Journal of Dental Sciences
University
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 100
University J Dent Scie 2017; No. 3, Vol. 1
Case Report
ABSTRACT: Prosthodontic rehabilitation of a patient with maxillofacial trauma often puts
challenge in front of the clinician. A candid technique for rehabilitation of a patient has been
presented with lingually collapsed mandibular jaw and missing anterior teeth due to trauma. A
simplified removable partial denture design has been made with midline split in the prosthesis, to
produce a hinge like action while inserting and removing the prosthesis from the oral cavity. This
design enables the partial denture to adapt closely to the lingual arch overcoming the undercuts
produced by the lingually tilted mandibular posterior teeth.
1 2 3 4Rahul S. Kulkarni, Poonam R. Kulkarni, Rupal J. Shah, Bharti Tomar1.M.D.S. (Senior Lecturer), Dept. of Prosthodontics, Index Institute of Dental Sciences, Index City, Indore 2.M.D.S. (Senior Lecturer), Dept. of Prosthodontics, Sri Aurobindo College of Dentistry and PG Institute, Indore3.Professor& Head, Dept. of Prosthodontics, Government Dental College & Hospital, Ahmedabad4.HOD & Director, The Healers Dental Group, D-215, Vivek Vihar, Phase-1, Delhi
INTRODUCTION : Prosthetic rehabilitation of patients
with maxillofacial trauma has always been a challenging task
for prosthodontists. Fracture of the lower third of the face is
about 60% of the total maxillofacial injuries; with
symphyseal and parasymphyseal fracture contributing 35.3%
of the mandibular fractures. [1]Fabrication of removable
partial denture in patients with lingually collapsed arch due to
trauma is often an arduous job for the prosthodontist. The
most frequently fabricated removable partial dentures are
Kennedy Class I (41.0%) followed by Class III (28.6%), Class
II (25.4%) and finally Class IV (4.9%). Class III are
predominated in the maxillary arch (43.3%), while Class I are
dominated the mandibular arch (55.6%). [2]Another study
revealed class-I in 32.33% cases, class-II in 15.66% cases,
class-III in 33% cases and class- IV in 19%.[3]In one study
custom attachment with stress-breaking effect had been used
for the rehabilitation of long-span Kennedy class IV
patients.[4]There are two major types of removable partial
denture, one is acrylic resin removable partial denture and
other is cast partial denture. But in all types of Kennedy
classes, most commonly used partial denture is of acrylic
resin, because of its ease of fabrication & low cost. [5]In
conjunction with its advantages, it has many limitations, such
as the damage to hard & soft tissues due to gratuitous load
placed on abutment teeth, plaque, and calculus accumulation
on teeth that can cause periodontal problems.[5,6,7]
Lingually inclined molars are common finding in removable
partial denture design in mandibular arch. Nowadays, flexible
dentures are frequently used in such cases,but it has its
limitations in severe undercut areas.[8] Cast partial
removable partial denture's construction in such cases also
faces similar problems, and modification in treatment plan is
often necessary like choosing a labial bar major connector or
contouring of the lingually tipped teeth.[9]The labial bar
major connector often feels bulky to the patient and needs
enough space in the vestibular area for its construction.
Contouring of grossly tipped molars demand for endodontic
treatment and violates the principles of conservation of tooth
structure. Fixed partial denture fabrication for missing teeth
in such cases also faces same problems. Hence an innovative
way to counteract these difficulties has been explained in this
technique.
CASE HISTORY: A 32 years old male patient came to the
department of Prosthodontics, Index Institute of Dental
Sciences, Indore, Madhya Pradesh, India, with chief
A CANDID TECHNIQUE FOR REHABILITATION OF A LINGUALLY COLLAPSED MANDIBULAR ARCH BY HINGED REMOVABLE PARTIAL DENTURE
Keywords :Mandibular fracture, Lingually collapsed arch, Removable Hinged partial denture.
Source of support : NilConflict of interest: None
complaint of difficulty in speech and poor facial appearance
[Fig. 1].
Fig 1. Intra-oral view of the patient with missing teeth and
lingually collapsed arch.
The patient had history of fracture of mandibular symphysis
region 1 year back due to trauma, for which he had been
operated. The re-union of fractured segment with bone plating
had resulted in lingually collapsed mandibular arch due to
irregular reporting by the patient.
Radiographic findings showed a reunited mandibular
symphysis fracture with mini bone plates. Teeth 41 and 42
were present with inadequate bone support at their apices
suggesting a poor prognosis [Fig. 2]. Clinically they revealed
grade III mobility and hence planned for extraction. Patient
recalled after 1 month of extraction of 41 and 42 & a detailed
clinical examination was done. There was no pain and
discomfort associated with the trauma site on palpation. TMJ
examination also revealed no abnormal findings.
Fig 2. Radiographic view of the patient.
On intra-oral examination patient had congenitally missing
33 & 43, & missing 31 & 32 due to trauma from accident &
completely healed extraction socket of 41 & 42. The patient
had poor oral hygiene. The lingually collapsed mandibular
arch produced severe undercut which was challenging for any
prosthetic option to be produced. There was pronounced bone
loss in the edentulous area due to loss of the teeth in trauma.
Healing of the wound due to loss of teeth resulted in
obliterated anteriorvestibule,hence there was not sufficient
space for the labial bar major connector [Fig. 1]. Hence it was
decided to plan a removable partial denture with midline split
to overcome the undercut in mandibular arch.
TECHNIQUE: The present candid technique of hinged
prosthesis fabrication was developed in the Department of
Prosthodontics including Crown and Bridge and
Implantology of Index Institute of Dental Sciences, Indore
(M.P.).
Impressions of the upper and lower arches were made with
irreversible hydrocolloid impression material (Neocolloid;
Zhermack) and casts were poured in dental stone (Type III
dental stone, Moldano, Heraeus Kulzer, Hanau, Germany).
Jaw relation was recorded in conventional manner. A 19
gauge orthodontic wire (Patterson Companies, INC, North
America) was adapted along the lingual surface of the arch
with incorporation of double loop in the midline of the
edentulous space [Fig. 3].
Fig 3. Adapted 19 gauge orthodontic wire along the lingual
surface of the arch with incorporation of double loop in the
midline of the edentulous space.
Jaw relation was recorded in conventional manner. Cross
linked acrylic teeth (Ruby Dental Pvt. Ltd. Jama Masjid,
Delhi) arrangement was done in edentulous space replacing
31, 32, 41, 42 teeth. Congenitally missing teeth 33 and 43
were not replaced due to lack of space. Try in was done in
patient's mouth. After getting approval from patient, wire
with midline loop was then adapted to the mandibular arch
with quick setting polyfix ® cynoacrylate adhesive (Benson
Polymers Limited, Karkar Dooma, New Delhi).
Special emphasis was given to the midline area that contained
the loop. The central incisors were spaced apart with 1mm gap
for proposed future split in the denture [Fig. 4].
Fig 4. Teeth arrangement and flasking
University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 101
University J Dent Scie 2017; No. 3, Vol. 1
The flasking of the cast was carried out by conventional
method and dewaxing was done. The wire was inspected for
correct position and the loop portion of the wire blocked by
the polyvinyl siloxane putty (Prime Dental Products Pvt. Ltd.
Kalher, Thane) to prevent inclusion of the acrylic resin in to
the loop [Fig. 5].
Fig 5. After de-waxing silicone putty incorporated in the loop.
Packing was done with heat cured PMMA resin (Acralyn-H,
Asian Acrylates, Mumbai, India) and denture was retrieved
[Fig. 6].
Fig 6. Cured prosthesis with silicone putty.
A midline split was made in the denture with diamond disc
(6934; Brasseler USA, Savannah, Ga) and loop was cleared
off with silicone putty material [Fig. 7,8,9]. It was then
properly finished and polished [Fig. 10].
Fig 7. Prosthesis after removal of silicone putty from loop.
Fig 8. A line drawn on labial and lingual surface of the
prosthesis
Fig 9. Split made on the labial and lingual surface of the
prosthesis
Fig 10. Completed split prosthesis with midline loop.
The fabricated removable partial denture had hinge like
movement in the midline. The lingual flanges of the
removable partial denture (RPD) were pressed with fingers
while inserting it in the oral cavity and released when placed
in position [Fig-11, 12]. Instruction regarding care and
maintenance of prosthesis were given to the patient.
Fig 11. Labial and lingual view of the prosthesis in patient's
mouth.
Fig 12. Patient's appearance before and after prosthesis
placement.
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DISCUSSION: The edentulous space in Kennedy Class IV
patients may be short span (missing incisors only) or long
span (missing anterior teeth & some premolars). In long span
class IV even if the potential abutments are favorable, a fixed
prosthesis would result in an unacceptable cantilever effect.
In Kennedy-Applegate classifications Class IV is the only one
which includes both tooth supported and tooth ridge
supported designs.[10]
Prosthodontic rehabilitation of a patient having maxillofacial
trauma often warrants special consideration. In present case,
mandibular arch exhibits 'v' shape, causing increase length of
the edentulous span for the replacement of the missing teeth.
Flexure of long span bridges during mastication can be a
problem. A very long span fixed prosthesis during centric
closure with no food in the mouth may present no real
problem in terms of flexure, because there is distribution of
forces among all the occlusal surfaces around the arch.
Nevertheless, when bolus of food interposed between the
pontic area of long span bridge and its opposing occlusal
surfaces, the effect can be quite different since the occlusal
contacts on the opposite side of the arch have not yet come
into play. In this case, all of the force is concentrated on the
bridge span, inducing a strain that the restoration and / or the
abutment teeth may not be capable of withstanding. In a cross-
sectional study of the lifespan of fixed prostheses, Schwartz et
al reported that the best longevity for fixed prostheses was
when canines were used as abutments.[11] In present case
lingually collapsed mandibular arch produces difficulties in
prosthesis fabrication because of severe lingual undercut.
Hence, modification in conventional techniques is required to
produce a successful prosthesis. A two part hinged denture
produces satisfactory solution but produces difficulties in
regular maintenance of a prosthesis [12]. A 19 gauge wire
gives sufficient rigidity to the prosthesis but long term follow
up is required regarding durability and effectiveness.
Technique given in this article is not technique sensitive and
easy to follow.
Advantages of this ingenuous technique are: This is a very
simple technique for both patient & dentist because there is no
need of surgery. This technique does not cause any damage to
the adjacent teeth, as in fixed partial denture and in cast partial
denture, preparation of adjacent teeth usually requires. Single
or multiple teeth can be replaced by this technique. Partial
denture fabricated by this technique can be aesthetically
pleasing in overall appearance. This technique is not time
consuming, a partial denture can be fabricate in single day
only.
Disadvantages of this ingenuous technique are: Removable
partial denture fabricated by this technique needs frequent
replacement because of the shrinkage of the bone & tissues
denture will become least retentive. There can be a food
lodgement in the loop of the wire that may irritate the patient.
Conclusion:
For the Class IV type of partially edentulous arch treatment
approaches may include explicit indications for fixed or
removable partial dentures, with the removable partial
denture having greater flexibility as a treatment modality for
conditions other than normal. While rehabilitating Class IV
type of partially edentulous arch the dentist can face a
biomechanical and cosmetic confront. This observation
increases more certainty when examined in a longitudinal
biomechanical perspective.
ACKNOWLEDGEMENT : The authors are very thankful
for Support from The Department Of Prosthodontics, Index
Institute of Dental Sciences, Index City, Indore -452001,
Madhya Pradesh, India, where the work was primarily carried
out.
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CORRESPONDING AUTHOR:
Dr. Poonam R. Kulkarni
8-A, Krishi Vihar Colony, Near Tilak Nagar, Indore
452001, M.P.
E mail: [email protected]
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University J Dent Scie 2017; No. 3, Vol. 1
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