Twelve-year results of a direct-bonded partial prosthesis in a patient with advanced periodontitis: A clinical report

Hiroyuki Minami, DDS, PhD,a Yoshito Minesaki, DDS, PhD,b Shiro Suzuki, DDS, PhD,c and Takuo Tanaka, DDS, PhDd Kagoshima University Medical and Dental Hospital, Kagoshima, Japan; University of Alabama at Birmingham, School of Dentistry, Birmingham, Ala
Prosthodontic treatment for patients with advanced periodontitis is a therapeutic challenge. A minimally invasive technique is preferred to preserve the remaining mobile abutment teeth. This report describes the initial clinical treatment and 12-year follow-up of a direct-bonded prosthesis reinforced with a cast metal framework, used as a conservative treatment option to replace periodontally involved maxillary lateral incisors. (J Prosthet Dent 2012;108:69-73) Prosthodontic treatment to replace periodontally involved anterior teeth requiring extraction usually includes partial fixed dental prostheses (PFDPs), resin-bonded partial fixed dental prostheses (RBPFDPs), or partial removable dental prostheses (PRDP). Although PFDPs exhibit high mechanical strength and resistance to dislodgement, their preparation requires significant tooth reduction.1-3 RBPRDPs are declined as a treatment option by many patients. RBPFDPs require less tooth reduction, less gingival disturbance, and reduced chair time.1-4 When planning prosthetic treatment for a patient with advanced periodontitis and gingival recession, clinicians prefer a less invasive technique and so have adopted the directbonded prosthesis to avoid the possible pulpal irritation5,6 or fracture5,7 of the prepared abutment teeth. Extracted teeth,8,9 composite resin,10 or ceramics10-13 have been used for pontics, allowing immediate esthetic recovery and splinting mobile teeth together. Splinted teeth have been reinforced with metal mesh plate,14 orthodontic wire,15-17 glass fiber,18-20 or polyethyla b

ene fiber.17 This report describes the clinical treatment and 12-year followup of a direct-bonded prosthesis replacing maxillary lateral incisors lost to advanced periodontitis.

CLINICAL REPORT
A 48-year-old woman with advanced periodontitis was referred for evaluation and treatment. The maxillary lateral incisors were extracted because of the extensive loss of their supporting tissues. The root of each tooth was resected, and the pulp cavity was sealed. The crowns of the teeth were then bonded with adhesive resin (Super-Bond C&B; Sun Medical Co, Ltd, Shiga, Japan) as interim pontics. After periodontal therapy, treatment options, a PFDP, an RBPFDP, or a direct-bonded prosthesis, were discussed. The patient selected the directbonded prosthesis, citing the minimally invasive nature of the procedure. Initial impressions were made with irreversible hydrocolloid impression material (Aroma Fine; GC Corp, Tokyo, Japan) without removing the interim pontics and were poured in

stone (New Plastone; GC Corp). The pontics were removed from the working cast, and composite resin denture teeth (Endura Anterio; Shofu Inc, Kyoto, Japan) were prepared to fit into the edentulous space (Fig. 1). Composite resin denture teeth with ovoid shape and A3 shade were selected so as to be harmonious with the abutment teeth. Three cavities (1 mm in diameter and 1 mm in depth) were prepared on the proximal surfaces with a tungsten carbide bur (E123A; Dentsply Maillefer, Ballaigues, Switzerland) to provide mechanical retention (Fig. 1). Bonding surfaces were airborne-particle abraded with 50 m aluminum oxide particles (Hi Aluminas; Shofu Inc) at 0.5 MPa pressure for 5 seconds with a 5 mm nozzle-topontic distance. In preparation for the replacement, the interim pontics were removed, and the abutment teeth were rotary cleaned with pumice and polishing paste (Fig. 2). The working area was isolated with a lip retractor and cotton rolls, and tooth surfaces were etched with 65% phosphoric acid (Red Activator; Sun Medical Co, Ltd)

Senior Assistant Professor, Fixed Prosthetic Clinic, Kagoshima University Medical and Dental Hospital. Senior Assistant Professor, Fixed Prosthetic Clinic, Kagoshima University Medical and Dental Hospital. c Visiting Professor, Department of Prosthodontics and Biomaterials, University of Alabama at Birmingham, School of Dentistry. d Professor and Chairman, Department of Fixed Prosthetic Dentistry, Kagoshima University Graduate School of Medical and Dental Sciences.

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1 Pontic fabricated with composite resin denture tooth. Width was adjusted, and root shape was added to ridgelap area by using indirect composite resin. Three cavities (1 mm in diameter and 1 mm in depth) were prepared on proximal surfaces (arrows) with a tungsten carbide bur to obtain mechanical retention.

2 Intraoral view before prosthetic treatment: Mobility of abutments was grade 2 for right canine and central incisor, grade 3 for left central incisor, and grade 1 for left canine, on scale ranging from 0 to 3.

3 Bonding of pontics fabricated with composite resin denture teeth. for 30 seconds.21,22 The denture teeth were bonded by using an adhesive resin (Super-Bond C&B; Sun Medical Co, Ltd) with a brush-bead technique (Fig. 3). Upon completion of the bonding procedure, the occlusion was adjusted by using articulating paper and carborundum points to eliminate premature contact with the pontics. One week after treatment, a ledge was prepared on the cingula of the pontics as a vertical stop for the cast metal reinforcement. A definitive impression of the palatal surface was made with a vinyl polysiloxane impression material (Exafine; GC Corp), and a definitive cast (Suprastone; Kerr Corp, Orange, Calif ) was fabricated. The cast was duplicated by using a die

4 Wax pattern obtained on die investment cast duplicated from definitive cast. es bond strength to noble alloys.23,24 Super-Bond C&B was bulk mixed and applied to the intaglio of the framework, which was then firmly seated. The excess resin was removed with a dental explorer, and the bonding layer was allowed to set for 10 minutes under finger pressure (Figs. 6, 7). The occlusion was carefully evaluated and adjusted to allow slight contact in the maximum intercuspation position and a smooth slide on the guiding surfaces of the abutment teeth during eccentric movements. The definitive restoration showed grade 1 mobility according to the Miller index tooth mobility score.25 The patient was recalled for regular follow-up visits at 3-month intervals. The patient has maintained the

investment material (Real Vest; Shofu Inc), and a wax pattern was obtained (Fig. 4). The metal reinforcement was cast in a silver-palladium-copper-gold alloy (Castwell M.C.12; GC Corp) by using a die investing method (Fig. 5). The pontics were cleaned by using intraoral airborne-particle abrasion (Air Eraser Compound; Paasche Airbrush Co, Chicago, Ill), and abutment teeth were etched with Red Activator (Sun Medical Co, Ltd). The intaglio of the reinforcement was airborne-particle abraded, then primed with a metal primer (V-Primer; Sun Medical Co, Ltd). V-Primer includes 6-(4-vinylbenzyl-n-propyl) amino-1,3,5-triazine-2,4-dithiol (VBATDT) monomer, which significantly enhanc-

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5 Cast metal reinforcement on definitive cast.

6 Intraoral view of definitive restoration (February 1999).

7 Radiograph of each abutment at delivery of definitive restoration in February 1999. Generalized alveolar bone loss was approximately one-third of root length for central incisors and one-half of root length for canines.

8 Frontal view of restoration at 12 years (February 2011). Slight staining was observed at adhesive resinabutment tooth interfaces and adhesive resin-pontic interfaces. However, neither abutment tooth caries nor delamination of cast metal splint was noted.

9 Palatal view of restoration at 12 years (February 2011). Neither abutment tooth caries nor delamination of cast metal splint was noted.

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10 Radiograph of each abutment tooth at 12 years (February 2011). Alveolar bone level of abutment teeth was approximately same as it was during initial treatment, 12 years previously (Fig. 5). satisfactory function and appearance of the restoration (Figs. 8, 9) and has continued to maintain a stable periodontal condition for the past 12 years (Fig. 10); the mobility of the restoration has remained at grade 1. effect on the design of cast metal reinforcement because it would be visible if extended too far apically. The long-term clinical success of the present treatment was most likely influenced by all of the above factors. Additionally, the use of the VBATDT monomer to enhance the bond to the silver-palladium-copper-gold alloy,23,24 along with the phosphoric acid etching to enamel,21,22 may have further contributed to the long-term clinical success of the definitive restoration. The success of bonding Super-Bond C&B to composite resin denture teeth was presumably caused by the macromechanical and micromechanical interlocking obtained by cavity preparation and airborneparticle abrasion. Subsequent study28 has substantiated the efficacy of these steps. The occlusal relationship needs to be favorable to allow placement of the direct-bonded prosthesis and the subsequent cast metal reinforcement so as not to interfere with the patients occlusion. Regular follow-up visits at 3-month intervals have been maintained for over 12 years. All these factors have contributed to the longevity of the direct-bonded prosthesis and the maintenance of the patients periodontal health. For the preservation of the restoration and her periodontal condition, careful and adequate occlusal adjustment needs to be performed. Although the patient has maintained an excellent level of care at home, her periodical followup visits are imperative. In addition, supportive periodontal management by the hygienist and examination for caries become more important.

DISCUSSION
A direct-bonded prosthesis enables immediate recovery after tooth extraction without a laboratory procedure or impression, which represents a definite advantage over conventional treatment. Additionally, because of the instability of the teeth and the force being applied, impressions of mobile, periodontally involved abutments may be inaccurate,26,27 which leads to complicated prosthetic procedures.5 Furthermore, the use of elastomeric impression materials may expose weakened roots to traumatic force during their removal. Another advantage of the directbonded prosthesis is the capability of making a precise impression for the cast metal reinforcement by immobilizing the mobile abutment teeth during the interim phase of treatment. However, since the esthetic result of this treatment method is compromised, it would only be acceptable to a patient who is not concerned with an esthetic outcome. The interdental loss of periodontal tissue also has an

SUMMARY
A long-lasting prosthodontic replacement of maxillary lateral incisors lost to advanced periodontitis was provided with a direct-bonded prosthesis of composite resin denture teeth and a cast metal reinforcement. The 12-year follow-up of this patient documents the longevity and the continued periodontal health that is achievable when a minimally invasive, creative approach to challenging treatment conditions is made.

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