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Pedodontics

Abstract:
There are many different types of splinting techniques described in the literature. But by virtue of wide spectrum of intended properties of Fiber reinforced composite (FRC), like, reinforced bonding, biocompatibility, esthetic, translucent and easy-to-use, it enjoys various applications in clinical dentistry. Fiber reinforced composite (FRC) can be used as an alternative to conventional treatment in pediatric dentistry. The present case report illustrates the use of Fiber reinforced composite (FRC) as a splint material, functional space maintainer and for immediate tooth replacement. An 11-year old boy with a lost permanent right maxillary central incisor and mobile teeth, splinting was done with Fiber reinforced composite (FRC), along with an acrylic tooth pontic, which also served as a space maintainer for the missing tooth. The same pontic was later used for fabrication of functional removable partial denture.

Key words:
Fiber reinforced composite (FRC), Trauma splint, Space maintainer, Acrylic tooth pontic Introduction:
Traumatic injuries in young children and adolescents are a common problem that usually results from accidents, contact sports, falls, and violence. In the permanent dentition, the peak age of trauma incidence is between 8 and 10 years and the most commonly affected teeth are the maxillary central incisors1. Tooth avulsion is the total displacement of a tooth out of its socket. It is an infrequent injury, comprising only 0.5-16% of all traumatic injuries. This is an alarming experience, which causes esthetic concern to the patient. Replantation of the avulsed tooth can be done, provided, the tooth can be traced, is not severely damaged and is carried in proper transport medium2.
In the ancient age there was an ambition to fix loose teeth. But a real breakthrough happened with the introduction of the etching method and the development of better composites as well as fiber-reinforced materials3 (FRC). The development of fiber-reinforced composite has brought a new material into the realm of metal-free, adhesive esthetic dentistry. Due to its significant mechanical properties, it has gained direct chairside application which makes it an attractive choice for a variety of dental applications4. Different types of fibers have been added to composite materials, such as glass fibers, carbon fibers, kevlar fibers and vectran fibers. Due to one or the other disadvantage of these fibers, the inclusion of polyethylene fibers has been found to be most appropriate and esthetic strengtheners of composite materials 5.
FRC consists of bondable, reinforced ultra-high-strength spectrum of 215 polyethylene fibers with a high elasticity coefficient (117 GPa) 5 that makes it highly resistant to stretch and distortion and a high resistance to traction (3 GPa) 5 that allows it to easily adapt to tooth morphology and dental-arch contours6. Ribbond fibers undergo “gas-plasma” treatment which reduces the fibers’ superficial tension, ensuring a good chemical bond to composite materials5.
FRC can be used in stabilizing traumatized teeth, restoring fractured teeth and creating a fixed partial denture and for direct-bonded endodontic posts and cores, orthodontic fixed lingual retainers and space maintainers5, 6. Inspite of being so versatile, there are few reports on the use of Ribbond in pediatric dentistry. Therefore, this case report illustrates the use of Fiber reinforced composite (FRC) as a splint material, functional space maintainer and for immediate tooth replacement.

Case report and Treatment:
An 11-year old male patient reported to the department of Pedodontics and Preventive Dentistry with chief complaint of fall from a bicycle 6 days back after which he lost his front tooth and is causing him serious esthetic concerns. According to the parents, the upper right front tooth was jarred from its socket and they could not trace the avulsed tooth [Figure-1, 2]. There was Grade I mobility with 21 and 22. The patient was inquired regarding injury to any other body part. Patient’s medical history was uneventful.
Radiographs were taken to rule out compete crown fracture or intrusion with 11 and for radiographic findings with 21 and 22. The radiograph confirmed avulsion with 11 and showed intact lamina dura with 21 and 22 [Figure - 3]. OPG and occlusal radiographs were also taken to rule out any jaw fracture.
Electric pulp vitality test was done with 21 and 22 which did not show any signs of non-vitality. There was no laceration of the maxillary labial mucosa or buccal gingiva in the maxillary permanent central incisors region. The socket of 11 showed incomplete healing.
The decision was made to do splinting on the labial surfaces of teeth from right side primary canine to the left side primary canine with FRC. After proper shade matching with adjacent teeth, an acrylic tooth was chosen and trimmed to adjust to the length of 21 and premature contacts were checked on the palatal aspect. The pontic was placed just below the gum tissue in 11 region and included in the splinting procedure.
The required length of 2-mm-wide FRC was cut with the scissors. The labial surfaces of the teeth, including the acrylic pontic, were cleaned, etched with 37% phosphoric acid, rinsed and dried. To ensure semi-rigidity, the interproximal regions were not etched or bonded. After applying Single Bond and flowable composite resin to the enamel surfaces, the FRC was slightly pressed through the composite against the teeth using a rounded instrument and cured for 20 sec. FRC was then coated with additional flowable composite which was cured again and polished with a polishing disc [Figure – 4, 5].
Two weeks later, the FRC splint was cut in the interproximal areas and the splint was completely removed from the abutment by using a scalpel blade between the splint and the teeth on the most distal end. The teeth surfaces were polished with non abrasive polishing discs. 21 and 22 showed reduced mobility and electric pulp testing was repeated to confirm that they were healthy teeth and did not require any endodontic treatment.
An impression was taken and the same acrylic pontic was incorporated into a removable partial denture [Figure – 6]. RPD was checked for any premature contacts on the palatal aspect and was delivered with proper instructions for its maintenance.
Regular recall was maintained on monthly basis for nearly 1.2 year to check for the healthy status of 21 and 22 and for the maintenance of RPD.

Rationale for the treatment approach:
Immediate replacement of tooth is important in cases of avulsion to retain the self esteem of young and adolescent patients and soothe the fear and apprehension of parents. FRC helps in serving the dual role of replacement and stabilization of adjacent injured teeth.

Discussion:
Tooth avulsion comprises only 0.5-16% of all traumatic injuries2, and it results most commonly following a blunt impact associated with the high resilience of tooth supporting structures1. The loss of maxillary incisors in childhood has always been problematic, requiring immediate attention to restore both esthetics and function. In the present case, we included an acrylic tooth in the splinting procedure, which ensured an immediate restoration of phonetics, esthetics and self esteem of the child. Growing children are very much influenced by peer pressure and disparaging remarks about the missing teeth might affect their confidence and performance in school.
In the clinical practice, it is commonly noted that if space is present in the anterior region due to loss of a tooth/teeth, the child pushes his tongue anteriorly during speech and swallow. The tongue pressure results in frequent dislodgement of splint. So the acrylic pontic maintained the arch continuity and helped in the better retention of splint and prevented the development of deleterious tongue thrust habit.
Inclusion of this acrylic pontic also served as a semi-rigid, fixed, functional space maintainer. Properly designed, fixed space maintainers are not only less of a nuisance to the child, they also cause less damage to the oral tissues. Polyethylene fiber-reinforced composite when used as a fixed space maintainer offers many advantages. It has an esthetic appearance, is easily manipulated, can be quickly inserted in a single-visit procedure that requires no laboratory services, poses no risk of damage to abutment teeth and is easy to clean7.
A fixed partial denture with the help of FRC should be considered as it is a more conservative treatment option than conventional fixed partial dentures and can be more cost-effective than other types of metal-free tooth replacements. A preliminary retrospective clinical study by Piovesan et al8 suggested that FRC fixed partial dentures (FPDs) could be a functional and esthetic alternative to replace a lost tooth in pediatric and adolescent patients. Also, for the child patients, this treatment could be considered as an interim treatment that can provide acceptable function and esthetics by replacing missing teeth and tissues until a definitive restoration can be performed. In a report by Meiers and Duncan9, a functional survival rate of 95% was noted for FRC fixed partial dentures (FPDs) after a follow-up period of 4.3 years.
In the present case, we could not place FRC on the palatal aspect of maxillary anteriors due to the decreased overjet. Continuous contact of FRC with opposing mandibular anterior teeth would have resulted in its early dislodgement and/or attrition of mandibular anteriors. Considering the co-operation of the patient, a removable partial denture was considered in which thin acrylic was used on the palatal aspect in 11 region. But in cases where overjet and overbite are favorable to place it palatally, palatal splinting can be practiced, providing a fiber-reinforced composite (FRC) fixed partial denture (FPD).

In traumatic injuries, splinting of mobile teeth is the primary concern. The period of splinting should be decided by the clinician based on the extent of alveolar fracture and mobility of injured tooth with follow-up appointments after every two weeks.
According to Oulis et al 10 the splint should include the injured teeth and one or two extra teeth on each side, to form a multiple semi-rigid splint unit. This composite dental unit will provide better stability to the injured periodontium of the mobile teeth.


Conclusion:
FRC can be used as an alternative to conventional treatment in pediatric dentistry. It is esthetic, thin, smooth and non-irritating to the lip. Expense is the one major disadvantage, but its ease of use and chair side application makes it a worthy material for regular practice. In case of loss of permanent maxillary central incisor, immediate replacement of the lost tooth during splinting procedure is important for esthetics, phonetics, swallowing, space maintenance and restoration of self-esteem of patients. It also prevents the occurrence of deleterious oral habits.

Bibliography:
1. Andreasen JO, Andreasen FM, Andersson L. Textbook and color atlas of traumatic injuries to the teeth. 4th ed. Oxford: Blackwell; 2007: 444-480.
2. Trope M. Clinical management of the avulsed tooth. Dent Clin North Am 1995;39:93-112
3. Valyi P, Gorzo I. Current splinting methods in dentistry. I. Fogorv Sz. 2003 Feb; 96(1):25-8.
4. Tezvergil A, Lassila LV, Vallittu PK. Strength of adhesive-bonded fiber-reinforced composites to enamel and dentin substrates. J Adhes Dent. 2003; 5:301–311.
5. Vitale MC, Caprioglio C, Martignone A, Marchesi U, Botticelli AR. Combined technique with polyethlene fibers and composite resins in restoration of traumatized anterior teeth. Dent Traumatol. 2004; 20:172–177.
6. Karaman AI, Kir N, Belli S. Four applications of reinforced polyethylene fiber material in orthodontic practice. Am J Orthod Dentofacial Orthop. 2002; 121:650–654.
7. Kargul B, Caglar E, Kabalay U. Glass fiber-reinforced composite resin as fixed space maintainers in chidren: 12-month clinical follow-up. J Dent Child. 2005; 72: 109–112.
8. Piovesan EM, Demarco FF, Piva E. Fiber-reinforced fixed partial dentures: a preliminary retrospective clinical study. J Appl Oral Sci. 2006; 14:100–104.
9. Freilich MA, Meiers JC, Duncan JP, Eckrote KA, Goldberg AJ. Clinical evaluation of fiber-reinforced fixed bridges. J Am Dent Assoc. 2002; 133:1524–1534.
10. Oulis C, Vadiakas G, Siskos G. Management of intrusive luxation injuries. Endod Dent Traumatol 1996;12:113-9.

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