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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 15  |  Issue : 2  |  Page : 144-147

Transition of a Misch removable prosthesis-5 to a fixed prosthesis-3: From a removable to a fixed complete denture


Department of Prosthodontics and Crown and Bridge, ADC (R&R), New Delhi, India

Date of Submission15-May-2020
Date of Decision10-Jun-2020
Date of Acceptance02-Dec-2020
Date of Web Publication17-Sep-2021

Correspondence Address:
Anup Gopi
ADC (R&R), New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JODD.JODD_34_20

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  Abstract 


An implant-supported denture is used when a person does not have any teeth in the jaw but has enough bone to support implants. Treatment options can be broadly divided into the fixed implant-supported prosthesis and removable implant-supported prosthesis (overdenture). However, when such completely edentulous patients who are already rehabilitated using removable implant-supported overdentures report for a fixed prosthesis, then it becomes a challenging situation. This article describes the challenges involved in the transition of one such patient rehabilitated previously using a RP-5 prosthesis to a fixed FP-3 prosthesis.

Keywords: Fixed implant prosthesis, FP-3, RP-5


How to cite this article:
Gopi A. Transition of a Misch removable prosthesis-5 to a fixed prosthesis-3: From a removable to a fixed complete denture. J Dent Def Sect. 2021;15:144-7

How to cite this URL:
Gopi A. Transition of a Misch removable prosthesis-5 to a fixed prosthesis-3: From a removable to a fixed complete denture. J Dent Def Sect. [serial online] 2021 [cited 2021 Oct 22];15:144-7. Available from: http://www.journaldds.org/text.asp?2021/15/2/144/326219




  Introduction Top


RP-5 is removable prosthesis or an overdenture supported by soft tissue and implant, while a FP-3 is a fixed prosthesis that replaces the missing crown and gingival portion of the edentulous site. The most common problem of a complete denture wearer is the loss of retention and stability of the mandibular denture. The commonly followed procedure in such cases is to rehabilitate the patient using an implant-retained overdenture. However, when such a patient reports for a fixed prosthesis, it becomes a challenge, especially if the implants placed earlier are single piece implants. This case report describes the challenges involved in the transition of a patient rehabilitated previously using a RP-5 prosthesis to a fixed FP-3 prosthesis.


  Case Report Top


The present case is being reported as per CARE guidelines.[1] A 60-year-old completely edentulous male presented with a chief complaint of difficulty in mastication and speech. Examination revealed moderately formed maxillary and mandibular residual alveolar ridges and Class I ridge relationship with adequate interarch space. There was no relevant medical history. The dental history revealed that he was rehabilitated about a year ago by a conventional maxillary complete denture and a mandibular implant-supported overdenture with two single piece implants at the mandibular cuspid positions [Figure 1]. Due to limitations in function and associated discomfort, the patient desired a fixed denture in both his upper and lower jaw.
Figure 1: Existing implants in the cuspid region

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Treatment procedure

After clinical and radiological investigations, a modified Laney Poitros template was fabricated using the existing maxillary and mandibular denture for use as a guiding stent for implant placement.[2] The distance between the two implants in the mandibular canine region was measured along the ridge, and three implants of size 3.8 mm diameter and 11 mm length (Equinox Connect, Netherlands) were placed surgically equidistant to each other [Figure 2]. The mandibular denture was used as a guide to surgically place six implants in the maxillary arch equidistant from each other [Figure 3]. The existing dentures were then adjusted and used as a transitional prosthesis for 6 months to allow adequate time for osseointegration of the implants. After 6 months, impressions were made using transfer copings, and the master casts were obtained. A spacer of uniform thickness of about 4 mm was adapted, denture bases were made, and occlusal rims were fabricated over these bases with access openings for the castable sleeves. The casts were mounted using a face bow record and a semi-adjustable articulator. The length of the cantilever was measured, and teeth setting was done extending only up to this marked length. The thickness of the acrylic teeth was kept to a minimum of 2 mm to maintain the adequate thickness of porcelain for strength and esthetics at a later stage. Try-in was done, and occlusion was verified. Subsequently, a putty index was made over the set teeth. Castable sleeves were adapted over the cast and trimmed to extend within the confines of the index. These sleeves were joined together using inlay wax to form the bar framework. The undercut over the ball head of the overdenture implant was blocked, and a wax pattern was prepared over it and joined to the framework. The location of the teeth was transferred to the bar framework using the putty index as a reference, ensuring that the access opening to the screws was patent. The pattern was finished and polished before spring and casting [Figure 4]. The metal framework was trimmed and evaluated intraorally to ensure a passive fit. The framework was transferred back to the articulator, and ceramic buildup was done using the putty index as a reference. Bisque trial was done to further refine the occlusion and esthetics before the final insertion [Figure 5]. The access opening for the screws was closed using light-cured composite restorative material after ensuring that the vertical dimension and teeth exposure were adequate. There was a marked improvement in overall health, comfort, function, and esthetics [Figure 6]. The patient was followed up subsequently every 3 months for the next 18 months. There was no peri-implantitis or any significant bone loss around the implants.
Figure 2: Placement of three additional implants in the mandibular arch

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Figure 3: Implants placed in the maxillary arch

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Figure 4: Castable sleeves within waxed up bar framework

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Figure 5: Postoperative photograph with prosthesis in situ

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Figure 6: Comparison of a conventional complete denture to a fixed prosthesis

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  Discussion Top


Osseointegrated implants have provided long-term success in edentulous and partially edentulous patients. An implant-supported denture is used when a person does not have any teeth in the jaw but has enough bone in the jaw to support implants. An implant denture has special attachments that snap into position on the implants.

Treatment options can be broadly divided into fixed implant-supported prosthesis and removable implant-supported prosthesis (overdentures). Fixed implant-supported prosthesis has various advantages over a removable implant-supported prosthesis such as less food entrapment, less maintenance, longevity, improved patient function, and most importantly gives the patient the psychological benefit of having fixed teeth.[3],[4] Proper diagnosis and treatment planning determine the correct number of implants, their location, and angulation and thus aids in the success of the prosthesis.

RP-5 is a removal prosthesis; overdenture supported by soft tissue and implant, while a FP-3 is a fixed prosthesis that replaces missing crown and gingival portion of the edentulous site-prosthesis most often uses denture teeth and acrylic gingiva but may be porcelain fused to metal (PFM).[5] A hybrid prosthesis using denture teeth or PFM teeth over a metal framework joining the elements together is the prosthesis of choice. Crown height plays a major role in determining the type of prosthesis to be provided. It is measured from the crest of bone to the plane of occlusion. When the space is more than 15 mm due to vertical loss of alveolar bone, a removable prosthesis can fill up this space. The minimum required crown height for a fixed prosthesis is 8 mm.[5] In the posterior region, it should be about 9 to10 mm, and in the maxillary central region about 10–12 mm as seen in this case. If crown space is less than osteoplasty and soft-tissue reduction can be carried out provided adequate bone height for predictable implant support.

Number and sizes of placed implants do not only affect the total support of the prostheses but also indirectly reflect the amount of bone available for fixture placement. Anticipated occlusal and chewing force should also be considered. Opposing dentition as well as type of patient and potential parafunctional mandibular movements should be noted. Branemark's classic design for cantilever prosthesis was to place 4–6 implants intraforaminally and to cantilever the size of two or three premolars bilaterally to obtain posterior occlusion. The distance from the center of the most anterior implant to a line joining the distal aspect of the two most distal implants is called the anterior posterior distance or A-P spread. The length of the posterior cantilever depends on this anteroposterior spread. It is recommended that the length of the mandibular posterior cantilever for a fixed-detachable prosthesis with five implants is 1.5 times the length of the anteroposterior spread.[5] Various studies have suggested mandibular posterior cantilever lengths varying from 1.5 to 2.5 mm; the cantilever in this case was, however, maintained at 1.5 times the anteroposterior spread.

In completely edentulous patients, implant-retained dentures should follow conventional occlusal concepts of bilateral balanced or lingualized occlusion. A medial positioned lingualized occlusion as established in this case is the occlusion of choice. For fixed full-arch restorations, the aim is simultaneous contact on anterior and posterior teeth in centric relation with anterior group function and multiple contacts in eccentric jaw movements (no canine guidance).[6],[7],[8],[9] There should be no posterior contact in any excursive movements in the presence of opposing fixed restoration or natural dentition. Occlusion should not load any cantilever, pontics, and implants that are not within 20° of the axial load. Primarily, the casting must fit passively, and no offset loads should be present. The final restoration is usually given with a modified ridge lap pontic in the anterior for speech and esthetics and open embrasures in the posterior for hygiene consideration.

Following fixation of the completed prosthesis, loss of implant, exaggerated soft-tissue response, or mechanical complications may occur. While procedural complications can occur during the fabrication phase of the prosthesis, most are technique related and are usually reversible. The loss of anchorage or nonintegration is generally the latent result of surgical trauma, contamination, or prosthesis overload. While it is difficult to specifically identify surgical trauma or contamination as the cause, when nonintegration occurs before stage 2 uncovering, either or both are likely factors. Among other causes, loss of anchorage attributed to fixed prosthesis function can result from an ill-fitting metal frame, overextended cantilevers, or a poorly conceived occlusal scheme, while prosthesis fracture is usually attributable to material defect or strength, poor stress distribution, and design.[10],[11],[12],[13],[14] Incompatible maxillomandibular relationships can also contribute to component failure. Patient factors such as diabetes, smoking, and parafunctional habits can also influence the treatment outcome. Our case was a healthy patient without any comorbidity.

Proliferation or hyperplastic responses from chronic irritation and poor oral hygiene can also be noticed in the long run.[15],[16] Typical clinical manifestations included gingivitis and hyperplasia. The patient is hence reviewed at frequent intervals in the first 3 months, and oral hygiene measures are reinforced. Follow-up care includes checking the peri-implant osseous condition, radiographic assessment, peri-implant soft-tissue evaluation, checking the prosthetic superstructure, the oral hygiene, and motivation.


  Conclusion Top


The commonly followed procedure in a completely edentulous patient is to rehabilitate the patient using an implant-retained overdenture. However, when such an edentulous patient reports for a fixed prosthesis, it becomes a challenge. The transition from an overdenture to a fixed prosthesis that is retained using screws or cement should be planned meticulously keeping the patient comfort and the long-term outcome of the prosthesis in mind.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Riley DS, Barber MS, Kienle GS, Aronson JK, von Schoen-Angerer T, Tugwell P, et al. CARE guidelines for case reports: Explanation and elaboration document. J Clin Epidemiol 2017;89:218-35.  Back to cited text no. 1
    
2.
Misch CE. Contemporary Implant Dentistry. 3rd ed. Philadelphia: Elseiver; 2008. p. 282-83.  Back to cited text no. 2
    
3.
Misch CE. Dental Implant Prosthetics. 2nd ed. Philadelphia: Elseiver; 2015. p. 194.  Back to cited text no. 3
    
4.
Zitzmann NU, Marinello CP. Treatment plan for restoring the edentulous maxilla with implant-supported restorations: Removable overdenture versus fixed partial denture design. J Prosthet Dent 1999;82:188-96.  Back to cited text no. 4
    
5.
Misch CE. Dental Implant Prosthetics. 2nd ed. Philadelphia: Elseiver; 2015. p. 195.  Back to cited text no. 5
    
6.
Misch CE. Dental Implant Prosthetics. 2nd ed. Philadelphia: Elseiver: 2015. p. 297.  Back to cited text no. 6
    
7.
Brosky ME, Korioth WP, Hodges J. The anterior cantilever in the implant-supported screw-retained mandibular prosthesis. J Prosthet Dent 2003;89:244-49.  Back to cited text no. 7
    
8.
Gallucci GO, Doughtie CB, Hwang JW, Fiorellini JP, Weber HP. Five-year results of fixed implant-supported rehabilitations with distal cantilevers for the edentulous mandible. Clin Oral Implants Res 2009;20:601-7.  Back to cited text no. 8
    
9.
Henry PJ. A review of guidelines for implant rehabilitation of the edentulous maxilla. J Prosthet Dent 2002;87:281-8.  Back to cited text no. 9
    
10.
Jemt T. Fixed implant-supported prostheses in the edentulous maxilla. A five-year follow-up report. Clin Oral Implants Res 1994;5:142-7.  Back to cited text no. 10
    
11.
Adell R, Eriksson B, Lekholm U. A long term follow up study of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants 1990;5:347-59.  Back to cited text no. 11
    
12.
Kwon T, Bain PA, Levin L. Systematic review of short- (5-10 years) and long-term (10 years or more) survival and success of full-arch fixed dental hybrid prostheses and supporting implants. J Dent 2014;42:1228-41.  Back to cited text no. 12
    
13.
Walton JN, MacEntee MI. Problems with prostheses on implants: A retrospective study. J Prosthet Dent 1994;71:283-8.  Back to cited text no. 13
    
14.
Jivraj S, Chee W, Corrado P. Treatment planning of the edentulous maxilla. Br Dent J 2006;201:261-79.  Back to cited text no. 14
    
15.
Pjetursson BE, Thoma D, Jung R, Zwahlen M, Zembic A. A systematic review of the survival and complication rates of implant-supported fixed dental prostheses (FDPs) after a mean observation period of at least 5 years. Clin Oral Implants Res 2012;23 Suppl 6:22-38.  Back to cited text no. 15
    
16.
Richard P, Paul P, Leslie H. Dental Implants: Complications and maintenance. Br Dent J 1999;187:653-58.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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