mark & steven bornfeld dds

I've given up Maryland bridges, as I had too many coming off.
However, I haven't used metal bonded retainers for splinting, for
example, lower incisors.
Anyone have experience using this? Are there lab-fabricated resin
(Fibercore or something like that) splints now that I should consider?

Steve

--
Mark & Steven Bornfeld DDS
Brooklyn, NY
718-258-5001
http://www.dentaltwins.com

dr steve

I agree with Joel.

As far as splinting,,,,,, wait for the Eastflex Tie-Bows. They will "blow
you away".

--
~+--~+--~+--~+--~+--
Stephen Mancuso, D.D.S.
Troy, Michigan, USA
DrSteve@Mancuso.d.d.s.com
{remove first 3 dots for email}
.................................................. ...

This posting is intended for informational or conversational purposes only.
Always seek the opinion of a licensed dental professional before acting on
the advice or opinion expressed here. Only a dentist who has examined you
in person can diagnose your problems and make decisions which will affect
your health.
.......................
Please ignore j..d...
~~~~``````````#####----

mark & steven bornfeld dds

I always made rest seat preps--the Maryland bridges fell out anyway. Of
course, adhesives have improved--haven't done any in maybe 15 years.
Tie-bows--isn't that some form of exercise/self defense?
I guess you still make proximal boxes to fit them in. I'm hoping not to have
to prep lower incisors. I secretly hate lower incisors. Steve

--
Mark & Steven Bornfeld DDS
Brooklyn, NY
718-258-5001
http://www.dentaltwins.com

dr steve

With the Tie-Bows, you have to make minimal class III preps. The Tie-Bow is
so small, you have to push a dot of flowable composite out the dispensing
tip, and pick up the Tie-Bow with the dispensing tip.

Maryland bridges need to be made similar to the old 3/4 gold anterior crown.
Reverse pin prepartions, and pronounced rest seats. You cannot use small
rests like you would for an RPD.

--
~+--~+--~+--~+--~+--
Stephen Mancuso, D.D.S.
Troy, Michigan, USA
DrSteve@Mancuso.d.d.s.com
{remove first 3 dots for email}
.................................................. ...

This posting is intended for informational or conversational purposes only.
Always seek the opinion of a licensed dental professional before acting on
the advice or opinion expressed here. Only a dentist who has examined you
in person can diagnose your problems and make decisions which will affect
your health.
.......................
Please ignore j..d...
~~~~``````````#####----

joel m. eichen d.d.s.

If your supplier does have "Tie-Bows," then GET!!!!!!! Tae Bo's!
Something like that .....

or bow ties!

--
Joel M. Eichen, D.D.S.
Philadelphia PA

http://www.phillyducks.com
We’re Just A Duck Call Away!


STANDARD DISCLAIMER applies ~
meaning no one IN PENNSYLVANIA
has seen the tooth or teeth in
question so take this advice in
proper context ~ its the internet!

We is guessin'!

joel m. eichen d.d.s.

Nope those are the things you eat with groats .......


--
Joel M. Eichen, D.D.S.
Philadelphia PA

http://www.phillyducks.com
We’re Just A Duck Call Away!


STANDARD DISCLAIMER applies ~
meaning no one IN PENNSYLVANIA
has seen the tooth or teeth in
question so take this advice in
proper context ~ its the internet!

We is guessin'!

joel m. eichen d.d.s.

Is there a video? Nope that's Tae Bo.

The Tie-Bow is

--
Joel M. Eichen, D.D.S.
Philadelphia PA

http://www.phillyducks.com
We’re Just A Duck Call Away!


STANDARD DISCLAIMER applies ~
meaning no one IN PENNSYLVANIA
has seen the tooth or teeth in
question so take this advice in
proper context ~ its the internet!

We is guessin'!

etukee

Monodonts are a great solution and very esthetic.

drcnbseen

<< I've given up Maryland bridges, as I had too many coming off.
However, I haven't used metal bonded retainers for splinting, for
example, lower incisors.
Anyone have experience using this? Are there lab-fabricated resin
(Fibercore or something like that) splints now that I should consider?

Steve

--
Mark & Steven Bornfeld DDS
Brooklyn, NY
718-258-5001
http://www.dentaltwins.com>>

Steve have done both (metal bonded and sculpture fiberkor bonded) splints.
both work very well. You may want to get a copy of my recently published
article "Intracoronal Splinting" in the Journal of the ASDA.

Here is a rough draft without the pictures:
Intracoronal Splinting Revisited

older dental techniques in a different light, particularly when new and
improved materials and systems have been introduced. Dental intracoronal
splinting, often referred to as “A splinting�, is not a new technique.
Splinting of periodontal teeth can be traced as far back as 500 B.C. to the
Phoenicians . Obin in the early 50’s suggested cutting slots in the lingual
surfaces of anterior teeth and tying them together with acrylic resin. In the
sixties Sturdavant, Burton et al described an intracoronal splinting technique
of connected gold inlays on posterior teeth with pin ledge gold restorations on
anterior teeth. Dentists have utilized amalgam, acrylic and composite with and
without wires, pins, and monofiliment for about fifty years to create
intracoronal splints for periodontally compromised teeth. However due to lack
of good cohesive dentinal bonds and weakness of the materials holding the
splint together, intracoronal splints have always been the “also ran� when
it came to stabilizing teeth. Extracoronal splinting with connected procelain
fused to metal crowns in general has been viewed as the “Cadillac�
approach to stabilizing periodontally compromised teeth.

Today with the introduction of indirect reinforced polymer-glass ceramic
restorative materials and improved dentin bonding, intracoronal splinting may
have some distinct advantages over the more conventional procelain fused to
metal (PFM) extracoronal splinting.

These include:
1. more conservative tooth preparation
2. supragingival margins
3. materials which are more compatible with opposing natural dentition
4. easier to modify or repair existing splint in the future
However some disadvantages also exist which include:
1. no long term data
2. long span replacement of teeth (over 15 mm) is contraindicated
3. less control over occlusion
4. more difficult to temporize

The use of polymer-glass ceramic fiber reinforced splints has only been used
for the last decade in dentistry. Similar products, however, have been
utilized in industry for almost half a century. Cars, bikes, airplane parts,
even poles for vaulting have shown us the strength and favorable properties of
these materials. In the mid eighties Golub first described an all resin bridge
using silk fibers for reinforcement. In 1990 ceramists Materdomini and
Yarovesky working with Drs. Nixon and Hornbrook created a fiber-reinforced
resin framework with a facial porcelain veneer bonded to the pontic core which
they named Encore. In the early 90’s the advent of indirect reinforced resin
materials such as Sculpture/FiberKor (Jeneric Pentron) and Targis/Vectris
(Ivoclar-Williams) with high rupture modulus gave us materials which rivaled
metal reinforcement and moved the bar up a notch for intracoronal splinting.

CASE REPORT:
Dental history and clinical evaluation:
A fifty six year old female presented herself for a consultation (while in the
final phase of orthodontic therapy) regarding her restorative needs. The
patient was referred by her periodontist. She had recently undergone
orthognathic surgery and orthodontics to correct an existing Class II division
1 malocclusion figures 1,2, and had been under the care of the periodontist for
approximately five years.

Periodontally the patient had no pocketing over 3mm. However she had
significant generalized horizontal bone loss approaching 60-70% with concurrent
gingival recession. Not surprisingly the patient had significant mobility on
most lower teeth, and all upper anterior teeth. Driven by her desire to
“keep her remaining teeth� the patient was extremely fastidious with her
oral home care and flawless in keeping her maintenance visits. As of her last
periodontal maintenance visit she had clinically healthy tissue with a bleeding
index of 0. Even with this, the periodontist felt that teeth #24 and 25 had
a poor long term prognosis, and teeth #18, 20, 23, 26, 29, 31 has a guarded
prognosis.

At the final phase of orthodontic therapy, the occlusal evaluation revealed a
Class I figures 3,4. She had group function right and left side with no
incisal guidance.

Clinical and radiographic examination revealed teeth #’s 1, 16, 17, 21, 28,
and 32 were missing. The remaining post-orthodontic edentulous space in area
#21 was ~9 mm, and the edentulous space in area #28 was ~6mm figures 5,6.
There was no evidence of either defective restorations or caries.

A smile ****ysis revealed she had a uniform lip rise with a high smile line
revealing the whole clinical crowns of teeth #4-13, as well as, 2 mm of
anterior maxillary gingiva. During normal conversation the patient displayed
the incisal half of teeth #4-12, and the incisal third of #22-27. The patient
was uncomfortable with the large visible gingival embrasures (areas 6/7, 7/8,
9/10. 10/11) when she smiled. She also expressed a concern of wanting
“slightly lighter-brighter teeth�. Her existing shade was very close to
Vita D-4 figure 7.

Discussion of Treatment options:
Due to the poor or guarded prognosis of all the lower incisors, the remaining
lower bicuspids, and lower second molars, a definitive treatment option might
have included full lower exodontia. At that point two to eight implant fixture
could have been placed, depending upon whether the patient elected for a
removable overdenture, a hybrid fixed prosthesis (described by
Branemark/Zarb/Albrektsson), or a full mouth implant
supported conventional reconstruction. The patient’s desire to keep all her
remaining teeth, her impeccable oral hygiene performance, as well as the
stability of the bone

level over the last five years guided us to look for different avenues to both
stabilize the mobile teeth and replace the missing lower 1st bicuspids.

The long term prognosis of all the upper teeth was brighter. However there were
other restorative obstacles that had to be overcome. These included; the
mobility of the upper anterior teeth, the lack of posterior dissocclusion with
protrusive movements, the large anterior gingival embrasures figures 5,6
creating the dreaded “black holes� , and the shade of her existing teeth.

Full upper and lower PFM fixed prosthetic reconstruction was considered. This
would have provided a proven way of stabilizing all teeth, replaced missing
teeth, changed the shade of the teeth, and sustained a mutually protective
occlusal scheme. However the downside of this option included; limited
flexibility for any lost teeth in the future, future esthetic compromise with
any recession in the anterior ***tant, limited repair capability for porcelain
or metal fractures, and the increased probability of devitalizing lower teeth
with long clinical crowns that were periodontally compromised.

An alternative fixed prosthetic option was explained to the patient and
mutually agreed upon by the patient, the restorative dentist, and the
periodontist. It consisted of
intracoronal splinting of teeth #4-13 and 18-31. In addition facial veneers
would be fabricated for teeth #4-13 to close gingival embrasures and improve
the color of the
existing teeth.

The advantages of this treatment option were many:
1. It calls for less invasive teeth preparations versus the conventional
extracoronal approach. This could mean less risk of devitalization of existing
teeth, particularly with periodontally compromised clinically long teeth.
2. Any additions, modifications, or repairs could be made in the future due to
the compatibility with most existing direct composite systems.
3. The material displays a wear resistance close to enamel tooth structure.
4. The material could be bonded to both enamel and dentin, hopefully
reinforcing the remaining tooth structure and preventing marginal leakage.
5. All margins could be kept supragingival .
6. With no metal to mask out long term aesthetics should be acceptable and
predictable.

Jeneric Pentron’s indirect resin system (Sculpture-FibreKorTM) was chosen for
this demanding intracoronal splinting. It provided the most favorable
characteristics. Sculpture is a polycarbonate dimethacrylate containing resin
matrix (PCDMA) filled with fumed silica and barium-based glass ~78% by weight
and an average particle size of ~ 0.6 microns. Sculpture has a polymerization
shrinkage of less than 2% and a wear resistance of less than 3 microns per year
in in-vitro testing. FiberKor is unique
from most woven glass or polyethylene fibers found in other dental products.
The unidirectional glass fibers are also preimpregnated with the PCDMA resin.
The resin
penetrates each glass filament to create a cohesive bonded bundle of fibers.
This is demonstrated on the scanning electron microphotograph figure 8. The
section view of the cured FiberKor shows void free complete resin impregnates
of each fiber strand. The cured material without voids or air pockets provides
a strong dense framework. FiberKor is ~60% filled by weight, has a flexural
strength of 138,000 psi, and a rupture strength of ~1000 M/Pa. This is
superior to all other fibers presently on the dental market today. Since the
chemistry of the resin in both the composite and the fiber are the same,
problems with debonding and fraying of rough fiber strands are
essentially eliminated. The SEM figure 9 shows the interface between the
composite, and the fiber has a seamless void free boundary zone once completely
cured.

Treatment:
Treatment protocol consisted of first establishing stability, then improve the
smile corridor, and finally building in a mutually protective occlusal scheme.
This order is certainly different then most conventional reconstructions. Due
to the mobility of many of the existing teeth it was a challenge to procure
accurate post orthodontic study models and a stable bite in order to evaluate
occlusion and create an ideal diagnostic wax up. By spot bonded the incisal
embrasure of all adjacent teeth together using a
flowable composite and blocking out gingival embrasures with LC Block-Out
ResinTM, a vinyl polysiloxane impression was taken. An aluwax bite was taken
at centric relation. A face bow transfer was also done at this appointment.
After pouring and mounting it was determined that centric occlusion and centric
relationship could be controlled with intracoronal preparations as long as
cir***ferential preparations were done on the lower anteriors in order to build
in both immediate incisal guidance and cuspid rise with posterior
dissocclusion.

Maxillary Intracoronal preparations were initiated at the next visit. Again
the teeth were stabilized prior to preparations by blocking out gingival
embrasures with LC Block-Out Resin. Teeth were then spot bonded together using
a flowable composite at the incisal embrasure figure 10. The intracoronal
preparation extended from upper right second bicuspid (#4) to upper left second
bicuspid (13) using a modified protocol recommended for inlays by
Jeneric/Pentron for Sculpture-FiberKorTM figure 11. Since interproximal caries
was not a problem no proximal boxes were needed. Instead the preparations
were kept at the same pulpal floor level, that is approximately 2.0 mm of
occlusal reduction figure 12. Once completed a final impression was taken of
the upper arch again using a vinyl polysiloxane. To temporize, FermitTM was
condensed into place and light cured. The LC Block-Out ResinTM helped to
prevent gingival excess, and the occlusal scheme of the Fermit was carefully
adjusted with Enhance bursTM. The LC Block-Out ResinTM was removed but the
flowable composite was left in place for additional stability. The technique
worked extremely well for the three weeks needed until the next appointment.

At this appointment the FermitTM and the spot flowable composite bonding were
carefully removed. A full arch rubber dam was placed figure 13. The
SculptureFibreKorTM splint was tried in place to check fit. Then different size
wooden wedge were gently placed in the gingival embrasure area to limit the
flow of composite luting resin once the splint was ready to be bonded into
place figure 14. The bonding technique followed conventional steps of etching
15-20 seconds with a 35% phosphoric acid, carefully blot drying the
preparations, applying a dual curing dental adhesive and air drying. A dual
cure resin cement was mixed and quickly loaded into a centric syringe. Here
the material could be carefully placed into the cavity preparation and the
intaglio surfaces of the splint. The splint was carefully carried, placed, and
seated aided by the use of Pic-n-SticsTM secured to the restoration. Once
seated the gross excess material was removed with a rubber tip. The material
was spot cured and additional excess was removed. After total light and self
curing took place the additional resin tags were removed with sharp scaler and
scalpels figure 15. The occlusion was checked and fine tuned with high speed
fluted burs. All adjusted areas were polished. The patient was dismissed and
reappointed for veneer preparations.

The veneer preparation and insertion visits followed classical protocol. Teeth
#4-13 were prepared over separate visits, respecting the patients request to
keep visits at
short as possible. Because of the bonded intraoral maxillary splint, the
preparations were carefully created as to not thin out the existing fiber or
composite. Prior to the
impression the lingual gingival embrasure was carefully blocked out to allow
ease of withdraw and prevent tearing of the vinyl polysiloxane material. The
final impression was successfully taken. Provisionals were then formed from a
clear template (made from the diagnostic wax up) utilizing a flowable
composite. The completed anterior provisional veneers were finished first
figure 16. The decision was made to use Sculpture for the final veneers. It
was felt this composite was the most wear compatible with both the splint and
natural tooth structure. A corrected study model was sent to the lab to aid in
the final shape and size of the veneers.

At the veneer placement visit, the multiple provisionals which were only
locked in the gingival embrasures were removed by wedging a sharp instrument at
several of the visible margins. After fit was confirmed, each Sculpture
veneer was spot bonded into place for 5-10 seconds. Gross excess was removed
and the next veneer was spot bonded. Once completed the remaining resin tags
were removed carefully using a #12 scalpel and high speed tapering fluted
carbide burs. All areas were polished using rubber finishing discs, cups,
points, and finally polishing pastes. The patient was reappointed for the
mandibular teeth splinting visits.

The preparation of the lower teeth followed a similar protocol to the earlier
maxillary
splinting with several exceptions. The preparations extended from second
molar to second molar (teeth #18-31) figure 17. A Sculpture-FiberKorTM crown
was deemed
necessary for tooth #19 because it would replace the existing PFM crown.
Furthermore, it was determined that in order to achieve immediate posterior
dissocclusion with protrusive movements and to also have cuspid rise, the
preparations of teeth #22-27 had to be extracoronal. These supragingival
preparation only had to extend down far enough to encompass the lower limits of
the “smile curtain�. To add additional strength in the anterior area a
continuous incisal groove was made from cuspid to cuspid figure 17. The
impression was taken and sent to the lab along with a new upper impression,
face bow transfer, and wax occlusal bites. An acrylic provisional splint
reinforced with one mm FiberKorTM post segments was temporarily cemented.

The patient was reappointed for the insertion of the lower splint. The lab
returned the lower reconstruction as two separate parts figure 18. One part
was a Sculpture/FiberKorTM crown for #19 with a grooved occlusal area provided
an ideal withdraw. The other part was an intracoronal / extracoronal splint
extended from teeth #18-31. A full arch rubber dam was placed figure 19.
The parts were tried in to verify the fit. The crown was bonded in place using
a resin cement. A similar protocol was used in bonding the mandibular
intracoronal / extracoronal splint as was used in the bonding of the maxillary
splint. Nonvital areas were blocked out. The remaining teeth were etched. A
duel cure bonding agent and resin cement were used. Care was taken in
removing the resin cement and polishing the restoration figure 20. Time was
spent to verify the bite, and adjust the occlusion.

For this particular reconstruction one might justifiable ask the question Why.
Why not simplify the procedures and do the A-splints as direct composite
restorations? Why not do the reconstruction conventionally with porcelain
fused to gold restorations? Why not extract questionable prognosis teeth
and do a more definitive treatment such as implants? In weighing the
advantages and disadvantages of all treatment options for this patient, the
polymer-glass ceramic system reinforced with fiber seemed to be the
protagonist. Dr. L. Rifkin wrote, “ To date, no singular material can
fulfill the requirements presented in all clinical situations. New
applications and hybrid formulations of these materials are providing
clinicians the opportunity to fulfill most of their treatment goals. This new
polymer-glass ceramic system represented such an opportunity. In order to
progress, it is essential that new materials be evaluated prudently in actual
clinical conditions. Successes, as well as failures, enable dental
professionals to make more accurate diagnoses and restorative decisions. Early
clinical experiences support the promising potential of this new system.�
The patient was extremely happy with the end results. After approximately one
year (now four years) the restorations are so far unchanged and holding
beautifully figure 21, 22, 23, 24. Time of course will be the final judge of
success.

My sincere gratitude must be given to the patient’s periodontist, Dr. Robert
DiSabatino, for both his input in restorative treatment options, and his
management of the periodontal health of our shared patient. Master technician
and ceramists Ms. Gwen Milbourne of Precision Dental Lab of Delaware must be
commending for her excellent work on a somewhat unique case. Finally Jeneric
Pentron needs to be thanked for its help and input in this difficult
restorative case.

References
1. Ring ME, Dentistry an Illustrated History , Harry N Abrams., Inc
Publishers, The C.V. Mosby Company pg 28-29.
2. Sturdavant CM, Barton RE, Brauer JC, The Art and Science of Operative
Dentistry, Mcgraw-Hill Book Company 1968, pg 332-335.
3. Ramfjord SP, Ash MM, Occlusion, WB Saunders Company 1969, pg 331-354
4. Goldberg AJ, Burstone CJ, The use of continuous fiber reinforcement in
dentistry. Dental Mat 1992;8(3)197-202
5. Miller MB, et al , Reality 2000, Indirect Resin Systems Pg 1-340-345,
Anterior Resin Bonded Bridges 3-78-101.
6. Suzuki S, Suzuki SH, Kramer C, In-vitro antagonistic enamel wear against
products, J, Dent Res 1997:76;32.Abstract
7. Zarb GE, Albrektsson T, Tissue Integrated Prostheses, Osseointegration in
Clinical Dentistry Quintessence Publishing 1985 pg 240-292.
8. Dietschi D, Spreafico R, Adhesive Metal-Free Restorations-Current Concepts
for the Esthetic Treatment of Posterior Teeth, Quintessence Publishing 1997,
pgs 79-100; 139-167; 185-199.
9. Rifkin LR, Maxillary Reconstruction Utilizing A Second Generation Glass
Reinforced Resin Material, PPAD March 1998 Pg 2-7.
10. Shavell HM, The aesthetics of occlusion: Form, Function and Finesse, PPAD
1993;5(3):47-55
11. Christensen GJ, Comparison of veneer types. CRA Newsletter 1986;10:4
12. Trinkner TF, Roberts M, Aesthetic restorations with full coverage
Porcelain veneers and a Ceromer / fiber reinforced composite framework: A Case
Report:PPAD 1998 ;10 (5) pg 547-554
13. Becker, CM, Kaiser DA, Kaldahi WB, The Evolution of Temporary Fixed
Splints-The A splint, The International Journal of Periodontics and Restorative
Dentistry 1998 , 18(3), pg 276-285
14. Magne P, Magne M, Belser U, The Diagnostic Template:A Key Element to the
Comprehensive Esthetic Treatment Concept, International Journal of Periodontics
and Restorative Dentistry 1996; 16(6)560-569.
15. Ferrell BC, The Finishing Touches for More Predictable Esthetic Dentistry,
Compendium of Continuing Education in Dentistry, 2001, 22(5) pg 381-388.


Legend:
Figure 1-Pre-orthodontic smile
Figure 2-Pre orthodontic facial view
Figure 3- Oral smile evaluation at time of finishing orthodontics
Figure 4- Facial view at time of finishing orthodontics
Figure 5- Lateral right view showing both gingival embrasures and lower
edentulous space
Figure 6- Lateral left view showing both gingival embrasures and lower
edentulous space
Figure 7- Shade evaluation reveals D-4
Figure 8-SEM of FiberKor
Figure 9-SEM of processed Sculpture-FibreKor
Figure 10-demonstrates block out and spot facial bonding
Figure 11-Jeneric Pentron’s recommended inlay preparation
Figure 12-Occlusal view of modified maxillary preparations with block out and
bonding in place
Figure 13- Rubber dam in place with cleaned preparations and spot bonding
removed
Figure 14-Try in of framework, note use of different size wooden wedges to
contain luting agent
Figure 15-Bonded maxillary intracoronal split
Figure 16-Provisional veneers teeth #7-10
Figure 17-Model of mandibular intracoronal-extracoronal preparations-note
incisal groove teeth #22-27
Figure 18-Mandibular intracoronal-extracoronal splint parts
Figure 19- Lower full arch rubber dam
Figure 20-Lower A Splint bonded in place
Figure 21 Finished case-Full smile view (note “smile curtain�)
Figure 22 Finished case-Frontal view
Figure 23-Finished case-Right working side view
Figure 24-Happy patient with the best smile in the group, surrounded by her
orthodontist on left and restorative dentist on right

Stan

steven bornfeld

(snip)

Thanks, Stan--very helpful as usual! Steve