Attachment Challenges in Compromised Situations—Part II
Exceptional results and a life-changing outcome for a very pleased patient.
In the May issue of Inside Dental Technology, we presented the first part of this case and discussed the challenges of attachments in compromised situations. To summarize, the patient has had eight surgeries, was referred for orthognathic surgery, and had multiple repairs including primary repair, alveolar grafts, and iliac grafts.
John A. Merrill, DDS, director of The Carolina Center for Oral Health, and the author came up with a case design for a temporary appliance that consisted of an acetal resin tooth-shaded framework which was later altered with Rhein83 low-profile Equator attachments (Rhein83 USA, www.rhein83usa.com). This appliance worked well in the short term but was compromised by limited esthetic value.
The final impression for the new case was taken with Equator impression analogs and a new overdenture case was ready to be made. The set-up was completed with high quality esthetic denture teeth, and a putty matrix of the set-up was made so the position of the denture teeth could be verified after the framework was fabricated (Figure 1). This framework was the same material as the temporary appliance, but this time the author changed the design to accommodate both the Rhein83 attachments and Ivoclar denture teeth on the anterior region, and only the necessary areas on the posterior teeth were covered with acetal resin to provide some occlusal guidance.
The original model was blocked out and duplicated and the framework wax-up was completed (Figure 2). The dental team also hollow-ground some posterior denture teeth and set them over the bicuspids to provide more natural anatomy (Figure 3 and Figure 4). These posterior denture teeth would eventually be removed before injection and replaced with acetal resin. Next, the waxed framework was invested, boiled out, and injected with duracetal material, using the FlexPress™ injection system (Myerson, www.myersontooth.com) (Figure 5). The case was de-flasked and the framework was finished placing retention holes on the anterior region to accommodate the denture teeth, acrylic, and Rhein83 Equator attachments (Figure 6). The acetal resin thermoplastic material is very easy to finish and polish and, in this situation, still provided enough strength to accommodate the Equator attachments.
The goal here was to give the patient a case in which natural dentition, overdenture attachments, and a framework would all work together harmoniously to meet the functional and esthetic demands of the patient.
The next step after the framework was finished was to cover the gingival areas of the acetal resin near the bicuspids with a light-cured composite resin (Figure 7). The author then reset the denture teeth in the exact position they were before the framework was made. The previously made putty matrix was used to position the denture teeth correctly (Figure 8).
The denture teeth were processed onto the anterior section of the framework with denture acrylic, (Figure 9), and the dental team was now ready for the final steps. The Rhein83 Equator attachments were placed on the original model and the housings with caps were processed into the framework with self-cured acrylic (Figure 10 and Figure 11). One of the nice features of the caps is that they have various levels of retentive value. In this particular case one pink cap (soft retention) and two yellow caps (extra soft retention) were used.
Everything was coming together nicely and the case was finished, polished, and perfectly fitted onto the original model. The bite was checked for high spots, and the case was ready for delivery.
The final insertion of the case exceeded all expectations (Figure 11 and Figure 12). Dr. Merrill inserted the overdenture with minimal occlusal adjustments. Keep in mind that this was a severe Class III bite and occlusion and function was always a major concern. But the one aspect of the case that was a surprise was that the overall design proved to benefit the patient’s phonetics dramatically. This young patient was not only transformed esthetically, but was now able to speak normally.
Looking back at the first part of this case in May’s issue of IDT to the final result, the work performed by the dental team is truly phenomenal (Figure 13 and Figure 14). Remember, the first appliance was an orthodontic wire-retained appliance (Figure 15). The attachment challenges in this compro-
mised situation were definitely met by using Rhein83 low-profile Equator attachments (Figure 16).
The collaboration by the dental team changed this patient’s life and lifted his self-esteem to a new level. This is something technicians do every day, and we should never lose sight of the ultimate goal—patient satisfaction.
Special thanks to Alex Skrypko and Burger Geldenhuys, RDT, two outstanding technicians with whom I have the pleasure to work with on a daily basis who greatly contributed to the success of this case. Also, thanks to Dr. Merrill for his help and expertise in making this case and article possible, and also sincere thanks to The Carolina Center for Oral Health.
Dennis Urban, CDT, has worked in dental technology for 35 years and was the recipient of the 2007 NADL Excellence in Education award. He is currently the technical consultant and removable manager for Drake Precision Dental Laboratory in Charlotte, North Carolina.
The preceding material was provided by the manufacturer. The statements and opinions contained therein are solely those of the manufacturer and not of the editors, publisher, or the Editorial Board of Inside Dental Technology.