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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 8  |  Issue : 3  |  Page : 473-478  

Prosthetic rehabilitation of mandibular defects with fixed-removable partial denture prosthesis using precision attachment: A twin case report


Department of Prosthodontics and Crown and Bridge, KLE VK Institute of Dental Sciences, Belagavi, Karnataka, India

Date of Web Publication14-Sep-2017

Correspondence Address:
Vimal Kantilal Munot
Department of Prosthodontics and Crown and Bridge, KLE VK Institute of Dental Sciences, KLE University, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ccd.ccd_117_17

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   Abstract 

The restoration of normal function and esthetic appearance with a dental prosthesis is a major challenge in the rehabilitation of patients who have lost their teeth and surrounding bone because of surgery for oral cyst or tumor. Rehabilitation with fixed or removable prosthesis is even more challenging when the edentulous span is long and the ridge is defective. Anatomic deformities and unfavorable biomechanics encountered in the region of resection add to the misery. In such situation, a fixed-removable prosthesis allows favorable biomechanical stress distribution along with restoration of esthetics, phonetics, comfort, hygiene, and better postoperative care and maintenance. This article describes rehabilitation of two cases with mandibular defects with an attachment-retained fixed-removable hybrid prosthesis.

Keywords: Fixed dental prosthesis, fixed-removable partial denture, mandibular defects, precision attachment, removable partial denture


How to cite this article:
Munot VK, Nayakar RP, Patil R. Prosthetic rehabilitation of mandibular defects with fixed-removable partial denture prosthesis using precision attachment: A twin case report. Contemp Clin Dent 2017;8:473-8

How to cite this URL:
Munot VK, Nayakar RP, Patil R. Prosthetic rehabilitation of mandibular defects with fixed-removable partial denture prosthesis using precision attachment: A twin case report. Contemp Clin Dent [serial online] 2017 [cited 2020 Aug 3];8:473-8. Available from: http://www.contempclindent.org/text.asp?2017/8/3/473/214525




   Introduction Top


Prosthetic dentistry involves the restoration and maintenance of oral functions, comfort, appearance, and health of the patient by the replacement of missing teeth and contiguous tissues with artificial substitutes.[1] Prosthetic options for partially edentulous patients include removable partial denture (RPD), fixed dental prosthesis (FDP), and an implant-retained prosthesis.

However, FDP and implant-retained prosthesis are not always feasible, particularly in participants with excessive residual ridge resorption and jaw defects due to trauma and/or surgical ablation. In such situation, a dentist may resort to another option of fixed-RPD prosthesis, to restore the defective hard and soft tissues so as to achieve natural esthetics, phonetics, comfort, and better hygiene. This hybrid prosthesis fulfills the objectives of the rehabilitation such as support, stability, and retention characteristics similar to a fixed prosthesis and esthetics and hygiene maintenance of a removable prosthesis.[2],[3],[4],[5]

Any prosthesis designed or fabricated should be based on the prosthetic principles of support, stability, retention, and preservation of remaining structures.[1] From patient's perspective, retention is one of the important factors for its acceptability. These retentive options range from a simple bar and clip attachments to more sophisticated spark erosion overdentures.[6],[7] Spark erosion prosthesis is technique sensitive, bulky, and require expensive equipment.[6],[7] On the other hand, precision attachments provide better vertical support and stimulation to the underlying tissue through intermittent vertical massage.[8]

Treatment with a hybrid denture is an affordable choice to fulfill the patient's esthetic demands together with providing a good prognosis for the prosthesis and preservation of the remaining dentition. This article presents two case reports of prosthodontic rehabilitation of a patient with mandibular defects using an attachment-retained fixed-removable hybrid prosthesis.


   Case Reports Top


Case 1

A 29-year-old male patient reported to the Department of Prosthodontics and Crown and Bridge, with a chief complaint of unesthetic appearance and difficulty in chewing food. History revealed that patient had undergone surgery for oral tumor present on the lower right posterior region of the jaw 1 year back, which resulted in a large hard and soft tissue deformity [Figure 1]. On examination of the maxillary arch, all the teeth were intact with good periodontal conditions. Mandibular arch examination revealed missing lower right canine, premolars, and first molar. Mild recession on the distal side of the lower right lateral incisor was seen. The restorative space of this Kennedy Class 3 defect was >15 mm [Figure 2]. Radiographic examination revealed 20% bone loss with lower right lateral incisor but no clinical mobility. Considering the extent of the defect, the required prosthesis was planned not only to restore the missing teeth but also to restore the deficient part of the ridge as well.
Figure 1: Computed tomography with three-dimensional reconstruction showing hard tissue defect in the lower right posterior region

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Figure 2: Intraoral view showing mandibular long-span Kennedy Class 3 partially edentulous arch

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Treatment options suggested were removable cast partial denture, and an implant supported FDP. The patient was not willing for a removable prosthesis and also could not afford the cost and elective surgery associated with an implant-supported prosthesis. Entirely tooth-supported conventional FDP could not be used in this situation because of the unfavorable long-term prognosis.

Considering the clinical findings, a fixed-removable dental prosthesis using cement retention for the fixed metal fused to ceramic bar framework and ball retention for the RPD was planned for the rehabilitation of the long span Kennedy Class 3 partially edentulous space in the lower right posterior region of the jaw. The patient was explained about the treatment procedures, and informed consent was obtained.

Diagnostic impressions of the maxillary and mandibular arches were made using irreversible hydrocolloid (Tropicalgin, Zhermack, Italy). The casts were poured with model plaster (Kalabhai, Kaldent, India) and were articulated using facebow and centric bite record. On these casts, a diagnostic wax pattern was fabricated of the missing teeth. A putty index of this pattern was made using addition silicone putty material (Aquasil, Dentsply, Germany) to fabricate temporary restoration at a later stage.

The abutment teeth were prepared to receive porcelain fused to metal restoration with lower right central incisor, lateral incisor, and second molar and all metal restoration with the third molar. A two-stage putty-light body impression of the lower arch was made and poured in die stone (Pearlstone, Asian Chemicals, India). Temporary FDP was fabricated using the putty index and cemented using temporary cement (Temp-Bond, Kerr Corporation, Romulus).

Wax patterns were fabricated for all the prepared teeth and a wax custom bar running over edentulous deficit ridge was connected to these prepared wax patterns. Ball attachment patterns (Rhein 83, USA) were attached to the custom bar in the region of second premolar and first molar. Selection criteria for precision attachment were based on location and length of the edentulous span; function, retention required, and economical constraints of the patient.

Spruing, investing, casting, and finishing and polishing of this nickel–chromium (Ni-Cr) alloy framework were done. Framework try-in was done in patient's mouth to assess the fit and availability of interarch space. After satisfactory try-in, the ceramic (VITA Zahnfabrik, Germany) layering was done for all the retainers, except for lower right third molar. The bisque trial was done to evaluate the shade and fit of the fixed prosthesis [Figure 3].
Figure 3: Bisque trial of a fixed prosthesis

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The single-stage putty-light body addition silicone pick-up impression of the lower arch was made with retention caps secured over the ball attachment. The cast was poured using die stone. Temporary denture base and the wax occlusal rim were fabricated covering the edentulous area. The jaw relation was recorded followed by articulation and teeth arrangement was done to achieve unilateral balanced occlusion with disclusion of all nonworking side teeth on lateral excursion. Waxed denture try-in was done followed by acrylization with heat-polymerized acrylic resin (Trevalon HI, Dentsply, India). Laboratory remounting and finishing and polishing of the prosthesis were done [Figure 4]. Standard retention caps were inserted in the slot present on the intaglio surface of the RPD.
Figure 4: Fixed and removable prosthesis before cementation

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Cementation of a metal framework with auxiliary attachment was done using Type 1 Glass ionomer cement (GC Gold Label 1, Japan) and the removable denture was attached to this framework using the ball attachment [Figure 5]. Postinsertion, hygiene, and home care instructions were explained to the patient. Recall visits of 1- and 3-month follow-up of the prosthesis were found to be satisfactory in terms of function and esthetics.
Figure 5: Intraoral view showing the removable prosthesis retained by metal framework with precision attachment

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   Case 2 Top


A 24-year-old male patient was referred to the Department of Prosthodontics and Crown and Bridge, for prosthetic rehabilitation of defect in the right posterior region of the lower jaw. History revealed that patient had ameloblastoma in the lower right posterior region of the jaw and was operated for the same a year back, during which his lower right molars and premolars were removed along with excised tissue. This resulted in large soft and hard tissue defect in relation to the lower right posterior region.

Initially, immediate surgical obturator was fabricated to reduce infection and facilitate healing. Interim obturator later replaced surgical obturator. A regular relining with soft liner (Soft-Liner, GC corporation, Japan) was done every 2 weeks, up to 10 months, during which postoperative healing was found to be uneventful with no clinical sign of recurrence.

Reevaluation of the oral condition was done after complete healing of the defect. On examination of the maxillary arch, all the teeth were found to be intact with good periodontal health. Mandibular arch examination revealed missing lower right premolar and molars [[Figure 6] and [Figure 7]]. The lower right canine showed recession but no mobility. Radiographic examination revealed 30% bone loss with a canine [Figure 8]. Restorative space of this Kennedy Class 2 defect was found to be >15 mm.
Figure 6: Intraoral view showing missing right mandibular premolars and molars along with soft tissue defect

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Figure 7: Preoperative intraoral occlusal view of mandibular arch

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Figure 8: Preoperative orthopantomogram (OPG) of a patient

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The replacement of right lower posterior teeth, along with soft tissue deformity, also needs to be restored. Hence, considering the age and financial constraints of the patient, a fixed-removable prosthesis with precision attachment was planned. The patient was explained in detail about the treatment procedure, and informed consent was obtained.

Diagnostic impressions of the maxillary and mandibular arches were made using irreversible hydrocolloid (Tropicalgin, Zhermack, Italy) and were poured using dental stone (Kalabhai, Kaldent, India). Diagnostic jaw relation was recorded and casts were articulated using facebow and centric bite record. These articulated casts were assessed for interarch space, existing occlusion, and extension of the prosthesis.

Abutment tooth preparations were done with lower left and right central incisor, left lateral incisor, and canine to receive porcelain fused to metal restoration. A two-stage putty-light body addition silicon impression of the lower arch was made and poured in die stone (Pearlstone, Asian Chemicals, India).

Wax patterns were fabricated for all the prepared teeth and a wax custom bar running over the edentulous area was connected to these prepared wax patterns. Ball attachment patterns (Rhein 83, USA) were attached to the custom bar in the region of first premolar and first molar [Figure 9]. Length of cantilever was decided based on remaining teeth and type of support required for the prosthesis. Since the prosthesis was tooth-tissue supported and the teeth absent was very few and limited only to the fourth quadrant, cantilever was extended more than the anteroposterior spread of the abutment teeth.
Figure 9: Wax pattern showing retainers attached to custom bar with ball attachment

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The pattern was invested and cast with Ni-Cr alloy, which was followed by finishing and polishing of the framework. Intraoral framework try-in was done to assess the fit and available interarch space. Ceramic (VITA Zahnfabrik, Germany) layering was done with respect to all the retainers and the bisque trial was done to evaluate the shade and fit of the fixed prosthesis [Figure 10].
Figure 10: Bisque trial of a fixed prosthesis

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Undercut blockout of the framework was done and single-stage putty-light body addition silicone (Aquasil, Dentsply, Germany) pickup impression was made with retention caps placed over the stud attachments and the cast was poured with die stone. Temporary denture base and the wax occlusal rim were fabricated covering the edentulous area. The jaw relation was recorded followed by facebow transfer and articulation. Teeth arrangement was done to achieve unilateral balanced occlusion with disclusion of all nonworking side teeth on lateral excursion. Waxed denture try-in was done followed by acrylization using heat-polymerized acrylic resin (Trevalon HI, Dentsply, India). Finishing and polishing of the prosthesis were done. Standard retention caps were inserted in the slot present on the undersurface on the RPD.

Prosthesis framework with auxiliary attachment was cemented using type 1 glass ionomer cement (GC Gold Label 1, Japan) and the removable denture was retained over this framework using the ball attachment [Figure 11]. The patient was trained about insertion and removal of the prosthesis followed by home care instructions. 1-, 3-, and 6-month [Figure 12] follow-up was found to be satisfactory in terms of function and esthetics.
Figure 11: Intraoral view showing the removable prosthesis retained by metal framework with precision attachment

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Figure 12: Sixth-month follow-up of the patient

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   Discussion Top


RPD, Clasp-retained RPD, FDP, and an implant-retained prosthesis are the various options available for rehabilitation of missing teeth. Fixed-removable dental prosthesis was introduced by Dr. James Andrews where fixed bridge is made of porcelain fused to metal crowns and fused to premanufactured bar that is permanently cemented to the prepared abutment, while the removable portion is made of acrylic and is retained on to fixed bar.[6] It is used principally when the placement of the pontics of an FPD would compromise esthetic appearance and when the abutments are capable of supporting an FPD, but the residual ridge has undergone extensive alveolar bone and soft tissue loss.[4]

Cheatham et al.,[2] Mueninghoff et al.,[3] and Jain [5] have described techniques for oral rehabilitation of missing anterior teeth with ridge defect using Andrew's bar system. Jeyavalan et al.,[4] Shetty et al.,[9] Patel et al.,[10] and Wangoo et al.[11] have described techniques for oral rehabilitation of missing teeth with ridge defect using either prefabricated or custom-made attachment. The placing implant was a questionable procedure considering the available bone length and bone graft procedures required. Considering severity of the defect, FDP was not suitable, which could have resulted in overly long pontics compromising the esthetics and biomechanics of the prosthesis. Hence, considering the age and financial status, precision attachment-retained fixed-removable prosthesis was selected over clasp-retained RPD to rehabilitate Kennedy Class 2 and 3 hard and soft tissue defect with a crown height space of >15 mm.

Persic et al. in their study evaluated the effects of various treatment options taking into consideration esthetics, chewing, and oral health-related quality of life and concluded that treatment outcomes were better in the precision attachment-retained RPD than the clasp-retained RPD.[12]

A fixed-removable prosthesis is an efficient and cost-effective treatment option for long span partially edentulous ridge. There are various advantages to such prosthesis. It has retention and stabilizing qualities of a fixed prosthesis and flexibility in teeth arrangement, hygiene maintenance, and esthetics of removable prosthesis. Apart from this, it also splints the teeth and provides favorable biomechanics. In addition, precision attachment allows the prosthesis to be inserted and removed a number of times without losing retention. The laboratory procedures involved in fabricating this prosthesis is similar to conventional laboratory techniques.

However, the use of precision attachment RPD design should be carefully considered, and clasp-type RPDs should be used whenever practical because of their lower cost, ease of fabrication and maintenance, and the predictability of results. Repeated removal and placement of prosthesis result in wear of the retention clip, requiring periodic replacement of the clip. Daily oral hygiene maintenance and care of the prosthesis are required on the part of the patient. The long-term success of the prosthesis requires knowledge of important laboratory techniques, clinical skills, and proper execution of all the clinical and laboratory procedures.

In the proper clinical scenario, the fixed-removable bridge meets all the demands of function and esthetic appearance with the added benefit of facilitating careful postoperative evaluation of oral soft tissue.


   Conclusion Top


This article describes rationale and technique for fabricating fixed-removable prosthesis using a precision attachment for rehabilitation of edentulous arch with hard and soft tissue defect. Various clinical and laboratory procedures have been discussed along with its indications, advantages, and disadvantages.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Carr AB, Brown DT. McCracken's Removable Partial Prosthodontics. 12th ed.. Elsevier Mosby; 2011. p. 1.  Back to cited text no. 1
    
2.
Cheatham JL, Newland JR, Radentz WH, O'Brien R. The 'fixed' removable partial denture: Report of case. J Am Dent Assoc 1984;109:57-9.  Back to cited text no. 2
    
3.
Mueninghoff KA, Johnson MH. Fixed-removable partial denture. J Prosthet Dent 1982;48:547-50.  Back to cited text no. 3
    
4.
Jeyavalan MI, Narasimman M, Venkatakrishnan CJ, Philip JM. Management of long span partially edentulous maxilla with fixed removable denture prosthesis. Contemp Clin Dent 2012;3:314-6.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Jain AR. A prosthetic alternative treatment for severe anterior ridge defect using fixed removable partial denture Andrew's Bar system. World J Dent 2013;4:282-5.  Back to cited text no. 5
    
6.
Walid MS. Bone anchored Andrew's Bar system a prosthetic alternative. Cairo Dent J 1995;11:11-5.  Back to cited text no. 6
    
7.
Weber H, Frank G. Spark erosion procedure: A method for extensive combined fixed and removable prosthodontic care. J Prosthet Dent 1993;69:222-7.  Back to cited text no. 7
    
8.
Prabhakar BA, Meena A, Cecil W, Suresh N. Precision attachments; applications and limitations. J Evol Med Dent Sci 2012;1:1113-21.  Back to cited text no. 8
    
9.
Shetty PK, Shetty BY, Hegde M, Prabhu BM. Rehabilitation of long-span Kennedy class IV partially edentulous patient with a custom attachment-retained prosthesis. J Indian Prosthodont Soc 2016;16:83-6.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Patel H, Patel K, Thummer S, Patel RK. Use of precision attachment and cast partial denture for long-span partially edentulous mouth – A case report. Int J Appl Dent Sci 2014;1:22-5.  Back to cited text no. 10
    
11.
Wangoo A, Kumar S, Phull S, Gulati M. Prosthetic rehabilitation using extra coronal castable precision attachments. Ind J Dent Sci 2014;6:38-40.  Back to cited text no. 11
    
12.
Persic S, Kranjcic J, Pavicic DK, Mikic VL, Celebic A. Treatment outcomes based on patients' self-reported measures after receiving new clasp or precision attachment-retained removable partial dentures. J Prosthodont 2015;24:1-8.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]



 

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