An alternative solution for a complex

prosthodontic problem: A modified

Andrews fixed dental prosthesis
Carly L. Taylor, BDS, MSca and
Julian D. Satterthwaite, BDS, MSc, PhDb
School of Dentistry, University of Manchester, Oxford Rd,
Manchester, UK
This report describes the prosthodontic rehabilitation of an alveolar defect in the posterior mandible after the excision of an
odontogenic myxoma. A minimally invasive technique that involves a modification of the traditional Andrews fixed dental
prosthesis was used to replace both soft and hard tissues. The clinical stages and materials used to provide this treatment are
discussed. (J Prosthet Dent 2014;-:---)

A significant component of restor- clearance and subsequent inadequate and predictable method of tooth
ative dentistry is the replacement of thickness of material.4 Such prostheses replacement.7 Although a variety of
missing teeth. The congenital absence of also can require greater maintenance techniques have previously been re-
a tooth or the extraction of a tooth is because the retentive elements can wear, ported, current practice involves bond-
associated with the progressive reduction which necessitates replacement.4 Finally, ing an airborne-particle abraded base
of the surrounding volume of hard and failure of the luting cement may occur if metal alloy wing to tooth tissue with
soft tissues.1,2 Loss of such tissues is even it is exposed to excessive tensile forces, a bifunctional resin. Such procedures
more pronounced in situations of trauma which results in microleakage and are technique sensitive, and, although
and cleft lip and palate, and after the recurrent caries. This may occur if the their lifespan is shorter than traditional
surgical excision of pathoses. The tradi- path of placements for the fixed and alternatives, the biologic cost is lower.
tional management of such patients re- removable components of the prosthe- Factors that reportedly influence the
quires the use of partial removable dental ses are identical.5 The widespread use of success of such restorations include
prostheses to replace the missing denti- dental implants now offers an alterna- the amount of enamel coverage, loca-
tion and associated structures. This can tive solution for many patients. Such tion, design, number of pontics, and
be associated with problems of patient partial removable dental prostheses can operator experience.7,8 Cantilever de-
adaptability, retention, and stability. be firmly attached to the underlying fix- signs are now advocated because of the
The Andrews fixed dental prosthesis tures with precision attachments and risk of debonding and recurrent caries,
was first introduced in 1976 by James require no preparation of the adjacent which is associated with fixed-fixed de-
Andrews, DMD and has been described teeth.6 For patients with a significant signs. The restoration must also be
as a partial fixed removable dental amount of vertical bone loss, however, designed to allow sufficient rigidity of the
prosthesis that consisted of a bar sol- implant placement may not be possible. connector and retainer and to direct
dered to retainers at each end onto In such patients, traditional techniques forces away from the bond.8 Correct
which a denture is clipped. It has been may be required to reconstruct the oral occlusal management is key to achieving
advocated for use in patients with tissues. the latter. This report describes a modi-
extensive alveolar bone loss, median A conventional Andrews fixed dental fication to the traditional Andrews fixed
diastema, and unfavorable skeletal re- prosthesis uses complete crowns as re- dental prosthesis to replace both soft
lationships that preclude the esthetic tainers. One of the major problems with and hard tissues after resection of an
positioning of pontics.3 Problems with these restorations is their destructive odontogenic myxoma in the posterior
the Andrews fixed dental prosthesis nature, which results in significant mandible.
include soft-tissue proliferation after removal of sound tooth tissue. With the
placement of the bar too close to the increasing predictability of adhesive CLINICAL REPORT
gingival tissues, which impedes oral hy- dentistry, minimally invasive techniques,
giene.4 Fracture of the solder joint can for example, resin-bonded fixed dental A 46-year-old woman was referred
also occur if there is insufficient occlusal prostheses, are becoming a popular to the University Dental Hospital

a
Clinical Lecturer and Honorary Specialty Trainee, Department of Restorative Dentistry.
b
Senior Lecturer and Honorary Consultant, Department of Restorative Dentistry.

Taylor and Satterthwaite

2 Volume - Issue -

of Manchester by her maxillofacial sur-

geon after the excision of an odonto-
genic myxoma in the right quadrant of
the mandible. Odontogenic myxomas
are rare benign tumors that originate
from dental mesenchyme. They can be
locally invasive, which results in signifi-
cant loss of bone and resorption of the
roots of adjacent teeth.9 It has been
estimated that they account for 1% of
all tumors found in the jawbones10 and
can occur in any part of the jaw but
most commonly in the molar and
ramus regions of the mandible.11,12
Because of their invasive nature, le- 1 Panoramic radiograph highlighting
sions may be asymptomatic until they depth of lesion and proximity of inferior
reach a considerable size. dental canal and mental foramen.
The patient’s presenting symptom
was the inability to clear food from the
base of the defect with her tongue. The
patient’s medical history was unre-
markable, with no known allergies and
no medication. Clinical and radio-
graphic examination revealed the loss of
the mandibular right first and second
premolars and first molar, and an asso-
ciated defect that extended almost to the
floor of the mouth (Figs. 1, 2). Results of
radiographic examination showed close
proximity of the base of the defect to the
mental foramen. In spite of this, the
patient did not have paresthesia of 2 Preoperative photograph. Note resolution of gingival
the lip or discomfort from the area. The inflammation after oral hygiene instruction that revealed
mandibular right canine had no resto- subgingival calculus.
rations, and the mandibular right sec-
ond molar had an occlusal amalgam of the inferior dental nerve precluded was considered. To provide adequate
restoration. No apical pathology was the use of distraction techniques for this support, retention, and reciprocation,
present on either tooth, and pulp sensi- patient.15 multiple teeth would need to serve as
tivity tests gave normal responses. The Unilateral edentulous areas are often abutments in conjunction with a lingual
second molar had good periodontal amenable to restoration with a sectional plate connector. Such a prosthesis
support. However, the labial and distal partial removable dental prosthesis. would retain significant plaque, and,
aspects of the canine had clinical Such prostheses have 2 or more com- given the patient’s history of periodontal
attachment loss, with the associated loss ponents with separate paths of place- disease, this was not deemed an ideal
of bony support that extended halfway ment. When connected intraorally, a option.
down the distal aspect of the root. high degree of retention can be achieved A unilateral partial removable den-
Due to the significant vertical loss of from the opposing undercuts. Unfortu- tal prosthesis would have overcome the
bone and proximity of the inferior dental nately, the excision of the lesion had problem of plaque retention but was
nerve, implant placement would not resulted in a defect with divergent walls discounted for several reasons. First,
have been possible without significant (Fig. 2). Adequate undercuts could not patients have swallowed or inhaled
grafting. Techniques such as onlay grafts have been provided by modifying the such prostheses,16,17 and 1 study re-
and distraction osteogenesis have been proximal surfaces of the abutment teeth ported that dental prostheses account
used, but they are not without com- because of the height of the lesion and for 11.5% of all impacted foreign
plications.13-15 Achieving soft-tissue would also have created significant pla- bodies.18 Because such prostheses
closure when grafting large amounts of que retentive factors. A conventional have sharp clasps, complications such as
bone can be challenging, and the vicinity partial removable dental prosthesis also the perforation of the internal mucous
The Journal of Prosthetic Dentistry Taylor and Satterthwaite
- 2014 3
membranes can occur with accompa- registration were made to obtain diag- extended across the central fissure of the
nying edema and possible obstruction nostic casts. A 2-mmespaced mandib- occlusal surface. Because of the lingual
and potentially fatal consequences.16 ular custom tray was made in addition to inclination of this tooth, occlusal con-
Second, given the size of the defect, a wax trial insertion to assess the tooth tacts were only present on the buccal
achieving satisfactory reciprocation and position and shade. The amalgam cusps, with adequate occlusal clearance
retention of the prosthesis with clasps restoration was removed from the on the lingual aspect so as not to require
alone would have been difficult. Signifi- mandibular right second molar under a occlusal reduction. A single-stage high-
cant undercuts would need to be created rubber dam and replaced with compos- viscosity and wash impression in addi-
on the mandibular right canine and ite resin (Filtek Z250; 3M ESPE). Tooth tion polymerized polyvinyl siloxane
second molar with additions of com- preparation confined to enamel was (Dimension Penta VPS impression ma-
posite resin. Such restorations, in carried out on the abutment teeth. For terial; 3M ESPE) and a registration
conjunction with an infrabulge clasp on the mandibular right canine, this (Futar D; Optident) were made. A
the canine could result in both aesthetic included a chamfer finish line, cingulum framework was fabricated in a nickel-
problems and increased plaque reten- rest, and proximal grooves to provide chromium alloy (Wiron 99; Metrodent)
tion. Finally, it would be difficult to resistance to torsional forces and flat- with a Hader bar (Cendres þ Metaux) to
achieve satisfactory support for such a tening of the distal surface to provide prevent the rotation of the prosthesis
large prosthesis, particularly on the an adequate height of metal for the (Figs. 3, 4). The bar was evaluated
molar abutment. Excessive force could connector. intraorally for fit and the ability for
be placed upon supporting elements, The preparation of the mandibular interproximal brushes to fit between the
which results in the bending or fracturing right second molar involved mesial and bar and gingival tissues at the proximal
of components. distal rest seats, a 180-degree wrap surfaces of the abutments. The occlusal
A conventional Andrews fixed dental around, and a chamfer finish line that relationships were recorded with acrylic
prosthesis was contemplated; however,
complete coverage indirect restorations
have been associated with a greater in-
crease in pulpal necrosis.19 It has been
reported that traditional metal ceramic
crown preparations on molar teeth
result in 8 times more tissue removal
than that required for a retainer in a
resin-bonded prosthesis.19 In addition
to this, further axial reduction is often
required adjacent to the edentulous area
to allow sufficient space for soldering the
bar to the retainer.2,5 This could result in
an even greater risk of pulpal necrosis of
the abutment teeth. The preservation of
both abutment teeth was considered 3 Occlusal view of resin retained bar on definitive cast.
important in this patient because loss of
either tooth would have made restora-
tion of the defect significantly more
challenging. It was decided to modify the
Andrews fixed dental prosthesis concept
by using resin-bonded retainers rather
than complete crown retainers. A previ-
ous clinical report described a similar
technique to restore an alveolar defect
that involved a maxillary incisor; how-
ever, no details of survival time were
presented.20
After periapical radiography and vi-
tality testing of the abutment teeth,
initial stabilization treatment was per-
formed. Primary impressions (Xantalgin; 4 Buccal view of bar on definitive cast. Note design to
Heraeus Kulzer Ltd) and a facebow permit adequate space for denture.
Taylor and Satterthwaite
4 Volume - Issue -

resin (Pattern Resin LS; GC) built up

onto the bar with a “brush bead” tech-
nique. The denture was processed with a
metal housing into which a resilient
plastic Hader clip (Cendres þ Metaux)
was inserted to engage the bar (Figs. 5,
6). To avoid tensile forces on the
cement lute, the lingual cusps of the
prosthetic teeth were reduced to ensure
canine guidance on natural teeth. The
framework was polished, and the fitting
surfaces were abraded with alumina. The
framework was cemented under a rubber
dam. A cement that contained 4-META
(Panavia F 2.0; Kuraray Dental) was
used to lute the framework by following
the manufacturer’s instructions. The
denture was evaluated, and occlusal
contacts were adjusted (Figs 7, 8). Oral
hygiene instruction and demonstration 5 Denture component of restoration,
were provided, including interproximal showing metal housing and plastic 6 Denture and bar components
brushes. Upon review, the oral hygiene Hader clip. connected extraorally.
was satisfactory, and the patient no
longer had problems with food accu-
mulating at the base of the defect. After
reviews at 2 and 12 weeks, the patient
was referred to her general dentist for
recall and a maintenance program.

DISCUSSION

This technique, just described, offers

a straightforward treatment option
for restoring defects that resulted in
both hard- and soft-tissue loss. It is a
cost-effective procedure that requires
no specialist equipment and only
minimal clinical time, which makes it
7 Occlusal view of completed restoration.
suitable for use in general dental prac-
tice. The restoration offers a satisfac-
tory esthetic outcome and has the
advantage of replacing both teeth
and their supporting structures while
providing optimal retention, support,
and bracing. From a biologic perspec-
tive, this type of restoration has a low
biologic cost because only minimal
tooth preparation confined to enamel
is required.
The technique does have several po-
tential shortcomings. First, the retention
of the prosthesis relies solely on the bond
between the retainers and the enamel.
Several studies investigated the longevity
and causes of failure of resin-bonded 8 Frontal view with prosthesis in situ.
The Journal of Prosthetic Dentistry Taylor and Satterthwaite
- 2014 5
fixed dental prostheses. Location is prosthesis at night. Unlike a unilateral 11. Noffke CEE, Raubenheimer EJ, Chabikuli NJ,
Bouckaert MMR. Odontogenic myxoma: re-
thought to affect survival rates, with the partial removable dental prosthesis, the
view of the literature and report of 30 cases
lowest survival times being reported in prosthesis does not contain any sharp from South Africa. Oral Surg Oral Med Oral
the posterior mandible.21,22 This has elements, such as clasps, which reduces Pathol Oral Radiol 2007;104:101-9.
been attributed to difficulty in achieving the risk of damage to internal soft issues 12. MacDonald-Jankowski DS, Yeung R, Lee KM,
Li TKL. Odontogenic myxomas in the Hong
adequate moisture isolation during if the prosthesis were to be ingested. Kong Chinese: clinico-radiological presenta-
bonding and the unfavorable forces tion and systematic review. Dentomaxillofac
placed on the restoration during SUMMARY Radiol 2002;31:71-83.
13. Saulacic N, Zix J, Iizuka T. Complication
function compared with maxillary res- rates and associated factors in alveolar
torations.21 The length and design of the The treatment of a mandibular distraction osteogenesis: a comprehensive
prostheses could also affect survival defect was achieved with a modified review. Int J Oral Maxillofac Surg 2009;38:
210-7.
times. Fixed-fixed designs and those that Andrews fixed dental prosthesis, which
14. Barone A, Ugo C. Maxillary alveolar ridge
exceed 4 units also were found to have comprises a resin-bonded Hader bar reconstruction with nonvascularized
higher failure rates in 1 study.7 Given the and partial removable dental pros- autogenous block bone: clinical results.
above information, the risk of debond- thesis. Given the size and location of J Oral Maxillofac Surg 2007;65:2039-46.
15. Perdijk FBT, Meijer GJ, van Strijen PJ,
ing could be increased for this restora- the restoration, the survival time of the Koole R. Complications in alveolar
tion, especially as it is opposed by a restoration should be somewhat lower distraction osteogenesis of the atrophic
natural dentition. Fixed-fixed designs than published figures for resin-bonded mandible. Int J Oral Maxillfac Surg
2007;36:916-21.
also are associated with a high risk of fixed dental prostheses. In spite of this, 16. Gallas M, Blanco M, Martinez-Ares D,
recurrent caries.21 In spite of this, the risk the restoration provides a minimally Rivo E, Garcia-Gontan E, Canizares M.
of recurrent caries might be lower for this invasive medium-term solution. Unnotices swallowing of a unilateral re-
movable partial denture. Gerodontology
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Taylor and Satterthwaite