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.