Journal of Experimental Medical & Surgical Research Cercetri Experimentale & Medico-Chirurgicale Year XV Nr.3/2008 Pag.

96-99

JOURNAL of
Experimental

Medical

Surgical

R E S E A R C H

TITANIUM COMPLETE DENTURE BASE IN A PATIENT WITH HEAVY BRUXISM: A CLINICAL REPORT
Corina Mrcueanu1, Luciana Gogu2, Anca Jivnescu2, Enik Demjan1, D. Bratu 2
SUMMARY Bruxism is a parafunctional habit that can affect complete denture wearers too. The most frequent problem encountered by these patients is the repeated fracture of the maxillary complete denture caused by flexural fatigue. The situation of a heavy bruxer treated with a titanium maxillary denture base is described. Titanium bases are ideal for maxillary dentures subjected to severe mechanical stresses in bruxing patients. In addition the patient should avoid wearing dentures during sleep and the dentist can decrease awake bruxism by making the patient aware of it and by managing psychogenic stress. Key Words: bruxism, complete denture, titanium BAZ DIN TITAN LA UN PROTEZAT TOTAL CU BRUXISM SEVER: PREZENTARE DE CAZ Rezumat: Bruxismul este un obicei parafuncional care poate afecta i purttorii de proteze totale. Problema ntlnit cel mai frecvent la aceti pacieni este fractura repetat a protezei totale maxilare datorit oboselii la ncovoiere. Articolul prezint cazul unui bruxoman tratat cu o protez total cu baza din titan.

Received for publication: 20.03.2008 Revised: 05.06.2008

1 - Department of Occlusion and Temporomandibular Disorders, 2 -Department of Prosthodontics, Faculty of Dental Medicine, University of Medicine and Pharmacy Victor Babe Timioara,

INTRODUCTION
Poly methyl methacrylate (PMMA) denture bases have good mechanical, biological and aesthetic properties. However, they may fail because of excessive para functional and/or functional forces (in cases of bruxism and/or complete dentures opposing natural mandibular teeth). In such circumstances metals or metal alloys can be used to strengthen the denture bases.1 These thin metallic bases have several advantages, besides rigidity and fracture resistance, like: excellent strength to volume ratio, good adaptation to the supporting tissues, enhanced control of denture plaque, high thermal conductivity, high biocompatibility, no dimensional changes in time through fluids absorption and no interferences with phonation.2-5 A treatment approach in a bruxing complete denture wearer is described.

CLINICAL REPORT
Bruxism is a para functional habit that can affect complete denture wearers too. A 60 year old male patient had been wearing dentures for four years. He was grinding the acrylic resin artificial teeth both while being awake and during sleep (Fig. 1.). The occlusal surfaces are flattened and the patient is complaining of poor masticatory efficiency (Fig. 2.). The maxillary complete denture has recurrently fractured and was repaired several times with autopolymerizing acrylic resin (Fig. 3.). Retention and stability of the old dentures were good. Clinical functional analysis revealed no signs or symptoms of temporomandibular disorders. The supporting soft tissues of the edentulous maxilla had no lesions or painful spots. The patient was advised to remove his dentures during the night. His diurnal bruxism was more difficult to handle.

Correspondence to: Dr. Corina Mrcueanu , phone nr. 0741182478, e-mail: marca_cori@yahoo.com

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Fig. 1. Excessive wear of acrylic resin complete denture teeth due to heavy bruxism.

Fig. 2. Wear facets on all denture teeth typical for horizontal parafunctional mandibular movements.

Fig. 3. Fracture of maxillary poly methyl methacrylate denture base under severe mechanical stress

The diagnosis of diurnal bruxism was confirmed by the increased masseter muscle electromyographic activity during ten minutes of silent reading.6 The patient developed heavy occlusal strains, which could explain the maxillary denture fracture through flexural fatigue.7 He needed a reinforced denture base. A maxillary metal

base cast from titanium was chosen to enhance the physical properties. All stages in denture manufacturing were carried out in accordance with standard practice. The metal framework was cast using fourth degree titanium and the Titanplus Unit (Seitelettronica, Manfredi, Italy).

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Fig. 4. Maxillary denture framework cast in titanium. There is a shoulder between the palatal metallic sheet and the surrounding net that provides sufficient bulk to the acrylic resin.

A critical point of the metal dental base was the interface between titanium and acrylic resin. Improper positioning of metal-resin finish lines can affect phonetics and its incorrect design will adversely influence the mechanical behavior of the adjoining acrylic resin (Fig. 4. and Fig. 5.). The low density of titanium allowed a pre-clinical radiographic quality control of the metallic base for the detection of internal defects8. Anatomic acrylic resin teeth have been selected to prevent fast bone resorbtion of the residual ridges and to avoid chipping/fracture that often appears in porcelain artificial teeth (Fig. 6.). The anatomic design of the occlusal surfaces raised some problems in the accommodation of the bruxing patient with the new dentures. He was accustomed with flattened occlusal surfaces. To help him, the diurnal parafunctional activity was reduced by education, voluntary avoidance, relaxation and biofeedback techniques.

DISCUSSION
There are several methods to increase the resistance to mechanical stress of a maxillary denture base. In a patient with recurrent fractures of the denture the choice must be made between a metal base (casted Cr-Co alloy or titanium, galvanoformed pure gold) or a PMMA base reinforced with wire netting, carbon fibre, glass fibre or ultra-high modulus polyethylene. 3,4,9, 10 Why titanium denture bases are rather used in heavy bruxers? A titanium denture base is lighter than the one cast from a Cr-Co alloy due to the low density of titanium (4,5 g cm-3).4,8 Its rigidity and mechanical resistance are much better than those of a galvanoformed gold denture base. The adaptation to supporting tissues of complete dentures reinforced with metal wire (1.0 mm in diameter) decreases in comparison with the unreinforced ones regardless of the polymerization method.11

Fig. 5. Maxillary complete denture with titanium framework. The metallic net covers the residual ridge and the posterior palatal seal area. This design offers optimum retention for the acrylic resin, a good marginal palatal seal and facilitates denture relining for the compensation of osseous resorption

Fig. 6. Stable centric stops and bilateral balanced occlusion obtained with anatomic acrylic resin teeth.

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Carbon or glass fibers and ultra-high modulus polyethylene are difficult to use from the point of view of the dental technician because of their processing characteristics.7 These reasons contributed to the selection of the titanium denture base. The main disadvantage of the titanium base is its high cost, conditioned by the increased incidence of failures as well as by the prolonged casting process.

CONCLUSIONS
Titanium bases are ideal for maxillary dentures subjected to severe mechanical stresses in bruxing patients. In addition the patient should avoid wearing dentures during sleep and the dentist can decrease awake bruxism by making the patient aware of it and by managing psychogenic stress.

REFERENCES 1. Ohkubo C., Kurtz K.S., Suzuki Y., Hanatani S., Abe M., Hosoi T. Comparative study of maxillary complete dentures constructed of metal base and metal structure framework. Journal of Oral Rehabilitation 2001; 28: 149156 2. Craig RG. Restorative dental materials. Twelfth Edition. St. Louis Mosby Year Book 2006:502-50. 3. Da Silva L, Martinez A, Rilo B, Santana U. Titanium for removable denture bases. J Oral Rehabil 2000;27:131-5. 4. Satyabodh Guttal, Narendra P. Patil. Cast titanium overlay denture for a geriatric patient with a reduced vertical dimension. Case report. Gerodontology 2005; 22: 242245 5. Thomas CJ, Lechner S, Mori T. Titanium for removable dentures. II. Two-year clinical observations. J Oral Rehabil 1997;24: 414-8. 6. Piquero K, Sakurai K. A clinical diagnosis of diurnal (non-sleep) bruxism in denture wearers. J Oral Rehabil 2000;27:473-82. 7. Jagger DC, Harrison A, Jandt KD. The reinforcement of dentures. Review. J Oral Rehabil 1999;26:185-94. 8. Mori T, Togaya T, Jean-Louis M, Yabugami M. Titanium for removable dentures. I. Laboratory procedures. J Oral Rehabil 1997;24:338-41. 9. Schneider RL, Stokes JL, LaDuke D. Design and fabrication technique for metal palates in maxillary complete dentures. J Dent Technol 2000;17:8-11. 10. Karacaer O, Dogan OM, Tincer T & al. - Reinforcement of maxillary dentures with silane-treated ultra high modulus polyethylene fibers. J Oral Sci 2001;43:103-107. 11. Teraoka F, Nakagawa M, Takahashi J. Adaptation of acrylic dentures reinforced with metal wire. J Oral Rehabil 2001;28:937-42.

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