Fracture of a xed partial denture abutment: A clinical report
Ronald G. Verrett, DDS, MS,
a and David A. Kaiser, DDS, MSD b Department of Prosthodontics, University of Texas Health Science Center at San Antonio Dental School, San Antonio, Texas Commonly observed complications associated with a conventional xed partial denture (FPD) include loss of retention and tooth fracture. This report describes the occurrence of an unusual FPD abutment fracture and subsequent treatment. The distal abutment of an FPD developed severe periodontal disease with mobility. The anterior abutment fractured in the middle of the clinical crown and experienced cement failure. (J Prosthet Dent 2005;93:21-3.) Fixed partial dentures (FPDs) have been shown to exhibit clinical complications due to a wide variety of factors. In a review of the literature, Goodacre et al 1 identied the most common FPD complications as car- ies, need for endodontic treatment, loss of retention, es- thetics, periodontal disease, tooth fracture, and prosthesis fracture. In that review, fracture of an abut- ment tooth occurred in 3% of prostheses. The technical and biomechanical complications for FPDs may result in loss of retention, abutment tooth fracture, and prosthesis fracture. Technical failures occur more frequently in FPDs with at least 1 cantilever exten- sion pontic, with the rate of failure increasing as the length of the cantilever span increases. 2,3 Fracture of an FPD abutment adjacent to a cantilever has been re- ported to occur twice as frequently as fracture of an abutment not adjacent to a cantilever. 4 Abutment frac- tures in conventional FPDs have also been documented in longitudinal clinical studies 5 ; however, abutment fracture of the type reported here is infrequent. 6,7 This clinical report describes an unusual fracture of an FPD abutment that occurred within the retainer of a conven- tional FPD and the subsequent treatment. CLINICAL REPORT A 69-year-old woman reported to the University of Texas Health Science Center at San Antonio Dental School clinic with a chief complaint that the bridge on the upper right side was loose. The patient reported that the FPD had been inserted 12 years ago (Fig. 1). The FPDwas found to be loose at the anterior abutment (maxillary right second premolar) but remained ce- mented on the distal abutment (maxillary right second molar). Clinical and radiographic examination revealed that the distal abutment had periodontal probing depths of 8 to 9 mm and exhibited Class III mobility (Fig. 2). The FPD was successfully removed and the maxillary right second premolar abutment was found to be frac- tured in the middle of the clinical crown, between the occlusal surface and the nish line of the preparation (Fig. 3). This abutment had remained asymptomatic de- spite the fracture of the coronal tooth structure. The margin remained intact around the circumference of the preparation. The patient was informed of the clinical ndings and was advised that the maxillary right second molar was not restorable due to severe periodontal pa- thology. The maxillary right second premolar had a wid- ened periodontal ligament space (Fig. 3), which is often indicative of occlusal trauma. This nding was related to the tipping forces transmitted to this abutment during occlusal loading of the mobile distal abutment of the FPD. It was noted that the mandibular right rst molar contacted the distal marginal ridge area of the retainer on the maxillary right second premolar. The possibility of supraeruption of an unopposed mandibular second molar and diminished masticatory ability on the right side of the arch following extraction of the maxillary sec- ond molar was discussed. Treatment options were pre- sented that included replacement of the maxillary right molars with a removable partial denture (RPD) or with implant-supported crowns that would likely require ad- junctive osseous augmentation. The patient declined the implant option owing to nancial considerations as well as the RPDoption because she did not want to wear a re- movable prosthesis. The patient stated that her desire Fig. 1. Maxillary right posterior FPD at time of insertion (12 years previous). a Assistant Professor. b Professor. JANUARY 2005 THE JOURNAL OF PROSTHETIC DENTISTRY 21 was to retain the maxillary second premolar and to have the second molar extracted. Endodontic treatment of the maxillary right second premolar was accomplished to place a dowel-retained foundation restoration. The most common dowel and core complication has been reported to be loosening of the dowel and root fractures. 8 Root fractures have been reported to account for 3% to 10% of dowel and core complications, and cemented dowels have been found to cause the least intraradicular stress. 8 A prefabricated passive parallel dowel (ParaPost Plus; Coltene/ Whaledent, Cuyahoga Falls, Ohio) was adaptedtothe ca- nal space and cemented with glass ionomer cement (Ketac-Cem; 3MESPE, St. Paul, Minn). Aprefabricated post was selectedbecause it was less expensive anddidnot require the additional appointment needed to restore the second premolar with a custom-cast dowel. According to Summitt et al, 9 prefabricated dowels have been shown to exhibit greater fracture resistance than custom-cast dow- els in laboratory studies and to provide a more favorable prognosis in retrospective clinical studies. The FPDwas then sectioned at the interproximal em- brasure between the maxillary second premolar and the rst molar, and the resultant second premolar crown was repolished. The crown was placed on the tooth and mar- ginal integrity was clinically conrmed. A core founda- tion of the coronal portion of the maxillary right second premolar was accomplished using an autopoly- merizing hybrid, lled resin composite, reinforced with titanium (Ti-Core; Essential Dental Systems, Hackensack, NJ). The resin composite was placed on the tooth and the crown was fully seated, shaping the core foundation and simultaneously cementing the crown (Fig. 4). The nonrestorable maxillary second mo- lar was extracted. Fig. 2. FPD at time of patient presentation with distal abutment exhibiting 8 to 9 mm periodontal probing depths and Class III mobility. Fig. 3. Removal of FPD revealed horizontal fracture through anterior abutment. Fig. 4. Maxillary right second premolar received endodontic treatment and prefabricated dowel with core foundation. FPD was sectioned and premolar crown was recemented. Fig. 5. Increased mobility of distal abutment (A), combined with occlusal forces (B), created shear forces between abutment anterior abutment and axial walls of retainer. These forces may result in fracture of abutment (C). THE JOURNAL OF PROSTHETIC DENTISTRY VERRETT AND KAISER 22 VOLUME 93 NUMBER 1 DISCUSSION This clinical report describes the catastrophic failure of an FPD. The etiology was severe periodontal disease localized to the maxillary second molar that permitted excessive forces on the second premolar abutment. A biomechanical challenge was created when the exces- sively mobile distal abutment was rigidly connected to an abutment with only limited physiologic mobility. When an excessively mobile FPD abutment is subjected to an occlusal force, a torquing force is created on the other abutment that may result in cement failure or frac- ture of the abutment (Fig. 5). The forces transmitted to the anterior abutment in this instance are similar to the forces that occur on a cantilever FPDabutment adjacent to the cantilever section when the cantilever is subjected to occlusal loading. SUMMARY An FPDabutment may fracture or the cement within a retainer can fail when subjected to excessive forces. Fortunately, retrospective clinical studies of conven- tional FPD complications have concluded that abut- ment fracture of the type reported is infrequent. REFERENCES 1. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications in xed prosthodontics. J Prosthet Dent 2003;90:31-41. 2. Karlsson S. Failures and length of service in xed prosthodontics after long-term function. A longitudinal clinical study. Swed Dent J 1989;13: 185-92. 3. Randow K, Glantz PO, Zo ger B. Technical failures and some related clinical complications in extensive xed prosthodontics. An epidemiolog- ical study of long-term clinical quality. Acta Odontol Scand 1986;44: 241-55. 4. Hammerle CH, Ungerer MC, Fantoni PC, Bragger U, Bu rgin W, Lang NP. Long-term analysis of biologic and technical aspects of xed partial den- tures with cantilevers. Int J Prosthodont 2000;13:409-15. 5. Valderhaug J. A 15-year clinical evaluation of xed prosthodontics. Acta Odontol Scand 1991;49:35-40. 6. Laurell L, Lundgren D, Falk H, Hugoson A. Long-term prognosis of exten- sive polyunit cantilevered xed partial dentures. J Prosthet Dent 1991;66: 545-52. 7. Cheung GSP, Dimmer A, Mellor R, Gale M. A clinical evaluation of con- ventional bridgework. J Oral Rehab 1990;17:131-6. 8. Goodacre CJ, Spolnik KJ. The prosthodontic management of endodonti- cally treated teeth: a literature review. Part 1. Success and failure data, treatment concepts. J Prosthodont 1994;3:243-50. 9. Summitt JB, Robbins JW, Schwartz RS. Fundamentals of operative dentistry. 2nd ed. Carol Stream (IL): Quintessence; 2001. p. 551. Reprint requests to: DR RONALD G. VERRETT DEPARTMENT OF PROSTHODONTICS UTHSCSA DENTAL SCHOOL 7703 FLOYD CURL DRIVE, MSC 7912 SAN ANTONIO, TX 78229-3900 FAX: 210-567-6376 E-MAIL: verrett@uthscsa.edu 0022-3913/$30.00 Copyright 2005 by The Editorial Council of The Journal of Prosthetic Dentistry. doi:10.1016/j.prosdent.2004.10.009 THE JOURNAL OF PROSTHETIC DENTISTRY VERRETT AND KAISER JANUARY 2005 23