A Quick Front Fix by Dr. Thomas Paumier

Figs. 1 and 2

Figs. 3 and 4

Figs. 5 and 6

Figs. 7 and 8

This patient, in his mid-60s, had experienced trauma to the lower anterior teeth decades earlier. Tooth #24 had been treated endodontically twice, with continued enlargement of the periapical granuloma (Figs. 1 and 2). Treatment options included endo on #25; apicoectomy of #24 and #25 with enucleation of the granuloma and bone grafting; extraction of #24 and #25 with two implants; a fixed partial denture (FPD) on #23–#26; or extraction of #23–#26 and an FPD #22–#27. (A flexible-style removable appliance also was a treatment option.)

The cost of all traditional options was a barrier to acceptance, and the patient did not want a removable appliance, so a direct-bonded bridge was the choice after extraction, granuloma removal and bone grafting. Before extraction, an alginate was taken to provide a study model for a mock-up, putty matrix fabrication and fabrication of an Essix retainer to wear until initial healing from extractions. The direct-bonded bridge was done within two weeks of the surgery.

Class 3-style preparations were made in the mesial of both #23 and #26 (Figs. 3 and 4). A facial reduction in enamel can extend to cover the entire facial—or, as was done in this case, only partial coverage. The incisal was reduced 1–2 mm and the lingual surface was simply roughened with a diamond with no reduction.

A Fiberkor “post” was prefit into the Class 3 preparations on the lingual. The teeth were pumiced, etched, rinsed, bonded and cured. Composite (3M Filtek Z-250) was placed in the preparation areas and across the lingual of #23 and #26, and the Fiberkor post was then embedded in the composite. The putty matrix is then pressed against the uncured composite and cured (Fig. 5).

Composite was then used to build against the putty matrix and bonded to the mesial of #23 and #26 from cervical to incisal. The final facial increment is placed with Filtek Supreme Ultra in one increment as a “veneer.” I simply build the pontics from lingual to facial in three to four increments, gently pressing the composite onto the tissue, attempting to shape the embrasures during the build-up to minimize final contouring and polishing. I use 12-fluted carbide finishing burs and final polish with the last two 3M Sof-Lex discs, and a final coat of Seal-n-Shine or any unfilled resin helps minimize stain.

There has been no tissue shrinkage in the pontic areas, because they were built directly to the grafted edentulous site. As you can see in Figs. 6 and 7, the resorbable sutures are still evident at the surgical site. I will adjust the occlusion into equal contact with the opposing dentition, trying to avoid lateral and protrusive interferences. The key to success is bulk of composite and wrapping the facial, lingual and incisal surfaces (Fig. 8), as well as splinting the entire length of the mesial contact area from cervical to incisal.

Figs. 9 and 10

Figs. 11 and 12

Figs. 13 and 14

Fig. 15

This case demonstrates the same technique with a single missing lateral. The patient was referred to me by a local oral surgeon after extraction of #23 (Figs. 9 and 10). He was undergoing chemotherapy and wanted a simple, quick replacement if possible.

I did the direct-bonded bridge (Figs. 11–15) one week after the extraction. This enables building the pontic into the healing extraction site, giving the best aesthetic result. At the initial visit, an alginate was taken to do a lab mock-up and make the putty matrix. There was also decay on the mesial of #24, which was restored, and #21 had an MODL fracture that was restored with a direct-bonded five-surface onlay.

Figs. 16 and 17

Figs. 18 and 19

Figs. 20 and 21

Figs. 22 and 23

Fig. 24: Direct FPD #9–11                 Fig. 25: Indirect FPD #6–8

Fig. 26

The next two cases involve the same technique with maxillary central incisors.

This patient, in his mid-80s, came in with the complaint of a “loose crown,” and the radiograph (Fig. 16) demonstrated a horizontal root fracture. I took an alginate to fabricate an Essix retainer, because it was clear the tooth would fracture completely quickly. He came in two weeks later with the crown and cervical root (Fig. 17) in his hand.

Finances were an issue, so we modified the Essix retainer to act like a putty matrix and did a direct-bonded bridge (Figs. 18–26) at that appointment. The tissue had nearly grown over the remaining root and it was left in place, because there was no periapical radiolucency and was asymptomatic. It has remained asymptomatic for four years to date.

Figs. 27 and 28

Figs. 29 and 30

Figs. 31 and 32

Figs. 33 and 34

Fig. 35

This patient had a vertical root fracture #8 requiring extraction; Fig. 27 was taken one week postoperatively with tooth preparation on #7 and #9. We made an Essix retainer from an alginate study model and placed the crown of the extracted #8 (Fig. 28) into the Essix, which he wore for one week until we placed the direct composite bridge (Figs. 29–33). I could have used pink composite at the cervical, but because it was not visible (Figs. 34 and 35), I did not.

Figs. 36 and 37

Figs. 38 and 39

Figs. 40 and 41

Figs. 42 and 43

Fig. 44

The final case is a patient who had a horizontal root fracture of #7. Teeth #8 and 9 are crowned. The tooth had previously had a root canal and was asymptomatic; the fracture was 3–4 mm below the crestal bone (Fig. 36). The coronal tooth was removed and glass ionomer was placed over the root to seal the gutta-percha (Figs. 37 and 38). The patient was Class 2 with 100% vertical overlap.

A putty matrix was made from a study model (Fig. 39). A larger Class 3 preparation was made on the ML #6 and the mesial facial was veneered (Fig. 40). The patient did not like the large incisal embrasure of #6–#7, so we used that to provide a stronger splint using a cantilever pontic (Figs. 41–44). The pontic is not bonded to the root #7 glass ionomer coping. A lubricant can be placed on the glass ionomer before building the pontic.