J Interdiscip Dentistry
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Table of Contents
CASE REPORT
Year : 2013  |  Volume : 3  |  Issue : 1  |  Page : 36-42

Oral rehabilitation using customized intra-radicular Dalbo attachments


1 Department of Prosthodontics and Implantology, D Y Patil Dental College, Nerul, Navi Mumbai, Maharashtra, India
2 Final year Post graduate student, D Y Patil Dental College, Nerul, Navi Mumbai, Maharashtra, India

Date of Web Publication25-Oct-2013

Correspondence Address:
Pinky Tolani
Final year Post graduate student, D Y Patil Dental College, Nerul, Navi Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.120528

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   Abstract 

Teeth may be lost because of trauma, caries, periodontal disease, congenital defects and iatrogenic treatment. Tooth loss has a negative impact on masticatory function, esthetics and self-image. Fixed partial dentures, removable partial dentures, complete dentures and implant-supported dentures can replace missing teeth comfortably and esthetically, but it is not known whether they differ in their ability to reconstruct the masticatory function, phonetics and esthetics and preserve the residual bone ridge. Despite recent developments in dental implantology, the conservative approach to root preservation is still valid. In view of increased root caries rate in the elderly arid lax oral hygiene habits of the most overdenture wearers, placing protective copings on root abutments, when economically feasible, is the preferred method of treatment. Retention of overdentures is increased by including stud attachments in the abutments. Incorporation of cast metal frameworks is recommended to prevent base fractures.
Clinical Relevance to Interdisciplinary Dentistry
With some patients, the operating dentist alone cannot accomplish the correction, but may require the assistance of other dental disciplines. This case report describes an interdisciplinary approach for the coordinated treatment of a patient with badly broken down and missing teeth. The patient's functional and esthetic expectations were successfully met with interdisciplinary treatments, including

  • Oral prophylaxis followed by treatment for benign migratory glossitis.
  • Endodontic treatment for two grossly carious teeth.
  • Cast partial dentures for the maxilla and mandible.

Keywords: Abutment, attachment, intra-radicular, overdenture


How to cite this article:
Shetty O, Tolani P, Rathod A. Oral rehabilitation using customized intra-radicular Dalbo attachments. J Interdiscip Dentistry 2013;3:36-42

How to cite this URL:
Shetty O, Tolani P, Rathod A. Oral rehabilitation using customized intra-radicular Dalbo attachments. J Interdiscip Dentistry [serial online] 2013 [cited 2019 Jun 19];3:36-42. Available from: http://www.jidonline.com/text.asp?2013/3/1/36/120528


   Introduction Top


In the past, when patients used to visit the dentist with a few teeth that were badly broken down with periodontal involvement, the only treatment modality offered was extraction followed by a complete denture. These complete dentures used to be satisfactory in the beginning, but with each subsequent denture, patients used to become more intolerant and due to resorption of the bone, dentures would ultimately fail.

In the year 1856, Ledger [1] and Atkinson [2] advocated leaving "Stumps" under artificial dentures for support. The concept of overdentures was presented at the World Dental Congress in 1861 by Butler, Roberts and Hays who presented history of 12 years treatment results. This treatment was not accepted worldwide that time. In 1896, Essig [3] described the use of teeth with telescope-like crowns. In 1955, Brill [4] coined the term "hybrid prosthesis" and stated that by reducing the crown root ratio, one might be able to retain teeth, which might be otherwise lost. In 1958, Miller [5] presented a report before the American Denture Society that suggested retaining a few isolated "weak teeth" and covering them with thimble copings under complete dentures. The teeth not only remained in position, but many had regained a healthier status. In 1967, Preiskel [6] in his book on precision attachments described various attachment systems such as Gerber, Dalbo and others for isolated gold copings.

It was not until Morrow et al., [7] in 1969 advocated the use of gold copings over retained teeth, with the concomitant use of metal castings within the denture base that these ideas began to become accepted by English dentists. In the same year, Lord and Teel [8] published a paper titled "The overdenture" in which they advocated elective decoronation of the tooth with endodontic therapy to reduce the height of the teeth to 1-2 mm above the ridge crest. They also believed that a rounded short gold coping was necessary to protect the tooth.

Overdentures have certain advantages and disadvantages. Preeminent among advantages are:



• Preservation of alveolar bone

Preservation of the teeth not only retains the alveolar bone supporting the teeth but also the alveolar bone adjacent to the teeth. In a 5 year study by Crum and Rooney [9] in 1978, serial diagnostic casts and cephalometric radiographs were studied. They found that the alveolar bone reduction was reduced by 8 times around the abutment teeth supporting the overdenture than when compared with the conventional dentures.

• Preservation of proprioceptive response

The success or failure of any removable prosthesis seems to be dependent upon the integration of sensory feedback and the appropriate motor response. Kawamura and Watanabe [10] in 1960 found a 100 fold difference in the tactile sensitivity of dentate versus edentulous patients.

• Support, stability and retention

Fenton and Hahn [11] in 1978 reported that overdentures were more stable than conventional complete dentures.

• Equally effective or superior method of treatment

In many situations, the overdentures give better service than alternative methods of treatment. They are particularly useful for patients with congenital defects, such as oligodontia, microdontia, cleft palate, cleidocranial dysostosis and for class III patients for whom surgical or orthodontic treatment is not amenable.

• Esthetic excellence

The extensive selection of artificial denture teeth and the many possible arrangements aid in creating an esthetic effect. The bony defects can be restored effectively with the overdenture than with the conventional prosthesis.

• Excellent patient acceptance or psychological advantages

Toolson et al., [12] in 1982 used a patient satisfaction questionnaire to establish patient acceptance of overdentures over a period of 5 years.

• Conversion to complete denture.

• If for some reason the abutment teeth must be extracted, the overdentures can be converted to the conventional complete denture by relining and rebasing, hence serving as effective transitional dentures as well.

• Open palate or roofless dentures possible.

Disadvantages of the overdenture treatment include:

• Caries susceptibility

The most common problem encountered is the carious involvement of the abutment teeth, especially without copings. The caries rates reported in studies varied from a high of 39% by Rantanen et al. [13] in 1971 to a low of 13.6% by Ettinger et al. [14] in 1984. Meticulous home care and frequent recalls help to detect the incipient lesions.

• Periodontal breakdown of the abutment teeth

An overdenture not only prevents natural stimulation and cleaning by tongue and cheeks, it promotes accumulation of plaque. Meticulous home care is essential to prevent periodontal involvement of teeth.

• Over and under contouring the prosthesis

If there are excessive undercuts, it is impossible to avoid excessive block out of existing undercuts. This leads to a poorly contoured base, resulting in improper lip fullness that disturbs its natural drape and leads to difficulty in patient acceptance. An over contoured flange does not interact well with the facial musculature.

Presence of bony undercut and limited path of insertion may necessitate under extending the denture border in order for the denture to go to the place. This leads to loss of retention and formation of a potential space for food impaction.

• Cost

Overdenture treatment is more expensive than conventional denture treatment because of the endodontic therapy and periodontal therapy and the subsequent restoration of the teeth with cast copings and internal attachments.

• Additional patient responsibilities

If the patient does not keep the retained roots or teeth and the overdenture clean, it may cause periodontal and carious breakdown of the teeth. Hence, the responsibility of the patient in maintaining a high level of oral hygiene is essential.


   Case Report Top


A 55 year-old male patient presented to the Department of Prosthodontics at D.Y. Patil Hospital with the chief complaint of masticatory inefficiency and an unesthetic appearance due to missing teeth [Figure 1]. Clinical examination revealed heat cured acrylic crowns on the two maxillary central incisors [Figure 2] and two full metal crowns on the mandibular premolars [Figure 3]. There was a cross arch maxilla-mandibular relationship [Figure 4] and generalized spacing in the mandibular teeth. The edentulous area was well-rounded and smooth in the maxilla and thin and sharp in the mandible. There was evidence of benign migratory glossitis on the tongue. The periodontal biotype was thin with recession seen in the mandibular anteriors. Radiographic examination revealed endodontic treatment and a metal post in relation to 11 and periapical radiolucency in relation to 21. 13 showed proximal decay extending until the pulp of the tooth.
Figure 1: Extra-oral pre-operative photograph

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Figure 2: Intra-oral maxillary photograph

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Figure 3: Intra-oral mandibular photograph

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Figure 4: Pre-operative frontal view

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  • Pre-prosthetic management involved oral prophylaxis, followed by endodontic therapy in 13 and 21.
  • Patient was advised local application of topical steroids, Candid and local anesthetic for the benign migratory glossitis. Patient was also asked to start gum astringent and fluoride mouthwash twice daily.
  • For the maxilla, a palate free metal denture was planned over customized radicular dalbo attachments - Richmond crowns (RHEIN 83) on 13 and 21 and a plain coping over 11. This line of treatment was confirmed after a diagnostic jaw relation was performed to evaluate the availability of vertical space. For the mandible, a cast partial denture in the form of a lingual plate with cut back design was planned, keeping in mind the spacing in the mandibular anterior teeth.
  • Primary impressions were made in impression compound modified with irreversible hydrocolloid. The primary casts hence obtained were used to construct special trays.
  • Following this, post-space preparations were performed in relation to 13 and 21. The maxillary teeth were prepared, gingival displacement was carried out and equinox impression posts [Figure 5] were used for the final pick up the impression in light body (AQUASIL) [Figure 6].
  • In the mandible, rest seat preparations were completed following which the border molding and final impression was taken [Figure 7].
  • Once the fit of the maxillary Richmond crowns [Figure 8] and mandibular framework was evaluated [Figure 9], jaw relation [Figure 10] and try-in [Figure 11] were completed and the dentures were processed [Figure 12],[Figure 13],[Figure 14],[Figure 15] and [Figure 16].
  • At 1 week post insertion, the patient complained of irritation to the tongue at night when the denture was removed. Hence, a night guard was fabricated for the patient to prevent trauma to the tongue [Figure 17].
Figure 5: Maxillary teeth prepared

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Figure 6: Maxillary final impression

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Figure 7: Mandibular final impression

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Figure 8: Intra-radicular attachments cemented

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Figure 9: Mandibular framework trial

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Figure 10: Jaw relation

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Figure 11: Denture try-in

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Figure 12: Processed dentures

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Figure 13: Dentures inserted in the oral cavity

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Figure 14: Maxillary palate free metal based denture

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Figure 15: Mandibular denture

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Figure 16: Extra-oral post-operative photograph

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Figure 17: Maxillary intra-oral splint

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   Discussion Top


Tooth-supported complete dentures are a step in the direction of preventive prosthodontics. Preservation of the residual ridge, support and stabilization for the denture base and giving patients a sense of security in knowing that teeth aid in support of their prostheses are but a few of the benefits derived from the overlay denture. The maxillary overlay denture is of great value when it opposes remaining mandibular anterior teeth because it aids in conserving the ridge against resorption from masticatory stress.

However, several cross-sectional and longitudinal studies have shown that patients with overdenture abutments are at a higher risk of developing caries and periodontal disease unless adequate preventive measures are taken.

Longitudinal studies of overdenture populations have not reported that tooth loss is a significant problem. [12],[14] The overall rate of tooth loss varied from a low of 1.5% to a high of 14.3%. Toolson and Smith [15] conducted a 5-year study of 133 overdenture abutments in 54 patients; 16 of these abutments were extracted. Of these, 5 were extracted because of periodontal disease, 10 because of caries and 1 because of endodontic failure. The authors concluded that periodontal problems were not a major cause of tooth loss. However, Reitz et al., [16] studied 35 patients with 95 overdenture abutments; 13 of these teeth were extracted, 12 of which because of periodontal disease.

Retrospectively, most of the failures could have been prevented. For a majority of the patients, maintenance of oral hygiene was a problem. Improved communication between the patient and the dentist with regard to oral hygiene practices as well as regular recall appointments are critical in the success of overdenture therapy.

Care of the abutment teeth

As established earlier in the discussion, the success or failure of overdenture hinges on maintaining the overdenture abutment teeth in a healthy state, free from caries and periodontal disease.

For the conscientious patient, the following procedures have been described:

  • For brushing, a soft, multi-tufted toothbrush with a flexible round tipped bristles is placed at a 45° angle and a vibrating action is used to clean the abutments. This allows the tips of the bristles to enter into the crevice. Patients should not use a stiff denture brush because it may be too abrasive and an energetic patient may abrade the prosthesis.
  • Patient is instructed to use fluoridated tooth paste. Toothpaste with abrasive particles should be avoided. Abrasive particles get embedded in the plastic clip and this erodes the metal attachments.
  • To clean the sulcus, the use of dental floss or tape roller bandage or gauze, soft 4-ply knitting yarn or a toothpick mounted on toothbrush handle is advocated. Interproximal aids clean interproximal areas and massage the gingiva to increase the blood flow and tone of surrounding tissues.
  • Antimicrobial mouth washes like Chlorhexidine 0.12% are very effective in reducing the oral bacterial population, but must be used for short-term periods as they affect the normal mouth flora. Staining can be kept to a minimum by dipping the floss, brush, etc., into the solution and applying it locally to the required area.
  • Salivary substitutes may be useful when the patient has a dry mouth.
  • Finally, the dentures should be removed at night.
  • Patient recalls every 6 months.



   Conclusion Top


It has been rightly said that "the best implants in the world are natural teeth or their remaining roots."

An overdenture is an excellent viable treatment alternative to conventional complete denture. Caries, periodontal involvement, repairs, relines and remakes are inevitable. However if success is measured by the rate of abutment tooth loss, patient acceptance and quality of retention and support, then overdentures are successful. A method has been described for the construction of tooth-supported dentures where the natural tooth was utilized and a palate free metal denture base was processed directly to the prepared cast. This technique provides excellent retention, support and stabilization and has full patient acceptance.


   Acknowledgment Top


The final outcome of these restorations would not have been possible without the dedication of Dr. Sarthak. Patel, Mumbai.

 
   References Top

1.Ledger E. On preparing the mouth for the reception of a full set of artificial teeth. Br J Sci 1856;1:90.  Back to cited text no. 1
    
2.Atkinson WH. Plates over fangs. Dent Reg 1861;15:213-6.  Back to cited text no. 2
    
3.Essig CJ. The American Textbook of Prosthetic Dentistry. Philadelphia: Lea Brothers & Co.; 1896. p. 439.  Back to cited text no. 3
    
4.Brill N. Adaptation and the hybrid prosthesis. J Prosthet Dent 1955;5:811-24.  Back to cited text no. 4
    
5.Miller PA. Complete dentures supported by natural teeth. J Prosthet Dent 1958;8:924-8.  Back to cited text no. 5
    
6.Prieskel HW. Precision Attachment in Dentistry. 3 rd ed. London: Henry Kimpton; 1979.  Back to cited text no. 6
    
7.Morrow RM, Powell JM, Jameson WS, Jewson LG, Rudd KD. Tooth-supported complete dentures: Description and clinical evaluation of a simplified technique. J Prosthet Dent 1969;22:415-24.  Back to cited text no. 7
    
8.Lord JL, Teel S. The overdenture. Dent Clin North Am 1969;13:871-81.  Back to cited text no. 8
    
9.Crum RJ, Rooney GE Jr. Alveolar bone loss in overdentures: A 5-year study. J Prosthet Dent 1978;40:610-3.  Back to cited text no. 9
    
10.Kawamura Y, Watanabe M. Studies in oral sensory thresholds. Med J Osaka Univ 1960;10:291-301.  Back to cited text no. 10
    
11.Fenton AH, Hahn N. Tissue response to overdenture therapy. J Prosthet Dent 1978;40:492-8.  Back to cited text no. 11
    
12.Toolson LB, Smith DE, Phillips C. A 2-year longitudinal study of overdenture patients. Part II: Assessment of the periodontal health of overdenture abutments. J Prosthet Dent 1982;47:4-11.  Back to cited text no. 12
    
13.Rantanen T, Mäkilä E, Yli-Urpo A, Siirilä HS. Investigations of the therapeutic success with dentures retained by precision attachments. I. Root-anchored complete overlay dentures. Suom Hammaslaak Toim 1971;67:356-66.  Back to cited text no. 13
    
14.Ettinger RL, Taylor TD, Scandrett FR. Treatment needs of overdenture patients in a longitudinal study: Five-year results. J Prosthet Dent 1984;52:532-7.  Back to cited text no. 14
    
15.Toolson LB, Smith DE. A five-year longitudinal study of patients treated with overdentures. J Prosthet Dent 1983;49:749-56.  Back to cited text no. 15
    
16.Reitz PV, Weiner MG, Levin B. An overdenture survey: Second report. J Prosthet Dent 1980;43:457-62.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]



 

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   Introduction
   Case Report
   Discussion
   Conclusion
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