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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 117-125

Efficacy of natural tooth pontic in periodontally compromised patients: A systematic review


1 Department of Periodontics, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
2 Department of Periodontology, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission23-Oct-2020
Date of Acceptance02-Dec-2020
Date of Web Publication16-Jul-2021

Correspondence Address:
Prajakta Sugdeo Umarkar
Department of Periodontics, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrr.jdrr_148_20

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  Abstract 


Periodontitis is a major concern for the dentist because the destruction of periodontal fibers causes mobility of teeth and eventually leads to tooth loss. Conventional techniques like removable temporary acrylic prosthesis, or resin-bonded bridges hold their own disadvantages and a fixed prosthesis may worsen the existing condition. Natural tooth pontic (NTP) in such cases may be advantageous in terms of esthetics and patient satisfaction along with cost effectiveness. Hence, the aim of this review was to evaluate the efficacy of NTP in periodontally compromised patients. Electronic search on data sources such as PubMed and Google scholar along with hand searching of the articles was done in institutional library. All case reports and case series were included in English language published till October 31, 2019, were included. After applying inclusion and exclusion criteria, ten articles were selected for the present review. The whole process was conducted by following the Preferred Reporting Items for Systematic Reviews guidelines. Our review noted that all the patients were satisfied with the appearance of the tooth and also comfortable in maintaining the oral hygiene as these pontics had a ridge lap design. Survival rate was 100% except for the case series which reported a survival rate of 75% while few others did not report anything since no follow-up was conducted. Overall NTP was well accepted by the patients. NTP can be of a great option as prosthesis in the patients with compromised periodontium. Patient's positive satisfaction, cost viability, and accomplishment of appearance in the esthetic zone of the oral cavity make this strategy as a valuable treatment option.

Keywords: Case reports, natural tooth pontic, periodontitis, prosthesis


How to cite this article:
Umarkar PS, Shetty SK, Kulloli AM, Martande S, Gopalakrishnan D. Efficacy of natural tooth pontic in periodontally compromised patients: A systematic review. J Dent Res Rev 2021;8:117-25

How to cite this URL:
Umarkar PS, Shetty SK, Kulloli AM, Martande S, Gopalakrishnan D. Efficacy of natural tooth pontic in periodontally compromised patients: A systematic review. J Dent Res Rev [serial online] 2021 [cited 2021 Aug 1];8:117-25. Available from: https://www.jdrr.org/text.asp?2021/8/2/117/321529




  Introduction Top


Periodontitis is defined as an inflammatory disease of supporting tissues of teeth caused by specific microorganisms or groups of specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with periodontal pocket formation, gingival recession or both.[1] It is a complex infectious disease which occurs as a results of interaction between the bacteria in the oral biofilm and the immune response of the host, which is further altered by the environmental and genetic factors.[2] Plaque-induced gingivitis is restricted to the gingival tissues while periodontitis in various forms affects whole of periodontium with the presentation of classic signs and symptoms of inflammation, swelling and redness of the tissues, alteration in the architectural form with reduced capability of the periodontium to bear occlusal forces.[3] Periodontal disease affects around 20%–50% of the population worldwide.[4] It is a major concern for the dentist because the destruction of periodontal fibers causes mobility of teeth and eventually leads to tooth loss. The tooth loss due to severe periodontitis has been reported to be affecting 5%–15% of the population.[5] Although various preventive measures are reported in the literature still, periodontitis is a major public health concern as it deteriorates the quality of life of people.

Dentists very often may face a challenging situation wherein the patient is suffering with periodontitis and visits a dentist to get his lost teeth replaced. In ideal condition, the measures to improve the periodontal health are undertaken and then the decision of providing the type of prosthesis is made. However, in severe periodontal diseases wherein the patient expects an immediate replacement for preserving the esthetics, like in case of tooth loss in the anterior region as a result of extraction due to trauma, root resorption or failure of endodontic retreatments; the condition may not favor the use of fixed prosthesis.[6] If fixed prosthesis are provided in such conditions the situation may worsen as it requires aggressive tooth preparation of adjacent tooth for abutment, which may pose a high risk of pulp exposures especially in the lower anterior.[7]

Conventionally, the replacement of a single tooth with removable temporary acrylic prosthesis, or resin bonded bridges has been the solution to this clinical problem but they both come along with some disadvantages. Acrylic removable partial dentures placed immediately after the tooth is extracted are bulky, they interfere with the healing process and may also be uncomfortable for the patients while the prefabricated acrylic denture teeth which are used as a pontic and are bonded to the adjacent teeth can presents challenges with respect to matching of color, shape, and size with that of adjacent natural teeth. These prefabricated resin bonded bridges require extensive modifications to achieve the shape and size of natural teeth and thus an acceptable appearance by the patients.[8]

In such situations, the natural tooth pontic (NTP) can prove to be advantageous. Natural tooth used as a pontic can very well match with the shape and size of natural tooth. The color matching also is not a challenge for the dentist. Since the patient's own tooth is used as a pontic, no adaptability issues arise as that with removable partial dentures.[7] The preparation procedure includes root canal treatment which is done after the extraction of natural tooth. Following root canal treatment the tooth is prepared for the desired height after measuring the tooth length with periodontal probe. An additional 2 mm length is added to the natural pontic to compensate for the gingival recession which will occur during the healing phase. Once the measurements are obtained the tooth is inserted back into the socket. To obtain stability for this pontic, it is bonded with the adjacent teeth with the help of flowable resin and reinforced fiber splint materials. In few instances, a metallic or nylon meshwork along with resin material is also used to provide extra stability.[9] Moreover, to improve the esthetic appearance further, these pontic are provided with a modified ridge lap shape that even makes is easier to maintain oral hygiene for the patient.[10] Studies have reported a positive patient's response toward the appearance, size, and acceptability of natural tooth as pontic.[7],[11],[12] In addition, the cost of the prosthesis to the patient is majorly reduced making it cost-effective. Although this concept is quite old, still there is a lack of literature which would provide an overall picture of this technique. Thus, this systematic review was initiated with an aim to evaluate the efficacy of NTP in periodontally compromised patients.


  Methodology Top


Search strategy

The comprehensive data search was performed in PubMed and Google scholar to identify all the articles that have evaluated the efficacy of NTP in periodontally compromised patients till October 31, 2019. The search strategy included appropriate changes in the key words following the syntax rules of each database. The following search parameters were used: primary keywords were – "periodontitis (P)," "natural tooth pontic (I)" and "Efficacy (O)" and secondary keywords were "periodontal disease," "chronic periodontitis," "adult periodontitis," "tooth pontic," "natural pontic," "Tooth as pontic," "pontic natural tooth," and "mobility." The boolean operators used were, "AND" and "OR" for a combination of keywords. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

The inclusion criteria of the review were case reports and case series conducted on periodontally compromised patients treated with natural pontic procedure in English or in other languages where translation to English was possible and those studies published till the October 31, 2019. The exclusion criteria was studies using natural pontic on healthy periodontium patients, all nonclinical studies, editorials, review articles, and short communications.

A total of 63 articles were evaluated for titles, citations and abstracts, and 38 articles were discarded. Hence, the remaining 25 articles were screened for duplicity and final 14 articles were subjected to abstract analysis, where 4 articles were excluded because they did not meet the eligibility criteria. Finally, 10 articles were included in qualitative analysis. [Figure 1] shows a PRISMA flowchart of the identification and selection of the study. A summary of the selected articles is presented in [Table 1].
Figure 1: Selection of articles (Preferred Reporting Items for Systematic Reviews and Meta.Analyses Flow Chart)

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Table 1:Summary of Selected Articles

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Materials and methodology of natural tooth pontic procedure

In general thorough Phase 1 therapy is done prior to procedure. After the re-evaluation of response to Phase 1 therapy [Figure 2], with the written informed consent, the NTP procedure was performed under local anesthesia.
Figure 2: Thorough scaling and root planing

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As a first step, the hypermobile and severely periodontally compromised tooth was removed [Figure 3]a and [Figure 3]b and the socket was curetted to clear the infected granulation tissue by using bone curettes. Root canal (RC) treatment was done for the extracted tooth, by following standard operative procedures [Figure 4] and once the RC treatment was completed, thorough debridement and planing of root surface of same tooth was done [Figure 5]. A Part of the root of tooth was resected and then the resected end was sealed by using biocompatible light cure flowable Resin Modified Glass Ionaomer Cement [Figure 6]a and [Figure 6]b. Subsequently this ready to use prepared pontic was inserted into the socket and it was stabilized using composite resin reinforced fiber splint with the adjacent teeth [Figure 7]. The number of teeth included in splinting process depends on mobility of teeth adjacent to pontic. Once splinting is completed, occlusal evaluation was done to assess any traumatic occlusion with opposing tooth [Figure 8]. Suitable antibiotic and analgesics were given to the patient. Usually, after 24 h, finishing and polishing is done. For the long-term success, the patient was instructed not to apply any excessive pressure on the splinted teeth. Case 2 [Figure 9]a and [Figure 9]b, [Figure 10]a and [Figure 10]b represents a case where Natural Tooth Pontic procedure was planed and performed with Maxillary left Central incisor. Similarly, a better esthetic outcome was achieved with maxillary left lateral incisor after performing Natural Tooth Pontic Procedure, Case 3, [Figure 11]a and [Figure 11]b.
Figure 3: (a) A traumatic extraction performed. (b) extracted tooth

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Figure 4: Root canal treatment

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Figure 5: Scaling and root planing of tooth

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Figure 6: (a) Etching with 37% phosphoric acid. (b) Bonding with light cure after sealing the canal with glass ionaomer cement

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Figure 7: Stabilization of natural tooth pontic with composite reinforced fibre splint

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Figure 8: Immediate postoperative image after occlusal adjustment

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Figure 9: (a) Preoperative picture in occlusion where natural tooth pontic is planned with tooth number 21. (b) Postoperative picture in occlusion after natural tooth pontic procedure with tooth number 21

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Figure 10: (a) Preoperative image in smile. (b) Postoperative image in smile

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Figure 11: (a) Preoperative image where natural tooth pontic was planned 22. (b) Postoperative image natural tooth pontic performed with 22

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  Results Top


Our study included 10 research studies of which qualitative synthesis was done [Table 1]. Among these studies, there were 9 case reports and 1 case series having a common condition studied; periodontitis. The age of the patients ranged from 30 years to 60 years, with the lowest age of 22 years reported by Raj et al.[11] and the highest age of 80 years as reported by Daly A et al.[16] With regard to gender, female patients were reported in maximum case reports. Almost all case reports noted mobility, deep pockets and bone loss as the most common findings, whereas draining sinus was reported by Walsh and Liew.[12] The treatment provided for all the patients in case reports was most commonly RC therapy and in some cases, scaling and root planning preceded this. In majority of the case reports, the most common natural pontic tooth involved was mandibular right central incisor, followed by left central incisors and then lateral incisors. Only in cases reported by Walsh and Liew[12] and Raj et al.,[11] maxillary central and lateral incisors were involved.

A generalized follow-up period of 6 months-1 year was noted in most of the case reports, whereas only 2–3 case reports, did not have any follow-up. Hence, this might have altered their treatment outcome. The splinting with adjacent tooth was done with ligature wire and fiber ribbond in almost all cases. The final treatment outcome was assessed in terms of periodontal component, patient satisfaction, and survival rate. The periodontal outcome was hardly reported in any case reports; except by Quirynen et al.[13] The patient satisfaction was evaluated as good in majority of the case reports, with almost 100% survival rate in all the cases; except a few case reports, where the survival rate was not reported. The overall inference derived from all case reports taken into consideration in this systematic review suggests that NTP provides a better treatment option in periodontally compromised patients and can be used effectively for the successful clinical outcome. Within the limitations and drawbacks of the case reports included in this systematic review, the final results observed that the various advantages of using natural tooth as a pontic, is significantly better than a few patient-related disadvantages encountered during the NTP as a treatment option.


  Discussion Top


This is a systematic review of the case reports and case series which have been reported in the literature regarding using natural tooth as a pontic in periodontally compromised patients.

Walsh and Liew[12] reported a case wherein the patient came with a chief complain of recurrent abscesses in the maxillary anterior region along with swelling episodes from the last 5 months. The patient had generalized pockets of around 6 mm thus periodontal condition of this patient was very poor. In this case, the tooth with complain was RC treated and the patient was sent back. The patient was without any complain for the next 18 months after which he again visited the clinic for the same tooth with suppuration. The RC was redone but patient came back again after 8 months with the same complain following which the decision was made to extract the tooth as it was not responding any more to the treatments. The extraction was done carefully so as to avoid trauma to the adjacent weak teeth. This extracted tooth was prepared in height and then used as a NTP. The patient was followed for 5 months. The patient was satisfied with the condition after 5 months and there was 100% survival rate.

Quirynen et al.[16] reported a case series of 41 patients with a mean age of 60 years which assessed the longevity of composite-bonded resin/natural teeth (reinforced only with a stainless steel mesh) as replacements for periodontally lost lower incisors. Besides the longevity of the restoration, the periodontal condition of the abutment teeth, and the general satisfaction of the patient was evaluated retrospectively through a phone interview. The survival rate for these NTPs was found to be around 80% after 5 years of function. This case series consisted of patients requiring single prosthesis or a bridge containing two natural pontics. However, both the type of prosthesis provided similar survival rate. The abutment teeth demonstrated stable probing depths and a negligible loss in attachment (0.1 mm/year). The satisfaction ratings were also favorable. This series inferred that NTP can be considered as a semi-permanent rehabilitation for the replacement of 1 or 2 periodontally lost lower incisors.

Pant and Rathore[10] reported a case report which aimed to provide an immediate interim restoration of a hopeless tooth using natural tooth as pontic in a patient with generalized aggressive periodontitis. When the tooth in the aesthetic zone gets extracted it becomes very distressful for the patients and these patients demand immediate replacement which becomes a difficulty in these periodontally compromised patients. This case used natural tooth as a pontic bonded to the adjacent abutment teeth with a fiber reinforced resin in 38 years of female who came with a complain of severe mobility in the lower front tooth since 1 year. The patient had generalized recession and pockets. The tooth was extracted after doing scaling and root planning. No RC treatment was done as the tooth was already RC treated a year back. The natural tooth was prepared and placed in the place of extracted tooth and bonded with the adjacent teeth with composite resin. This case provided a step of NTP used successfully to treat the loss of a lower incisor in a patient with generalized aggressive periodontitis, subsequently acting as a splint for the remaining teeth, with a follow-up of 2 years.

Another case was reported by Sheikh et al.[14] wherein a chair side technique for replacing the missing tooth using the patient's own natural tooth as a pontic in the three-dimensional original position using a fiber reinforced composite resin splint was done. This helped in restoring the aesthetics and relieving the apprehension of the patient. The patient had pockets of 9 mm and mobility with upper left central incisor. The natural tooth with hopeless prognosis was extracted and used as a pontic in that same place after preparation. A 100% survival rate was found at 1 year follow-up. Using natural tooth as pontic proved to be an easy to handle treatment option and promised an excellent transient esthetic solution for a lost tooth. Moreover, it requires minimal or no tooth preparation, thus avoiding the laboratory cost.

Srinidhi and Raghavendra et al.[15] reported a case of 58-year-old female who came with a chief complain of mobility in lower central incisor. The only option was to extract the tooth but the replacement was the patient's main concern. Providing an immediate prosthesis that too in such a worse periodontal condition was a challenge. Thus, the same tooth which was extracted was used to replace the missing tooth. The replaced tooth has great esthetic appearance similar to that of natural tooth.

A 38-year-old patient case with mobility of lower incisors was diagnosed with generalized periodontitis. The patient desired immediate treatment but the clinical examination revealed gingival recession with 8 mm loss of attachment and thus natural tooth as a pontic was decided to be used as a replacement of its own. Scaling and root planing along with the RC treatment of the extracted tooth was done. The tooth was prepared of according size and placed back in to the socket. The bonding with the adjacent teeth was done with ligature wires and composite resin. A follow-up of 8 weeks revealed that the patient was highly satisfied with the pontic and there was 100% survival rate as the condition of the pontic was good enough.

Daly A[16] reported a case report employing an e-max lingual retainer combined with a NTP to manage the immediate restoration of a postextraction space in the lower anterior region. The loss of an anterior tooth can present a challenging clinical situation with regards to the esthetic, functional and psychosocial concerns for the patient, in addition to the difficulty of restoring such an edentulous space in a timely if not immediate manner. The patient in this case was diagnosed with generalized chronic periodontitis with periapical abscess and mobility of tooth. The decision to extract the tooth with hopeless prognosis was made. The natural tooth was placed as a pontic after preparation and no follow-up was done and thus no information on satisfaction was obtained.

Kumar et al.[7] undertook a case of 30-year-old male patient who came with a complaint of mobility in lower front teeth. The examination revealed that patient had 8 mm pocket and bone loss around the tooth. As the patient was highly concerned with esthetics, the possibility of using the clinical crown as a natural pontic was proposed. The lower central incisor was extracted and prepared to be placed as a pontic. Before placing, RC treatment of the tooth was also performed. A follow-up of 1 year reported that the patient was satisfied with the appearance of the tooth along with the function.

Raj et al.[11] presented two cases in their case series wherein patients were of 22 and 35 years complaining of mobility and bone loss around the tooth with abscess formations. In both the patients the teeth were extracted and RC treated and prepared. The follow-up in one patient was done for 6 months while in other for 9 months. At the end of the follow-up, both the patients were satisfied and the replaced tooth showed 100% survival.

Vaghani et al.[17] reported a case of 32-year-old female who came with a complain of mobility and extrusion of maxillary left lateral incisor. On clinical examination, there was mobility, gingival recession, and the tooth was extruded from the socket. Radiographic examination revealed horizontal bone loss up to apical one-third of the tooth. The tooth had hopeless prognosis and thus was extracted. After preparation of the tooth, it was placed back post scaling and RC therapy. The success rate was not reported as the follow-up was not conducted.

In this systematic review, only 10 articles could fit into the eligibility criteria. Although this concept is quite old, search did not yield much literature on this topic. One case was reported in 1990 followed by 1999 and then directly in 2011. There was a huge gap found in reporting studies on NTP in periodontally compromised patients. Post 2011, two cases were reported in 2014, one in 2015, three in 2016 and one reported recently in 2019. From the studies included, only two were case series while all other were case reports and thus one patient in cases while one series reported study on 41 patients. The age of patients ranged from 22 years as the youngest and 80 years as the oldest.

The maximum follow-up of 5 years was done in the study conducted by Quirynen et al. in 1999 which was a case series involving 41 patients while the smallest follow-up period was with the case reported by Aeran H and et al. which was of 8 weeks. There were few studies which did not do any follow-up. The natural tooth was placed as pontic and the patient was not recalled for the follow-up to check for any parameters. The patients included in the case series had terminal periodontitis while others either had localized or generalized chronic periodontitis. In all the patients, RC was performed postextraction of the tooth except in Walsch LJ and Liew VP and Pant VA who already had cases wherein the teeth were RC treated. Along with RC treatment, even scaling and root planing were performed in the patients.

All patients reported with recession, deep pockets, severe mobility, and bone loss as seen in the radiograph. Few also presented with draining sinus and episodic abscess. When a splinting modality was assessed in the included cases and series of patients, it can be seen that metallic mesh work, interlig fiber ribbon and ligature wire along with composite resin were the choice of materials. All the patients were satisfied with the appearance of the tooth and also comfortable in maintaining the oral hygiene as these pontics had ridge lap design. Survival rate was 100% except for the case series which reported a survival rate of 75% while few others did not report anything as no follow-up was conducted. Only one article assessed periodontal condition posttreatment. Overall NTP was well accepted by the patients.


  Conclusion Top


Within the limitation of this systematic review, it can be concluded that NTP can be of a great option as prosthesis in the patients with compromised periodontium. Moreover, the utilization of the NTP while the gingival tissue recuperates is a phenomenal, stylishly worthy treatment choice for circumstances in which foremost teeth should be evaluated, and reflects the dental specialist's anxiety for the patient's facial deformation. Patient's positive satisfaction, cost viability, and accomplishment of appearance in the esthetic zone of the oral cavity make this strategy valuable. Few recommendations which can be done in future studies like randomized clinical trials of NTP with other treatment modality (e.g., fixed partial denture, Implant) can be assessed. Periodontal parameters such as periodontal pocket depth, clinical attachment loss in abutment teeth should be recorded and presence of periapical lesion (if any) should be evaluated postoperatively and the follow-up should be done for a longer period of time.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Walsh LJ, Liew VP. The natural tooth pontic – A compromise treatment for periodontally involved anterior teeth. Aust Dent J 1990;35:405-8.  Back to cited text no. 12
    
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Quirynen M. A long-term evaluation of composite-bonded natural/resin teeth as replacement of lower incisors with terminal periodontitis. J Periodontol, 1999;70(2): 205-12.  Back to cited text no. 13
    
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Sheikh NS, Rajhans N, Mundhe P, Fernandez G, Mhaske N, Moolya N, Sudeep HM. A single visit immediate temporization with natural tooth pontic for periodontally involved anterior teeth: an esthetic and innovative approach Int J Med Res Heath Sci. 2015;4(1):214-218  Back to cited text no. 14
    
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