PONTICS

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Introduction Pontic or artificial tooth, the name is derived from the Latin word pons meaning bridge. It is not a simple replacement because placing an exact anatomic replica of the tooth in the space would be hygienically unmanageable. The design of the pontic will be dictated by esthetics, function, ease of cleaning, maintenance of healthy tissue on the edentulous ridge and patient comfort.

Pre treatment assessment iagnostic casts and waxing procedures may prove especially

valuable for determining optimal pontic design.

A. Pontic space !ne function of fixed partial denture is to prevent tilting or drifting of ad"acent teeth into the edentulous space. If such movement has already occurred the space available for the pontic may be reduced and its fabrication complicated. #areful diagnostic waxing up will help to

determine the most appropriate treatment. !rthodontic repositioning can be considered and if it is not possible increasing the proximal contours of the ad"acent teeth may be a better option than ma$ing an undersi%ed pontic. B. Residual Ridge contour

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 Ideally should have a smooth regular surface of attached gingiva, which facilitates the maintenance of a pla'ue free environment. Its height and width should allow placement of a pontic that appears to emerge from the ridge and mimics the appearance of the neighbouring teeth. (acially it must be free of frenum attachment and of ade'uate facial height to sustain the appearance of interdental papillae.

c. Gingival architecture preservation )lthough, the degree of *** following tooth extraction is

unpredictable, resulting deformities are not inevitable. Preservation of the alveolar process can be achieved through immediate restorative and periodontal intervention at the time of tooth removal.

Biologic considerations a. Ridge contact ) passive contact of pontic is preferred that too on $eratini%ed attached gingiva. Pressure free contact between the pontic and the underlying tissue is indicated to prevent ulceration and inflammation of the soft tissues. If any blanching of the soft tissue is observed the pressure area should be identified with a disclosing medium and the pontic recontoured

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until tissue contact is entirely passive. Portion of the pontic touching the ridge should be as convex as possible.

b. Oral h giene considerations ,ormally when tissue contact occurs, the gingival surface of a pontic is inaccessible to the bristles of a toothbrush- therefore the patient must develop excellent hygiene habits.

evices li$e proxy brushes, pipe cleaners, super floss and dental floss can be used. The passive contact between the residual ridge and the pontic permits the passage of floss over its entire tissue surface. If the pontic has a depression or concavity in its gingival surface, pla'ue will accumulate as the floss cannot clean this area and tissue irritation will follow. This is usually reversible and when the surface is subse'uently modified to eliminate concavity inflammation disappears.

c. Pontic material .hould have /ood esthetics 0iocompatibility *igid and strong to withstand occlusal forces and longevity

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 It should be rigid because any flexure during mastication or Para function may cause pressure on the gingiva and may cause fracture of veneering material. !cclusal contact should not fall on the "unction between the metal and porcelain during centric and eccentric tooth contact. ,or should a

metal ceramic "unction occur in contact with the residual ridge on the gingival surface of the pontics. (or easier pla'ue removal and biocompatibility the tissue surface of the pontic should be made in gla%ed porcelain. 2owever, ceramic tissue contact may be contraindicated in edentulous areas where there is minimum distance between residual ridge and the occlusal table.

!echanical considerations 3echanical problems may be caused by Improper choice of materials Poor framewor$ design Poor tooth preparation Poor occlusion

They can lead to fracture of prosthesis or displacement of retainers. Long span posterior (P s are particularly susceptible to mechanical

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problems. There is significant flexing from high occlusal forces and because the displacement effects increase with the cube of span length. ) well5fabricated metal ceramic pontic is strong, easy to $eep clean and loo$s natural. There must be ade'uate bul$ of the metal to ensure rigidity for strength.

Incisal configuration of the lingual aspect of the coping can be of scalloped or trestle design. ) reliable method for ensuring uniform thic$ness of porcelain is to wax the (P to complete anatomic contour and

then accurately cut bac$ the maximum to a pre5determined depth. The metal surfaces to be veneered should be smooth and free of pits 6surface irregularities will cause incomplete wetting by porcelain slurry7 lending to voids. .harp angles on the veneering area should be rounded as they produce increased stress concentrations that can cause mechanical failure. Location and design of the external metal porcelain "unction re'uire particular attention. )ny deformation of the metal framewor$ at the "unction can lead to chipping of porcelain. !cclusal centric contacts should be placed at least 8.&mm away from the "unction.

Resin veneered pontics

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Their resistance to abrasion was lower than enamel or porcelain and:: noticeable wear occurred with normal tooth brushing. ;ater absorption and dimensional change was seen. #ontinuous dimensional change of veneers often caused lea$age at metal resin interface with subse'uent discoloration. )dvantages include < ease of manipulation and repair, and do not re'uire high melting range alloys as for metal ceramic techni'ues.

Composite resin They have a higher density of inorganic ceramic filler than traditional direct and indirect composite resins. 3ost of them use post curing process that result in high flexural strength. They have minimal polymeri%ation

shrin$age and wear rates comparable to tooth enamel.

"iber rein#orced composite resin The physical proportion of this system combined with excellent marginal adaptation and esthetics ma$es it a possible metal free alternative for (P =s. $sthetic considerations Inciso gingival length The height of a tooth is immediately obvious when the patient smiles and shows the gingival margin.

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 )n abnormal labiolingual position or cervical contour however is not immediately obvious. This fact can be used to produce a pontic of good appearance by recontouring the gingival half of the labial surface. The observer sees a normal tooth length but is unaware of the abnormal labial contour and the illusion is successful. ?ven with moderately severe bone resorption obtaining a natural appearance by exaggerated contouring of the pontics may still be possible. In areas where tooth loss is accompanied by excessive loss of alveolar bone a pontic of normal length would not touch the ridge at all. !ne solution is to shape the pontic to simulate a normal crown and root with emphasis on the cementoenamel "unction. *oot can be stained to simulate exposed dentin. Pin$ porcelain can be used to simulate gingival tissues. *idge augmentation has been used successfully in areas of limited resorption. !esiodistal %idth (re'uently, the space available for a pontic will be greater or smaller than the width of the contralateral tooth. This is due to uncontrolled tooth movement that occurred when a tooth was removed and not replaced.

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 If possible such a discrepancy should be corrected by orthodontic treatment. If this is not possible an acceptable appearance may be obtained by incorporating visual perception principles into the pontic design. The width of anterior tooth is identified by the relative positions of the mesiofacial and distofacial line angles, and the overall shape by the detailed pattern of surface contour and light reflection between these line angles. The features of contalateral tooth should be duplicated as precisely as possible in the pontic and the space discrepancy can be compensated by altering the shape of the proximal areas. The retainers and the pontics can be proportioned to minimi%e the discrepancy. .pace discrepancy presents less of a problem when posterior teeth are replaced because their distal halves are not normally visible from front and a discrepancy here can be managed by duplicating the visible mesial half of the tooth and ad"usting the distal half Pontic designs Types are .addle 6ridge lap7 3odified ridge lap 2ygienic #onical

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 !vate

Saddle Loo$s most li$e a tooth replacing all the contours of the missing tooth (orms a large concave contact with the ridge obliterating the facial, lingual and proximal embrasures )lso called as ridge lap because it overlaps the facial and lingual aspects of the ridge 2ave the contact with the ridge extends beyond the midline of the edentulous ridge or a sharp angle at the linguogingival aspect of the tissue contact

&isadvantages .addle pontic is impossible to clean since floss cannot traverse the tissue facing area of the pontic because it bridges across the linguogingival and faciogingival angles of the pontic, causing tissue inflammation.

!odi#ied ridge lap 3ost commonly used design used along with porcelain veneer in appearance %one for both maxillary and mandibular (P

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 (loss passes over a smooth round surface more easily than over a flat surface and sharp angles #ombines the best features of hygienic and saddle pontic combining esthetic with easy cleaning. This design gives the illusion of a tooth but it possesses all or nearly all convex surfaces for ease of cleaning The lingual surface should have a slight deflective contour to prevent food impaction and minimi%e pla'ue accumulation

' gienic The term hygienic is used to describe pontics that have no contact with the edentulous ridge also called as sanitary pontic Ased mostly in non appearance %one particularly for replacing mandibular first molars It restores occlusal function and stabili%es ad"acent and opposing teeth Indicated in impaired oral hygiene situations. It is also called as ar$ fixed partial denture ) modified sanitary pontic Perel pontic

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escribed by Tin$er in 8984 an sanitary dummy *ounded and cleanable, tip is small in relation to the overall si%e of the pontic ;ell suited for use in thin mandibular ridge Its use is restricted to replacement of teeth over thin ridges in non appearance %one Poor esthetics #ontraindicated in patients with poor oral hygiene.

Ovate pontic #urrently used where esthetics is a primary concern The tissue contact segment of the ovate pontic is bluntly rounded and it is set into a concavity in the ridge It is easily flossable 6food entrapment is negligible7 The concavity can be created by placement of a provisional (P the pontic extending one 'uarter of the way into the with soc$et

immediately after extraction of the tooth It also can be created surgically at some later time This pontic wor$s well with a broad flat ridge giving the appearance that it is growing from the ridge

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 Indicated for patients who desire optimal esthetics, and who has high smile line

Classi#ication o# the edentulous ridge /rouped into three by .iebert #lass I loss of faciolingual ridge width with normal apicocoronal height #lass II loss of ridge height, with normal width #lass III loss of both ridge width and height

Pontic modi#ication Pin$ porcelain can be added to the gingival embrasure area of the pontic to simulate interdental papilla This can be done when replacing mandibular molars and mandibular incisors where the gingival area is not sub"ect to close scrutiny however it is more difficult to achieve an esthetic result simply by modification of the embrasure spaces in a high profile area such as the maxillary incisor region In the presence of a large deformity an unmodified pontic would leave large unsightly gingival embrasures and the addition of a gingival flange may be too conspicuous.

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Surgical correction Techni'ue devised by Langer and #alagna ) partial thic$ness pedicle graft is dissected from the palatal area Incision are made on 8mm on either side of the defect in the edentulous ridge onor tissue is placed into the defect under the base of the flap until the defect is filled. (lap is then sutured stabili%ing the donor material. 2owever apicocoronal class II and class III defects cannot be ade'uately treated by a pouch type II ridge augmentation .o better used an onlay graft which .eibert describes as a thic$ free gingival graft .urface of the ridge is planed with a scalpel followed by parallel striations #uts should bleed profusely so that the graft can ta$e up (ull thic$ness donor tissue is placed on the prepared area and sutured. If the facial contour of the ridge has a convex shape or irregularities that will prevent the use of a convex pontic the soft tissues may be recontoured surgically to provide an easily cleanable and esthetic pontics.

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 Preparing the abutment teeth before the extraction is the preferred techni'ue. ) provisional (P immediate insertion. The extraction of tooth should be atraumatic and aimed at preserving the facial plate of bone. The scalloped architecture of interproximal bone forming the can be fabricated indirectly ready for

extraction site is essential for proper papilla form. 0efore or during extraction the soc$ets can be grafted or during extraction the soc$ets can be grafted with an allograft material 6hydroxyapatite, tricalcium phosphate or free%e dried bone7 )fter the extraction site is prepared a carefully shaped provisional (P is placed. The tissue side of the pontic should be ovate form and according to spear it should extend approximately 2.&mm apical to the facial free gingival margin of the extraction soc$et. )s the soft tissues of the soc$et will begin to collapse immediately after tooth extraction the pontic will result in tissue blanching as it supports the papillae and facial : palatal gingiva. !ral hygiene in this area is difficult during the initial healing period so the provisional should be highly polished to minimi%e pla'ue retention. )fter one month of healing oral hygiene access is improved by recontouring the pontic to provide 8 to 8.&mm of relief from the tissue.

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;hen the gingival levels are stable the final restoration can be fabricated.

"abrication o# a pontic (irst the retainer wax patterns are fabricated ) stic$ of inlay wax is attached to the retainer wax pattern #arving of the pontic is done. ) PBT no. 4 is used to define the gingival embrasure and to smooth the undersurface of the pontic. Pattern is placed on the wor$ing cast and the contours of the pontics are chec$ed one last time. ) runny mix of 'uic$ side plaster is painted around the undersurface of the pontic and also on the facial side once the plaster has set the wax pattern is removed and the plaster matrix is trimmed so that the occlusal surface is free of plaster. ,ow the occlusal surface can be built up with wax added techni'ue 3argins are finished on the A shaped die with a beavertail burnisher. !ne sprue is attached to every retainer and to each cusp of the pontics. Pattern is removed by grasping the facial and lingual surface of pontic.

Post insertion h giene

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 The mesial, distal and lingual gingival embrasures of the pontic should be wide open to allow patient easy access for cleaning. #ontact between the pontic and tissue must allow the passage of floss from one retainer to another. 3otivate the patient to practice good hygiene around and under the pontic with dental floss,interproximal brushes, or pipe cleaners The method used will depend on embrasure si%e accessibility and patient s$ill ?valuate home care at each appointment and reinforce necessity for good hygiene and s$ill to accomplish it. If cleaning is not done at fre'uent regular intervals the tissue around the pontic will become inflamed.

Summar ;e as dentists should aim to create a pontic design that combines easy maintenance with natural appearance and ade'uate mechanical

strength. !nce the appropriate design has been selected it must be accurately conveyed to the dental technicians.

Re#erences

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8. Tylmans theory and Practice of fixed ProsthodonticsC 4 t h ?dition Ishiya$u ?uro )merica Inc. Publishers. Tokyo. St. louis 2001. 2. *osenstielC #ontemporary fixed prosthodontics. @ r d ?dition. 3osby 2>>8. @. (undamentals of (ixed ProsthodonticsC 2erbert T. .hilling burg, Dr. @ r d ?dition. Euintessence Publishing co. Inc 8991. 4. Leuticia 0orges Dac'ues et alC Tissue sculpturing- an alternative method for improving esthetics of anterior fixed prosthodontics. D. Prosthet ent 8999- 48C +@>5 +@@.

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