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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 13  |  Issue : 5  |  Page : 514-518

An alternative technique for fabrication of a tooth-supported removable partial overdenture: A case report


Department of Restorative Dentistry, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia

Date of Submission01-Apr-2021
Date of Decision21-Jun-2021
Date of Acceptance23-Jun-2021
Date of Web Publication11-Oct-2021

Correspondence Address:
Dr. Noorhayati Raja Mohd
Department of Restorative Dentistry, Faculty of Dentistry, University of Malaya, 50603 Kuala Lumpur.
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JIOH.JIOH_72_21

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  Abstract 

Overdenture is one of the recommended treatment methods for elderly patients with few remaining teeth and deeply resorbed ridges. Root retained under the denture base maintains more alveolar ridge resorption, which provides sensory feedback and improves the stability of the dentures. In addition, after endodontic therapy, the use of copings (short/long) and braces on the remaining teeth improves denture protection. This case report aimed to describe prosthodontic rehabilitation of a tooth-supported removable partial denture using a Locator attachment.A 48-year-old woman presented to the Faculty of Dentistry, University of Malaya, complaining looseness and repeated fracture of her denture, which led to difficulty in eating and chewing. She presented with Kennedy Classification II modification 1 on the maxilla with 23 and 24. The treatment plan was to provide her with maxillary cobalt–chromium overdenture using the Locator attachment system. The abutment teeth were designed, prefabricated using Locator, and were attached to the root of 23. Esthetics was achieved, and the patient reported satisfactory outcome.The present case report signifies that few remaining teeth are effectively preserved to support tooth-retained overdenture. This treatment approach was chosen considering the patient’s favorable inter ridge distance and economic status rather than full extractions accompanied by a complete denture or implant-supported overdenture. This technique using a Locator attachment on a natural tooth can be an alternative method in prosthodontic rehabilitation of a partially edentulous adult patient with a distinct approach to meet the needs, esthetics, and psychological well-being of the patient.

Keywords: Cobalt–Chromium, Locator Attachment, Overdenture, Tooth-Supported Overdenture


How to cite this article:
Raja Mohd N, Ahmad SF, Etajuri EA. An alternative technique for fabrication of a tooth-supported removable partial overdenture: A case report. J Int Oral Health 2021;13:514-8

How to cite this URL:
Raja Mohd N, Ahmad SF, Etajuri EA. An alternative technique for fabrication of a tooth-supported removable partial overdenture: A case report. J Int Oral Health [serial online] 2021 [cited 2021 Dec 6];13:514-8. Available from: https://www.jioh.org/text.asp?2021/13/5/514/327870


  Introduction Top


Tooth loss is usually associated with an esthetic, functional, and psychological impairment that may harm the patient’s self-esteem and quality of life.[1] Despite a high prevalence of adult patients requiring prosthetic treatment due to partial or total tooth loss, prosthetic treatment options may vary according to patient condition and needs.[2] Overdenture is one of the prosthetic options in restoring missing teeth. The denture could be supported either by natural teeth or an implant that improves the prosthesis’s retention and stability. The retention and stability of tooth-supported overdenture can be enhanced with attachments while concurrently decreasing alveolar bone resorption. In comparison with implant-supported overdentures, tooth-supported overdenture is more cost-effective, and it preserves more dental proprioception.[3] However, it requires proper oral health maintenance to avoid failures. For tooth-supported overdenture to provide an efficient prosthetic treatment, an appropriate diagnosis of abutment and planning is necessary to warrant satisfactory long-term performance and sufficiently maintain alveolar bone height and periodontal support.[3],[4]

Numerous attachment systems for tooth-supported overdenture are available, including clip and bar, ball and O-ring, and magnet attachments.[5] The choice of the tooth-supported overdenture attachment system could vary according to the number, distance, and position of the remaining natural teeth and the clinician’s preference.[6] However, the selection must be determined after analyzing the occlusal vertical dimension (OVD) and the vertical bone height of each abutment.[7] Several clinicians are still avoiding tooth-supported overdenture due to the problem of attachment angulations. Yet, there are now advanced techniques and products that allow clinicians to create more reliable and effective attachments than previously available.

This clinical case report presents an alternative method in fabricating tooth-supported removable partial overdenture using a Locator attachment.


  Case Report Top


A 48-year-old woman presented to the Faculty of Dentistry, University of Malaya, complaining looseness and repeated fracture of her denture, which led to difficulty in eating and chewing. She had been wearing single-acrylic “spoon” denture for more than 10 years. She presented with Kennedy Classification II modification 1 on the maxilla with 23 and 24. Clinical examination revealed the presence of few teeth that were heavily restored with amalgam and tooth-colored restorations. The patient had a reduced OVD [Figure 1].
Figure 1: Preoperative intraoral view

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Radiographic findings revealed bone resorption on teeth 18, 15, 23, and 24 of about one-third of the root length, and severe bone loss on tooth 13 of more than two-thirds of the root length. However, there was a radiopacity on teeth 13 and 23, indicating root canal treatments and postrestoration. On tooth 24, radiopacity was seen on the crown with different densities and encroach onto the pulp. There was a presence of periapical radiolucency on the palatal root. On the lower arch, she was diagnosed with Kennedy Classification I.

The treatment plan was to provide the patient with a maxillary tooth-supported overdenture. The treatment started with the extraction of teeth 13 and 1 and periodontal therapy on teeth 18, 23, and 24, followed by root canal treatment on tooth 24. Teeth 23 and 24 were used as an abutment for the overdenture, whereas tooth 18 was used to provide retention on the first quadrant using a retentive arm. Another retention source was planned to be on the second quadrant by adding an attachment to one of the abutments. Accordingly, teeth 23 and 24 were decoronated at about 1 mm above the gingival margin [Figure 2]A and B.
Figure 2: (A) Teeth 23 and 24 before decoronation, (B) teeth 23 and 24 after decoronation, (C) impression of the canal of 23, (D) the post space was lubricated, (E) DuraLay was filled into the canal together with fiber post, and (F) the final wax-up of the pattern resin of the metal post

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The post and gutta-percha of the 23 were removed using an endodontic scaler and post drill burs, and the post spaces were prepared and cleaned. The impression of the canal was then taken using an elastomer impression material [Figure 2C]. The impression is then poured in die stone, and the cast is recovered. An indirect technique of custom-made metal attachment was applied. The post space was lubricated [Figure 2D]. In order to fill the post space with red DuraLay self-curing acrylic (Reliance Dental Manufacturing, Worth, Illinois), powder and liquid brush techniques were used, and a fiber post was used to apically pump the soft acrylic to the base of the post preparation [Figure 2E]. An acrylic core was then built up around the post. The post pattern was then removed from the tooth and verified for accuracy [Figure 2F]. Afterward, the post was cast into metal. Once the post was cast, the Locator head (Locator, ITI, Straumann Holding AG Co., Basel, Switzerland) was soldered to the metal post [Figure 3]A–C. After soldering, the post and core were sandblasted and cleaned [Figure 3]D and E.
Figure 3: (A) Cast metal post of 23, (B) Locator, (C) Locator (female part) tried on a metal post, (D) metal post and core abutment in a working model, and (E) Locator abutment soldered to the metal post and core

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The metal post was tried into the patient’s mouth, and adjustments were made until maximum seating, and correct clearance was obtained. After the fit was verified, the metal post and core were cemented using resin luting cement (RelyX Luting Cement, 3M ESPE, St. Paul, MN, USA) into the canal of 23 [Figure 4]A and B.
Figure 4: (A) Tooth 23 before cementation, (B) after cementation of the custom-made metal post and core with Locater attachment, (C) relief holes were made on the prosthesis, (D) the block-out spacer and utility wax were placed on the Locator attachment to block the undercut area, (E) chairside cold cure acrylic resin was placed on the venting holes of the denture, (F) denture fitted into the patient’s mouth, and (G) anterior intraoral view

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Maxillary and mandibular cobalt–chromium removable partial dentures (RPDs) were fabricated. The metal housings were picked up with processed male components on the maxillary denture using autopolymerizing resin (Kooliner, GC America, Alsip, Illinois). Prior to the pickup, a relief area was created to create space for the new acrylic resin to cover the attachment [Figure 4C]. The relief holes were drilled on the relief space to ensure passive seating over the abutments. White block-out spacer attachments were used to avoid locking acrylic resin into undercut areas [Figure 4D]. The denture was removed from the mouth following resin polymerization. Denture stability and adequate encasement in the attachment housing acrylic resin were confirmed [Figure 4E and F].

The black processing elastic band was then replaced with pink color males and firmly pressed onto the female Locator. Minor adjustments were made in the intaglio surface of the maxillary denture. After verifying the patient’s stability, retention, and comfort, the prosthesis was issued to the patient [Figure 4G]. The patient was satisfied with her esthetic and functional outcomes during the review visit within 4 weeks, followed by 6 months.


  Discussion Top


This patient’s treatment consisted of providing her with a maxillary tooth-supported cobalt–chromium overdenture with a Locator attachment system. Tooth-supported overdentures are often used as the last resort before patients become entirely edentulous. They can help in the transitional phase, especially in elderly patients with reduced capacity for adaptation. Tooth-supported overdenture with cast coping is still a viable treatment option in partially edentulous patients with proper design, planning, and aftercare.[8]

Retention of the roots of one or more canines for overdenture provides the patient with several benefits from both a practical and a biological perspective. In addition to maintaining proprioception of the periodontal ligament and minimizing bone loss, some teeth are retained to sustain and retain the prosthesis and improve prosthesis stability.[9] The use of preferred teeth in strategic locations would drastically improve the outcome of care in terms of overdenture stabilization and preservation. In the present case report, tooth 23 was selected to provide support and retention to the overdenture due to the characteristics and position of the canine associated with alveolar bone support, greater periodontal area for attachment, long single-rooted nature of the teeth, and the transition area between anterior and posterior teeth rather than tooth 24 which has more tendency to be fragile after root canal treatment as compared with single-rooted teeth. Hence, using the root of tooth 23 showed satisfactory retention for the prosthesis.

When cast copings are used on natural abutment teeth, they can also be used to provide precision attachments that create additional retention to the overdenture. The precision attachments are composed of two male cast root caps. The retentive part is soldered (e.g., spherical attachment, cylinder, and magnet), and the corresponding female caps are embedded into the prostheses’ fitting surface.[10],[11],[12] The retention band inside the female caps can be modified, and the components can be changed once they get worn out. The choice of Locator was beneficial in this case as this will help to reduce the stress distribution direct to the abutment tooth due to the high modulus elasticity of the O-ring.[13]

A number of studies have shown that abutment teeth for RPDs tend to accumulate more plaque than other teeth, which are also at higher risk of periodontitis and root caries.[14],[15]

By changing abutment teeth, which have an unfavorable crown–root ratio into an overdenture abutment, these destructive forces can be decreased, and the survival rate of such teeth increases when used as prosthetic abutments.[16],[17] The disadvantages of using Locator system as tooth-supported overdenture are that it is both time-consuming and costly. The cost of fabricating custom-made post as well as the Locator itself is expensive. Furthermore, the tooth is required to undergo root canal therapy following the construction of the prefabricated post. Besides that, other disadvantages include difficult construction and high maintenance and repair. The patient is required for frequent reviews to monitor the abutment. Improper overdenture maintenance may result in periodontal breakdown and will lead to the loss of the tooth.

The most difficult aspect in this case of using Locator attachments is their “complex design.” Customization of Locator attachments is difficult to carry out. It requires proper planning and communication between the dentist and the technician as it requires specialized skills at both levels. Consequently, the limitation for this case is that more designing and laboratory work is required. The post needs to be customized and fabricated according to the canal shape of the abutment. As a result, it necessitates perfection and skill on the part of both the dentist and the dental technician.

Furthermore, the system cannot be used in cases with limited inter-arch space or bony undercuts adjacent to abutments because it may interfere with vertical dimension and tooth placement.

The success of a tooth-supported overdenture is determined by the selection of the right patient that can perform vigorous oral hygiene care and a proper treatment planning that satisfies both the patient and the dentist. According to few studies, RPD-related issues persisted for 1–5 years after treatment. And after wearing the prosthesis for a while, retention may decrease due to wear of the O-ring, in which case it can be easily replaced chairside. Therefore, routine annual follow-ups are required in all cases, without exception.[18],[19] Nevertheless, in this case, follow-up had been made 6 months after issued, and the Locator is still intact and the denture is retentive and functioning well.


  Conclusion Top


This technique using a Locator attachment on a natural tooth can be an alternative method in prosthodontic rehabilitation of a partially edentulous adult patient with a distinct approach to meet the patient’s needs, esthetics, and psychological well-being.

Acknowledgement

We would like to express our gratitude to our devoted prosthetic laboratory assistants for their outstanding job in prosthesis construction and also to our dental surgery assistant who assisted in the treatment sessions.

Financial support and sponsorship

This study was self-funded.

Conflicts of interest

There are no conflicts of interest.

Author contributions

NRM contributed to conceptualization, methodology, and original draft writing. EAE contributed to writing, editing, and reviewing the manuscript. SFA contributed to supervision and reviewing the manuscript. All authors have read and agreed to the published version of the manuscript.

Ethical policy and institutional review board statement

Nil.

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 initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Data availability statement

The data are available itself in the presented manner.

 
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Renner RP, Gomes BC, Shakun ML, Baer PN, Davis RK, Camp P. Four-year longitudinal study of the periodontal health status of overdenture patients. J Prosthet Dent 1984;51:593-8.  Back to cited text no. 3
    
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Mercouriadis-Howald A, Rollier N, Tada S, McKenna G, Igarashi K, Schimmel M. Loss of natural abutment teeth with cast copings retaining overdentures: A systematic review and meta-analysis. J Prosthodont Res 2018;62:407-15.  Back to cited text no. 8
    
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Tokuhisa M, Matsushita Y, Koyano K. In vitro study of a mandibular implant overdenture retained with ball, magnet, or bar attachments: Comparison of load transfer and denture stability. Int J Prosthodont 2003;16:128-34.  Back to cited text no. 10
    
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