- Email: [email protected]
Management of the marginal dentition
Management of the marginal dentition
Richard A. Smith, DDS, York, Pal
For the patient with a marginal dentition— that is, a dentition of a borderline prognosis because of dental disease or previous tooth loss— a decision must be made as to which treatment method to use. Among the wide spectrum of treatment meth ods available are conventional fixed and removable partial dentures, modified types of removable par tial dentures, tooth-supported overdentures, and complete dentures. The unique requirements of the patient must be considered carefully when a treatment plan is formulated. Whatever treatment procedures are selected, an essential portion of therapy is that performed after insertion of the res toration. Continuing professional care is a lifetime necessity.
Many patients have already lost or must lose various numbers of teeth because of carious breakdown or periodontal disease. One treat ment method often used for such patients is the removal of all remaining teeth, and then the con struction of complete dentures after a period of ridge healing. More desirable alternatives are usually possible. Many conditions may affect the choice of a specific plan of treatment. The degree of patient interest, economic factors, the patient’s emo tional makeup as it affects his ability to cope with the stress of certain treatment procedures, oral hygiene maintenance level, and the presence of systemic disease all play a role. In a realistic ap proach to treatment of any patient, the removal of all remaining teeth may be an unavoidable necessity. However, in every feasible instance, some
teeth should be retained for support of a prosthodontic appliance, particularly in the mandibu lar arch. Even when the prognosis is poor, some teeth can be retained for years by a conservative approach. Although the patient may eventually lose all his teeth, his adaptation to and emotional acceptance of complete dentures may be better if he is brought to the edentulous state gradu- ally.
Alternate treatment methods Some of the workable possibilities for treatment of a dentition after tooth removal are fixed par tial dentures, conventional removable partial dentures, rigid-splinting removable appliances, swing-lock type of removable partial dentures, tooth-supported complete overdentures, and im mediate complete dentures. If enough sound teeth are present, if the pa tient is healthy and cooperative, if he is able to maintain an acceptable level of oral hygiene, and if he can cope adequately with the stress of treat ment procedures, fixed appliances are prefer able. This type of restoration is generally the most comfortable and functional. With proper care by the patient, many years of service may result. Continuing attention to plaque control must be emphasized to minimize the chances of recurrent caries or periodontal involvement. If construction of a fixed prosthesis is not feas ible because of too many missing teeth, the re movable partial denture may be considered. This type of restoration is one of the most versatile in dentistry. An infinite number of designs and conJADA, Vol. 89, September 1974 ■ 649
figurations may be used in the replacem ent o f various patterns o f m issing teeth. O ne o f the m odifications o f the conventional rem ovable partial denture is the rigid removable splint (Fig 1). In som e instances after extensive o sseo u s and soft tissu e surgery for definitive per iodontal treatm ent, teeth with long clinical crow ns and different degrees o f mobility may re main. With proper planning and preparation of a dental arch, it m ay be possible to make a rigid appliance that splints all the remaining teeth when it is seated in position. Since the restora tion is rem ovable, the patient has ready access to proximal areas for plaque control with dental floss. A nother useful option is the sw ing-lock type o f restoration with a m ovable labial portion that locks against the natural teeth to give a splint ing effect. It is not a panacea, but it is helpful in many clinical situations. T he restoration should be designed to produce minimal impingement on the periodontal tissues. T he design should also place the labial metallic struts as far gingivally as possible for acceptable appearance (F ig 2). A n effective restoration for the patient nearly at the edentulous state is the tooth-supported overdenture (F ig 3). In appearance it is similar to a com plete denture. H ow ever, since it is con structed over prepared natural teeth, it could be considered a form o f rem ovable partial denture. T his restoration differs from a conventional com plete denture in that part o f its support is derived from natural teeth. T his added support can give increased stability and, in som e instanc-
F ig 1 ■ F r a m e f o r r ig id
F ig 2 ■ T o p , la b ia l s t r u t s o f s w in g - lo c k a p p lia n c e a re p la c e d as f a r g in g iv a lly a s p o s s ib le . B o tt o m , a c c e p ta b le a p p e a r a n c e u s u a lly c a n b e a c h ie v e d , a s w e ll a s e f fe c t iv e s t a b iliz a t io n o f r e m a in in g te e th .
r e m o v a b le s p lin t is t r ie d in a n d c a r e
f u ll y f it t e d b e fo r e a r t if ic ia l te e th a re a tta c h e d . T h is v a r ia tio n o f
F ig 3 ■ O v e rd e n tu re , s h o w n h e r e w ith a c a s t m e ta l b a s e , c a n
c o n v e n tio n a l r e m o v a b le p a r tia l d e n tu r e p r o v id e s f u ll a r c h s t a b il
p r o v id e y e a r s o f m o re e f fe c t iv e f u n c t io n t h a n c o n v e n tio n a l c o m
iz a tio n w h ile it is in p o s itio n .
p le te d e n tu r e .
650 ■ JADA, Vol. 89, September 1974
F ig 4 ■ S e c o n d p r e m o la r a n d c a n in e t h a t c o u ld n o t b e u s e d a s a s u p p o r t f o r c o n v e n tio n a l r e m o v a b le p a r t ia l d e n tu r e w e re t r e a t e d e n d o d o n t ic a lly a n d re d u c e d t o a m o r e fa v o r a b le c r o w n - r o o t r a tio f o r s u p p o r t o f o v e r d e n tu r e . N o tic e c o n t r a s t in r id g e r e s o r p t io n b e tw e e n a re a in w h ic h le ft c a n in e is r e m a in in g a n d t h a t in w h ic h r ig h t c a n in e w a s r e m o v e d .
e s, increased retention over that obtained with a conventional com plete denture supported only by the residual ridge. With use o f an overdenture, m any patients can be given years o f comfort and function that they might not have had with conventional com plete dentures. Teeth that cannot be used as abut ments for a rem ovable partial denture can be treated endodontically and prepared for sup port o f an overdenture (Fig 4). T he gross short ening o f the clinical crown, which is then possi ble, provides such a favorable crown-root ratio that years o f useful support may be provided by otherw ise unusable teeth. A lthough the teeth may ultim ately be lost, the clinician may u se ap propriate repair procedures to m odify the den ture to the contour o f the ridge after tooth extrac tion. L oiselle and a sso cia tes1 concluded that “ the reduction o f the crowns o f at least tw o mandib ular canine teeth and the use o f overlay dentures will help to conserve the residual mandibular al veolar ridge and the proprioceptive inputs to the neural cen ters.” Schw eitzer and a ssociates2 said, “ W here low er natural anterior teeth exist, the retention of even tw o or three upper incisors provides the bony support in the anterior part of the upper ridge with protection against traumatic vertical and horizontal pressures from the lower teeth .” T he presence of natural teeth beneath the denture helps to prevent alveolar ridge re sorption in the maxillary arch as well as in the mandibular arch. If the prognosis for the remaining teeth in an arch to be used as abutm ents for support o f an
appliance is hopeless, the dentist should con sider constructing a com plete denture o f som e type. I f a com plete denture must be made, I think that an im mediate denture is advantageous in m ost instances. T he patient is saved the embar rassm ent o f being without teeth for w eeks or months. T he remaining natural teeth serve as highly useful guides to shape, size, color, and arrangement of the artificial teeth. The vertical dim ension o f occlusion and the centric relation are much easier to determine and record when som e natural teeth remain as guides. T he func tion o f phonetics is enhanced by the relative ease o f favorable tooth placem ent and by the preven tion o f altered speech patterns that result from an extended period o f edentulousness. A favorable emotional response also may be brought about by this form of treatment. W hatever type o f com plete denture is planned and inserted, eventual tissue contour changes will make either rebasing or a new denture n eces sary. T he new denture is beneficial as an added service to the patient and also for greater con venience o f the dentist when repairs or rebasing are needed. A second denture facilitates the im portant phase o f continuing treatment for the patient. T he edentulous patient has as great a need for regular recall and continuing attention as the pa tient with natural teeth. T he patient must be ed ucated about this fact before he becom es eden tulous. Professional exam ination and treatment must not stop after the initial insertion and ad justm ent phase o f the restorations. Professional care should continue through the lifetim e o f the patient.
Conclusion M any workable approaches to treatment are available for management of a marginal denti tion. W hatever type o f restoration is u sed , an essential part o f therapy is that performed after insertion. O ngoing professional care is a lifetim e necessity.
D r. S m ith is d ir e c t o r o f p r o f e s s io n a l re s e a rc h a t D e n ts p ly In te r n a tio n a l, 5 0 0 W C o lle g e A v e , Y o r k , P a 17404. 1. L o is e lle ,
R .J., a n d
o th e r s . T h e
p h y s io lo g ic
b a s is f o r t h e
o v e r la y d e n tu r e . J P r o s th e t D e n t 2 8 :4 J u ly 1972. 2. S c h w e itz e r , J .M .; S c h w e itz e r , R .D .; a n d S c h w e itz e r , J. T h e t e le s c o p e d c o m p le te d e n tu r e : a re s e a r c h r e p o r t a t th e c lin ic a l le v e l. J P r o s th e t D e n t 2 6 :3 5 7 O c t 197 1.
Smith: MARGINAL DENTITION ■ 651
Richard A. Smith, DDS, York, Pal
For the patient with a marginal dentition— that is, a dentition of a borderline prognosis because of dental disease or previous tooth loss— a decision must be made as to which treatment method to use. Among the wide spectrum of treatment meth ods available are conventional fixed and removable partial dentures, modified types of removable par tial dentures, tooth-supported overdentures, and complete dentures. The unique requirements of the patient must be considered carefully when a treatment plan is formulated. Whatever treatment procedures are selected, an essential portion of therapy is that performed after insertion of the res toration. Continuing professional care is a lifetime necessity.
Many patients have already lost or must lose various numbers of teeth because of carious breakdown or periodontal disease. One treat ment method often used for such patients is the removal of all remaining teeth, and then the con struction of complete dentures after a period of ridge healing. More desirable alternatives are usually possible. Many conditions may affect the choice of a specific plan of treatment. The degree of patient interest, economic factors, the patient’s emo tional makeup as it affects his ability to cope with the stress of certain treatment procedures, oral hygiene maintenance level, and the presence of systemic disease all play a role. In a realistic ap proach to treatment of any patient, the removal of all remaining teeth may be an unavoidable necessity. However, in every feasible instance, some
teeth should be retained for support of a prosthodontic appliance, particularly in the mandibu lar arch. Even when the prognosis is poor, some teeth can be retained for years by a conservative approach. Although the patient may eventually lose all his teeth, his adaptation to and emotional acceptance of complete dentures may be better if he is brought to the edentulous state gradu- ally.
Alternate treatment methods Some of the workable possibilities for treatment of a dentition after tooth removal are fixed par tial dentures, conventional removable partial dentures, rigid-splinting removable appliances, swing-lock type of removable partial dentures, tooth-supported complete overdentures, and im mediate complete dentures. If enough sound teeth are present, if the pa tient is healthy and cooperative, if he is able to maintain an acceptable level of oral hygiene, and if he can cope adequately with the stress of treat ment procedures, fixed appliances are prefer able. This type of restoration is generally the most comfortable and functional. With proper care by the patient, many years of service may result. Continuing attention to plaque control must be emphasized to minimize the chances of recurrent caries or periodontal involvement. If construction of a fixed prosthesis is not feas ible because of too many missing teeth, the re movable partial denture may be considered. This type of restoration is one of the most versatile in dentistry. An infinite number of designs and conJADA, Vol. 89, September 1974 ■ 649
figurations may be used in the replacem ent o f various patterns o f m issing teeth. O ne o f the m odifications o f the conventional rem ovable partial denture is the rigid removable splint (Fig 1). In som e instances after extensive o sseo u s and soft tissu e surgery for definitive per iodontal treatm ent, teeth with long clinical crow ns and different degrees o f mobility may re main. With proper planning and preparation of a dental arch, it m ay be possible to make a rigid appliance that splints all the remaining teeth when it is seated in position. Since the restora tion is rem ovable, the patient has ready access to proximal areas for plaque control with dental floss. A nother useful option is the sw ing-lock type o f restoration with a m ovable labial portion that locks against the natural teeth to give a splint ing effect. It is not a panacea, but it is helpful in many clinical situations. T he restoration should be designed to produce minimal impingement on the periodontal tissues. T he design should also place the labial metallic struts as far gingivally as possible for acceptable appearance (F ig 2). A n effective restoration for the patient nearly at the edentulous state is the tooth-supported overdenture (F ig 3). In appearance it is similar to a com plete denture. H ow ever, since it is con structed over prepared natural teeth, it could be considered a form o f rem ovable partial denture. T his restoration differs from a conventional com plete denture in that part o f its support is derived from natural teeth. T his added support can give increased stability and, in som e instanc-
F ig 1 ■ F r a m e f o r r ig id
F ig 2 ■ T o p , la b ia l s t r u t s o f s w in g - lo c k a p p lia n c e a re p la c e d as f a r g in g iv a lly a s p o s s ib le . B o tt o m , a c c e p ta b le a p p e a r a n c e u s u a lly c a n b e a c h ie v e d , a s w e ll a s e f fe c t iv e s t a b iliz a t io n o f r e m a in in g te e th .
r e m o v a b le s p lin t is t r ie d in a n d c a r e
f u ll y f it t e d b e fo r e a r t if ic ia l te e th a re a tta c h e d . T h is v a r ia tio n o f
F ig 3 ■ O v e rd e n tu re , s h o w n h e r e w ith a c a s t m e ta l b a s e , c a n
c o n v e n tio n a l r e m o v a b le p a r tia l d e n tu r e p r o v id e s f u ll a r c h s t a b il
p r o v id e y e a r s o f m o re e f fe c t iv e f u n c t io n t h a n c o n v e n tio n a l c o m
iz a tio n w h ile it is in p o s itio n .
p le te d e n tu r e .
650 ■ JADA, Vol. 89, September 1974
F ig 4 ■ S e c o n d p r e m o la r a n d c a n in e t h a t c o u ld n o t b e u s e d a s a s u p p o r t f o r c o n v e n tio n a l r e m o v a b le p a r t ia l d e n tu r e w e re t r e a t e d e n d o d o n t ic a lly a n d re d u c e d t o a m o r e fa v o r a b le c r o w n - r o o t r a tio f o r s u p p o r t o f o v e r d e n tu r e . N o tic e c o n t r a s t in r id g e r e s o r p t io n b e tw e e n a re a in w h ic h le ft c a n in e is r e m a in in g a n d t h a t in w h ic h r ig h t c a n in e w a s r e m o v e d .
e s, increased retention over that obtained with a conventional com plete denture supported only by the residual ridge. With use o f an overdenture, m any patients can be given years o f comfort and function that they might not have had with conventional com plete dentures. Teeth that cannot be used as abut ments for a rem ovable partial denture can be treated endodontically and prepared for sup port o f an overdenture (Fig 4). T he gross short ening o f the clinical crown, which is then possi ble, provides such a favorable crown-root ratio that years o f useful support may be provided by otherw ise unusable teeth. A lthough the teeth may ultim ately be lost, the clinician may u se ap propriate repair procedures to m odify the den ture to the contour o f the ridge after tooth extrac tion. L oiselle and a sso cia tes1 concluded that “ the reduction o f the crowns o f at least tw o mandib ular canine teeth and the use o f overlay dentures will help to conserve the residual mandibular al veolar ridge and the proprioceptive inputs to the neural cen ters.” Schw eitzer and a ssociates2 said, “ W here low er natural anterior teeth exist, the retention of even tw o or three upper incisors provides the bony support in the anterior part of the upper ridge with protection against traumatic vertical and horizontal pressures from the lower teeth .” T he presence of natural teeth beneath the denture helps to prevent alveolar ridge re sorption in the maxillary arch as well as in the mandibular arch. If the prognosis for the remaining teeth in an arch to be used as abutm ents for support o f an
appliance is hopeless, the dentist should con sider constructing a com plete denture o f som e type. I f a com plete denture must be made, I think that an im mediate denture is advantageous in m ost instances. T he patient is saved the embar rassm ent o f being without teeth for w eeks or months. T he remaining natural teeth serve as highly useful guides to shape, size, color, and arrangement of the artificial teeth. The vertical dim ension o f occlusion and the centric relation are much easier to determine and record when som e natural teeth remain as guides. T he func tion o f phonetics is enhanced by the relative ease o f favorable tooth placem ent and by the preven tion o f altered speech patterns that result from an extended period o f edentulousness. A favorable emotional response also may be brought about by this form of treatment. W hatever type o f com plete denture is planned and inserted, eventual tissue contour changes will make either rebasing or a new denture n eces sary. T he new denture is beneficial as an added service to the patient and also for greater con venience o f the dentist when repairs or rebasing are needed. A second denture facilitates the im portant phase o f continuing treatment for the patient. T he edentulous patient has as great a need for regular recall and continuing attention as the pa tient with natural teeth. T he patient must be ed ucated about this fact before he becom es eden tulous. Professional exam ination and treatment must not stop after the initial insertion and ad justm ent phase o f the restorations. Professional care should continue through the lifetim e o f the patient.
Conclusion M any workable approaches to treatment are available for management of a marginal denti tion. W hatever type o f restoration is u sed , an essential part o f therapy is that performed after insertion. O ngoing professional care is a lifetim e necessity.
D r. S m ith is d ir e c t o r o f p r o f e s s io n a l re s e a rc h a t D e n ts p ly In te r n a tio n a l, 5 0 0 W C o lle g e A v e , Y o r k , P a 17404. 1. L o is e lle ,
R .J., a n d
o th e r s . T h e
p h y s io lo g ic
b a s is f o r t h e
o v e r la y d e n tu r e . J P r o s th e t D e n t 2 8 :4 J u ly 1972. 2. S c h w e itz e r , J .M .; S c h w e itz e r , R .D .; a n d S c h w e itz e r , J. T h e t e le s c o p e d c o m p le te d e n tu r e : a re s e a r c h r e p o r t a t th e c lin ic a l le v e l. J P r o s th e t D e n t 2 6 :3 5 7 O c t 197 1.
Smith: MARGINAL DENTITION ■ 651