Construction of Fibre Reinforced Bridges for Upper and Lower Jaws using the Direct Technique

The patient is a 58-year-old woman who is suffering from degenerative arthritis. She also has temporomandibular joint problems caused partly by her general illness and partly by an incomplete occlusion. For financial reasons, the patient can not, for the moment, consider as an option suitable length a conventional fixed bridge construction. In addition, she does not want removable dentures as she regards them as unpleasant. After consulting the patient, it was decided that a glassfibre reinforced bridge was to be constructed for both upper and lower jaws. Both of the bridges were made on the same appointment using the direct technique and premoistened everStick reinforcement fibres as the reinforcing material. The patient has no missing teeth in the first and third quadrants. The premolar d.25 is missing from the second quadrant. The premolar d.44 and the molar d.46 are missing from the fourth quadrant. The premolar d.45 is a vital residual root with the lingual cusp still remaining intact. Tooth d.47 has a large class-II amalgam filling, the vital tooth d.45 has a provisional glass ionomer filling and tooth d.42 is intact. In the second quadrant, there is a large class-II amalgam filling on tooth d.26, and two class-II composite fillings on tooth d.24. The work was done by Kari Pihlman, D.D.S., Finland.

1.	During the first session, the old amalgam was removed from the d.26. The cavity was prepared according to the demands of the adhesive technique. Old composite fillings were removed from the premolar d.24. Using dental floss as a measurement aid, a proper length of everStick fibres was cut for the frame of the bridge. Two pieces were cut from the fibre bundle and pressed together using tweezers.
2.	The fibre bundle was moistened with flow-micro hybrid composite to activate its surface and to achieve an easier handling of the fibre. The prepared everStick bundle was then placed in a light protected container. Etch, primer and resin were applied on the prepared surfaces of the tooth according to manufacturer’s instructions. The borders of the approximal boxes were sealed with a layer of flow composite and light cured. At this point a thin layer of flow composite was applied on the cavity floor followed by the everStick fibre bundle. The distal end of the fibres was light cured with a Ų 2 mm size tip. The rest of the fibres were placed correctly, followed by an immediate light curing of the mesial end. Final polymerisation was done using the Turbo-curing tip. The pontic and the associating structures on the supporting teeth were constructed using universal micro hybrid composite using the layering technique. After light curing, primary finishing was done on the bridge. Occlusion was corrected and all the other surfaces, including the base of the frame, were finished and polished. The whole bridge was then treated with phosphoric acid gel and non-filler resin and light cured. The oxygen inhibition layer was removed with ethanol saturated cotton balls.
3.	The occlusion of the upper jaw was controlled a week later. In the same session a fibre reinforced bridge was constructed for the lower jaw. The amalgam was removed from the molar d.47 and a cavity prepared according to the demands of the adhesive technique. The provisional glass ionomer protection was then removed from the premolar d.45. The lingual surface of the canine d.43 and the incisive edge of d.42 were prepared with a finishing-diamond tip.
4.	As before, two suitable lengths of everStick fibres were cut, with the help of dental floss as measurement, and pressed together. An extra piece of fibre, for joining together d.45 and d.47, was cut. The fibre bundles were moistened with flow composite for surface activation and easier handling. The prepared fibres were again placed in a light protected container. Since the d.45 had to be elongated with composite prior to the placing of the fibre, the tooth was prepared accordingly, following the manufacturer’s instructions. After light curing the bonding composite, the base and the approximal edges of the cavity on the d.47 were formed with flow composite and light cured. A thin layer of flow composite was applied on the cavities and on the lingual surfaces of the d.42 and d.43. The fibre bundle was placed into the cavities. The distal end of the fibre was rapidly light cured with a Ų 2 mm tip. D.45 and finally the mesial end of the fibre was then light cured.
5.	The final polymerisation was done with a Turbo curing tip. The pontic and the associated structures on the supporting teeth were repaired with micro hybrid composite. After light curing, a primary finishing was done on the bridge. Occlusion was corrected and all the other surfaces finished. Following finishing and polishing, the bridge was treated with phosphoric acid gel and resin as described above. It was then light cured and the oxygen inhibition layer was removed with ethanol. Two further appointments were arranged with one week intervals to check and correct the occlusion.
6.	After six months, during a control appointment, both bridges are found to be in a faultless condition. A slight reduction adjustment of the dd.25/35 intercuspidation area was done to correct the interference during lateral movements (Fig. 6 ). The patient uses both sides of her mouth for chewing her food. Neither the occlusion nor home-care cleaning of the teeth, has posed any problems for the patient. She has found the cone shaped interdental brush to be most convenient.
7.	In January 2005, after 4.3 years, both bridges are found to be in a faultless condition. Materials: everStick-reinforcement fibre (premoistened BisGMA/PMMA). Filling materials: Tetric Ceram and Tetric Flow (Vivadent, Schaan, Liechtenstein), D/E Bonding materials: Excite (Vivadent, Schaan, Liechtenstein). Etch: Ultra-Etch (Ultradent Products, Inc. Salt Lake City, Utah, USA). Forming and finishing instruments: polishing diamonds, finition discs Control and reduction of occlusion: R.A.P.T.O.R. – system(BISCO, Chicago, Illinois, USA) Polishing: silica tips for polishing of hybrid composite (Kenda, Vaduz, Liechtenstein) and Occlubrush -tips (Hawe Neos Dental SA. Bioggio, Switzerland)

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