivadent, Schaan, Liechtenstein) to achieve a smooth surface for minimal irritation to the healing extraction site and to enable adequate plaque control.
  • Figure 2: Smooth and polished apical contour of the modified pontic for maxillary central incisor

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  • Splinting the prepared pontic to the adjacent teeth in the oral cavity.


To enhance mechanical retention, a groove was created in the lingual surfaces of the pontic. However, the adjoining abutments were subjected only to etching (Ultra-Etch, Ultradent, South Jordan, UT, USA) and bonding (Single Bond, 3M ESPE, USA). The well contoured pontic was then placed in its socket and its final position was determined with reference to the adjacent and opposing teeth. It was then splinted to the adjoining abutments in the oral cavity using either a multi-flex orthodontic wire or a fiber reinforced splinting material and flowable composite resin (Filtek Supreme XT, 3M ESPE, USA).

When multiple tooth pontics were involved, an additional support was desired for which flowable composite was placed in the inter-proximal areas in such a way that the inter-proximal embrasures were open to maintain adequate plaque control with no damage to the underlying gingival tissues. Once stabilized, the tooth/teeth were corrected for occlusal prematurities in centric as well as excursive movements using an articulating paper and diamond finishing points [Figure 3].
Figure 3: Completed splinting of NTP with multi-flex wire and composite resin

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Patient instructions: The patients were instructed to primarily keep the site free of plaque and debris. Use of inter-dental brushes (Stim Inter-dental Brush, Dent- Aids India) and super-floss (Oral B, London, UK) was demonstrated to the patient to enable good oral hygiene.

The patients were followed-up for a period of 12 weeks, at the end of which the various treatment options available were explained to them. They were then asked to fill out a simple close ended questionnaire (appended below). The results of the questionnaire were subjected to statistical analysis to assess patient's expectations from the treatment modalities. Keeping in view the patients choice, the decision for any further permanent prosthetic restoration was made. Since the data had categorical variables, they were described as frequencies and proportions. Proportions were compared using Chi square or Fisher's exact test whichever was applicable. All statistical tests were two-sided and performed at a significance level of α=0.05.


   Results Top


The results of the close ended questionnaire meted out to them revealed that 100% of the patients were happy with the esthetics of the treatment provided with no discoloration of the pontics over the period of 12 weeks. Amongst the 15 patients examined, 9 (60%) patients were dissatisfied with the function that this treatment provided [Table 1]. Of the total 15 patients who underwent the treatment, 11 experienced some or the other problem with this treatment. Two patients conveyed to be satisfied with the function of the treatment despite having some problems. The primary problem with this treatment was that of difficulty in chewing faced by eight out of the nine patients who were dissatisfied with the function (88.9%) and this data was found to be statistically significant (P=0.011*). Data on additional problems associated with the usage of prosthesis has been tabulated as well as depicted picto-graphically [Table 2] and [Figure 4].
Figure 4: Bar diagram showing various problems cited by the patients associated with the treatment

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Table 1: Percentages of various patient responses related to the parameters

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Table 2: Data revealing the problems faced due to placements of NTP in patients dissatisfied with function

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Four out of the fifteen patients assessed had two teeth as against one tooth replaced by this treatment. Presence of multiple pontics posed major problems regarding mobility as well as irritation to the soft tissues with the data being statistically significant [Table 3].
Table 3: Data on problems faced in patients with multiple teeth as pontics

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Hundred percent of the patients wanted a permanent option and all of them opted for tooth supported fixed prosthesis over an implant supported one. Hundred percent of them refused implant treatment due to the cost involved. The other factors affecting the decision of the permanent treatment option have been tabulated [Table 1]. The study comprised of 10 males and 5 females; out of which 60% of the females and 80% of the males faced one or the other problem. However, due to the limited number of patients the influence of gender on the reported result was not statistically significant (P=0.560).


   Discussion Top


Replacement of the extracted anterior tooth in the immediate post extraction period and healing of the extraction site has to be given due consideration for the sake of esthetics, patient's needs, and function to some extent.

In addition to ease of usage and almost no adaptability period as is with the removable partial denture, NTP's achieves good esthetics and have a positive psychological effect on the patient. This procedure is also associated with a number of limitations like relying on patient's motivation and manual dexterity to maintain oral hygiene around the pontic, limited functional efficiency, irritation to the tongue, and chances of splint breakage. Eleven patients reported of having some or the other problem with the treatment provided and all of them opted for a permanent and more durable prosthesis for the lost teeth.

Two studies have shown a successful long term follow-ups of such natural tooth pontics. [8],[9] The number of patients treated by Kermanshah and Motevasselian [9] were limited and cavity preparations was done on the adjacent teeth which were restored with composite resin along with the splint material and the reported study did not elaborate on the potential discoloration of the pontic over the years. Quirynen et al.[10] have done a long term prospective study using natural teeth and acrylic resin teeth as pontics following loss of lower anterior teeth due to periodontal breakdown have reported a favorable long term results. However, no data was provided on the patient's perspective with respect to permanent prosthetic solution. In the present case series, we minimized the surface changes on the adjacent abutments keeping the treatment option of implant supported prosthesis in mind and the treatment was provided irrespective of the either arch.

Presence of mal-aligned or pathologically migrated teeth especially if more than one, sometimes poses a problem in placement of these pontics due to presence of limited space to accommodate them. In such cases, inter-proximal reduction may need to be done in order to adjust them in the narrow arch form.

In the present case series of 15 patients, 11 were treated for the loss of single tooth and 4 for the loss of two teeth. Three patients were retreated for the fracture of the splint. Modified natural teeth were made to serve as pontics for 12 weeks. This transition period of healing provided an opportunity to evaluate periodontal maintenance in general and formulating a plaque control regime for the patient for further treatment planning. Hundred percent of the patients were satisfied with the esthetics provided; however, all of them desired a more permanent treatment option.

The major limitation anticipated with this restoration was of functional efficacy; hence, a more permanent solution should be offered to the patient. This could be either a tooth or implant supported fixed partial denture. Hundred percent of the patients demanded a tooth supported fixed prosthesis due to the low cost involved, less time needed, and elimination of need for surgery. Despite the fact that this data is obtained from limited number of patients, this study highlights the importance of maintaining esthetics and space as well as preparation of tissues following the loss of teeth with a subsequent permanent prosthesis being provided within a suitable time frame [Figure 5].
Figure 5: Definitive porcelain fused to metal fixed partial denture

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   Conclusion Top


Natural teeth serve as an excellent yet transient treatment option for immediate replacement following extraction in the anterior esthetic zone. The patient satisfaction of continuing to have their natural teeth in the post-extraction period, taking care of his esthetic needs and simultaneously providing him with time to choose from the various final treatment options available is immense. Patient's positive psychological response, cost effectiveness, and achievement of excellent soft tissue contours make this technique very useful. However, appropriate patient selection, their motivation levels, plaque control and precision during placement should be kept in mind to achieve the desired objective.

 
   References Top

1.Brunswold MA. Pathologic tooth migration. J Periodontol 2005;76:859-66.  Back to cited text no. 1
    
2.Ulusoy AT, Cehreli ZC. Provisional use of a natural tooth crown following failure of replantation: A case report. Dent Traumatol 2008;24:96-9.  Back to cited text no. 2
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3.Bissada NF, Ibrahim SI, Borsoum WM. Gingival response to various types of removable partial dentures. J Periodontal 1974;45:651-9.  Back to cited text no. 3
    
4.Kretzschmar JL. The natural tooth pontic: A temporary solution for a difficult esthetic situation. J Am Dent Assoc 2001;132:1552-3.  Back to cited text no. 4
[PUBMED]    
5.Parolia A, Shenoy KM, Thomas MS, Mohan M. Use of a natural tooth crown as a pontic following cervical root fracture: A case report. Aust Endod J 2010;36:35-8.  Back to cited text no. 5
[PUBMED]    
6.Stoller NH, Green PA. A comparison of a composite restorative material and wire ligation as methods of stabilizing excessively mobile mandibular anterior teeth. J Periodontal 1981;52:451-4.  Back to cited text no. 6
[PUBMED]    
7.Friskopp J, Bromlof F, Soder PO. Fiber glass splints. J Periodontol 1979;50:193-6.  Back to cited text no. 7
    
8.Stumpel LJ 3 rd . The Natural Tooth Pontic; Simplified. J Calif Dent Assoc 2004;32:257-60.  Back to cited text no. 8
    
9.Kermanshah H, Motevasselian F. Immediate Tooth Replacement Using Fiber-reinforced Composite and Natural Tooth Pontic. Oper Dent 2010;35:238-45.  Back to cited text no. 9
[PUBMED]    
10.Quirynen M, Mongardini C, Lambrechts P, Geyseleer CD, Labella R, Vanherle G, et al. A long term evaluation of composite bonded natural/resin teeth as replacement of lower incisors with terminal periodontitis. J Periodontol 1999;70:205-12.  Back to cited text no. 10
    

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Correspondence Address:
Sudhir Bhandari
Unit of Prosthodontics, Oral Health Sciences Centre, PGIMER, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.99040

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]

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