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CASE REPORT<br />
<strong>Telescopic</strong> <strong>complete</strong> <strong>denture</strong>-<strong>with</strong> a <strong>custom</strong> <strong>mode</strong> stud attachment<br />
1 1 1 1<br />
Ravikumar , Raghavendra Prasad. S , K.R. Kashinath , Naveen B.H.<br />
1 Department of Prosthodontics<br />
Sri Siddhartha Dental College<br />
Tumkur.<br />
JOURNAL OF DENTAL SCIENCES AND RESEARCH<br />
Vol. 2, Issue 3, Pages 10-13<br />
ABSTRACT<br />
“It is more important to preserve what already exists than to replace what is missing” as stated<br />
by M.M.Devan has never been challenged or disapproved. As dentist our main aim should be<br />
prevention which not only includes prevention of caries and or periodontal disease but also<br />
prevention of residual alveolar bone loss after teeth are extracted. Unfortunately little progress<br />
has been made in this area. The resorption being progressive and irreversible and if allowed to<br />
proceed to excessive levels will jeopardize the ability to construct satisfactory removable<br />
prosthesis.<br />
It was due to this stated uncontrollable bone resorption that other techniques for alveolar bone<br />
maintenance were evaluated, over <strong>denture</strong>s being one of them.<br />
This is a clinical report which describes use of selectively retained teeth as abutments to<br />
minimize alveolar ridge resorption below the <strong>complete</strong> <strong>denture</strong>s.<br />
Key Words: telescopic <strong>denture</strong>, residual ridge resorption, stud attachment.<br />
Most common debilitating oral condition existing on a<br />
[1]<br />
routine level is edentulism, especially in the mandible .<br />
It remains one of the more challenging procedures in the<br />
dental practice to fabricate a <strong>complete</strong> mandibular<br />
<strong>denture</strong> offering patient comfort, function, and esthetic<br />
[2]<br />
harmony <strong>with</strong> retention and stability . In the past when<br />
patients presented themselves as candidates for a <strong>denture</strong><br />
<strong>with</strong> teeth that were badly broken down <strong>with</strong> periodontal<br />
involvement or <strong>with</strong>out the ability to financially support<br />
an extensive restorative treatment, those teeth were<br />
extracted that could have been retained under more<br />
favorable conditions which leads to severe residual ridge<br />
resorption. Over <strong>denture</strong>s helps to overcome this<br />
problem along <strong>with</strong> other problems posed by<br />
conventional <strong>complete</strong> <strong>denture</strong>s like poor stability,<br />
retention, loss of periodontal proprioception, low<br />
[3]<br />
masticatory efficiency, etc. Over <strong>denture</strong> therapy is<br />
essentially a preventive prosthodontic concept since it<br />
attempts to conserve the few remaining natural teeth.<br />
There are two physiologic tenets related to this therapy:<br />
the first concerns the continued preservation of alveolar<br />
[4]<br />
bone around the retained teeth while the second relates<br />
to the continuing presence of periodontal sensory<br />
mechanisms that guide and monitor gnathodynamic<br />
[5]<br />
functions . Removable <strong>denture</strong>s attached by means of<br />
telescopic anchors are regarded to be a good clinical<br />
solution. <strong>Telescopic</strong> crowns were initially introduced as<br />
retainers for removable partial <strong>denture</strong>s. (RPDs) These<br />
crowns consist of an inner or primary telescopic coping,<br />
permanently cemented to an abutment, and a congruent<br />
detachable outer or secondary telescopic crown, rigidly<br />
connected to a detachable prosthesis. Copings were<br />
designed to protect the abutment from dental caries and<br />
thermal irritations and also provided retention and<br />
stabilization of the secondary crown. The secondary<br />
crown engages the primary coping to form a telescopic<br />
unit and serves as an anchor for the remainder of the<br />
dentition.<br />
Synonyms<br />
Overlay <strong>denture</strong>, telescoped <strong>denture</strong>s, tooth supported<br />
<strong>denture</strong>s, hybrid prosthesis, crown and sleeve prosthesis,<br />
and the superimposing <strong>denture</strong>s.<br />
Address for correspondence:<br />
Dr. Ravikumar<br />
E-mail: drravi_kn@yahoo.com<br />
Access this article online<br />
Website: http://www.ssdctumkur.<strong>org</strong>/jdsr.php<br />
10<br />
Non plagiarized Content<br />
declaration provided by<br />
author<br />
Yes<br />
Case report<br />
A 60 year old male patient reported to the department of<br />
Prosthodontics, Crown &Bridge and Implantology <strong>with</strong>
Vol. 3, Issue 1, February 2012<br />
the chief complaint of difficulty in chewing and<br />
dissatisfaction <strong>with</strong> his speech. Patient gave history of<br />
loss of teeth since three years due to caries and gum<br />
problems. On extra-oral examination patient had a<br />
convex profile and TMJ was normal.<br />
Intra-oral examination revealed remaining 34, 35, 43 and<br />
45 teeth, <strong>with</strong> edentulous maxillary arch. The edentulous<br />
span had favorable ridge <strong>with</strong> firmly attached<br />
keratinized mucosa <strong>with</strong> respect to both arches. After<br />
clinical and radiographic evaluation, 43 have been<br />
extracted due to mobility and severe periodontitis. All<br />
treatment options were presented and discussed <strong>with</strong> the<br />
patient, including total extraction and conventional<br />
<strong>denture</strong>, cast partial <strong>denture</strong>, implant supported <strong>denture</strong>,<br />
telescopic <strong>complete</strong> <strong>denture</strong> <strong>with</strong> lower arch and<br />
conventional or implant supported over <strong>denture</strong> <strong>with</strong><br />
upper arch. After considering financial aspect, and<br />
amount of time the patient elected to have conventional<br />
upper <strong>complete</strong> <strong>denture</strong> and telescopic lower <strong>complete</strong><br />
<strong>denture</strong>. After taking consent from patient, oral<br />
prophylaxis, root planning and endodontic treatment of<br />
abutment teeth i.e 34, 35 and 45 were carried out,<br />
emphasizing oral hygiene instruction and maintenance.<br />
After assessing endodontic therapy, tooth preparation<br />
was done for receiving primary copings to 35 and 45.<br />
Impressions were made by putty reline technique. Wax<br />
pattern were invested, cast, finished and modified on<br />
surveyor for parallelism, castings were polished and<br />
cemented in patient mouth. (Fig-1) Post space was<br />
prepared and recorded to 34. (Fig-2a) Custom made cast<br />
dowel and stud were fabricated by using burnout post and<br />
cemented to 34. (Fig-2b)<br />
Border moulding and secondary impression were carried<br />
out and stud attachment was replicated <strong>with</strong> acrylic resin<br />
on the master cast. (Fig-3) Custom made female<br />
attachment analog to 34 and x-ray foil to primary coping<br />
were attached. Temporary <strong>denture</strong> bases and occlusal<br />
rims were fabricated upon this. Maxillomandibular<br />
relationship and teeth selection was done and definitive<br />
casts were mounted on semi-adjustable articulator. In the<br />
mean time secondary copings <strong>with</strong> interconnecting<br />
Fig 1. Primary copings cemented on 35 & 45<br />
Fig 2(a) : Cast showing Post Space<br />
Fig 2(b) : Custom made stud attachment on 34<br />
Fig 3 : Custom made acrylic resign stud<br />
attachment on master last<br />
11
Journal of Dental Sciences and Research<br />
lingual bar was fabricated on duplicated casts and<br />
evaluated intraorally for fit, retention, and stability.<br />
Artificial acrylic resin teeth were arranged in bilateral<br />
balanced occlusal scheme <strong>with</strong> wax patterns on the<br />
secondary copings. Porcelain firing was carried<br />
out on the resulted wax patterns shape. During<br />
try-in appointment windows were created on<br />
trial <strong>denture</strong> to pick-up secondary copings <strong>with</strong><br />
interconnecting bar by using putty index and placed on<br />
the master cast to ensure single path of insertion and<br />
removal as shown in the picture. (Fig-4a) Esthetics,<br />
phonetics, maxillomandibular relation, retention,<br />
stability etc all are checked during try-in appointment.<br />
Vertical slots were created on interconnecting bar for<br />
mechanical retention <strong>with</strong> heat cure acrylic resin.<br />
(Fig-4b) Dentures were finished and polished in<br />
conventional method, female component for the stud<br />
attachment was placed by direct method using<br />
autopolymerising resin and inserted. (Fig-5 and Fig-6)<br />
Occlusion was evaluated and adjusted, post operative<br />
instructions on how to insert and maintain the prostheses<br />
and also adequate oral hygiene maintenance were given.<br />
After minor adjustments during post insertion visits, the<br />
patient was placed on a six month recall visit.<br />
Discussion<br />
It is a documented fact that after the loss of the teeth the<br />
residual alveolar ridge undergoes rapid loss in all<br />
dimensions. The residual ridge resorption (RRR) is<br />
stated to be rapid, progressive, irreversible and<br />
inevitable and has been well observed and documented in<br />
[7,8]<br />
literature . It is equally well observed that bone is<br />
maintained around long standing teeth and implants.<br />
Retaining teeth as over <strong>denture</strong> abutments seems to slow<br />
[9,10]<br />
the rate of alveolar resorption . The physiologic<br />
objective is to provide for the tensile stimulation of as<br />
Fig 4(a) : Inter connecting bar and secondary Copings<br />
Fig 4(b) : Vertical slots on Inter connecting bar<br />
Fig. 5 : Female component on Intalgio sorface of<br />
<strong>denture</strong><br />
Fig 6 : Prosthesis - Intra Oral View<br />
12
Vol. 3, Issue 1, February 2012<br />
many of the oblique periodontal fibers as possible, the<br />
end result is the deposition of more bundle bone followed<br />
by concomitant decrease in abutment mobility.<br />
The support provided by the abutment teeth is in<br />
addition to that supplied by the residual ridges. The<br />
stability is enhanced by the vertical component of the<br />
retained tooth/root in the alveolar bone. The factors of<br />
border seal and tissue adaptation are more constant<br />
during function in over <strong>denture</strong>s than in conventional<br />
<strong>denture</strong>s, and retention is enhanced by the increased<br />
support and stability. An additional feature is<br />
proprioception through the periodontal fibers, over<br />
<strong>denture</strong>s gives a patient a sense of discrimination to touch<br />
and pressure, which is less possible by using<br />
[4, 6, 10]<br />
conventional <strong>complete</strong> <strong>denture</strong>s .<br />
There are many advantages of telescopic crowns like<br />
axial load of the tooth and full covering of the abutment<br />
(on the contrary to clasps), which may reduce tilting<br />
forces <strong>with</strong> their negative influence on abutment<br />
supporting tissues. The axial forces stimulate<br />
periodontal tissues and alveolar bone. They also provide<br />
indirect splinting influence, easy oral hygiene<br />
[6]<br />
maintenance and easy ways of repair . In this case the<br />
interconnecting lingual bar to the secondary copings and<br />
stud attachment ensures single path of insertion and<br />
removal, retention and stability to the lower <strong>denture</strong>.<br />
2. Epstein DD, Epstein PL, Cohen BI, Pagnillo MK:<br />
Comparision of the retentive properties of six prefabricated<br />
post over <strong>denture</strong> attachment systems. J Prosthet Dent 1999;<br />
82:579-84.<br />
3. Reitz PV, Weiner MG, Levin B: An over <strong>denture</strong> survey;<br />
Preliminary report. J Prosthet Dent 1977; 37:246-58.<br />
4. Prince IB. Conservation of the supporting mechanism.<br />
J Prosthet Dent 1965;15:327.<br />
5. Yalisove IL. Crown and sleeve coping retainers for removable<br />
partial prosthesis. J Prosthet Dent 1966;16:1069-85.<br />
6. Langer Y, Langer A. Tooth supported telescopic prostheses in<br />
compromised dentitions: A clinical report. J. Prosthet Dent.<br />
2000;84:129-32.<br />
7. Toolson LB, Smith DE. A two year longitudinal study of<br />
over<strong>denture</strong> patients, Part 1: Incidence and control of caries on<br />
over<strong>denture</strong> abutments. J Prosthet Dent 1978;40:486-91.<br />
8. Atwood DA: Reduction of residual ridges; A major oral<br />
disease entity. J Prosthet Dent 1971;26:266-279.<br />
9. Tallgren A. The continuing reduction of the residual alveolar<br />
rides in <strong>complete</strong> <strong>denture</strong> wearers: a mixed longitudnal study<br />
covering 25 years. J Prosthet Dent 1972;27:120-32.<br />
10. James L. Lord and Stephen Teel.: “The over<strong>denture</strong>: Patient<br />
selection, use of copings, and follow-up evaluation”.<br />
J. Prosthet. Dent., 1974; 32:41-51.<br />
As the over <strong>denture</strong> status of the prosthesis and its<br />
benefits to the patient depend solely on the continued<br />
retention of the underlying abutments, it becomes<br />
obligatory to periodically monitor their health and<br />
institute necessary steps to prolong their useful span.<br />
Here in lies the importance of periodical recall and<br />
review and patient motivation which makes over <strong>denture</strong><br />
therapy a continued service.<br />
Although there are increased costs and appointments<br />
associated <strong>with</strong> this technique are, however justified<br />
because over <strong>denture</strong>s are a superior health service<br />
[1]<br />
compared to the standard <strong>complete</strong> <strong>denture</strong> .<br />
Conclusion<br />
As the coming decade are opting for Branemark<br />
introduced 'third dentition of titanium roots' i.e implants,<br />
tooth / root supported over <strong>denture</strong> still remains excellent<br />
treatment modality, which is cost effective, if fabricated<br />
well <strong>with</strong> good clinical and laboratory Expertise,<br />
maintained <strong>with</strong> excellent care, then each telescopic over<br />
<strong>denture</strong> treatment can be a successful one.<br />
REFERENCES:<br />
1. Bolender C, Zarb G, Carisson G: Boucher's prosthodontic<br />
treatment for edentulous patients. 11th ed. St.Louis Mosby<br />
year book, 1997:46-47.<br />
13