|Year : 2021 | Volume
| Issue : 3 | Page : 177-180
Tooth-supported attachment retained overdenture: forgotten concept revisited - A case report
BT Pradeep Raja, PS Manoharan, E Rajkumar
Department of Prosthodontics, Crown and Bridge, Indira Gandhi Institute of Dental Sciences, Puducherry, India
|Date of Submission||13-May-2021|
|Date of Decision||26-Jul-2021|
|Date of Acceptance||31-Jul-2021|
|Date of Web Publication||17-Sep-2021|
Dr. B T Pradeep Raja
Department of Prosthodontics, Crown and Bridge, Indira Gandhi Institute of Dental Sciences, Puducherry - 607 402
Source of Support: None, Conflict of Interest: None
Overdentures have been considered as a viable treatment alternative for complete dentures in preserving the alveolar ridge integrity. Overdentures remain the choice of the treatment for edentulous patients because of its associated advantages such as increased retention, stability, and support; decreased ridge resorption; and enhanced masticatory efficiency compared to the conventional dentures. Although implant-supported prosthesis provides a better survival, tooth-supported ball attachment retained prosthesis (TBSP) has its own advantages in terms of providing proprioception and economical alternative. Recent advancements with attachment-retained prosthesis enhanced the retention, stability, and support. With proper postoperative follow-up, it is possible for a practitioner to monitor the status of the abutments and provide the necessary care for longevity of the prosthesis. This case report postulates a technique for the fabrication of TBSP with stud attachments in the mandibular arch. Follow-up radiographs after 1 year revealed that alveolar bone of abutment teeth was considerably preserved.
Keywords: Ball attachment, case report, overdenture, tooth-supported prosthesis
|How to cite this article:|
Pradeep Raja B T, Manoharan P S, Rajkumar E. Tooth-supported attachment retained overdenture: forgotten concept revisited - A case report. SRM J Res Dent Sci 2021;12:177-80
|How to cite this URL:|
Pradeep Raja B T, Manoharan P S, Rajkumar E. Tooth-supported attachment retained overdenture: forgotten concept revisited - A case report. SRM J Res Dent Sci [serial online] 2021 [cited 2022 Oct 6];12:177-80. Available from: https://www.srmjrds.in/text.asp?2021/12/3/177/326210
| Introduction|| |
The main aim of preventive prosthodontics is to delay or eliminate the inevitable problems such as residual ridge resorption and to preserve the remaining structures. Tooth-supported overdenture has been recommended by preventive prosthodontics for preserving the remaining natural teeth as well as providing stability and additional retention to the prostheses, especially in mandible. Evidences suggest that, in patients treated with overdentures although the treatment seems satisfactory, complications and maintenance difficulties after the treatment cannot be entirely ruled out. As always, the success of the treatment depends on proper oral hygiene and periodic recalls.
In developing countries, tooth-supported ball attachment retained prosthesis (TBSP) can be an economical treatment option with an optimal prognosis and success rate. With the use of attachments such as bar and clip, stud attachment, or magnetic attachment for enhanced retention, tooth-supported overdentures provide an alternative solution for implant-supported overdentures. However, with minimal literature evidence available, it is difficult to draw a conclusion on the survival rate of TBSP and as is a lack of evidence suggesting the use of attachments in tooth-supported overdenture. Custom-made attachments have been used to retain the prosthesis in similar case reports.,, This clinical case report was aimed at presenting the rehabilitation of mandible using custom-made stud attachment for enhanced retention, where simplified procedures were used in impression making and follow-up assessment was done to evaluate the prognosis of the case.
| Case Report|| |
A 65-year-old female reported to the Department of Prosthodontics, Indira Gandhi Institute of Dental Sciences with the chief complaint of difficulty in chewing hard food and loose-fitting dentures. She gave a history of teeth removal before 6 years due to gum diseases and dental caries. She was a denture wearer (upper complete denture and lower partial denture) for the past 4 years. The patient is not associated with any systemic conditions.
Extraoral examination revealed that the vertical dimension was lost, and lips were unsupported. She had a convex profile, and no abnormalities were seen in temporomandibular joint evaluation. On intraoral examination, a completely edentulous maxillary arch was seen. It also revealed a partially edentulous mandibular arch depicting normal alveolar ridge mucosa and Kennedy's Class I Modification I with remaining canines, right lateral incisor, and premolars [Figure 1]a. Adequate bone width and height were present in the maxillary ridge with favorable throat form. There was moderate resorption in the mandibular ridge.
|Figure 1: (a) Preoperative intraoral picture, (b and c) preoperative intraoral periapical|
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After a proper clinical and radiographic assessment [Figure 1]b and [Figure 1]c, we came up with a treatment plan to fabricate a conventional complete denture in the maxillary arch and stud attachment overdenture in the mandibular arch by preserving the mandibular canines, right lateral incisor, left first premolar wherein attachments will be placed on canines, and metal copings on the rest. Before commencing with the treatment, the possibility of using a stud attachment was confirmed by determining the vertical dimension with the help of tentative jaw relation. The patient was informed about the proposed treatment, and consent was obtained.
Initially, patient's radiographic examination revealed periapical lesion in the remaining natural tooth. After consultation with the endodontists and periodontists, the mandibular canines, right lateral incisor, and left first premolar were endodontically treated and kept under observation. Once the teeth were asymptomatic, postspace preparation was done [Figure 2]a and [Figure 2]b, and teeth were prepared to achieve a favorable crown root ratio. After endodontic treatment, Peeso Reamers and Gates Glidden drills were used for preparing the postspace by removing gutta-percha leaving one-fourth of the material in the apex. This facilitates the placement of copings within the canal space. Then postspace impression was obtained with light body and lower pickup impression was obtained using putty and light body [Figure 2]c. Cobalt chromium copings were fabricated and evaluated for the fit And were inserted individually into each canal for evaluating the fit and its parallelism. After the trial fit, copings were cemented in the prepared root canal space with glass ionomer cement [Figure 2]d. The primary impressions were obtained with irreversible hydrocolloid material (Algitex®, DPI, India), and custom trays were fabricated using auto polymerizing resin with double spacer.
|Figure 2: (a and b) Postspace preparation, (c) canal impression with putty light body, and (d) cemented copings|
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Border molding was done using tracing sticks (DPI® Pinnacle, India) and secondary impressions were obtained using polyvinyl siloxane light body (Photosil™, DPI, India). For the mandibular arch, during the secondary impression procedure, temporary silicone stoppers were attached to the male component and picked up along with the impression [Figure 3]a and [Figure 3]b. Maxillomandibular relations were recorded, and teeth arrangement was done in a conventional manner, and dentures were processed. Mandibular overdenture was reinforced with the metal framework for additional strength, and temporary silicone stoppers on the tissue side of the dentures were replaced by metal housing and O-ring [Figure 4]b and [Figure 4]c. Dentures were delivered after necessary adjustments [Figure 4]a. Postinsertion follow-ups were done on the 1st day, 1 week, and 1 month. After that, a 6-month follow-up and 1-year follow-up were done, radiographs revealed that the alveolar bone around the retained teeth was considerably preserved [Figure 3]c and [Figure 3]d.
|Figure 3: (a) Temporary sleeves placed over the ball attachment, (b) pickup impression, (c and d) recall visit intraoral periapical showing substantial reduction of periapical lesion with good prognosis|
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|Figure 4: (a) Denture insertion, (b) tissue surface of mandibular denture enhanced with Co-Cr framework showing metal housing and O-ring, (c) tissue surface of maxillary denture|
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Periodic recall of the patient revealed her satisfaction with ball attachment-retained denture as it increased her masticatory efficiency compared to her previous removable prosthesis. The main advantage as mentioned by the patient is the stability of the denture during chewing.
| Discussion|| |
Implants have taken over the concept of overdentures when additional retention for the removable prosthesis is required. Although tooth-supported overdentures seem an alternative, a very few number of case reports were available in the literature to support the statement.,, More case reports, followed by randomized controlled trials (RCTs) in this area, will pave for the systematic reviews or comparative studies with implant overdentures.
Endo-perio assessment was done to assess the intensity of the periapical lesion before the treatment. In most of the clinical situations associated with endo-perio lesions, tooth may not be retained for overdenture prosthesis, but in this case, the tooth has been retained after a proper multidisciplinary treatment planning involving endodontist and periodontist. After which root canal treatment was done for the tooth and kept under observation until the lesion is subsided. In the cases involving endo-perio lesions, a proper treatment planning followed by an observation period can enhance the prognosis of the tooth which in turn enables the success of the overdenture therapy.
Intentional RCTs were done to achieve a more favorable crown-root ratio by reducing the crown size. This decreased size of the crown will reduce the stresses over the abutment teeth. During the early days, cores of different sizes more than 2 mm were used for the support and stability of the dentures. In this technique, the abutment teeth were reduced to a height of around 1–2 mm, for the placement of copings. Advantages of this technique were, less time for preparing the abutment teeth and ease of maintenance for the patient. All the abutment teeth were prepared to a dome shape, and fluoride application was done to prevent secondary caries.
In this case report, a temporary sleeve was used whereas taking secondary impression which was helpful in incorporating the female components in the tissue surface of the denture during the fabrication which in turn reduces the chairside working time. With proper treatment planning and parallel preparation of the abutment, postinsertion adjustments were avoided. The use of metal-reinforced denture base helped in avoiding the breakage of the denture. With the minimal height of the abutment teeth, wear of the teeth, or denture during functional movements was reduced. Sore spots can be identified and relieved using pressure-indicating paste.
In most of the situations, complete dentures remain the treatment of choice for elderly patients due to the unavailability of other treatment options such as implant-supported dentures. This may be due to severe ridge resorption or any other systemic conditions which limit the placement of implants. Although mutilated dentition is common in elderly patients, preserving the selected teeth with a good prognosis in appropriate positions will aid in retention and stability of the denture. Retaining the natural teeth for overdentures will prevent the progressive alveolar atrophy and reduce the bone loss.
However, patient cooperation is necessary for the success of the treatment by maintaining the oral hygiene to eliminate any chance of periodontal disease or secondary caries. Minimal evidence has been seen in the literature regarding the survival of tooth-supported overdentures, but those evidence showed a very good survival rates and suggested the need for the maintenance phase after the prosthetic rehabilitation with tooth-supported overdentures. Dome-shaped abutments and attachment over it reduces the occlusal forces and abutment mobility is decreased by means of tensile stimulation of periodontal fibers. Along with the residual alveolar ridge retained abutment, teeth provide additional retention to the denture. Other added advantages with retaining the natural teeth are improved occlusal stress distribution, proprioception, improved masticatory efficiency, and psychological advantage of the presence of the natural tooth to the patient., Added to the advantages, this is a technique-sensitive procedure which is time-consuming and has certain disadvantages such as difficulties in path of insertion which requires proper training of the patient, susceptibility of caries, and periodontal disease which requires maintenance phase.
The success of the overdenture treatment depends on maintaining the oral health status of the patient by assessing the prosthetic, restorative, and periodontal conditions. This can be achieved by means of recall visits and radiographic examinations at regular intervals. Postoperative radiographs revealed that periapical lesion subsided over a period of time postendodontic therapy indicative of a good prognosis. Formation of the secondary caries was eliminated by motivating the patient to maintain proper oral hygiene. Brushing techniques, the use of fluoride dentifrice, and massaging the gingival tissues were taught to the patient for the long-term success of the overdenture therapy.
| Conclusion|| |
With the evolution of implant dentistry, the concept of tooth overdenture has been overshadowed, but the treatment costs involved may not be affordable for all the patients. Tooth-supported attachment-retained overdentures are the better alternatives for implant overdentures, but the success rate of the treatment needs to be explored.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that their name 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.
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