Combinations of fixed and removable partial dentures

REMOVABLE

COMBINATIONS

PARTIAL

DENTURES

OF FIXED AND REMOVABLE

PARTIAL

DENTURES

ERNESTA. JOHNSON,JR.,D.D.S. Bismarck,

N. D.

IN THE GENERAL PRACTICE of dentistry must decide what type of dental service they will provide for their patients. The one big stumbling block to providing the best possible dentistry is the lack of patient education concerning the various phases of operative dentistry, such as gold foil and multiple inlays, as well as general oral rehabilitation by means of both fixed and removable partial dentures. The cost of either fixed or removable prosthesis, or a combination of both, is a limiting factor. Here a choice of procedure is involved to provide the best dentistry for the individual requirements of the patient. Therefore, the matter seems to be one of motivation. How does the dentist guide the patient to an understanding of what the best dentistry will provide, within recognizable limitations? Probably the question most frequently asked of all dentists is : “Are my remaining teeth worth saving, and if so how much will it cost ?” This one question, besides bringing in the economic issue, also evidences on the patient’s part a search for advice. It is the degree to which the dentist discusses this question that the patient will be motivated to desire the best available service. The one item of the monthly budget on which the average family spends more than anything else is food. Surprisingly, many people forget that teeth are primarily used in mastication and not to just look attractive. If much of the dentition is missing, especially in the molar and bicuspid region, the dental arch eventually collapses and causes subsequent periodontal involvement. Therefore, how is one able to masticate properly with missing posterior teeth? Also, since food takes the largest part of the monthly budget, a person is not getting full value if the food he eats is not properly chewed and digested. Why is it that so many geriatric patients have chronic stomach and bowel disorders? Could it be due to the early insertion of dentures and subsequent changes in supporting tissues which leads to a continuing decrease of the masticatory function ? It is not up to the dentist to decide what type of dentistry should be done for the patient but rather to guide the patient with a clear explanation of the advantages and disadvantages of alternate treatment plans. Thus, the patient can arrive at a sound decision based on an adequate diagnosis by the dentist. Applegate’ states, “It

D

EKTISTS

1099

1100

JOHNSON

J, I’ros. ?rTov.-Tkx..

Ikn. lQh4

has always seemed to me that the approach to the problem frequently has been from the wrong direction. Instead of asking, ‘Is it worth the time and expense to replace just this one tooth or these few teeth to recover this minor amount of occlusion ?,’ the dentist should ask, ‘Can this patient afford to take the risk of serious damage to these other fine teeth and healthy supporting tissues by allowing this break in the dental arch to remain?’ “The partial denture must be considered not as a means only to the correction of certain impaired functions, but also the still more important means of preventing further oral disorganization. No one denies the value of improved mastication, of more complete insalivation or of better phonation . . . . However, even those important advantages have not been enough to arouse or interest the majority of laymen and a considerable number of dentists to the desirability of early replacement of lost teeth.” In the following treatments, full series of roentgenograms were made. Diagnostic casts were poured and mounted on an adjustable articulator and alternate treatment plans suggested to the patients with the appropriate fees presented for their consideration. TREATMENT

OF

PATIEKT

NO.

1

A man in his early fifties had extensive fixed restorations \vith caries around the margins of the anterior three-quarter crowns and Class 3 gold foil restorations (Fig. 1 j Iioentgenographic examination revealed excellent periodontal supporting structures with minimal bone loss. However, there was some extrusion of the maxillary molars due to the loss of the mandibular posterior teeth. This patient was reluntantly brought into the office by his wife and his first statement was, “Since I thought I’d have to wear dentures eventually, I didn’t realize anything else could be done to save my teeth.” The lower dental arch was rebuilt first to maintain the vertical dimension of occlusion. A lower removable partial denture was utilized to prevent further extrusion of the maxillary molars. A shell crown on an existing mandibular right cuspid was removed because of extensive caries at the gingival margin. This tooth was in extreme labial version and, since the patient had a high lower lip, a full cast crown was surveyed for clasp retention and inserted. The two lower left bicuspids were splinted together by means of a full cast crown on the second bicuspid and an acrylic resin veneer crown on the first bicuspid, and surveyed for retention of a clasp. A lower chrome-cobalt removable partial denture \vith a split Kennedy bar across the lingual surfaces of the lower anterior teeth was inserted. Full cast crowns were prepared and cemented on the four maxillary molars. Full coverage was employed throughout the upper jaw since recurrent caries were prevalent and margins on existing restorations or crowns had failed. The teeth from the maxillary left second bicuspid to the left central incisor were prepared for por&lain veneer crowns. Existing caries were removed and all concavities in the preparations were rebuilt to normal contour with a zinc oxide and eugenol base and cement and alloy mixture. Full gingival shoulders were used on all veneer preparations. Individual copper band impressions with modeling compound were made of each preparation and transfer copings were constructed with which to check

yLger u

Fig. Fig. Fig. health. Fig.

16”

COMBINATIONS

OF PARTIAL

DEKTCRES

1101

l.-The oral condition of the patient indicates the need for extensive dental procedures. 2.-Transfer copings are in place on the maxillary anterior teeth. X.--The anterior porcelain veneer restorations are c,ontoured to maintain gingival 4.-The

lower removable

partial

denture is in place in

the

mouth.

gingival fit and vertical alignment (Fig. 2). The right central and lateral incisors and cuspid were also prepared for porcelain veneer crowns and transfer copings were made from band impressions. A full mouth plaster impression was made of the maxillary teeth with the copings in place. Then, the three right individual crowns were completed and the porcelain metal frame work was finished and tried in the mouth. After cementing the fixed partial denture and the separate castings in place in the mouth, the same procedure was used for veneer crowns on the maxillary right bicuspids. Plaster interocclusal records were used, the jaw relations verified, and the work performed on an adjustable articulator (Figs. 3 and 4). TREAThlENT

OF PATIENT

NO.

2

A man 45 years of age and in good general health was brought to the office by his sister for whom satisfactory dental restorations had previously been completed. The patient was extremely reluctant to have dental procedures performed. As he explained, “All my experiences in a dental chair were extremely painful.” Six maxillary anterior teeth and a root tip of the right first bicuspid remained in the upper jaw. The lower dental arch contained teeth from second bicuspid to second bicuspid. A reduction of the vertical dimension of occlusion had created

J. Pros. Den. Nov.-Dec.. 1964

JOHNSON

Fig. 5.-An Fig. &-The

Fig. 7.-Maxillary

extreme vertical overlap exists between the opposing anterior maxillary tuberosity contacts the retromolar pad.

and mandibular splints are in place and the vertical has been increased approximately 2.5 mm.

teeth.

dimension

of occlusion

a deep vertical overlap of the opposing anterior teeth (Fig. 5). The maxillary tuberosities on both sides were in contact with the mandibular retromolar pads and had to be reduced surgically before any type of prosthesis could be completed (Fig. 6). However, the remaining teeth were in excellent condition and, after examination of roentgenograms and mounted diagnostic casts, it was decided that all existing teeth could be retained. The root tip was removed. The first problem was the correction of the vertical dimension of occlusion. Two acrylic resin splints were made and inserted with a new occlusal vertical dimension that approximated a 2.5 mm. increase over the existing occlusal vertical dimension. Since the patient had a pronounced tongue thrust habit, chrome-cobalt clasps were used, and a double crib clasp was placed on the lower bicuspids to obtain maximum retention of the splints. The splints were worn for approximately 2 months to determine if the new occlusal vertical dimension could be tolerated (Fig. 7). No discomfort was experienced after this time and treatment was continued. Full crowns were constructed for the four lower bicuspids. The crowns on the right and left sides were soldered together for splinting purposes, surveyed for

Fig. Fig.

8.-The R.-The

completed removable

restorations are in place partial denture is “arch

in the form”

mouth. in design.

clasps, and a removable partial denture with a chrome-cobalt metal framework was constructed to maintain the new occlusal vertical dimension. Then, the six maxillary anterior teeth were prepared for full shoulder porcelain veneer crowns. Copper band impressions were made, and transfer copings were constructed to verify the accuracy of gingival fit in the mouth and on the amalgam dies, and also to determine the vertical position in the arch. A complete arch maxillary plaster impression was made over the copings and the metal framework was constructed. The crowns for the three teeth on the right side and those for the three teeth on the left side were soldered together to function as three-tooth splints. The two central incisors were not connected on the mesial surfaces because of the rather wide diastema between them. It would have been necessary to overcontour the porcelain to close this space. This would have resulted in a possible strangulation of the interdental papilla and the production of unsatisfactory esthetics. The lingual surfaces of the cuspids and lateral incisors were recessed with a micro-drill to produce a modified recess which would receive a lingual rest from a completed removable partial denture. The original maxillary splint was usecl in obtaining plaster centric relation records. These were used in conjunction with a face-bow to remount the cast on the articulator and to establish the new vertical dimension of occlusion. The right and left three-tooth porcelain splints lvere then cemented in the mouth. Later, an impression of the complete maxillary arch \vas made, and a maxillary removable partial denture was constructed (Figs. 8 and 9 ) . TREATMENT

OF

PATIENT

NO.

3

The maxillary right lateral and central incisors were positioned lingually in relation to the lower anterior teeth and the left central and lateral incisors and first bicuspid were missing in the mouth of a woman 50 years of age. Complete mouth roentgenograms revealed excellent supporting bone with no apparent periodonal involvement. However, the mandibular incisors were extruding from the sockets due to a Class 3 type of occlusion. The lower molars were missing with evident destruction of the residual alveolar ridge (Fig. 10). The teeth of the lower arch were prepared and their restorations were finished first. Due to the short apicoincisal length of the second bicuspids on each side, full cast crowns were inserted

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JOHNSON

on the first and second bicuspids on each side and soldered together. The crowns were surveyed for clasp retention and a lower chrome-cobalt removable partial denture with double crib clasps was made. The remaining maxillary teeth, from the right lateral incisor to the left second

Fig. IO.-The maxillary dibular anterior teeth. Fig. Il.-The maxillary denture are in place.

Fig.

Fig. Fig.

12.-The

right anterior

preoperative

central fixed

oral

and partial

lateral

incisors

denture

conditions

are

locked

and the mandibular

of the maxillary

13.-The maxillary anterior teeth are prepared. 14.-Transfer copings are in place on the maxillary

preparations.

dental

lingual

to

removable

arch.

the

manpartial

COMBINATIONS

OF PARTIAL

DErU‘TI.RES

1105

bicuspid were prepared for full coverage restorations. Three-quarter or pin ledge retainers were not used because of Class 5 restorations existing in these teeth. 1t is necessary to protect patients with average oral hygiene conditions from caries recurring aroutld abutment margins. Therefore, the right lateral incisor was restored with a singl’e veneer crown while a fixed partial denture was constructed from the right central incisor to the left second bicuspid, using the cuspid as an intermediate almtment tooth. A complete maxillary hydrocolloid impression was made, and the gold framework was constructed and tried in the mouth to verify the gingival fit and centric relation. The fixed partial denture was contoured to an edge-to-edge relationship with the lower anterior teeth. The castings were finished, polished, and temporarily cemented in the mouth prior to final cementation (Fig. 11) . TREATMEiVT

OF PATIENT

NO. 4

The fourth patient was similar to the third except that a normal vertical and horizontal overlap relationship of the anterior teeth existed. A complex compound odontoma was seen lying adjacent to the root of the maxillary left central incisor on the roentgenograms. The root of the incisor was gradually being resorbed so that removal of both it and the odontoma was necessary. The maxillary right cuspid contained a large Class 3 carious lesion which involved the distal half of the tooth. ‘Both the mesial and the distal incisal angles were involved on the lateral incisor because of the fracture of large silicate restorations. The left lateral incisor was missing and had been supplied as a cantilever fixed partial denture from the left central incisor. The left cuspid had large mesial and distal Class 3 cavities and both left bicuspids were missing. However, the space had closed to the size of one tooth due to mesialward drifting of the molar (Fig. 12 1. The cuspid, first bicuspid, first and second molars on the right side, and the second bicuspid and second molar on the left side were missing from the mandibular dsental arch. Acrylic resin veneer crowns were used because the cost of porcelain crowns prevented their use. The lower dental arch was restored with a chrome-cobalt removable partial denture rather than fixed restorations. Full gold crowns that had been surveyed for clasping were constructed for the posterior teeth and the right lateral incisor was restored with an acrylic resin veneer

Fig. Fig.

X.-The l&--The

completed restorations are in place and the teeth lingual contours of the upper restoration.

are in centric

occlusion.

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J. Pros. Den. Xov:Dec., 1964

JOHNSON

crown. All crowns were constructed together from a master hydrocolloid impression. A lower chrome-cobalt removable partial denture was then constructed to occlude with the remaining teeth in the upper dental arch. After the restorative procedures for the lower arch were completed, the maxillary teeth were prepared (Fig. 13). Due to the extensive caries, it was necessary to use a cement and alloy mixture to recontour the teeth after the caries was removed. The right cuspid and lateral incisor were prepared with a labial shoulder for single veneer crowns. The left central incisor and cuspid were prepared for veneer crowns, and the left first molar was prepared for a full crown. Similar impression procedures as discussed previously were employed (Fig. 14). After the castings and fixed partial denture were finished, they were temporarily cemented in the mouth and worn for a 2 week period before final cementation (Figs. 15 and 16).

Methods of restoration for various mouth conditions have been presented. The merit of an explanation to patients of what can be done to rebuild the mouth has been discussed. Once patients have been motivated to appreciate the value of wellconstructed fixed and removable dentures based on a sound diagnosis, dentists will have a challenging service to perform. REFERENCE

1. .\pplegate, 0. C.: Essentials of Removable Partial 1959, W. B. Saunders Company, p. 107. 410 E. THAYER BISMARCK,

AVE. NORTH DAKOTA

Denture

Prosthesis,

ed. 2, Philadelphia,