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Cairo Dental Journal (24) Number (I), 163:169 January, 2008

TwIN-Flex Clasp as aN esTheTIC appROaCh FOR RemaININg CeNTRal INCIsOR abUTmeNT IN UNIlaTeRal maxIlleCTOmy Cases
salah aF hegazy1 and emiel am hanna2

1. 2.

Lecturer, Faculty of Dentistry, Mansoura University Lecturer, Faculty of Dentistry, 6 October University

clasp. Ten patients with unilateral maxillectomy of ages ranged from 30-40 years, and of either sex were represented in this study. The patients were with completely dentulous mandibular arch , and intact maxillary side. Two types of clasps with the same obturator design. Were used, conventional obturators with simple circlet wrought wire clasps group I, while the other type with twin-flex clasp on the remaining central incisors group II. The effect of both clasps on the remaining central incisor abutments was evaluated by measuring the alveolar bone height changes and probing depth. The results showed statistical insignificant difference in the degree of mesial marginal bone loss around maxillary central incisor between the two groups after first and second six months from insertion (T=0.16, P<0.87and t=1.15, p<0.28 respectively). While, there was statistical significant difference in the degree of distal marginal bone loss around maxillary central incisor between the two groups after first six months and statistical insignificant difference after second six months from insertion (t=3.16 and p<0.01, and t=0.81 and p<0.43). There was statistically significant difference of the probing depth appeared between the mesial and distal aspect of the maxillary central incisor in the first and second six months of the study for the group I. It was concluded that the Twin - flex clasp considered a promising esthetic clasp in cases with unilateral maxillary defects

AbstrAct
he aim of this study was to evaluate the use of esthetic twin-flex clasp on remaining central incisor abutment in unilateral maxillectomy case regarding the alveolar bone height changes and probing depth compared with the conventional simple circlet

INTRODUCTION
Special prostheses are necessary to seal acquired

defect, and the positioning of remaining hard and soft tissues

Successful obturation depends on the volume of the

tissues openings of the palate and contiguous structures. Obturators close or seal these defects allowing for deglutition, and speech .
1

Obturator designs for partial maxillectomy defects have included open and closed hollow obturators
11 3-10

to be used to retain, stabilize, and support the prosthesis.2

restoration of esthetics and function such as mastication,

obturators , and 2-piece hollow obturator prostheses12.

, inflatable

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C.D.J. Vol. 24. No. (I)

unilateral maxillectomy defect should have a rest and retainer if adequate retention is to be achieved. This anterior rest and retainer ensure proper orientation of the

The tooth closely adjacent to the anterior margin of

The patients have completely dentulous maxillary intact side against completely dentulous mandibular arch Fig. (1). acrylic surgical obturator and two weeks postsurgical to Patients were presented before surgical intervention to make make intermediate obturator. During the first six month, the patients had restricted surgical and dental follow up for proper hygiene measures. After complete healing, radiotherapy obturators construction. treatment and, the patients presented for definitive metallic

prosthesis. If this concept is not employed, the prosthesis will tend to rotate out of retentive areas posteriorly. However, the poor bony support of the tooth adjacent abutment 13.

to the defect does not permit its use as a partial denture It was suggested to use a wrought wire clasp to

decrease the forces on the upper central incisor instead of amputating the tooth to serve as overdenture abutment. shown is not esthetically accepted. Unfortunately, the wrought wire retentive clasp arm Many authors have described methods for the
14-17

elimination of facial clasp arms in anterior applications proposed alternatives to circumferential clasping Twin flex clasps could be used in both anterior and .

posterior application. The clasps were said to provide improved esthetics, while permitting increased clasping is less noticeable to the patient. It serves as a flexible, hidden clasp that engages the proximal undercut 19. options.18 This clasp can provide a flexible clasp that
Fig.(1) Dentulous patients presented with unilateral hemimaxillectomy .

esthetic clasp in obturators used for reconstruction of unilateral maxillectomy cases. The effect of twincompared with the conventional wrought wire clasp used was clinically evaluated. flex clasp on the upper central incisor abutment when

This work aimed to use the twin flex clasp as an

impression were made and poured in dental stone**. in autopolymerizing acrylic resin***.

Maxillary and mandibular irreversible hydrocolloid*

Maxillary and mandibular custom trays were constructed Preparation of rest seats on both remaining maxillary

premolars and molars, and necessary guiding planes preparation was made. The maxillary custom tray was border molded with green stick compound**** and used

maTeRIals aND meThODs


Ten patients presented with unilateral maxillectomy of

blocking of undesirable soft tissue undercuts with cotton bellets. The definitive obturator had double aker clasps on

to record maxillary final rubber base impression*****after

age ranged from 30 to 40 years of both sex were selected from the Faculty of Dentistry, Mansoura University, and Faculty of Oral and Dental Medicine 6 October University.
*cA 37.superior pink, cover, Holland bv. **Moldano,bayer co.,Leverkusen. ***Pekatray,bayer co.,Leverkusen, ****Xantygen,bayer co.Leverkusen, West Germany ***** Provil by Oyer Dental d.5090 Lever Kausen

maxillary first and second molars and on first and second

Twin-Flex clasp as an esTheTic approach

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premolars in intact side. According to the type of the near the surgical site, the patients were classified into two equal groups randomly:

wrought wire clasp used on the maxillary central incisor

GROUP I.
conventional simple circlet wrought wire clasp on the remaining central incisor abutments. Patients were received their obturators with

slight amount of wax was flow to maintain the wires in place on the teeth block.The rest of the cast was blocked out as for a conventional RPD, and an additional wax was flow to the wire along its length beneath its height of contour. The master cast was duplicated with the wire in place and the refractory cast was prepared for waxing and 24-gauge sheet wax over the shape of the wire in the investment to allow 2 mm of the tip of the wire to remain uncovered. After an accurate framework has been confirmed, the wax was flushed from the master cast with boiling water or stream and was cleaned the wire. The metallic frameworks of both groups were tried intraorally and maxillomandibular relationship was recorded using modeling wax. Setting of artificial teeth was made and after finishing and polishing of the definitive obturators it was inserted and adjusted intraorally using pressure indicating paste. Fig. (2-5).

GROUP II.
clasp on the remaining abutment central incisors as an esthetic alternative. The twin- flex clasp was constructed as follows: proper path of insertion. The central incisor abutments were prepared for adequate rests to help prevent them from rotating. The master cast surveyed for proper determing Patients were received their obturators with twin-flex

Methods of evaluation 1. Radiographic assessment of marginal bone loss:


This was assessed using the Corel Draw No.11 software*. A standardized digital panoramic radiograph** was taken for each patient to measure the marginal bone loss for the natural upper central abutment mesially and distally. The mean marginal bone loss was calculated by measuring the difference between crestal bone height in relation to the fixed cervical line of the natural central incisor.

into a 0.01inch under cut on the tooth surface adjacent to edentulous space in a manner similar to a rotational path design. The length of the wire was 15 mm and 3mm away from the free gingival margin of each abutment.

A 19-gauge Ticonium round wire (Co.N.) was placed

After the wires were carefully adapted to the surface of the tooth, they were hold in the proper position and a

Fig. (2) The fitting surface of the circumferential wrought

wire clasp

Fig (4) Patient with circumferential wrought wire

*corel Draw, Version 11, corel corporation ** MrO5,Villa,Italy

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Salah AF Hegazy and Emiel AM Hanna

C.D.J. Vol. 24. No. (I)

Fig (4) Patient with circumferential wrought wire clasp

Fig. (5) Patient with twin flex clasp

2. Peri-abutment probing depth:


mm using a pressure sensitive plastic periodontal probe* distal, then results were divided by four. The probing depth was measured to the nearest 0.5

P<0.018), and insignificant difference for group II (T = 2.02; P<0.071). The mean value at the distal aspect after 1st 6 months

at four sites for each implant; labial, lingual, mesial and

was 1.420.08 for group I and 1.560.07 for group II.

Statistically, there was significant difference in the degree of marginal bone loss between the two groups at first 6 months. t=3.16 and P value <0.01. After the 2nd 6 months,

ResUlTs:
Table (1) shows the mean marginal bone loss around

the mean value at the distal aspect was 1.650.04 for group I and 1.620.08 for group II. Statistically, there was insignificant difference in the degree of marginal bone loss between the two groups at second 6 months. t=o.81 difference in the degree of marginal bone loss at the distal and P value <0.43. There was a statistically significant aspect between the two periods of times for group I (T = 6.08; P<0.001), and insignificant difference for group II (T = 1.28; P<0.22).

mesial and distal aspects of maxillary central incisor mean value at the mesial aspect after 1st 6 months was

after different periods of study for both groups. The 1.970.16 for group I and 1.95 0.019 for group II . Statistically, there was insignificant difference in the degree of marginal bone loss between the two groups at first 6 months. t=0.16 and P value <0.87. After the 2nd 6 months, the mean marginal bone

loss value at the mesial aspect was 2.230.15 for group

I and 2.130.12 for group II. Statistically, there was insignificant difference in the degree of marginal bone P value <0.28 loss between the two groups at 2nd 6 months. t=1.15and There was a statistically significant difference in

height changes in each period of the study .There was

Table (2) shows the mesial and distal marginal bone

statistically significant difference between marginal bone 6 months ( t=7.38 and P<0.001)and for group II ( t=4.77

loss between mesial and distal aspects for group I at first and P<0.0008).Also there was statistically significant and distal aspects for group II at second 6 months( t=8.89 and P<0.001)and for group II ( t=8.76 and P<0.001).

the degree of marginal bone loss at the mesial aspect

difference between marginal bone loss between mesial

between the two periods of times for group I (T = 2.82;


* Prisa, acer, acerscan. 620st. Acer peripherals America Inc

Twin-Flex clasp as an esTheTic approach

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Table (1) The mean marginal bone loss around mesial and distal aspects of maxillary central incisor after different periods of study for both groups.
Mesial Group N 1st 6 Month Means 6 6 1.97 1.95 0.16 0.87 sD 0.16 0.19 2nd 6 Month Means 2.23 2.13 1.15 0.28 sD 0.15 0.12 Distal 1st 6 Month Means 1.42 1.56 3.16 0.01 sD 0.08 0.07 2nd 6 Month Means 1.65 1.62 0.81 0.43 sD 0.04 0.08

t value 2.82 2.02

P value 0.018 0.071

t value 6.08 1.28

P value 0.001 0.22

I II t value P value

Table (2) The mesial and distal marginal bone height changes in each period of the study Groups I II 1st 6 Month t value 7.38 4.77 P value 0.0001 0.0008 t value 8.89 8.76 2nd 6 Month P value 0.0001 0.0001

Table (3) shows the mean probing depth around mesial and distal aspects of maxillary central incisor after different periods of study for groups. The mean value at the mesial aspect after 1st 6 months was 2.150.24 for group I and 2.110.016 for group II . Statistically, there was insignificant difference in the degree of probing depth between the two groups at first 6 months. t=0.35 and P value <0.73 After the 2nd 6 months, The mean probing depth value at the mesial aspect was 2.420.15 for group I and 2.330.08 for group II . Statistically, there was insignificant difference in the degree of probing depth between the two groups at second 6 months. t=1.21and P value <0.25 There was a statistically significant difference in the degree of probing depth at the mesial aspect between the two periods of times for group I (T = 2.3; P<0.044), and significant difference for group II (T = 3.03; P<0.018). The mean probing depth value at the distal aspect after 1 6 months was 1.610.08 for group I and 1.980.23 for group II . Statistically, there was significant difference in
st

the degree of probing depth between the two groups at first 6 months. t=3.75 and P value <0.04. After the 2nd 6 months, The mean probing depth

2.280.21 for group II. Statistically, there was insignificant difference in the degree of probing depth between the two groups at second 6 months. t=5.81 and P value <0.002 There was a statistically significant difference in the

value at the distal aspect was 1.740.08 for group I and

degree of probing depth at the distal aspect between the two periods of times for group I (T = 2.88; P<0.016), and significant difference for group II (T = 2.33; P<0.042).

each period of the study. There was statistically significant distal aspects for group I at first 6 months( t=5.19 and

Table (4) shows the mesial and distal probing depth in

difference between probing depth between mesial and P<0.004)and statistically insignificant difference for

group II ( t=1.08 and P<0.3). Also there was statistically insignificant difference probing depth between mesial and distal aspects for group II at second 6 months(t=9,87 and P<0.54)and for group II ( t=.54 and P<0.604)

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Table (3) The probing depth around mesial and distal aspects of maxillary Significance of the central incisor after different periods of study for groups. Group Mesial N 6 6 1st 6 Month Means 2.15 2.11 0.35 0.73 sD 0.24 0.16 2nd 6 Month Means 2.42 2.33 1.21 0.25 sD 0.15 0.08 t value 2.3 3.03 P value 0.044 0.018 Distal 1st 6 Month Means 1.61 1.98 3.75 0.004 sD 0.08 0.23 2nd 6 Month Means 1.74 2.28 5.81 0.0002 sD 0.08 0.21 t value 2.88 2.33 P value 0.016 0.042

I II

t value P value

Table (4) The Significance between mesial and distal probing depth in each period of the study Significant test between Mesial and Distal in the same period Group T value I II 5.19 1.08 1st 6 Month P value 0.0004 0.300 T value 9.87 0.54 2nd 6 Month P value 0.0001 0.604

DIsCUssION
During construction of the definitive obturator for

difference in the degree of mesial marginal bone loss

The results of this study showed statistical insignificant

partially edentulous patients after surgical removal of remaining abutments, improve stability, and support of the partial prostheses. Retention provided by the

around maxillary central incisor between the two

hemimaxillectomy defects, the main aim is to preserve

groups after first and second six months from insertion (T=0.16, P<0.87and t=1.15, p<0.28 respectively). While, there was statistical significant difference in the degree of distal marginal bone loss around maxillary central incisor between the two groups after first six months and statistical insignificant difference after second six months

remaining central incisor abutments should be within physiologic limits of the abutment teeth. Within the scope of these objectives, the designs provided for clasping were either by using flexible wrought wire clasp soldered

from insertion (t=3.16 and p<0.01, and t=0.81 and

to the framework, or using conventional infrabulgand circumferential clasps, and the use of a combination clasp assembly with one flexible retentive arm and rigid to the esthetic demands of these patients especially young provide clasp for the remaining maxillary central incisor providing both esthetic and preservation demands. bracing . In all these designs, little concern was provided
20

p<0.43 ). This may be attributed to the unique placement

of the retentive terminal of the Twin Flex clasp in the mesial undercut of the maxillary central incisor that will minimize forces on the abutment in the mesial aspect and movement of the prostheses 21. On the other hand, the transmit more forces on the distal aspect during rotational retentive terminal of the simple circlet wrought wire clasp stresses on the distal aspect of the abutment.

and middle aged patients. The aim of this study was to

engages the distolabial under cut which will cause greater

Twin-Flex clasp as an esTheTic approach

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There was statistically significant difference in the mesial and distal bone height changes for group I at the two different periods of study, while there was statistically insignificant difference mesial and distal bone height changes for group I at the two different periods of study. This may be due to the incorporating of the wrought wire clasp of Twin flex clasp within a channel on the intaglio surface of the RPD framework, and the reciprocation provided by the cast circumferential bracing arm on the lingual plating. This would result in minimizing the stresses on the abutment and decrease alveolar bone height changes 22. The main disadvantage of the wrought wire clasps is the allowance of impaction of debris when they are not well adapted to the abutment teeth. A space is often created where the clasp emerges from the framework, adjacent to the guidepalate. This fact explains the statistically significant difference of the probing depth appeared between the mesial and distal aspect of the maxillary central incisor in the first and second six months of the study for the group I.

6. 7. 8. 9.

AS el Mahdy, Processing a hollow obturator, J Prosthet Dent. 22, 682686, 1969. B Palmer and KW Coffey, Fabrication of the hollow bulb obturator.J Prosthet Dent. 53, 595596,1985. V, Matalon and H, LaFuente. A simplified method for making a hollow obturator. J Prosthet Dent. 36, 580582,1976. SM, Parel and H, LaFuente. Single-visit hollow obturators for edentulous patients, J Prosthet Dent. 40, 426429 1978.

10. VA, Chalian and MO, Barnett. A new technique for constructing Prosthet Dent. 28, 448453, 1972.

a one-piece hollow obturator after partial maxillectomy, J

11. AG Payne, and WG, Welton. An inflatable obturator for use following maxillectomy, J Prosthet Dent. 759763, 1965. 12. AC Cheng, DA Somerville and AG Wee. Altered prosthodontic treatment approach for bilateral complete maxillectomy: a clinical report, J Prosthet Dent. 92, 120124,2004.

13. Beumer J, Curtis TA and Firtell DN: maxillofacial rehabilitation Toronto, London. 230-232,1979.

;Prosthodontic and surgical considerations. Mosby Company

14. Burns DR, ward JE: A review of attachments for removable partial denture design: part I. classification and selection. Int J Prosthodont.; 3:98-102 ,1990.

CONClUsION

1. The Twin - flex clasp considered a promising esthetic clasp in cases with unilateral maxillary defects. 2. Using esthetic clasp for patients with unilateral maxillectomy had a dramatic effect on the psychogenic status of the patients.

15. Jacobson Te, and Krol: Rotational path removable partial denture design. J Prosthet Dent; 48:370-376, 1982. Tech Contemp Dent Lab. 8:45-52,1991. 16. Goodman JJ: The Equipoise removable restoration. Trends 17. Soo S and Leung T: Hidden claps versus C clasp and I bars: A comparison of retention. J Prosthet dent; 75:622-625, 1996 . April: 2-3, 1977. 18. Technology, Timoniums twin-flex clasp. Contacts; March 19. Pboenix RD, Cagna DR, and DeFreet CF: Stewarts Clinical removable partial prosthodontics third ed. Quintessence publishing co. 335, 2003.

.
1.

ReFeReNCes
Wu YL, Schaaf NG. Comparison of weight reduction in Prosthet Dent. 62:214-7,1989. different designs of solid and hollow obturator prostheses. J Watson RM and BJ Gray. Assessing effective obturation, J Prosthet Dent. 54, 8893, 1985. Dent. 97103, 1969. KE Brown. Fabrication of a hollow-bulb obturator, J Prosthet KT Shaker. A simplified technique for construction of an interim obturator for a bilateral total maxillectomy defect, Int J Prosthodont. 13, 166168,2000.

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20. Parr GR, Tharp GE and Rahn AO: Prosthodontic principles in the framework design of maxillary obturators prostheses. J Prosthet Dent., 62:205-212, 1989.

21. Keyf,F: Obturator prostheses for hemimaxillectomy patients. Journal of Oral Rehabilitation, 28;821-829, 2001. 22. Dumbrigue HB and Fyler A: Minimising prosthesis movement in a midfacial defect: a clinical report Journal of Prosthet. Dent.78,341, 1997

5.

TJ Nidiffer and TH Shipmon. The hollow bulb obturator for acquired palatal openings, J Prosthet Dent. 7, 126134, 1957.

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