Maxillary and mandibular overlay removable partial dentures for the restoration of worn teeth

Mario R. Ganddini, DDS,a Majd Al-Mardini, DDS,b Gerald N. Graser, DDS, MS,c and Dov Almog, DMDd University of Rochester Eastman Dental Center, Rochester, NY
This clinical report describes the fabrication of maxillary and mandibular cast overlay removable partial dentures for the restoration of severely worn teeth with accompanying loss of vertical dimension of occlusion. The frameworks supported porcelain veneers for esthetics and metal occlusal surfaces for strength and durability. (J Prosthet Dent 2004;91:210-4.)

rolonged tooth retention by the aging population increases the likelihood that clinicians may treat patients with advanced levels of wear. Tooth wear occurs as a natural physiological process; the average wear rates on occlusal contact areas were estimated to be 29 mm per year for molars and 15 mm per year for premolars.1 Pathologic wear occurs when the normal rate of wear is accelerated by endogenous or exogenous factors.2 Tooth wear caused by para-function is estimated to progress 3 times faster than physiological wear.3 Tooth surface loss has been classied4 into the following types: (1) erosion, loss of tooth surface by chemical processes not involving bacterial action, (2) attrition, tooth structure loss by wear of surface of tooth or restoration caused by tooth-to-tooth contact during mastication or para-function, and (3) abrasion, loss of tooth surface caused by abrasion with foreign substances other than tooth-to-tooth contact. Another classication divides tooth wear into 2 categories: mechanical wear caused by attrition or abrasion and chemical wear caused by erosion.2 A differential diagnosis is not always possible because there may be a combination of these processes occurring.5-8 Etiologic factors include bruxism, harmful oral habits, diet, gastroesophageal reux disease, occupation, eating disorders, xerostomia, and congenital anomalies such as amelogenesis imperfecta and dentinogenesis imperfecta.1-12 Clinical parameters have been suggested to aid in diagnosing the type of tooth wear and determining its cause.2 Loss of vertical dimension of occlusion (VDO) caused by physiologic tooth wear is usually compensated by continuous tooth eruption and alveolar bone growth.13 In situations where tooth wear exceeds compensatory mechanisms, loss of VDO occurs.

The determination of the VDO can be achieved with several methods such as phonetics, interocclusal distance, swallowing, and patient preferences.8,14-16 In situations where loss of tooth structure has occurred and the VDO is still acceptable, treatment may include crown lengthening, orthodontic movement with limited intrusion, surgical repositioning of a segment of teeth and supporting alveolar bone, and placement of crowns and xed partial dentures.8 In situations where loss of VDO has occurred, the cast overlay removable partial denture (CORPD) may be a treatment option.17-24 This treatment option has been suggested to be efcient and cost effective, with the nal outcome pleasing to the patient.18 Potential disadvantages of CORPD prostheses include compromised esthetics when the dentures are removed, development of caries or periodontal disease as a result of poor oral hygiene, porcelain or resin veneer fracture or discoloration, and possible patient dissatisfaction with a removable prosthesis. This clinical report describes the use of maxillary and mandibular CORPDs consisting of anterior porcelain veneers, posterior cast overlays, and acrylic resin denture bases in the treatment of a patient with severe tooth wear caused by attrition and erosion.

CLINICAL REPORT
A 58-year-old white man was seen at the University of Rochester Eastman Dental Centers prosthodontic clinic. The medical and dental histories were recorded, and a complete series of radiographs was made. History of high consumption of fruit juices and carbonated drinks and history of bruxing were reported. The clinical examination revealed severe tooth wear extending to the cervical level of the teeth in some areas. Clinical determination of the VDO was achieved with the following methods: phonetics, interocclusal distance, swallowing, patient preferences, and facial appearance. After careful assessment, it was determined that a 6-mm loss of VDO was caused by a combination of attrition and erosion (Figs. 1 and 2). The chief complaints included a desire to improve esthetics (poor appearance)
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Graduate student, Prosthodontics. Graduate student, Prosthodontics. c Professor, Prosthodontics. d Associate Professor, Prosthodontics.
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and function (would like to chew better), and eliminate tooth sensitivity (my teeth are sensitive). Impressions were made of both arches using stock trays and irreversible hydrocolloid (Jeltrate Plus; Dentsply Caulk, Inc, Milford, Del) and poured in stone (Quickstone; Whip Mix, Louisville, Ky). The diagnostic casts were articulated in a semiadjustable articulator (Hanau H2; Hanau Teledyne, Buffalo, NY), using a centric relation record and a face-bow transfer. During the following visit, treatment options were discussed with the patient, including crown lengthening, endodontic therapy, and xed restorations. After considering the life expectancy of xed partial dentures,25 invasiveness, amount of time, and nancial aspects, the patient elected to have CORPDs with anterior porcelain veneers, posterior cast overlays, and acrylic bases. Porcelain veneers were used in the anterior area because they are more durable and color stable than composite.26,27 Moreover, composite veneers are more expensive than porcelain, while resin laminates are the least expensive. Metal coverage was used on the occlusal surface of the posterior teeth to maintain the newly established VDO. Once sufcient occlusal support was established, resin teeth were used for the edentulous areas as a matter of laboratory convenience and ease of fabrication. After extractions of nonrestorable teeth because of extensive decay or wear, and restoration of carious teeth, the patient was re-evaluated and referred to a dental hygienist for oral hygiene instructions and a maintenance program (once every 6 months). After approximately 6 weeks of healing, prosthetic treatment commenced. The new diagnostic casts were articulated with a new centric relation record and a face-bow transfer. Diagnostic tooth arrangements were made to establish the new VDO and the plane of occlusion, on the basis of anatomic landmarks and averaged values.15 The diagnostic arrangements were duplicated using irreversible hydrocolloid (Jeltrate Plus; Dentsply Caulk, Inc) and then poured in dental stone (Quickstone, Whip Mix Corp). Thermal forming material, 1.0-mm thick, (Splint; Henry Shein, Melvile, NY) was then applied over the new casts. The occlusal aspects of the thermo forming material were lubricated and then lled with autopolymerizing acrylic resin (Jet Tooth Shade Acrylic; Lang Dental, Wheeling, Ill). After polymerization, the occlusal aspects of the thermal forming material were cut away to expose the underlying acrylic resin teeth, and then positioned back on a duplicate of the diagnostic casts. These served as a transitional VDO device, which was then transferred to the patient. These devices t tightly over the teeth and soft tissues, enabling evaluation and adjustment for phonetics, esthetics, and occlusion.14-16 On the basis of the newly established VDO, the transitional maxillary and mandibular VDO devices
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Fig. 1. Intraoral anterior view of patient presenting severely worn maxillary and mandibular dentition and loss of VDO.

were given to the patient. The transitional VDO devices were worn for approximately 6 weeks, during which occlusal adjustments were made on a weekly basis, and occlusion was modied on the basis of phonetic and esthetic principles, as well as patient comfort and ease of function. The diagnostic casts were surveyed to determine the most suitable path of insertion of the denitive prostheses. Each cast was placed in a horizontal position and slowly lowered posteriorly on the surveyor until undercuts at the distobuccal of the rst and second molar regions were of sufcient depth (0.25 mm). As these teeth were not present in all quadrants, undercut considerations were applied to the most posterior teeth. A slight undercut in the anterior region allowed for the use of a rotational path of insertion. The information from the diagnostic cast was now replicated intraorally. Unsupported enamel was recontoured and polished. In some instances, facial reduction of enamel surface in the esthetic zone was required to accommodate the porcelain veneers which would be fused to the CORPD framework. Guide planes were placed on proximal tooth surfaces. Because of the wear on many of the remaining teeth, a natural undercut for adequate retention could not be located. Therefore, existing enamel surfaces were modied to create an undercut of 0.25 mm, for the use of cast half-round circumferential clasps. Dentin exposure occurred, but this was managed with a thorough maintenance program. Rest seat preparations were not needed because the entire occlusal surface of all the teeth served as rests under the cast framework. Denitive impressions were made using a polyether impression material (Permadyne Penta H and Permadyne Garant 2:1, 3M ESPE, St Paul, Minn) and custom trays (Triad VLC Materials; Denstsply International,
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Fig. 2. Intraoral occlusal view of maxillary (A) and mandibular (B) dentition.

Fig. 3. Intraoral occlusal view of maxillary (A) and mandibular (B) CORPD frame try-in. Note alloy copings in esthetic zone.

York, Pa). Casts were made and mounted in centric relation. The incisal guiding pin was then adjusted for a 6-mm increase in VDO. Once the path of insertion was established for both casts, the undesirable undercuts were blocked out with wax and the casts were duplicated and poured in a refractory investment (Hi-Temp; Whip Mix Corp). The refractory casts were also mounted in the articulator using a cross-cast mounting procedure between the denitive casts and the refractory casts. The frameworks were waxed, using a thin layer of wax (Flexseal Patterns; Dentsply Trubyte/Austenal, York, Pa) over the teeth to be included in the prosthesis, except for the surfaces to be clasped. The posterior occlusal surfaces were waxed to occlusion and patterns for clasps and mesh to retain the acrylic resin were added. A butt joint was placed on the lingual surfaces of the
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anterior portion of the frameworks to support porcelain veneers. The wax patterns were cast in a chrome-cobalt alloy (Vitallium; Dentsply Austenal). The cast frameworks were then nished. The frameworks were evaluated intraorally for t, occlusion, retention, and stability (Fig 3). A new maxillomandibular relationship record was made with the frameworks in position, and the denitive casts were mounted in the articulator. The frameworks were returned to the laboratory for the application of porcelain veneers in the esthetic zone, and articial acrylic resin teeth (Dentsply Trubyte, York , Pa) and heat-polymerizing acrylic resin (Lucitone 199; Dentsply Trubyte) in the edentulous posterior regions. A bilaterally balanced occlusal scheme was developed using a 20-degree plane. Although the esthetic zone in the CORPD can be
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with instructions on adequate oral hygiene, and caries and erosion prevention. These included the application of sodium uoride neutral mineral (PreviDent 5000 Plus; Colgate Oral Pharmaceuticals, Canton, Mass) in the intaglio of the CORPDs, and dietary counseling. The patient was also instructed to remove the CORPDs at night and wear a maxillary soft night guard made of 3.0-mm thermal forming material (Mouthguard; Great Lakes Orthodontics, Ltd, Tonawanda, NY). After 2 postinsertion visits that included minor adjustments, the patient was placed on a 6-month recall.

SUMMARY
Fig. 4. Intraoral anterior view of restored maxillary and mandibular dentition.

This clinical report demonstrated that the use of CORPDs can be a viable, relatively inexpensive, and noninvasive choice of treatment for a patient with a severely worn dentition who expresses concerns over treatment longevity, invasiveness, cost, and long-term maintenance.
The authors thank Mike Hagan from Hagan Prosthetic Services, Inc, Rochester, NY, who provided the laboratory work presented by the authors in this clinical report.

REFERENCES
1. Lambrechts P, Braem M, Vuylsteke-Wauters M, Vanherle G. Quantitative in vivo wear of human enamel. J Dent Res 1989;68:1752-4. 2. Verrett RG. Analyzing the etiology of an extremely worn dentition. J Prosthodont 2001;10:224-33. 3. Xhonga FA. Bruxism and its effect on the teeth. J Oral Rehabil 1997;4: 65-76. 4. Glossary of Prosthodontic Terms. J Prosthet Dent 1999;81:39-110. 5. Smith BG, Bartlett DW, Robb ND. The prevalence, etiology and management of tooth wear in the United Kingdom. J Prosthet Dent 1997;78:367-72. 6. Smith BG, Knight JK. A comparison of patterns of tooth wear with aetiological factors. Br Dent J 1984;157:16-9. 7. Lewis KJ, Smith BG. The relationship of erosion and attrition in extensive tooth tissue loss. Case reports. Br Dent J 1973;135:400-4. 8. Turner KA, Missirlian DM. Restoration of the extremely worn dentition. J Prosthet Dent 1984;52:467-74. 9. Gregory-Head BL, Curtis DA, Kim L, Cello J. Evaluation of dental erosion in patients with gastroesophageal reux disease. J Prosthet Dent 2000; 83:675-80. 10. Smith BG, Knight JK. A comparison of patterns of tooth wear with aetiological factors. Br Dent J 1984;157:16-9. 11. Johansson A, Omar R. Identication and management of tooth wear. Int J Prosthodont 1994;7:506-16. 12. Dahl BL, Carlsson GE, Ekfeldt A. Occlusal wear of teeth and restorative materials. A review of classication, etiology, mechanism of wear, and some aspects of restorative procedures. Acta Odontol Scand 1993; 51:299-311. 13. Murphy T. Compensatory mechanisms in facial height adjustment to functional tooth attrition. Aust Dent J 1959;4:312-23. 14. Tjan AHL, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent 1984;51:24-8. 15. Halperin AR, Graser GN, Rogoff GS, Plekavich EJ. Mastering the art of complete dentures. 1st ed. Chicago: Quintessence Publishing; 1988: 94-7. 16. Lundquist DO, Luther WW. Occlusal plane determination. J Prosthet Dent 1970;23:489-98. 17. Brewer AA, Morrow RM. Overdentures. 2nd ed. St. Louis: Mosby; 1975: 89-99.

Fig. 5. Facial view of restored maxillary and mandibular dentition.

fabricated either with composite28 or porcelain veneers, in this patient, microcrystal porcelain veneers (Avante; Pentron Laboratory Technology, Wallingford, Conn) were applied directly to the framework.29 Chrome cobalt bonding agent (CKB; Bredent, Miami, Fla) enabled bonding of the veneers directly onto the casting. CKB is a ceramic material used to form a layer between metals and ceramic and is purported to compensate for different expansion coefcients between metal and ceramic and blocks escaping metal oxides. After processing, the casts were remounted, and the occlusion was adjusted to remove any processing errors. At the next visit, the CORPDs were inserted (Figs. 4 and 5). After postoperative instructions on how to properly insert the prostheses, the patient was provided
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18. Graser GN, Rogoff GS. Removable partial overdentures for special patients. Dent Clin North Am 1990;34:741-58. 19. Pavarina AC, Machado AL, Vergani CE, Giampaolo ET. Overlay removable partial dentures for patients with ectodermal dysplasia: a clinical report. J Prosthet Dent 2001;86:574-7. 20. Sato S, Hotta TH, Pedrazzi V. Removable occlusal overlay splint in the management of tooth wear: a clinical report. J Prosthet Dent 2000; 83:392-5. 21. Matsumoto W, Hotta TH, Bataglion C, Rodovalho GV. Tooth wear: use of overlays with metallic structures. Cranio 2001;19:61-4. 22. Farmer JB, Connelly ME. Treatment of open occlusions with onlay and overlay removable partial dentures. J Prosthet Dent 1984;51:300-3. 23. Friedman MH, Howard I. Framework design for overlay removable partial dentures. J Prosthet Dent 1983;50:866. 24. Windchy AM, Morris JC. An alternative treatment with the overlay removable partial denture: a clinical report. J Prosthet Dent 1998;79: 249-53. 25. Walton TR. An up to 15-year longitudinal study of 515 metal-ceramic FPDs: Part 1. Outcome. Int J Prosthodont 2002;15:439-45. 26. Jones RM, Moore BK, Goodacre CJ, Munoz-Viveros CA. Microleakage and shear bond strength of resin and porcelain veneers bonded to cast alloys. J Prosthet Dent 1991;65:221-8.

27. Jones RM, Goodacre CJ, Moore BK, Dykema RW. A comparison of the physical properties of four prosthetic veneering materials. J Prosthet Dent 1989;61:38-44. 28. Kolodney H Jr, Akerly WB. A composite resin veneer occlusal surface on an overlay partial denture. Compendium 1991;12:66-70. 29. Lewis GR, Munro AM. Advances in partial denture ceramics. Quintessence Int. 1995;26:617-20. Reprint requests to: DR DOV M. ALMOG UNIVERSITY OF ROCHESTER EASTMAN DENTAL CENTER 625 ELMWOOD AVE ROCHESTER, NY 14620 FAX: (585) 273-1372 E-MAIL: dov_almog@urmc.rochester.edu 0022-3913/$30.00 Copyright 2004 by the Editorial Council of The Journal of Prosthetic Dentistry doi:10.1016/j.prosdent.2003.12.021

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