A Splint-Supported Porcelain Pontic After Adult Orthodontic Treatment

A number of alternatives presently exist for replacement of a missing front tooth. An implant, 3-unit bridge, or metal or all-porcelain Maryland Bridge¹ are the most common options. However, all of these pose a problem if the patient wishes to have a lingual splint placed after undergoing orthodontic treatment. Adhesion of composite splints to ceramic or metal is poor long-term and generally will not withstand the forces of mastication. Composite crowns (Cristobal [DENTSPLY])² are compatible with the splint,³ but have inferior aesthetics and (aesthetic) durability versus ceramic options.
This paper describes a protocol whereby the patient can attain the aesthetic benefits of an all-ceramic pontic veneer, which is retained by a lingual composite-Ribbond splint for a practical and conservative alternative. In addition, this pontic is anchored by 5 anterior abutments, which are held in place for orthodontic retention. The composite-porcelain hybrid pontic offers strength, provides long-term aesthetics, and stabilizes all anterior teeth without a Hawley retainer.

SHORT-TERM ADULT ORTHODONTICS

The cosmetic dentistry revolution has begun to include adult short-term cosmetic orthodontics. Since I first wrote about chief complaint adult cosmetic orthodontics in 1999,⁴ many have begun “6-month orthodontics” discussions and Web-based Internet advertising campaigns. There has been at least one dental office founded completely on the basis of the “6-month braces” concept (Dr. Ryan Swain, N. Chili, NY). Adult patients are realizing that practical, realistic options now exist to “straighten” their teeth in the commonly understood way. However, many of these patients have concurrent orthodontic problems that often caused the aesthetic problem.  Missing or malformed teeth requiring the addition of porcelain-like materials can now be fabricated in a way that still allows placement of a lingual splint to stabilize the orthodontic movement.
In the past, one had to choose between either the aesthetic benefits of ceramic or the bondability characteristic of composite.^5,6 Through the use of a ceramic veneered pontic, a missing tooth can be replaced with an aesthetic and durable option.⁷ This may even prove to be more durable than an all-ceramic Maryland Bridge, and certainly is more easily repaired.

TECHNIQUE STEPS

1. Teeth are straightened via orthodontics, and the correct pontic width is established.  Slight overjet (2 mm) must be left in the final result to allow space for splint placement.
2. An upper alginate is taken with the brackets still on and sent to the lab with instructions to fabricate a porcelain veneer the width of the pontic space.
3. Upon bracket debonding, the veneer is silanated and bonded to the Ribbond composite splint and locked in with proximal undercuts.

CASE 1

1. The patient was missing tooth No. 8 and had spacing too large for a single pontic (Figures 1 and 2).
2. Spacing was closed (Figure 3), and a Ribbond splint was placed (Figures 4 and 5). The laboratory had previously made a porcelain veneer pontic, which was silanated and bonded to the splint. Proximal undercuts in veneer design enhance mechanical retention.

Figure 1. No. 8 pontic space was too large, and patient disliked spacing.

Figure 2. Facial view before.	Figure 3. Pontic space after orthodontics but before veneer splint placement.
Figure 4. After veneer and splint placement.	Figure 5. Six-month recall retracted view after whitening.

CASE 2

This case demonstrates a similar splint concept except with crowns instead of pontics.

1. The patient wanted 2 crowns on teeth Nos. 8 and 9 splinted in place (Figure 6) after having orthodontic treatment for a second time. Diastemas should always be splinted after correction because of their high tendency to relapse.
2. The crowns were ready to be splinted through a window in back, which allows splinting directly to preps (Figure 7).
3. Figure 8 shows the concept of the Ribbond splint.

Figure 6. Crowns to be splinted.	Figure 7. Crowns in place before splint placement.

Figure 8. Splinting.

CONCLUSION

This technique is a simple alternative to implant surgery or crown preparations on healthy abutments. Simultaneously, this resolves the problem of orthodontic relapse common in the adult patient in a durable fashion with the superior aesthetics of porcelain or porcelain-like materials.

References

1. Bassett JL. Replacement of missing mandibular lateral incisors with a single pontic all-ceramic prosthesis: a case report. Pract Periodontics Aesthet Dent. 1997;9:455-461.
2. Estafan DJ, Dussetschleger F. Fabrication of resin-bonded three-unit prostheses. Am J Dent. 1999;12:51-52.
3. Arteaga S, Meiers JC. Single-tooth replacement with a chairside prefabricated fiber-reinforced resin composite bridge: a case study. Gen Dent. 2004;52:517-519.
4. Georgaklis CC. Six-month adult aesthetic orthodontic treatment. Dent Today. Sept 1999;18:110-113.
5. Husein A, Berekally T. Indirect resin-bonded fibre-reinforced composite anterior bridge: a case report. Aust Dent J. 2005;50:114-118.
6. Meiers JC, Kazemi RB. Chairside replacement of posterior teeth using a prefabricated fiber-reinforced resin composite framework technique: a case report. J Esthet Restor Dent. 2005;17:335-342.
7. Ajlouni R, Ajlouni K, Oonsombat C, et al. Conservative inlay fixed partial denture: a clinical and laboratory technique. Gen Dent. 2005;53:266-269.

Dr. Georgaklis originated the concept of 6-month adult cosmetic orthodontics in his Boston practice. He has performed it since 1991, and has been publishing and lecturing on various aspects of it since 1999. He teaches an in-office, over-the-shoulder course, and can be reached at (617) 277-5200.