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Authors: Dr. Ansu Kuruvila, Dr. Suja Joseph, Dr. Sujith K

ABSTRACT

The presence of the missing anteriors with long edentulous span is a difficult esthetic problem to resolve and a challenge for a prosthodontist.Diastema existing before extraction may result in excessive mesio-distal width to the pontic space. FPD with loop connectors are sometimes required to address this problem of excessive mesio-distal width of pontic space, when an implant supported FPD is contraindicated. This article describes the procedure for the fabrication of a fixed partial denture with loop connector to restore an excessively wide anterior edentulous space in a patient with existing spacing between the maxillary anterior teeth.

INTRODUCTION

A variety of factors affecting esthetics may motivate a patient to seek prosthodontic treatment. Missing anteriors with long edentulous span is a difficult esthetic problem to resolve and an unusually wide or large restoration will not only affect occlusal function but will also produce an unnatural appearance. [1]Drifting of teeth into the edentulous area may reduce the available pontic space; whereas a diastema existing before extraction may result in excessive mesio-distal width to the pontic space. 1 In these situations, the simplest approach would be to maintain the existing diastemata. Although rarely used, loop connectors are sometimes required to address this problem of excessive mesio-distal width pontic space.2

CASE REPORT

A 19 year-old male patient reported to the Department of Prosthodontics, chief complaint of missing teeth in upper front region due to trauma. His prime concern was aesthetic replacement as well as maintenance of diastema. Clinical and radiological examination revealed periodontally sound14,13,22,23 and missing 12, 11, 21.[figure 1,2].Less amount of bone was available in upper anterior region and the available edentulous span was greater than the approximate size of the missing teeth.Therefore, it was decided to fabricate a loop connector fixed partial denture (FPD) with the 12,11,21 as pontic and 14,13,22 and 23 as the abutment maintaining diastema between 21 and 22. The patient was explained about the treatment modality, and procedure was performed with required consent of the patient. His past dental history revealed that he was having localised spacing between his upper anterior teeth and medical history was non-contributory. The treatment options included an implant-supported prosthesis, FPD with loop connectors, RPD. Considering his financial status, availability of bone and esthetic requirement of maintaining the diastema between 12, 11, 22, and 21, the treatment option of 7 unit porcelain fused to metal FPD from 14 to 23 with loop connector between 21and 22 was planned.

Teeth preparation for porcelain fused to metal was done on 14, 13, 22 and 23with sub-gingival finish line.[Figure 3] Two retainers were used on either side considering the occlusal stresses due to overjet, overbite and canine guided occlusion. Final impressions were made with two stage double mix putty light body rubber base impression material (Aquasil, Denstply) and poured in Type IV dental stone (Bego stone; BEGO, Bremen, Germany). Master casts were retrieved and die cutting was done. A quick-setting rigid poly vinylsiloxaneinterocclusal registration material was used to record the maxillomandibular relationship. The provisional FPD was fabricated and cemented using non-eugenol cement Casts were mounted on a semi-adjustable articulator (Hanau H2) using a face-bow transfer. A 0.5 mm thick wax sheet was placed on the edentulous ridge to create a space to allow convenient access for oral hygiene. Patterns of the modified FPD with loop connector were fabricated by using inlay wax indirectly on the cast, adjusted for optimal occlusal contacts, and contoured to final shape, and form .

To ensure optimum rigidity length of the connector was decreased and half round form of cross section was given. The dimension of the connector was 2 mm with a relief provided by 0.5mm relief wax to ease in maintaining oral hygiene and avoid any marginal gingiva inflammation . The patterns were invested with a phosphate-bonded investment (Bellawest, BEGO) and cast in a base metal alloy (Wiron 99; BEGO). After confirming the metal try in, the porcelain (Vita, Germany) was fired according to the manufacturer's recommendations.[figure4]Pontics were contoured with a fine-grained bur maintaining the diastema and evaluated for esthetics and adaptation to the ridge .The occlusion was evaluated and necessary adjustments were made. After glazing and polishing, the intaglio surface of the retainers was sandblasted using airborne-particle abraded with 50-mm aluminum oxide. Try in was done and interferences if any were removed. [figure 5,6].The surfaces of abutment teeth were steam cleaned and the restorations were cemented with Glass ionomer cement (GIC) Type I luting cement [Figure7,8]. This prosthesis design may decrease access for plaque removal because palatal connectors are over-contoured by design. The patient was instructed to maintain the proper oral hygiene. Use of dental floss (Superfloss; Oral B, UK) and interdental brush (Interdental; Oral B) were recommended. The patient was evaluated after 1 week to assess the oral hygiene status.

DISCUSSION

Connector is the portion of a fixed dental prosthesis that unites pontic and retainer. Their designing determines the health of periodontal ligament under FPD. They may be either rigid or non-rigid. The presence of the missing anterior teeth with a wide span is a difficult esthetic problem to resolve with conventional FPDs.The modified FPD with loop connectors enhance the natural appearance of the restoration by maintaining the spacing and the proper emergence profile, and preserve the remaining tooth structure of abutment teeth3,4. Loop connector is a non-rigid connector and consists of a loop on the lingual aspect of the prosthesis that connects adjacent retainers and/or pontic. 5However, this type of prosthesis requires additional laboratory procedures. In addition, the prosthesis design may cause difficulty in maintenance of oral hygiene, interference in tongue movement6 and may affect phonetics especially linguopalatal sounds.4 However keeping the connectors round and small in size will not affect the phonetics.

In a loop connector fixed partial denture, the connector consists of a loop on the lingual aspect of the prosthesis that connects adjacent retainers and/or pontic. The loop may be cast from sprue wax that is circular in cross section or shaped from platinum-gold-palladium (Pt-Au-Pd) alloy wire. 2,7 The choice is entirely up to the dentist or the dental laboratory. Meticulous design is important to ensure that plaque control is not impeded.8

CONCLUSION

Although they are rarely used, a loop connector FPD offers a simple solution to a prosthodontic dilemma involving an anterior edentulous space, albeit with the maintenance of the diastemas.

REFERENCES
  1. Tylman's Theory and Practice of Fixed Prosthodontics. 8 th ed. St Louis: IshiyakuEuroamericaInc; 1989. p. 12-3.
  2. Shenoy K, Sajjad A. Anterior loop connector fixed partial denture: A simple solution to a complex prosthodontic dilemma. J Indian ProsthodontSoc 2008;8:162-4
  3. Chapman KW, Hamilton ML. Maintenance of diastem as by a cast lingual loop connector and acid-etch technique. JADA.1982;104:49-50.
  4. Ashish Kalra, Mahesh E. Gowda, and Kamal Verma.Aesthetic rehabilitation with multiple loop connectors.ContempClin Dent. 2013 Jan-Mar; 4(1): 112–115.
  5. Rosenstiel S, Land MF, Fujimoto J. Connectors for partial fixed dental prosthesis. Contemporary fixed prosthodontics. 4th edition. Elsevier;2007:843869
  6. Plengsombut K, Brewer JD, Monaco EA, Jr, Davis EL. Effect of two connector designs on the fracture resistance of all-ceramic core materials for fixed dental prostheses. J Prosthet Dent. 2009;101:166–73.
  7. Stephen F, Rosenstiel, Land MF, Fujimoto J. Contemporary fixed prosthodontics. 3 rd ed. St Louis: Mosby; 1995. p. 564-5.
  8. Modi N, Bhayana R, Kaurani P and Padiyar N. Loop Connectors: Aesthetic Solution to Spaced Mandibular Anteriors-Case Report. www. j our nalofdentofacials ciences.com , 2014; 3(2): 11-15

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