CASO CLÍNICO

Clínica Estomatológica Provincial Docente 

Puente fijo de resina autopolimerizable a un año de uso sin fallas
Autopolymerizable resin fixed bridge after a year of use without failure

Armandry Pascual Pico Cid,  ¹  Clariuska Nieves Cervantes,  ²   Ruth Ramón Jiménez ²   y Eugenia González Heredia ⁴

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RESUMEN

Se describe el caso de un paciente a quien se le construyó un puente fijo de resina autopolimerizable en consulta de atención primaria, el cual estuvo constituido por 3 elementos: una corona completa de resina sobre el 21, el póntico 11 y una restauración por mesial del 12, a manera de retenedor intracoronal. Después de un año de uso sin fallas, este proceder demostró ser una alternativa para resolver, aunque de forma provisional, la necesidad de este tipo de tratamiento protésico en la comunidad.

Descriptores:DENTADURA PARCIAL FIJA,PRÓTESIS E IMPLANTES;ODONTOLOGÍA COMUNITARIA;ODONTOLOGÍA;RESINAS COMPUESTAS;ATENCIÓN PRIMARIA DE SALUD  

Límites:HUMANO MASCULINO,ADULTO;HUMANO

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ABSTRACT

The case of a patient is described, in whom an autopolymerizable resin fixed bridge was built in a primary care outpatient clinic, which consisted of three elements: a resin complete crown on 21, pontic 11 and a mesial restoration on 12 as a intracoronal retainer. After a year of use without failure this procedure demonstrated to be an alternative to solve, although temporarily, the necessity for this type of prosthetic treatment in our community.

Subject headings:DENTURE,PARTIAL,FIXED;PROSTHESES AND IMPLANTS;COMMUNITY DENTISTRY;DENTISTRY;COMPOSITE RESINS;PRIMARY HEALTH CARE

Limits: HUMAN MALE, ADULT; HUMAN

Recibido:  12 de marzo del 2008
Aprobado: 14 de abril del 2008

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     La elaboración de puentes fijos permanentes constituye un proceso largo y laborioso. El uso de provisionales durante ese proceso es una práctica rutinaria. El acelerado desarrollo de la odontología moderna ha  puesto en manos del personal de estomatología, materiales cada vez mejores, entre ellos los composites o resinas compuestas. Estos, con cada entrega, presentan menos módulo de contracción  y sus coeficientes de expansión térmica son cada vez más cercanos a los del propio tejido dentario. Su resistencia a la fractura y al envejecimiento ha mejorado, lo que unido a su agradable apariencia natural y a las amplias posibilidades que brinda la “era de la odontología adhesiva” convierten a estos materiales en los mejores para construir puentes fijos provisionales de confección directa y eliminar lo largo, aunque no lo laborioso, del proceso constructivo. ^{1- 4}

     Los puentes de confección directa deben ser considerados como recursos provisionales a corto plazo, aunque algunos autores han observado que estos son capaces de mantenerse en la boca durante períodos considerablemente más largos que lo que se puede esperar de algo estrictamente provisional, aunque el número de investigaciones publicadas sobre el tema son realmente escasas. ⁵

     Los puentes de confección directa se pueden reforzar con fibra de vidrio o alambre de ortodoncia, aunque puede continuarse con el método tradicional, es decir, tallando en mayor o menor grado los pilares. ^{5, 6} 

CASO CLÍNICO

     Se presenta el caso de un paciente de 41 años de edad, quien reiteradamente había acudido a consulta en busca de tratamiento protésico para la pérdida de la pieza dentaria 11 por destrucción cariosa irreparable. Al no existir disponibilidad cercana de turnos para prótesis y luego de una exhaustiva revisión bibliográfica sobre el tema, se decidió confeccionar un puente provisional de resina autopolimerizable en consulta de atención primaria. En la evolución posterior, el paciente refirió dolor localizado en la pieza 21, de corta duración, no espontáneo, que aparecía al consumir alimentos fríos, lo cual fue considerado como una reacción inflamatoria transitoria, causada por el trauma sufrido durante la preparación dental, de modo que se indicó una tableta de ibuprofeno (400 mg) cada 8 horas durante 3 días, así como evitar el consumo de alimentos muy calientes o fríos. Evoluciones posteriores cada 15 días, así como al primer y tercer meses, mostraron vitalidad pulpar positiva y desaparición de los síntomas referidos. A un año de uso, el puente se mantiene sin fallas (figura 1).

     Una ligera inflamación gingival crónica de tipo edematosa indica retención de placa en la pieza dentaria 21, debido a la pérdida del pulido de la restauración en cervical. La remoción de la placa subgingival, irrigación con clorhexidine al 0,12 % y retoque en el pulido, así como insistencia en la educación para la salud en cuanto al hábito del cepillado, resolvieron este pequeño problema periodontal (figura 2).El paciente se ha negado a recibir tratamiento definitivo.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Figura                                                1. Vista lingual del puente. Se observa la zona higiénica
                                                   correspondiente al póntico, necesaria para mantener la
                                                                                salud de la mucosa

                                                                           

Figura 2. Vista bucal del puente a un año de uso 

Comentarios

     Según el último análisis de la situación de salud realizado en Cuba, ⁷ el índice de desdentamiento en la población de 35-44 años es algo elevado, con un promedio de 8,9 dientes perdidos.  Aunque el estudio no consideró los dientes perdidos por sectores, es de suponer que el anterosuperior tenga una frecuencia media, pero importante. De ahí que la necesidad de tratamiento protésico parcial sea elevada. Considerando que estos tratamientos no tienen la necesaria celeridad que el paciente demanda, los autores de este artículo proponen como una alternativa la confección de puentes fijos de resina autopolimerizable, previo al análisis meticuloso de sus ventajas, limitaciones e indicaciones.

     En el caso descrito, los inconvenientes que pudieran aparecer por el uso de una resina autopolimerizable (carisma de Kulzer) en ausencia de una de polimerización por luz halógena, fueron superados al modificar la mezcla de base y catalizador, en dependencia de si se necesitaba una polimerización lenta o rápida. Las resinas tienen innumerables ventajas sobre el acrílico: son de apariencia parecida al diente, fáciles de manipular, resistentes al desgaste e inodoras, entre otras favorables peopiedades.

     Radigales ⁵ utilizó fibras de vidrio empapadas en composites o resinas  fotopolimerizables como únicos medios adhesivos, por lo que habla de puentes adheridos sin lesión de los pilares. El argumento es efectivo, pero el apoyarse en restauraciones antiguas, cercanas al póntico, permiten que puedan ser usadas también como elementos retentivos válidos, como en el caso presentado. Mientras llegan las mencionadas fibras de vidrio, la imaginación, el estudio y el incremento de la experiencia clínica a través de una casuística más numerosa, proporcionarán mejores y más duraderas soluciones en el territorio. 

REFERENCIAS BIBLIOGRÁFICOS

1.Flores Martínez AO.¿Malos materiales?Odontología.<http://www.odontologia-online.com/index.html>[consulta:6 noviembre 2007].

2. Vanini L,Mangani F,Klimovskaia O.Conservative restoration of anterior teeth.ACME 2005;12(3):37-41.

3.Goldstein RE.Odontología estética<http://www.laislalibros.com/libros/ODONTOLOGIA-ESTETICA-VOLII/LM612000001/978-84-9751-008-0>[consulta:12 mayo 2008].

4. Jordan RE.Composites en odontología estética.Técnicas y materiales.3 ed.Barcelona:Salvat,1997:7-8.

5. Antón Radigales M.Puentes de fibra de vidrio de confección directa:diez años después.RCOE 2001;6(2):197-208.

6. Van Wijlen P.A modified technique for direct, fibre-reinforced, resin-bonded bridges:clinical case reports.J Can Dent Assoc 2000;66:367-71.

MsC. Armandry Pascual Pico Cid.Clínica Estomatológica Provincial Docente.Moncada, Santiago de Cuba, Cuba

MsC. Armandry Pascual Pico Cid

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¹  Especialista de I Grado en Estomatología General Integral.  Máster en Urgencia Estomatológica
   Clínica Estomatológica Provincial Docente,Santiago de Cuba, Cuba
²  Especialista de I Grado en Estomatología General Integral.  Máster  en Salud Bucal Comunitaria
   Clínica Estomatológica Provincial Docente, Santiago de Cuba, Cuba
³  Especialista de I Grado en Estomatología General Integral.  Máster en salud Bucal Comunitaria
   Clínica Estomatológica “José Luis Tassende”, Santiago de Cuba, Cuba
⁴  Especialista de II Grado en Organización y Administración de Salud Pública y en Estomatología General Integral. Máster en Atención Primaria en Salud y en Salud Bucal Comunitaria. Profesora Auxiliar
   Facultad de Estomatología, Santiago de Cuba, Cuba

CÓMO CITAR ESTE ARTÍCULO

Pico Cid AP,  Nieves Cervantes C,  Ramón Jiménez R,  González Heredia E. Puente fijo de resina autopolimerizable a un año de uso sin fallas [artículo en línea] MEDISAN 2009;13(2). <http://bvs.sld.cu/revistas/san/vol13_2_09/san14209.htm>[consulta: fecha de acceso].