|Year : 2008 | Volume
| Issue : 7 | Page : 98-103
Glass fiber–reinforced composite resin as a space maintainer: A clinical study
P Subramaniam, GKL Babu, R Sunny
Department of Pedodontics and Preventive Dentistry, The Oxford Dental College, Hospital and Research Centre, Bommanahalli, Hosur Road, Bangalore-560 068, Karnataka, India
Department of Pedodontics and Preventive Dentistry, The Oxford Dental College, Hospital and Research Centre, Bommanahalli, Hosur Road, Bangalore-560 068, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The aim of this study is to evaluate the use of glass fiber–reinforced composite resin (GFRCR) as a space maintainer and to compare it with a conventional band-and-loop space maintainer. A total of 30 children (23 boys and 7 girls) aged 6–8 years were selected for the study. Each of these children required maintenance of space due to premature loss of primary first molars in at least two quadrants. In one quadrant, a GFRCR space maintainer was applied and in the other quadrant a band-and-loop space maintainer was cemented. Patients were recalled at regular intervals over 12 months and retention of both the types of space maintainers was evaluated. The retention of the GFRCR space maintainer was found to be superior to that of the band-and-loop space maintainer, but this difference was not statistically significant.
Keywords: Band-and-loop, glass fiber-reinforced composite resin, retention, space maintainer
|How to cite this article:|
Subramaniam P, Babu G, Sunny R. Glass fiber–reinforced composite resin as a space maintainer: A clinical study. J Indian Soc Pedod Prev Dent 2008;26, Suppl S3:98-103
|How to cite this URL:|
Subramaniam P, Babu G, Sunny R. Glass fiber–reinforced composite resin as a space maintainer: A clinical study. J Indian Soc Pedod Prev Dent [serial online] 2008 [cited 2020 Oct 23];26, Suppl S3:98-103. Available from: https://www.jisppd.com/text.asp?2008/26/7/98/44836
| Introduction|| |
When a primary tooth is extracted or is exfoliated prematurely, the teeth mesial and distal to the space tend to drift or be forced into it. This may result in the impaction of the succedaneous tooth, a shift of the midline of the dental arch to the affected side, and over-eruption of the opposing tooth, with subsequent impairment of function. Maintenance of the space may eliminate or reduce these consequences.
To avoid malocclusion due to premature loss of the primary teeth, clinicians may advise various types of space maintainers (removable or fixed appliances), depending on the child's stage of dental development, the dental arch involved, and the location of the missing primary teeth. Although removable space maintainers have certain advantages, such as being easier to clean and allowing better maintenance of oral hygiene, they may be removed and worn at the whim of the patient and may be broken or lost easily and, if they are not used properly, they will not be effective.
In contrast, fixed appliances, if properly designed, are less damaging to the oral tissues and are less of a nuisance to the patient as well as the dentist because they are worn continuously for a longer period. It has been reported that a well-designed fixed space maintainer is more preferable than a removable appliance to both patient and dentist. The most commonly used fixed space maintainers for posterior teeth loss are those made of a wire soldered to a band or a pedodontic crown. Although these fixed appliances are well tolerated and durable, they do not restore normal function. It has also been suggested that the band-and-loop space maintainer should be removed once a year to allow inspection, cleaning, and application of fluoride to the teeth.
With advances in technology, attempts have been made to utilize newer materials in the fabrication of space maintainers. One such material is glass fiber–reinforced composite resin (GFRCR; everStick C and B®, Stick Tech Ltd., Turku, Finland) [Figure 1]. This material is a translucent, semi-manufactured product made of glass fiber. Although fiber-reinforced composite resins have been developed for dental use, their application in pediatric dental practice is still limited. GFRCR has been used for making frames of bridges and crowns, in resin-bonded bridges, for permanent splinting, in removable dentures, and as intracanal posts. GFRCR could be an alternative to the conventional and commonly used band-and-loop space maintainer. Hence, the aim of the present study was to evaluate GFRCR as a space maintainer and to compare its efficacy with that of the conventional band-and-loop space maintainer.
| Materials and Methods|| |
Normal, healthy, and cooperative children were selected for the study from among the patients attending the Department of Pedodontics and Preventive Dentistry, The Oxford Dental College, Hospital and Research Centre, Bangalore, India. A total of 30 children (23 boys and 7 girls) aged 6–8 years, who had no medical condition that would contraindicate space maintainer therapy, were selected. A brief history was recorded and a clinical examination was done. Intraoral periapical radiographs were taken in the areas of tooth loss. Every child had premature loss of a primary first molar in at least two quadrants and required space maintenance for the same. Impressions were made, study models were prepared, and a space analysis was done for every child. The criteria for inclusion in the study are given in [Table 1]. The treatment plan was explained to the parents and their written consent was obtained before the study. The research protocol of the study was reviewed by the institutional review board, who gave ethical clearance to conduct the study.
In each child, the two quadrants that required space maintainers were either both in the same arch (maxillary or mandibular) or were in opposing arches (i.e., one in the maxillary arch and one in the mandibular arch). Patients selected for this study were aged 6–8 years. In most of these children the first permanent molars had not yet completely erupted into the oral cavity and thus they could not be banded. Also, many children did not have all their mandibular permanent incisors erupted. Due to these reasons it was not possible to give a fixed lingual arch. Moreover, the purpose of this study was to compare two types of fixed space maintainers that are indicated for unilateral premature loss of a single primary molar.
For every selected child [Table 1] oral prophylaxis and other restorative treatment was done prior to the placement of space maintainers. In one quadrant a GFRCR space maintainer was applied and in the other quadrant a band-and-loop space maintainer was cemented [Figure 2].
| Technique for GFRCR application|| |
In order to determine the length of GFRCR required, the distance between the mesiobuccal line angle of the primary canine and distobuccal line angle of the second primary molar was measured using a digital vernier caliper. After administration of adequate anesthesia, isolation was done using a rubber dam and suction. Both the abutment teeth (primary canine and second primary molar) were cleaned with pumice slurry and then etched with 35% orthophosphoric acid for 40 s. The teeth were rinsed, air-dried, and wetted with an adhesive (Adper Single Bond-2® 3M) that was light-cured for 20 s. This application was repeated 2–3 times to prevent contraction gap formation. A thin layer of flowable composite (Filtek Z350® 3M) was applied to the buccal surfaces of the abutment tooth without light-curing it. The cut length of GFRCR was placed on this flowable composite, extending from the buccal aspect of primary second molar to buccal aspect of primary canine. The ends of the fiber were adapted to the teeth surfaces with a plastic filling instrument. Preliminary curing was done individually at each end of the fiber framework for 40 s, during which the other end was protected from the light source. An additional layer of flowable composite was applied over the area where the fiber abutted the tooth surface and this was light-cured for 40 s. A similar procedure was repeated on the lingual aspect of the abutment teeth. Any uncovered fiber was further covered with flowable composite. The space maintainer was checked for gingival clearance and occlusal interference. Finishing was done using composite finishing burs. Finally, as per the manufacturer's instructions, bonding agent was applied over the fiber frame and light-cured at multiple points for the purpose of reactivation.
In the other quadrant a conventional band-and-loop space maintainer was given as per the technique described by Graber and Finn.
Instructions on oral hygiene and appliance maintenance were given to both children and parents. They were instructed to return promptly if an appliance was loosened, dislodged, or broken. All patients were recalled at 1, 3, 6, and 12 months for evaluation of both types of space maintainers using the criteria given by Kirzioglu and Erturk and Qudeimat and Fayle [Table 2]. During evaluation, the space maintainers were removed if failures had occurred and were either repaired or replaced; these cases were not considered for further evaluation in the study [Table 3] & [Table 5]. The data obtained was tabulated and subjected to statistical analysis using the chi square test and Fisher's exact test.
| Results|| |
At the 1st month follow-up, there were no failures in either type of space maintainer. At the 3rd month, 80% success was observed with GFRCR space maintainers. The 20% failure was mainly due to debonding at the enamel-composite interface (10%) and fracture of the fiber frame (10%). Thirty-three percent [Figure 3] of band-and-loop space maintainers showed cement loss [Figure 4], i.e., there was 67% success. At the 6th month, 66.7% success was observed with the GFRCR space maintainer. Failures were due to debonding at the enamel–composite interface (4.2%), fracture of the fiber frame (8.3%), and debonding at the composite–fiber interface (4.2%). The band-and-loop space maintainer showed 43.3% success; 25% showed cement loss and 10% showed breakage [Figure 5]. At the 12th month, the overall success was 53% for GFRCR and 33.3% for band-and-loop space maintainers. On analysis, there was statistically no significant difference in retention between these two types of space maintainers [Table 4] & [Graph 1].-[Additional file 1]
| Discussion|| |
The space maintainer most commonly used in the event of premature loss of a single posterior tooth is reported to be the band-and-loop or crown-and-loop space maintainer. These appliances adjust easily to accommodate changing dentition. But they have disadvantages, such as a tendency for disintegration of the cement, inability to prevent the rotation and tipping movement of abutment teeth, a tendency to get embedded in gingival tissues or for promoting caries formation , the need for a cast or model, the need for a second visit, and the possibility of metal allergy., These limitations of the conventional type of space maintainers indicate the need for newer materials and designs of the appliances.
The recently introduced GFRCR is essentially silanated glass E-fibers that are pre-impregnated. These glass fibers are linked to each other by linear polymethyl methacrylate (PMMA) chains and cross-linking monomers of bis-GMA. GFRCR can be cured with light-cure composites and its translucency makes it an excellent esthetic choice .
There are limited reports on the clinical efficacy of space maintainers and how variables such as design, construction, and materials used affect their survival time and longevity. Hence, the present study was undertaken to evaluate the retention of GFRCR fixed space maintainers and compare it with that of conventional band-and-loop space maintainers over a period of 12 months.
Both for ethical reasons as well as for the purpose of comparison both types of space maintainers (GFRCR and band-and-loop space maintainers) were given in each child, since we selected children requiring space maintenance in at least two quadrants. Thus, no child was denied the benefits of either type of space maintainer. Also, we hypothesized that since both types of space maintainers were in the same oral cavity they would both be exposed to the same environment, e.g., diet, oral hygiene, and occlusal forces.
As moisture contamination has been reported to be one of the main reasons for failure of the GFRCR space maintainer, all GFRCR space maintainers in our study were applied under rubber dam isolation and the use of high-volume suction. The presence of a chairside dental assistant further facilitated effective patient and time management.
In order to improve the retention of the GFRCR space maintainer, different designs and materials have been used.
, In an earlier study, the fiber was placed only on the lingual surface to minimize the occlusal forces acting upon it. However, there was a high failure rate, which was probably due to a change in the available occluso-gingival dimension. In order to increase the surface area and thus improve retention, in our design, an additional length of fiber was adapted to the buccal aspect of the abutment teeth.
No grooves or slots were prepared on the abutment teeth in order to prevent unnecessary loss of tooth structure. However, it has been recommended to use small cavity preparations, where caries or filled surfaces are detected.
Initially, both types of space maintainers showed no failures. This may have been because patients were more careful in the immediate post-appliance-placement period. It is also possible that the parents were more vigilant and more strictly compliant with post-treatment instructions during this period.
With the GFRCR space maintainers, debonding at the enamel–composite interface was observed as early as 3 months and continued to be the main reason for failure at subsequent evaluations. As all the GFRCR space maintainers were placed on primary teeth, the presence of prismless enamel could have negatively influenced the retention of resin. In another study, which did not use rubber dam isolation, a relatively high percentage (32%) of GFRCR space maintainers showed debonding at the enamel–composite interface during the first month of placement. Wire and composite, observed for 30 months showed 4% failure at the end of 6 months. However, Swaine and Wright reported 30% failure for a similar type of space maintainer evaluated for the same period.
Fracture of the fiber frame was the other significant type of failure seen with the GFRCR space maintainer at evaluation at the end of both the 3rd month and the 6th month. Such fractures have not been reported in earlier studies.,, In our study, the fiber frame fractured because the patient had chewed on hard foods. With longer intervals of time, there is a possibility of supraeruption of the opposing tooth and its impingement on the fiber frame. This could result in increased concentration of mechanical stresses on the fiber frame and its subsequent fracture.
Another type of failure observed at the 6th month evaluation was debonding at the composite–fiber interface. Overzealous finishing of the space maintainer could have resulted in excessive removal of the resin overlying the fiber. Further wearing away of this thin layer of composite during mastication could have debonded the composite from the fiber frame.
In this study, cement loss was considered as one of the criteria for failure of the band-and-loop space maintainer. Although recementation of the appliance was carried out, these patients were excluded from further evaluation in the study. Cement loss was initially seen at the 3rd month of evaluation (33.3%) and continued to be observed till the end of the study. This was consistent with the findings of Moore et al. and may have been because of non-application of rubber dam during cementation.
Some studies have reported cement loss to be the most common cause of failure of fixed space maintainers., Although glass ionomer cement has low oral solubility, cement loss could be due to difficulty in achieving complete isolation during cementation, especially in young patients. In comparison to resins and reinforced glass ionomer cements, the conventional glass ionomers have low flexural strength. Also, the mechanical bonding between the band material and the luting cement is less strong than the combined mechanical and chemical adhesion of glass ionomer to tooth enamel. According to certain studies, cases of failure classified as being due to cement loss are likely to be due to poor band fit.
Approximately 7% of the band-and-loop space maintainers placed in the present study showed breakage of the wire loop at the 6th month. Such a high rate of mechanical failure could have been due to the poor quality of construction, for example, an incomplete solder joint,,, overheating of the wire during soldering,,, thinning of wire by polishing, and failure to encase the wire in the solder.
When comparing the retention of both types of space maintainers, GFRCR space maintainers showed a higher success of 53%, while only 33% success was seen with the band-and-loop space maintainer. However, this difference was not statistically significant. Non-application of rubber dam during cementation could be one reason for the lower rates of success with the band-and-loop space maintainers. In addition to being applied under rubber dam isolation, the GFRCR space maintainer has the advantage that resins are virtually insoluble in oral fluids. The improvised design of the GFRCR space maintainer allowed for bonding on both buccal and lingual surfaces of the two abutment teeth; this provided adequate surface area for firm bonding and micro-mechanical retention.
According to Baroni et al., in the long-term use of space maintainers, the mechanical stresses to which the appliance is subjected is more important than its design. It has been reported that children prefer the right side of the mouth for chewing. This could imply that space maintainers placed on the right side of the mouth are more prone to occlusal stress and early loss. In our study, GFRCR space maintainers were placed on the right side of the mouth in 26 children and 46% of them showed a failure.
The GFRCR space maintainer seems to be a suitable alternative to the conventional fixed space maintainer. GFRCR space maintainers are easy to apply and require only one visit. There is no need for making impressions and cumbersome laboratory procedures are eliminated. Patients are satisfied because these space maintainers are esthetic, less bulky, occupy less space in the oral cavity, and feel natural. In the design of a band-and-loop space maintainer, the band encompasses the entire circumference of the abutment tooth; whereas, in our study, the GFRCR space maintainer was bonded only to the middle third of the abutment teeth surfaces. Also, the design of the GFRCR space maintainer provided ample clearance between the fiber frame and the underlying tissue. Thus, the GFRCR space maintainer is likely to permit better oral hygiene maintenance and cause fewer traumas to the gingival tissue.
It is our hope that the findings of this study will enable the pediatric dentist to follow a simple method for space maintainer application, while making the appliance more comfortable and esthetically pleasing for young patients.
| Conclusion|| |
The following conclusion was drawn from this study:
- GFRCR space maintainers showed superior retention (53%) compared to band-and-loop space maintainers (33.3%), but this difference was not statistically significant.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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