Fixed-Removable Combination Cases

Reprinted from Connections: ADSBC - October 2002:

In general practice there is an acute awareness of the need for implants as a useful aspect of prosthetic dentistry. Nonetheless we all have patients who have been presented with the implant recommendation and rejected same for a variety of reasons. To those whom we serve, the prospect of bone augmentation might not be pleasant, and the real and perceived expense of implant procedures can place them beyond the means of many others. As a result, these patients are often wearing clasped partial dentures in their pocket or purse.

Shown below are before and after photographs of a combination case:

Before :

After :

Combination cases are reliable alternatives to the implant prosthesis and the clasped partial denture. Often bite raising or re-establishing the occlusal plane is required as part of the process of providing the combination case. This is the middle ground which was part of our presentation at the Pacific Dental Conference 2003.

Firstly the principles of fixed crowns in combination with attachment-retained partial dentures must be reviewed. We have developed a Protocol for Crowns and Precision Partial Dentures which provides a step-by-step guide for the management of this kind of case. There are a large variety of external and internal precison attachments which can be considered, and from which the dentist must choose. Treatment planning and educational resources need to be available to assist the treatment planning process.

Developing the resources for case presentations like this is an essential element of the delivery process. A formula for fee determination that is not punative to the dentist or the patient is needed. Locating and working with the kind of skilled technician to provide support for these cases is another important part of our program.

There is sound research to support the use of nylon or plastic inserts to maintain the retention of partial dentures while simultaneously reducing component wear. Most of the cases which will be discussed will show how these inserts can be used to maintain a constant seating and retentive perception over the long term. The timing and assessment of the need for saddle area relines will be discussed.

This presentation has developed from the Treatment Planning and Rehabilitation study group of Dr. John Nasedkin a Vancouver prosthodontist. This year he will have presented programs in Canada and the US, England, Italy and India.

Extensive Treatments

Short history: Orthodontics 15 years prior to upright lower molar teeth. Recent root fracture and loss of UR first premolar. Both jaw joints clunk on opening and closing. Masseter muscles are stiff and temporal headaches are a problem. Bite is collapsed.

Initial Treatment position: The mandible is opened and advanced to anterior Class I with a tongue blade between her teeth. Tm joint disk recapture occurs and her face is more harmonious.

Rehabilitation: Implant supported crowns in LR first molar and UR first premolar. Posterior teeth are rebuilt and there are porcelain canine risers on both L canines. Upper 6 anteriors have dSign porcelain veneers.