Dear Label_Name,

Greetings! I hope you are well.

I am writing on behalf of an international publishing house, Science and Education Publishing, USA (http://www.sciepub.com).

Science and Education Publishing (SciEP) is a multidisciplinary open access publisher of Journals covering the fields of Science, Technology and Medicine. All SciEP publications are subject to high-quality peer review, editorial and production processes and are freely available online.

Welcome to the April, 2013 edition of SciEP newsletter, providing monthly summaries of articles on science & education related topics of interest to scientist and professionals. The mission of our journals is to provide an open access forum for publishing new findings on issues pertinent to scientific and academic field. We also invite you to submit original research papers, review articles, short reports, or case studies are considered for publication in our Multidisciplinary Journals.

American Journal of Public Health Research
DOI: 10.12691/ajphr-1-1-3

The Implementation of a Tele-Homecare System with Service Oriented Architecture and HL7 Message Transmission Standard
Ching-Sung Wang

American Journal of Medical and Biological Research
DOI: 10.12691/ajmbr-1-1-2

The Influence of Ethanol on Pyruvate Kinases Activity in Vivo, in Vitro, in Silico
Lelevich Sergey Vladimirovich, Khrustalev Vladislav Victorovich, Barkovsky Eugene Victorovich, Shedogubova Tatyana Aleksandrovna

American Journal of Medical Sciences and Medicine
DOI: 10.12691/ajmsm-1-1-1

Clinical and Histological Features in Wegener Granulomatosis
Li Cavoli Gioacchino, Passantino Rita, Bono Luisa, Tortorici Calogera, Ferrantelli Angelo, Giammarresi Carlo, Rotolo Ugo

American Journal of Infectious Diseases and Microbiology
DOI: 10.12691/ajidm-1-1-2

The Curse of Lymphatic Filariasis: Would the Continual Use of Diethylcarbamazine Eliminate this Scourge in Papua New Guinea?
Anne Lanham, Lillian Mwanri

We have released issues of some journals on February 2013.
American Journal of Public Health Research
American Journal of Medical Sciences and Medicine
American Journal of Medical and Biological Research
American Journal of Pharmacological Sciences
American Journal of Clinical Medicine Research
American Journal of Nursing Research
American Journal of Cancer Prevention
American Journal of Medicine Studies
American Journal of Infectious Diseases and Microbiology
American Journal of Cardiovascular Disease Research
American Journal of Biomedical Research
American Journal of Mechanical Engineering
American Journal of Microbiological Research
Journal of Preventive Medicine
American Journal of Food and Nutrition
American Journal of Hypertension Research
American Journal of Sports Science and Medicine
Journal of Cancer Research and Treatment
American Journal of Zoological Research
Journal of Biomedical Engineering and Technology
American Journal of Microbiological Research
Biomedical Science and Engineering

We are pleased to announce that submissions are now being accepted for peer review for all the journals across all our subject areas in SciEP.

Please submit your manuscript via our online submission system:
http://www.sciepub.com/author/signin

To unsubscribe from our mailing list, please click on the following link: unsubscribe

I am looking forward to hearing from you.

Kind regards,

David Rain
Email:join@sciepub.com
Science and Education Publishing (http://www.sciepub.com)

Maxillary Canine Pier Abutment Management Using Fixed Movable Bridge Design

Othman EH Ageeli, Ramzi M Ibrahim, Faisal EM Aidhy, Salman JS Loghbi, Ali MA Kaabi, Hamood MH Mahdali, Abdulmajeed AY Kariri, Abdullah AH Najmi, Fuad Al Sanabani*, Khurshid Mattoo*

Department of Prosthetic Dental Sciences, College of Dentistry, Jazan University, Jazan, Saudi ArabiaDepartment of Prosthetic Dental Sciences, College of Dentistry, Jazan University, Jazan, Saudi Arabia

Abstract: A fixed movable bridge is a type of fixed partial denture that is exclusively indicated where a lone standing abutment is situated between two partially edentulous spaces. The prosthesis design involves fabrication of two separate fixed partial dentures that are joined in one place with a non-rigid connector. Such design provides independent movement of two separate fixed partial dentures which may occur as a result of periodontal tooth movement of mandibular flexure. Most of the reported cases have been successfully designed in either posterior or anterior region. We present a case of a fixed movable bridge whose one component restored a missing anterior tooth and the other component a missing posterior tooth. With maxillary canine as a pier abutment, the challenges in designing included to place the non-rigid connector in a space that had two different angles in the horizontal plane. Another challenge was to provide an adequate thickness of the distal retainer without the retainer encroaching on the overjet and overbite of natural occlusion. This was successfully accomplished by preparing a rest seat that had different width and depth on the distal aspect as compared to the mesial aspect. The patient reported to be extremely satisfied with the design outcome for his complex partial edentulous situation.

Keywords: pier abutment, fixed movable bridge, anterior guidance, overjet and overbite

Received February 20, 2023; Revised March 25, 2023; Accepted April 03, 2023

Citation: Othman EH Ageeli, Ramzi M Ibrahim, Faisal EM Aidhy, Salman JS Loghbi, Ali MA Kaabi, Hamood MH Mahdali, Abdulmajeed AY Kariri, Abdullah AH Najmi, Fuad Al Sanabani, Khurshid Mattoo, Maxillary Canine Pier Abutment Management Using Fixed Movable Bridge Design. American Journal of Medical Case Reports, 11 (4). 67-70. January 2023. doi:10.12691/ajmcr-11-4-1

1. Introduction

The use of a natural tooth to support a restoration has always been in the eyes of critics who support the view that natural teeth are affected by such procedures. Advances in restorative dentistry have seen a plethora of research in the most compatible restorative material that can be used in the oral cavity. Stem cell research has been found effective to regenerate existing cells within the pulp and periodontium. [1] It may or may not be possible to regenerate an entire biological natural tooth in the near future, till then the choice remains to replace missing tooth with fixed or removable prosthesis. Selection of a natural tooth to support a prosthesis is a clinical step that requires a clinician to have a very sensitive and insightful diagnostic ability. [2] A fixed prosthesis can be either a conventional fixed partial denture (FPD) that includes single crown or it can be an implant supported single crown or an FPD. [3] Conventional FPD are ideally indicated in a class III or class IV partial edentulous situation in which natural teeth are present on either side to support and retain the prosthesis. Absence of teeth on either side of a single standing tooth/teeth have been restored traditionally with a removable partial denture. [4] In earlier FPD designs such situations were successfully restored using an FPD with a cantilever extension that replaced additional missing tooth on one side. Cantilever extensions have been limited to very specific clinical situations that need to thoroughly evaluate before indicating such FPD designs. [5] The single standing or a lone standing natural tooth between two partially edentulous spaces is termed as pier abutment. [6] For fixed partial to be successful in such situations means that the FPD design should prolong the longevity of pier abutment. This is because when such tooth is connected to remaining natural teeth on either side with a fixed restoration, the forces on the restoration will act like that of a seesaw and invariably cause damage to the periodontal structures around the tooth. Authors have suggested that instead of using a rigid connector, one must use at least one non-rigid connector at any end. [7,8] This would break the stresses and the FPD will be functionally independent of each other. Such type of FPD are called as a fixed movable bridge (FMB) in prosthodontic terms.

Use of a completely fixed prosthesis without any stress breaking mechanism in such cases is also bound to be loaded by stresses that are related to mandibular flexure. [9] When masticatory muscles contract, they tend to move the two sides of the mandible closer together. This induces stresses on the fixed partial denture if it is present on one side of the mandible. Depending upon the strength of the cement used, the fixed prosthesis may either be decemented or transmit the whole stresses to the periodontium of the pier abutment. Many authors have reported the use of non-rigid connectors in prosthetic management of pier abutments. [2,4,6,9] The majority of these cases have been reported in either mandibular or maxillary posterior regions. There are very few cases reported exclusively in the anterior region while there are scant cases that have a pier abutment that supports anterior and posterior teeth simultaneously. This article in the form of a clinical case report presents one such rare rehabilitation of a Kennedy class III modification 1 partially edentulous situation with an FMB using a semi precision non-rigid connector. The main aim of presenting the case is to discuss the problems in designing that were encountered and the means to overcome such issues.

2. Case Report

An elderly adult male patient in his early fifties reported to the undergraduate clinic for clinical fixed prosthodontics for his treatment of missing maxillary right central incisor and first premolar. The patients personal, medical, social, drug history was not relevant to the current treatment. The patient reported that he had multiple teeth in both maxillary and mandibular arches extracted due to caries. Patients oral hygiene status indicated that he had a fair oral hygiene maintenance with both gingival and periodontal conditions being satisfactory. In the maxillary arch the patient had an existing fixed partial denture on the left side that extended from left canine to the second molar. Patients extra oral examination revealed normal clinical features in terms of aesthetic evaluation for low and high lip lines, lymph nodes, mandibular movement and temporomandibular joints. Intra oral examination revealed a Kennedy class 2 modification 2 partial edentulous situation for maxillary arch and a Kennedy class 1 modification 1 for mandibular partial edentulous arch. Maxillary arch presented a pier abutment situation in which the maxillary right canine was a pier with maxillary right lateral incisor and first premolar missing. The patient had already a five unit fixed partial denture on the left side that had a left second premolar as a pier abutment with missing first premolar and first molar. The FPD design was that of a rigid connector in the posterior segment. The patient was provided with different treatment options. These included implant supported prosthesis for all partially edentulous situations, fixed partial denture with non-rigid connectors for both maxillary segments (after removal of existing prosthesis), a combination of fixed and removable partial denture. The patient was also recommended to undergo preprosthetic non-surgical preparation that included oral prophylaxis. The patient opted for the treatment of fixed prosthesis without replacement of old prosthesis and without using any removable partial denture. For FMB routine clinical and laboratory procedures were done. The preparation for right canine however included a modification which was in the form of a wide cingulum rest once the preparation for metal ceramic retainer was done. The final FPD was designed to be fabricated of a base metal alloy (Remanium CSe, Dentaurum J.P. Winkelstroeter KG, Ispringen, Germany), on which feldspathic dental porcelain (VMK-95 Metall Keramik; Vita Zahnfabrik, Bad Sackingen, Germany) would be fused. In the laboratory, the FMB was fabricated together in terms of wax patterns. The mesial component included a three unit FPD with rest seat on the occlusal surface and the distal component included a two unit FPD with one side having an occlusal rest (Figure 1 A, B). When placed together on the cast (Figure 1C), the whole assembly would have anterior teeth having contact with metal while the posterior component having occlusal contact with metal supported occlusal ceramic. The anterior component was cemented with zinc phosphate cement while the other component was cemented on the second premolar with the rest seat having a free non-cemented contact to allow stress breaking effect (Figure 1 D). Opposing occlusion was adjusted before final cementation. The shade of the anterior bridge matched the remaining natural teeth while the shade of the posterior previously made fixed fixed prosthesis had too high value that made it look artificial (Figure 2). This was also one of the reasons why the patient was advised to remove the existing fixed partial denture. The patient was given instructions for fixed partial denture maintenance, [10] and was put on a follow up for one year at regular three-month interval. During subsequent follow up visits, the patient was highly satisfied with the outcome of the prosthetic treatment.

Figure 1. (A) Mesial component of FMB shows a rest seat placed within restoration on left canine (B) Distal component of FMB shows the rest as the form of non-rigid connector between two prosthesis segments (C) Two components of FMB in place (D) Intra oral view of the completed restoration

Figure 2. Occlusal view of completed prosthesis FMB using the pier abutment (canine) with a non-rigid connector in the form of a semi precision attachment

3. Discussion

A partial edentulous situation that comprises of a pier abutment in between the two edentulous spaces has been presented in this case report. The significance and the main feature of this report being the fabrication of an FMB that unites the anterior with the posterior arch. A prosthesis irrespective of the design should be planned with caution. The pier abutment acts as a fulcrum in between the two edentulous spaces thereby causing a teetering movement around the middle retainer in an FPD that has rigid connectors on both sides. [11,12] Studies show that the stress distribution in such designs is affected by connectors location and presence. [2,13,14] The replacement of two teeth on either side results in a long span edentulous area. Conventionally and traditionally a fixed partial denture is not indicated in case the span is long. A long span FPD that has been obtained from a single casting will inevitably result in marginal discrepancies which is why all long span FPD should be cut followed by soldering. Zirconia as a substructure is also not indicated since zirconia reinforced ceramics are limited to only short span replacements and zirconia won’t allow placement of the non-rigid connector. [16]

The problems or the challenges faced during treating this patient were mostly related to bridge designing and patient related factors. Among FPD designs, the use of a non-rigid connector at the corner of the mouth poses technical challenges. [17,18] These were anticipated during wax up of the diagnostic casts. One of the challenge was how to place the rest and rest seat at an angle. Since the canine is placed at an angle the distal surface of the canine variety in terms of the mesial aspect of the canine. Placing an occlusal rest had to conform to these variations otherwise the retainer would have had less thickness of metal which on the long term would have fractured after repeated loading. To avoid such complications, it was decided that the rest seat within the cingulum of the canine was to be made different when compared to the mesial side. The width and the taper of the rest seat on the distal side were therefore increased relatively than to the mesial side. This allowed the bulk of the rest seat to be on the distal side which enhanced strength of the occlusal rest that was carried by the distal component of the retainer. The patient was informed about the possibility of failure in the future and the measures that were necessary to be taken at the appropriate time. The cementation process was modified, and a relatively weaker cement for definitive cementation was decided accordingly. Another issue that was important during designing was not to encroach upon the existing overjet and overbite. Since the placement of the extra thickness of metal on the rest was mandatory, it would have interfered in the existing overjet and overbite. [19] This was the main reason for preparing a deep rest seat in the canine to overcome any possibility of encroaching upon the overjet or overbite. Both of these two spaces are naturally present in the anterior teeth and they are protective in nature. [20]

The challenges that were patient related involved inability to motivate the patient to remove existing rigid design of previous FPD. The patient had got the maxillary FPD done few months back. Besides design, another problem in the previous FPD was shade not matching with adjacent teeth. The mismatch between the proposed ceramic shade and the restoration shade can be attributed to multiple factors. Different shade guides used by the clinician and the laboratory technician are one of the common reasons. [21] In this case the patient was told by the previous dentist that the mismatch was because of the above mentioned discrepancy. But the patient had no complaints about the aesthetic mismatch between the two. Variations in perceptions of patients regarding aesthetics and its constituents have also been reported in the literature. [22] Prescribing the use of a cast partial denture for treatment of long span partial edentulous space has been recommended in the literature. [23] This case presented with a Kennedy class II partial edentulous situation in the maxillary arch. Even after closure of anterior partitioning edentulous space, it was mandatory that patient replaces the distal extension base on the same side with a cast partial denture. However, the patient decided not to go for a removable partial denture despite being educated about the ill effect on current treatment.

4. Conclusion

Fixed movable bridge is an excellent treatment option that has been reported scantly in the literature. Long term clinical studies should be directed in this FPD designing to understand their clinical performances and patient satisfaction. The FMB that was designed in this case was not difficult to fabricate or difficult to be placed.

Acknowledgements

We acknowledge the efforts of dental technicians for their whole hearted interest in completing the treatment of this case.

Conflict of Interest

None.

References

[1]   | Matichescu A, Ardelean LC, Rusu LC, Craciun D, Bratu EA, Babucea M, Leretter M. Advanced biomaterials and techniques for oral tissue engineering and regeneration—a review. Materials. 2020 Nov 23; 13(22): 5303.
[2]   | Mattoo K, Brar A, Goswami R. Elucidating the problem of pier abutment through the use of a fixed movable prosthesis – A Clinical case report. International Journal of Dental Sciences and Research 2014; 2(6): 154-157.
[3]   | Al-Quran FA, Al-Ghalayini RF, Al-Zu'bi BN. Single-tooth replacement: factors affecting different prosthetic treatment modalities. BMC oral health. 2011 Dec; 11(1): 1-7.
[4]   | Botelho MG, Chan AW, Leung NC, Lam WY. Long-term evaluation of cantilevered versus fixed–fixed resin-bonded fixed partial dentures for missing maxillary incisors. Journal of Dentistry. 2016 Feb 1; 45: 59-66.
[5]   | Brar A, Mattoo K, Jain P. Designing Cantilever Prosthesis: A Case Study. RRJoD 2014; 5(3): 5-9.
[6]   | Venkataraman K, Krishna R. The lone standing abutment: A case report. Int J Appl Dent Sci. 2016; 2: 20-3.
[7]   | Shillingburg HT, Fisher DW. Nonrigid connectors for fixed partial dentures. J Am Dent Assoc1973; 87: 1195-99.
[8]   | Standlee JP, Caputo AA. Load transfer by fixed partial denture with three abutments. Quintessence Int 1988; 19: 403-10.
[9]   | Gaba N, Mattoo K. Converting a removable prosthetic option into fixed by using custom made non-rigid connector. WebmedCentral DENTISTRY 2014; 5(9): WMC004695.
[10]   | Jindal S, Mattoo KA, Arora P. Post care instructions for dental prosthesis (Fixed). LAP Lambert Academic Publishing; 2013; pp 1-72.
[11]   | Savion I, Saucier CL, Rues S, Sadan A, Blatz M. The pier abutment: a review of the literature and a suggested mathematical model. Quintessence Int. 2006 May; 37 (5): 345-352.
[12]   | Markley K. Broken-Stress ‘Principle & design in fixed bridge prosthesis. J Prosthet Dent 1951; 1: 416-423.
[13]   | Sutherland JK, Holland GA, Sluder TB, Whie JT. A Photoelastic stress analysis of stress distribution in bone supporting fixed partial dentures of rigid & nonrigid designs. J Prosthet Dent 1980; 44: 616-23.
[14]   | Mattoo KA, Jain S. Managing a case of sensitive abutment situations through use of a Fixed Movable Prosthesis – A clinical report. Journal of Medical Science and Clinical Research 2014; 2(7): 1858-63.
[15]   | Campbell SD, Sozio RB. Evaluation of the fit and strength of an all-ceramic fixed partial denture. Journal of Prosthetic Dentistry. 1988 Mar 1; 59(3): 301-6.
[16]   | Goswami R, Garg R, Mattoo K. Impact of anterior guidance in designing of All-ceramic anterior fixed partial denture - Case Report. Journal of Advanced Medical and Dental Sciences Research 2019; 7 (11): 59-61.
[17]   | Lin CL, Wang JC, Chang WJ. Biomechanical interactions in tooth-implant-supported fixed partial dentures with variations in the number of splinted teeth and connector type: a finite element analysis. Clinical oral implants research. 2008 Jan; 19(1): 107-17.
[18]   | Kumar L, Mattoo K, Goswami R. Spring Fixed Partial Denture Designing. International Journal of Medical Research and Pharmaceutical Sciences 2017; 4 (10): 1-3.
[19]   | Kaifu Y, Kasai K, Townsend GC, Richards LC. Tooth wear and the “design” of the human dentition: a perspective from evolutionary medicine. American Journal of Physical Anthropology: The Official Publication of the American Association of Physical Anthropologists. 2003; 122(S37): 47-61.
[20]   | Gohal MRA, Mattoo KA, Nazish A, Youseef AM. Corrective Prosthodontics – Curating Semi Functional Anterior Guidance in Full Mouth Rehabilitation: Case Report. Journal of Medical Science and Clinical Research. 2017; 5(08): 26777-781.
[21]   | Öngül D, Şermet B, Balkaya MC. Visual and instrumental evaluation of color match ability of 2 shade guides on a ceramic system. The Journal of prosthetic dentistry. 2012 Jul 1; 108(1): 9-14.
[22]   | Al Moaleem MM, Alkhayrat FM, Madkhali HA, Geathy IH, Qahhar MAW, Yaqoub A, Mattoo KA. Subjective differences between dentists and patients about relative quality of metal ceramic restorations placed in the Esthetic Zone. J Contemp Dent Pract 2017; 18(2): 112-116.
[23]   | Mattoo K, Shujaurrahman, Yadav L. Cast partial denture – A non-motivated treatment option in the present era. Medico Research Chronicles 2015; 2(2): 191-94.