|Year : 2008 | Volume
| Issue : 4 | Page : 141-148
Comparative in vivo evaluation of restoring severely mutilated primary anterior teeth with biological post and crown preparation and reinforced composite restoration
N Grewal, R Seth
Department of Pedodontia and Preventive Dentistry, GDC, Amritsar, India
Department of Pedodontics and Preventive Dentistry, Punjab Government Dental College, Amritsar
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: This study was designed to compare the success rate of biological and composite restorations when used to replace structural loss of primary anterior teeth using intracanal post for radicular support of the restoration.
Materials and Methods: Forty-two patients aged between 3-5 years presenting with early childhood caries (ECC) received at least one or more composite and biological restorations for comparative evaluation. A total of 150 restorations were done (75 biological restorations and 75 composite restorations). The restorations were evaluated single-blind according to a modified USPHS system. Assessment of the patient's response in accepting a biological restoration, psychological impact of the restorations, view of the parents, and peer group reviews, etc. were recorded in a response sheet in presence of the child and the parents.
Observations and Results: In vivo clinical performance of biological post and crown restorations and intracanal reinforced composite restorations was comparable with respect to shade match, marginal discoloration, marginal integrity, surface finish, gingival health, retention, and recurrent carious lesions. The cost effectiveness of biological restorations was certainly a positive attribute.
Conclusion: The biological restoration presented as a cost effective, clinician friendly, less-technique sensitive, and esthetic alternative to commercially available restorative materials used for restoring deciduous teeth affected by ECC.
Keywords: Biological restoration, early childhood caries, reinforced composite restorations
|How to cite this article:|
Grewal N, Seth R. Comparative in vivo evaluation of restoring severely mutilated primary anterior teeth with biological post and crown preparation and reinforced composite restoration. J Indian Soc Pedod Prev Dent 2008;26:141-8
|How to cite this URL:|
Grewal N, Seth R. Comparative in vivo evaluation of restoring severely mutilated primary anterior teeth with biological post and crown preparation and reinforced composite restoration. J Indian Soc Pedod Prev Dent [serial online] 2008 [cited 2020 May 31];26:141-8. Available from: http://www.jisppd.com/text.asp?2008/26/4/141/44028
| Introduction|| |
Most frequent presentation of early childhood caries (ECC) is severely mutilated primary anterior teeth. In the past, the most expedient treatment was to extract the involved teeth because restoration of mutilated primary teeth was a challenging job.
Primary maxillary anterior teeth dominate the physical appearance, and their structural loss affects not only esthetics but also leads to compromised mastication, poor phonetics, development of aberrant habits, neuromuscular imbalance, and difficulty in social and psychological adjustment of the child.
Recent developments in restorative materials, placement techniques, preparation designs, and adhesive protocols have facilitated restoration of mutilated maxillary incisors to quite an extent. There is, however, no synthetic restorative material that can replicate the esthetic characteristics or color stability of the natural tooth structure. Therefore, a biological restoration could be an adequate restorative alternative for the mutilated anterior teeth which meets up to the esthetic and structural standards of healthy teeth.
The concept of attaching natural tooth fragments began when Chosack and Eidelman  used a cast post and conventional cement to reattach an anterior crown segment. However, the term 'biological restoration' was introduced by Santos and Bianchi  to describe an alternative technique that uses adhesive capabilities of materials in combination with strategic placement of parts of extracted human teeth. Ramires-Romito et al ,  used teeth from the Human Tooth Bank of Sao Paulo University Dental School to be used as natural posts and crowns to fit into the roots and replace the crowns as well.
However, various parameters like esthetics, longevity, patient acceptance, etc. still need to be clinically evaluated in comparison with conventional restorative materials. Hence, it was prudent at this point of time to evaluate success of biological restorations as compared to the conventional composite restorations.
| Materials and Methods|| |
For this prospective study, 42 patients aged between 3-5 years presenting with ECC were selected from the OPD, Department of Pedodontia and Preventive Dentistry, GDC, Amritsar, India. Each individual received at least one or more composite and biological restorations for comparative evaluation. A total of 150 restorations were done, of which 75 were biological restorations (group I) and 75 were composite restorations (group II). One operator, well experienced with both materials, placed all restorations.
Healthy children with no mental or medical disorders were selected for the study. The selection of patients was further based on the following criteria:
- Primary anterior teeth with ECC or fractures due to trauma involving more than half to three-fourths of the crown.
- Sound root structure and no caries of the root dentin.
- Endodontically treated deciduous teeth.
- No mobility.
- No gingival recession.
- No trauma from occlusion as in cross bite, deep bites, etc.
- No hypoplasia of teeth.
- No deleterious oral habits.
- Normal root formation with sufficient amount of root structure present (at least one-third).
Informed consent from the parents of each patient undergoing treatment was obtained on the prescribed proforma. Teeth to be used as biological restoration were obtained from tooth bank of Department of Pedodontia and Preventive Dentistry, GDC, Amritsar, India. The human tooth bank (HTB) in the Department of Pedodontia and Preventive Dentistry, GDC, Amritsar, India, is a nonprofit institution where teeth from healthy donors are stored for research purposes. Appropriate records of the donors and beneficiaries are maintained. A universal protocol of consent, storage, and sterilization is followed.
Criteria for selection of extracted teeth for this study were:
- Deciduous teeth, free from caries.
- Deciduous teeth, free from any morphological defects.
- Deciduous teeth with no previously placed restorations.
- Deciduous teeth, free from cracks.
Each donor was asked to provide confidential histories by answering questions in a proforma which was kept in the tooth bank record. Parents of the patients undergoing extraction procedure for a variety of reasons were explained about the future use of these extracted teeth as biological restoration. The consent of donors was obtained on a duly signed consent form.
Tooth bank procedure
The collected samples of extracted teeth were thoroughly scaled, polished, and freed of soft tissues and periodontal remnants [Figure 1]. The pulps were removed from root canals and complete biological preparation was done [Figure 2]. After preparation, all the sample teeth were placed in the ultrasonic tank operating at 42 GHz and 100 W output, at five working cycles in 6% H 2 O 2 [Figure 3]. Each tooth was sonicated for 30 minutes. Teeth were stored at 4 o C in Hank's balanced salt solution (HBSS) with donor identification till the time it was used [Figure 4] and [Figure 5].
Preparation of biological restoration
Teeth selected from the tooth bank were reshaped to be used as natural post and crown using crown preparation kit (Shofu) [Figure 6]. The roots that were shaped to function as posts were strengthened by retro filling of flowable composite material [Figure 7].
Tooth selected and prepared for use as biological restoration was then autoclaved for 30 minutes at 121 o C and 15 lbs pressure before cementation. The tooth was then tried for fit and adjustments were done [Figure 8]. The prepared post and crown were cemented using dual cure resin modified GIC (GC Fuji Plus) [Figure 9].
Due to extensive crown destruction, the use of intracanal posts was necessary. Omega loop intracanal retainers were fabricated on the dental casts. The length of the post was kept less than 5 mm beyond the cementoenamel junction and never beyond cervical one-third of the root length. The composite restorations were done after placement of intracanal retainers [Figure 10] and [Figure 11]. Nanofilled composite material (Filtek Z-350, 3M ESPE) and self-etching adhesive (Adper Prompt L-Pop Self-Etch Adhesive, 3M ESPE) were used for reconstructing and shaping of the crown for the composite restoration using layering technique. After checking the occlusion, and the removal of any interference, final finishing and polishing of the restorations were performed with polishing disks and polishing strips (Shank FG, Shofu) [Figure 12] and [Figure 13]. Pretreatment and post-treatment photographs of cases are presented in [Figure 14] and [Figure 15].
| Results|| |
Due to patient dropout, restoration failure, failure due to trauma, and RCT failure, 69 composite restorations, out of the total 75, were evaluated at three-month interval, further on, 61 composite restorations were evaluated at six-month interval, 47 composite restorations were evaluated at nine-month interval, and 35 composite restorations were evaluated at 12 months. Similarly, 67 biological restorations, out of the total 75, were evaluated at three months, 56 biological restorations were evaluated at six months, 43 biological restorations were evaluated at nine months, and 31 biological restorations were evaluated at 12 months, respectively. These restorations were evaluated for various parameters in accordance with modified version of Cvar and Ryge evaluation criteria. ,,,,
Results observed from Chi-square test and P -values noted are presented in the [Table 1],[Table 2],[Table 3],[Table 4],[Table 5],[Table 6],[Table 7],[Table 8].
From the statistical analysis, it was observed that color matching in group I (composite restorations) was better than group II (biological restorations) at baseline ( P < 0.001). The difference was also highly significant at three months ( P < 0.001). In the later observations at 6, 9, and 12 months the difference between color-matching property of group I and group II was nonsignificant [Table 1].
In the case of marginal discoloration, significant difference was observed at 12 months ( P < 0.01). Restorations in group I were performing better than group II with Chi-square value of 10.2 [Table 2].
As regards to marginal adaptation, both the groups were similar [Table 3].
More cases with surface roughness were recorded in group II at 6-month and 9-month observation. However, the difference was not significant at 12 months as cases with surface roughness were also recorded in group I [Table 4].
The probability for gingival degradation was insignificant since there were no incidences of gingival degradation at 3, 6, 9, and 12 months interval in both the groups [Table 5].
Fractured restorations were observed at the 3 and 6 months in both the groups; however, the difference was not significant [Table 6].
Though recurrent carious lesions were observed at 9 and 12 months in both the groups the difference was not statistically significant [Table 7].
The difference observed on statistically analyzing the patient's response before and after treatment was highly significant for improvement in esthetics, speech, and self-esteem [Table 8].
| Discussion|| |
When assessed for color match in the present study, both groups showed some degree of discoloration. Discoloration of the restoration is dependent upon the surface conditions and physicomechanical characteristics. At baseline, 100% of the group I (composite restorations) earned grade alpha and matched well with the natural counterparts, whereas 100% of the restorations in group II (biological restorations) were graded as bravo as these appeared whiter in shade when compared to their natural counterparts. This observation can be attributed to the fact that the sterilizing medium used before storage, which is 6% H 2 O 2 , could have had a bleaching effect on the teeth used for biological restorations.
Depositions of exogenous, colored pigments on the surface of biological restorations gradually brought about the change of shade to grade alpha in that particular oral environment which clinically matched with their counterparts at later observations. This change occurred as some of the composite restorations also got stained. This finding was in agreement with that of other studies , which had used nanocomposites as a restorative material and found that extrinsic staining did effect a shade change over a period of time.
Some marginal discoloration was observed on both composite and biological restorations, but, the difference was nonsignificant till the nine-month follow up. In biological restorations, cemented with resin-modified glass ionomer cement, marginal discoloration was observed in 1.49% of the restorations at three months and was more pronounced than composite restorations at later observations. This can be due to lower bond strength and some polymerization shrinkage of RM-GIC, which may have led to the formation of marginal gaps. Marginal discoloration of nanocomposites was also observed which can be ascribed to polymerization shrinkage. 
Regarding marginal integrity, both composite and biological restorations showed some imperfect margins where the explorer was slightly caught. The difference was not significant as reflected by low values of Chi-square.
Considering the surface texture, clinically detectable roughness with bravo grading was exhibited by a total of 12.9% biological restorations and 5.71% composite restorations. The autoclaving procedure could have caused the enamel to become brittle which later on presented as craze lines in biological restorations as suggested by Parsell et al.  The observation was seen only in four (7.14%) of the 56 biological restorations assessed after six months. However, at 9 and 12 months, these four biological restorations showing surface roughness represented 9.3% and 12.9% of the biological restorations. Good score of 94.29% alpha grading at 12-month recall for the surface texture of composite restorations suggest good polishability and low abrasion values. Only two composite restorations showed surface roughness which could be attributed to little breakouts.
Gingival health deterioration was not observed in either of the groups after 3, 6, 9, and 12 months recall. Gingival tissue in both the groups was healthy with no deposition of calculus and no bleeding on probing. Consequently, it was concluded that both groups performed equally well in respect to gingival health.
At the three-month recall, two patients reported with loss of restorations. Failure rate for composite restoration was 1.42 % (one restoration) and for biological restoration it was 3.17 % (two restorations). The difference between the two groups was insignificant. One biological and one composite restoration showed partial loss of restorations because of trauma at three months.
At the sixth month, failure rate for composite restoration was 4.28% (three restorations) compared to biological restoration which was 8.19% (five restorations). One patient reported with gross fracture of all the four restorations (two composite restorations and two biological) due to trauma. The other two patients had lost a total of three biological restorations and the composite restorations were intact. However, the result was statistically nonsignificant. The greater loss of biological restorations may mainly be accounted for by lack of precision fit and operator's clinical preparation.
Recurrent carious lesions around the margins of the restorations were observed at 9 months and 12 months, but the difference between composite and biological group was not statistically significant. A total of 11.43% composite restorations and 9.68% biological restorations had evidence of recurrent caries over the 12-month follow-up period. These seven recurrent carious lesions were seen in three children and they presented with recurrent caries in both composite and biological restorations. Children presenting with ECC are a high caries risk group and failure to follow proper preventive regimen can result in caries recurrence. Lack of compliance with the preventive instructions resulting in caries recurrence even in treated cases of ECC has also been reported previously by Sheehy et al ,  Berkowitz et al ,  Eidelman et al ,  and Almeida et al.  The percentage of patients reporting with recurrent caries in this study is much lower than in the above said studies, which can be attributed to the preventive measures instituted along with parental counseling regarding diet and oral hygiene.
All the endodontically treated primary teeth near the age of primary tooth exfoliation with intraradicular retainers and biological posts were examined with pre and postoperative IOPA X-ray in order to check for normal root resorption as suggested by Wanderlay.  At recall visits, all the roots with intraradicular retainers and biological posts showed normal root resorption patterns [Figure 16].
The evaluation of both parents/patients response to the questionnaire regarding their perception to treatment indicated positive response vis a vis improvements in esthetics, self-esteem, and speech were particularly positive. Lower cost for biological restorations was cited as positive feature by patients/parents. The duration of the entire treatment period was mentioned as a negative feature by three patients. When asked if they would go through the same treatment again, two patients in group I and one in group II said "no" and referred to the treatment duration as stressful experience during treatment, since four of the patients had to undergo treatment under conscious sedation.
| Conclusion|| |
This method of using biological crown and post restoration for restoring teeth affected by ECC has shown promising results when compared to the conventional method of using intracanal reinforced composite resin restorations. When the cost incurred on both the treatments was compared, it was deduced that composite restorations cost six to seven folds more than the biological restorations making them a useful option for developing countries. However, although psychological behavior improvement and patient acceptance were noteworthy findings in both groups biological crown and post restoration methodology proved to be a cost effective alternative making it possible to recycle precious biological tissue which has been discarded until now.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]
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