A 5-year dentures geriatric
longitudinal compared population
Ejvind Budtz-J@rgensen, Fleming Isidor, D.D.S.,
study of cantilevered with removable partial
fixed partial dentures in a
D.D.S., Dr.Odont.,* and Lic.Odont., Dr.Odont.**
Universit& de GenBve,Switzerland, and Royal Dental College,Aarhus, Denmark Prosthesis function and dental conditions were observed for 5 years in 27 elderly patients treated with mandibular cantilevered fixed partial dentures (FPDs) and in 26 elderly patients treated with distal-extension removal partial dentures (RPDs). All patients were treated with a complete upper denture. The patients were assigned randomly into two treatment groups that had the same composition with regard to sex, age, and distribution of teeth. The patients were under supervised oral hygiene and prosthodontic care. Clinical examination of prostheses, masticatory system, periodontal status, and caries was carried out yearly. Oral hygiene was good, and the periodontal status was maintained in both groups. Caries was observed six times more frequently in the RPD group than in the group with fixed restorations, however. Occlusal and functional conditions deteriorated in the RPD group only. Eight of 42 fixed partial dentures (19%) failed; of these, six were recemented with composite resin. Generally the need for dental and prosthetic follow-up treatment was more pronounced in the RPD group than in the FPD group. (J PROSTHET DENT 1990;64:42-7.)
E
pidemiologic studies have shown that the anterior mandibular teeth usually are retained for the longest period of time and that the canines are the most persistent.‘12 It has been shown that a dentition of the anterior teeth and one to two premolars is present in 20 % to 30 % of elderly patients.t 4 Thus, treatment for them with a complete maxillary denture and a mandibular removable partial denture (RPD) is a common prosthodontic procedure. Recently it was shown, however, that treatment with simple cantilevered fixed partial dentures (FPDs) was an alternative to RPDs for patients in this situation.5 A subjective improvement of chewing function was observed in patients who previously had successfully worn RPDs. Data have indicated that both FPDs and RPDs may influence oral hygiene and mobility of the abutment teeth and hence contribute to caries and progression of periodontal disease.“,7It has also been demonstrated that with proper oral hygiene, minimal periodontal changes occur adjacent to abutment teeth that support fixed or removable partial denture restorations.*-l1 Prosthodontic, functional, and periodontal conditions Supported by a grant from the Danish Dental Association. *Professor and Chairman, Division de Pro&h&e Adjointe et d’0cclusodontie Prosthetique, Univesiti! de Genitve. **AssociateProfessor,Department of Prosthetic Dentistry, Royal Dental College,Aarhus. 10/l/18986
42
during a a-year period of supervised oral hygiene in patients treated with either RPDs or distally extending cantilevered fixed partial dentures were reported in previous studies.12*I3 It was found that the signs and symptoms of mandibular dysfunction were less pronounced in the group of patients treated with fixed restorations. Furthermore, higher plaque scores and more caries were observed in the RPD group compared with the FPD group. This study compared longitudinally functional and prosthodontic conditions and the need for dental and prosthodontic treatment in two groups of patients during a 5-year study period. A subsequent article will focus on the periodontal conditions.14
MATERIAL
AND METHODS
The testing population originally consisted of 53 patients with complete maxillary dentures and mandibular RPDs who were registered for prosthodontic treatment during 1980-1981 in the Department of Prosthetic Dentistry, Royal Dental College, Aarhus, Denmark. On the basis of radiographs, the patients were divided into a FPD group and a RPD group, with the same distribution of the patients according to age and sex as well as remaining mandibular teeth and periodontal conditions (Table I). The RPDs were designed according to accepted principles. They consisted of a cobalt-chromium framework containing either a sublingual or a dental bar (on teeth), occlusal rests, and two clasps for primary retention.15 Care
JULY
1990
VOLUME
64
NUMBER
1
CANTILEVERED
FPDs
OR RPDs
Table I. Distribution according to sex, age, and number of remaining mandibular teeth of patients treated with cantilevered fixed partial dentures (FPDs) and removable partial dentures (RPDs) Sex No. of patients
Prosthesis FPD RPD
Table
27 26
Women
Men
Mean
Range
Number of teeth +- SD
14 14
13 12
69.7 68.3
61-83 61-81
6.9 i 1.7 7.5 _t 1.7
II. Classification of prostheses and failures of cantilevered fixed partial dentures No. of patients
9-11-unit
prostheses
3-4-unit prostheses 2-3-unit prostheses
No. of prostheses
3-4 2
1 0
12
21
1
1
The patients were examined 1 to 2 months after comple(day zero examination) and reexamined
tion of treatment
OF PROSTHETIC
No. of abutments fractured
8 12
EXAMINATIONS Intervals
JOURNAL
No. of abutments
8 7
was taken to keep bases, connectors, and clasps as far as possible from the gingivae and to sufficiently extend distal-extension denture basesto obtain maximum support from the alveolar ridge and the buccal shelf of the mandible. Treatment with a RPD/complete denture was performed by dental students, but the final result of treatment was evaluated by an experienced prosthodontist. The design of the FPDs has been described in a previous publication.5 The fixed restorations were performed with minimum preparation of the teeth, and their margins were placed as far as possible from the gingivae. Retention of the restorations was secured by parallel pin preparations whenever possible. The 27 patients were provided with a total of 41 cantilevered FPDs with 83 pontics, and 79 teeth were prepared for retainers. Treatment with fixed restorations and a complete maxillary denture was carried out by one of the authors (E. B.-J.). Eight of the patients were provided with lo-unit cantilevered FPDs (Table II). The remaining patients received simple cantilevered FPDs with one or two abutments and one or two cantilevered pontics placed unilaterally or bilaterally. The restorations were designed with open embrasure spaces and spacing from the mucosa of the alveolar ridge. The FPDs were cast in a silver-palladium alloy (Pallorag, Cendres et Meteaux, Biel-Bienne, Switzerland) with pins in iridioplatinum. Facings and pontics were produced of heat-cured acrylic resin (Biodent Plus, De Trey, Wiesbaden, West Germany). The restorations were cemented with zinc-phosphate cement (De Trey).
THE
Age
DENTISTRY
No. of prostheses with cementation failures 1 2 3
Number of patients treate,d with cantilevered fixed partial dentures (FPDs) and removable partial dentures (RPDs) attending yearly examinations and distribution of patients according to clinical dysfunction index (CDI)
Table III.
Year
FPDs
CD1
0
1
2
3
4
5
0
19 5 3
18 6 3
17 7 3
15 10 2
15 8 2
16 6 1
27 20 4 2
21 15 8 3
27 10 10 5
27 9 8 5
25 9 8 5
23 8 8 4
26
26
25
22
22
20
1 2
Attending recall RPDs
0 1 2
Attending recall
1,2,3,4, and 5 years after the day zero examination (Table III). At all examinations, periodontal, dental, functional, and prosthetic parameters were recorded and periodic identical radiographs were obtained.
Periodontal
conditions
and caries
Gingival inflammation was assessed according to the Gingival Index systemi and the state of the oral hygiene according to the Plaque Index system.l” A more comprehensive description of the periodontal conditions, including pocket depth and radiographic bone level, is presented elsewhere.14 Caries was identified clinically and radiographically.
43
BUDTZ-J@RGENSEN
AND
ISIDOR
%
FPDS
RPDS
ACCEPTABLE FPDS
RPDS
60 40 20 0
012345
1 2 3 4 5 YEARS
Fig. 1. Percentage of patients in FPD and RPD groups exhibiting balanced occlusion in retruded contact position (RCP) at various examinations.
Prosthodontic
system
Clinical examination of the masticatory system included palpation of the temporomandibular joints (TMJs) and masticatory muscles, evaluation of function of the TMJs, and movement capability of the mandible. A modification of Helkimo’s Dysfunction Index21 was used to describe the degree of dysfunction.22 Group Die: No dysfunction, evidenced by lack of signs and symptoms of dysfunction Group Dir: Slight dysfunction, evidenced by symptoms such as clicking or crepitation of the TMJ, tenderness to palpation of one muscle, deviation of the mandible on opening (>2 mm), and TMJ sounds Group DI2: Moderate dysfunction evidenced by additional symptoms such as slight or infrequent pain in muscles or TMJ, significant tenderness of several muscles and TMJ on palpation, and slight pain on opening of the mandible (
longitudinal compared population
Ejvind Budtz-J@rgensen, Fleming Isidor, D.D.S.,
study of cantilevered with removable partial
fixed partial dentures in a
D.D.S., Dr.Odont.,* and Lic.Odont., Dr.Odont.**
Universit& de GenBve,Switzerland, and Royal Dental College,Aarhus, Denmark Prosthesis function and dental conditions were observed for 5 years in 27 elderly patients treated with mandibular cantilevered fixed partial dentures (FPDs) and in 26 elderly patients treated with distal-extension removal partial dentures (RPDs). All patients were treated with a complete upper denture. The patients were assigned randomly into two treatment groups that had the same composition with regard to sex, age, and distribution of teeth. The patients were under supervised oral hygiene and prosthodontic care. Clinical examination of prostheses, masticatory system, periodontal status, and caries was carried out yearly. Oral hygiene was good, and the periodontal status was maintained in both groups. Caries was observed six times more frequently in the RPD group than in the group with fixed restorations, however. Occlusal and functional conditions deteriorated in the RPD group only. Eight of 42 fixed partial dentures (19%) failed; of these, six were recemented with composite resin. Generally the need for dental and prosthetic follow-up treatment was more pronounced in the RPD group than in the FPD group. (J PROSTHET DENT 1990;64:42-7.)
E
pidemiologic studies have shown that the anterior mandibular teeth usually are retained for the longest period of time and that the canines are the most persistent.‘12 It has been shown that a dentition of the anterior teeth and one to two premolars is present in 20 % to 30 % of elderly patients.t 4 Thus, treatment for them with a complete maxillary denture and a mandibular removable partial denture (RPD) is a common prosthodontic procedure. Recently it was shown, however, that treatment with simple cantilevered fixed partial dentures (FPDs) was an alternative to RPDs for patients in this situation.5 A subjective improvement of chewing function was observed in patients who previously had successfully worn RPDs. Data have indicated that both FPDs and RPDs may influence oral hygiene and mobility of the abutment teeth and hence contribute to caries and progression of periodontal disease.“,7It has also been demonstrated that with proper oral hygiene, minimal periodontal changes occur adjacent to abutment teeth that support fixed or removable partial denture restorations.*-l1 Prosthodontic, functional, and periodontal conditions Supported by a grant from the Danish Dental Association. *Professor and Chairman, Division de Pro&h&e Adjointe et d’0cclusodontie Prosthetique, Univesiti! de Genitve. **AssociateProfessor,Department of Prosthetic Dentistry, Royal Dental College,Aarhus. 10/l/18986
42
during a a-year period of supervised oral hygiene in patients treated with either RPDs or distally extending cantilevered fixed partial dentures were reported in previous studies.12*I3 It was found that the signs and symptoms of mandibular dysfunction were less pronounced in the group of patients treated with fixed restorations. Furthermore, higher plaque scores and more caries were observed in the RPD group compared with the FPD group. This study compared longitudinally functional and prosthodontic conditions and the need for dental and prosthodontic treatment in two groups of patients during a 5-year study period. A subsequent article will focus on the periodontal conditions.14
MATERIAL
AND METHODS
The testing population originally consisted of 53 patients with complete maxillary dentures and mandibular RPDs who were registered for prosthodontic treatment during 1980-1981 in the Department of Prosthetic Dentistry, Royal Dental College, Aarhus, Denmark. On the basis of radiographs, the patients were divided into a FPD group and a RPD group, with the same distribution of the patients according to age and sex as well as remaining mandibular teeth and periodontal conditions (Table I). The RPDs were designed according to accepted principles. They consisted of a cobalt-chromium framework containing either a sublingual or a dental bar (on teeth), occlusal rests, and two clasps for primary retention.15 Care
JULY
1990
VOLUME
64
NUMBER
1
CANTILEVERED
FPDs
OR RPDs
Table I. Distribution according to sex, age, and number of remaining mandibular teeth of patients treated with cantilevered fixed partial dentures (FPDs) and removable partial dentures (RPDs) Sex No. of patients
Prosthesis FPD RPD
Table
27 26
Women
Men
Mean
Range
Number of teeth +- SD
14 14
13 12
69.7 68.3
61-83 61-81
6.9 i 1.7 7.5 _t 1.7
II. Classification of prostheses and failures of cantilevered fixed partial dentures No. of patients
9-11-unit
prostheses
3-4-unit prostheses 2-3-unit prostheses
No. of prostheses
3-4 2
1 0
12
21
1
1
The patients were examined 1 to 2 months after comple(day zero examination) and reexamined
tion of treatment
OF PROSTHETIC
No. of abutments fractured
8 12
EXAMINATIONS Intervals
JOURNAL
No. of abutments
8 7
was taken to keep bases, connectors, and clasps as far as possible from the gingivae and to sufficiently extend distal-extension denture basesto obtain maximum support from the alveolar ridge and the buccal shelf of the mandible. Treatment with a RPD/complete denture was performed by dental students, but the final result of treatment was evaluated by an experienced prosthodontist. The design of the FPDs has been described in a previous publication.5 The fixed restorations were performed with minimum preparation of the teeth, and their margins were placed as far as possible from the gingivae. Retention of the restorations was secured by parallel pin preparations whenever possible. The 27 patients were provided with a total of 41 cantilevered FPDs with 83 pontics, and 79 teeth were prepared for retainers. Treatment with fixed restorations and a complete maxillary denture was carried out by one of the authors (E. B.-J.). Eight of the patients were provided with lo-unit cantilevered FPDs (Table II). The remaining patients received simple cantilevered FPDs with one or two abutments and one or two cantilevered pontics placed unilaterally or bilaterally. The restorations were designed with open embrasure spaces and spacing from the mucosa of the alveolar ridge. The FPDs were cast in a silver-palladium alloy (Pallorag, Cendres et Meteaux, Biel-Bienne, Switzerland) with pins in iridioplatinum. Facings and pontics were produced of heat-cured acrylic resin (Biodent Plus, De Trey, Wiesbaden, West Germany). The restorations were cemented with zinc-phosphate cement (De Trey).
THE
Age
DENTISTRY
No. of prostheses with cementation failures 1 2 3
Number of patients treate,d with cantilevered fixed partial dentures (FPDs) and removable partial dentures (RPDs) attending yearly examinations and distribution of patients according to clinical dysfunction index (CDI)
Table III.
Year
FPDs
CD1
0
1
2
3
4
5
0
19 5 3
18 6 3
17 7 3
15 10 2
15 8 2
16 6 1
27 20 4 2
21 15 8 3
27 10 10 5
27 9 8 5
25 9 8 5
23 8 8 4
26
26
25
22
22
20
1 2
Attending recall RPDs
0 1 2
Attending recall
1,2,3,4, and 5 years after the day zero examination (Table III). At all examinations, periodontal, dental, functional, and prosthetic parameters were recorded and periodic identical radiographs were obtained.
Periodontal
conditions
and caries
Gingival inflammation was assessed according to the Gingival Index systemi and the state of the oral hygiene according to the Plaque Index system.l” A more comprehensive description of the periodontal conditions, including pocket depth and radiographic bone level, is presented elsewhere.14 Caries was identified clinically and radiographically.
43
BUDTZ-J@RGENSEN
AND
ISIDOR
%
FPDS
RPDS
ACCEPTABLE FPDS
RPDS
60 40 20 0
012345
1 2 3 4 5 YEARS
Fig. 1. Percentage of patients in FPD and RPD groups exhibiting balanced occlusion in retruded contact position (RCP) at various examinations.
Prosthodontic
system
Clinical examination of the masticatory system included palpation of the temporomandibular joints (TMJs) and masticatory muscles, evaluation of function of the TMJs, and movement capability of the mandible. A modification of Helkimo’s Dysfunction Index21 was used to describe the degree of dysfunction.22 Group Die: No dysfunction, evidenced by lack of signs and symptoms of dysfunction Group Dir: Slight dysfunction, evidenced by symptoms such as clicking or crepitation of the TMJ, tenderness to palpation of one muscle, deviation of the mandible on opening (>2 mm), and TMJ sounds Group DI2: Moderate dysfunction evidenced by additional symptoms such as slight or infrequent pain in muscles or TMJ, significant tenderness of several muscles and TMJ on palpation, and slight pain on opening of the mandible (
