Written by Paul Kaplan, MSci, DDS, MSD Sunday, 30 November 2008 19:00
The use of aesthetic flexible removable partial dentures (FRPD) has sky-rocketed over the last several years (Figure 1). Multiple advertisements can be found in every journal with laboratories promoting lower cost (compared to conventional partial dentures with cast frameworks), fast service, and better aesthetics than conventional metal-based removable partial dentures (RPD). In speaking with prosthodontists, I still get the feeling they believe that the use of FRPDs is somehow still ìnot quite the right thingî to do. Although, some are now openly admitting that these prostheses may, in fact, have their place, I think that many are still a bit unsure about exactly what that place is. This article will describe techniques needed to provide aesthetic FRPDs to your patients, and I will also share my opinions regarding these appliances and the need to embrace them as a viable treatment option.
RIGID METAL-BASED RPDS VERSUS FLEXIBLE RPDS
OBSERVATIONS AND INDICATIONS
From the perspective of my personal clinical experience, the facts are simple: FRPDs (such as Valplast [Valplast International, Inc.]) work extremely well in some situations, and reasonably well in others. Although some periodontists have been quick to tell of some cases or situations where tissue stripping has occurred with the use of these appliances, I have not observed this condition in cases that I have done, nor in patients that I have seen who were treated by other dentists. In the small number of patients I have observed who have worn FRPDs for an extended period of time, I have not seen bone damage or resorption in the traditional pattern of posterior ridge resorption (saddle ridge) that is so common under chrome/acrylic saddles used on metal-based RPDs. Time and increased patient utilization may bring some of these issues forward, but for the moment they do not seem to be a problem. Present observations reveal that patient satisfaction with FRPDs is high, the equipment costs and technology to make them are low, and the aesthetics can also be outstanding when compared to conventional metal-based RPDs.
FRPDs are extremely useful as a provisional in lieu of restorative temporaries or a standard acrylic partial. While the cost is a little more, the higher patient satisfaction usually found with these, and the fact that they will not break, is worth any extra expense. No repairs are necessary, and no patients are at the door with a broken acrylic partial in hand.
FRPDs have also been used successfully as obturators in conjunction with maxillectomy procedures. The weight of the appliance (Valplast) is usually about one third that of the conventional obturator. In addition, the clasping and stability potentials can often far exceed that of a metal-based RPD used in the same fashion.
MATERIAL CONSIDERATIONS AND DESIGN CONCEPTS
MODELS, SURVEYING, AND TOOTH PREPARATION
Figure 1. Aesthetic partials are possible with modern materials and thoughtful designs.
Figure 2. Light enameloplasty to create survey zone.
As in most things in dentistry, the FRPD begins with an accurate diagnostic model. An accurate opposing model is also essential since the occlusion will dictate the placement of components; and because success can only come through careful consideration and incorporation of the occlusion into the final design.
Survey the teeth on the stone model: level the plane of occlusion, stabilize the surveyor table, and run the carbon rod around the teeth. That's the survey line. It sounds dangerously traditional, but is now a new concept. Metal clasps were all about survey lines, being above them or being below them. This concept, although important, is different with flexible partials. Polynylon/Valplast likes a "survey zone," not a survey line. The survey line just indicates to you where you are going to take a fine-tapered diamond and do a little enameloplasty (Figure 2). Think of it as making a 2.0 mm guideplane that goes around the tooth. That survey zone, or circumferential guideplane, is the generator of the required stability and retention.
A LOOK AT CLASP DESIGNS
Figure 3. Bulk is not required for strength or retention.
Figure 4. A circumferential clasp.
Figure 5. A 2-tooth continuous clasp.
Figure 6. Circumferential clasp for a mesially-tipped distal molar.
Figure 7. A combination clasp.
Figure 8. Preparation to allow for crossing the occlusal table.
Let's first consider the design of the "standard" or "main" clasp. If you look at any FRPD advertisement you will see the basic "main clasp" (Figure 3). This is certainly a useful clasp, but its design is often far too large and bulky. Tooth preparation to improve the contact zone is essential for increased retention and stability. These do not need to cover large amounts of tooth structure. A few millimeters of tooth contact and a few millimeters of tissue contact are all that is necessary for retention and stability. More is not better!
The circumferential clasp (Figure 4) is just that. It goes totally around a free-standing tooth. It can also engage all available surfaces of multiple teeth (Figure 5), in which case it may be referred to as a "continuous circumferential clasp." This is an ideal clasp for a free-standing, mesially-tipped distal abutment (Figure 6). What makes this ìclaspî so unbelievably retentive is the prepared survey zone.
The combination clasp (Figure 7) is, in fact, a combination of the circumferential clasp and the conventional main clasp. Its key ingredient is a component that crosses the occlusal table. This component also acts as a "rest seat" and although it may or may not transfer ìloadî to the axial root of the tooth, it certainly does provide stability and strength to the FRPD by linking the palatal (or lingual) components to the buccal. This basic engineering concept of mutual reinforcement cannot be overlooked or discarded. This can be accomplished through a prepared slot (Figure 7), if occlusion or res-torations do not permit; or through a wide embrasure space that may be enlarged with a diamond (Figure 8). Valplast does not have to be thick and bulky, however, it does need a reasonable amount of material for strength. Therefore, it must be reinforced by components that link the palatal/lingual with the buccal.
TROUBLESHOOTING: CLASP DESIGNS TO AVOID
Figure 9. The "reach around"clasp design should be avoided.
|Figure 10. Separated clasps that lose strength and function.|
Figure 11. A hopeless 2-tooth clasp that will hinge open, providing no strength or retention.
Figure 12. A well-designed flexible removable partial denture with 2 circumferential clasps and 2 combination clasps.
The "reach-around clasp" is almost the single worst design concept (Figure 9). It has to be waxed thick for adequate strength, and as a result, it becomes bulky and uncomfortable. I recently received such a clasp design from a laboratory where the prosthetic technician did not understand the concept of survey area, the circumferential clasp, or combination clasp design. The patient was not impressed by the size, look, or feel of what they provided for us. This type of clasp is usually done by a dental technician that simply does not understand the concept of crossing the occlusal table for strength, rigidity, and retention.
The "separated" clasps (Figure 10) are also a waste of strength and retention. These are clasps from a laboratory in which the prosthetic technician still thought clasps were made of metal and had to be separate. This technician sacrificed all the strength of the circumferential clasp and gained nothing in exchange.
The prize for simply the worst design and execution is the 2-tooth clasp (Figure 11). Clinically it will always be a failure. This is because the physics will force the unsupported end to hinge away from the tooth surface when it is seated. It will have absolutely no function, no retention, and be of no use. The only thing possible here was to remove it.
The use of FRPDs is growing. Patient success is high since these appliances can be extremely aesthetic. One must remember that careful attention must be paid to the basic concepts of diagnosis and design, and a different approach to clasp design is essential (Figure 12).
I certainly do not believe that (FRPDs) are the answer to everything. However, they represent a great stride forward as an excellent prosthetic choice available for our patients. When appropriate, their use should be considered by dental health professionals as a viable treatment option.
Disclosure: Dr. Kaplan has no relationship with Valplast or any dental product company.
Dr. Kaplan is a graduate of Indiana University School of Dentistry. He received his postgraduate prosthodontic training through the Air Force at Wilford Hall Medical Center, and completed his Maxillofacial Prosthodontic Fellowship at the University of Chicago. He is currently working with the US Army in Wiesbaden, Germany, and can be reached at firstname.lastname@example.org.
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