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Pontics in Fixed Partial Dentures

Pontics in Fixed Partial Dentures

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Pontics in Fixed Partial Dentures

  1. 1. PONTICS IN FIXED PARTIAL DENTURE 1 PRESENTED BY DR KELLY NORTON 81
  2. 2. CONTENTS 2  INTRODUCTION  DEFINITION  PRETREATMENT ASSESSMENT  PONTIC SPACE  RESIDUAL RIDGE CONTOUR  SURGICAL MODIFICATION  GINGIVAL ARCHITECTURE PRESERVATION  CLASSIFICATION OF PONTICS  BIOLOGIC CONSIDERATIONS  MECHANICAL CONSIDERATIONS  ESTHETIC CONSIDERATIONS  CROSS REFERENCES  REFERENCES 81
  3. 3. •Esthetic appearance •Enabling adequate oral hygiene •Preventing tissue irritation 3 INTRODUCTION 81
  4. 4. ACCORDING TO :  GPT-8 An artificial tooth on a fixed dental prosthesis that replaces a missing natural tooth, restores its function, and usually fills the space previously occupied by the clinical crown.  TYLMAN the suspended member of a fixed partial denture which replaces the lost natural tooth, restores function and occupies the space of the missing tooth. 4 DEFINITION . The Glossary of Prosthodontic Terms. The Journal of Prosthetic Dentistry. 2005;94(1):10-92. Tylman SMalone W. Tylman's Theory and practice of fixed prosthodontics. 8th ed. 81
  5. 5. OPTIMAL PONTIC DESIGN 5 81
  6. 6. PRETREATMENT ASSESSMENT 6 I] PONTIC SPACE: One function of FPD is to prevent tilting or drifting of the adjacent teeth into the edentulous space. Drifting / tilting Reduced pontic space Difficulty in fabricating pontic 81
  7. 7. ESTHETIC ZONE • Orthodontic alignment • Abutment modification with complete coverage retainers NONESTHETIC ZONE • Overly small pontics are unacceptable •Trap food •Difficult to clean•Careful diagnostic waxing to determine most appropriate treatment 7 81
  8. 8. 2) RESIDUAL RIDGE CONTOUR 8 Features of Ideal Ridge Contour:  Smooth and regular surface of attached gingiva -Facilitate maintenance of plaque-free environment  Sufficient height and width -Mimic adjacent tooth contours- Appear to emerge from the ridge  Facially, free of frenal attachment 81
  9. 9. LOSS OF RESIDUAL RIDGE CONTOUR:  Unesthetic open gingival embrasures “BLACK TRIANGLES”  Food impaction  Percolation of saliva during speech 9 81
  10. 10. 10 SIEBERT’S CLASSIFICATION OF RESIDUAL RIDGE DEFORMITIES :  Class I defects  Faciolingual loss of tissue width with normal ridge height.  Class II defects  Loss of ridge height with normal ridge width.  Class III defects  a combination of loss in both dimensions. 81
  11. 11. 91% residual ridge deformities ↓ Anterior tooth loss ↓ Majority of patients with class II & class III defects ↓ Unsatisfied with esthetics ↓ Pre-prosthetic surgery Ridge augmentation 11 81
  12. 12. SURGICAL MODIFICATION 12  Ridge augmentation with hard tissue grafts is not indicated unless it is to receive an implant. Class I Defects:  Infrequent  Not esthetically challenging 81
  13. 13. THE ROLL TECHNIQUE FOR SOFT TISSUE RIDGE AUGMENTATION: 13 81
  14. 14. II] THE POUCH TECHNIQUE FOR SOFT TISSUE RIDGE AUGMENTATION: 14 81
  15. 15. CLASS II & CLASS III DEFECTS 15 I] INTERPOSITIONAL GRAFT:  Variation of pouch technique  Augmentation of ridge height & width 81
  16. 16. II] ONLAY GRAFT 16 81
  17. 17. 17 81
  18. 18. GINGIVALARCHITECTURE PRESERVATION 18  By conditioning the extraction site and providing a matrix for healing, the pre-extraction gingival architecture, or “socket,” can be preserved.  If bone levels are compromised :  Allograft materials  Hydroxyapatite  Tricalcium phosphate  Freeze dried bone Can be grafted into the sockets 81
  19. 19.  The tissue side of the pontic should be:  an ovate form - 2.5 mm apical to the facial free gingival margin  The pontic causes tissue blanching as it supports the papillae and facial/palatal gingiva.  The tissue side of the pontic must conform to within 1 mm of the interproximal and facial bone contour to act as a template for healing.  After approximately 1 month of healing, oral hygiene access is improved by recontouring the pontic to provide 1 to 1.5 mm of relief from the tissue. 19 81
  20. 20.  Orthodontic Extrusions  Avoids ridge augmentation and gain vertical ridge height  However, Additional time and expense of orthodontic treatment, as well as previous endodontic treatment is necessary 20 81
  21. 21. CLASSIFICATION 1. Depending on shape of surface contacting the ridge(Tylman)  Sanitary  Modified sanitary  Spheroidal  Saddle  Ridge lap  Modified ridgelap  Ovate 2.According To Rosenstiel Depending On Mucosal Contact  A. Mucosal contact Ridge Lap Modified Ridge Lap Ovate Conical  B. No Mucosal Contact Sanitary(hygenic) Modified Sanitary 3. Based on materials used •Metal and porcelain veneered •Metal and resin veneered •All metal pontic •All ceramic pontic 81 21
  22. 22. 4. METHOD OF FABRICATION: •Custom made pontic 81 22
  23. 23. Pontic selection depends primarily on esthetics and oral hygiene.  ANTERIOR REGION  POSTERIOR REGIONS 23 PONTIC SELECTION 81
  24. 24. ANTERIOR PONTIC DESIGN – a correctly placed anterior pontic should have 1. All surfaces should be convex, smooth and properly finished. 2. Contact with the labial mucosa should be minimal (pin point) and pressure free (lap facing). 3. The lingual contour should be in harmony with adjacent teeth or pontics. 24 Pontic- residual ridge relationship: A research report. Stein RS, J Prosthet Dent 1966; 16: 251 81
  25. 25. POSTERIOR PONTIC DESIGN – a correctly designed pontic should have 1. All surfaces should be convex, smooth and properly finished. 2. Contact with the buccal contiguous slopes should be minimal (pin point) and pressure free (modified ridge lap). 3. Occlusal table must be in functional harmony with the occlusion of all of the teeth 4. Buccal and lingual shunting mechanism should conform to those of the adjacent teeth. 5. The overall length of buccal surface should be equal to that of the adjacent abutments or pontics. 25 Pontic- residual ridge relationship: A research report. Stein RS, J Prosthet Dent 1966; 16: 251 81
  26. 26. PRE-FABRICATED PONTIC FACINGS These are commercially available porcelain pontics which can be altered by the dentist and reglazed if necessary. These include: a) Trupontic – A horizontal tubular slot in the center of the lingual surface of the facing. b) Interchangeable facings/flat back facing– Manufactured with vertical slot running down the flat lingual surface, this facing is retained with a lug which engages the retention slot.81 26
  27. 27. c) Sanitary facing –flat occlusal surface and a slot on the proximal surface to fit into the metal projections made in the FDP d) Pin facing – A flat lingual facing with two horizontal pins for retention. 81 27
  28. 28. e) Modified Pin Facing Facing is modified by adding porcelain to lingual gingival area of a pin facing f)Reverse pin facing – Porcelain denture teeth can be modified to be used as the bridge facing. Porcelain is added to the gingival end of the facing and multiple precision pin holes are drilled into the lingual surface 81 28
  29. 29. g. Harmony facing – This facing is supplied with an uncontoured porcelain gingival surface and usually two retentive pins on the flat lingual side. h. Porcelain fused to metal facing Facing consists of a metal core over which porcelain is fused. i. Pontips: Convex gingival surface having pinpoint tissue contact and attached to the backing occlusally with retentive pins. 81 29
  30. 30. SANITARY OR HYGIENIC PONTIC  Zero tissue contact  Occlusalgingival thickness should be atleast 3mm  Convex mesiodistally and faciolingually  Space beneath the pontic – 2mm ( Rosenstiel)  - 3 mm ( Tylman)  Adequate space for cleaning  Modified sanitary pontic:- gingival portion is shaped like a concave archway mesiodistally between the retainers and convex faciolingually.  Allows increased connector size while decreasing the stress concentrated in the pontic and connectors.  Recommended for mandibular posteriors FISH BELLY ARC-FIXED OR PEREL 81 30
  31. 31. A modified sanitary pontic 31 Perel M L : J Prosthet Dent 1972; 28: 587 81
  32. 32. SADDLE PONTIC OR RIDGE LAP PONTIC The saddle pontic has a concave fitting surface that overlaps the residual ridge buccolingually, simulating the contours and emergence profile of the missing tooth on both sides of the residual ridge. 81 32
  33. 33.  Saddle or ridge lap designs should be avoided  The concave gingival surface of the pontic is not accessible to cleaning with dental floss>>>>plaque accumulation>>>>> tissue inflammation. 33 81
  34. 34. The modified ridge lap pontic combines the best features of the hygienic and saddle pontic designs, combining esthetics with easy cleaning. 34 MODIFIED RIDGE LAP PONTIC • Overlaps the residual ridge on the facial (to achieve the appearance of a tooth emerging from the gingiva) • Remains clear of the ridge on the lingual side. 81
  35. 35. Tissue contact should resemble a letter T whose vertical arm ends at the crest of the ridge. The ridge contact should be upto the midline of the edentulous ridge.  Most common pontic form used in areas of high visibility---  maxillary and mandibular anterior teeth and maxillary premolars and first molars 35 81
  36. 36. CONICAL PONTIC • egg-shaped, bullet-shaped, or heart-shaped • Convex with only one point of contact at the center of the residual ridge. • recommended for the replacement of mandibular posterior teeth where esthetics is a lesser concern. 81 36
  37. 37. The facial and lingual contours are dependent on the width of the residual ridge;  a knife-edged residual ridge necessitates flatter contours with a narrow tissue contact area.  This type of design may be unsuitable for broad residual ridges, because the emergence profile associated with the small tissue contact point may create areas of food entrapment 37 81
  38. 38.  most esthetically appealing  Its convex tissue surface resides in a soft tissue depression or hollow in the residual ridge, which makes it appear that a tooth is literally emerging from the gingiva 38 OVATE PONTIC 81
  39. 39. Socket-preservation techniques should be performed at the time of extraction to create the tissue recess from which the ovate pontic form will emerge. For a preexisting residual ridge, soft tissue surgical augmentation is typically required. When an adequate volume of ridge tissue is established, a socket depression is sculpted into the ridge with surgical diamonds or electrosurgery. 39 81
  40. 40. 40 81
  41. 41. 41 Rosenstiel S F et al : Contemporary Fixed Prosthodontics, 4th edn 81
  42. 42. 42 Aesthetic replacement of an anterior tooth using the natural tooth as a pontic; an innovative technique Purra A Mushtaq M.. The Saudi Dental Journal. 2013;25(3):125-128. 81
  43. 43. The biologic principles of pontic design pertain to the maintenance and preservation of the residual ridge, abutment and opposing teeth, and supporting tissue. Factors of specific influence are, 43 BIOLOGIC CONSIDERATIONS 81
  44. 44.  Pressure free contact between the pontic and the underlying tissue is indicated to prevented ulceration and inflammation of the soft tissues.  When a pontic rests on mucosa, some ulcerations may appear as a result of the normal movement of the mucosa in contact with the pontic.  Positive ridge pressure (hyperpressure) may be caused by excessive scraping of the ridge area on the definitive cast 44 RIDGE CONTACT 81
  45. 45. Pontic- residual ridge relationship: A research report. Stein RS, J Prosthet Dent 1966; 16: 251 - To determine the frequency and the nature of tissue reaction of underlying the residual ridge mucosa to specific pontic designs and various materials used in pontic constructions. - Upon removal of pontics, inflammatory reactions of the underlying mucosa were found under 95 per cent of the pontics.  The ideal design was shown to be a “modified ridge lap” in the posterior region and a “lap facing” in the anterior region, with a pinpoint contact on the facial contiguous slope of the residual ridge.  The ideal design should include surface smoothness and a fine finish  A successful artificial tooth replacement was characterized by a healthy tissue response with the appearance of a lack of contact between the residual ridge and undersurface of the pontic. 45 81
  46. 46. Cavozos E : Tissue response to fixed partial denture pontics. J Prosthet Dent 1968; 20: 143 46 A study to demonstrate that the adaptations of pontic to the ridge or the amount of “relief” on the cast is highly significant and directly proportional to the amount of unfavourable tissue change. Absolute minimal (0.0 to 0.25mm of cast scraping) produced no tissue changes. When the cast scraping was increased to 1mm, tissue changes were produced varying from mild inflammation to acute ulceration81
  47. 47. Ridge irritation microbial plaque between the gingival surface of the pontic and the residual ridge tissue inflammation and calculus formation. 47 ORAL HYGIENE CONSIDERATIONS Normally, where tissue contact occurs, the gingival surface of a pontic is inaccessible to the bristles of a tooth brush. Therefore, excellent hygiene habits must be developed by the patient. 81
  48. 48. 48 Devices such as proxy brushes, pipe cleaners, Oral-B Super Floss, and dental floss with a threader are highly recommended Gingival embrasures around the pontic should be wide enough to permit oral hygiene aids. 81
  49. 49.  Should provide good esthetic results, biocompatibility, rigidity, and strength to withstand occlusal forces; and longevity.  Occlusal contacts should not fall on the junction between metal and porcelain during centric or eccentric tooth contacts, nor should a metal ceramic junction occur in contact with the residual ridge on the gingival surface of the pontic.  Investigations into the biocompatibility of materials used to fabricate pontics have centered on two factors : 1. The effect of the materials and 2. The effects of surface adherence. 49 PONTIC MATERIAL 81
  50. 50.  Well-polished gold is smoother, less prone to corrosion, and less retentive of plaque than an unpolished or porous casting.  For easier plaque removal and biocompatibility, the tissue surface of the pontic should be made in glazed porcelain  However, ceramic tissue contact may be contraindicated in edentulous areas where there is minimal distance between the residual ridge and the occlusal table. 50 81
  51. 51. HENRY P J ET AL: TISSUE CHANGES BENEATH FIXED PARTIAL DENTURES. J PROSTHET DENT 1966; 16: 937  placed 14 pontics on human gingival tissue.  gingival response to polished gold, Glazed porcelain or unglazed porcelain  there were general histologic changes in the tissue under all the materials tested.  noted that glazed porcelain was the most hygienic material used and it is superior in terms of esthetics and ease of cleaning. 51 81
  52. 52.  Reducing the buccolingual width of the pontic by as much as 30%  12% increase in chewing efficiency can be expected from a one third reduction of pontic width.  Narrowing the occlusal table may actually impede the development of a harmonious and stable occlusal relationship  Difficulties in plaque control and improper cheek support.  Pontics with normal occlusal widths (at least on the occlusal third) are generally recommended.  One exception is if the residual alveolar ridge has collapsed buccolingually. Reducing pontic width may then be desired, thereby lessening the lingual contour and facilitating plaque control measures. 52 OCCLUSAL FORCES 81
  53. 53. Mechanical problems may be caused by  improper choice of materials  poor frame work design  poor tooth preparation  poor occlusion.  Therefore, evaluating the likely forces on a pontic and designing accordingly are important. For example, a strong all metal pontic may be needed in high stress situations rather than a metal ceramic pontic which would be more susceptible to fracture. 53 MECHANICAL CONSIDERATIONS 81
  54. 54.  A well fabricated metal ceramic ponti is strong, easy to keep clean, and looks natural. 54 METAL CERAMIC PONTICS  The framework must provide a uniform veneer of porcelain (approximately 1.2 mm).  The metal surfaces to be veneered must be smooth and free of pits  Sharp angles on the veneering area should be rounded.  Occlusal centric contacts must be placed at least 1.5 mm away from the metal-porcelain junction 81
  55. 55.  Resistance to abrasion is lower than enamel or porcelain,  no chemical bond existed between the resin and the metal framework, 55 RESIN-VENEERED PONTICS • Continuous dimensional change of the veneers often caused leakage at the metal-resin interface, with subsequent discoloration of the restoration. • New-generation indirect resins- High flexural strength, minimal polymerization shrinkage, and wear rates comparable with those of tooth enamel 81
  56. 56.  Composite resins can be used in fixed partial dentures without a metal substructure.  A substructure matrix of impregnated glass or polymer fiber provides structural strength.  Excellent marginal adaptation and esthetics 56 FIBER-REINFORCED COMPOSITE RESIN PONTICS 81
  57. 57. SUMMARYSUMMARY 57 81
  58. 58.  No matter how well biologic and mechanical principles have been followed during fabrication, the patient will evaluate the result by how it looks, especially when anterior teeth have been replaced. 58 ESTHETIC CONSIDERATIONS 81
  59. 59.  An esthetically successful pontic will replicate the form, contours, incisal edge, gingival and incisal embrasures, and color of adjacent teeth.  The pontic’s simulation of a natural tooth is most often betrayed at the tissue pontic interface.  Special attention should be paid to the contour of the labial surface as it approaches the pontic-tissue junction to achieve a “natural” appearance. 59 THE GINGIVAL INTERFACE 81
  60. 60. This cannot be accomplished by merely duplicating the facial contour of the missing tooth. If the original tooth contour were followed, the pontic would look unnaturally long incisogingivally. 60 81
  61. 61. Special care must be taken when studying where shadows fall around natural teeth, particularly around the gingival margin. If a pontic is poorly adapted to the residual ridge, there will be an unnatural shadow in the cervical area >> spoils the illusion of a natural tooth. Recesses occurring at the gingival interface collect food debris, further betraying the illusion of a natural tooth. 61 81
  62. 62.  The modified ridge-lap pontic is recommended for most anterior situations; it compensates for lost buccolingual width in the residual ridge by overlapping what remains  However, When appearance is of utmost concern, the ovate pontic, used in conjunction with alveolar preservation or soft tissue ridge augmentation 62 81
  63. 63.  Ridge resorption will make a pontic look too long in the cervical region.  An abnormal labiolingual position or cervical contour, however, is not immediately obvious.  This fact can be used to produce a pontic of good appearance by recontouring the gingival half of the labial surface. 63 INCISOGINGIVAL LENGTH 81
  64. 64.  In areas where tooth loss is accompanied by excessive loss of alveolar bone, the pontic is shaped to simulate a normal crown and root with emphasis on the cementoenamel junction. The root can be stained to simulate exposed dentin 64 81
  65. 65. If augmentative measures are contraindicated or undesirable, small alveolar deficiencies and missing papillae can be reconstructed by restorative measures.  The exact shade of the gingiva has to be established with special gingival shade guides. The basal surface must demonstrate a convex shape similar to the ovate pontic designs for the dental floss to establish tight contact with all the surface areas. 65 GINGIVA-COLORED CERAMICS Daniel E , H Spiekermann: A review of esthetic pontic design options. Quintessence Int 2002;33:736-746 81
  66. 66.  Separately fabricated ceramic gingival masks can be used to make subsequent adjustments in permanently placed restorations.  This method is particularly suitable for patients with a local alveolar ridge defect that has not been corrected by augmentation of the soft tissue. 66 ALL-CERAMIC GINGIVAL MASKS Daniel E , H Spiekermann: A review of esthetic pontic design options. Quintessence Int 2002;33:736-746 81
  67. 67.  Frequently, the space available for a pontic will be greater or smaller than the width of the contra lateral tooth.  If possible, such a discrepancy should be corrected by orthodontic treatment.  If this is not possible, an acceptable appearance may be obtained by incorporating visual perception principles into the pontic design. 67 MESIODISTAL WIDTH 81
  68. 68.  The features of the contra lateral tooth should be duplicated as precisely as possible in the pontic, and the space discrepancy can be compensated by altering the shape of the proximal areas.  The retainers and the pontic can be proportioned to minimize the discrepancy. (This is another situations in which a diagnostic waxing procedure will help solve a challenging restorative problem). 68 81
  69. 69.  Space discrepancy presents less of a problem when posterior teeth are being replaced because their distal halves are not normally visible from the front.  Discrepancy here can be managed by duplicating the visible mesial half of the tooth and adjusting the size of the distal half. 69 81
  70. 70. CROSS REFERENCES 70 81
  71. 71. 71 J Prosthet Dent 2009;102:205-210 SIMULATED TISSUE USING UNIQUE PONTIC DESIGN Kim.T.H.Yet al, 81
  72. 72. 72 81
  73. 73. 73 PURPOSE: To evaluate the load-bearing capacities of fiber- reinforced composite (FRC) fixed dental prostheses (FDP) with pontics of various materials and thicknesses. MATERIALS: 72 FDPs with frameworks made of continuous unidirectional glass fibers (everStick C&B) were fabricated. Three different pontic materials were used: glass ceramics, polymer denture teeth, and composite resin. The FDPs were divided into 3 categories based on the occlusal thicknesses of the pontics (2.5 mm, 3.2 mm, and 4.0 mm). Fiber-reinforced Composite Fixed Dental Prostheses with Various PonticsThe Journal of Adhesive Dentistry2014Vol 16, No 2 81
  74. 74. 74 CONCLUSION: •By increasing the occlusal thickness of the pontic, the load- bearing capacity of the FRC FDPs may be increased. •The highest load-bearing capacity was obtained with 4.0 mm thickness in the ceramic pontic. •However, with thinner pontics, polymer denture teeth and composite pontics resulted in higher load-bearing values 81
  75. 75. 75 Enhancing Esthetics with a Fixed Prosthesis Utilizing an Innovative Pontic Design and Periodontal Plastic Surgery This article addresses how to reestablish or maintain papilla height and the facial gingival tissue between a single or multiple missing teeth adjacent to a natural tooth or an implant by using a pontic design termed the E-pontic Limitations: when there is an alveolar ridge defect with apico-coronal loss of tissue and/or a combination of buccolingual and apico-coronal loss of tissue At least 2 mm of soft tissue over the alveolar bone is necessary to create the site; 3–5 mm of soft tissue coverage is ideal. Journal of Esthetic and Restorative Dentistry, 2014 81
  76. 76. 76 81
  77. 77. 77 PREFABRICATED WAX PONTICS Advantages: * Without collar * Reduced occlusal depths * Reinforced approximal surfaces * Perfect scraping and modelling characteristics Primary use: Temporary Bridges Plastic to fabricate quick and economical temporary bridges. •Wear-resistant, vacuum- processed synthetic resin •Special lingual channel ensures pontic locks into the plastic 81
  78. 78.  The pontic design is said to determine the success or failure of a bridge.  Designs that allow easy plaque control are especially important to a pontic’s long term success.  Minimizing tissue contact by maximizing the convexity of the pontic’s gingival surface is essential.  Special consideration is also needed to create a design that combines easy maintenance with natural appearance and adequate mechanical strength. 78 CONCLUSION The dentist should not attempt to duplicate nature exactly, but should attempt to support it by supplying a prosthesis based on sound biomechanical principles.81
  79. 79. 1. Rosenstiel S F et al : Contemporary Fixed Prosthodontics, 4th edn Missouri, Mosby Inc, pg 513 2. Shillingburg H T et al : Fundamentals of fixed prosthodontics, ed 4, Chicago , Quintessence Publishing, pg 485 3. Tylman SMalone W. Tylman's Theory and practice of fixed prosthodontics. 8th ed. 4. The Glossary of Prosthodontic Terms. The Journal of Prosthetic Dentistry. 2005;94(1):10-92. 5. Cavozos E : Tissue response to fixed partial denture pontics. J Prosthet Dent 1968; 20: 143 6. Daniel Edelhoff, H Spiekermann: A review of esthetic pontic design options. Quintessence Int 2002;33:736-746 7. Henry P J et al: Tissue changes beneath fixed partial dentures. J Prosthet Dent 1966; 16: 937 79 REFERENCES 81
  80. 80. 7. Perel M L : A modified sanitary pontic. J Prosthet Dent 1972; 28: 587 8. Stein RS: Pontic- residual ridge relationship: A research report. J Prosthet Dent 1966; 16: 251 9. Korman R. Enhancing Esthetics with a Fixed Prosthesis Utilizing an Innovative Pontic Design and Periodontal Plastic Surgery. Journal of Esthetic and Restorative Dentistry. 2014;27(1):13-28. 10. Fiber-reinforced Composite Fixed Dental Prostheses with Various Pontics The Journal of Adhesive Dentistry2014Vol 16, No 2 11. Kim T, Cascione D, Knezevic A. Simulated tissue using a unique pontic design: A clinical report. The Journal of Prosthetic Dentistry. 2009;102(4):205-210. 12. Purra AMushtaq M. Aesthetic replacement of an anterior tooth using the natural tooth as a pontic; an innovative technique. The Saudi Dental Journal. 2013;25(3):125-128. 80 81
  81. 81. 81 THANK YOU 81

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