Distal implants to modify the Kennedy classication of a removable partial denture: A clinical report

Dusan V. Kuzmanovic, DDS, MDS, DipClinDent,a Alan G. T. Payne, BDS, MDent, DDSc,b and David G. Purton, BDS, MDSc School of Dentistry, University of Otago, Dunedin, New Zealand
Dental implants or precision attachments can be used to resolve the bilateral distal extension removable partial denture (RPD) dilemma. This report describes the fabrication of a mandibular implant-supported chromium-cobalt RPD with a combination of bilateral single molar implants and metal ceramic crowns using the principles of the channel-shoulder-pin system. The maxillary arch was restored with splinted metal crowns and a conventional RPD retained by extracoronal precision attachments. (J Prosthet Dent 2004;92:8-11.)

common clinical problem confronting prosthodontists is the design and maintenance of bilateral distal extension partial dentures,1 as support is required from the teeth, the mucosa, and underlying residual alveolar ridges. There has been concern about the control of destructive forces that may act on the abutment teeth and the posterior mandibular residual alveolar ridges.1-4 Recently, it has been reported that freestanding single dental implants can be used to resolve problems with mandibular bilateral distal extension removable partial dentures in a cost-effective manner. 5-7 This report describes the fabrication of a mandibular implant-supported chromium-cobalt RPD with a combination of bilateral single molar implants and metal ceramic crowns using the principles of the channel-shoulder-pin system.

CLINICAL REPORT
A 66-year-old partially dentate man was referred by his general dentist to the Graduate Prosthodontic Clinic at the University of Otago School of Dentistry, for treatment of the severe wear of his maxillary anterior teeth. His chief complaint was the poor appearance and reduced function of his remaining teeth as a consequence of gradual wear. Four treatment options were discussed with the patient: bilateral implant-supported xed prostheses, conventional removable partial dentures, removable partial dentures retained by metal ceramic restorations and precision attachments, or implant-supported removable partial dentures.6,7 Finances inuenced the patients decision to request a combination of the last 2 options. The medical history

revealed that the patient was taking antihypertensives and a medication to reduce gastric acid production. He was not aware of any parafunctional activity such as grinding or clenching. The analysis of a thorough 3-day recording of each meal, snack, and drink did not indicate any excessively acidic drink or food intake. Intraoral examination revealed that the patient would be categorized clinically as a Class IV8 partially endentulous patient (Fig. 1). Edentulous areas were found in both arches, and physiologic abutment support was compromised. Due to severe wear of the anterior maxillary teeth with loss of palatal and incisal enamel, several carious lesions, amalgam overhangs, and failing restorations were noted, and extracoronal restorations and adjunctive therapy were envisaged. Supra-eruption of maxillary posterior and anterior teeth and an unfavorable gingival appearance made the occlusion severely compromised and necessitated the re-establishment of the occlusal vertical dimension with a proper occlusal scheme. Periodontal examination showed localized bleeding on probing, generalized calculus, localized gingival recession, and furcation involvement of some teeth. Radiographic examination demonstrated periapical radiolucencies, external root resorption, and inadequate root canal treatment of some teeth (Fig. 2).

Initial treatment phase

Stone casts prepared from preliminary impressions were mounted in a semiadjustable articulator (Denar D5A; Water Pik Technologies, Newport Beach, Calif) at the desired occlusal vertical dimension, using an arbitrary face-bow and a centric relation record made with prefabricated occlusal rims on stable record bases. The initial treatment phase consisted of scaling, root planing, oral hygiene instruction, restorative dentistry, and extraction of periodontally and endodontically compromised teeth. Carious lesions were treated and failed restorations were replaced, followed by endodontic treatment of the maxillary right canine and lateral incisor. Two solid screw, airborne-particleabraded, large-grit, acid-etched implants (ITI implants; No
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Presented at the 2003 Annual Conference of European Prosthodontic Association and Swiss Society of Reconstructive Dentistry, Geneva, Switzerland. a Senior Lecturer/Prosthodontist, Department of Oral Surgical and Diagnostic Sciences. b Senior Lecturer/Prosthodontist, Department of Oral Rehabilitation. c Senior Lecturer/Restorative Dentist, Department of Oral Rehabilitation.

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Fig. 1. Initial presentation. Fig. 2. Pretreatment radiograph.

Fig. 3. Healing caps on distally placed implants.

043.033S, 4.1 mm in diameter, 12 mm in length, Straumann AG, Waldenburg, Switzerland) were placed in the mandibular left rst molar and right second molar regions using a nonsubmerged surgical procedure (Fig. 3). This changed the Kennedy classication of the partially edentulous arch from Class I (tooth-tissue supported) to Class III (tooth-implantsupported). Crown lengthening procedures were performed to provide ferrule effects on the maxillary right canine and lateral incisor, to avoid subgingival placement of the crown margins, and to correct irregular gingival architecture. Approximately 20 weeks after the crown lengthening procedure, heat-processed acrylic resin (SR Orthosit PE denture teeth with Ivocron; Ivoclar Vivadent, Amherst, NY) provisional crowns were cemented (TempBond; Kerr Corp, Orange, Calif). Interim maxillary and mandibular acrylic resin partial dentures were then inserted at the designated occlusal vertical dimension, using the principle of canine-protected articulation. Oral hygiene regimens were maintained during the course of treatment and the patient received instruction in home care. During this interim prosthesis stage, the presence of wear facets, mastication, speech, and level of oral hygiene were monitored. Absence of any symptoms conrmed the patients tolerance of the increased occlusal vertical dimension and his approval of appearance and function.
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Fig. 4. Modied channel-shoulder-pin and RPD framework.

Fig. 5. Lingual surface of mandibular canine restorations.

Denitive treatment phase

Following a 20-week trial period with the provisional restorations and interim acrylic resin partial dentures, the determination was made to proceed with the
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Fig. 6. A, Healing caps replaced with patrices. B, Gold matrix inclusion.

Fig. 7. A, Maxillary RPD at 2-year recall. B, Mandibular RPD at 2-year recall.

Fig. 8. Panoramic radiograph at 2-year recall.

denitive crowns and chromium-cobalt removable partial dentures (RPDs). Following complete arch impressions with silicone impression material (Exahiex injection/regular type; GC Corp, Tokyo, Japan), the centric relation record was made at the increased occlusal vertical dimension. The mandibular arch was reconstructed with a chromium-cobalt (Remanium GM 380; Dentaurum, Pforzheim,
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Germany) RPD, using a modication of the intracoronal attachment method of the channel-shoulder-pin system originally developed by Steiger and Boitel9 (Fig. 4), in metal ceramic (Evolution; Ivoclar Vivadent, Amherst, NY) restorations on both mandibular canines (Fig. 5). Labial surface porcelain staining was used for improved esthetics. The major connector was a lingual plate where the apron contacted the cingula of all the mandibular incisors, but was extensively relieved in the interproximal areas to facilitate oral hygiene. The 3-mm healing caps (product number 0.48.034; Straumann AG) were left in place to provide support in the region of the distal extension of the partial denture. One month later, the healing caps were replaced with the denitive patrices (product number 0.48.439, height 3.4 mm; Straumann AG) (Fig. 6, A). The previously fabricated RPD framework was designed to accommodate subsequent inclusion of 2 gold cap matrices (product number 0.48.410; Straumann AG) on the intaglio (Figs. 4 and 6, B). The maxillary arch was restored with splinted metal ceramic restorations (maxillary right canine, lateral incisor and maxillary left canine and rst premolar),10,11 single metal ceramic restorations (both maxillary central incisors and left
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lateral incisor), and a chromium-cobalt RPD retained by extracoronal precision attachments (Mini SG R; Cendres & Metaux SA, Biel-Bienne, Switzerland). The maxillary major connector was a broad palatal strap with appropriate beading of the anterior and posterior borders. All metal ceramic restorations were cemented with a glass ionomer cement (Fuji I; GC Corp). A canine-protected articulation was also used in this denitive phase (Fig. 7, A and B). Oral hygiene instructions and aids were provided, particularly in relation to the home care of the splinted metal ceramic restorations. The patient was informed of several longterm studies showing favorable survival rates of attachment-retained RPDs compared with conventional RPDs,12,13 and the need for patrix and matrix maintenance.14,15 The maxillary RPD was retained with semiprecision attachments with plastic inserts, which have been reported to have reduced wear compared with metal precision attachments.16 A scheduled recall after 2 years showed no prosthodontic maintenance was required other than the need for simple activation of the gold matrices of the mandibular RPD to re-establish retention on the patrices (Fig. 8).

a cost-effective treatment. It demonstrates the conversion of the mandibular removable partial denture from tooth-tissuesupported to tooth-implantsupported.
REFERENCES
1. Krol A. RPI (rest, proximal plate, I bar) clasp retainer and its modications. Dent Clin North Am 1973;17:631-49. 2. Kratochvil FJ, Caputo AA. Photoelastic analysis of pressure on teeth and bone supporting removable partial dentures. J Prosthet Dent 1974;32: 52-61. 3. Pezzoli M, Appendino P, Calcagno L, Celasco M, Modica R. Load transmission evaluation by removable distal-extension partial dentures using holographic interferometry. J Dent 1993;21:312-6. 4. Ben-Ur Z, Gorl C, Shifman A. Designing clasps for the asymmetric distal extension removable partial denture. Int J Prosthodont 1996;9:374-8. 5. Brudvik JS. Implants and removable partial dentures. In: Brudvik JS, editor. Advanced removable partial dentures. Chicago: Quintessence Publishing Co; 1999. p. 153-9. 6. Keltjens HM, Kayser AF, Hertel Rm Battistuzzi PG. Distal extension removable partial dentures supported by implants and residual teeth: considerations and case reports. Int J Oral Maxillofac Implants 1993;8: 208-13. 7. Gifn KM. Solving the distal extension removable partial denture base movement dilemma: a clinical report. J Prosthet Dent 1996;76:347-9. 8. McGarry TJ, Nimmo A, Skiba JF, Ahlstrom RH, Smith CR, Koumjian JH, Arbree NS. Classication system for partial edentulism. J Prosthodont 2002;11:181-93. 9. Prieskel HW. Intracoronal attachments. In: Prieskel HW, editor. Precision attachments in prosthodontics: the applications of intracoronal and extracoronal attachments. Volume 1. London: Quintessence Publishing Co; 1985. p. 174-80. 10. Altay OT, Tsolka P, Preiskel WH. Abutment teeth with extracoronal attachments: the effects of splinting on tooth movement. Int J Prosthodont 1990;3:441-8. 11. el Charkawi HG, el Wakad MT. Effect of splinting on load distribution of extracoronal attachment with distal extension prosthesis in vitro. J Prosthet Dent 1996;76:315-20. 12. Owall B. Precision attachment retained removable partial dentures: Part 1. Technical long-term study. Int J Prosthodont 1991;4:249-57. 13. Owall B. Precision attachment-retained removable partial dentures: Part 2. Long-term study of ball attachments. Int J Prosthodont 1995;8:21-8. 14. Stewart BL, Edwards RO. Retention and wear of precision-type attachments. J Prosthet Dent 1983;49:28-34. 15. Shaw MJ. Attachment retained overdentures: a report on their maintenance requirements. J Oral Rehabil 1984;11:373-9. 16. Wichmann MG, Kuntze W. Wear behaviour of precision attachments. Int J Prosthodont 1999;12:409-14. Reprint requests to: DR ALAN GT PAYNE SENIOR LECTURER/PROSTHODONTIST DEPARTMENT OF ORAL REHABILITATION, SCHOOL UNIVERSITY OF OTAGO PO BOX 647, DUNEDIN 9003 NEW ZEALAND 9003 FAX: + 64 3 479 5079 E-MAIL: alan.payne@dent.otago.ac.nz

DISCUSSION
The literature supports the use of precision attachments to rehabilitate partially dentate patients with removable prostheses.9 However, while this clinical report complements others relating to implantsupported partial dentures,6,7 the treatment differs in that patrices were placed on the distal implants in contrast to the healing abutments as previously recommended.5 This allowed the patient to benet from both improved support and retention of the mandibular implant-supported RPD. Randomized, controlled trials are needed to provide a higher level of evidence-based literature than clinical reports for implant-supported removable partial dentures overcoming the bilateral distal extension dilemma.

SUMMARY
This report describes a mandibular arch restored using a combination of bilateral single molar implants, a chromium-cobalt removable partial denture, and crowns with modied use of the channel-shoulder-pin system. The maxillary arch was reconstructed with splinted metal-ceramic crowns and a conventional removable partial denture retained by extracoronal precision attachments. The use of freestanding, bilateral distal single implants helped both support and retain the mandibular removable partial denture and presents

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0022-3913/$30.00 Copyright 2004 by The Editorial Council of The Journal of Prosthetic Dentistry

doi:10.1016/j.prosdent.2004.04.010

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