esthetic rehabilitation of anterior primary teeth using polyethylene with two different approaches

Case Report

Esthetic rehabilitation of anterior primary teeth using polyethylene fiber with two different approaches Abstract An acceptable treatment approach for early childhood caries in the past may not necessarily be the best treatment option for our young patients today. Technological advances in dental materials and the approach to their use need to be considered, and the introduction of new adhesive systems, restorative materials, and the approach toward treating these teeth has yielded convincing results. Two such clinical case reports where polyethylene fibers were used as intra-canal posts and to splint the pontic fabricated with polyethylene fibers reinforced composite are reported.

Key words Composite pontic, maxillary incisors, polyethylene fibers, strip crowns

Jain M1, Singla S, Bhushan BAK1, Kumar S2, Bhushan A1

Department of Pedodontics and Preventive Dentistry, People’s Dental Academy, Bhanpur, Bhopal, 1Department of Pedodontics and Preventive Dentistry 2Department of Oral and Maxillofacial Surgery, M.N. D.A.V Dental College and Hospital, Tatul, Solan, Himachal Pradesh, India Correspondence: Dr. Mansi Jain, W/o Dr. Sanjay Soni, Kailash View, Buria, District Yamunanagar, Haryana, India.

E-mail: mansiynr@yahoo.com

Access this article online Quick Response Code:

Website: www.jisppd.com DOI: 10.4103/0970-4388.86381 PMID:

Introduction Early childhood caries is a serious public health problem in disadvantaged communities, in both the developing and industrialized countries, where malnutrition is common. Maintenance of primary dentition in a healthy condition is important for the well-being of the child as far as proper masticatory, esthetics, phonetics, space maintenance, and prevention of aberrant habits are concerned.

The esthetic restoration of severely mutilated anterior primary teeth has been for long a challenge to a pediatric dentist, not only because of the available materials and techniques, but also from the point of view of pediatric patients, who are usually among the youngest and least manageable group. Inadequate esthetic options in addition to the severity of the condition have prompted extraction in most of the cases, in spite of the treatment being not convincing both to the parents as well as the clinicians.

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Even though treatment modalities for esthetic restoration of anterior primary teeth range from placement of stainless steel crowns to ceramo – based metal crowns, the use of a composite strip crown has been preferred and has performed well in spite of its limitations, due to the type of material and size of the lesion, which may affect its stability, retention, and marginal adaptation.[1] In extreme forms, extraction can be an alternative followed by a removable or fixed appliance.

Anterior primary teeth, when grossly decayed, lack a coronal structure, leading to decreased support and adhesion for a composite crown. Hence, use of a resinbased composite reinforced with polyethylene fibers is preferred and the technique is referred to as the ‘short post technique,’ which requires root canal treatment and a short composite post.[2,3]

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In restorative dentistry, a relatively new technique of etching the enamel surface and bonding composite artificial teeth directly to the adjacent natural teeth reinforced with high density fibers, without metal frameworks, has yielded remarkable results. The advantage of minimal tooth preparation, little or no tissue removal and low laboratory cost has drawn extensive attention.

This article presents two case reports where fiber composite resin, reinforced with polyethylene fibers, is utilized to restore mutilated and extracted primary anterior teeth.

Case Reports

Figure 1: Multiple carious lesions [Pre-operative]

Case 1 Parents with a four-year-old girl, reported to the Department of Pediatric and Preventive Dentistry with the chief complaint of poor facial appearance due to discolored and worn out front teeth. On examination multiple carious lesions with root stumps of 52, 53, 61, and 62 were observed [Figure 1]. The root stumps were found to be firm, with less than 2 mm of the crown above the gingival margin being intact. Radiographic examination revealed no signs of exfoliation, with normal development of a permanent successor.

Endodontic treatment and esthetic rehabilitation of the mutilated incisors were considered in phase 1 and phase II, respectively.

Figure 2: Radiograph showing endodontic management

Step-wise treatment was carried out as mentioned herewith: • Pulpectomy followed by obturation of 52, 53, 61 and 62 [Figure 2] • Removal of 2 mm of the coronal portion of the root filling [Figure 3] • Coronal structures and pulp chamber were etched and conditioned • Polyethylene fibers conditioned with bonding agent, placed in the slot of the root canal, were stabilized with composite material [Figure 4] • Polyethylene fibers, 2 – 3 mm in length, were maintained above the crown to reinforce the coronal structure • Dental morphology was restored and complete function attained with strip crowns [Figures 5 and 6] Clinical and radiographic examination after one, three, and six months revealed the presence of 328

Figure 3: Slot preparation for laying down of polyethylene fibers

an intact crown and the absence of periapical pathology, confirming the efficacy of the combined technique.

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Jain, et al.: Esthetic rehabilitation of anterior primary teeth

Figure 4: Polyethylene fibers stabilized in slots with composite

Figure 5: Trial fit of strip crowns

Figure 6: Morphology restored with strip crowns [Post-operative]

Figure 7: Grossly decayed 51, 61, and 52 and fenestration i.r.t 62

Figure 8: Occlusal view

Case 2 A four-and-a-half-year-old boy reported to the Department of Pediatric and Preventive Dentistry with a chief complaint of decayed teeth. On examination 51,

Figure 9: Radiograph showing endodontic management of the affected incisors

61, and 52 were grossly carious, to the extent that only 2 – 3 mm of the crown structure above the gingival margin was intact, with the presence of fenestration

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Figure 10: Trial fit of strip crowns

Figure 11: Pontic preparation

Figure 12: Cured composite pontic

Figure 13: Splinting of pontic

Figure 14: Occlusal view [Post-operative]

i.r.t 62 [Figures 7 and 8]. Radiographic examination revealed the presence of a fully formed root without any signs of early resorption of 51, 61, and 52.

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The management was carried out in two phases: Phase I - Rehabilitation of 51, 61, and 52 with endodontic treatment followed by extraction of 62 [Figure 9].

Phase II - Esthetic rehabilitation of the mutilated incisors by, • Drilling the canals at least 1 – 2 mm, to create a coronal space for the composite • Etching the incisors, and before the trial, fit strip crowns were bonded followed by occlusion adjustment on removal of the strip crowns [Figure 10] • Strip crown best suited for 62 was selected for the preparation of the pontic • Additional strength was attained by passing a fiber splint from the center of the strip crown [Figure 11] • Crown along with splint was loaded with composite, cured outside the oral cavity before splinting

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Jain, et al.: Esthetic rehabilitation of anterior primary teeth

to 61 and 63 with the help of composite resin [Figures 12 – 14].

Morphology along with complete functional recovery was restored with placement of strip crowns and composite pontic for 62. Periodic recall at every three months revealed the absence of any discoloration, secondary caries, or change in gingival and periapical conditions, confirming the efficacy of the used technique.

Discussion Despite the decline in overall caries prevalence, its incidence continues to be as high as 18% in two to four-year-old and 52% in six to eight-year-old children Kaste et al.[4] In the restoration of the anterior teeth, esthetics and mechanical resistance to fracture are of great importance for obtaining a long-lasting result, which can be attained through reinforcement of the resinous matrix with fibers.[5] Polyethylene fibers are preferred as they improve the impact strength, modulus of elasticity, and flexural strength, and are almost invisible in the resinous matrix, in contrast to glass fibers, which fail to stick to the resinous matrix and carbon and Kevlar fibers, which interferes with the esthetics.[6] The morphology and histology of primary teeth present a lesser surface for bonding, a pulp chamber that is relatively large, and enamel that is inheritantly difficult to etch, due to its aprismatic nature.[7] Thus, the destruction of the tooth structure frequently involves the entire crown, leaving just the root dentine for bonding of the restorative material, thereby increasing the failure rate.[8] The above-mentioned adopted technique, in spite of being simple and quick, achieved excellent cosmetic results.

In view of the physiological resorption that occurs in primary dentition, innovations for short retentive posts are needed, unlike the post and core used in adult dentition.[9] A combined technique of glass fiber post and composite, with final morphology achieved with strip crowns, was found to be a simple and efficient technique with excellent esthetic and functional results, which was in accordance with the technique described

by Webber and co-workers.[10]

Occurrence of a homogeneous mechanical and chemical bonding of a fiber core post, with a flowable composite, forms a unit where both components are bonded firmly to reinforce the tooth, Sidoli et al.[11] As post retention is an important factor with little or no coronal dentin (Cohen et al.),[12] the fiber core exhibiting Young’s modulus of elasticity approximating to that of the tooth decreases the stress concentration and increases the longevity of the restoration.

In case II, as an effective alternative, a fixed functional space maintainer was used for restoring 62, which was a single visit procedure, biocompatible, esthetically acceptable, patient friendly, and needing no reliance on any compliance or laboratory service, in contrast to a conventional removable acrylic plate Artun.[9,13,14] Use of ultra-high molecular weight polyethylene fiber in the fabrication of a fixed space maintainer and a space maintainer with an artificial tooth has yielded promising results (Karaman et al.)[14,15] Mandibular lateral incisor and canine interferences during parafunctional mandibular movements or a physiological forward mandibular shift need attention.

These can be overcome by restoring crowns slightly shorter, with labial proclination, (Judd).[2] In the techniques discussed, the etchant used was an aqueous phosphoric ester solution, which removed the smear layer, etched the enamel, and demineralized the dentine to form a hybridized layer for bonding to the dentine along with a micro-mechanical bonding with the enamel.[16,17] Another factor that added to the success of these techniques was the use of a bonding agent that increased the resistance of the core to the torsional forces (Cohen et al.)[18,19] In view of the cases discussed herein, it can be concluded that intervention using polyethylene fiber posts to support composite strip crowns on severely mutilated primary anterior teeth may be a valuable clinical procedure.

Conclusions Early loss of the anterior primary teeth may lead to psychological disturbances and affect the child’s selfesteem and socialization during the important phase of development. Teeth lost in the anterior region infrequently require space maintenance, but demand rehabilitation from a psychological point of view, as

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many a time, children suffer without being vocal about it. Technological advances in dental materials and new approaches in their use, such as polyethylene fibers used to reinforce the composite strip crown, have yielded convincing results in various studies and also in our cases. Further similar studies with increased followup time and newer hybrid composites are required to establish the superiority of the polyethylene fibers in comparison to other fiber core posts, which are under trial at present.

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How to cite this article: Jain M, Singla S, Bhushan B, Kumar S, Bhushan A. Esthetic rehabilitation of anterior primary teeth using polyethylene fiber with two different approaches. J Indian Soc Pedod Prev Dent 2011;29:327-32.

Source of Support: Nil, Conflict of Interest: None declared.

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