|Year : 2015 | Volume
| Issue : 1 | Page : 42-46
Triad treatment option to restore full mouth
Neelam Abhay Pande, Maithili Kolarkar
Department of Prosthodontics, VSPM Dental College and Hospital, Nagpur, Maharashtra, India
|Date of Web Publication||26-Aug-2015|
Dr. Neelam Abhay Pande
Department of Prosthodontics, VSPM Dental College and Hospital, Nagpur, Maharashtra
Source of Support: None, Conflict of Interest: None
The primary consideration for continued denture success with a single conventional complete denture is the preservation of that which remains in the oral cavity. The single denture is a complex prosthesis that requires a complete understanding of the basics of denture occlusion. The problems involved in providing comfort, function, proper esthetics, and retention for the maxillary complete denture patient with natural opposing dentition may be challenging. The damage to the edentulous ridge and inability to wear the denture may be avoided by good prosthetic treatment which includes adequate denture base, correct jaw relation record, and proper occlusion. In this case report, a female patient reported with generalized attrition of the remaining maxillary dentition. After clinical evaluation, taking into consideration the patient's expectations, treatment plan was decided. Using fixed, removable, and complete denture prosthesis, patients functional and esthetic requirements were fulfilled, which gave her comfort and satisfaction.
Keywords: Cast partial denture; metal base; occlusal plane; recontouring
|How to cite this article:|
Pande NA, Kolarkar M. Triad treatment option to restore full mouth. Indian J Multidiscip Dent 2015;5:42-6
| Introduction|| |
Many patients become edentulous in one arch while retaining some or all of their natural teeth in the opposing arch. Several difficulties are encountered in providing a successful, single complete denture treatment. Regrettably, this service is envisioned as only half as difficult and time consuming as the construction of opposing complete dentures. Single complete dentures may be opposed by: (1) Natural teeth, (2) fixed restorations, (3) a removable partial denture, or (4) an existing complete denture. Each of these situations may present difficulties which must be recognized and thoroughly assessed before definitive treatment is planned.
The natural teeth which will oppose a complete denture almost always require recontouring to some degree to provide a harmonious occlusion. The reasons for this are: (1) The inclination of the occlusal plane is usually unfavourable, (2) the individual teeth may be malpositioned and may have assumed positions that present excessively steep cuspal inclinations, and (3) the buccolingual width of the natural teeth may be too wide. The occlusal plane is dictated by the opposing teeth, and it usually has a series of unfavorable tooth inclinations due to supra-eruption of teeth that had no opposing contacts. These unfavorable inclinations will promote undesirable directions of force on the opposing denture. Shunting type forces often result in the resorption of the bone underlying the denture or an inflammatory reaction of the basal seat tissues. 
| Case History|| |
A female patient aged 72 years reported to the Department of Prosthodontics with chief complaint of difficulty in mastication. The patient's systemic history was not significant. Extraoral examination was normal. The past dental history was not significant. On examination, teeth present were 11, 12, 13, 16, 17, 21, 22, 23, 25, 26, and 27 [Figure 1].
The sequential prosthetic treatment plan included:
- Maxillary arch: Anterior teeth restored by fixed partial denture was planned, thereby establishing the anterior occlusal plane, followed by restoration of maxillary posterior teeth by cast partial denture, thereby establishing posterior occlusal plane and
- Finally, the restoration of mandibular arch by complete denture with metal base, which occluded to the opposing maxillary teeth in balanced occlusion.
There was generalized attrition with the remaining teeth and lower arch was completely edentulous. She was prescribed calcium, multivitamins, and iron supplementation to improve her general health which would also help her in adjusting to the new prosthesis. The treatment plan included scaling and root planing with the remaining teeth, extraction with 12, 16, 25, and 26 teeth because they were periodontally weak, with grade III mobility.
| Case Report|| |
For the restoration of maxillary arch (anterior region)
Individual full veneer restorations were planned with 21, 22, 23, 27, and 17 because they showed generalized attrition. Porcelain fused to metal fixed partial denture was planned with 11 and 13, for replacing 12. Teeth required recontouring to provide a harmonious occlusion. However, in this case, patient's remaining teeth were not supra-erupted; therefore only minor corrections were needed to round off the sharp edges on occlusal surface of posterior teeth, for the correction of occlusal plane. For this, on the diagnostic mounting, diagnostic wax-up was done [Figure 2]. The maxillary cast was duplicated in irreversible hydrocolloid impression material to fabricate a clear acrylic resin template. Intra-orally, this template was used for occlusal plane adjustment of the posterior teeth [Figure 3]. Once the occlusal plane was adjusted with the occlusal plane analyzer, the tooth preparations were done according to the biomechanical principles. Impression was taken in vinyl polysiloxane impression material. Working cast was retrieved. Metal copings were fabricated and were tried in patient's mouth. Porcelain build up was done and porcelain fused to metal full veneers and porcelain fused to metal fixed partial denture replacing 12 were fabricated. They were finished, polished, and cemented with glass inomer luting cement on 11, 13, 17, 21, 22, 23, and 27 [Figure 4].
For the restoration of maxillary arch (posterior region)
The remaining maxillary teeth were somehow periodontally compromised, so removable cast partial denture using palatal strap major connector was planned. The strap acts as a splint for periodontally weakened teeth. About 13, 17, 23 and 27 were selected as abutments on which direct retainers were given. "Circumferential" clasp with 17 and 27 were given. A gingivally approaching clasp was planned with 13 as it was more esthetic and would provide retention. There was a soft tissue undercut in association with 23, so a "circumferential" clasp had to be planned though it was unesthetic. Therefore, another impression for cast partial denture was taken in regular body silicone impression material, and master cast was obtained [Figure 5].
For restoration of mandibular arch
Whenever a single complete denture opposes natural dentition, there are chances of midline fracture of the complete denture because of the masticatory forces exerted by the opposing natural dentition. The mandibular alveolar ridge was resorbed as well. Taking into consideration of all this, mandibular single complete denture with metal base was planned. There are many advantages of metal base. It reinforces the complete denture prosthesis and prevents fractures when opposing the natural dentition. Wettability of metal is more than denture base resins. Hence, surface tension on metallic base will be more and therefore retention also will be increased. This is of great advantage in case of resorbed ridges. Furthermore, casting shrinkage is less. Thus, denture base is more accurate.
The primary impression for lower arch was taken with pressure technique followed by final impressions by selective pressure technique and the final cast was retrieved [Figure 6]. After casting, metal trial of maxillary framework, as well as mandibular metal base, were checked in patient's mouth [Figure 7] and [Figure 8]. The design for the mandibular metal base was nonrelieved bead type, in which no relief was provided below the metal and it was in direct contact with the alveolar ridge. After satisfactory evaluation of metal bases, jaw relation was recorded and was transferred to the semi adjustable articulator. Teeth were arranged in balanced occlusion. Trial of the waxed-up dentures was also checked [Figure 9]. After acrylization, the dentures were inserted in the patient's mouth [Figure 10]. The lady patient was satisfied with the esthetics and the function of the prosthesis [Figure 11]. She was kept on recall and was given instructions regarding oral hygiene and prosthesis maintenance. The prosthesis helped the patient in improving mastication and ultimately improved her general health.
| Discussion|| |
A complete denture opposing maxillary natural teeth is contraindicated in most instances. A smaller basal seat area is available for the support of the lower denture than for an upper denture. Therefore, more stress per unit area is usually transferred to the lower residual ridge than to the upper. The greater amount of stress per unit area exerted through the natural upper teeth decreases the retention and stability of the lower denture. A rapid loss of mandibular supporting bone, and continual soreness should be avoided as far as possible.
There are, however, some situations in which the construction of a lower denture against natural teeth is necessary. Health factors that prohibit the removal of teeth may justify this procedure. Complete lower denture opposing an upper removable partial denture. The clinical indications are generally the same as for complete lower dentures opposing upper natural teeth. The few advantages of retaining the natural teeth are outweighed by the disadvantages of having the resorbed lower ridge.  The problems involved in providing comfort, function, proper esthetics, and retention for the maxillary complete denture patient with natural opposing dentition may be challenging. Careful attention of the patient is important. It provides the complete denture wearer the opportunity to adapt with the complete denture and allows the dentist to evaluate the patient physically and emotionally before fabrication of the final complete denture. 
In case of the treatment of the complete maxillary denture opposing the mandibular bilateral distal extension partial denture, the dentist should approach cautiously, and the institution of correct treatment initiatives is essential. Every patient must be aware from the outset that the longest possible life of any prosthesis with the least harm to the remaining tissues can only be ensured by regular recall and maintenance care. 
Other treatment modalities in this case can be precision attachments with 13 and 23 which would give a better esthetic result and increased retention. The attachments wear with time and have to be replaced. Furthermore, they are costly. Anteroposterior strap type major connector can be given if periodontally sound teeth are present. Implant retained or implant supported mandibular overdenture can be another option. Completely implant supported fixed partial dentures in maxillary and mandibular arch can also be planned.
However, in the existing situation, the patient opted for the treatment plan, which was comparatively economical. The triad treatment option using fixed, removable and complete denture prosthesis restored her functional and esthetic demands, giving her comfort and satisfaction.
| Summary|| |
According to Devan's statement, the primary consideration for continued denture success with a dental prosthesis is preservation of that which remains. The single denture is a complex prosthesis that requires a complete understanding of the basics of denture occlusion. Theilemann's formula must be applied to each individual patient and appropriate treatment must be taken to assure complete balance in all excursive movements. The basic principles of retention, stability, and support should not to be taken for granted, and steps must be completed so that all components are working in harmony for success of the single denture. 
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sharry JJ. Complete Denture Prosthodontics. 2 nd
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]