Esthetic rehabilitation of the partially edentulous patient

with porcelain-fused-to-metal restorations and a precision-

attachment-supported partial denture.
Heydecke, Guido, DDS, Dr Med Dent

Scherzinger, Peter, CDT

Key Words: combined fixed-removable partial denture, precision attachment, porcelain-fused-to-metal

crowns

Combined fixed-removable partial dentures can be used for the esthetic and functional
rehabilitation of partially dentate patients. This report describes how porcelain-fused-to-metal
crowns were combined with a precision-attachment-retained denture for the restoration of the
maxillary arch in a 72 year-old patient. For the mandible, PFM bridges were created and
cemented. Two missing molars were not replaced, because the patient refused implant
placement. An esthetically pleasing result was reached with fully individualized porcelain and
resin veneering.

INTRODUCTION
Today, dentistry seems to be moving increasingly toward implant procedures, even for the
partially edentulous patient. A number of reports have documented very favorable implant
success rates in partially dentate patients [1], [2], [3]. Notwithstanding this, the removable
partial denture (RPD) still remains a valuable treatment option for the majority of patients [4].
In many instances, removable partial dentures can be retained either by clasps or in
combination with fixed restorations. In the latter situation, double crowns or precision
attachments can be used for retention. In either situation, the coupling of RPDs to a retention
device creates what is referred to as a 'combined fixed-removable partial denture' (CFRP).
CFRPs have been shown to offer improved retention and esthetics when compared to
conventional RPDs. [5], [6]

Longitudinal studies of patients treated with clasp-retained RPDs have demonstrated varying
therapeutic success rates, depending on study criteria and the duration of follow-up. Survival
rates of 73% five years post procedure [7] to 50% after 10 years [8] have been reported. In the
study by Vermeulen [8], any alteration of a prosthesis was considered a criteria for failure.
This explains the lower success rate when compared to the longer term results of Bergman et
al [4] who demonstrated a success rate of 65% after 25 years of use.

For RPDs combined with fixed restorations (CFRPs), a survival rate of 62% was reported
after 8 years, though there were significant differences between semi-rigid and rigid
reconstructions [9]. A study of slightly longer duration by Kerschbaum et al [10] noted an even
higher success rate of 85% after nine years.

The occurrence of biologic and technical failures needs to be addressed in different ways.
Caries and periodontal diseases can be reduced by improved oral hygiene [11]. Technical
problems often appear as fractures involving the framework and clasp, or loss of retention
due to wear on attachments [12], [13]. If designed with non-friction construction and
exchangeable friction elements that can be easily repaired (for example, the FR-
Chip®),precision attachments can be utilized to counteract failures. A ninety-five percent
success rate has been reported for this attachment in a two-year study [14].
CASE REPORT
Initial Evaluation
A 72-year-old patient presented with the chief complaint of dissatisfaction with his 25 year-old
restorations. The patient was especially concerned about the discoloration of the upper left
canine crown and changes to the composite fillings on his central incisors (Figure1A).

Careful examination revealed several missing teeth in the upper jaw. These had been
replaced with a removable partial denture which was retained by an attachment on the right
canine and a Bonwill-clasp to the left first and second premolars, as well as a clasp on the
second left molar. The right canine had been restored with a resin-veneered crown. The
lateral incisors and the upper left first and second premolars had also undergone restoration
with PFM crowns with a full gold crown identified on the second molar (Figure 1B).

In the lower jaw, a shortened arch existed due to the absence of posterior teeth on the left
side. All premolars and the second molar on the right side had previously required PFM
crowns, while the missing first right molar had been replaced with a PFM bridge (Figure 1C).

Figure 1a Figure 1b Figure 1c

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Treatment procedures
Because the patient refused to receive dental implants, a partial denture was chosen as the
treatment option to replace the upper missing teeth. He also refused a telescopiccrown
retained denture, even after discussion about the risk of gold margin exposure and potential
discoloration of veneering resin on the telescopic crowns. Instead, a precision-attachment
removable partial denture was planned for the upper jaw. The lower jaw was to be restored by
fixed crowns and bridges without replacing the missing molars on the left side.

After removing calculus and tobacco stains by supragingival scaling, impressions were taken.
Then, a diagnostic wax-up was performed from which shell provisionals were created on the
dies using PMMA resin (K + B®, De Trey, Konstanz, Germany).

The patient was found to have a healthy periodontium except for the maxillary left second
molar which was extracted due to the presence of excessively mobile deep pockets. In
addition, the lower left first premolar was also removed because of the existence of a fistula
from a previously perforated endodontic dowel (Figure 2).

Figure 2

Larger View
Temporary restoration
The missing lower left first premolar was replaced with a provisional bridge that extended
from the mandibular left second premolar to the canine. Subsequently, the crown on the
second premolar was removed using a crown-cutter and forceps. The adjacent canine was
prepared using a diamond bur. The shell provisional was relined with self-curing acrylic resin
(TAB 2000, Kerr, Karlsruhe, Germany) after applying a petroleum based lubricant to the teeth.

All the crowns and the mandibular right bridge were removed, and the abutment teeth
provisionally prepared. The upper central incisors also required preparation due to extensive
composite fillings. The teeth were temporized using the created shell provisionals which were
relined with acrylic resin. The crowns retaining the upper partial denture were repaired with
acrylic resin and then provisionally re-cemented. All provisionals were cemented with a
temporary luting agent (Freegenol®, GC, Tokyo, Japan).

Next, removal of all old fillings and inadequate core build-ups found on the abutment teeth
was performed.

Maxillary arch
It was determined that the upper central incisors were non-vital and therefore were
endodontically treated via standard procedure.

Two Zirconia posts (Cerapost®, Brasseler, Lemgo, Germany) were placed and cemented in
the maxillary central incisors with Panavia® (Kuraray, Osaka, Japan). The remaining
approximal cavities were filled with self-curing composite resin (Clearfil®, Kuraray, Osaka,
Japan). The existing post on the left lateral incisor could not be removed without the risk of
fracture. Therefore, it was retained, and the core was built up with composite resin after
intraoral sandblasting of the metal surface. The right lateral incisor had been restored
previously with a screw-type dowel. After the successful removal of this post, a tapered gold-
alloy post (Heraplat ER® Brasseler, Lemgo, Germany) was placed, and the core was built up
using pattern resin (GC, Tokyo, Japan). A cast gold post-and-core was manufactured in the
dental laboratory and later cemented with Ketac-Cem® (ESPE, Seefeld, Germany) (Figure 3).

In the upper jaw, all abutment teeth were prepared using a 1.2 mm butt shoulder with a
rounded inner angle (Figure 4A).

Mandibular arch
After removal of the lower right bridge, limited tooth structure remained on the second
premolar as well as the second molar. For both teeth, cast gold post-and-cores were created
using cast-on ER-posts. For the molar, a split-design was chosen.

The gold post-and-cores for the lower right second premolar and the second molar were cast
in high precious alloy (Degulor® M, Degussa, Frankfurt, Germany) and cemented using a
glass-ionomer cement (Ketac-Cem®, ESPE, Seefeld, Germany).

On the lower right second molar minimal buccal tooth structure was left above the furcation.
There was no furcation involvement, but a conventional crown lengthening could not be
performed without opening the furcation. Therefore, a flap was elevated, and using a diamond
bur, the bone was smoothly shaped without touching intrafurcal bone. The tooth was prepared
using a flame-shaped diamond bur to the alveolar crest following the principles of Carnevale
[15]. The flap was internally thinned, and the wound was closed using Gore-Tex sutures (W. L.
Gore, Newark, USA). A periodontal dressing was applied (Coe-Pak®, GC, Tokyo, Japan), and
the tissue was allowed to heal for 7 days before removing the sutures.
 Figure 3 Figure 4a Figure 4b

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In the lower jaw, all teeth (excluding the right second molar) were prepared with a chamfer
using appropriate diamond burs (Figure 4B).

Two retraction cords of size #0 and #1 were applied on each tooth except for the lower right
second molar (Ultrapak®, Ultradent Inc., South Jordan, USA). The second cord (#1) was
removed and impressions were taken using Impregum® polyether impression material
(ESPE, Seefeld, Germany) which was syringed around the teeth and also on the custom
complete arch trays (Lightplast®, Dreve-Dentamid, Unna, Germany) (Figure 5A, 5B).

A facebow transfer and check-bite were used to mount the master-casts in a semi-adjustable
articulator. Full contour-wax-ups were performed in the dental laboratory, tried-in, and
modified to the patient's satisfaction (Figure 6).

Figure 5a Figure 5b Figure 6

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The metal substructures for all PFM crowns and bridges were waxed-up and cast in a high-
precious gold alloy (V-Classic, Métalor, Stuttgart, Germany). The upper left two premolars and
the right lateral incisor and canine were splinted. Individual attachments were milled and
combined with the FR-Chip® retention element on the most distal maxillary abutment teeth
(Efercon, Kaiserslautern, Germany) (Figure 7).

The metal frameworks of the PFM restorations were tried in with the fit checked using a low
viscosity silicone material (Fit-Checker®, GC, Tokyo, Japan). In the maxillary, arch an
impression of the edentulous areas was performed, and the PFM substructures were picked-
up in this impression (Impregum®).

All PFM copings were veneered to the determined shade with feldspathic porcelain (Création
Willi Geller, Girrbach, Pforzheim, Germany). All crowns were tried in after firing for color
matching and occlusal adjustment.

For the upper posterior denture-teeth, "crown substructures" with the integrated secondary
attachment were cast out of high-precious gold alloy (Degulor M®, Degussa, Frankfurt,
Germany). The partial denture framework was cast (Biosil F®, Degussa, Frankfurt, Germany),
soldered to the posterior substructures and veneered with Chromasit® light curing resin
except for the occlusal surface due to limited interarch space (Ivoclar, Schaan, Liechtenstein).
The denture base was completed with individually stained denture resin (Autopolymerisat 81,
Candulor, Wangen, Switzerland).
Finally, after glazing, all crowns were cemented using a glass-ionomer cement (Ketac-Cem®,
ESPE, Seefeld, Germany) (Figures 8A,B; 9A,B; 10).

Figure 7 Figure 8a Figure 8b

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Figure 9a Figure 9b Figure 10

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DISCUSSION
Today, many implants are placed in the posterior maxillary and mandibular region, often in
combination with bone augmentation. However, this procedure does not guarantee
permanent success as the literature reports survival rates of 90 to 95% over 5 years in the
upper jaw, and 92% in the lower jaw [1], [2], [3], [16]. Furthermore, sinus augmentation
procedures have been refused by some patients, and as shown in this case report, some
individuals refuse simple implant placement. In selected cases, if all premolars are present,
the uni- or bilateral shortened arch is an excellent treatment option, and according to Witter et
al [17], [18], functional or occlusal problems are not likely to occur in healthy patients. Although
the shortened-archconcept could not be utilized in the maxillary area of this patient, it was
applied in the mandibular arch. The patient had been without lower left molars for such a long
period of time that he could not remember when they were lost and hadnever experienced
any temporo-mandibular pain or discomfort while chewing. Therefore, he was not concerned
about replacing the molars on his left side.

In the upper jaw, the number and location of abutment teeth permitted treatment only with a
removable partial denture. Because his old partial denture had been partially retained by
invisible attachments, the patient requested invisible retention elements. One option was to
use telescopic or conical crown-retained dentures which have a documented 78% survival
rate over eight years [19], [20]. However, since secondary crowns can only be veneered with
composite resin, they carry a risk of resin discoloration within one year of treatment even with
the newer composites [21]. This patient had already experienced discoloration of the
composite veneer and fillings over the years and continued to use tobacco. Hence, porcelain-
fused-to-metal crowns were the preferred treatment option for the upper anterior segment.
The PFM crowns showed a remarkable esthetic result which can be expected to last. A
pleasing color match with the natural teeth was obtained. Satisfactory light diffusion on the
PFM crowns was achieved by reducing the metal collars of the maxillary crowns by 1 mm,
thus excluding the palatal quarter as described by O'Boyle et al. [22]

One disadvantage of attachment retained partial dentures is their lower success rate when
compared to other treatment modalities. A number of approaches have been made to reduce
wear on the attachments. Elements without friction, like the FR-Chip® used in this case, are
less subject to wear from paraxial load [23] which remains a major problem for friction-based
attachments [12]. The main impediment to more extensive use of all partial dentures remains
unsolved. This entails the frequent need for re-treatment that occurs as a result of caries,
periodontal disease and fractures to teeth and framework. These are the subjects of a
number of long-term follow-up reports [8], [9], [10]. Therefore, as stated in earlier studies [4],
[13], it is imperative to utilize a patient recall system in order to monitor and prevent the
potential causes of partial denture failure.

The authors wish to thank Dr. Zahra Rashid for her help in preparing this manuscript.

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