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Prosthodontic Rehabilitation with Onlay Removable Partial Denture: a Case

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DOI: 10.7454/uiphm.v1i0.38

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UIP HEALTH MED., 2016, 1(1)
doi: http://dx.doi.org/10.7454/uiphm.v1i0.38

Prosthodontic Rehabilitation with Onlay Removable Partial Denture: a Case

Report

Chang Wei Zhi1, Ho Ting Khee2*

1.
Faculty of Dentistry, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia
2.
Department of Prosthodontics, Faculty of Dentistry, Universiti Kebangsaan Malaysia, Jalan Raja Muda
Abdul Aziz, 50300 Kuala Lumpur, Malaysia.

*E-mail: [email protected]

Abstract
Restoring occlusal plane and occlusal vertical dimension (OVD) in patient with existing indirect restorations who must
wear removable prostheses may be a challenge to the dental operator. Onlay removable partial dentures (RPD) are used
to re-establish the occlusion in conjunction to replace missing teeth without having to remove the existing indirect
restoration. This case report described prosthetic rehabilitation with onlay RPD in patients who were partially
edentulous and has reduced OVD. The treatment involved a set of provisional RPD to re-establish the OVD, as well as
to evaluate the function, esthetic and speech of the patient, followed by definitive onlay RPD. The mandibular onlay
RPD was used to provide stable occlusion and to correct the uneven occlusal surface on the abutment teeth. This
treatment able to improve patient’s chewing function through a simple removable prosthesis and conservative on the
existing restorations.
Keywords: dental prostheses, overlay denture, partially edentulous, vertical dimension

Introduction posterior teeth. A physiological tooth wear usually

happened over a long period of time and can be preserved
Overdenture refers to any removable partial denture by dento-alveolar compensatory mechanism via extrusion
(RPD) that covers or rests on one or more remaining of worn teeth and alveolar bone remodeling.5 However,
natural teeth, their roots or dental implant.1 On the other pathological tooth wear will need intervention to prevent
hand, onlay RPD is a subset of overdenture where RPD further loss of hard tissue and to restore the form and
has part of their components such as onlay covering the function of the dentition. Altered OVD can be accessed
occlusal surface of the abutment teeth.2 It can be used to through several clinical examinations such as loss of
restore facial aesthetic, masticatory function and speech posterior teeth, signs of tooth wear, phonetic evaluation,
via conservative modification of existing dentition and interocclusal distance and facial appearance of drooping
particularly applicable to increase vertical dimension of commissures.4 A reduced OVD from tooth wear and loss
occlusion and to improve an uneven occlusal plane. Onlay of posterior support is always a challenge to the dental
RPD is most often used as interim prostheses for patient operator due to limited interocclusal space for
with reduced occlusal vertical dimension (OVD) prior to restorations. Hence, one of the management to such
fixed full mouth rehabilitation or prior to combined problem includes increase in OVD and it should be
treatment of fixed and removable prostheses.3 Besides, it approached with caution as it may result in harmful
can also be used as a definitive prosthesis to re-establish consequences such as hyperactivity of masticatory
vertical dimension and achieve stable occlusion.2, 4 Some muscles, elevation in occlusal forces, bruxism and
clinicians prefer to have fixed restorations in increasing temporomandibular disorder.6
OVD instead of removable prostheses due to predictable
patient’s comfort and adaptation. However, the efficacy, There are several approaches to gain interocclusal space
simplicity, reversibility, conservative and low cost of RPD as well as re-establish the vertical dimension. This
has enhanced its use widely. Nevertheless, there is not includes the records of maxilla-mandibular relationship
much scientific evidence on onlay RPD being prescribed (MMR) in centric relation, where mandible is at its most
to patient with reduced OVD. superior and posterior position of glenoid fossa. By
recording the difference between centric relation and
The loss of OVD is a possible consequence of tooth wear maximal intercuspation, horizontal space obtained inter-
as well as loss of posterior support due to missing incisally can be utilized for tooth restoration.6 Although

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adequate interocclusal clearance may exist in intercuspal on the onlay and crown on tooth 44 and 46 respectively.
position (ICP) or there may be marked deviation between Patient also presented with reduced OVD due to loss of
ICP and retruded contact position (RCP), space can also posterior teeth. In addition, mild attrition exposing dentine
be acquired via placement of restorative material in supra- was also found on the over-erupted mandibular teeth,
occlusion, subtractive tooth preparation and a planned involving tooth 33 to 42. Patient had an unstable
overall increase in patient’s OVD.7 The ideal OVD to be re- occlusion where she tended to protrude the mandible to
established can be obtained by determining the rest vertical achieve maximum intercuspation (Figures 4 – 6). With
dimension (RVD) from MMR in centric relation and rest vertical dimension (RVD) when the mandible was at
subtracting the physiological freeway space of 2 to 4mm rest and OVD being measured at 65mm and 60mm
from it. Several studies also showed that fixed and removable respectively, there was an increase of freeway space of
prostheses are reliable to re-establish vertical dimension, to 5mm.
provide space for restorative materials, enhance aesthetic
tooth display, and minimize the need for biologically
invasive clinical surgery and elective endodontic
treatments.8, 9

This case report described prosthetic rehabilitation with

onlay RPD in patient who was partially edentulous with
multiple indirect fixed restorations, occlusal wear of lower
teeth and has reduced OVD. The treatment involved a
maxillary provisional RPD to reestablish the OVD, as
well as to evaluate the function, esthetic and speech of the
patient. This is then followed by definitive maxillary Co-
Cr and mandibular onlay RPD. Besides re-establishing the
vertical dimension in conjunction to replacing missing a b
teeth without the need to remove existing indirect
restorations, the mandibular onlay RPD was used to . .
provide stable occlusion and to correct the uneven
occlusal surface on the abutment teeth. This treatment
able to improve patient’s chewing function through a Figure 1. (a) Frontal view of patient with overclosure of
simple removable prosthesis and conservative to the mouth. (b) Right profile view showing drooping
existing restorations. lips commissures and protruded chin.

Case Report
A 53-year-old Chinese female presented to the dental
clinic in Faculty of Dentistry at National University of
Malaysia (UKM) with chief complaint of unretentive
upper denture and loss of multiple teeth which affect
chewing function and esthetic appearance. She had two
maxillary dentures before but fractured upon mastication
and during cleaning respectively. Dental history also
suggested multiple fixed restorations done by previous
dentist. Medical history revealed mild iron-deficiency Figure 2. Preoperative occlusal view of maxillary arch
anemia. She took iron tablets as supplement and vitamin demonstrating Kennedy Class II Modification I.
C to increase iron absorption in body as prescribed by her Presence of tooth 15 and 28.
medical practitioner.

Upon extra-oral clinical examination, patient exhibited no

signs or symptoms of temporomandibular disorder but
with dropping commissures around the mouth (Figure 1).
Intra-orally, patient presented with Kennedy Class II
modification I for upper arch (Figure 2) and Kennedy
Class II for lower arch (Figure 3), had a fair oral hygiene
with no deep periodontal pocket indicating absence of
active periodontal disease. Multiple restorations were
noted, with fixed prostheses on tooth 35, being restored
with porcelain-fused-to-metal crown, tooth 44 restored Figure 3. Preoperative occlusal view of mandibular arch
with metal onlay and tooth 46 restored with full-metal demonstrating Kennedy Class II with presence
crown. At RCP, the upper premolar was having light of tooth 35 to 46. Tooth 35 was restored with
contact with the lower right premolar, and the mandible porcelain-fused-to-metal crown, 44 with metal
was translated anteriorly and vertically into maximum onlay and 46 with full metal crown. Mild
intercuspation. At ICP, the upper premolar was occluding

113
 attrition was shown from tooth 33 to 42, with Fabrication of provisional maxillary acrylic denture was
slight overeruption of lower teeth. done to re-establish the OVD and has been wore for 6
weeks to determine patient’s adaptation and
comfortability to the new OVD (Figures 7 – 9).The
impressions were made with addition silicone polyvinyl
siloxane (Aquasil Ultra, Dentsply International, York, PA,
USA) to fabricate definitive casts for provisional denture.
The new OVD was determined using upper baseplate with
wax rim during the maxilla-mandibular (MMR) jaw
registration stage and jaw record at centric relation. The
orientation of upper occlusal plane was determined
according to the ala-tragus line and interpupillary line.
The anterior incisal level was determined based on
patient’s preference of 1mm below upper lip line. The
freeway space was reduced to 3mm by re-established the
OVD to 62mm with RVD remained.
Figure 4. Preoperative frontal view of ICP. There is
presence of limited vertical space between the Wax setup of denture acrylic teeth was tried in to evaluate
upper alveolar ridge and lower teeth for the OVD, occlusion, phonetic and appearance. The
removable prostheses. provisional maxillary denture was then processed and
delivered. Denture hygiene care was given to patient and
she was instructed to wear all day except night time to
enhance adaptation to the increase vertical dimension. The
patient was follow-up at one-, four- and six-week
postoperative visits and minor adjustment to the denture
was made to suit patient’s comfortability. Upon
examination, patient reported no muscle or temporo-
mandibular joint tenderness, clicking nor deviation. In
addition to satisfaction with the facial appearance, she was
also comfortable and functioned well with the maxillary
denture. However, the occlusal stability was not achieved
as the abutment tooth 15 was not occluding to the
mandibular fixed prostheses (Figure 8). This was one of
the reasons why onlay RPD was planned for mandibular
Figure 5. Right view of ICP. Tooth 15 is the only tooth arch to achieve stable occlusion.
occludes to the lower teeth.

Figure 6. Left view of ICP. Tooth 28 is not in occlusion

with the lower teeth.
Figure 7. Frontal view of interim upper acrylic denture in
centric occlusion
The treatment plan was to restore the vertical height,
facial appearance, mastication and phonetics. Treatment
options were presented to the patient in the following
order: (1) Re-construction of fixed crowns for mandibular
posterior teeth at centric occlusion by aiming to restore
the OVD and occlussal plane followed by maxillary RPD,
(2) maxillary RPD at appropriate OVD and mandibular
onlay RPD. Patient was fully informed of all risks,
benefits and alternatives, and decided on treatment option
#2 as it was less destructive, less time consumed and less
expensive.

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 Figure 10. Postoperative occlusal view of maxillary arch
restored with Cobalt-chrome (Co-Cr) denture.

Figure 8. Right view of interim upper acrylic denture.

Note that tooth 15 is not in occlusion with the
lower 44 and 46.

Figure 11. Postoperative occlusal view of mandibular arch

restored with Co-Cr onlay removable partial
denture (RPD). The onlay was seating partially
on full metal crown of 46 and metal onlay of 44.

Figure 9. Left view of interim upper acrylic denture.

After six weeks of using provisional dentures without sign

and symptom, definitive prostheses were made of Cobalt-
chrome (Co-Cr) at the same OVD and occlusion as of
provisional denture. The maxillary Co-Cr denture (Figure Figure 12. Postoperative ICP of upper Co-Cr denture re-
10) and mandibular onlay Co-Cr denture (Figure 11) at establishing the occlusal vertical dimension and
established OVD had achieved an even and stable lower onlay RPD achieving stable occlusion and
occlusion (Figures 12 - 14). The onlay was seated on fixed even lower occlusal plane.
prostheses of tooth 44 and 46 when onlay RPD was
loaded in patient’s mouth, and was in occlusion with
upper tooth 15 (Figure 13). In this way, occlusal stability
was attained in re-established OVD and patient can have
better adaptation and comfort during functioning. The
patient was followed up at one week, one month, and
finally six months. She reported comfortable with the
prostheses, able to perform mastication and speech
effectively. Besides, she was satisfied with the facial
appearance (Figures 15 and 16).

Figure 13. Right view of ICP, showing onlay RPD seating

on occlusal surface of 44 and 46 to achieve an
even lower occlusal plane. Besides, it is in contact
with tooth 15 to achieve stable occlusion.

115
 Discussion
Long term loss of posterior maxillary and mandibular
teeth will result in unstable posterior support, uneven
occlusal plane and tooth wear of mandibular teeth (tooth
33 to 42).This is due to deranged occlusion causing high
occlusal load to the anterior teeth which lead to tooth
attrition and aggravated by erosion, subsequently OVD
will be reduced. In this case, 2mm of OVD has been
added to the maxillary Co-Cr denture to re-establish the
vertical dimension. A provisional period of 6 weeks with
acrylic denture was given where patient reported no
muscle or TMJ pain and feeling comfortable. According
Figure 14. . Left view of ICP, with lower onlay RPD to a systematic review investigating the implications of
restoring the missing teeth and achieve stable increasing OVD, a permanent increase in vertical
occlusion. dimension from 1 to 5 mm is a safe and reliable procedure
and the associated signs and symptoms are self-limiting
with a tendency to resolve within 2 weeks.10 With such
increase, there is sufficient interocclusal space for the
placement of denture’s acrylic teeth.

In addition, mandibular onlay RPD has been used as

definitive prosthesis to achieve even occlusal plane and
stable occlusion in a re-establised vertical height.11 The
a occlusal contacts allowed masticatory forces to be
. distributed in a simultaneous and homogenous way along
the long axis of abutment. There was also a coordinated
mandibular movement. In consideration of restorative
procedures for the elderly patient that should be
conservative, maintaining tooth structures as well as
ensuring comfort and function,12 the onlay RPD was the
best choice of treatment. Furthermore, the onlay RPD has
been suggested to be simple, efficient, cost effective with
the final outcome well pleasing to the patient. Patient was
able to gradually accustomised to the newly adjusted
vertical height with the use of onlay RPD and sufficient
b time was provided for remodeling of temporo-mandibular
joint and occlusion. Besides aesthetic concerns, patient’s
Figure 15. Postoperative frontal view of patient. (a) The re- clinical features of multiple teeth absence and posterior
established vertical dimension of occlusion has edentulous spaces were indeed a classical indication for
eliminate the drooping of commissures. (b) A onlay RPD.
confident smile and aesthetic have been achieved.
The use of onlay RPD has eliminated the need of
complicated treatment such as removing fixed prostheses,
re-do fixed prostheses, surgical crown lengthening,
orthodontically tilting of tooth, etc. The fixed restorations
in this patient were also in satisfactory condition where
their removal was not indicated. This has eventually
reduced the risk of destructive fixed prostheses removal
which includes pulpal exposure, tooth crack, tooth
fracture and unnecessary tooth removal. In fact, a proper
and thorough clinical examination and evaluation prior to
any fixed restorations are crucial as they are irreversible.
A good treatment plan should include assessment of
patient’s occlusion as a whole. If the fixed restorations
(crowns and onlay) were at ideal vertical occlusal height,
Figure 16. Postoperative right profile view of patient
showing better nasolabial support, absence of
the fabrication of onlay RPD can be avoided and
commissural drooping and better overall facial subsequently reduce the overall treatment cost.
aesthetic.
Nevertheless, potential risks for framework component
fracture, caries and periodontal disease if removable
dentures are not well-maintained should be discussed with

116
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