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Removable partial denture design using

milled abutment surfaces and minimal


soft tissue coverage for periodontally
compromised teeth: A clinical report
Yada Chaiyabutr, DDS, DSc,a and James S. Brudvik, DDSb
School of Dentistry, University of Washington, Seattle, Wash

This clinical report describes the treatment of a partially edentulous patient with periodontally compromised teeth
using a combination of single crowns and a removable partial denture (RPD). The RPD was designed to combine the
benefits of milled surfaces and hygienic principles while allowing modification and addition of artificial teeth, should
natural teeth be lost. (J Prosthet Dent 2008;99:263-266)

Continued loss of teeth after res- of milled guiding planes on lingual CLINICAL REPORT
toration with an RPD is often consid- and proximal surfaces of these res-
ered a failure of the prosthesis itself torations enhances the stability and A 70-year-old white man present-
rather than the patient’s inability to retention of the prosthesis.5 The de- ed for possible complete mouth res-
control the disease process. Addi- sign and fabrication philosophy of toration of a failing dentition due pri-
tionally, the RPD fails when some the combined prosthesis, that is, one marily to a long history of periodontal
component fractures in function, composed of both fixed and remov- disease. Findings included generalized
contributes to plaque retention, or able components, is based upon the moderate horizontal bone loss with
is unacceptable esthetically. Clinical following concepts. First, using single localized moderate to severe vertical
studies indicate that the periodontal crowns permits access to proximal bone defects, severe loss of gingival
condition of surviving abutments is surfaces for plaque control. Secondly, attachment and labial bone on the
related to RPD design,1 and appropri- major and minor connectors should mandibular anterior teeth (Fig. 1),
ate design and good oral hygiene may cover the minimum amount of soft and the presence of plaque, calculus,
decrease the incidence of periodontal tissue while contacting every remain- and gingival inflammation with bleed-
disease.2 Therefore, several factors ing tooth. The tooth contact will not ing on probing. Internal and external
should be considered when designing only aid in splinting of the teeth but root resorption was also observed
an RPD that must use periodontally will provide the metal support for the upon radiographic examination of all
compromised teeth as abutments. addition of an artificial tooth for the remaining mandibular teeth (Fig. 2).
Stewart and Rudd3 stated that broad replacement of a natural tooth, if nec- The dental history revealed that the
distribution of stress through use of essary. Thirdly, the interface between patient had received orthognathic
rigid major and minor connectors the fixed and removable components treatment to correct a class III maloc-
and multiple rests or guiding planes consists of surfaces milled parallel to clusion 20 years before, and the pa-
is of primary importance. Additional the path of insertion, creating fric- tient did not seek follow-up or regular
design considerations include stabili- tional retention and stability. Lastly, dental care.
zation of all compromised teeth, the the contact surfaces of the RPD cast- A variety of treatment options
potential for the addition of artificial ing are left in the as-cast state by the were presented, including fixed res-
teeth if natural teeth are lost, and a laboratory with no finishing or polish- torations with single tooth implants
minimum of soft tissue coverage, es- ing, to retain as much frictional reten- in edentulous areas, which would re-
pecially those tissues at the gingival tion as possible.6 This clinical report quire both soft and hard tissue aug-
margins of remaining teeth.4 Many, if describes the treatment of a patient mentation, and were rejected by the
not all, abutment teeth require some using a combination of fixed and re- patient. Full-arch splinting with fixed
form of restoration of tooth struc- movable prostheses to stabilize peri- partial dentures was questionable
ture. The most common fixed resto- odontally compromised teeth. due to the angulations of the anterior
rations are complete crowns. The use teeth. Intentional endodontic treat-

Graduate student, Department of Restorative Dentistry.


a

Professor Emeritus, Department of Restorative Dentistry.


b

Chaiyabutr and Brudvik


264 Volume 99 Issue 4

1 Pretreatment view.

2 Radiographs at time of initial presentation showing severe loss of labial bone and internal and external root resorp-
tion in mandible. Note root proximity between maxillary central incisor and lateral incisor.

ment would have been required to ate, to create an angle iron effect to The parallel surfaces, combined with
create a path of insertion. The patient maximize rigidity. A cast circumferen- an accurate RPD casting, would pro-
reported a dental history of recurrent tial clasp was placed into a 0.010-inch vide for some frictional retention for
root resorption; therefore, since in- undercut on the mesio-buccal of the the partial denture.5 Anterior restora-
tentional endodontic treatment may right first molar with a gold 19-gauge tions were fabricated with continuous
have resulted in future root resorp- wire circumferential clasp (Jelenko lingual rest seats that would allow for
tion,7 this treatment was rejected by Clasp Wire; Jelenko, San Diego, Ca- stabilization of the incisors without
the patient. For financial reasons as lif ) placed into a 0.010-inch undercut covering the anterior palate (Fig. 3).
well as technical considerations, the on the mesio-buccal surface of the The crowns were cast (Olympia; Jelen-
definitive treatment plan included ex- left terminal abutment. All remain- ko) and verified intraorally before the
traction of all mandibular teeth due ing maxillary teeth were prepared for addition of porcelain (IPS d.Sign; Ivo-
to the severe horizontal and vertical metal ceramic crowns. A full-contour clar Vivadent, Amherst, NY) (Fig. 4).
bone loss and extensive internal and diagnostic waxing was completed It is preferable to include all fixed
external root resorption, then restora- with parallel guide planes on proxi- components on the definitive cast for
tion with an implant-supported com- mal and lingual tooth surfaces. The the removable partial denture when
plete denture. For the maxilla, all teeth posterior milled surfaces were limited all the remaining teeth have been
were planned to receive single metal to the coronal two thirds of the fixed crowned.5, 8 This provided a solid cast
ceramic crowns and an RPD. For the restorations to reduce the coverage for final milling as well as reducing
RPD design, the broad palatal strap of of the gingival tissue by the RPD. The errors in the reproduction of crown
the major connector was reduced an- width of the lingual ledge rest was 1.0 contour. The intaglio surfaces of the
terior posteriorly to a minimum of 18 to 1.2 mm, and the lengths of vertical crowns were lubricated with petro-
mm. The strap was placed in 2 planes, guide planes were 3.0 to 4.0 mm, de- leum jelly (Vaseline; Unilever, Green-
the rugae area and the posterior pal- pending on the height of the crowns. wich, Conn), and then acrylic resin
The Journal of Prosthetic Dentistry Chaiyabutr and Brudvik
April 2008 265

3 Wax crowns cut back and milled in wax on posterior 4 Milled crowns on definitive RPD cast after veneering
palatal surface and in cingulum areas to create positive with porcelain.
rest and guide plane components.

5 Metal surfaces of guide plane receive final milling with fine milling burs.

(Pattern Resin; GC America, Alsip, Ill) NY) were used to create the major Ga). Once the framework was fully
dies with guide pins were fabricated.5 connector, clasps, and finishing lines. seated intraorally, the crowns were
A rigid impression material (Aqua- The extended lingual rest was hand removed and replaced on the defini-
sil Ultra; Dentsply Intl, York, Pa) was waxed to blend in with the plastic pat- tive cast, and the fit of the frame was
used to transfer the individual crowns terns (Fig. 6). The wax framework was verified. It is essential that the com-
for the RPD definitive cast.8 Provision- sprued, invested, and cast (Jelenko JD; ponent fit both intraorally and on the
al cement (TempBond; Kerr Corp, Or- Jelenko) in the conventional manner.8 definitive cast in an identical manner,
ange, Calif ) placed in small amounts The internal surface of the casting so that errors are not induced during
and only at the margins, was used to was left in the as-cast condition in the resin processing. Artificial teeth (Enig-
stabilize and retain the crowns before areas in contact with the milled sur- ma; Dillon Co, Inc, Cranston, RI) were
the definitive impression. The impres- faces, while all other surfaces received positioned in harmony with the diag-
sion was poured with a type IV stone a standard finish and polish. The cast nostic waxing, and the RPD was com-
(Fujirock; GC America). After recovery framework was then returned for ini- pleted. At that point the crowns were
of the definitive cast, final milling was tial fitting intraorally, with the crowns definitively cemented (RelyX Luting
completed using an electrical mill- again provisionally cemented. A vinyl Cement; 3M ESPE, St. Paul, Minn),
ing machine (KaVo Typ9; KaVo Den- polysiloxane indicating material (Fit and the RPD was inserted with ap-
tal Corp, Lake Zurich, Ill) with a fine Checker; GC America) was placed propriate adjustments. The occlusal
milling bur (XPdent Corp; Miami, Fla) on the internal surfaces of the cast scheme developed for this patient was
(Fig. 5). The definitive cast was sent framework. Gross interferences were canine protected articulation with
to a commercial dental laboratory for identified, and those contacts were provision made for group function
blockout and duplication. Commer- removed from the framework with a should the acrylic resin canine lose
cially available plastic patterns (No- small round diamond rotary cutting its eccentric contacts through wear.
bilium Wax; Nobilium Co, Albany, instrument (Brasseler USA, Savannah, Instructions regarding insertion and
Chaiyabutr and Brudvik
266 Volume 99 Issue 4
theses with milled contacting surfaces
should be considered. The removable
prosthesis should have multiple rests
to ensure maximum support. In this
clinical report, the extended lingual
rests were placed across the posi-
tive lingual rest seats on the anterior
teeth, and the minor connector rests
were placed on the lingual ledge of
the posterior teeth. These rests aid in
the stabilization of the mobile teeth
in both centric occlusion and during
eccentric movements. In addition, the
6 Wax framework for RPD. Rests were hand waxed to blend with plas- lingual milled surfaces also increase
tic patterns. Bead retention was added for single tooth replacement. stability and resistance to rotational
movements. The precise fit of the RPD
to the milled surfaces of the crowns
eliminates the need for visible ante-
rior clasping. The placement of 1 con-
ventional clasp on the most posterior
tooth of each side provides adequate
retention.

REFERENCES
1. Kern M, Wagner B. Periodontal findings
in patients 10 years after insertion of
removable partial dentures. J Oral Rehabil
2001;28:991-7.
2. Zlataric DK, Celebic A, Valentic-Peruzovic
M. The effect of removable partial den-
tures on periodontal health of abutment
and non-abutment teeth. J Periodontol
2002;73:137-44.
3. Stewart KL, Rudd KD. Stabilizing periodon-
tally weakened teeth with removable partial
dentures. J Prosthet Dent 1968;19:475-82.
4. Becker CM, Kaldahl WB. Using removable
partial dentures to stabilize teeth with
secondary occlusal traumatism. J Prosthet
Dent 1982;47:587-94.
5. Brudvik JS, Shor A. The milled surface as a
precision attachment. Dent Clin North Am
2004;48:685-708.
6. Brudvik JS, Reimers D. The tooth-removable
partial denture interface. J Prosthet Dent
1992;68:924-7.
7. Cholia SS, Wilson PH, Makdissi J. Multiple
idiopathic external apical root resorption:
7 Posttreatment view. report of four cases. Dentomaxillofac
Radiol 2005;34:240-6.
8. Brudvik JS. Advanced removable partial
removal, oral hygiene, and required is essential. Acrylic resin retention for
dentures. Chicago: Quintessence; 1999. p.
home care were given to the patient additional teeth can be easily added 65-73.
(Fig. 7). For this type of patient, one to the RPD frame with laser welding
Corresponding author:
with periodontally involved abutment so that the RPD need not be remade. Dr Yada Chaiyabutr
teeth, recall within 3-6 months is es- 1001 Fairview Ave, N
sential so that mobility and probing SUMMARY Suite 2200
Seattle, WA 98109
depth can be compared with baseline Fax: 206-621-7609
data from prosthesis insertion. Since When limitations exist with re- E-mail: cyada@u.washington.edu
it is likely that additional teeth may be spect to either finances or the number
Copyright © 2008 by the Editorial Council for
lost in time, the contact of all abut- of missing teeth in an arch, a combi- The Journal of Prosthetic Dentistry.
ment teeth with the RPD framework nation of fixed and removable pros-
The Journal of Prosthetic Dentistry Chaiyabutr and Brudvik

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