Clinieal Communication

Immediate and indirect woven polyethylene ribbon-reinforcedperiodontal-prosthetic splint: A case reportThomas E. Miller*/Farid Hakimzadch^'*/David N. Rudo***

The patient described in this case report required removai of several mandibular incisor leethbecause of severe periodontal disease. She demanded an immediate replacement for theseteeth, but, because ofthe periodontat conditions, it was not possible to use conventionalapproaches tofiilfil! her request. The decision was made to fabricate an immediate indirect-direct, reinforced, bonded composite resin periodontal prosthesis. The patient's extractedmandibular central incisors were used as pontic replacements. The procedure was expedient,inexpensive, and conservative, and the results were esthetic.(Quintessence Int ¡995:26:267-271. )

Introduction

Traditionally, to splint teeth or to reimplant avulsedteeth, the teeth were wired in place. This technique wasaltered so that the wiie was embedded into shallowtroughs prepared in the enamel and dentin and held inplace with poly{methylacrylate) (PMMA) and eventu-ally bis-GMA composite resins in the form of an A-splint.'"'

Techtiiques of splinting evolved to include the acidetching of enamel surfaces and the bonding and/or wir-ing together of the loose teeth with FMMA and com-posite resins to achieve a less invasive, reversible meth-od of splinting. For wiring, surgical stainless steel is thematerial of choice of many clinicans. but fiberglass**'and other types of reinforcement materials, such asTri-lene** (Du Pont). Kevlar'"" (Du Pont), and silk," areembedded into composite resins. Trilene is a monolila-ment nylon fishing line material, whereas Kevlar is apolyaramid and reportedly strengthens the splint.

•• Associate Professor. Department of Restorative Dentistry.University of Maryiand. Baltimore, Maryland.

" Senior Dental Studeni.Utiiversilyor Maryland.

*•** Private Practice, Seattle, Washington.Repnnt requests: Dr T. E. Miller. Department of Restorative Den-tistry, University of Maryland. Denial School. 666 West BaltimoreStreet, Baltimore. Maryland 21201-1586.Dr David N. Rudo is the developer ot Ribbond and has a financialinterest in Ribbond. fne.

In addition to the splinting of loose teeth, this tech-nique aliows the prosthodontic replacement of theavulsed orlost tooth, with the patient's natural tooth oradenture tooth acting as the pontic.''''

In this case report, the patient's extracted leeth wereused as pontics attached to a woven polyethylene-rein-forced, posterior composite resin, periodontal-pros-thetic splint.

The splint was fabricated indirectly in the laboratoryon the mandibular cast. A poly(vinylsiloxanc) orienta-tion matrix was used to position the extracted teeth onthe splint. The splint was then bonded to the patient'sremaining mandibular anterior teeth with a visiblelight-curing composite resin. Tlicsc procedures result-ed in an esthetic and functional splint.

Case report

A 76-year-old woman cotnplained of pain and discom-fort in the mandibular anterior region and an inabilityto eat her normal diet. Tlie gingival tissues were in-flamed (Figs 1 and 2). Tlie teeth displayed a MillerClass III mobility pattern, and, when the sulcular tis-sues were pressed from the incisai direction, suppura-tion was discharged.

Fretreatment panoramic and periapical radiographsreveaJed that the patient was completely edentulous inthe maxillae, and that there was moderate-to-severe

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Clinieal Communication

Fig 1 At the initial visit, the patient lias an old, repairedcomplete denture in the maxillary arch and the mandibularincisor region is periodontally involved.

Fig 2 The mandibular incisor teeth exhibit swollen tissues,calcareous deposits, and spacing.

loss of supporting tissues in the mandibular anterior re-gion. Pocket probing depths averaged 9 mm (Fig 3).

Other than this localized periodontal problem andthe need for endodontic treatment of the mandibularleft first premolar, the initial interview revealed noother medical or systemic complications or diseases.

The existing maxillary complete denture was un-stable. A new maxillary denture was made and the ex-isting denture was relined. Tlie indicated endodontic.periodontic, and restorative procedures were accom-plished; however, in the mandibular arch, the majorarea of concern was the incisor teeth. After the patientunderwent initial closed subgingivai scaling and rootplaning, pain became an issue.

After the treatment options were explained to thepatient, it was mutually agreed to make an immediatesplint by using the patient's extracted teeth as the pon-tics,'"""'The splint would span from the mandibular leftcanine to the mandibular right canine,

Atasubsequent appointment, a new cast of the man-dibular arch was made after the right and left canineswere prepared with a high-speed rotary diamond in-strument to create shallow orientation grooves in thelingual surfaces. These grooves were confined to theenamel tooth structure, and the patient, therefore, didnot require an anesthetic, Tlie interdental spaces wereblocked out with soft utility beading wax (Orthodon-tics Tray Wax, Kerr/Sybron) to prevent the impressionmaterial from locking around the loose teeth. An irre-versible hydrocolloid impression was made. For accu-racy of the impression technique." the stock metai traywas fitted lo the patient's original diagnostic cast, wax

was molded into the peripheral areas for support andextension, and an alginate adhesive (Hold ImpressiotiTray Adhesive, Teledyne Getz) was employed to rnitii-mize distortion.

After the impression was made and examined for ac-curacy, it was immersed in sterilizing solution andpoured. The double-pour technique was used to pre-vent slumping of the tooth and soft tissue imprints inthe inverted position. After the standards for steriliza-tion were met, the casts were made and based,

A tooth-colored shade was selected and a poly(vinyl-siioxane) index was made of the patient's mandibularincisai relationship. This matrix replicated the labioin-cisai positional relationship of the canine-to-canineteeth. The matrix would be used to transfer the spatialrelationship of the patient's extracted teeth to thesplint. To make sure there was no contamination ofthepoly(vinylsiloxane} putty material, the operator'sgloves were washed with surgica! soap and water fourtimes before the putty material was manipulated be-cause there is evidence that the protective material onunwashed gloves delays the setting of the puttymaterial.'^ The master cast was dried and the lingualsurfaces in the position ofthe splint were coated with athin layer of a lubricant.

Small, thin pads of a heavily filled posterior compos-ite resin shade''* (Herculite XR'V Lab. Kerr/Sybron)matched to the 'Vita Lumin Vacuum Shade guide (VitaZahnfabrik) were adapted to the lingual aspects oftheremaining teeth,

A strip of woven polyethylene reinforcing material(Ribbond, Ribbond Inc) was measured and cut to fit

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Fig 3 The panoramic radiograph reveals the edentulousmaxillae and the severe Pone loss in the mandibular anteriorregion.

Fig 4 The neutral-colored Ribboncdesired length with special scissors.

materiai is cut to the

from canine to canine (Fig 4). The woven lock-stitchedribbon, a gas plasma-treated, bondable segment ofuitrahigh molecular weight polyethylene, was wettedwith a lightly filled resin, positioned into the pads ofcomposite resin, and cured with a visible light source(Fig 5).

The patient returned to have the mandibular centralincisor teeth removed. The teeth were shortened andcontoured apically with a high-speed rotary diamondand retrofilled in accordance with standard endodonticprocedures. The roots were then highly polished.

The coronal portions of the retrieved teeth receivedlingual retentive grooves for mechanical retention. Theextracted teeth were air abraded, etched with phos-phoric acid, and bonded to the reinforced compositeresin; the poly(vinylsiloxane) orienting index was usedfor proper positioning of the extracted teeth.

The guidelines outlined by Jerbi-° for trimming themaster cast for the fabrication of an immediate denturewere followed; the stone mandibuiar central incisorswere removed from the cast and the "alveoli" weretrimmed to accept the patient's natural tooth pontics.After the extracted teeth were placed on the linguaiperiodontal splint and polymerized with heavily filledbis-GMA, the splint was removed from the cast.

The composite resin surface of the splint was sand-blasted by air abrasion (Microetcher. Danville Engi-neering) and chemically etched with hydrofluoric acid(Competch, Gresco) for 5 minutes. Etching of the com-posite resin splint and the phosphoric acid etching ofthe patient's enamel provide a solid bonding environ-ment. The patient's teeth were isolated with a rubberdam, cleaned with medium particle-sized pumice,

Fig 5 The periodontal prosthesis, with the patient's naturalteeth bonded in piace to the Ribbond-reinforced splint, isready for bonding to the patient's canines and laferai incis-ors.

washed, and etched for 30 seconds with 32% to 37%phosphoric acid.

The teeth were washed with water for 30 seconds,dried with air, and then dried with a chemical dryingagent (Dry-Bond. Den-Mat). After it was confirmedthat the proper condition of the etched enamel hadbeen achieved, the splint was bonded to place with avisible hght-curiog, heavily filled posterior compositeresin (Marathon, Den-Mat) (Fig 6).

'ITie occlusion was evaluated to assure the absence ofinterferences, and the patient scheduled appointmentsfor réévaluation and follow-up treatments. ITie patientwas extremely pleased with the efforts and the result-ant esthetic results. She was given written and oral

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Fig 6 The final periodontai prosthesis is bonded to themandibular incisors; the immediate results are esthetic.

2. In composite resin-reiiiforced prostheses fabri-cated directly in the mouth or indir^-ctly in the labor-atory

3. For reinforcement of composite resin crowns4. In (II thodonlic retainers5. For strapping of cracked teeth6. fn provisional implant fixed partial dentures and

splints7. For repairing complete or removable partial den-

tures''^8. For reinforcement of dentures and removable or-

thodontic retainers in critical areas of the horseshoearea of mandibuiar and palateless maxiiiary modi-fied Hawley retainers

9. For reinforcement of endodontically treated teeth

instructions on the home care required for properhygienic maintenance of the periodontai prostheticsplint.

Discussion

Ribbond reinforcing ribbon material becomes an inté-grai part of the splint because the activated surfacechemically reacts with the unfilled resin ofthe compos-ite resin or PMM A. Ribhond is one ofthe first reinforc-ing materials that reacts with the resin matrix. It hasbeen reported that because of its woven and flexibletexture, the Ribbond material dampens the stresses ex-erted onto and into the splinting material and the sup-porting teeth.-' Ribbond reinforcing material has ahigh molecular weight, a tensile strength of 4.30.000 psi.and a modulus of elasticity of 24.8 million psi.

The dynamic and physical factors that impact on res-torations take their collective toll on every restorativematerial. The woven ribbon ofthe Ribbond strands im-parts a multidirectional reinforcement to the compos-ite resin, unlike the unidirectional reinforcement pro-vided by single-stranded or multifibered reinforcingmaterials.

The neutral color and transiucency of the polyethy-lene strands permits improved color control of the res-in in which it is embedded because Ribbond is maskedby the color uf the composite resins or PMMA resinsthat surround it. Tlie show through resulting from oth-er splinting materials is eliminated.

The materiai has other uses:

1. In provisional prostheses for long-term provisional-ization and observation

Summary

This case report discussed the immediate and indirectfabrication of a pcriodontal-prosthetic splint for apatient concerned about the esthetic and functionalloss of mandibular anterior teeth. The treatment wasimmediate, in that the teeth were extracted and the re-placement was inserted on the same day, and indirect,in that the prosthesis was fabricated on a cast in thelaboratory.

The patienfs extracted incisor teeth were modifiedwith retrofilled endodontic treatment and used as thepontics in the prosthe.sis. The strength and color oftheheavily filled composite resin splint was enhanced bythe incorporation of a reinforcing woven polyethylenematerial.

The use of bonding to etched enamel with heavilyfilled composite resins and reinforcing woven ribbonfibers offers a conservative approach to preservation ofthe remaining dentition's enamel and pulpal tissues,and the prosthesis is positioned supragingivally.

Referencest. Baum hammers A. Cold-curing acrylic reinforced lempoiary

wire ligatLon splinls. Dent Dig l%6;72;41)0.

2. Weisgold AS. Temporary slabilbalion. In; Goldman HM, Co-tien DW (eds). Periodontal Ttierapy. St Louis; Mosby 1973;463^90.

3. Amsterdam M. Periodontai prosthesis; 25 years in retrospect.Alpha Omegan 1974;67;S-52.

4. Greenfield DS, Nathanson P. Periodontat splinting with wireand composite resin—A revised approach. J Pei iodontol 19Rt)-5t:465.

5. Klassman B, Zucker HW. Combination wire-composite resmintracoronal splinting; Rationale and technique. J Periodonto]1Ç176;47;481.

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Clinical Communication

6. Friskopp J, Blomlof L, Soder P-O. Fiberglass splints. J Pcriod-otitoll975:50:193.

7 Friskopp J, Blomlot L. Intermediate fiberglass splints. J Pros-Ihet Detil l984;.St:334.-337,

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9. MuUarky RH, Ryan DE, Reinforcement ol" dental plastics withpotyaramid fiber. Trends Techn Contemp Dent Lab iy87;32-38,

10. Berrong JM, Weed RM, Young JM, Fraeture resistance of Kev-lar-reinforced poly(methyl metliacrylate) resins: A preliminarystudy, Int J Prusthodotit 1 Wn;3;391-395,

11. Walinehus RE, Silk bonded replacements wiili porcelain ve-neers: A cosmetic alternative in dental treatment. J Esthet Denl1990;2:117-121.

12. Heymanti HO, Resin-retained bridses: The natural-tooth pon-tic. Gen Dent 1983;31:479^82,

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16. Stiasslei HE. Gerhardt DE. Trouble-shooting everyday restor-ative emergencies. Dent Clin North Atn 1993;37:353-365.

17. Rudd KD, Morrow RM, Banse AA, Accurate casts. J ProsthelDent l%i';21:545-554.

18. Neissen LC. Strassler HE, Levinson PD, et al. Effect of latexgloves un setting time of polyvinylsiloxane putty impressionmaterial, J Prosihet Dent 1986:55:128-129.

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21. Mito RS, Capnto AA, James DF. Load transfer to abutmentteeth by two non-metal adhesive bridges. Pract Periodont Aes.thet Dent 1991:3:31-37.

22. Miller TF.,Barrick JA. Pédiatrie trauma and polyethylene rein-forced composite fixed partial denture replacements: A newmethod. J Can Dent Assoc 1993;59:252-256.

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25. Miller TE, Connelly ME. Guidelines for salvage, repair, andconversion of existing prostheses, Calif Am Dent Inst ContinEducl993;45:l'l^28, •

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