169

Pontics
Definition A pontic is defined as a suspended member of a FPD, replacing the lost tooth, restoring its function & usually occupying space of the missing natural tooth

!he pontic or artificial tooth is the raison d"#tre of a fi$ed partial denture %ts name is deri&ed from the 'atin (ord pons (hich means bridge %t is not a simple replacement, because placing an e$act anatomic replica of the tooth in the space (ould be unhygienic Pontics may be metal)ceramic, cast metal, or less commonly today, resin processed to metal

The edentulous ridge *efore the FPD is underta+en, the edentulous ridge should be e$amined carefully !he type and amount of destruction (ill play a role in selecting the pontic to be used and also indicate the necessity for reshaping the ridge surgically

1,Classification .idge deformities ha&e been grouped into / categories by 0iebert 1lass 1 'oss of faciolingual ridge (idth, (ith normal apicocoronal height 1lass 2 'oss of ridge height (ith normal (idth 1lass / 'oss of both ridge (idth and height

%f a normal classification 3class n4 (ith minimal deformity is added, there are 5 classes of ridge contours %n a study of 516 diagnostic casts, Abrams et al sho(ed class 1 defects to constitute /2 56 of the edentulous ridges ,(ith 2 96 being class 2,77 96 being class / and only 8 86 ha&ing no defects

Surgical correction .idge augmentation can be accomplished by the addition of either soft or hard tissue, although filling the ridge defect (ith bone is not essential unless the ridge is to be used for implants 9$cellent esthetic results can be got in class 1 defects by connecti&e tissue plastic surgery in the form of a sub epithelial or sub mucosal connecti&e tissue graft !he techni:ue for a connecti&e tissue graft is based on the procedures described by 'anger and 1alagna and ;aldahl et al

1,1 Post insertion instructions !he mesial, distal, and lingual gingi&al embrasures of the pontic should be (ide open to allo( the patient easy access for cleaning, and the contact bet(een the pontic and the tissue must allo( the passage of floss from one retainer to the other After the FPD is cemented teach the patient appropriate

techni:ues that can be mastered <oti&ate the patient to practice good oral hygiene around and under the pontic (ith dental floss, inter pro$imal brushes, or pipe cleaners 9&en the smoothest pontic should be cleaned (ell and often to pre&ent accumulation of pla:ue %f cleaning is not done fre:uent, regular inter&als, the tissue around the pontic (ill become inflamed

Classification Pontics are classified in se&eral (ays 1 !he shape of the surface contacting the ridge 2 !he materials used in constructing the pontic / Pontics prefabricated by the manufacturer *ased on Materials used: a <etallic ) =old alloys, >ic+el chromium b >onmetallic)Acrylic, Porcelain

1,2 c 1ombination )Alloy (ith acrylic & porcelain Relationship w ith soft tissues A 0anitary b .idge)lap 1 0pheroidal or conical d 0addle

Prefabricated pontics Type of retention used for facing:Pins, rails, posts? mechanical interloc+ing undercuts, bonded to metal

The Various Requirements of the Pontic are 1 .estore function 2 Pro&ide esthetics and comfort / *e biologically acceptable 5 Permit effecti&e oral hygiene 7 Preser&e underlying residual mucosa 6 0hould not o&erload the abutment

Biologic considerations !he biologic principles of pontic design pertain to the

maintenance and preser&ation of the residual ridge, abutment & opposing teeth & supporting tissues

1,/

Ridge contact Pressure free contact bet(een the pontic & underlying tissues is indicated to pre&ent ulceration & inflammation of the soft tissues %f the tip of the pontic e$tends past the muco)gingi&al @unction, an ulcer (ill form there %f any blanching is obser&ed at try) in, the pressure area should be identified (ith a pressure indicating paste & the pontic recon toured until tissue contact is entirely passi&e !he pontic should contact only attached +eratiniAed gingi&a !he once popular practice of scraping the cast to obtain close adaptation of the pontic (ith tissue compression is not indicated, because of the resultant inflammation Bne author has gone so far as to suggest that the contact be a thin film of sali&a on the ridge Bthers flatly state that pontic should not contact the tissue at all Although one study has sho(n that the tissue under the pontic can be maintained in an inflammation)free state if the patient flosses &igorously at least once a day, there (ill be an imprint, or footprint, of the pontic on the ridge (ithout inflammation !here is increased ris+ of failure of if success depends too much on patient"s cooperation

1,5

Dental plaque !he chief cause of ridge irritation is the to$ins released from microbial pla:ue, (hich accumulates bet(een the gingi&al surface of the pontic & the residual ridge causing tissue inflammation & calculus formation !o enhance pla:ue control, the patient must be taught to perform efficient oral hygiene techni:ues

ingi!al surface of the pontic !here is (idespread agreement that the area of contact bet(een the pontic and the ridge should be small & the portion of the pontic touching the ridge should be as con&e$ as possible Co(e&er, if there is contact along the gingi&o)facial angle of the pontic, there must be no space bet(een the pontic & soft tissue on the facial side of the ridge Dhen esthetics is of main concern, li+e in the anterior region, the pontic should contact the gingi&al tissue on the labial or buccal side to gi&e the appearance of emerging from the tissue to ma+e it loo+ more natural 3attention paid to pre&ent inflammation4

%n the posterior region more attention should be paid to occlusion, function & hygiene 0ince 1918 it has been a popular

1,7 concept that the tissue surface of the mandibular posterior pontic should sometimes be left clear of the residual ridge

Pontic material .e:uirements of pontic materialsE) 1 Pro&ide good esthetic results (here needed 2 *iocompatible / 0trength & rigidity to (ithstand occlusal forces & 5 'onge&ity %n fabrication of metal)ceramic bridges for esthetics, porcelain should be e&aluated as it is a brittle material and may fracture easily? also it abrades the opposing dentition if the occlusal contacts are enamel or metal =laAed porcelain is considered to be the most biocompatible and clinical data tend to support this opinion, although the critical factor here is the materials ability to resist pla:ue rather than the material itself Cighly polished gold is more resistant to initial pla:ue

accumulation than rougher surfaces Although glaAed porcelain loo+s &ery smooth, microscopically its surface can contain many &oids & actually be rougher than polished gold or acrylic resin Cighly glaAed porcelain is relati&ely easy to clean, ma+ing pla:ue remo&al easier than other materials

1,6 %f good oral hygiene is maintained, patients are able to pre&ent inflammation (ith any pontic material

"cclusal forces .educing buccolingual (idth of pontic by as mu8ch as /-6 has been suggested as a means of reducing occlusal forces on & hence loading of abutment teeth 3this practice continues e&en though there is no scientific basis4

1ritical analysis re&eals that forces lessened only (hen che(ing food of uniform consistency and a mere 126 increase in che(ing efficiency can be e$pected from a one)third reduction of pontic (idth

Para functional habits or accidental biting forces on an FPD may produce harmful forces, (hich cannot be reduced by narro(ing the occlusal table Decreasing the occlusal table may act as a malposed tooth, hampering the hygiene

Cence for these reasons a normal occlusal (idth 3at least one) third4 is ad&ocated residual ridge An e$ception here is a collapsed buccolingual

1,, Mechanical considerations %n the design of FPD pontics, if insufficient attention is paid to mechanical principles, the prognosis (ill be compromised

Mechanical problems ma#be due to E %mproper choice of materials Poor frame (or+ design Poor tooth preparation or Poor occlusion

$!ailable pontic materials Prefabricated porcelain pontics: <any are no longer a&ailable, as demand for <etal)ceramic increased >e&ertheless, they do pro&ide a practical & e$pedient (ay to fabricate an esthetic pontic (here partial co&erage is needed Metal%ceramic pontics: !hese are strong, easy to clean & natural appearing

$luminous porcelain pontics: 1ustom)made aluminous porcelain pontics can be used in place of prefabricated porcelain types !hese are cemented to a cast metal

frame(or+ (ith retention pro&ided by the high Alumina ceramic tubing or slotted rod onto (hich porcelain is fired

1,8 0uch facings are less prone ton fracture than prefabricated pontics since high alumina ceramic is eight times stronger than con&entional porcelain Resin !eneered pontics Advantages: 9asy to manipulate and repair Doesn"t re:uire the high melting range alloys .ecent de&elopments in the use of acid etching to impro&e the bond bet(een resin & metal & use micro filled composites may lead to a reappraisal of resin &eneers Disadvantages: 'o( resistance to abrasion Dear occurs (ith normal tooth brushing

&sthetic considerations Bne problem in replacing missing teeth (ith an FPD is achie&ing a natural appearance >o matter ho( (ell the biologic & mechanical principles ha&e been met during its fabrication, the patient (ill e&aluate the result from the esthetic standpoint, especially (hen anterior teeth are being replaced An contours, esthetically gingi&al successful pontic (ill replicate gingi&al the and form, incisal

margin,

incisal

edge,

embrasures, and colour of the ad@acent teeth

1,9 !his cannot be accomplished merely by duplicating the facial contour of the missing tooth? the al&eolar bone undergoes resorption and remodeling, or both, after a tooth is remo&ed %f the original tooth contours (here follo(ed, the pontic (ould loo+ unnaturally long inciso)gingi&ally %t is therefore necessary to

understand ho( the brain interprets (hat is seen & ho( this interpretation can be altered

Visual perception !he &isual center of the brain interprets information recei&ed from the outside (orld &ia light)sensiti&e receptors in the retina !his interpretation is based to a large e$tent on the pre&ious conditioning, (ith the brain continually ma+ing certain assumptions as to (hat is normal

'ight ( Shade 0pecial care must be ta+en in studying (here shado(s fall around natural teeth, particularly around gingi&al margin %f a pontic is poorly adapted to the residual ridge, there (ill be an unnatural shado( in the cer&ical area that loo+s odd & spoils the illusion of a natural tooth

18"ptical illusion !he brain can be confused into trying to interpret t(o)

dimensional dra(ing as three dimensional ob@ects Bther illusions can confuse the brain because of an erroneous interpretation of perspecti&e A pontic of abnormal siAe maybe designed to gi&e the illusion of being a more natural siAe *y contrast, e&en a tooth of normal siAe can be positioned to destroy the e$pected harmony and loo+ unnatural

Proportion 9sthetics depends largely on proportion 1oncepts of proportion are probably based on (hat is found in nature >atural gro(th is

closely related to a mathematical progression 3Fibonacci series)after the %talian mathematician, 'eonardo Fibonacci4 in (hich each number is the sum of the t(o immediately preceding it )1,1,2,/,7,8,1/,21,/5,77 so on !he ratio bet(een succeeding terms con&erges on appropriately 1 619 to 1, +no(n as the =olden proportions

Balance A balanced arrangement implies stability and permanence !he obser&er e$pects the left and right sides of the mouth if not to match precisely at least to balance out An ob&ious restoration on one side maybe balanced if there is a diastema or a large tooth on the other side %f something is out of balance the brain infers it as an unreciprocated

181 force &the arrangement is unstable .idge resorption (ill ma+e a tooth loo+ too long in the cer&ical region !he height of the tooth is

immediately ob&ious (hen the patient smiles & sho(s the gingi&al margin An abnormal labio)lingual or cer&ical contour ho(e&er is not ob&ious !his fact can be used to produce a pontic of good appearance by recontouring the gingi&al half of the labial surface !he obser&er sees a normal tooth length but is una(are of the abnormal labial contour !he illusion is successful &)cessi!e bone loss Dhere tooth loss is accompanied (ith e$cessi&e loss of al&eolar bone, a pontic of normal length (ill not touch the ridge at all Solutions are:% !o shape the pontic to simulate a normal cro(n & root (ith emphasis on the cemento)enamel @unction !o use pin+ porcelain to simulate gingi&al tissues .idge augmentation procedures are successful in correcting limited areas $bnormal mesio%distal w idth Fre:uently the space a&ailable for a pontic (ill be greater or smaller than the (idth of the contralateral tooth 3due to uncontrolled tooth mo&ement4

182 Cere an acceptable appearance can be obtained be incorporating the principles of &isual perception into the pontic design !he (idth of an anterior tooth is usually identified by the relati&e positions of the mesio)facial & disto)facial line)angles, & the o&erall shape has a detailed pattern of surface contour & light reflection bet(een these line angles !he features of the contralateral tooth should be duplicated as precisely as altering the shape of the pro$imal areas can compensate possible in the pontic and the space discrepancy 0pace discrepancy is less of a problem (hen replacing the posterior teeth because the distal hal&es are not &isible from the front A discrepancy here can be

managed by duplicating the &isible mesial half of the tooth & compensating by ad@usting the siAe of the distal half

Pontic designs 0addle 3.idge lap4 <odified ridge lap Cygienic 1onical B&ate Prefabricated pontic designs & <etal ceramic pontics

18/

Pontic design classification $* Mucosal contact 1 0addle 2 <odified saddle / .idge lap 5 <odified ridge lap

B* +o mucosal contact 1 0anitary 3Cygienic4 2 <odified sanitary / *ullet

Saddle !his pontic loo+s most li+e a tooth, replacing all the contours of the missing tooth %t forms a large conca&e contact (ith the ridge %t is also

obliterating the facial, lingual and pro$imal embrasures

called the ridge lap because it o&erlaps the facial & lingual aspects of the ridge A contact (ith the ridge that e$tends beyond the midline of the edentulous ridge, or a sharp angle at the linguogingi&al aspect of the tissue contact, constitutes the ridge lap

185 !his design has long been recogniAed as being unclean and

uncleanable !he saddle is impossible to clean, as the floss cannot trans&erse the tissue)facing surface of the pontic because it bridges across the faciogingi&al and linguogingi&al angles of the pontic

Modified ridge lap !his design gi&es the illusion of a tooth, but possesses all or nearly all con&e$ surfaces for ease of cleaning !he lingual surface has a slight deflecti&e contour to pre&ent food impaction and minimiAe pla:ue accumulation

!here maybe a slight faciolingual conca&ity on the facial side of the ridge, (hich can be cleaned & tolerated by the tissue as long as the tissue contact is narro( mesiodistally and faciolingually .idge contact must not e$tend no further lingually than the midline of the edentulous ridge, e&en on the posterior teeth Dhene&er possible, the contour of the tissue)contacting area of the pontic should be con&e$, e&en if a small amount of soft tissue on the ridge must be surgically remo&ed to facilitate it !his design (ith the porcelain &eneer is the most commonly used in the appearance Aone for both ma$illary &mandibular FPD ,#gienic

187 !he term hygienic is used to describe pontics that ha&e no contact (ith the edentulous ridge !his design is fre:uently called a sanitary

pontic 3(hich in the years past (as the trade name for a prefabricated, con&e$ facing (ith a slot bac+, used for mandibular molar pontics4 Fsed most commonly in the non)appearance Aones particularly to replace the mandibular first molars %t restores occlusal function &

stabiliAes ad@acent & opposing teeth !he occluso)gingi&al thic+ness of the pontic should not be less then / -mm and there should be ade:uate space under it to facilitate cleaning !he hygienic pontic is mostly

made in an all)con&e$ configuration faciolingually & mesiodistally !he round design has been described fish belly An alternati&e design, in (hich the pontic is made in the form of an arch(ay mesiodistally, has been suggested !he undersurface of the pontic is con&e$ faciolingually, gi&ing the tissue)facing surface of the pontic the configuration of a hyperbolic parabola !here is added bul+ for strength in the connectors, and access for cleaning is good An esthetic &ersion of this pontic can be created by &eneering (ith porcelain those parts of the pontic that are li+ely to be &isibleE the occlusal surface & occlusal half of the facial surface, (hich happens to be the entire facial surface of this pontic !his design has been called an arc)fi$ed partial denture, a modified sanitary pontic, or simple a Perel pontic

186

Conical !he conical pontic is rounded and cleanable, but the tip is small in relation to the o&erall siAe of the pontic %t is (ell suited for use on a thin mandibular ridge Dhen used (ith a broad, flat ridge the resulting large triangular embrasure spaces around the tissue contact ha&e a tendency to collect debris !his pontic is related to the sanitary dummy described by !in+er in 1918 %ts use is limited to replacement of teeth o&er thin ridges in the non)appearance Aone

"!ate !he o&ate pontic is a round)end design currently in use (here esthetics is a primary concern %ts antecedent (as the porcelain root)tipped pontic, (hich (as used considerably before 19/as an esthetic & sanitary

substitute for the saddle pontic !he tissue)contacting segment of the o&ate pontic is bluntly rounded and it is set into the conca&ity in the ridge %t is easily flossed

18, Placing a pro&isional FPD (ith the pontic e$tending one):uarter of the (ay into the soc+et immediately after e$traction of the tooth can get the conca&ity %t also can be created surgically at some later time !his pontic (or+s (ell (ith a broad, flat ridge, gi&ing the appearance that it is gro(ing from the ridge Prefabricated pontic facings At one time preformed porcelain facings (ere popular for fabricating pontics !hey re:uired adaptation to a specific edentulous space, after (hich they (ere reglaAed 0ome such as !rupontics, 0anitary pontics & 0teele"s facings relied on a lug in a custom cast metal bac+ing to engage a slot in the occlusal or lingual surface of the facing !he large bul+ of porcelain could result in a thin gold bac+ing susceptible to fle$ing Carmony & !rubyte facings used horiAontal pins that fit into the gold bac+ing !hey (ere difficult to use in patients (ith limited occlusogingi&al space, & refitting the pins into a bac+ing after casting (as demanding 1 2
! . F P B > ! %1 %> ! 9 . 1 C A > = 9 A * '9 FA1 %> =

188 / 5 7 6 ,
P %> FA 1 % > = < B D %F%9 D P %> FA1 %> = C A . < B > G FA 1 % >= P B . 1 9 'A %> FF 09 D ! B <9 ! A' . 9H 9 . 09 P %> FA 1 %> =

Porcelain denture teeth (ere also modified to use as pontic facings <ultiple pin holes, 2 -mm deep, (ere made (ith a drill press in the lingual surface of the re&erse pin facing !he pins came out of the bac+ing, pro&iding retention (here a deep o&erbite (ould ha&e o&er shortened con&entional pins Fnfortunately, the pin holes in the facing (ere stress points that led to fracture

Metal ceramic pontics Dith the (idespread use of metal)ceramic restorations, metal ceramic pontics ha&e replaced other types of pontics employing porcelain <etal)ceramic pontics ha&e the greatest esthetic potential as prosthetic replacements or missing teeth

Additionally, metal)ceramic pontics are stronger, since the porcelain is bonded to the metal substrate rather than cemented to it !hey are easier to use because the bac+ing is custom made for a space 3no need to adapt a premade porcelain facing to the space4 Pontic selection

189 !he design or type of pontic for a specific FPD is determined byE 1 !he retainers 2 9sthetics / Bcclusal gingi&al height & mesiodistal (idth of the edentulous area 5 .idge resorption & contour Dhen porcelain)bonded)to)metal retainers are used, porcelain) bonded)to)metal pontics are selected in order to coordinate the lab procedures and enhance esthetics Dhen partial &eneer retainers are used, prefabricated facings are indicated, using the same metal as retainer %f all metal retainers are used, an all metal pontic is appropriate %n the ma$illary anterior

segment, esthetics dictates pontic selection A modified ridge lap is the design of choice, since this is a rational compromise bet(een esthetics & hygiene %n ma$illary posteriors if esthetics is also of primary

concern, a modified ridge lap is the design Dhen multiple teeth are missing, the interpro$imal embrasures are minimiAed on the facial surface to pre&ent unsightly spaces & to a&oid (histling sounds !he gingi&al contour of the pontic usually

conca&e from facial contact to the crest of the ridge and con&e$ in the mesiodistal direction

Pontic fabrication ArmamentariumE)

190able brush Plaster bo(l 0patula Iuic+)setting plaster *unsen burner & matches P;! (a$ing instruments *ea&er tail burnisher >o , (a$ spatula %nlay casting (a$ Die lubricant Jinc stearate 1otton pliers Collo( plastic sprue

$ll metal h#gienic pontic fabrication Pour the full arch impression, filling the prepared teeth & one tooth on either side of them to a height of / 8cm off the tabletop !rim the die to an o&erall ht Bf about / 2cm 'ea&e the dies attached to a common base, (hich (ill retain the e$act relationship of the t(o preparations !rim a(ay the stone 1 2cm apical to the finish line to produce a F)shaped die 1oat the die (ith cement spacer & lubricant

191 9&erything but the prepared teeth is trimmed from the poured cast 0egment bet(een preparations is reduced to allo( access to finish line

Place (a$ on the lubricated dies is trimmed from the poured cast 0egment bet(een preparations is reduced to allo( access to finish line Dipping the die into molten (a$ can start (a$ coping >o , (a$ spatula can be used to add (a$ Da$ pattern is placed on (or+ing cast 1onnect the retainer patterns (ith short stic+ of inlay (a$ Dipping the die into molten (a$ can start (a$ coping

A$ial contours ad@usted on (or+ing cast 9$cess (a$ remo&ed from occlusal aspect (ith hot bea&ertail burnisher 9$cess (a$ is remo&ed from occlusal aspect (ith hot bea&ertail burnisher P;! no 5 used to define gingi&al embrasure and undersurface =et a con&e$ fish belly 0mooth & round the undersurface of the pontic (ith instruments & clean cotton roll dipped in Die lubricant Bcclusal surface is built up (ith a (a$)added techni:ue P;! no 5 used to define gingi&al embrasure and undersurface

192 After lubricating the area ad@acent to the edentulous ridge 1onstruct a matri$ on facial & lingual surfaces of cast & (a$ pattern (ith :uic+ setting plaster After plaster sets remo&e (a$ pattern & trim the matri$? so that it is 1mm belo( the occlusal edge of pontic Dith the (a$ pattern on the cast, close the articulator & reproduce all functional mo&ements Bcclusal surface is de&eloped by placement of cones & ridges %f FPD is to be cast as 2 pieces (ith assembly follo( !ry) in, sa( through larger connector (ith no / sil+ Bcclusal surface is built up (ith a (a$)added techni:ue

-n!esting ( casting Attach 1-)gauge hollo( sprue to the non)functional cusps 1onnect the free ends of all the sprues (ith stic+y (a$ %n&est & cast Bne sprue is attached to each retainer and to each cusp of the pontic

Metal%Ceramic .PD Da$ coping is added in the same manner surface 1ar&e the tissue

19/ Pour a putty inde$ to access the cut bac+ Fse a discoid car&er to place a groo&e ad@acent to the outline of the boundaries of &eneering area For posteriors the groo&e is placed @ust buccal to pro$imal contact? so that contact is in metal For anteriors the groo&e is placed @ust lingual to the contact so that contact is in porcelain Dith discoid car&er place groo&es 3- ,)1mm depth4 on the facial surface Fse a sharp no 27 blade to remo&e bul+ of (a$ left bet(een groo&es 'ea&e 1mm (ide collar of (a$ at the gingi&al margin to ensure ade:uate bul+ !here should be no sharp angles in areas to be &eneered Pro$imal e$tensions mar+ed All angles co&ered by porcelain are rounded, contours

smoothened All aspects of porcelain)metal @unction line are sharply defined Prepare pattern for in&esting Brientation groo&e car&ed along linguo)gingi&al porcelain)metal @unction line Porcelain)metal @unction line accentuated (ith Discoid car&er

195 Da$ pattern for a ma$illary posterior

Conclusion !he end point of fi$ed prosthesis design is an esthetic & functional pontic that is compatible (ith the soft tissues %t is clear that the

choice & fabrication of the pontic demands as much care as any other of restorati&e planning & e$ecution 9$isting designs appear to ta+e into account e&ery concei&able situation Presently a&ailable materials seem ade:uate to meet re:uirements !he role of bacterial pla:ue

control in the maintenance of all pontic materials & designs must be recogniAed, patient highly moti&ated as to his responsibility

R&.&R&+C&S Shillingburg ,T/ ,obo S/ 0hitsett 'D/ 1acobe R/ and Brac2ett S&: Fundamentals of fi$ed prosthodontics, ed /, 1hicago, 2--1,

Iuintessence, %nc Roberts D,: Fi$ed bridge prosthesis, ed 1, *ristol, 19,/, Kohn Dright & 0ons Rosenstiel S./ 'and M. and .u3imoto 1: 1ontemporary fi$ed prosthodontics, 2--1, ed /, > Delhi, Carcourt