Prosthodontics

Planning fixed partial dentures for severely misaligned abutments

Gabriel R. Zuckerman*
Abstract

fVhen the abtttment teeth of a fixed partial denture are severely mlmligned.
insertion ofthe pmsthesis becotnes tnore difficult. Some ofthe tnethods
traditionally recomtnended to overcome the probletns associated with this situation
are examitied. Otie design that simplifies treatment and improves the prosthesis is
suggested. (Quintessence hit 1996:27:527-532.)

Clinical relevance

A segmented fixed partial denture design with an

extracoronal interlocking attachment made from
prefabricated plastic patterns is tnore esthetic and
requires less tooth reduction than do traditional
designs recommended for ftxed partial dentures on
severely misaligned abutments.

Introduction
Placement of a fixed partial denture (FFD) can be
complicated by misaligned abutment teeth. Ideaily, the
long axes ofthe abutment teeth of an FPD shouid be
parallel to one another. When the abutment teeth are
severely misaligned, the design for the proposed
prosthesis must be modified. Careful platining prior to
treatment is necessary if the prosthetic result is to be
predictable and successful. Misalignment is most
frequently encountered when a mandibular first molar
is to be replaced after the second and third molars have
drifted and tilted mesially and lingually (Fig I ).
Traditional procedures
Orthodontics
Use of orthodontic treatment to upright the mesially
tipped molar has been suggested.'- Aithough this
approach is ideal, patients are often reluctant to
* Private Practice, East Nonhpon, New York.
Reprint requests: Dr Gabriel R. Zuekerman, 1199 Fifth Avenue, East
Northporl, New York 11731.

Quintessence International

Volume 27, Number 8/t996

commit the time and funds necessary for this extended

and extensive treatment, requiring the coordinated
services of an orthodontist and a restorative dentist.
A Itered path of insertion
It is possible to prepare the molar abutment with a path
of insertion that is compatible with the premolar preparation, but this approach has several disadvantages.
The retention and resistance of the molar prepared
under these conditions are severely compromised,-"'*
and the risk of creating a mechanical exposure ofthe
mesial pulp horn ofthe molar is increased. Furthermore, the mesial marginai ridge ofthe third molar, if
present, would interfere with insertion ofthe prosthesis (Fig 2).
Mesial half-crown retainer
Rosenstiel et a!^ and Shillingburg et ai- have recommended the use ofthe mesial half crown as a retainer
for tilted molars (Fig 3). A mesial half-crown retainer
has several disadvantages:
1. The mesial half crown cannot be used if the molar
has previously been restored on the distal surface.
2. Preparation ofthe molar could resuit in exposure of
the mesial pulp horn.
3. The patient may object to the use of a cast-metal
restoration.
4. Caries occurring on the unrestorcd distai surface of
the second molar abutment after insertion ofthe
prosthesis jeopardizes the restoration.
Shillingburg et al- have suggested use of a complete
coping with retentive grooves and a teiescopic mesial
halfcrown for the molar retainer {Fig 4). A retainer of
this design requires more tooth reduction and could

527

Fig 1 The missing mandibular first molar has allowed

second and third molars to tilt mesially. Note the severe
misalignment between the long axes of the second premolar (A) and the second molar (B),

Fig 2 Three-unit FPD with rigid connectors. The prosttiesis will not seat because the distal margin of the molar
retainer engages the mesial marginal ridge of the third
molar during insertion. Note the proximityof the mesial pulp
horn to the mesial axial wall of the molar preparation.

Fig 3 Three-unit FPD with rigid connectors. The second

molar abutment has been prepared for a mesial half-crown
retainer with facial and lingual grooves for added retention.
Note the proximity of the mesial pulp horn to the mesial axial
wall of the molar preparation.
Fig 4 fr/gh Three-unit FPD with full coping and telescopic
mesial half crown on the molar abutment.

result in pulpal exposure or an overcontoured retainer.

Preparation of the tooth for the complete-coverage
coping would be excessively tapered. Even if retention
between the mesial half crown and the coping were
ideal, retention ofthe coping to the abutment tooth
might fail because of the excessively tapered tooth
preparation,^-^
Segmented FPD
The use of a segmented FPD, in which each section of
the prosthesis has its own path of insertion and there is
a mechanical interlock between segments, has been
528

advocated. The literature contains a variety of segmented prosthetic designs recommended to overcome
the problems associated with insertion of an FPD
when the abutments are divergent,
Shillingburg et a|- have suggested the use of a
segmented FPD with a nonrigid attachment between
the second premolar retainer and pontic. This design
requires tooth preparation ofthe premolar with a box
on the distal surface to accommodate the female
component of a nonrigid connector (Fig 5), Tooth
preparation of the premolar to accomrnodate this
connector could jeopardize the pulp and the retentive
Quintessence International

Volume 27, Number 8/1996

Fig 5 Segmented FPD witb nonrigid connector between

premolar and pontic. Excessive tooth reduction s required
to accommodate the female section of the interlock on the
distal surface of the premolar retainer.

properties ofthe preparation. The ocelusal surface of

the nonrigid attachment is visible on the occlusal
surface ofthe anterior retainer and can be cosmetically
objectionable to the patient. It is also possible to
design the prosthesis so that the female component of
the nonrigid connector is on the mesial surface ofthe
molar retainer (Fig 6)- However, the preparation of
the molar abutment to accommodate this configuration increases the risk of pulpal exposure and compromises the retention ofthe molar preparation,
O'Connor et a!^ have proposed a segmented FPD
with a split pontic containing a nonrigid connector
The nonrigid connector is oriented parallel to the path
of insertion ofthe molar retainer. The gingival half of
the pontic is connected to the distal surface of the
premolar retainer and contains the male component of
the nonrigid cormector. The occlusal half of the pontic
is attached to the molar retainer and houses the female
component ofthe nonrigid connector (Fig 7). This
complex design is time consuming to produce and,
when completed, results in an unesthetic display of
metal at the base of the pontic.
Moulding et al^ have advocated the use of a
segmented FPD with a nonrigid cormector between
the premolar retainer and the pontic. The male
component ofthe connector is inverted and placed on
the distal surface ofthe premolar retainer, parallel to
the path of Insertion ofthe molar retainer (Fig 8),
When the nonrigid connector is positioned in this
location, there is an unsightly display of the metal
guiding planes of the connector, and a large gingival
embrasure is created below the connector

Quintessence International

Volume 27, Number 8/1996

Fig 6 Segmented FPD with an interlock between the

second molar retainer and the ponfic. Excessive tooth
reduction is required on the mesial surface of fhe second
molar abutment to accommodate the female portion of fhe
interlock.

Fig 7 Segmented FPD with a split pontic containing a

nonrigid connector.

Alternative procedure

A segmented FPD with a nonrigid connector between

the pontic and the molar retainer can be designed
without the disadvantages of the previously described
prostheses. The male portion of tbe nonrigid connector can be placed on the mesial surface of the molar
retainer and oriented parallel to the path of insertion of
the premolar retainer (Fig 9 ), The female section ofthe

529

Fig 8 Segmented FPD with a nonrigid connector. The

premolar has the maie portion of the inleriock on its distal
surface. Note the iarge gingival embrasure between the
premolar and the pontic.

Fig 9 Segmented FPD with the maie portion of tiie

interiook on the mesial surface of the second molar retainer
The tooth preparation of the second molar is retentive hut
without r^sii oi pulpal exposure.
Fig 10

(left) Design and dimensions of PDC components.

Fig 11 (below) ivtale portion of the PDC on tfie mesiai axiai

wail of the moiar retainer. (1) Guiding piane; (2| crest of
ridge; (3] gingival end of male PDC contoured to ridge.

Size 1mm)
Smail
i_arge

70

2.8
3.5

2.0
2.5

6.7
7.0

2.4
3.0

23
33

ao

nonrigid connector is located under the pontic in the

anterior segment ofthe prosthesis.
This design is ideal for metal-ceramic restorations.
Both abutments are prepared for metal-ceramic complete yeneer crowns with a path of insertion parallel to
their long axes. This allows the dentist to prepare the
teeth with maximum retention and minimal risk of
pulpa! exposure.
The male and female components of this nonrigid
connector are manufactured in two sizes and are listed
in the catalogs of denial supply dealers as Plastic
530

Dovetail Connector (PDC} attachments (Fig 10). The

PDC attachments are designed so that the mating
surfaces of male and female components restrict the
movements of the two segments of the FPD to ore
plane. If the vertical height for the connector is limited,
the PDC components may be reduced in height about
40% and still remain effective.
Disadvantages
Use of this design for FPDs with long spans should be
ayoided, particularly when the connector has beeti
Quintessence internationai

Voiurne 27, Number 8/1996

Zuckerman

Fig 12 Molar preparation with palh ot insertion along ts

long axis.

Fig 13 Molar retainer with male porlion of the PDC on Ihe

mesial surface. The nonrJgid conneotor is aligned parallel to
Ihe path ol insertion of the premolar preparation.

Fig 14 Anterior section ot FPD placed over the PDC and

on the premolar abutment.

Fig 15

reduced in height. Slight movement of the abutment to

which the pontics are rigidly connected can produce
excessive muvement between the components of the
nonrigid connector.
Another disadvantage of this design is that the
iaboratory costs for a segmented FPD are higher than
the cost of a rigidly assembled FPD. Furthermore,
most laboratory technicians are unfamiliar with this
unusuai application ofa nonrigid connector and will
have to he instructed accordingly.

4. The guiding plane of the connector is located in the

contact area between the molar retainer and the
pontic. The gingiva! end of the connector is
contoured to establish even contact with the crest of
the ridge (Fig 11).
5. The female pattern of the PDC is piaced over the
male pattern. A wax pattern for the pontic is made
over ihc female pattern. The gingival facing end of
the assembled connector should present a smooth, uninterrupted continuation of the ridge lap surface of
the pontic when the prosthesis has been completed.
6. The patterns of the pontic and the premolar
retainer are connected and cast as one piece.
7. The sections of the FPD framework are assembled
and the gingival embrasure between the moiar and
pontic is contoured with an abrasive separating disk.

Technical procedure
1. The dies and casts are fabricated and articulated as
for any FPD.
2. Wax patterns are made for both retainers.
3. The male pattern of the PDC is recessed into the
mesial surface of the pattern for the molar retainer.
The male attachment is positioned parallel to the
path of insertion of the premolar retainer.

Quintessence International

Volume 27, Number 8/1996

Completed prosthesis atter insertior.

Figures 12 to 5 illustrate the clinical application of

the PDC, which is completely concealed within the
FPD,
531

Zuckerman

Summary
Segmented FPDs are a well-established method recommended to overcotne the problems associated with
the insertion of FPDs when the abutments are severely
misaligned. Traditional designs used to create segmented FPDs were examined, and their disadvantages
were discussed.
A new design was suggested that does not have most
ofthe disadvantages associated with segmented prostheses. Manufactured plastic patterns that can be used
to create this segmented FPD design are available.
These economical, prefabricated, burnout patterns
simplify laboratory fabrication and produce uniform,
consistent, and reliable nonrigid connectors. The
extracoronal application of an interiocking attachment
for segmented FPDs provides a practical solution to a
difficult probiem.
References
1. Lubow RM, Cootey RL, Kaiser D. Periodontat and restorative
aspects of molar uprighting. J Prosthet Dent I982;47:37.1.
2 Shillingburg HT, Hobo S. Whitsett LD. Fundamentals of Fixed
Prosthudonties, ed 2. Chicago: Quintessence, i9Bi.
1 Zuckerman GR. Faetors that influence the meciianicai retention o
the complete erown. Int J Proslhodont 19SB;i; 36-20O.
4. Zuckerman GR. Resistance form for the complte veneer crown:
Principles ofdesign and anaiiis. Int JProsthodont t9S;l:302-:!07.

Aesthetic Design
for Ceramic Restoratioiis

he most
natrural,
esthetic results
in dental
ceramics can
be achieved
with contemporary' techniquesand this hook descrihes
how. Investigated are the characteristics of
natural dentition, tissue tnanagement, impressions, occlusal records, waxing techniques,
color, and lahorator)' techniques, including
methods for an aesthetic ceramic margin,
opalescence, and development ofthe dentine
mamelon. Filled with practical tips, this hook
is ideal for dentists and technicians.
159 pages; 292 color illus; ISBN 1 -85097-034-3

5. Rosenstiel SF. Land ME Fujimoto J Contemporary Fked Prosthodontics. ed I. St Louis: Mosby. 19S8
6. O'Connor RP. Caughman WF. Bemis C. Use of the split pontic
nonrigid connector with the tilted molar abutment. J Prosthet Dent
1986;56:249-2;i.
7. Moulding MB, Holiand GA. Sulik WD. An alternative orientation of
nondgid connectors in fixed partial dentures. J Prosthet Dent
8.
D

Contents
1 Studies of Natural Dentition
2 Dentist-Technician-Paticnt Communication
3 Tissue Management for Aesdietic
and Biological Harmony
4 Impressions artti Occlusai Records
5 Aesthetic Wax Diagnostic Control
6 Accurate Registration and Communication
of Colour Characteristics
7 Advanced Laboratory Techniques
8 Case Studies

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