Distal extension mandibular removable partial denture connected to an anterior fixed implant-supported prosthesis: A clinical report
Identifieur interne : 000D09 ( Istex/Corpus ); précédent : 000D08; suivant : 000D10Distal extension mandibular removable partial denture connected to an anterior fixed implant-supported prosthesis: A clinical report
Auteurs : Mario Pellecchia ; Roberto Pellecchia ; Shahram EmtiazSource :
- The Journal of Prosthetic Dentistry [ 0022-3913 ] ; 2000.
English descriptors
- KwdEn :
- Abutment, Access holes, Alveolar ridge, Analog, Centric relation record, Clinical report, Conical, Conical laboratory analogs, Dalbo, Dalbo attachment, Dalbo attachments, Definitive cast, Dentistry, Denture, Emtiaz, Healing abutments, Implant, Infrastructure, Initial loading, Mandibular, Normal bone levels, Occlusal, Overdenture, Partial denture, Pellecchia, Periapical radiographs, Prosthesis, Prosthet dent, Prosthetic, Prosthetic dentistry, Prosthetic solution, Protective caps, Putty, Putty index, Removable, Removable prosthesis, Superstructure, Transmucosal abutments.
- Teeft :
- Abutment, Access holes, Alveolar ridge, Analog, Centric relation record, Clinical report, Conical, Conical laboratory analogs, Dalbo, Dalbo attachment, Dalbo attachments, Definitive cast, Dentistry, Denture, Emtiaz, Healing abutments, Implant, Infrastructure, Initial loading, Mandibular, Normal bone levels, Occlusal, Overdenture, Partial denture, Pellecchia, Periapical radiographs, Prosthesis, Prosthet dent, Prosthetic, Prosthetic dentistry, Prosthetic solution, Protective caps, Putty, Putty index, Removable, Removable prosthesis, Superstructure, Transmucosal abutments.
Url:
DOI: 10.1016/S0022-3913(00)70057-6
Links to Exploration step
ISTEX:1A8D3181698507DF15E9612FA5BB7D287BDAB2F7Le document en format XML
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report</title></titleStmt><publicationStmt><authority>ISTEX</authority><publisher>ELSEVIER</publisher><availability><p>©2000 Editorial Council of The Journal of Prosthetic Dentistry.</p></availability><date>2000</date></publicationStmt><notesStmt><note>J Prosthet Dent 2000;83:607-12.</note><note>Reprint requests to: Dr Shahram Emtiaz, 160 E 48th St, # 12-L, New York, NY 10017-1225, Fax: (212) 752-5929, E-mail: demtiaz@aol.com</note><note type="content">Section title: Original Articles</note></notesStmt><sourceDesc><biblStruct type="inbook"><analytic><title level="a" type="main" xml:lang="en">Distal extension mandibular removable partial denture connected to an anterior fixed implant-supported prosthesis: A clinical report</title><author xml:id="author-0000"><persName><forename type="first">Mario</forename><surname>Pellecchia</surname></persName><roleName type="degree">DDS</roleName><affiliation>College of Dentistry, New York University, New York, N.Y</affiliation><affiliation>Implant Fellow, Arthur Ashman Department of Implant Dentistry, New York University College of Dentistry</affiliation></author><author xml:id="author-0001"><persName><forename type="first">Roberto</forename><surname>Pellecchia</surname></persName><roleName type="degree">DDS</roleName><affiliation>College of Dentistry, New York University, New York, N.Y</affiliation><affiliation>Private Practice, Rome, Italy</affiliation></author><author xml:id="author-0002"><persName><forename type="first">Shahram</forename><surname>Emtiaz</surname></persName><roleName type="degree">DDS</roleName><affiliation>College of Dentistry, New York University, New York, N.Y</affiliation><affiliation>Clinical Associate Professor and Director of the International Implant Program, Arthur Ashman Department of Implant Dentistry</affiliation></author><idno type="istex">1A8D3181698507DF15E9612FA5BB7D287BDAB2F7</idno><idno type="DOI">10.1016/S0022-3913(00)70057-6</idno><idno 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id="mmc1"><ce:caption><ce:simple-para>portuguese PDF</ce:simple-para></ce:caption><ce:link locator="mmc1"></ce:link><ce:alt-e-component><ce:caption><ce:simple-para>portuguese PDF</ce:simple-para></ce:caption></ce:alt-e-component></ce:e-component></ce:floats><head><ce:article-footnote><ce:label>☆</ce:label><ce:note-para>J Prosthet Dent 2000;83:607-12.</ce:note-para></ce:article-footnote><ce:article-footnote><ce:label>☆☆</ce:label><ce:note-para>Reprint requests to: Dr Shahram Emtiaz, 160 E 48th St, # 12-L, New York, NY 10017-1225, Fax: (212) 752-5929, E-mail: demtiaz@aol.com</ce:note-para></ce:article-footnote><ce:dochead><ce:textfn>Original Articles</ce:textfn></ce:dochead><ce:title>Distal extension mandibular removable partial denture connected to an anterior fixed implant-supported prosthesis: A clinical report</ce:title><ce:author-group><ce:author><ce:given-name>Mario</ce:given-name><ce:surname>Pellecchia</ce:surname><ce:degrees>DDS</ce:degrees><ce:cross-ref refid="aff1"><ce:sup>∗</ce:sup></ce:cross-ref><ce:cross-ref refid="aff2"><ce:sup>a</ce:sup></ce:cross-ref></ce:author><ce:author><ce:given-name>Roberto</ce:given-name><ce:surname>Pellecchia</ce:surname><ce:degrees>DDS</ce:degrees><ce:cross-ref refid="aff1"><ce:sup>∗</ce:sup></ce:cross-ref><ce:cross-ref refid="aff3"><ce:sup>b</ce:sup></ce:cross-ref></ce:author><ce:author><ce:given-name>Shahram</ce:given-name><ce:surname>Emtiaz</ce:surname><ce:degrees>DDS</ce:degrees><ce:cross-ref refid="aff1"><ce:sup>∗</ce:sup></ce:cross-ref><ce:cross-ref refid="aff4"><ce:sup>c</ce:sup></ce:cross-ref></ce:author><ce:affiliation id="aff1"><ce:label>∗</ce:label><ce:textfn>College of Dentistry, New York University, New York, N.Y</ce:textfn></ce:affiliation><ce:affiliation id="aff2"><ce:label>a</ce:label><ce:textfn>Implant Fellow, Arthur Ashman Department of Implant Dentistry, New York University College of Dentistry</ce:textfn></ce:affiliation><ce:affiliation id="aff3"><ce:label>b</ce:label><ce:textfn>Private Practice, Rome, Italy</ce:textfn></ce:affiliation><ce:affiliation id="aff4"><ce:label>c</ce:label><ce:textfn>Clinical Associate Professor and Director of the International Implant Program, Arthur Ashman Department of Implant Dentistry</ce:textfn></ce:affiliation></ce:author-group></head><body><ce:sections><ce:para>A continuing complaint of edentulous patients is related to the difficulty of adapting to a removable prosthesis. This is usually because of the reduced stability when compared with natural teeth or a fixed partial denture.<ce:cross-ref refid="bib1"><ce:sup>1</ce:sup></ce:cross-ref> There is also an emotional component for some patients who do not like that their teeth are removable. If the patient is recalled on a routine basis, the stability can be improved by rebasing the ridge-bearing area of the removable prosthesis when needed. This still does not create a high level of comfort and function for many patients.<ce:cross-ref refid="bib1"><ce:sup>1</ce:sup></ce:cross-ref> Alternative treatments for fully edentulous patients include an implant-supported overdenture or a fixed implant-supported prosthesis with bilateral distal cantilevers.<ce:cross-refs refid="bib2 bib3"><ce:sup>2,3</ce:sup></ce:cross-refs> In the mandible, a fixed implant-supported prosthesis with posterior cantilevers offers the advantage of being fixed versus having an overdenture prosthesis. The disadvantages of a fixed implant-supported prosthesis with distal cantilevers could be functional and biomechanical.<ce:cross-refs refid="bib4 bib5 bib6 bib7"><ce:sup>4-7</ce:sup></ce:cross-refs> The design of the framework and the rigid connection between the framework and implants determines a transfer of bending moments to the bone-implant interface and development of shearing forces that can damage the osseointegration process. From a functional point of view, the implant-supported fixed prosthesis with distal cantilevers does not significantly improve masticatory effectiveness compared with an implant-supported tissue-borne overdenture that uses the alveolar ridge as additional support to resist occlusal load.<ce:cross-ref refid="bib8"><ce:sup>8</ce:sup></ce:cross-ref></ce:para><ce:para>Overdentures create a proper craniomandibular stability because of the posterior extension of the occlusal relationship, but it can be responsible for resorption of the alveolar ridge caused by the compression in function.<ce:cross-ref refid="bib9"><ce:sup>9</ce:sup></ce:cross-ref> Nerve repositioning and/or guided bone regeneration (GBR) to rebuild the ridge height can be considered to allow implant placement in the atrophic mandible. These procedures are not always acceptable treatment options for the patient or are they always predictable.</ce:para><ce:para>An alternative reconstructive option that does not involve grafting and multiple surgical procedures for the patient is a bilateral removable partial denture anchored to a fixed prosthesis, supported by implants placed in the interforaminal region, with stress directors near the connection with the fixed prosthesis. This prosthetic option, in addition to the esthetic and functional advantage of an overdenture, gives a decreased compression of the edentulous ridge in function and the immovability of the anterior segment. This clinical report describes the treatment of a patient with this prosthetic solution.</ce:para><ce:section><ce:section-title>Clinical report</ce:section-title><ce:para>A 65-year-old white man was evaluated for treatment; his chief complaint was that his mandibular denture was not stable. A lack of retention and stability of the denture was confirmed during intraoral examination. The patient’s medical history was evaluated and was found to be noncontributory.</ce:para><ce:para>Several treatment options were offered to the patient: a new complete mandibular denture, an implant-supported overdenture, a fixed implant-supported prosthesis after GBR to rebuild the ridge height in the posterior mandible, or a combination of a fixed implant-supported anterior prosthesis with a distal extension mandibular removable partial denture (RPD). After reviewing the options, the patient accepted the latter treatment option. A surgical template was fabricated by duplicating the patient’s mandibular complete denture. After exposure of the alveolar ridge at stage 1 surgery, 3 implants (3.75 × 13 mm, 3I Implant Innovations Inc, Palm Beach Gardens, Fla.) were placed in the mandibular ridge between the mental foramen. One week after stage 1 surgery, the patient’s mandibular complete denture was relined with resilient material (Visco-Gel, De-Trey, Konstanz, Germany) to reduce patient discomfort and to condition the soft tissues. The implant site was relieved to avoid transmucosal loading and to assist the osseointegration process. This relining procedure was repeated once a month during the 4 months of healing.</ce:para></ce:section><ce:section><ce:section-title>Procedure</ce:section-title><ce:para>After 4 months healing, the following procedure was followed.
<ce:list><ce:list-item><ce:label>1.</ce:label><ce:para>At the second stage surgery, expose the implants and insert healing abutments (Fig. 1, <ce:italic>A</ce:italic> ). (Radiographs were made to serve as a baseline reference [Fig. 1, <ce:italic>B</ce:italic> ].)</ce:para></ce:list-item><ce:list-item><ce:label>2.</ce:label><ce:para>After additional healing time, remove the healing abutments and replace them with transmucosal abutments (conical abutments) (3I, Implant Innovations Inc) with protective caps over the transmucosal abutments.</ce:para></ce:list-item><ce:list-item><ce:label>3.</ce:label><ce:para>Reline the patient’s denture with the protective caps in place.</ce:para></ce:list-item><ce:list-item><ce:label>4.</ce:label><ce:para>Remove the protective caps and place conical impression copings on the mandibular transmucosal abutments, make definitive mandibular impression (Fig. 2), attach the conical laboratory analogs, and make a definitive mandibular cast in improved dental stone (Fig. 3). Make a maxillary impression for an opposing cast and pour it in improved dental stone.</ce:para></ce:list-item><ce:list-item><ce:label>5.</ce:label><ce:para>Replace the protective caps over the transmucosal abutments in the mouth and dismiss the patient.</ce:para></ce:list-item><ce:list-item><ce:label>6.</ce:label><ce:para>Make an occlusion rim on the cast over the conical laboratory analogs.</ce:para></ce:list-item><ce:list-item><ce:label>7.</ce:label><ce:para>Make a centric relation record and lateral and protrusive records.</ce:para></ce:list-item><ce:list-item><ce:label>8.</ce:label><ce:para>Mount the maxillary definitive opposing cast in a semiadjustable articulator using a face-bow record.</ce:para></ce:list-item><ce:list-item><ce:label>9.</ce:label><ce:para>Mount the mandibular definitive cast in the same articulator using the centric relation record (Fig. 4).</ce:para></ce:list-item><ce:list-item><ce:label>10.</ce:label><ce:para>Use putty impression material on the cast, to make an index around the conical laboratory analogs (implant abutments) (Fig. 5).</ce:para></ce:list-item><ce:list-item><ce:label>11.</ce:label><ce:para>Trim some of the stone from around the implant abutments, make a mix of resilient material (GI-MASK, Coltene/Whaledent Inc, Mahwah, N.J.), apply it to the cast and inside the putty index, then seat the index on the cast.</ce:para></ce:list-item><ce:list-item><ce:label>12.</ce:label><ce:para>When the resilient material sets, remove the putty index to reveal the resilient replacement of the soft tissue around the implants.</ce:para></ce:list-item><ce:list-item><ce:label>13.</ce:label><ce:para>Place gold cylinders on the conical laboratory analogs on the cast (Fig. 6).</ce:para></ce:list-item><ce:list-item><ce:label>14.</ce:label><ce:para>Wax-up the mandibular anterior segment of teeth and soft tissue on the cast, paying particular attention to make access for hygiene and cleansability for the patient (Fig. 7). (These segments will act as a guide for the dental technician and they may be tried in the patient mouth and adjusted as necessary.)</ce:para></ce:list-item><ce:list-item><ce:label>15.</ce:label><ce:para>Use some putty impression material again to make a labial index of the waxed unit on the cast (This index is used to guide the dental technician when he is waxing the infrastructure [Fig. 8] so the technician can leave enough clearance for the prosthetic superstructure. An infrastructure [Figs. 9 and 10] is a cast metal framework that fits onto the top of the implant or the transmucosal abutments and is usually retained with screws. A second metal framework is waxed and cut to fit onto this infrastructure and is called a superstructure. The superstructure may be retained by screws or may be cemented to the infrastructure. When screws are to be used, and the access holes of the implant are too far to the facial or lingual aspect, causing an angulation problem, the holes can be redirected in either the infrastructure or superstructure, or both.)</ce:para></ce:list-item><ce:list-item><ce:label>16.</ce:label><ce:para>Remove the putty index and the anterior tooth section. Wax the infrastructure (Fig. 8) using the front part of the index as a guide. (It is helpful to mill the wax infrastructure before it is cast in metal. The milling of the infrastructure provides an accurate fit of the superstructure, which will be waxed and cast later.)</ce:para></ce:list-item><ce:list-item><ce:label>17.</ce:label><ce:para>Align and attach, with wax, a castable key Dalbo attachment (Cendres Mataux, Biel-Bienne, Switzerland) to each extremity of the infrastructure (Fig. 8).</ce:para></ce:list-item><ce:list-item><ce:label>18.</ce:label><ce:para>Sprue, invest, cast, fit, and polish the infrastructure and attach it to the conical laboratory analogs with the 3 screws (Fig. 9). Mill in 2 screw access holes on the occlusal surface of the infrastructure (Fig. 9) to be used to screw in the superstructure. Wax the superstructure over the infrastructure using the putty index and subsequently invest, cast, fit, and polish the superstructure.</ce:para></ce:list-item><ce:list-item><ce:label>19.</ce:label><ce:para>Use the index and waxed anterior segment as a guide to stack porcelain on the superstructure and develop the desired anatomy. When the porcelain is stacked as desired, bisque bake the porcelain directly on the superstructure.</ce:para></ce:list-item><ce:list-item><ce:label>20.</ce:label><ce:para>Try the porcelain superstructure in the patient’s mouth and make necessary adjustments (Fig. 10). Make the final glaze bake. Examine it again in the mouth and when it is satisfactory, remove it from the mouth and fasten it to the cast (Fig. 11).</ce:para></ce:list-item><ce:list-item><ce:label>21.</ce:label><ce:para>With the porcelain superstructure secured to the cast, place the keyway portions of the Dalbo attachments on the key portions, and duplicate the cast to make a refractory cast.</ce:para></ce:list-item><ce:list-item><ce:label>22.</ce:label><ce:para>Wax the RPD framework on the refractory cast, then sprue, invest, cast, and polish it.</ce:para></ce:list-item><ce:list-item><ce:label>23.</ce:label><ce:para>With the keyway portions of the Dalbo attachments in place on the definitive cast over the key portions of the attachments, seat the RPD framework on the cast and secure the keyway attachments to the RPD framework with resin (Duralay, Resiliance Dental Mfg Co, Worth, Ill.) (Fig. 12) .</ce:para></ce:list-item><ce:list-item><ce:label>24.</ce:label><ce:para>Reseat the mandibular cast assembly in the articulator and set the posterior teeth on the RPD framework.</ce:para></ce:list-item><ce:list-item><ce:label>25.</ce:label><ce:para>Assemble the parts of the restoration in the patient’s mouth and examine it for stability and balanced occlusion with the maxillary denture (Fig. 13). (The occlusion of the restoration should have slightly lighter contact on the implant-supported portion when compared to the occlusal contacts of the teeth on the RPD.)</ce:para></ce:list-item><ce:list-item><ce:label>26.</ce:label><ce:para>Remove the assembly from the mouth, reseat it on the cast, and complete the wax-up for processing.</ce:para></ce:list-item><ce:list-item><ce:label>27.</ce:label><ce:para>Invest, boil out, pack, process, recover, and finish the RPD.</ce:para></ce:list-item><ce:list-item><ce:label>28.</ce:label><ce:para>Fit the RPD in the mouth and carefully adjust the occlusion. Schedule follow-up visits with the patient.</ce:para></ce:list-item></ce:list><ce:display><ce:figure><ce:label>Fig. 1</ce:label><ce:caption><ce:simple-para><ce:bold>A,</ce:bold> Implants are exposed and healing abutments in place in mouth. <ce:bold>B,</ce:bold> Periapical radiographs made immediately after healing abutments were placed.</ce:simple-para></ce:caption> <ce:link locator="gr1"></ce:link></ce:figure></ce:display><ce:display><ce:figure><ce:label>Fig. 2</ce:label><ce:caption><ce:simple-para>Definitive impression made 6 weeks after second-stage surgery showing pickup-type conical impression copings in mandibular impression.</ce:simple-para></ce:caption> <ce:link locator="gr2"></ce:link></ce:figure></ce:display><ce:display><ce:figure><ce:label>Fig. 3</ce:label><ce:caption><ce:simple-para>Definitive cast with conical laboratory analogs.</ce:simple-para></ce:caption> <ce:link locator="gr3"></ce:link></ce:figure></ce:display><ce:display><ce:figure><ce:label>Fig. 4</ce:label><ce:caption><ce:simple-para>Maxillary and mandibular definitive casts mounted on semiadjustable articulator with aid of face-bow transfer and centric relation record.</ce:simple-para></ce:caption> <ce:link locator="gr4"></ce:link></ce:figure></ce:display><ce:display><ce:figure><ce:label>Fig. 5</ce:label><ce:caption><ce:simple-para>Impression putty index made over conical laboratory analogs on definitive mandibular cast.</ce:simple-para></ce:caption> <ce:link locator="gr5"></ce:link></ce:figure></ce:display><ce:display><ce:figure><ce:label>Fig. 6</ce:label><ce:caption><ce:simple-para>Gold cylinders screwed onto conical laboratory analogs in definitive cast.</ce:simple-para></ce:caption> <ce:link locator="gr6"></ce:link></ce:figure></ce:display><ce:display><ce:figure><ce:label>Fig. 7</ce:label><ce:caption><ce:simple-para>Frontal view of wax-up of mandibular teeth and gingiva.</ce:simple-para></ce:caption> <ce:link locator="gr7"></ce:link></ce:figure></ce:display><ce:display><ce:figure><ce:label>Fig. 8</ce:label><ce:caption><ce:simple-para>Infrastructure waxed in relation to facial index. (1) Screws in place in gold copings included in wax-up of infrastructure, (2) threaded inserts included in wax-up for attachment of substructure, (3) castable key Dalbo attachment forms aligned, and waxed in place on infrastructure. Dalbo attachments are parallel to each other and are in alignment along crest of ridge.</ce:simple-para></ce:caption> <ce:link locator="gr8"></ce:link></ce:figure></ce:display><ce:display><ce:figure><ce:label>Fig. 9</ce:label><ce:caption><ce:simple-para>Completed infrastructure fastened with 3 screws to implant analogs in definitive cast. (1) Screws holding infrastructure to analogs in cast, (2) threaded receptacles ready to receive screws to attach superstructure to infrastructure, (3) key portion of Dalbo attachment milled to assure they are parallel to each other.</ce:simple-para></ce:caption> <ce:link locator="gr9"></ce:link></ce:figure></ce:display><ce:display><ce:figure><ce:label>Fig. 10</ce:label><ce:caption><ce:simple-para>Exploded view of prosthesis without RPD; (<ce:italic>A</ce:italic> ) Infrastructure, (<ce:italic>B</ce:italic> ) substructure. (1) Screws to attach infrastructure to implant, (2) access holes for infrastructure screws, (3) threaded holes to receive substructure screws, (4) key portion of Dalbo attachments cast as part of infrastructure, (5) access holes in metal part of superstructure to permit fastening it to infrastructure, (6) screws to attach superstructure to infrastructure.</ce:simple-para></ce:caption> <ce:link locator="gr10"></ce:link></ce:figure></ce:display><ce:display><ce:figure><ce:label>Fig. 11</ce:label><ce:caption><ce:simple-para>Anterior view of completed metal-ceramic superstructure on definitive cast.</ce:simple-para></ce:caption> <ce:link locator="gr11"></ce:link></ce:figure></ce:display><ce:display><ce:figure><ce:label>Fig. 12</ce:label><ce:caption><ce:simple-para>Completed RPD framework with plain lingual bar assembled with superstructure and infrastructure attached to implant analogs in definitive cast. (1) Access holes in superstructure with screws holding it to infrastructure, (2) prefabricated keyway Dalbo attachment placed over key attachment, (3) plain lingual bar of RPD framework. (4) Tang of keyway Dalbo attachment fastened to RPD framework with Duralay resin.</ce:simple-para></ce:caption> <ce:link locator="gr12"></ce:link></ce:figure></ce:display><ce:display><ce:figure><ce:label>Fig. 13</ce:label><ce:caption><ce:simple-para>Completed restoration in patient’s mouth.</ce:simple-para></ce:caption> <ce:link locator="gr13"></ce:link></ce:figure></ce:display></ce:para><ce:para>At the follow-up visits, the patient acknowledged a remarkable improvement of his masticatory function and a general feeling of comfort. The patient returned for follow-up visits every 6 months during a 3-year period. During that time, the maxillary denture and the mandibular RPD did not require relining, and the functional capability of the patient did not show any changes. Three years after initial loading, the radiographic examination (standardized periapicals) showed normal bone levels around the implants (Fig. 14).
<ce:display><ce:figure><ce:label>Fig. 14</ce:label><ce:caption><ce:simple-para>Periapical radiographs of implants at 3 years of continuous loading.</ce:simple-para></ce:caption> <ce:link locator="gr14"></ce:link></ce:figure></ce:display></ce:para></ce:section><ce:section><ce:section-title>Discussion</ce:section-title><ce:para>The treatment option for a fixed implant-supported prosthesis and RPD with resilient attachments has been achieved as an alternative treatment to an overdenture. The patient in this clinical report was satisfied with function and esthetics. Similar to an overdenture, the fixed prosthesis reestablished adequate support for the soft tissues. The implant prosthetic treatment of complete denture wearers influences mandibular border movement and the chewing pattern.<ce:cross-ref refid="bib10"><ce:sup>10</ce:sup></ce:cross-ref> There is a reduction of the chewing cycle duration, which in turn causes a decrease in the inclination angle of the chewing movement. Hence, an improvement in chewing efficiency and function is observed.<ce:cross-ref refid="bib11"><ce:sup>11</ce:sup></ce:cross-ref> Chewing movements become more balanced and regular than those executed with complete RPDs.<ce:cross-ref refid="bib11"><ce:sup>11</ce:sup></ce:cross-ref></ce:para><ce:para>At the 3-year follow-up, radiographic examination revealed normal bone levels around the implants. The stress-director system (Dalbo attachment) connected to the RPD probably reduced the masticatory load on the supporting implants.<ce:cross-ref refid="bib12"><ce:sup>12</ce:sup></ce:cross-ref> This vertical resilient hinge system is provided with a helical coil spring in the attachment housing, which decreases the shearing action and the bending moment of the occlusal force, turning the base of the RPD into a beam continuously supported in function by the alveolar ridge. The infrastructure of the fixed prosthesis is anchored to the implants by retaining screws. It is probable that the cumulative effect of the resiliency of the stress-director system and of the connection of the bar with the implants is responsible of the integrity of the bone architecture. The RPD supported by an implant-supported fixed prosthesis is rarely mentioned in the literature. In one instance, a maxillary removable prosthesis was inserted on a fixed prosthesis supported by a combination of natural abutments and implants joined by an interlock.<ce:cross-ref refid="bib13"><ce:sup>13</ce:sup></ce:cross-ref> In another article, a mandibular partial prosthesis was connected to a single porcelain-fused-to-metal crown supported by an implant in the site of the mandibular left cuspid.<ce:cross-ref refid="bib14"><ce:sup>14</ce:sup></ce:cross-ref></ce:para><ce:para>Normal bone levels were detected at 14 months after initial loading in that report. This article reports on a restoration where the periapical radiographs made at 3 years after initial loading did not show any detectable change in the peri-implant bony architecture. The increased costs of this prosthetic solution are balanced by the psychologic benefit for the patient who refused an overdenture. Other types of partial denture will have to be evaluated in the future to determine whether the stress-director designs similar to the one in this report are necessary for long-term success.</ce:para></ce:section><ce:section><ce:section-title>Summary</ce:section-title><ce:para>This clinical report demonstrates the possibility of achieving positive results with a removable prosthesis connected to an implant-supported fixed prosthesis. Bone quality and quantity at the implant sites are essential requirements for the success of the treatment. The support of the RPD and its connection with the fixed prosthesis creates stability during chewing activity and allows a functional activity similar to that involving an overdenture. The adoption of an occlusal scheme with subocclusion of the fixed prosthesis contacts compared with those of the removable prosthesis, together with the stress-director system of the RPD can be effective factors that decrease the risk of loss of implant integration. Further long-term follow-up studies with a larger patient population are needed to confirm the clinical and biomechanical validity of the prosthetic solution described in this clinical report.</ce:para></ce:section><ce:section view="extended"><ce:section-title>Supplementary Files</ce:section-title><ce:para><ce:float-anchor refid="mmc1"></ce:float-anchor></ce:para></ce:section></ce:sections></body><tail><ce:bibliography><ce:section-title>References</ce:section-title><ce:bibliography-sec><ce:bib-reference id="bib1"><ce:label>1</ce:label><sb:reference><sb:contribution><sb:authors><sb:author><ce:given-name>LW</ce:given-name><ce:surname>Lindquist</ce:surname></sb:author><sb:author><ce:given-name>GE.</ce:given-name><ce:surname>Carlsson</ce:surname></sb:author></sb:authors><sb:title><sb:maintitle>Long-term effects on chewing with mandibular fixed prostheses on osseointegrated implants</sb:maintitle></sb:title></sb:contribution><sb:host><sb:issue><sb:series><sb:title><sb:maintitle>Acta Odontol 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partial denture connected to an anterior fixed implant-supported prosthesis: A clinical report</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Distal extension mandibular removable partial denture connected to an anterior fixed implant-supported prosthesis: A clinical report</title></titleInfo><name type="personal"><namePart type="given">Mario</namePart><namePart type="family">Pellecchia</namePart><namePart type="termsOfAddress">DDS</namePart><affiliation>College of Dentistry, New York University, New York, N.Y</affiliation><affiliation>Implant Fellow, Arthur Ashman Department of Implant Dentistry, New York University College of Dentistry</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Roberto</namePart><namePart type="family">Pellecchia</namePart><namePart type="termsOfAddress">DDS</namePart><affiliation>College of Dentistry, New York University, New York, N.Y</affiliation><affiliation>Private Practice, Rome, Italy</affiliation><role><roleTerm type="text">author</roleTerm></role></name><name type="personal"><namePart type="given">Shahram</namePart><namePart type="family">Emtiaz</namePart><namePart type="termsOfAddress">DDS</namePart><affiliation>College of Dentistry, New York University, New York, N.Y</affiliation><affiliation>Clinical Associate Professor and Director of the International Implant Program, Arthur Ashman Department of Implant Dentistry</affiliation><role><roleTerm type="text">author</roleTerm></role></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="Full-length article" authority="ISTEX" authorityURI="https://content-type.data.istex.fr" valueURI="https://content-type.data.istex.fr/ark:/67375/XTP-1JC4F85T-7">research-article</genre><originInfo><publisher>ELSEVIER</publisher><dateIssued encoding="w3cdtf">2000</dateIssued><copyrightDate encoding="w3cdtf">2000</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><note>J Prosthet Dent 2000;83:607-12.</note><note>Reprint requests to: Dr Shahram Emtiaz, 160 E 48th St, # 12-L, New York, NY 10017-1225, Fax: (212) 752-5929, E-mail: demtiaz@aol.com</note><note type="content">Section title: Original Articles</note><relatedItem type="host"><titleInfo><title>The Journal of Prosthetic Dentistry</title></titleInfo><titleInfo type="abbreviated"><title>YMPR</title></titleInfo><genre type="journal" authority="ISTEX" authorityURI="https://publication-type.data.istex.fr" valueURI="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</genre><originInfo><publisher>ELSEVIER</publisher><dateIssued encoding="w3cdtf">200006</dateIssued></originInfo><identifier type="ISSN">0022-3913</identifier><identifier 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