EQUILIBRATING FUNCTIONAL STABILITY WITH AESTHETIC HARMONY IN A KENNEDY CLASS II SADDLE AREA USING PRECISION ATTACHMENT: A DEXTEROUS ALTERNATIVE TO IMPLANTS !

The vigilance and demand for quality of dental treatment is relatively incrementing in recent generation and more so, as far as aesthetics are concerned, along with other functions of the prosthesis. Distal-extension removable partial dentures have always posed a challenging situation to the clinician and in such cases the strategic positioning of the direct retainers would ascertain the long-term prosperity of the prosthesis. The balance between functional stability and cosmetic appeal is a major challenge to dentists, and a variety of solutions have been proposed in the form of minuscule interlocking devices, often called “precision attachments,” designed to connect the prosthesis to the abutment teeth. Attachment retained RPD is a viable treatment alternative to implant through which a significant number of patients could be benifited both long and short term.


Case History
A 55-year old female reported to government dental college and hospital ahmedabad with chief complain of missing teeth in upper posterior region and inability to eat food.
She was wearing a distal extension removable partial denture and the presence of mandibular extra coronal clasp retainers was negatively affecting the aesthetics. On clinical examination maxillary 1 st & 2 nd molar were absent and maxillary 1 st & 2 nd premolar was of adequate height with sound periodontal support. [ Figure 1] Radiographic evaluation showed adequate bone support around the teeth present.
In lieu of compromised aesthetics, impaired function with existing partial denture it was planned to construct mandibular removable partial denture with extra coronal attachment. The patient rejected the options of implants because of the need for additional surgery and the unacceptable duration of treatment phase.

METHODOLOGY
1. Diagnostic impressions were made and mounted on semi adjustable articulator using a face bow.
Following which diagnostic wax-up was done on the mounted casts.
wax-up for evaluation of the existing space for the extra coronal resilient attachment. 3. The attachment system was selected on the basis of available space. (OT CAP, Rhein 83 Inc, USA) 4. Tooth preparation was done on maxillary 1 st & 2 nd premolar to receive PFM crowns. [ Figure 2] Impression was made and poured in die stone.[ Figure  3] Following which crowns have been waxed to full contour and milled in wax for maximum guiding plane surface. The patrice was added to the axial surfaces of the abutment using a dental surveyor, lingual to the centre of proximal contour. [ Figure 4]This ensures that the bulk of matrice does not interfere with aesthetic of buccal cusp of replacing denture tooth.
5. Following which casting, finishing, and veneering of the fixed component was done.
6. Metal trial of copings was evaluated on master cast [ Figure 5] as well as in patient's mouth. [ Figure 6] 7. The fixed component including veneered metalceramic crowns & the patrices were tried in the patient mouth [ Figure 7] and picked up using putty impression for fabrication of removable partial denture. (Imprint II; 3M ESPE) The wax up of framework of the removable partial denture was done, invested and casted. 9. The framework was evaluated in the patient mouth and jaw relation was done using occlusal rims and Try-in was done. [ Figure 8] 10. Acrylisation of removable partial denture was performed and final prosthesis was evaluated in patient's mouth. [ Figure 9]

DISCUSSION
Rehabilitation options for the partially edentulous patient with a single tooth or multiple missing teeth include interim acrylic resin removable partial denture (RPD), conventional cast partial denture, partial denture with attachment, fixed partial denture, or implant-retained prosthesis. Clinical decision-making is critical in deciding the most suitable treatment option for a particular patient.
Our ever-incrementing erudition of the oral environment, together with technological ameliorations and good armamentarium, has taken us to give a restoration which is esthetically delectating and comfortable. This makes it all the more consequential to reconcile what is genuinely feasible with the patient's own prospects.
The clinical use of unilateral removable partial denture (RPD) is limited because of poor satability and retention. A regular problem is faced by the partial edentulous patient is the nuance of adapting to removable prosthesis. A unilateral prosthesis is always less stable, because it lacks the effect of cross arch stabilization.
Rehabilitation of partially edentulous situations can be challenging when it is distal extension situations where a fixed prostheses cannot be fabricated. Implant retained restoration are an option but this is sometimes not possible due to insufficient amount of bone or economic reasons. In these cases acrylic or cast partial denture was largely preferred, with barely satisfactory esthetical results.
Precision attachment has long been considered the highest form of partial denture therapy. Precision attachment is an interlocking device, one component of which is fixed to an abutment or abutments, and the other is integrated into a removable dental prosthesis in order to stabilize or retain it. These attachments take the place of damaging clasp arm. Mensor (1971) (Mensor MC. Classification and selection of attachments. The Journal of prosthetic dentistry. 1973 May 31;29(5):494-7.) has classified attachments as intra-coronal, extra-coronal, push button type, bar type and auxiliary type. Based primarily on the function of these attachments they are classified as rigid or passive. (Makkar S, Chhabra A, Khare A. Attachment retained removable partial denture: A Clinical Report. International Journal of Clinical Dental Science. 2011 May 7;2(2).)   (3):268-82) has suggested that splinted 1st and 2nd premolar by full coverage crown , has provided good support and improved the prognosis of cast partial denture. Moreover Extracoronal OT CAP (Attachment and Prefabricated Castables Component. Accessed on 2016 july 18. Available from: http://www.rhein83.com.) are castable attachments with elastic retention. With its elasticity it is possible to control the flexure and construct a resilient and shock absorbing prostheses.

CONCLUSION
Removable partial dentures fabricated with precision attachments are the viable options for patients in whom fixed prosthesis, implants are contraindicated. Adherence to precision techniques, proper diagnosis and periodic recall preventative therapy will result in successful treatment and preservation of the patient's existing dentition.