Fixed-removable prostheses

Done by : Tabark Y. Mizil

Supervised by :
Dr. Abdalbasit Ahmed
Prosthodontic rehabilitation of a large anterior ridge defects is often a
challenge. This requires replacement of form, function and aesthetics. Pre-
operative classification of the localized alveolar defect can be used as a guide
in evaluating the prognosis and technical difficulties.
Seibert classified alveolar crestal defects as Class I, Class II and Class III:
Class I: Buccolingual loss with crestal height maintained.
Class II: Vertical loss with buccolingual width maintained.
Class III: Combination of buccolingual and vertical loss.
Various treatment options available to treat such ridge defects are:
1. Soft Tissue Procedures include various options like.
The Roll Technique: for Class I defects.
The Interproximal Graft Technique: for Class II and III defects.
2. Free Gingival Graft.
3. The Onlay Graft for augmentation of ridge width and height.
4. Distraction osteogenesis.
5. Combination of a ridge augmentation using bone grafts followed by implant
supported prosthesis.
6. Other methods include removable cast partial dentures, fixed partial denture
and fixed removable partial denture .
The loss of the residual ridge, however, precludes or makes extremely
difficult an esthetic and hygienic restoration with a conventional fixed
prosthesis (Fig.1)

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 Fig.1
Due to the constraints of fixed pontics in relation to the residual ridge, the use
of this modality is virtually eliminated as a successful means of restoring such
defects.
It remains, then, for the replacement to be predicated on the use of a
removable prosthesis to supply missing tissue contour and provide a means of
positioning the replacement teeth in their natural relationships. The use of a
conventional removable partial denture of necessity incorporates coverage of
soft tissue by major connectors and other necessary elements of the prosthesis
and involves several of the teeth as suitable abutments for stabilization. An
approach to the treatment of such problems was conceived where by a
removable pontic section could be supported directly by adjacent abutment
teeth in a manner similar to that of a fixed prosthesis (Fig. 2).

Fig.2

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Fig. 3 Fig.4

Description
The fixed-removable prosthesis to be described consists of a milled
substructure bar (designed for the specific contours of the problem being
treated) that is rigidly attached to abutment castings (Fig. 2). The bar is
specifically designed and fabricated to the contours of the residual ridge. A
matching suprastructure to which the replacement teeth are attached is
fabricated and fitted accurately to the substructure (Fig. 3, B) The irregularly
arcuate contour provides exceptional retention and resistance to rotational
forces for the suprastructure (Fig.4)

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Indication
a) Absolute Indications -
1) Excessive residual ridge defect.
2) Ridge defects/ jaw defects either due to trauma and/or surgical ablation.
3) Cleft palate patients with congenital or acquired defects.
b) Relative Indications -
1) Often fixed partial denture failure with badly damaged, cracked or
weakened teeth by fillings and disproportionate teeth.
2) Sometimes could be used in patients with periodontal problems.

Contraindication
1. Gross periodontal disease
3. High caries rate
4. Inadequate room

Advantages
1.Flexibility of design. The basic elements of the system lend themselves to a
variety of applications to meet the requirements of any particular situation.
Being custom made to the contours and alignment of each individual mouth,
the substructure affords opportunity for wide variation in design, placement,
contour, and retentive capability.

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2.Oral hygiene. The fixed substructure’s narrowness in its contact with the
underlying tissue permits optimum hygiene of abutment teeth and adjacent
tissue (Fig. 16). The removal of the suprastructure permits easy cleaning of
the underlying tissues, which are habitual problems associated with
conventional fixed partial dentures.
3.Minimal tissue coverage. Being greater only where loss of contour of the
residual ridge has occurred. The tissue contact and coverage can approximate
that of the fixed partial denture. It is unnecessary to cover extensive areas of
palatal OF lingual tissue with the prosthesis (major connectors) and to involve
a number of teeth with clasp retainers as is necessary with a conventional
removable partial denture. The bulk of the prosthesis that essentially replaces
the contour of missing dental structures (and only that) affords greater
acceptance by the patient.
4.Durability. Experience has shown this approach to be most durable and to
have presented few maintenance problems. Breakage and major repair have
been found to be infrequent.
5.Esthetic results. The wide selection of replacement teeth and restorative
materials that can be used allows optimum esthetic results to be obtained even
in patients in whom considerable deformity exists (Fig.5) .
6. Ease of adjustment. The broad frictional areas presented by the lateral
surfaces of the mating parts enable an inherently stable prosthesis to be
developed. The wear of the frictional surfaces, which occurs with time, is
distributed over a large surface with relatively little effect on the retentive
character of the suprastructure. The retentive pins of the suprastructure that
traverse the corresponding holes in the substructure can be adjusted easily to
provide adequate frictional retention as the necessity arises.

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Limitations
In general the limitations associated with use of the fixed-removable
prosthesis are similar to those encountered in conventional fixed partial
dentures.
1.Abutment requirements. The abutment requirements for the fixed-removable
partial denture are identical to those of the fixed partial denture. Both derive
their entire support from the abutment teeth, none from the ridge.
2.Common path of placement. All abutment teeth are tied or splinted together
through the rigid connection to the substructure bar, a condition comparable to
that in the fixed partial denture when the abutments are affixed to one another
through the interposed pontic section. Accordingly the path of placement and
removal of the retentive elements of the abutment preparations must be in
directional harmony with each other. Long axes of the teeth that are to serve as
abutments must be sufficiently harmonious so that the preparation of the teeth
may present the required degree of parallelism and occlusogingival length to
provide adequate retention and stability.
3.Crown-to-root ratio. The bony support of the abutment teeth as influenced
by root morphology and length, amount and character of supporting bone, and
ratio of root length embedded in bone to tooth length coronal to the alveolar
crest is vital to the success and longevity of any fixed prosthesis.
4.Span length. The length of the pontic space between abutments presents the
same requirements for the fixed-removable partial denture as for the
conventional fixed prosthesis. If excessively long spans are encountered the
use of multiple abutments may be required.
5. Interocclusal space requirements. A minimum occlusogingival height of 3
to 4 mm is necessary for proper function of the prosthesis.

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Drawbacks
1. Tooth preparation is required.
2. Teeth with large and vital pulp are often at risk because of large amount of
tooth structure that has to be removed.
3. Crowns with short height are usually unfavorable.
4. Their problems in free end saddle cases because of complexity of
movement and their so-called stress breaking action, which is often
theoretically unsound.
5. Cost and time high and technical expertise required is considerable.

Case Report
A 23 year old female patient named prabhjyot kaur reported with the chief
complaint of missing teeth in her right upper front region of mouth (fig. 5,6)
since last 2 years. Patient gave history of bone augmentation to replace the
missing teeth with implant, which was done 1 year back to cover the defect
but due to the bone loss, it was impossible to place the implant. So Andrew’s
bridge was planed.

Fig. 5 - pre-operative Fig. 6 - intra-oral vie

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Procedure is as below.
1. Alginate impresion of upper and lower arch has been made; impression was
poured with dental stone.
2. Treatment partial denture has been fabricated with heat cure polymethyl
methacrylate acrylic resin and inserted in patient’s mouth.
3. Tooth preparation of the abutment tooth adjacent to edentulous area has
been done, and final impression of the maxillary arch has been made with
elastomeric impression material.
4. Temporary crown has been fabricated and cementation was done, treatment
partial denture was inserted in patient’s mouth.
5. Metal copings were fabricated and bar was attached to it and ceramic build-
up was done over the metal coping (fig7). Crown with metal bar was checked
for the fit and esthetic (fig.8). Lingual interferences were removable

Fig.7 - crown with metal bar Fig. 8 - try in of crown with metal bar

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6. Pick-up impression was made (fig 9) and cast has been fabricated.
Removable partial denture was made and clip attachment (fig.10) was inserted
in the intaglio surface of the removable partial denture.

Fig.9 - pick-up impresion of metal-bar assembly Fig.10 - clip attachment in removable

partial denture

7. Try-in was done and interferences were removed.

8. Crown and bar assembly was cemented with glass ionomer cement and
removable partial denture was inserted (fig. 11).

Fig.11 - post operative

9. Patient was recalled after 1 week for follow-up.

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Telescopic retainers for removable partial
dentures
The Glossary of Prosthodontic Terms defines a telescopic crown as an artificial crown
constructed to fit over a coping (framework). The coping can be another crown, a bar, or
any other suitable rigid support for the dental prosthesis.

Three different types of double crown systems

are used to retain RPDs. They are distinguished from each other by their
retention mechanisms:
• Cylindrical crowns that exhibit retention through friction fit of
parallel‑milled surfaces
• Conical crowns or tapered telescopic crowns that exhibit friction only when
completely seated using a “wedging effect.” The magnitude of the wedging
effect is mainly determined by the convergence angle of the inner crown; the
smaller the convergence angle, the greater is the retentive force
• Double crown with clearance fit (hybrid telescope or hybrid double crown)
exhibits no friction or wedging during insertion or removal. Retention is
achieved by using additional attachments or functional‑mold denture borders.
Telescopic prosthesis is a double crown system. The procedure involves
covering the remaining teeth which are used as abutments with inner copings
followed by outer crowns as part of the removable partial denture. Root canal
treated teeth can be used as abutments for removable and fixed partial
dentures depending on the root condition.

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 Endodontically treated teeth need to fulfill certain criteria to be considered as
an abutment for removable or fixed prosthesis. These include
1. No evidence of any periodontal disease.
2. Adequate crown root ratio.
3. Well obturated canals without any peri-apical pathology.
4. Sufficient crown height without undesirable angulations.

Advantages
1. Creation of a common path of insertion
2. Easy to perform routine oral hygiene
3. Rigid splinting action
4. Distribution of stresses to the abutment teeth
5. Provision of suitable abutments for RPDs even when the remaining teeth
are periodontally compromised
6. Much easier insertion and removal for the patient
7. Accommodates future changes in the treatment plan
8. Psychologically well‑tolerated by patients.

Disadvantages
1. Increased cost
2. Complex laboratory procedures
3. Extensive tooth reduction required
4. Increased number of dental appointments
5. Difficulty in achieving esthetics
6. Retention diminishes after repeated insertion/separation cycles
7. Readjustment of retentive forces is difficult.

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Case report
A 40 year old male patient reported with a chief complaint of missing right
upper teeth since two years. Medical and dental history revealed that the
patient had lost 11, 12, and 13 due to trauma two years back [Fig. 12].

Fig 12- Pre-op view.

Subsequently he reported to a dentist, who performed root canal treatment on

21, 22 and placed implants in relation to the missing teeth. Implants failed
within six months due to recurrent infections and were explanted. The patient
was diagnosed with diabetes recently and was on antidiabetic therapy. A
thorough clinical and radiological evaluation was carried out. Examination of
21 and 22 revealed well-obturated root canals without any pathology. There
was severe bone resorption in the region of missing 11, 12 & 13 (Seibert's
class III). The bone support around 21 & 22 were also not favorable for using
them as an abutment for fixed partial dentures. Various treatment options like
fixed partial dentures and implants were considered. Considering the long
span and previous history of failure with implants, a treatment plan of a cast

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partial denture with telescopic retainers on 21, 22 was offered to the patient.
Diagnostic casts were obtained and after surveying, designing was done. For
the cast partial denture, the preferred design was a double palatal strap major
connector with occlusal rest seats on 16, 17, 26, 27 and embrasure clasps.

21 & 22 were prepared with a shoulder finish line. Walls of the preparation
were kept nearly parallel or within the accepted range of 2-5 to improve the
retention. Upper and lower Impressions were made using putty-wash
technique with elastomeric impression material poured with Type IV dental
stone and casts retrieved. A coping of base metal alloy of 0.5 mm thickness
was fabricated following manufacturer’s instructions to act as telescopic
retainer and fixed to 21 and 22 with glass ionomer luting cement [Fig. 13].

Fig 13- Telescopic crowns on 21 & 22.

Occlusal rest seats were prepared on16, 17, 26 & 27 (distal occlusal rests on
16 & 26, mesial occlusal rests on 17 & 27) and impression made with
elastomeric impression material. Master cast was retrieved and cast partial
framework was fabricated with Co-Cr alloy following manufacturer's
instructions and extending the framework over 21 & 22 [Fig. 14].

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Fig 14- Cast partial denture framework with telescopic retainers for 21 & 22.

The RPD framework was evaluated for fit and retention. Porcelain (Vita,
Germany) build up was done for 11, 12, 13 ,21 ,22 region and the ridge defect
was covered using gingival porcelain following manufacturer's instructions
and fulfilling esthetic requirements. Bisque trial was done and contours
verified and telescopic portion was inserted after glazing and polishing in the
subsequent appointment [Fig. 15].

Fig.15 - Telescopic retained cast partial denture in situ.

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Occlusion was checked thoroughly both in centric and lateral excursions. It
was ensured that there was no interferences. Patient was instructed regarding
the insertion and removal of the prosthesis, care of the prosthesis and oral
hygiene maintenance protocols. There was considerable improvement in
esthetics and function after the insertion of prosthesis. The patient was
scheduled for follow-up visits every three months and he reported no
complaints during the 2 years of follow-up.

Fixed Dentures Combined with Removable

Dentures
Classification of Abutment Teeth
The subject of abutment preparations may be grouped as follows:
(1) those abutment teeth that require only minor modifications to their
coronal portions,
(2) those that are to have restorations other than complete coverage crowns,
(3) those that are to have crowns (complete coverage).

Abutment Preparations Using Crowns

When multiple crowns are to be restored as removable partial denture
abutments, it is best that all wax patterns be made at the same time,The same
sequence for preparing teeth in the mouth applies to the contouring of wax
patterns. After the guiding planes are parallel and any other contouring to
accommodate the removable partial denture design is accomplished, occlusal
rest seats are carved in the wax pattern.

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 One of the advantages of making cast restorations for abutment teeth is that
mouth preparations that would otherwise have to be done in the mouth may be
done on the surveyor with far greater accuracy, It is generally impossible to
make several proximal surfaces parallel to one another when preparing them
intraorally.
The opportunity for contouring wax patterns and making them parallel on the
surveyor in relation to a path of placement should be used to its full advantage
whenever cast restorations are being made.
The ideal crown restoration for a removable partial denture abutment is the
complete coverage crown, which can be carved, cast, and finished to ideally
satisfy all requirements for support, stabilization, and retention without
compromise for cosmetic reasons (Fig.16). Porcelain veneer crowns can be
made equally satisfactory but only by the added step of contouring the
veneered surface on the surveyor before the final glaze. If this is not done,
retentive contours may be excessive or inadequate.

Fig. 16
The three-quarter crown does not permit creation of retentive areas as does the
complete coverage crown. However, if buccal or labial surfaces are sound and
retentive areas are acceptable or can be made so by slight modification of
tooth surfaces, the three-quarter crown is a conservative restoration of merit.

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Regardless of the type of crown used, preparation should be made to provide
the appropriate depth for the occlusal rest seat.
This is best accomplished by altering the axial contours of the tooth to the
ideal before preparing the tooth andcreating a depression in the prepared tooth
at the occlusal rest area (Fig. 17).

Fig.17

Ledges on Abutment Crowns

In addition to providing abutment protection, more ideal retentive contours,
definite guiding planes, and optimum occlusal rest support, complete coverage
restorations on teeth used as removable partial denture abutments offer still
another advantage not obtainable on natural teeth. This is the crown ledge or
shoulder, which provides effective stabilization and reciprocation.
True reciprocation can be obtained only by creating a path of placement for
the reciprocal clasp arm that is parallel to other guiding planes. In this manner,
the inferior border of the reciprocal clasp makes contact with its guiding
surface before the retentive clasp on the other side of the tooth begins to flex

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(Fig.18).

A ledge on an abutment crown has still another advantage. The usual

reciprocal clasp arm is half-round, and therefore convex, and is superimposed
on and increases the bulk of an already convex surface. A reciprocal clasp arm
built on a crown ledge is actually inlayed into the crown and reproduces more
normal crown contours (Fig. 18). The patient’s tongue then contacts a
continuously convex surface rather than the projection of a clasp arm.
The full effectiveness of the crown ledge can be achieved only when the
crown is returned to the surveyor for refinement after casting. This can be
accomplished with precision only by machining the casting parallel to the path
of placement with a handpiece holder in the surveyor or some other suitable
machining device (Fig.19).

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 Fig.19
Veneer Crowns for Support of Clasp Arms
For cosmetic reasons, resin and porcelain veneer crowns are used on abutment
teeth that would otherwise display an objectionable amount of metal. Veneer
crowns must be contoured to provide suitable retention. This means that the
veneer must be slightly overcontoured and then shaped to provide the desired
undercut for the location of the retentive clasp arm (Fig .20).

Fig.20

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ATTACHMENT
The advantages are:
- Eliminate the friction between natural teeth and clap;
- The attachments will be obligatory placed parallel one with the other and it
will not provide stress forces on the remaining teeth during insertion and
removal of the removable dentures;
- Attachments help at distributioning masticatory stress forces all over the
prosthodontics field;
- Dentures are more comfortable for patients comparing with the ones with
claps;
- Dentures have an extraordinary esthetics, being used especially in young
patients.

The disadvantages of the special systems are:

- Cannot be used on teeth with small crowns.
- They needs performance laboratory endowment and clinical experience.
- They needs special retain techniques for the fixed dentures (the one that
anchor the teeth) because, the move of a quarter of millimeter won’t allow
optimal denture insertion.
- Optimization and reoptimization of the hybrid dentures are extremely
difficult.
- Handiness is requested.

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Indications of extracoronal attachments:
- Removable dental bridges.
- Partial skeletal dentures.
- Overdentures.
- Implant dentures.
The placement of attachment on dental structure:
- Intracoronal.
- Extracoronal (staple, slide).
- Around/inside tooth root.
- Intermediary (in breaches).
- Bar tipe (fixe or mobile joint).
- Auxiliary: screw type systems, closing systems, latch, tipping stoppers
(hinges), patricematrix drive systems, pins screws, articular support, magnetic
systems.
The attachments are classified in two categories:
- Precision. - Semi-precision.
Precision attachment parts are made of special alloys with precision
tolerance around 0.01 mm. Since the specific hardness of alloys can be
determined, the attachments precision offer the advantage of light load on the
remaining teeth. The standard component parts can be changed,offering a
simple to use solution in case of damage.
Semi-precision attachments are made through direct casting, industrial type,
from plastic or wax. The majority of these type of attachments are included in

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the costs of model in order to reduce expenses. They are considered semi-
precision because, during the fabrication process, there is an inconstant rate of
liquid/powder at specific temperature and there are presents also other
variables.
Intracoronal attachments are included in the shape of tooth crown. Their
major advantage is the distribution of occlusal forces in the ax of tooth and
the hygienic process is much easier. The disadvantage consists in the
important loss of tooth tissue and the special design.
Extracoronal attachments are placed entirely outside tooth crown perimeter.
These type of attachments are commonly used in dental practice, they have
the classical name of slides and staple. The advantage of using these types of
attachments consists in maintaining the external shape of the tooth.

Case report
Male patient, 46 years old, addresses to Prosthetics , motivate severe
masticatory, phonetics and esthetics dysfunction. After clinical and
radiographic examination, severe coronary destructions due to untreated
complicated decays are found. The treatment plan is established and it is
presented to the patient to obtain written consent. After compromised teeth
extraction and periodontal clinical status and diagnosis, the diagnosis of
Kennedy 1st class edentation with one modification in the maxillary arch is
made and Kennedy 1st Class edentation in the mandible (Figs 21, 22).
Remaining teeth are 11,13,21,22,23,31,32,33,34,41,42,43,44 (Fig 1).

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Fig 21. Preoperative Intra oral picture Fig 22. X-Ray Exam

Prosthodontic treatment aims to achieve prosthetic restorations with metal-

ceramic abutments and removable partial dentures anchored with extracoronal
attachments. Preparation of remaining teeth is done in order to be restored
with fixed metal-ceramic bridge (Fig.23). Gingival retraction was achieved by
double wire method (Ultradent Products Inc). Final impression was made with
polyvinyl siloxane puty-wash method (Fig 24).

Fig .23. Teeth prepared receive porcelain

fused to metal crowns Fig 24. Definitive impressions

Dental preparation were covered temporarily after definitive impression with

Protemp finished and provisionally cemented. The final model was performed

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in gypsum type IV mounted in articulator based on interocclusal record In
laboratory the metal-ceramic restorations models are made and distal
attachments were attached. The stages of casting, finishing, cape probe, and
color selection for ceramics follow (Fig 25). Frosting of metal-ceramic
crowns, intraoral prosthodontics probation (Fig 26, 27). Impressions of
prosthodontics areas (Fig 28), model probation and laboratory polymerization
follow.

Fig.25. Metal framework on the master cast Fig.26. Try-in of the joint PFM crown
with attachments on the master cast

Fig.27. Try-in of the joint PFM Fig.28. Definitive impressions for cast mobile

crown with attachments denture

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Colorful rubber bands were placed inside the matrix in order to improve
retention as strong force breaker (Fig 29, 30). The metal-ceramic crowns were
cemented using glass ionomer cement. During cementation, a special care was
given to the attachments. Petroleum jelly was applied inside of the
attachments in order to facilitate removal of cement. After final adjustment,
occlusion is checked and the patient is recalled by protocol to regulate
evaluation (Fig 31, 32).

Fig. 29. Final Prosthesis Fig.30. Male and female parts of extracoronal
attachment

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Fig.31. Postinsertion photo with Fig32. Showing post-treatment intra-oral

combined prosthesis seated view of restoration

The patient was instructed regarding oral hygiene, use of interproximal

brushes, how to remove and insert the denture and the time to recall for
matrices check, in order to have a good functionality. The end result has
provided patient satisfaction regarding the combination of fixed dentures and
removable skeletal dentures anchored by extracoronal attachments.
Occlusion stabilization was achieved, improved chewing and good aesthetics.

Reference
1. CONTEMPORARY FIXED PROSTHODONTICS FIFTH EDITION
2. McCRACKEN’S REMOVABLE PARTIAL PROSTHODONTICS,
a. TWELFTH EDITION.

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3. The fixed-removable partial denture John E. Rhoads, D.D.S. Monterey,
Calif.
4. Management of anterior ridge defect with fixed-removable partial
denture – Andrew’s bridge Dr. Harsh patel, Dr. Pranav solanki, Dr.
Sameer patel, Dr. Ushir patel.
5. Evaluation of a fixed removable partial denture:Andrews Bridge System
Robert J. Everhart, D.D.S., and Edmund Cavazos, Jr., D.D.S.
6. Andrews Bridge: A fixed removable prosthesis Anup Gopi, N.K. Sahoo
. CMDC(WC), India .
7. Bar and Sleeve Attachment: Yogesh Rao1, Pankaj Yadav, Mariette
D’Souza, Jagjeet Singh4, Anurag Jain .
8. Telescopic Partial Dentures-Concealed Technology Tushar Vitthalrao
Bhagat1, Ashwini Nareshchandra Walke Journal of International Oral
Health 2015; 7(9):143-147
9. Telescopic retainers for removable partial dentures Maj Gen S.H. Gupta,
VSM a, Col M. Viswambaran b, , Maj R. Vijayakumar c , medica l
journal a rmed forc e s i n d i a xxx ( 2 0 1 5 ) 1e3
10. Telescopic overdenture : Perio-prostho concern for advanced
periodontitis Roma Goswami, Puneet Mahajan , Awit Siwach , Ankur
Gupta Jul-sep 2013.
11. A FIXED REMOVABLE PARTIAL DENTURE TREATMENT
FOR A SEVER RIDGE DEFECT - GITAM Dental College & Hospital,
Visakhapatnam Article · August 2011.
12. Fixed Dentures Combined with Removable Dentures Retained
with Extracoronal Attachments Agripina Zaharia1, Aureliana Caraiane,
Corina Ştefănescu,Rodica Murineanu,Carolina Davidescu, Francisc
Florin Bartok Ovidius Dentistry Journal, vol. 1, no. 1, 2014.

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