|Year : 2022 | Volume
| Issue : 2 | Page : 180-182
Occlusal metal onlays in complete dentures
Anoopa Nataraj, Rubina Tabassum, Asha M Rathod, Gaurang Mistry
Department of Prosthodontics, DY Patil University School of Dentistry, Navi Mumbai, Maharashtra, India
|Date of Submission||08-Jan-2022|
|Date of Decision||04-May-2022|
|Date of Acceptance||07-May-2022|
|Date of Web Publication||22-Aug-2022|
C-15, Nirmal Park, Central Railway Officers Flats, Dr. Ambedkar Road, Byculla East, Mumbai - 400 027, Maharashtra
Source of Support: None, Conflict of Interest: None
Flabby tissues and enlarged maxillary tuberosities in completely edentulous patients arise as a consequence of combination syndrome which affects complete denture treatment planning. A completely edentulous 70-year-old male denture wearer is presented in this article with flabby tissues and enlarged maxillary tuberosities. Flabby tissues need to be recorded in an undisplaced state to avoid overcompression due to realeff effect. Wear of acrylic teeth and perforation of denture base in the posterior region of his existing denture denotes a lack of interocclusal space. This is due to downward displacement of maxillary tuberosities which affects the posterior interocclusal space and requires special consideration. This article describes the prosthodontic management of the presented challenges with regard to the impression technique used to record flabby tissue and the need to maintain the occlusal vertical dimension to prevent denture base wear using occlusal metal onlays.
Keywords: Enlarged maxillary tuberosities, flabby ridge, metal occlusals, reduced interocclusal space
|How to cite this article:|
Nataraj A, Tabassum R, Rathod AM, Mistry G. Occlusal metal onlays in complete dentures. J Dent Res Rev 2022;9:180-2
| Introduction|| |
“Combination syndrome,” as described by Kelly, comprises a group of complications affecting maxillary edentulous arch and mandibular partially edentulous arch such as loss of bone from the anterior part of the maxillary ridge, overgrowth of the tuberosities, papillary hyperplasia in the hard palate, extrusion of the lower anterior teeth for a patient presenting with upper complete denture and lower distal extension removable partial denture. On loss of lower anterior teeth, a complete denture fabrication becomes imperative with added complications of fibrotic and enlarged tuberosities, affecting the jaw relation record as the occlusal plane migrates upward in the anterior and downward in the posterior region.
Ways to manage flabby ridge involve surgical removal, implant retained prosthesis (fixed/removable), and conventional complete dentures. Surgical removal is considered risky when little or no alveolar bone remains. Although the flabby ridge may provide poor retention for the denture, it may still be better than no ridge at all.
Maxillary ridges with enlarged tuberosities pose a problem of lack of interocclusal space in the posterior region. When this occurs in a patient with enlarged tuberosities, frictional contact occurs in the posterior denture region, leading to acrylic wear and subsequent perforation of the denture base.
| Case Report|| |
A 70-year-old male patient presented to the Department of Prosthodontics of D. Y. Patil University School of Dentistry with a chief complaint of worn out denture teeth and a hole in the lower denture. The patient was a denture wearer for the past 7 years, with a total of two sets of dentures made in this time span.
On examination of the dentures, an uneven acrylic tooth wear was seen, and perforation of the denture base was noted in the lower left denture heel region. On intraoral examination, the patient was completely edentulous in the maxillary and mandibular arches [Figure 1], with exceptionally large maxillary tuberosities and displaceable soft tissue in the anterior region of upper and lower ridges. This case was diagnosed as completely edentulous arches with combination syndrome involving massively overhanging tuberosities, causing a decreased interarch space in the posterior region. A treatment plan consisting of an appropriate impression technique for the flabby tissue was made, with the restoration of vertical dimension and developing an occlusal surface anatomy to avoid acrylic wear.
|Figure 1: Occlusal view of maxillary (a) and mandibular edentulous arch (b)|
Click here to view
Preliminary impressions were made with irreversible hydrocolloid in a stock perforated tray. After pouring in dental plaster, a custom tray was fabricated on the primary casts in autopolymerizing resin with an extra relief spacer over the displaceable tissue. The tray was made such, that relief holes would encompass the region of the flabby tissue, so as to accomplish a one-part impression technique with a selectively perforated tray. The tray handle was fabricated palatal to the anterior ridge with the help of a 19-gauge wire, bent in the form of a ring, as a modified tray handle for the operator's convenience [Figure 2]a. Sectional border molding was carried out with low fusing compound (DPI Pinnacle, India) and a final impression with polyether light body material (Impregum soft, 3M ESPE, United States) was made using selective pressure technique, causing minimal displacement of relief areas with the help of relief wax and relief holes [Figure 2]b.
|Figure 2: Custom trays (a) and final impressions (b) of the respective arches|
Click here to view
Orientation of jaw relation was done by mounting the upper cast on a semi-adjustable articulator (HANAU™ Wide-Vue) using a facebow transfer, followed by a determination of vertical and horizontal jaw relation.
The vertical dimension of occlusion was assessed with the patient's esthetics and phonetics such that adequate posterior clearance was achieved between the maxillary tuberosity and retromolar pad [Figure 3] at centric occlusion., On verification of the same, a teeth arrangement trial was done and approved by the patient. The final denture insertion was done, and postinsertion instructions were given with several follow-up appointments.
|Figure 3: Jaw relation showing available vertical space in the posterior region|
Click here to view
After 3 weeks of denture usage by the patient, a check bite record was made with bite registration wax (MAARC, India) so as to mount the dentures at the desired occlusion. Posterior teeth were prepared for onlay preparations, with retention holes of 2 mm depth, in the center of each tooth. Wax patterns were made and cast in base metal alloys. The castings were cemented onto the teeth with resin-modified glass ionomer cement (GC FujiCEM, Japan) extraorally, and occlusal adjustments were made to eliminate any interference in centric [Figure 4] and eccentric [Figure 5] occlusal relations.
| Discussion|| |
The reported case presents features of combination syndrome, comprising of flabby tissues in the anterior ridge region and enlarged maxillary tuberosities in the posterior region. The impression technique required for dealing with flabby tissues is based on the need to avoid over displacement of the same when recording the impression. In this case, a selectively perforated custom tray was used on account of minimal displaceable tissue. Thus, any flabby tissue would be recorded with minimal pressure due to the material used and the relief provided.
Vertical jaw relation procedure ensured that posterior denture contact was avoided at occlusion. Considering the previous history of wear of denture teeth and denture base and the need to maintain the vertical dimension, it was decided to have metal occlusal surfaces over the denture teeth.
Bell and Richardson, in 1981 used a technique to combat the problem of enlarged tuberosities touching the retromolar pad, wherein he used gold shims to cover the posterior areas of the upper and lower denture. He advocates the use of this technique even when surgical reduction is not possible.
In this case, metal occlusals were preferred to be used. Wallace mentions the various advantages of using metal occlusals in complete dentures, such as:
- An increased chewing efficiency
- Minimal loss of interach distance due to wear on the teeth
- Maintenance of centric occlusion
- Their superiority in patients who have an insufficient interarch distance for porcelain teeth the occlusal preparations were made on acrylic teeth with central holes on each tooth so as to aid in added retention of the metal alloys, as described by Wallace.
Metal occlusals help to maintain the vertical dimension of occlusion on acrylic teeth by preventing acrylic wear and tuberosity to retromolar pad contact. This allows avoidance of acrylic tooth wear and posterior denture base perforation in one go. Although increased load transmission is suspected due to the use of a material of higher modulus of elasticity (cobalt-chromium alloy), its effect is not proved to cause resorption in edentulous ridges.
| Conclusion|| |
The challenge of managing an edentulous patient with enlarged maxillary tuberosities and flabby ridges is presented with a thoughtful solution to maximize the duration of our prosthetic treatment in edentulous patients.
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.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kelly E. Changes caused by a mandibular removable partial denture opposing a maxillary complete denture. J Prosthet Dent 1972;27:140-50.
Antonelli J, Guerrero M, Georgescu M, Ortiz J. Quantifying flabby ridge tissue displacement during impression-making for patients with combination syndrome. Compend Contin Educ Dent 2019;40:e1-7.
Crawford RW, Walmsley AD. A review of prosthodontic management of fibrous ridges. Br Dent J 2005;199:715-9.
Grant AA, Johnson W. Removable Denture Prosthodontics. 2nd
ed. Edinburgh: Churchill Livingstone; 1992. p. 61.
Carlsson GE. Clinical morbidity and sequelae of treatment with complete dentures. J Prosthet Dent 1998;79:17-23.
Lamb DJ. Problems and Solutions in Complete Denture Prosthodontics. London: Quintessence; 1993. p. 57-60.
Silverman MM. Determination of vertical dimension by phonetics. J Pros Dent 1956;6:465-71.
McGee GF. Use of facial measurements in determining vertical dimension. J Am Dent Assoc 1947;35:342-50.
Bell RA, Richardson A. Prosthodontic treatment of pendulous maxillary tuberosities. J Am Dent Assoc 1981;103:894-5.
Wallace DH. The use of gold occlusal surfaces in complete and partial dentures. J Prosthet Dent 1964;14:326-33.
Mercier P, Bellavance F. Effect of artificial tooth material on mandibular residual ridge resorption. J Can Dent Assoc 2002;68:346-50.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]