T i t a n i u m f r a m e w o r k r e m o v a b l e p a r t i a l d e n t u r e u s e d for p a t i e n t a l l e r g i c to o t h e r metals: A clinical r e p o r t and literature review

Mauno KSn6nen, DDS, Odont Dr, a Juha Rintanen, DDS, b Antii Waltimo, DDS, c and Pentti Kempainen, DDS, PhD c Institute of Dentistry, University of Helsinki, Helsinki, Finland

N u m e r o u s articles have described hypersensitivity and toxic reactions to dental materials. The most common is acrylic resin polymers, especially the liquid monomer component, when used for denture bases and crown facings. 1S Metal sensitivity reactions t h a t develop through cutaneous contact are exceptionally common in the population. 915 Local hypersensitivity and toxic reactions are reported less often regarding metals and alloys used in intraoral prosthetic devices. Case reports have described sensitivity reactions to g o l d 1618 and gold alloys 4,19-25 and alloys t h a t contain cobalt, chromium, and molybdenum. 26 It has been reported t h a t nickel, cobalt, and chromium used in a denture base alloy may cause not only local sensitivity such as gingivitis and stomatitis b u t also sensitivity t h a t results in eczema and dermatitis without mucosal manifestations. 2733 Of the base metals, titanium and its alloys m a y be one alternative for a patient who is sensitive to chrome-cobalt alloy and who needs prosthetic devices.34, 35 Removable partial denture frameworks of titanium can be manufactured by casting. 35, 36 CLINICAL REPORT

In 1984 a male p a t i e n t who was allergic to cobalt, as confirmed by epicutaneous test (1% cobalt chloride), sought t r e a t m e n t at the Institute of Dentistry, University of Helsinki, for partial edentulism in the mandible. The patient had complete maxillary dentition, except for the left firs~~ molar and a decayed root of the left lateral incisor. Mandibular teeth were missing distal to the left cuspid and distal to the right second premolar (Fig. 1). The occluding teeth were worn. The t r e a t m e n t plan included post crowns and a three-unit fixed partial denture in the maxilla. Because metals m a y cause skin disorders in some patients, but not mucosal manifestations, it was decided in cooperation with the p a t i e n t to make a partial denture with a chromecobalt framework for the mandible.

aActing Professor, Department of Prosthetic Dentistry. bDentist, Department of Prosthetic Dentistry. CAssistant Professor, Department of Prosthetic Dentistry. J PROSTHETDENT 1995;73:4-7. Copyright 9 1995 by The Editorial Council of THE JOURNALOF PROSTHETIC DENTISTRY. 0022-3913/95/$3.00 + 0. 10/1/59082
4 THE JOURNAL OF PROSTHETIC DENTISTRY

In 1986 the patient claimed intraoral symptoms occurred when a m a n d i b u l a r partial denture was used. After a short use of the denture, symptoms occurred in the following order: soreness and burning of labial mucosa; dryness of the mouth; and, after the mouth dried, soreness and redness of the tissues. Subsequently, the throat dried and felt sore and vesicles were manifest in the palatal mucosa. The symptoms ceased after removal of the denture. It was decided to remove acrylic resin parts of the denture and to electroplate the metal framework with gold to prevent corrosion of the base metal alloy (Leleux P G 1, Dental Ger~ite Leleux, Germany). During a 2-week wearing period the denture did not appear to cause any symptoms. The patient was instructed to contact the school if the intraoral or general symptoms returned. In 1987 the patient returned for an annual checkup and stated t h a t after the gold plating had worn away from some places on the metal, the symptoms had occurred again. He removed the partial denture and was now reluctant to use any kind of metal-containing partial denture. During his annual dental checkup in 1991, he was told about the availability of titanium for making the partial denture framework. Because of additional attrition of teeth and increased chewing difficulties, the patient was willing to t r y a bilateral distal extension partial denture made of commercially pure titanium (ASTM Grade 2) (Fig. 2). A titanium framework Was made and a radiograph was taken to check for possible pores in the casting. Some minor pores were detectable. Clinically, the precision of the t i t a n i u m framework was acceptable and the retention of the cast titanium clasps was adequate. One week after insertion and wearing of the denture the patient was examined clinically and interviewed and no signs or symptoms t h a t suggested sensitivity reactions were found. Further, after 2 years of use no complications occurred and the precision of the framework and the retention of the clasps are well maintained. The oral mucosa and periodontium were healthy and there were no adverse reactions (Fig. 3). The p a t i e n t was pleased with the denture, especially because the titanium framework was comfortable, tasteless, and warm. DISCUSSION Commercially pure t i t a n i u m is classified into so-called grade classes according to its content of oxygen, carbon,
V O L U M E 73 NUMBER 1

K6N6NEN ET AL

THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 1. Panoramic radiogram of patient's dentition.

Fig. 2. Occlusal view of prosthesis in mouth.

hydrogen, and iron. Although these species are usually regarded as impurity elements, addition of oxygen and iron is used to increase the strength of titanium. Because of its unique mechanical and chemical properties, commercially pure titanium is an ideal biomaterial. The casting of titanium requires special equipment and materials because of its high melting point, low specific gravity, and reaction with oxygen at high temperatures. Even with special casting methods, pores may develop during the casting process, especially with complicated structures. 37, 3s Therefore castings should be examined with nondestructive methods; for
JANUARY 1995

example, with radiographs. On the other hand, the allotropic transformation of titanium allows as-cast products to be improved with, for example, heat treatment or hot isostatic pressing. These treatments eliminate porosities and change the microstructures to improve the mechanical properties. Although 2 years with no complications is a relatively short time, the sensitivity to other metals was manifest in a few days. Therefore it seems that titanium is a suitable material for a removable partial denture framework for this patient and it may be an ideal alternative for other allergic
5

THE JOURNAL OF PROSTHETIC DENTISTRY

K6NONEN ET AL

F i g . 3. Occlusal view of oral m u c o s a after 2-year wearing of partial d e n t u r e with t i t a n i u m framework.

patients. A t i t a n i u m f r a m e w o r k m u s t be p l a n n e d w i t h respect to rigidity. T h e f r a m e w o r k in this r e p o r t d e m o n s t r a t e d noticeable horizontal flexibility, b u t little vertical flexibility. In t h e m o u t h , t h e t i t a n i u m f r a m e w o r k was stable on t h e r e m a i n i n g teeth. T h e clasps f u n c t i o n e d well because of the good recovery p r o p e r t i e s of t i t a n i u m . T h e pat i e n t ' s c o m m e n t s a b o u t the t i t a n i u m f r a m e w o r k ' s being comfortable, tasteless, and w a r m can be explained because of t h e excellent corrosion resistance and low t h e r m a l cond u c t i v i t y of t i t a n i u m . T h e sensitivity reaction can occur only if a given m e t a l or m e t a l alloy corrodes in an application e n v i r o n m e n t . T h u s t i t a n i u m and its alloys are m a t e rials of choice for d e n t a l p r o s t h e t i c devices because t h e y show excellent corrosion resistance and b i o c o m p a t i b i l i t y in t h e oral e n v i r o n m e n t . 39, 40 T h e corrosion resistance results f r o m the strong t e n d e n c y of t i t a n i u m to f o r m t h e r m o d y n a m i c a l l y stable and m e c h a n i c a l l y a d h e r e n t continuous oxide layers on its surface. 39 T h e r e are only two cases of rep o r t e d h y p e r s e n s i t i v i t y to t i t a n i u m alloys in man, namely, Ti_6A1.4V.41,42 M i t c h e l l et al. 43 r e p o r t e d on two p a t i e n t s who had skin grafts in t h e m a n d i b l e and in w h o m persist e n t epithelial h y p e r p l a s i a d e v e l o p e d s u r r o u n d i n g the a b u t m e n t s m a d e of c o m m e r c i a l l y p u r e t i t a n i u m . T o our knowledge c o m m e r c i a l l y p u r e t i t a n i u m has n e v e r been rep o r t e d to h a v e caused adverse reactions on original oral mucosa.
CONCLUSION

ular for this use. In this clinical report, a r e m o v a b l e partial d e n t u r e with a t i t a n i u m f r a m e w o r k was m a d e for a p a t i e n t w i t h a partially e d e n t u l o u s m a n d i b l e who was hypersensitive to o t h e r metals. T h e d e n t u r e has b e e n in use more t h a n 2 years with no complications. It seems t h a t t i t a n i u m is a suitable m a t e r i a l for r e m o v a b l e partial d e n t u r e frameworks and it m a y be an ideal a l t e r n a t i v e for patients allergic to other metals.
REFERENCES

T i t a n i u m is a relatively new m a t e r i a l for r e m o v a b l e partial d e n t u r e frameworks. As casting procedures and m a t e rials develop, t i t a n i u m will m o s t likely become more pop-

1. Crisseys JT. Stomatitis, dermatitis and denture materials. Arch Dermatol 1965;92:45-8. 2. Fernstr6m AI, ()quist G, S6remark R. Location of the allergenic monomer in warm-polymerized acrylic dentures. Swed Dent J 1982;6:87-91, 3. Fisher AA. Allergic sensitization of the skin and oral mucosa to acrylic denture materials. J PROSTHETDENT1956;6:593-602. 4. Fisher AA. Contact dermatitis. Philadelphia: Lea and Febiger, 1973:87. 5. Hensten-Pettersen A. Dermatitis and dental materials. Contact Dermatitis 1981;7:174-5. 6. Heys RJ. Biologic considerations of composite resins. Dent Clin North Am 1981;25:257-70. 7. Sisca RF' Th~ JC' L~ DA' Ge~ WA" Resp~ ~ epitheliallike cells in tissue culture to implant materials. J Dent Res 1967;46:24852. 8. Spangberg L, Rodrigues H, Langeland L, Langeland K. Biological effects of dental materials. II--toxicity of anterior tooth restorative materials on Hela-cells in vitro. Oral Surg 1973;36:713-24. 9. Camarasa JMG, Aspiolea F, Alomar A. Patch tests to metals in childhood. Contact Dermatitis 1983;9:157-8. 10. Hammershoy 0. Standard patch tests results in 3,225 consecutive Danish patients from 1973 to 1977. Contact Dermatitis 1980;6:263-8. 11. Menne T, Thorboe A. Nickel-dermatitis-nickel excretion. Contact Dermatitis 1976;2:353-4. 12. Peltonen L. Nickel sensitivity in the general population. Contact Dermatitis 1979;5:27-32. 13. Peltonen L, Fraki J. Prevalence of dichromate sensitivity. Contact Dermatitis 1983;9:190-4.

VOLUME 73

NUMBER 1

K~}NONEN ET AL

THE JOURNAL OF PROSTHETIC DENTISTRY

14. Rudner EJ, Clendenning WE, Epstein E, et al. Epidemiology contact dermatitis in North America 1972. Arch Dermatol 1973;108:537-40. 15. Rudner EJ, Clendenning WE, Epstein E, et al. The frequency of contact dermatitis in North America 1972-74. Contact Dermatitis 1975; 1:277-80. 16. Bergenholtz A, Hedegard B, Soremark R. Studies of the transport of metal ions from gold inlays into environmental tissues. Acta Odontol Scand 1965;23:135-46. 17. Izumi AK. Allergic contact gingivostomatitis due to gold. Arch Dermatol Res 1982;272:387-91. 18. S6remark R, Freedman G, Goldin J, Gettleman L. Structure and microdistribution of components of gold alloys. J Dent Res 1966;45:172335. 19. Elgart ML, Higdon RS. Allergic contact dermatitis to gold. Arch Dermatol 1971;103:649-53. 20. Fischer T, Fregert S, Gruvberger B, Rystedt I. Contact sensitivity to nickel in white gold. Contact Dermatitis 1984;10:23-4. 21. Fregert S, Kollander M, Poulsen J. Allergic contact stomatitis from gold dentures. Contact Dermatitis 1979;5:63-4. 22. Klaschka F. Contact allergy to gold. Contact Dermatitis 1975;1:264-5. 23. Shepard FE, Grant GC, Moon PC, Fretwell LD. Allergic contact stomatitis from a gold alloy-fixed partial denture. J Am Dent Assoc 1983;106:198-9. 24. Wiesenfeld D, Ferguson MM, Forsyth A, MacDonald DG. Allergy to dental gold. Oral Surg 1984;57:158-60. 25. Young E. Contact hypersensitivity to metallic gold. Dermatologica 1974;149:194-8. 26. Brockhurst PJ, McLaverty V. Alloys for crown and bridgework. Aust Dent J 1981;26:287-94. 27. Blanco-Dalmau L, Carrasquillo-Alberty H, Silva-Parra J. A study of nickel allergy. J PROSTHETDENT 1983;52:116-9. 28. Brendlinger DL, Tarsitano JJ. Generalized dermatitis due to sensitivity to a chrome cobalt removable partial denture. J Am Dent Assoc 1970;81:392-4. 29. deMelo J, Gjerdet NR, Erichsen ES. Metal release from cobaltchromium partial dentures in the mouth. Acta Odontol Scand 1983; 41:71-4. 30. Hildebrand HF, Veron C, Martin P. Les alliages dentaires en metaux non precieux et l'allergie. J Biol Buccale 1989;17:227-43. 31. Hubler WR Jr, Hubler WR Sr. Dermatitis from a chromium dental plate. Contact Dermatitis 1983;9:377-83.

32. Levantine A, Bettley F. Sensitivity to metal dental plate. Proc R Soc Med 1974;67:1007. 33. Mj~r I, Christensen GJ. Assessment of local side effects of casting alloys. Quintessence Int 1993;24:343-51. 34. Andersson M, Bergman B, Bessing C, Ericson G, Lundquist P, Nilsson H. Clinical results with machine duplication and spark erosion. Acta Odontol Scand 1989;47:279-98. 35. Yamauchi M, Sakai M, Kawano J. Clinical application of pure titanium for cast plate dentures. Dent Mater J 1988;7:39-41. 36. Blackman R, Barghi N, Tran C. Dimensional changes in casting titanium removable partial denture frameworks. J PROSTHET DENT 1991;65:309-15. 37. Bessing C, Bergman B. The castability of unalloyed titanium in three different casting machines. Swed Dent J 1992;16:109-13. 38. Watanabe K, Okawa S, Miyakawa O, Nakano S, Shiokawa N, Kobayashi M. Molten titanium flow in a mesh cavity by the flow visualization technique. Dent Mater J 1991;10:128-37. 39. Schutz RW, Thomas DE. Corrosion of titanium and titanium alloys. In: ASM Handbook Committee. Metals handbook (Corrosion; vol 13). 9th ed. Metals Park, Ohio: ASM International, 1987:669-706. 40. Van Noort R. Titanium: the implant material of today. J Mater Sci 1987;22:3801-11. 41. Lalor PA, Revell PA, Gray AB, Wright S, Railton GT, Freeman MAR. Sensitivity to titanium: a cause of implant failure? J Bone Joint Surg Br 1991;73-B:25-8. 42. Peters MS, Schroeder AL, van Hale HM, Broadment JC. Pacemaker contact sensitivity. Contact Dermatitis 1984;11:214-8. 43. Mitchell DL, Synnott SA, VanDercreek JA. Tissue reaction involving an intraoral skin graft and CP titanium abutments: a clinical report. Int J Oral Maxillofac Implants 1990;5:79-84. Reprint requests to: DR. MAUNOKbNbNEN DEPARTMENT OF PROSTHETICDENTISTRY INSTITUTEOF DENTISTRY P.O. BOX 41 UNIVERSITYOF HELSINKI(MANNERHEIMINTIE172) SF-00014 HELSINKI FINLAND

J A N U A R Y 1995