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Esthetic and functional combination of fixed and removable prostheses

Article in General Dentistry · March 2012

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 Fixed/Removable Prosthodontics

Esthetic and functional combination of

fixed and removable prostheses
Michael Patras, CDT, DDS, MSc  Q Nikitas Sykaras, DDS, PhD

When creating optimally esthetic contemporary prosthetic restora- paramount importance, while knowledge of material science and
tions, clinicians should balance patient preferences and requests laboratory steps is needed to guarantee successful execution of
with functional and esthetic demands. Beyond fulfilling the clinical procedures. This article provides methods and techniques
treatment objectives of restoring function and optimizing esthetics, for improvement of the esthetic outcome through the description of
the combination of fixed and removable dental prostheses should clinical and laboratory steps of a clinical case.
also blend seamlessly into the oral environment. Received: December 16, 2010
Treatment planning and proper design of the prostheses is of Accepted: April 25, 2011

D
ental implants are widely used restorations.3-5 This combination can the initial steps of treatment plan-
to restore partial or complete take the form of telescopic crowns ning, precisely executed during the
edentulism. Advancements in and a removable superstructure or, clinical phases, and meticulously
basic research and evidence-based in a more common design, crowns evaluated after final delivery.12
clinical protocols have turned this or fixed partial dentures (FPDs) This article reports on a complex
treatment modality into a well- associated with a removable partial clinical case of a full-mouth restora-
documented and highly predictable denture (RPD).6 The Kennedy clas- tion utilizing fixed and removable
treatment option.1,2 However, sification offers the basis for unfa- prostheses and combining them
limitations remain with respect to vorable or advantageous parameters with semi-precision attachment
the clinical application of implants, in the clinical use of various RPD mechanisms. Several concepts con-
including anatomic deficiencies (for designs, depending on the distribu- cerning techniques and materials
example, residual ridge resorption), tion and extent of the edentulous for the improvement of the esthetic
systemic diseases, psychological areas and the number and location result will be outlined. The article
problems, and financial restrictions. of abutment teeth. Patient expecta- also emphasizes the value of precise
When clinicians are faced with these tions regarding stability, retention, maxillomandibular relationship
conditions, conventional fixed and support, and esthetics are important recording, analyzes the function of
removable prosthodontic alternatives factors in suggesting and approving interim prostheses for envisioning
must be used to provide optimal a treatment plan involving an RPD.7 the final outcome, and depicts
functional and esthetic restorations. The retentive mechanism and the various technical factors for repro-
The esthetic appearance of a metal framework design of RPDs ducing the aging procedures in the
restoration has become the main are of paramount importance for final restorations.
concern for the majority of patients; the esthetic outcome of the final
in many cases, this request dictates restoration.8 At the same time, Case report
the treatment plan, guides the clini- conventional clasps or attachment A 70-year-old man came to the
cal steps, and determines the design mechanisms determine the design graduate prosthodontics clinic
of the prosthesis. The combination of the fixed prosthesis and have of the Athens University School
of fixed and removable prostheses different effects on the transmission of Dentistry to have his miss-
is a very common clinical approach of functional loads to the anatomic ing dentition restored and the
for the restoration of partial eden- substrate and the supporting natural functional and esthetic problems
tulism. Such treatment modalities teeth.9-11 The incorporation of an associated with it corrected.
combine the flexibility and simplic- attachment in the fixed prosthesis Maxillary porcelain-fused-to-metal
ity of removable prostheses with presents a challenge for the clinician (PFM) restorations combined with
the support and stability of fixed and must be properly assessed in nocturnal parafunctional activity

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Fixed/Removable Prosthodontics Esthetic and functional combination of fixed and removable prostheses

Fig. 1. Initial extraoral view. Fig. 2. Initial maximum intercuspation at reduced VDO.

As the patient considered the

visibility of metal clasps and other
elements of the removable prosthesis
framework to be unacceptable,
it was decided to incorporate a
semi-precision attachment as the
definitive treatment option.17
Fig. 3. Initial view of the maxillary arch. Fig. 4. Initial view of the mandibular arch. After a combined full-contour
waxing of existing restorations and
arrangement of acrylic teeth in the
edentulous areas (Fig. 5), the old
restorations were removed. Both
the maxillary and mandibular
anterior teeth were initially restored
with fixed provisional restorations
duplicating the diagnostic wax-up.
Interim acrylic removable prostheses
were fabricated at the new VDO,
securing their stability and reten-
Fig. 5. Diagnostic wax-up and arrangement of the artificial teeth. tion with wire clasps (Fig. 6 and 7).
The provisional restorations re-
established the VDO, maintained
it throughout the execution of the
treatment plan, and provided a tem-
and loss of posterior support had The need for multiple surgical plate for the definitive restoration.
contributed to exaggerated attri- and grafting procedures and The initial preparatory phase
tion of the mandibular anterior subsequent prolonged healing time included periodontal therapy, root
teeth, resulting in a reduction of caused the patient to reject the canal treatments, post and core fab-
vertical dimension of occlusion option of implant-supported res- rication, and minor relines or occlu-
(VDO) and extraoral manifesta- torations. Therefore, rehabilitating sal adjustments of the provisional
tions (Fig. 1–4).13-15 Clinical and the extended partial edentulism restorations (Fig. 8 and 9). All of
radiographic evaluation, together and the hard and soft tissue defi- these steps enabled the clinician to
with study cast analysis, revealed ciencies required a combination of evaluate the patient’s adaptation to
the need for a full-mouth rehabili- fixed and removable prostheses to the increased VDO for a prolonged
tation that required re-establish- restore the maxillary and mandib- period of time.18 During this trial
ment of the VDO and adequate ular arches and replace the missing period, critical components of
interocclusal space.16 tissue volume in the esthetic sites. function and esthetics, such as

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Fig. 6. Try-in of the partial dentures’ setup. Fig. 7. Fixed and removable provisional restorations assembled intraorally.

Fig. 8. Direct intraoral formation of post and core pattern with resinous
material. Fig. 9. Cast post and cores cemented in place.

Fig. 10. Displacement cord inserted around maxillary teeth. Fig. 11. Displacement cord inserted around mandibular teeth.

facial appearance, lip support, bending moments of the extracoro- relation interocclusal record sup-
occlusal plane orientation, incisal nal attachments. Double retraction ported by occlusal rims helped the
edge position, phonetics, and cord placement (Fig. 10 and 11) was articulation of the mandibular cast
mastication, were also evaluated followed by final impressions with (Fig. 14–16).21 This jaw registra-
and all necessary modifications polyvinylsiloxane impression mate- tion technique is a fundamental
were made.19 The patient’s adapta- rial (Fig. 12 and 13). prerequisite for space evaluation and
tion was remarkable, allowing him The maxillary working cast was accurate design of the frameworks.
to function without any reported mounted in a semi-adjustable Metal framework design of the
muscle fatigue or other problems. articulator using a facebow record.20 FPDs included splinting of the
After the patient’s approval, the With the anterior provisional abutment teeth to minimize stress
preparations were finalized with the restorations maintaining the through a more favorable distribu-
axial walls as parallel as possible, VDO and vertical and horizontal tion of the occlusal load.22 After
in order to adequately resist the jaw relations, an accurate centric the working casts were surveyed,

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Fixed/Removable Prosthodontics Esthetic and functional combination of fixed and removable prostheses

Fig. 12. Final impression of the maxillary arch. Fig. 13. Final impression of the mandibular teeth.

Fig. 15. Baseplates with wax rims registering the occlusal plane and the
Fig. 14. Anterior provisional restorations maintain the VDO. centric relation at the determined VDO.

porcelain (Fig. 20). The shade

of the PFM restorations was
selected based on skin complexion,
age, and personal habits of the
patient.23,24 Yellow-brown pig-
ments on the occlusal surfaces,
proximal discolorations, smoking
stains, and enamel crack lines were
incorporated in the labial surfaces,
Fig. 16. Silicone registration material between the prepared teeth provides an accurate and stable enabling the individualization of
articulation of working casts. the restoration in accordance with
aging characteristics (Fig. 21).
Occlusal facets and incisal edge
attrition better simulated wear
and matched an aged dentition
the most favorable path of inser- Dental, LLC) were positioned, that might have been affected by
tion was determined, and milled ensuring adequate space for oral parafunctional habits, diet, and
lingual shelves were carved in the hygiene and the restorative materials oral hygiene procedures. Irregular
wax patterns for the reciprocating in buccolingual and occlusogingival arrangement of the incisal edges
clasp arms of both RPDs.20 At this directions (Fig. 17–19). at the lower arch, tooth shape and
stage, the preformed burnout plastic Following casting with a Cr-Co size, and appropriate surface texture
receptacles of the semi-precision alloy and framework try-in, the are also thought to be important
attachment (ERA, Sterngold FPDs were veneered with feldspar parameters for natural appearance.

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Fig. 17. Burnout matrix of the semi-precision
attachment incorporated in the wax pattern of Fig. 18. Metal framework of the maxillary fixed Fig. 19. Metal framework of the mandibular
the metal framework. prosthesis. fixed prosthesis.

Fig. 21. Verification of VDO with final fixed Fig. 22. Pick-up impression of maxillary
Fig. 20. FPD veneered with porcelain. prostheses in place. prosthesis.

Fig. 23. Metal framework of maxillary RPD with artificial teeth. Fig. 24. Metal framework of mandibular RPD with artificial teeth.

During the porcelain biscuit- palatal strap and a lingual bar were The transition from the fixed res-
bake try-in, pick-up impressions selected as the maxillary and man- toration to the removable prosthesis
were made utilizing custom trays dibular major connectors, respec- presents a challenge because of the
to facilitate the RPD’s framework tively. The natural appearance and different materials that are used.
design (Fig. 22). This technique the esthetic blend and transition The optical behavior of porcelain
enables the dental technician to of the two types of prostheses in is different than that of artificial
accurately design and relate the both arches were planned in detail teeth, while the visible portion of
RPD framework to the FPDs. A (Fig. 23 and 24). the pink acrylic resin flanges often

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Fixed/Removable Prosthodontics Esthetic and functional combination of fixed and removable prostheses

Fig. 25. Final biscuit-bake and setup try-in. Fig. 26. Custom shaping and staining of labial flange.

Fig. 28. Layering of acrylic flanges with

Fig. 27. Transitional harmony of flange and soft photopolymerized resin produced a superior Fig. 29. Esthetic blend of fixed and removable
tissues together with porcelain and acrylic teeth. esthetic result. prostheses.

tissues. In particular, the vertical

border of the maxillary labial flange
was waxed and processed so that it
was concealed in the concavity next
to the central incisor’s root eminence
(Fig. 26). Digital photography was a
critical parameter in the communi-
cation of all details about texture and
Fig. 30. Occlusal view of the maxillary arch. Fig. 31. Occlusal view of the mandibular arch. color and helped in tissue mapping
with the use of pink shade tabs.
After processing with conven-
tional acrylic resins, carbide burs
were used to remove a 1.0-mm thick
has an unnatural appearance due of the adjacent fixed restoration and layer from the labial surface of the
to its opacity and uniform color contralateral porcelain teeth. Further flanges. After sandblasting, a primer
compared to the variability of the reshaping or contouring helped to was coated to the acrylic surface
gingival tissue. Those parameters are achieve harmony in shape and avoid corresponding to the gingival area.
frequently the weak link that com- excessive dark spaces in the inter- Through a meticulous incremental
promises the entire esthetic result.25 proximal areas between the artificial layering process, photopolymer-
For this reason, denture teeth (SR teeth and the FPDs (Fig. 25). ized resins (Gradia Gum, GC
Orthotype, Ivoclar Vivadent) were The buccal and lingual flanges America) were custom-stained and
selected with an appropriate length were made thin for the initial try-in characterized to produce features
and width corresponding to the size and precisely adapted to the soft of the gingival tissues and mucosa

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Fig. 32. Maximum intercuspation at corrected VDO. Fig. 33. Extraoral view of completed rehabilitation.

next to the root eminences of the modalities with new materials and in every clinical effort.31,32 Such
remaining teeth in both arches techniques, they develop higher complex and technically demand-
(Fig. 27 and 28). The flanges were demands. It is the clinician’s obli- ing cases must be designed in a
not polished to a high shine, thus gation to identify patients’ chief way that the risk of a weak link
leaving a stippled surface, which complaints and expectations, then is minimized and, if present,
produces natural optimal light provide them with a comprehensive potential complications can be
transmission. Finally, tinting of treatment plan that meets their resolved simply. For this reason, the
the acrylic teeth (Lightpaint-On, needs. Contemporary prosthodon- design of the restorations should
Dreve Dentamid GmbH) enhanced tics and recent advances in materials consider biomechanical guidelines
individualization and made them and techniques allow the modern and respect hygienic principles.33,34
indistinguishable from the adjacent clinician to provide numerous mod- Furthermore, attachment selection
ceramic FPD (Fig. 29). ifications and satisfy the esthetic should be based on carefully evalu-
Upon delivery, the FPDs were expectations of patients undergoing ated characteristics (function, dura-
luted with a dual-cured resin cement complex therapeutic treatments.26-29 bility, ease of repair) and the patient
and the RPD was immediately Combining fixed and remov- should follow a recall program to
placed intraorally, thereby ensur- able prostheses requires a wide ensure long-term preservation.
ing accurate fit and the right path knowledge of both fields as far as
of insertion for all restorations clinical procedures and laboratory Acknowledgements
(Fig. 30–33). After minor adjust- techniques are concerned. Similarly, The authors would like to thank
ments, simultaneous occlusal attention to detail in designing and D. Karvelas, CDT, and G. Passias,
contacts in centric relation were processing critical elements of the CDT, for the detailed, precise, and
obtained. The patient was also final restorations make the transition artistic execution of the laboratory
provided with a full-coverage maxil- from the FPD to the RPD nearly work presented in this article.
lary occlusal splint made from hard undetectable in esthetically chal-
acrylic resin. The earlier detection of lenging sites. The coordination of Disclosure
parafunctional activity determined interdisciplinary collaboration and The authors do not have any
the need to protect the restorations communication between the patient, financial interest in the companies
and minimize the risk for differential dentist, and dental technician are whose products are mentioned in
wear of the restorative materials.26 key factors for optimal rehabilita- this article.
tion.30 Lifelike restorations require
Discussion enhanced artistic skills and are Summary
Partial edentulism can be predict- considered to improve the patient’s A combination of fixed and remov-
ably restored with a combination satisfaction and compliance. able restorations can be utilized
of fixed and removable prosthe- Evidence-based treatment plan- in a wide range of clinical cases
ses. As patients become better ning and long-term prognosis and provide viable alternatives
informed about current treatment are the most important elements to implant restorations when

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 Fixed/Removable Prosthodontics Esthetic and functional combination of fixed and removable prostheses

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