Hindawi Publishing Corporation

Scientifica
Volume 2016, Article ID 4127472, 7 pages
http://dx.doi.org/10.1155/2016/4127472

Research Article
Atraumatic Restoration of Vertical Food Impaction with
an Open Contact Using Flowable Composite Resin Aided by
Cerclage Wire under Tension

Quan-Li Li, Chris Ying Cao, Qiang-Jian Xu, Xiao-Hua Xu, and Jia-Li Yin
Department of Prosthodontics, College of Stomatology, Anhui Medical University, Hefei 230032, China

Correspondence should be addressed to Quan-Li Li; ql-li@126.com

Received 13 March 2016; Revised 9 June 2016; Accepted 3 July 2016

Academic Editor: Gary Lopaschuk

Copyright © 2016 Quan-Li Li et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

To date, treating vertical food impaction with open contact effectively, especially with an atraumatic therapy, remains a challenge.
In this study, we developed a simple, atraumatic, and economic therapeutic measure to treat vertical food impaction. The scientific
rationale of our therapeutic technique is to restore an intact and firm proximal contact with proper location and form relationships
to prevent forceful interproximal wedging of food, which in turn protects interdental papilla. We performed the procedure using
flowable composite resin or composite resin cement with the aid of a cerclage wire under tension to rebuild the contact area. The
reported method is especially useful for some challenging clinical cases, such as food impaction after crown and inlay on onlay
restoration, and some conventional treatment methods, such as contouring the marginal ridge and developmental grooves, are
ineffective.

1. Introduction of the possible causes of vertical food impaction. According

to the abovementioned reason, the treatment usually includes
Food impaction is the occlusal force wedging of food into the contour of the marginal ridge and developmental grooves,
interproximal periodontal tissue and is classified into vertical the contour of the facial and lingual surfaces by occlusal
and horizontal [1]. Horizontal food impaction is character- adjustment, or leveling of the occlusal height of the marginal
ized by lateral pressure from lips, cheeks, and tongue, forcing
ridge, as well as recarving of the obliterated fossa to a
food dregs and fibers into the enlarged interproximal gingival
shallow, saucer-shaped fossa and groove to facilitate food
embrasure for gingival recession caused by all kinds of
escape (creating food escape groove adjacent to marginal
periodontal disease. This situation is relatively more tolerable
compared with vertical food impaction because the food ridge) [2, 4]. Loss of proximal contact (open contact) is
dregs can be easily removed using a dental floss or a tooth the most common reason of vertical food impaction. The
pick in gingivoocclusal direction, giving a momentary relief. abovementioned types of vertical food impaction often finally
At present, horizontal impaction is usually remedied with result in open contact. The other possible reasons for loss
removable prosthetics including hard splint and soft artificial of proximal contact include occlusal force causing tooth
gingival [2]. By contrast, vertical food impaction often results migration, proximal caries, and improper restoration, such
in acute papilla gingivitis and gingival abscess, which is often as extraction of the maxillary third molar causes gradual
difficult to endure and usually requires a visit to the dentist shifting of adjacent tooth, thus creating open proximal
[3]. contact between maxillary first and second molars, adjacent
The cause of vertical food impaction is relatively complex. teeth oblique drift due to nonreplacement of a missing tooth,
The treatment for vertical food impaction often corresponds habits forcing teeth out of position, and periodontal disease.
to its reason, but the results are often nonperspectives. Food impaction associated with open contact causes more
Occlusal step deformity between marginal ridges of the probing depth and clinical attachment loss interproximally
adjacent teeth and plunger cusp caused by occlusal were some than that associated with uneven marginal ridge. Treatment
2 Scientifica

of vertical food impaction caused by open contact often relays

on the use of fixed prosthetics including inlay, onlay, crown, 0.3 mm
and splint according to the cause of food impaction [2, 4].
However, apart from injury to sound tooth tissue leading Double 0.2 mm twisting wire
to dentin hypersensitivity, all methods above occasionally fall
short, causing frustration to dentists and patients alike. To 0.25 mm
date, treating vertical food impaction effectively, especially
with an atraumatic therapy, remains a challenge. Thus, in this 0.2 mm
study, we developed a simple and atraumatic technique to
treat patients who suffer from vertical food impaction.

Figure 1: Selecting the stainless wire for tension around the contact
2. Materials and Methods area. 0.2, 0.25, or 0.3 mm stainless wire or double 0.2 mm twisting
wire can be chosen according to the mesiodistal distance of the
2.1. Patient Inclusion Criteria contact area. The double-twist 0.2 mm wire should be softened by
heat treatment to reduce the rigidity.
Inclusion Criteria. Adult patients, suffering from vertical
food impaction for the reason of open contact (defined by
unrestricted passage of unwaxed dental floss through the
interproximal area) were included in the study. All patients both ends of the wire encircled the contact area and crossed
had at least one open contact area between second premolar along the occlusal buccal-lingual embrasure (Figure 2(c)).
and first molar or between first molar and second molar of Two hemostatic forceps were clamped to both ends of the
posterior teeth. Patients who fulfilled the inclusion criteria wire to enforce buccal-lingual tensile stress (Figure 2(d)). A
and agreed to participate in the 6-month duration of the study large force was required for the tension to separate the teeth.
signed an informed consent. The position and form of the area encircled by the wire, which
The food impaction involved teeth between natural tooth represents the contact to be, were evaluated; if they were
and natural tooth, natural tooth and prosthesis, silica-based inappropriate, then the size of the wire was changed.
ceramic prosthesis and silica-based ceramic prosthesis, or
silica-based ceramic prosthesis and other material prostheses. 2.2.3. Acid-Etching of the Contact Area under Tension Stress
with the Cerclage Wire. H3 PO4 gel (20% or 37.5%) was
Exclusion Criteria. Cases of loose tooth or the food impaction applied around the contact area of the natural teeth contact
involved teeth between metal prosthesis and metal pros- or the natural tooth and artificial crown contact (Figure 3(a)).
thesis, metal prosthesis and aluminum/zirconium ceramic The tension band was then enforced with the cerclage wire by
prosthesis, and aluminum/zirconium ceramic prosthesis and squeezing the acid agent into the contact area for 20 s (Figures
aluminum/zirconium ceramic prosthesis were excluded. 3(b) and 3(c)). Finally, the acid agent was thoroughly rinsed
with water (Figure 3(d)).
2.2. Step-by-Step Procedure For contact between silica-based ceramic prostheses, we
used 10% HF gel to etch the contact area for 60 s.
2.2.1. Prelude
Eliminating Other Evident Causes of Food Impaction. Prior to 2.2.4. Applying Flowable Composite Resin or Composite Resin
the procedure, the evident causes of vertical food impaction Cement to Rebuild the Contact Area under Tension Stress
must be eliminated or relieved through grinding, such as with the Cerclage Wire. The primer and/or bond resin was
enlarging the buccal and lingual embrasure, creating a food applied to the etching surface following the manufacturer’s
escape groove adjacent to the marginal ridge, leveling the instruction (Figure 4(a)). The flowable composite resin
occlusal height of the marginal ridge, and plunger cusp. (Tetric N-Flow, Ivoclar Vivadent AG, Schaan, Liechten-
stein) or composite resin cement (ParaCore, COLTENE,
Evaluating the Contact Area. The contact area must be Coltène/Whaledent AG, Altstätten, Switzerland) was then
evaluated thoroughly based on its tightness, location, width, injected around the contact area (Figures 4(b) and 4(c)),
and height. enforcing the tension band with the cerclage wire as described
above for about 30 s to squeeze the paste of composite resin
2.2.2. Selecting the Stainless Wire for Tension around the into the contact area (Figure 4(d)). The tensile stress was then
Contact Area. We selected 0.2, 0.25, or 0.3 mm stainless wire, relieved, and redundancy was removed immediately with a
or double-twist 0.2 or 0.25 mm wire, which is often used in point probe (Figure 4(e)). The restoration was polymerised
orthodontic clinics, according to the mesiodistal distance of by light curing from all aspects: occlusal, buccal, and lingual
the contact area (Figure 1). The double-twist 0.2 or 0.25 mm surfaces (Figure 4(f)).
wire and the 0.3 mm wire were softened by heat treatment to
reduce their rigidity. 2.2.5. Occlusal Adjustment, Polish, and Finish of the Restora-
The selected wire passed through the gingival embrasure tion. Occlusal adjustment was conducted to remove all
from buccal surface to lingual surface (Figure 2(b)), and then occlusal interferences (Figure 5). Polish was initiated with
Scientifica 3

(a) (b)

(c) (d)

Figure 2: Selecting the stainless wire for tension around the contact area. (a) Evaluating the contact area. Unwaxed dental floss passed through
the interproximal area without resistance (open contact). (b) The selected wire passed through the gingival embrasure from buccal surface
to lingual surface. (c) Both ends of the wire encircled the contact area and crossed along the occlusal buccal-lingual embrasure. (d) Two
hemostatic forceps were clamped to both ends of the wire to enforce buccal-lingual tensile stress, which can separate the teeth appropriately.

(a) (b)

(c) (d)

Figure 3: Acid-etching of the contact area under tension stress with the cerclage wire. (a) Applying 20% or 37.5% H3 PO4 gel around the
contact area. ((b), (c)) The tension band was enforced with the cerclage wire by squeezing the acid agent into the contact area for 20 s. (d)
Rinsing the acid agent thoroughly with water.
4 Scientifica

(a) (b)

(c) (d)

(e) (f)

Figure 4: Applying flowable composite resin or composite resin cement to rebuild the contact area under tension stress with the cerclage
wire. (a) Applying the primer and bond resin to the etched surface. ((b), (c)) Injecting the flowable composite resin or composite resin cement
around the contact area. (d) Enforcing the tension band with the cerclage wire for about 30 s to squeeze the paste of composite resin into the
contact area. (e) Relieving the tensile stress and removing the redundancy immediately with a point probe. (f) Light curing from all aspects.

(a) (b)

Figure 5: Occlusal adjustment, polish, and finish of the restoration.

Scientifica 5

prepolish and high shine porcelain silicone points, and be selected by splint. A larger mesiodistal distance of the
definitive polish and high luster were accomplished with a contact area indicates a more difficult technique. In a patient
soft hair brush. The final restoration was ensured when the with habitual food impaction at the contact area between the
dental floss could not pass through the contact area. upper first molar and the second molar (without the third
molar), the result is questionable. The result may be due to the
2.3. Typical Case. A 65-year-old female complained of food loose maxillary bone and hence cannot endure the occlusal
impaction at the right mandible teeth for about 6 months. force leading to frequent movement of the second molar.
Oral examination showed that the right mandibular first Because the resin adhesive system has limited adhesive
molar was restored with porcelain-fused-to metal crown, and strength to metal or aluminum/zirconium ceramics, this
the right mandibular second premolar was restored with a procedure were not recommended for use in the situa-
distal-occlusal metal inlay. The gingival papilla between the tion that food impaction involved teeth between metal
second premolar and the first molar in the right mandible prosthesis and metal prosthesis, metal prosthesis and alu-
receded. Unwaxed dental floss was easily passed through the minum/zirconiumprosthesis, aluminum/zirconium ceramic
interproximal area between the two teeth showing an open prosthesis and aluminum/zirconium ceramic prosthesis.
contact area. The open contact area was etched with 10%
HF gel and reconstructed following the method as shown in 4.2.2. Key Step of the Technique. For the technique to be
Figures 6 and 7. successful, the tensile stress must be enforced through the
cerclage wire to separate the contact area and squeeze the
3. Results acid agent and paste of composite resin into the contact area.
Another tip is to completely remove the acid-etch agent from
Thirteen patients, aged 46 to 76 years, suffering from ver- the contact area, and adequate water rinsing is also required;
tical food impaction, were selected. Of them, sixteen open otherwise, the technique will be unsuccessful. Finally, before
contact areas between second premolar and first molar, or resin setting, the tension stress must be relieved; otherwise,
between first molar and second molar of posterior teeth, were if resin setting was conducted under tensile stress with the
treated following the protocol. After 6 months, patients were cerclage wire, the tooth will enforce a mesiodistal lateral force
examined using flosses. Two of the patients were unable to after resin setting, resulting in trauma to the periodontal
come back but reported that they did not experience food ligament and tooth migration and finally resulting in the
impaction after restoration through telephone. Except for two proximal contact being unstable.
cases, the others were satisfied with the treatment, and no A good proximal contact is important for a well function-
complication, such as gingivitis caused by restoration, was ing dentition. Some techniques to improve the quality of a
reported after the treatment. In one patient, food impaction proximal contact have developed for Class II direct composite
recurred about 2 months after the surgery. From checkup, it resin restoration, such as a sectional matrix system combined
we observed that the restoration was maintained. The surgery with a separation ring (Palodent) and a circumferential
was repeated; however, food impaction recurred more than 1 matrix system in combination with a retainer (Tofflemire):
month after the surgery. The food impaction occurred at the a precontoured sectional matrix system (Palodent matrix
contact area between the upper first molar and the second bands) combined with the separation ring, a precontoured
molar (without the third molar), and the second molar was circum-ferential matrix system (Hawe Contoured Tofflemire-
slightly loose. In another case, food impaction recurred 1 Bands) without separation rings, and contact Matrix system
week after the surgery. From checkup, we found that the (Danville Materials). Use of the sectional matrix system gets a
restoration was lost. The surgery was repeated and was a tighter proximal contacts than the use of the circumferential
success for more than 6 months. However, the longevity of matrix system [5, 6]. In our study, the abovementioned
success of this method needs more evidence-based research. technique cannot be used in our clinical cases because
mesiodistal distance of the contact area was very small. We
used the wire that acts as a matrix and separation device at
4. Discussion the same time. However, our aims were to squeeze the agents
4.1. Key Ideals of the Strategy. The technique aim is to restore into the contact area and construct the form of the contact
an intact and firm proximal contact with proper location and area. Thus, we emphasized that the tension stress must
form relationships to prevent forceful interproximal wedging be relieved before resin setting. A previous study reported
of food, which in turn protects interdental papilla, and is not that the proximal contacts of a posterior composite resin
to adhere the two teeth together like splint. We performed the restoration, which are stronger compared with those before
procedure using flowable composite resin or composite resin treatment, tend to diminish after a 6-month period, whereas
cement with the aid of a cerclage wire under tension to rebuild the proximal contacts, which are weaker compared with those
the contact area. before treatment, remain almost unchanged after a 6-month
period [5, 6]. Thus, we reject the proposal of restoring the
contact areas tighter than it used to be.
4.2. Tips to Achieve a Successful Technique
4.2.1. Case Selection. Loose tooth was the absolute con- 4.3. Advantage and Disadvantage of the Technique. The
traindication. In this situation, a prosthodontic crown should advantage of the technique is that it is very simple, atraumatic,
6 Scientifica

(a1) (a2) (a3)

(a)

(b1) (b2) (b3)

(b)

(c1) (c2) (c3)

(c)

(d1) (d2) (d3)

(d)

(e1) (e2) (e3)

(e)

(f1) (f2) (f3)

(f)

Figure 6: The steps of treatment for food impaction at the right mandible teeth in a typical case. (a) Evaluating the contact area by unwaxed
dental floss. (b) Selecting the stainless wire for tension around the contact area. (c) Using 10% HF gel to etch the open contact area. (d)
Applying the primer and bond resin to the etched surface. (e) Injecting the flowable composite resin or composite resin cement around the
contact area and light curing. (f) Occlusal adjustment, polish, and finish of the restoration.
Scientifica 7

(a) (b)

Figure 7: X-ray diagnosis of the interproximal contact area before (a) and after (b) the treatment.

and economic. The result is immediate, and the patient is 5. Conclusion

satisfied. Even if the procedure fails, it can be carried out
repeatedly without trauma to the sound tooth tissue. The proposed technique is a simple, atraumatic, and eco-
Usually, adjacent teeth, such as the adjacent teeth between nomic therapeutic measure that used flowable composite
natural tooth and natural tooth and silica-based ceramic resin or composite resin cement to restore vertical food
prosthesis and silica-based ceramic prosthesis, will become impaction with the aid of cerclage wire under tension stress.
connected with each other after performing this method. As an auxiliary measure for treating vertical food impaction,
After restoration, dental floss cannot be used at this situation. the technique is useful for challenging clinical cases.
Of course, interdental tooth brush can be the candidate for
the interdental hygiene care. However, we may modify this Competing Interests
technique by applying a small amount of petroleum jelly on
one side of a thin strip and passing it through the contact All authors declared that they have no financial conflict of
area. Therefore, one of the teeth will not be sensitive for the interests regarding this study.
adhesion procedure. This allows the use of dental floss and
reduces the possibility of the restoration fracture. References
On the other hand, for their low viscosity, flowable
composites or resin cements were selected for the restoration. [1] M. Khairnar, “Classification of food impaction-revisited and its
Both materials have a relatively low filler content making management,” Indian Journal of Dental Advancements, vol. 5,
them sensitive for wear and fracture. An adhesive connection pp. 1113–1119, 2013.
between teeth will produce stress when teeth are loaded and [2] M. Peng, Z. Zhu, and X. Yang, “Investigation and treatment of
lead to uncontrolled fracture. It was one of the main reasons food impaction,” Journal of Oral Science Research, vol. 21, pp.
of failure of the method and limited the longevity of success. 462–464, 2005.
In particular, the use of a resin cement is much concerned, [3] G. R. Jernberg, M. B. Bakdash, and K. M. Keenan, “Relationship
as this material is not designed for restorative procedures. between proximal tooth open contacts and periodontal disease,”
However, the resin cement used in our study belongs to Journal of Periodontology, vol. 54, no. 9, pp. 529–533, 1983.
cone building composite resin cement (see Section 2). It has [4] D. H. Newell, V. John, and S.-J. Kim, “A technique of occlusal
relatively high strength. In the future, we will use some new adjustment for food impaction in the presence of tight proximal
flowable composites to restore the contact zone. These new contacts,” Operative Dentistry, vol. 27, no. 1, pp. 95–100, 2002.
flowable composites have higher filler content which makes [5] B. A. C. Loomans, N. J. M. Opdam, F. J. M. Roeters, E.
them stronger and more wear resistant, such as Majesty Flow M. Bronkhorst, R. C. W. Burgersdijk, and C. E. Dörfer, “A
and Grandio Flow. Or we may modify the procedure by using randomized clinical trial on proximal contacts of posterior
composites,” Journal of Dentistry, vol. 34, no. 4, pp. 292–297,
the flowable composites as a surface lubricant but not curing
2006.
it directly; then, a normal high strength composite resin
[6] B. A. C. Loomans, N. J. M. Opdam, F. J. M. Roeters, E. M.
is injected directly afterwards. We expect this method may
Bronkhorst, and A. J. M. Plasschaert, “The long-term effect of
improve the strength of the adhesive composite restoration, a composite resin restoration on proximal contact tightness,”
therefore, to improve the longevity of success. Journal of Dentistry, vol. 35, no. 2, pp. 104–108, 2007.
Another issue is that the shape of the wire will leave
an impression in the composite and might promote food
retention. It can be improved by fine finishing and polishing
the restoration.
Certainly, this is only primary results, and the evaluation
period is rather short. We need a thorough study and
evaluation.