- Email: [email protected]
Use of a multifunctional precision attachment in a fixed partial denture with limited periodontal support. A clinical report
PROSTHESIS
FOR
CHRONIC
GAGGING
PATIENT
mastication and function, which may also reduce the patient’s ability to satisfy nutritional requirements. The dental implants placed in this situation will stabilize the maxillary prosthesis to an acceptable level. Only three implants could be used with the bone levels in the patient presented. The maxillary left incisor bone was too thin in the labial-palatal axis to allow for any type of implant design. One of the advantages of using the IMZ implant system is that it can minimize the stresses placed at the bone/metal interface with the use of the stress-absorbing intramobile elements. The bar system can be removed by simply unthreading the seating screws to allow for easy management and hygiene. The transmucosal implant extension permits a tight ada.ptation of the mucosal tissue to the polished TIE, which (contributes to the long-term success of the treatment. The ERA is a simple and effective retentive device because it has a variety of color-coded retention attachments. The synthetic attachments are easily and quickly removed and replaced when indicated. The attachments are durable, securely retaining the prosthesis for years before replacement is necessary. In some instances heavy calculus formation will change the surface of the nylon, thereby requiring replacement. Hence, denture maintenance is essential. ‘Because they are not rigid, they provide a comfort zone for the osteointegrated dental implant.
CONCLUSION Fabrication of a stable and retentive maxillary overdenture using dental j.mplants provides an excellent alternative to conventional prosthetic design, especially in the compromised patient. The IMZ dental implant system provides excellent retrievability and functional support and minimizes stresses on the bone with its stress-absorbing elements.
The design used with the ERA retention system including the new overdenture attachment permitted micromovement between the nylon attachment and metal receptacle portions. The appearance of the completed prosthesis was excellent because of the easy placement of the retainers. Patient acceptance was excellent, with no complaints regarding hygiene or loss of retention. The attachments also provided versatility to correct or improve retention, which may not be possible with other systems. REFERENCES 1. Cranin N. Oral implantology. Springfield, 111: Charles C Thomas, 1970:241-61. 2.. Mentag PJ, Kosinski TF, Sowinski LL. IMZ overdenture construction using the Stern ERA attachment. Gen Dent 1988$ept-O&399-2. 3. Kirsch A. The two-phase implantation method using IMZ intramobile cylinder implants. J Oral Implant. 1983;11:197-210. 4. Kirsch A, Mentag PJ. The IMZ endosseous two-phase implant system: a complete oral rehabilitation treatment and concept. J Oral Implant 1986;12:578-89. 5. Mentag PJ, Kosinski TF. Increased retention of a maxillary obturator prosthesis using osteointegrated intramobile cylinder dental implants: a clinical report. J P~UJSTHET DENT 1988;80:411-5. 6. Meroueth KA, Watanabi F, Mentag PJ. Finite element analysis of a partially edentulous mandible rehabilitated with osteointegrated cylindrical implant. J Oral Implant 1987;13:215-38. 7. Shifman A, Kusner W. A prosthesis fabrication technique for the edentulous maxillary resection patient. J PROSTHBT DENT 1986,56:586-92. 8. Mentag PJ, Kosinski TF. Increased retention of a maxillary obturator prosthesis using osteointegrated intramobile cylinder dental implants: a clinical report. J PROSTI-IW DENT 1988,60:411-415. 9. Lorenxana RE. Strength properties of soldered joints for a gold-palladium alloy and a palladium alloy. J PROS= DENT 1987;57:459-3. 10. Hickey JC, Zarb GA. Boucher’s prosthodontic treatment for edentulous patients. 9th ed. St Louis: CV Mosby, 1985:3-43. Reprint
requests
to:
DR. PAUL J. MENTAG 15901 W. NINE MILE RD., STE. 206 SOUTHFIELD, MI 48075
Use of a multifunctional precision attachment in a fixed partial denture with limited periodontal support. A clinical report Lambert J. Stumpel, Breda, The Netherlands
D.D.S.,*
I
and Ruud W. Sips**
t is often difficult to determine the minimal amount of periodontal support necessary for prosthetic treatment *Private practice. **Certified Dental Technician. 10/l/22134
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
of a particular patient. Occlusion, quality and position of existing abutment teeth, amount of remaining bone, and patient hygiene areonly afew of the many factors that must be evaluated in planning treatment for the periodontally compromisedpatient. For many years “Ante’s 1aw”l served as a reference for
335
STUMPEL
AND
SIPS
Fig. 1. Abutments for maxillary reciprocal splinting fixed partial denture. Fig. 2. Metallic substructure during try-in. Fig. 3. Finished reconstruction with spreadingscrewsinserted. Fig. 4. Lateral view, attachment is incorporated in first premolar pontic.
the minimal amount of periodontial support needed. In short, it stated that the amount of periodontal support of the abutment teeth had to equal the supporting tissue of the teeth to be replaced. Nyman et a1.2and Nyman and Lindhe3 proved that far less periodontal support was neededfor extensive fixed prostheses.They showedthat no abutments werelost becauseof periodontitis over a lo-year period. Failures that did occur were caused by loss of retention, fractures in the metal, and fracture of the abutment teeth. Guilbert et al4 describeda formula to compute the so-calledstrategic value of an individual abutment that considersthe remaining periodontal support and the position of the tooth. In the treatment described in this article, a maxillary fixed prosthesis was made on two canines and two hemisectedpalatal roots of first molar teeth. On the basisof the strategic value formula, the long-term prognosis for such a prosthesisis questionable.To anticipate future loss of the most vulnurable posterior abutments, a newly
336
designedprecision attachment (Combi-snap, C&M, BielBienne, Switzerland) wasincorporated in the construction. In the event of lossof one or both of the distal abutments, reconstruction of the posterior segmentby meansof either osseointegratedimplants or a removable partial denture is possible.This procedure will enhancethe serviceability of the total reconstruction.
TREATMENTPROCEDURE A 52-year-old woman with a combined prosthetic-periodontal problem wasseenasa patient. Multiple teeth were missingas a result of trauma and periodontal diseaseconsistingof adult periodontitis with bone loss,lossof attachment, and severefurcation involvement. The temporomandibular joint washealthy. Many posterior teeth had to be extracted or hemisected.After completion of the periodontal treatment, an evaluation was made of the prosthodontic possibilities. The mandibular quadrants did not imposerestorative problems.The maxillary quadrants, on
MARCH
1991
VOLUME
85
NUMBER
3
USE
OF MULTIFUNCTIONAL
PRECISION
ATTACHMENT
6. Close-upof receptaclewith horseshoemilling. Horseshoewill protect attachment against 1ateraI and axial forces. Fig. 6. Close-upof attachments. Note that spreadingscrewis not inserted. Fig. 7. Duplication of provisional restorations. Incisor interdental embrasureswere closedfor phonetic purpose.Interdental spacesof abutments are readily accessiblefor oral hygiene. Fig. 8. Frontal view at 6-month recall. Fig.
the other hand, were a prosthodontic challenge, because only two caninesand the palatal roots of the first molar teeth were present (Fig. 1). The data of a Pantronic pantograph (Denar Corp., Anaheim, Calif.) registration were transferred to a Denar D5A fully adjustable articulator, and diagnostic casts were mounted. In the initial diagnostic wax-up, an occlusal schemewas designedthat would direct most of the functional stress to the stronger canine abutments, and no working or nonworking balancing contacts were allowed in the posterior segments.Becausethe maxillary incisorshad been missing for over 30 years, modifications had to be made to recreate the original morphology and tooth position. This final diagnostic wax-up was duplicated in the provisional restorations. Initial tooth preparation was dictated by the final waxup. The two canines were made parallel to each other,
TEE
JOURNAL
OF PROSTHETIC
DENTISTRY
whereasthis wasnot mandatory for the molar abutments becausethey were paralleled to the alignment of the precision attachments. The supragingival molar abutment preparation conservedas much tooth structure aspossible to minimize weakening. During the 3-month trial period, minor modifications weremadeon the provisional restorations.The trial period allowed monitoring for function, esthetics, and plaque control. After successfulcompletion of this period, final modification of the preparations was made and polyvinyl siloxane impressions(Provil, Bayer Dental, Leverkusen, Germany) were obtained. Working castswere madeof improved dental stone (Fujirock, G.C.-Dental Inc. Corp., Tokyo, Japan), and mounted in the previously adjusted articulator. Impressionsof the provisional restoration were made, and the castswere mounted to serve asa guide for the construction of the definitive restoration. The sub-
337
structure was constructed with high-palladium alloy (Estheticor Biennor, C&M, Biel-Bienne, Switzerland) to a minimum 0.5 mm thickness with broad metal cervical collars mandatory for rigidity of the long-span prosthesis (Fig. 2). The “Combi-snap” is a prefabricated, multifunctional, intracoronal precision attachment. It can be incorporated in either a rigid fixed partial denture or, after interchanging the spreading screw, in a combined fixed and removable construction. In the treatment described, the attachments were placed in first premolar cantilevered pontics, facilitating correct placement of the attachments (Figs. 3 and 4). Emergence profile, canine guidance, and horseshoe milling would have been difficult to accomplish had the attachments been positioned in the canine retainers. The Combi-snap attach-, ments were positioned parallel to the distal aspect of the molar abutment preparation. The primary function of the attachment in this construction was to connect the posterior and anterior segments rigidly, thus creating reciprocal splinting. Adjustment of the spreading screw in the attachment separates two lamellas. The concavity on the outmost lamella engages its counterpart in the matrix. This interlocking creates the rigid connection (Figs. 5 and 6). If future loss of the distal abutments should necessitate making a fixed/removable construction, the spreading screw would be replaced by an occlusal lock screw, and by adjusting the two attachment lamelas, the retention of the removable partial denture could be determined. The existing anterior segment could continue to function with the new removable partial denture. After a 4-month trial period, the fixed partial denture was luted with hard cement. All parts of this prosthesis
Restoration onlays
of canine disocclusion
were cemented with a single mix of slow-setting cement. The anterior segment was placed first, followed immediately by the two posterior segments. The two spreading screws were placed while the cement was still soft. The entire prosthesis was then completely seated under vibration and pressure. The patient was placed on a 2-month periodontal/ grosthodontic recall program during the first year, and after 1 year was placed on a 3-month recall (Figs. 7 and 8).
SUMMARY A multifunctional precision attachment used in a fixed partial denture with questionable prognosis enhances the serviceability of the reconstruction. In the treatment presented, future loss of the posterior abutments will not jeopardize the complete rehabilitation. Osseointegrated implants used in conjunction with a fixed prosthesis or a removable partial denture can restore the missing segments. REFERENCES 1. Ante IH. The fundamental principles of abutments. Mich State Dent Sot Bui 1926;8:14-20. 2. Nyman S, Lindhe J, Lundgran D. The role of occlusion for the stability of fixed bridges in patients with reduced periodontal tissue support. J CIin Periodont 1975;2:53-66. 3. Nyman S, Lindhe J. Prosthetic rehabilitation of patients witb advanced periodontal disease. J Clin Periodont 1976;3:135-47. 4. Guilbert PN, Rozanes SD, Tscucianu JF. Periodontal and prosthodontic treatment for patients with advanced periodontal disease. Dent Clin North Am 193&32:331-56. Reprint
requests
DR. LAMBERT
to:
J. STUMPEZ
WILHFLMINASTMAT 4818 SH BREDA TI-IS NETHERLANDS
44 A
by using etched porcelain
Carl G. Glaser, D.M.D.,* and William W. Nagy, D.D.S.** U.S. Army
Dental
Activity,
Fort
Drum,
N.Y.
I
n our fast-moving competitive society bruxism seemsto be on the increase.Tension causedby employ-
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the viewsof the Departmentof the Army or the Department of Defense. *Chief Clinician, Dental Clinic No. 1. **Chief, Fixed Prosthodontics, Burke Dental Clinic, Fort Ord, Cahf.
10/1/16016
338
ment and other interpersonal situations may causesuch parafunctional habits asclenchingand grinding. Repeated parafunctional maneuversmay establisha self-perpetuating cycle of pain and musclespasm.lMalocclusion may also contribute to the perpetuation of craniomandibular disorders. In addition, psychopathologic disorders may occur, characterized by patient complaints that often cannot be substantiated by physical or radiographic findings. The following clinical report describesthe useof etched porcelain veneers in the treatment of a patient with a craniomandibular disorder.
MARCH
1991vors~rex66
NUMBER
9
FOR
CHRONIC
GAGGING
PATIENT
mastication and function, which may also reduce the patient’s ability to satisfy nutritional requirements. The dental implants placed in this situation will stabilize the maxillary prosthesis to an acceptable level. Only three implants could be used with the bone levels in the patient presented. The maxillary left incisor bone was too thin in the labial-palatal axis to allow for any type of implant design. One of the advantages of using the IMZ implant system is that it can minimize the stresses placed at the bone/metal interface with the use of the stress-absorbing intramobile elements. The bar system can be removed by simply unthreading the seating screws to allow for easy management and hygiene. The transmucosal implant extension permits a tight ada.ptation of the mucosal tissue to the polished TIE, which (contributes to the long-term success of the treatment. The ERA is a simple and effective retentive device because it has a variety of color-coded retention attachments. The synthetic attachments are easily and quickly removed and replaced when indicated. The attachments are durable, securely retaining the prosthesis for years before replacement is necessary. In some instances heavy calculus formation will change the surface of the nylon, thereby requiring replacement. Hence, denture maintenance is essential. ‘Because they are not rigid, they provide a comfort zone for the osteointegrated dental implant.
CONCLUSION Fabrication of a stable and retentive maxillary overdenture using dental j.mplants provides an excellent alternative to conventional prosthetic design, especially in the compromised patient. The IMZ dental implant system provides excellent retrievability and functional support and minimizes stresses on the bone with its stress-absorbing elements.
The design used with the ERA retention system including the new overdenture attachment permitted micromovement between the nylon attachment and metal receptacle portions. The appearance of the completed prosthesis was excellent because of the easy placement of the retainers. Patient acceptance was excellent, with no complaints regarding hygiene or loss of retention. The attachments also provided versatility to correct or improve retention, which may not be possible with other systems. REFERENCES 1. Cranin N. Oral implantology. Springfield, 111: Charles C Thomas, 1970:241-61. 2.. Mentag PJ, Kosinski TF, Sowinski LL. IMZ overdenture construction using the Stern ERA attachment. Gen Dent 1988$ept-O&399-2. 3. Kirsch A. The two-phase implantation method using IMZ intramobile cylinder implants. J Oral Implant. 1983;11:197-210. 4. Kirsch A, Mentag PJ. The IMZ endosseous two-phase implant system: a complete oral rehabilitation treatment and concept. J Oral Implant 1986;12:578-89. 5. Mentag PJ, Kosinski TF. Increased retention of a maxillary obturator prosthesis using osteointegrated intramobile cylinder dental implants: a clinical report. J P~UJSTHET DENT 1988;80:411-5. 6. Meroueth KA, Watanabi F, Mentag PJ. Finite element analysis of a partially edentulous mandible rehabilitated with osteointegrated cylindrical implant. J Oral Implant 1987;13:215-38. 7. Shifman A, Kusner W. A prosthesis fabrication technique for the edentulous maxillary resection patient. J PROSTHBT DENT 1986,56:586-92. 8. Mentag PJ, Kosinski TF. Increased retention of a maxillary obturator prosthesis using osteointegrated intramobile cylinder dental implants: a clinical report. J PROSTI-IW DENT 1988,60:411-415. 9. Lorenxana RE. Strength properties of soldered joints for a gold-palladium alloy and a palladium alloy. J PROS= DENT 1987;57:459-3. 10. Hickey JC, Zarb GA. Boucher’s prosthodontic treatment for edentulous patients. 9th ed. St Louis: CV Mosby, 1985:3-43. Reprint
requests
to:
DR. PAUL J. MENTAG 15901 W. NINE MILE RD., STE. 206 SOUTHFIELD, MI 48075
Use of a multifunctional precision attachment in a fixed partial denture with limited periodontal support. A clinical report Lambert J. Stumpel, Breda, The Netherlands
D.D.S.,*
I
and Ruud W. Sips**
t is often difficult to determine the minimal amount of periodontal support necessary for prosthetic treatment *Private practice. **Certified Dental Technician. 10/l/22134
THE
JOURNAL
OF PROSTHETIC
DENTISTRY
of a particular patient. Occlusion, quality and position of existing abutment teeth, amount of remaining bone, and patient hygiene areonly afew of the many factors that must be evaluated in planning treatment for the periodontally compromisedpatient. For many years “Ante’s 1aw”l served as a reference for
335
STUMPEL
AND
SIPS
Fig. 1. Abutments for maxillary reciprocal splinting fixed partial denture. Fig. 2. Metallic substructure during try-in. Fig. 3. Finished reconstruction with spreadingscrewsinserted. Fig. 4. Lateral view, attachment is incorporated in first premolar pontic.
the minimal amount of periodontial support needed. In short, it stated that the amount of periodontal support of the abutment teeth had to equal the supporting tissue of the teeth to be replaced. Nyman et a1.2and Nyman and Lindhe3 proved that far less periodontal support was neededfor extensive fixed prostheses.They showedthat no abutments werelost becauseof periodontitis over a lo-year period. Failures that did occur were caused by loss of retention, fractures in the metal, and fracture of the abutment teeth. Guilbert et al4 describeda formula to compute the so-calledstrategic value of an individual abutment that considersthe remaining periodontal support and the position of the tooth. In the treatment described in this article, a maxillary fixed prosthesis was made on two canines and two hemisectedpalatal roots of first molar teeth. On the basisof the strategic value formula, the long-term prognosis for such a prosthesisis questionable.To anticipate future loss of the most vulnurable posterior abutments, a newly
336
designedprecision attachment (Combi-snap, C&M, BielBienne, Switzerland) wasincorporated in the construction. In the event of lossof one or both of the distal abutments, reconstruction of the posterior segmentby meansof either osseointegratedimplants or a removable partial denture is possible.This procedure will enhancethe serviceability of the total reconstruction.
TREATMENTPROCEDURE A 52-year-old woman with a combined prosthetic-periodontal problem wasseenasa patient. Multiple teeth were missingas a result of trauma and periodontal diseaseconsistingof adult periodontitis with bone loss,lossof attachment, and severefurcation involvement. The temporomandibular joint washealthy. Many posterior teeth had to be extracted or hemisected.After completion of the periodontal treatment, an evaluation was made of the prosthodontic possibilities. The mandibular quadrants did not imposerestorative problems.The maxillary quadrants, on
MARCH
1991
VOLUME
85
NUMBER
3
USE
OF MULTIFUNCTIONAL
PRECISION
ATTACHMENT
6. Close-upof receptaclewith horseshoemilling. Horseshoewill protect attachment against 1ateraI and axial forces. Fig. 6. Close-upof attachments. Note that spreadingscrewis not inserted. Fig. 7. Duplication of provisional restorations. Incisor interdental embrasureswere closedfor phonetic purpose.Interdental spacesof abutments are readily accessiblefor oral hygiene. Fig. 8. Frontal view at 6-month recall. Fig.
the other hand, were a prosthodontic challenge, because only two caninesand the palatal roots of the first molar teeth were present (Fig. 1). The data of a Pantronic pantograph (Denar Corp., Anaheim, Calif.) registration were transferred to a Denar D5A fully adjustable articulator, and diagnostic casts were mounted. In the initial diagnostic wax-up, an occlusal schemewas designedthat would direct most of the functional stress to the stronger canine abutments, and no working or nonworking balancing contacts were allowed in the posterior segments.Becausethe maxillary incisorshad been missing for over 30 years, modifications had to be made to recreate the original morphology and tooth position. This final diagnostic wax-up was duplicated in the provisional restorations. Initial tooth preparation was dictated by the final waxup. The two canines were made parallel to each other,
TEE
JOURNAL
OF PROSTHETIC
DENTISTRY
whereasthis wasnot mandatory for the molar abutments becausethey were paralleled to the alignment of the precision attachments. The supragingival molar abutment preparation conservedas much tooth structure aspossible to minimize weakening. During the 3-month trial period, minor modifications weremadeon the provisional restorations.The trial period allowed monitoring for function, esthetics, and plaque control. After successfulcompletion of this period, final modification of the preparations was made and polyvinyl siloxane impressions(Provil, Bayer Dental, Leverkusen, Germany) were obtained. Working castswere madeof improved dental stone (Fujirock, G.C.-Dental Inc. Corp., Tokyo, Japan), and mounted in the previously adjusted articulator. Impressionsof the provisional restoration were made, and the castswere mounted to serve asa guide for the construction of the definitive restoration. The sub-
337
structure was constructed with high-palladium alloy (Estheticor Biennor, C&M, Biel-Bienne, Switzerland) to a minimum 0.5 mm thickness with broad metal cervical collars mandatory for rigidity of the long-span prosthesis (Fig. 2). The “Combi-snap” is a prefabricated, multifunctional, intracoronal precision attachment. It can be incorporated in either a rigid fixed partial denture or, after interchanging the spreading screw, in a combined fixed and removable construction. In the treatment described, the attachments were placed in first premolar cantilevered pontics, facilitating correct placement of the attachments (Figs. 3 and 4). Emergence profile, canine guidance, and horseshoe milling would have been difficult to accomplish had the attachments been positioned in the canine retainers. The Combi-snap attach-, ments were positioned parallel to the distal aspect of the molar abutment preparation. The primary function of the attachment in this construction was to connect the posterior and anterior segments rigidly, thus creating reciprocal splinting. Adjustment of the spreading screw in the attachment separates two lamellas. The concavity on the outmost lamella engages its counterpart in the matrix. This interlocking creates the rigid connection (Figs. 5 and 6). If future loss of the distal abutments should necessitate making a fixed/removable construction, the spreading screw would be replaced by an occlusal lock screw, and by adjusting the two attachment lamelas, the retention of the removable partial denture could be determined. The existing anterior segment could continue to function with the new removable partial denture. After a 4-month trial period, the fixed partial denture was luted with hard cement. All parts of this prosthesis
Restoration onlays
of canine disocclusion
were cemented with a single mix of slow-setting cement. The anterior segment was placed first, followed immediately by the two posterior segments. The two spreading screws were placed while the cement was still soft. The entire prosthesis was then completely seated under vibration and pressure. The patient was placed on a 2-month periodontal/ grosthodontic recall program during the first year, and after 1 year was placed on a 3-month recall (Figs. 7 and 8).
SUMMARY A multifunctional precision attachment used in a fixed partial denture with questionable prognosis enhances the serviceability of the reconstruction. In the treatment presented, future loss of the posterior abutments will not jeopardize the complete rehabilitation. Osseointegrated implants used in conjunction with a fixed prosthesis or a removable partial denture can restore the missing segments. REFERENCES 1. Ante IH. The fundamental principles of abutments. Mich State Dent Sot Bui 1926;8:14-20. 2. Nyman S, Lindhe J, Lundgran D. The role of occlusion for the stability of fixed bridges in patients with reduced periodontal tissue support. J CIin Periodont 1975;2:53-66. 3. Nyman S, Lindhe J. Prosthetic rehabilitation of patients witb advanced periodontal disease. J Clin Periodont 1976;3:135-47. 4. Guilbert PN, Rozanes SD, Tscucianu JF. Periodontal and prosthodontic treatment for patients with advanced periodontal disease. Dent Clin North Am 193&32:331-56. Reprint
requests
DR. LAMBERT
to:
J. STUMPEZ
WILHFLMINASTMAT 4818 SH BREDA TI-IS NETHERLANDS
44 A
by using etched porcelain
Carl G. Glaser, D.M.D.,* and William W. Nagy, D.D.S.** U.S. Army
Dental
Activity,
Fort
Drum,
N.Y.
I
n our fast-moving competitive society bruxism seemsto be on the increase.Tension causedby employ-
The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the viewsof the Departmentof the Army or the Department of Defense. *Chief Clinician, Dental Clinic No. 1. **Chief, Fixed Prosthodontics, Burke Dental Clinic, Fort Ord, Cahf.
10/1/16016
338
ment and other interpersonal situations may causesuch parafunctional habits asclenchingand grinding. Repeated parafunctional maneuversmay establisha self-perpetuating cycle of pain and musclespasm.lMalocclusion may also contribute to the perpetuation of craniomandibular disorders. In addition, psychopathologic disorders may occur, characterized by patient complaints that often cannot be substantiated by physical or radiographic findings. The following clinical report describesthe useof etched porcelain veneers in the treatment of a patient with a craniomandibular disorder.
MARCH
1991vors~rex66
NUMBER
9