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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 2  |  Page : 109-112

A case report of modified removable partial denture design for the rehabilitation of partially edentulous arches with multiple exostoses


1 Department of Prosthodontics, Faculty of Dentistry, AIMST Dental Institute, AIMST University, Kedah, Malaysia
2 Department of Dental Graduate Student, Faculty of Dentistry, AIMST Dental Institute, AIMST University, Kedah, Malaysia
3 Department of Oral Medicine and Radiology, Faculty of Dentistry, AIMST Dental Institute, AIMST University, Kedah, Malaysia

Date of Submission09-Apr-2020
Date of Decision29-Sep-2020
Date of Acceptance12-Oct-2020
Date of Web Publication16-Feb-2021

Correspondence Address:
Assoc. Prof. Dr. Ajay Jain
Department of Prosthodontics, Faculty of Dentistry, AIMST Dental Institute, AIMST University, Kedah
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_9_20

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  Abstract 


The presence of palatal and lingual tori complicates the rehabilitation of partially edentulous maxillary and mandibular arches with a removable partial denture, as a major connector in denture crosses the midline and joins the components on one side of the arch with another side. The present case report describes the modified design of major connectors used in maxillary and mandibular removable partial dentures for the management of Kennedy's Class 3 maxillary partially edentulous arch and Kennedy's Class 2 mandibular partially edentulous arches with multiple exostoses.

Keywords: Multiple exostoses, partially edentulous maxillary and mandibular arches, removable partial denture, torus mandibularis, torus palatinus


How to cite this article:
Jain A, Feng SS, Ugrappa S. A case report of modified removable partial denture design for the rehabilitation of partially edentulous arches with multiple exostoses. Int J Oral Health Sci 2020;10:109-12

How to cite this URL:
Jain A, Feng SS, Ugrappa S. A case report of modified removable partial denture design for the rehabilitation of partially edentulous arches with multiple exostoses. Int J Oral Health Sci [serial online] 2020 [cited 2021 Feb 27];10:109-12. Available from: https://www.ijohsjournal.org/text.asp?2020/10/2/109/309455




  Introduction Top


Multiple exostoses in maxillary and mandibular arches are commonly localized overgrowth of the jaw bone[1] and need to be distinguished from other lesions, notably osteomas, which may be diagnostically very significant.[2] These occur along the maxillary or the mandibular regions and are frequently located in the premolar and the molar regions.[3] In the jaws, depending on the anatomic location, they are named as torus palatinus (TP), torus mandibularis (TM), or buccal bone exostoses.[4] TP is a nodular bone mass that occurs along the midline of the hard palate, and TM is a bone protuberance that is located on the lingual aspect of the mandible, normally in the region of the canine and the premolars.[5] According to the shape, TP can be classified as flat, spindle-shaped, nodular, and lobular, whereas TM can be classified as unilateral and bilateral solitary, unilateral and bilateral multiple, and bilateral combined.[6] The size of TP is highly variable, varying from that of a small pea to an enormous enlargement that may cover the entire palate to the extent of the occlusal plane. Reichart et al. have classified TP, based on their size, as small (<3 mm), medium (3–6 mm), and large (more than 6 mm) tori.[7] TM may also show variation in size but is usually small in size. TP and TM present many challenges when fabricating a complete denture or removable partial denture for a patient. The mucosa tends to be thin and will not tolerate the occlusal loading of a denture. Large mandibular tori and palatal tori may prevent complete seating of impression trays and the dentures. The large undercuts may lock the denture into place or preclude any sort of lingual flange in the area. The present case report describes the modified design of major connectors for maxillary and mandibular removable partial dentures in a patient with TP and TM.


  Case Report Top


A 74-year-old male patient reported to the Faculty of Dentistry, AIMST University, Kedah, Malaysia, with the chief complaint of missing maxillary and mandibular teeth and desired them to be replaced [Figure 1]. He was concerned about his oral function like chewing and talking but least bothered about his dental esthetics. The patient underwent multiple extractions of maxillary and mandibular arches 2 years ago; since then, he has been partially edentulous. He was known diabetic and currently under oral hypoglycemics. He was a heavy smoker since young (approximately 40–50 years ago). On intra-oral examination, missing teeth 17, 16, 15, 14, 11, 21, 24, 25, and 26 in maxillary arch and missing teeth 37, 36, 35 and 45 in mandibular arch were noted [Figure 2]. A large TP of lobular type with a dimension of more than 6 mm anterior-posterior and mediolaterally and TM of bilateral solitary type with smaller in dimension was noted [Figure 2]. Various treatment options were given to the patient such as dental implants, fixed partial denture, and removable cast partial denture. Due to financial constraints, the patient opted for removable cast partial denture. All the treatment procedures were explained to the patient, and informed consent was obtained. The diagnostic impression was obtained using irreversible hydrocolloids (Cavex CA37, Holland BV, The Netherlands). The facebow transfer and mounting on semi-adjustable Hanau wide-vue articulator (Whip Mix Corporation, KY, USA) were performed to evaluate the state of occlusion and various mandibular movements. The models were surveyed using a dental surveyor (Dentsply Ney dental surveyor, USA) to evaluate the path of insertion and depth of undercuts in primary abutments. After the surveying procedure was completed, the designing of the models was carried out on the laboratory prescription card [Figure 3]. The modified anteroposterior palatal strap major connector was used for maxillary denture which relieved the palatal tori in the center of the maxilla. The margin of the inner aspect of the strap was kept 2–3 mm away from the periphery of the tori for easy removal and insertion of the denture. The author mentioned this type of modified major connector as oval-shaped anteroposterior palatal strap major connector. RPI (mesial rest, proximal plate, and I-bar) clasp was provided in relation to teeth 13 and 23. The cast circumferential clasp was given on teeth 18 and 27, whereas the occlusal and canine rests lie on teeth 13, 18, 23, and 27. The modified lingual plate major connector was used for the mandibular denture which relieved bilateral lingual tori, and the author has mentioned this type of modified major connector as nasal-shaped lingual plate major connector. RPI clasp was given in relation to tooth 34, cast circumferential clasps on teeth 44 and 46, and the occlusal and cingulum rests lie on teeth 34, 44, and 46. The mouth preparation was performed and a definitive impression was made using putty and light body polyvinyl siloxane impression material (Exaflex® GC America Inc., USA) [Figure 4]. The impressions were poured using Type IV dental stone (UltraRock, Kalabhai Karson Pvt. Ltd., Mumbai, India) to get the master models, and later on, these models were blocked out [Figure 5] to receive the refractory models. The wax pattern was adapted on the refractory models after the hardening heat treatment and casting were completed, finished, and polished [Figure 6]. The metal frameworks were tried in the mouth, border molding was performed and secondary impression was made for both the arches, altered cast was fabricated for mandibular arch, followed by bite registration and try-in of dentures, and final issue was completed [Figure 7]. The follow-up was done after 24 h and 1 week of denture insertion. The patient was asked of any problems encountered such as discomfort, pain, or ulcers caused by the dentures. Occlusion and bite of the patient were checked and adjusted accordingly.
Figure 1: Preoperative photograph (frontal view)

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Figure 2: Maxillary and mandibular occlusal view

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Figure 3: Designing of removable partial dentures on the laboratory prescription card

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Figure 4: Definitive impression after mouth preparation is performed

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Figure 5: Blocked out maxillary and mandibular master casts

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Figure 6: Finished and polished maxillary and mandibular removable partial dentures

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Figure 7: Postoperative photographs

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  Discussion Top


Tori are common and are usually seen with increasing prevalence in aging populations.[8],[9] Palatal and lingual tori, if present, can complicate prosthetic treatment to replace the missing teeth When fixed dental prosthesis and surgical removal of the tori are not the suitable options for the treatment, these tori may complicate the prosthetic treatment to replace the missing teeth using removable partial denture, thus preventing the usual placement of the major connector and resulting in disruption of speech and /or function.[10],[11] Systemic health, financial, and personal issues may eliminate the implant option in patients, who have palatal tori. Because of the financial constraints, patient's systemic status (diabetic) and, his old age, dental implant and fixed partial denture could not be provided in the present case report. The choice of prosthetic replacement is largely determined by the patient's choice and economic status, available technology and expertise, as well as the number of missing teeth.

Patients with single tooth loss can be rehabilitated by tooth-supported bridges, resin-bonded bridges, or implant-supported crowns. For patients with more extensive tooth loss, rehabilitation can be achieved by bridgework supported by the natural teeth or implants or alternatively with a removable partial denture.[11] The present case report describes the management of extensive tooth loss by a removable partial denture.

The partially edentulous arches are difficult to rehabilitate because of the presence of both teeth as well as the edentulous portion of the arch. All Kennedy's partially edentulous arches usually require a major connector extending to the opposite side of the arch to gain retention of the denture and provide cross arch stabilization. The design of conventional major connectors is commonly affected, when a torus is present and poses a challenge to the prosthodontist in modifying the design. The modification in the designing of the major connector should be in a way, so that rigidity of the connector is not compromised. In the present case report, the author modified the major connector design to relieve the palatal and lingual tori and mentioned as the oval-shaped anteroposterior palatal strap and the nasal-shaped lingual plate major connectors, respectively. The advantages of these modified major connector designs are to have relief from the tori as well as provide rigidity. The oval-shaped anteroposterior maxillary major connector would have an advantage over conventional anteroposterior major connector in terms of increased support from the palate and less bending forces during mastication, but hygiene maintenance could be a problem. The nasal-shaped mandibular major connector would have a disadvantage over conventional lingual bar or lingual plate major connectors in terms of superior hygiene maintenance under the tori region but could be of little discomfort while functioning. Kurtzman and Melton in 2004 have rehabilitated maxillary partially edentulous arch with palatal tori using the eclipse denture system.[12] The horseshoe shape major connector could be a good option if the maxillary partially edentulous arch is Kennedy's Class IV, which prevents its flexion under compression. In the case of a mandibular arch, there are two situations when the use of a labial bar should be considered. Mandibular lingual tori are extremely large and interfere with the satisfactory placement of a conventional lingual bar or lingual plate. The lower anterior teeth and/or premolars are lingually inclined to such an extent that satisfactory placement of a lingual bar is not possible.[13] In the present case report, the author describes the modified lingual plate major connector design which is relieved from the bilateral lingual tori and giving a nasal shape appearance. Ezzat et al. in 2013 described the butterfly-shaped design for the mandibular arch with big-sized bilateral TM.[14] The patient's satisfaction after rehabilitation was sustained by improved retention, good stability, agreeable esthetic, and convenient phonetic pattern.


  Conclusion Top


Maxillary and mandibular posteriorly extended edentulous areas are successfully rehabilitated by removable dentures for improved function, esthetics, self-confidence, and life quality. Proper treatment planning is of utmost importance to achieve the exceptional outcome, and modifications in the conventional removable partial denture design should be done meticulously without jeopardizing the quality of the prosthesis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Bansal M, Rastogi S, Sharma A. Multiple mandibular exostoses: A rare case report. J Clin Diagn Res 2013;7:1802-3.  Back to cited text no. 1
    
2.
Chaudhry SI, Tappuni AR, Challacombe SJ. Multiple maxillary and mandibular exostoses associated with multiple dermatofibromas: A case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:319-22.  Back to cited text no. 2
    
3.
Czuszak CA, Tolson GE 4th, Kudryk VL, Hanson BS, Billman MA. Development of an exostosis following a free gingival graft: Case report. J Periodontol 1996;67:250-3.  Back to cited text no. 3
    
4.
Smitha K, Smitha GP. Alveolar exostosis– revisited: A narrative review of the literature. The Saudi J for Dent Res 2015;6:67-72.  Back to cited text no. 4
    
5.
Jainkittivong A, Langlais RP. Buccal and palatal exostoses: prevalence and concurrence with tori. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:48-53.  Back to cited text no. 5
    
6.
Simunković SK, Bozić M, Alajbeg IZ, Dulcić N, Boras VV. Prevalence of torus palatinus and torus mandibularis in the Split-Dalmatian County, Croatia. Coll Antropol 2011;35:637-41.  Back to cited text no. 6
    
7.
Reichart PA, Neuhaus F, Sookasem M. Prevalence of torus palatinus and torus mandibularis in Germans and Thais. Commun Dent Oral Epidemiol 1988;16:61-64.  Back to cited text no. 7
    
8.
Chohayeb AA, Volpe AR. Occurrence of torus palatinus and mandibularis among women of different ethnic groups. Am J Dent 2001;14:278-80.  Back to cited text no. 8
    
9.
Sonnier KE, Horning GM, Cohen ME. Palatal tubercles, palatal tori, and mandibular tori: prevalence and anatomical features in a U.S. population. J Periodontol 1999;70:329-36.  Back to cited text no. 9
    
10.
Sawyer DR, Allison MJ, Elzay RP, Pezzia A. A study of torus palatinus and torus mandibularis in pre-columbian peruvians. Am J Phys Anthropol 1979;50:525-6.  Back to cited text no. 10
    
11.
MacInnis EL, Hardie J, Baig M, al-Sanea RA. Gigantiform torus palatinus: Review of the literature and report of a case. Int Dent J 1998;48:40-3.  Back to cited text no. 11
    
12.
Kurtzman GM, Melton AB. Improving accuracy and simplifying treatment with full arch removable prosthetics: a case report. Dent Today 2004;23:82-7.  Back to cited text no. 12
    
13.
Wood R, Winkler S, Lanza J. The mandibular labial bar major connector. J Oral Implantol 2003;29:284-5.  Back to cited text no. 13
    
14.
Ezzat AK, Tayel SB, Al-Khiary YM. A Suggested butterfly design for mandibular tori in partially edentulous patient: Clinical case report. J Oral Hyg Health 2013;1:116-18.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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