Rational use of endosteal implants.
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Absence of a mandibular posterior tooth, particularly the first molar, is the basic common denominator in a wide range of dental disorders. Despite their awareness of this fact, many dentists are deterred from the routine construction of mandibular posterior fixed partial dentures because of several technical difficulties. An attempt has been made to show how these difficulties may be overcome to give a predictable and satisfactory result.
A preventive prosthodontic technique has been described which utilizes hemisected teeth for overdenture support. This multidiscipline procedure provides firm denture support and preserves posterior residual alveolar ridges. By retaining posterior roots, proprioceptive mechanisms are maintained, and psychologically, the patient does not seem edentulous. As Brewer and Fenton stated, "The application of this method of treatment is limited only by the imagination of the dentist."
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The use of a resilient denture lining material and the rationale for the selection of the particular material used has been described. A resilient lining material provides primary retention for prostheses that may be difficult or impossible to obtain by other means. The improved compatibility of delicate tissues with a resilient material as compared to a rigid material has also been discussed.
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Alternative approaches toward the resolution of difficulties associated with severe attrition are offered. A clinical approach is advocated which first proves the acceptance of an increase in the occlusal vertical dimension before initiating definitive treatment. The various aspects of removable treatment are considered. A sequential approach is suggested in fixed reconstruction which avoids inaccuracies of multiabutment registration and orientation associated with complete arch preparation.
A crown and sleeve-coping prosthesis retainer has been defined. Some causes for the loss of the coping and subsequential clinical manifestations have been discussed. A step-by-step procedure for remaking the coping was presented.
Telescope crowns used in removable partial dentures reduce the destructive horizontal and rotational occlusal forces by directing them more axially and less traumatically than other retainers. These properties are combined with excellent conditions for cross-arch and multiple abutment splinting. If one of the abutment teeth needs extracting, the denture can be repaired with acrylic resin simply by remaking the secondary crown into a pontic. The single copings can be easily cleaned due to the good accessibility around their gingival margins. They also protect the abutment teeth against caries and thermal irritation. Soldering of the primary copings or their connection with accessory bars is not necessary in rigidly constructed telescope crowns, because the secondary crowns incorporated in the superstructure provide sufficient rigidity. In addition, the splinted copings often cause inflammatory gingival hyperplasia because the solder joints are too close to the gingival margins, preventing proper hygiene maintenance. The taper configuration or vertical height of the coping, which determines the amount of load transferred to each abutment, can be planned to suit each tooth's condition and designated function in the restoration. In a fixed restoration, the load is always evenly distributed among all the abutment teeth regardless of their condition, because the crowns are permanently cemented to them. In the telescope denture, the amount of force can be individually regulated by modifying the form and leverage of the retainers, according to their position, bone support, and occlusal conditions.
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Entirely tooth-supported removable dentures with telescope crowns may be considered a good alternative to a fixed restoration of the whole dental arch. They provide a rigid splinting and stable occlusion and offer a better safety factor owing to their removability and their lesser dependence on each single abutment. Also they are applicable when parallelism among the abutments does not permit making a fixed restoration. Furthermore they can be cemented in stages, decreasing the risk of washout later. Psychologically, they are well tolerated by patients.
The development of an endosseous implant has followed a logical and formal plan. 1. Extensive experiments with animals provided preliminary statistics of successful function, extensive histologic studies, evaluation of biocompatibility, and a preliminary assessment of contraindications. 2. Carefully developed and controlled clinical study of human subjects with frequent examinations and detailed records of both successes and failures again provided new bases for contraindications. The statistics on the clinical study are satisfactory in their results, although they should be regarded as having a somewhat conservative slant. This is because implant failures became a learning base for improved procedures. The program so far has been limited to a single implant design that, with size variants, will serve most applications. However, it is not feasible to modify the design in terms of dimensions for application in the anterior portion of the mouth. A design for this purpose is established on paper and will become a future additional development.
Laboratory procedures in support of maintenance therapy for a typical patient with a removable partial overdenture were described. These procedures consisted of the fabrication of a gold metal coping and the reline of the prosthesis with autopolymerizing acrylic resin. In designing the coping contours, the technician must consider the path of insertion of the prosthesis and the space requirement for the overlying resin tooth. Reproduction of the dowel preparation is facilitated by using a plastic dowel as part of the coping wax pattern. The removable partial overdenture was relined with autopolymerizing acrylic resin in a reline jig. Tooth-colored acrylic resin was used in the concavity formed by the overdenture abutment to enhance esthetics. The requirement of a coordinated effort between the dentist and the dental laboratory technician is critical to the successful treatment of the removable partial overdenture patient.
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A technique has been presented that involves the use of a telescopic ceramometal pontic soldered to a type III alloy substructure (Figs. 4 and 5). This technique eliminates the need for manufactured facings or the use of processed acrylic resin, but it incorporates the advantages of porcelain esthetics and wear with the increased ability to burnish the retainer margins.
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