Case Report INTRODUCTION CASE REPORT. Sneha Gada 1, Deepak Nallaswamy 2, Ashish R. Jain 2 * ABSTRACT

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1 Case Report Full mouth rehabilitation of periodontally compromised partially edentulous arches with multiple missing teeth using telescopic crown and bridge - A case report Sneha Gada 1, Deepak Nallaswamy 2, Ashish R. Jain 2 * ABSTRACT Telescopic crown and bridge has been a treatment of choice in cases with feeble abutment to pontic ratio to provide a semi-fixed prosthesis for the patient. In cases of advanced periodontal disease, telescopic copings provide a solution which does not cause periodontal destruction or worsen an existing periodontal condition. The current case report describes a case where in the patient has periodontally compromised sparse abutment teeth. The treatment of choice was telescopic crown and bridge. The case report not only describes the treatment planning but also displays the laboratory steps. KEY WORDS: Copings, Periodontally compromised, Semi-fixed, Telescopic INTRODUCTION Telescopic crown and bridge, also known as German crown, is one of the most used dental procedure by us to construct removable dentures. Telescoping refers to the use of primary full coverage casting (coping/ male telescopic portion) luted to the prepared tooth with a secondary casting (superstructure/secondary crown/female telescopic portion), which is a part of the denture framework and is connected by means of interfacial surface tension over the primary casting. [1,2] They act by transferring forces along the direction of the long axis of the abutment teeth and provide guidance, support, and protection from movements the might dislodge the removable partial dentures. [3] Telescopic crowns can also be used as indirect retainers to prevent dislodgement of distal extension bases away from the edentulous ridge. [2,3] In cases of the advanced periodontal disease, telescopic copings have been used as a proposal for oral rehabilitation. In such cases, teeth represent with minimal supportive tissue and increased tooth Access this article online Website: jprsolutions.info ISSN: mobility; therefore, it is extremely important for the prosthesis not to cause periodontal destruction or worsen an existing periodontal condition. [4,5] Cylindrical crowns that exhibit retention through a friction fit of parallel-milled surfaces. [3,4] CASE REPORT A 65-year-old male reported to the Department of the Prosthodontics, Saveetha Dental College, with a chief complaint of multiple missing teeth and unesthetic appearance of his smile. The patient did not give any significant medical history. He gave a dental history of multiple dental extractions due to carious and periodontally compromised teeth over the past 4 years and recently extracted lower premolars. The preliminary examination revealed that the patient s upper arch only had 5 remaining teeth, namely: 15, 14, 13, 11, 23, and 25. The patient s mandibular dentition included anterior and third molar bilaterally. Full mouth radiographs and orthopantomogram were made to evaluate the condition of the remaining teeth [Figure 1]. Oral prophylaxis along with deep subgingival curettage was performed as the patient s oral hygiene status was fair. Diagnostic impressions were made using addition silicone of putty and light body consistency using single 1 Department of Prosthodontics, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India, 2 Department of Prosthodontics, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India *Corresponding author: Dr. Ashish R. Jain, Department of Prosthodontics, Saveetha Dental College and Hospital, Saveetha University, Poonamallee High Road, Chennai , Tamil Nadu, India. Phone: dr.ashishjain_r@yahoo.com Received on: ; Revised on: ; Accepted on:

2 Figure 1: The pre-operative records casts were mounted using the centric bite record which was recorded using Blue Denar Wax [Figure 2]. On the evaluation of the diagnostic records, the maxillary right first premolar showed proximal root caries which could not be restored. Hence, it was indicated for extraction. The lower anterior had multiple carious lesions as well as periapical changes were seen with respect to 41. Root canal therapy was advocated for all the lower anterior to improve the long-term survival and prognosis. Figure 2: The diagnostic records before proceeding with the treatment plan step technique. The diagnostic casts were poured to obtain the diagnostic casts. Ivoclar tentative centric record tray was used to take a tentative bite of the patient to mount the diagnostic casts for diagnosis and treatment planning. At this stage, the current mounting was used to fabricate an anterior deprogrammer, which was used to record the centric bite of the patient. The diagnostic Pondering over the treatment options, for a case with sparse abutments and periodontally compromised situation, considering a fixed treatment option would be difficult. However, a semi-fixed treatment plan would help meet the two ends of the patient s desire and the dentist s ethical duty. Telescopic crown and bridge was one such prosthetic solution, chosen for both the upper and the lower arch. Subsequently, the articulated models were used for the diagnostic wax-up. Root canal treatment was performed for the upper abutments, as the excessive 2000

3 Figure 3: The tooth preparation, master impression, temporization, and facebow record Figure 4: The jaw relation record using gothic arch tracing Figure 5: The fabrication and verification of the metal copings reduction is needed to accommodate the primary, secondary coping, and the overlay esthetic material, which was Adaro composite in this case. Tooth preparation was done followed by temporization using heat cure acrylic lab fabricated temporaries, relined by self-cure acrylic. These temporaries were used to evaluate the required reduction, esthetics, vertical dimension, and patient comfort. Once the temporaries were evaluated, the master impression was taken for the upper and the lower arch 2001

4 Sneha Gada, et al. Figure 6: The fabrication and verification of the secondary framework Figure 7: The entire procedure flow of full mouth rehabilitation 2002

5 using a custom tray and polyether impression material using double retraction cord and two-step putty light body impression [Figure 3]. The jaw relation was recorded using intraoral gothic arch tracing method to locate the centric relation at the established vertical dimension of occlusion [Figure 4]. The master casts were die sectioned and mounted using the centric bite. Primary copings were first fabricated in pattern resin and tried in with a trial jig to verify the parallelism of the prepped teeth. Once the fit was verified in the patients mouth, the pattern resin copings were cast to form the primary metal copings. The finishing of the metal copings and the parallelism was maintained using a surveyor attached milling machine [Figure 5]. Once the metal copings were reverified in the patient, we proceeded with the secondary copings [Figure 6]. [6] The secondary copings were made along with the framework with retentive beads for the overlaying of the Adaro composite. The fit of the framework was verified and checked. Now the last and the most crucial step is the layering of the Adaro composite. The Adaro composite needs adequate thickness and curing time to have good strength and longevity. Once the layering was completed, the pre-polished prosthesis was tried intra-orally. The esthetics, vertical, and occlusion were evaluated. The final polishing of the prosthesis was done. The primary copings were cemented, and the prosthesis was delivered. The entire flow of the case is depicted in Figure 7. DISCUSSION Telescopic crowns have been used over the years to connect widely spaced natural teeth, correct the angulation of tilted teeth, to connect dentures to natural teeth. The primary role of the telescopic prosthesis is the maintenance of oral hygiene along with the relative independence of the abutments allowing the use of the prosthesis after the loss of the periodontally affected abutments. [7,8] Along with minimal need of retainers, telescopic prosthesis provides a high level of retention. The retention is mainly through frictional resistance. However, there is wear of the metal surfaces over a period causing loss of retention. [9] Another disadvantage of this prosthesis is the amount of tooth reduction required to accommodate for the material of the two copings as well as the composite. The weight of the prosthesis due to the amount of the metal is another compromising factor. [10,11] The most important condition for improved prognosis for periodontally involved teeth is adequate oral hygiene maintenance, regular evaluation of the abutments and regular scaling. [7] Telescopic crown and bridge prosthesis is one such option which not only looks like a fixed prosthesis but also provides the advantages of a removal prosthesis. [12] Compared to telescopic overdenture, telescopic crown and bridge presents as a semi-fixed prosthetic option. It is more esthetic, more hygienic due to lesser extensions and a more durable option. [9,13] CONCLUSION Telescopic crown and bridge seemed like an opt treatment option for this patient, taking care of the periodontal condition, as well as ensuring a long-term prognosis of the treatment. REFERENCES 1. Weaver JD. Telescopic copings in restorative dentistry. J Prosthet Dent 1989;61: Langer A. Tooth-supported telescope restorations. J Prosthet Dent 1981;45: Wenz HJ, Hertrampf K, Lehmann KM. Clinical longevity of removable partial dentures retained by telescopic crowns: Outcome of the double crown with clearance fit. Int J Prosthodont 2001;14: Polansky R, Haas M, Lorenzoni M, Wimmer G, Pertl C. The effect of three different periodontal pre-treatment procedures on the success of telescopic removable partial dentures. J Oral Rehabil 2003;30; Yalisove IL, Dietz JB. Telescopic Prosthetic Therapy: Periodontal Prosthesis, Fixed And Removable. Philadelphia, PA: Lippincott Williams and Wilkins; Shankargouda SB, Sidhu P, Kardalkar S, Desai PM. A simple technique for accurate transfer of secondary copings in a toothsupported telescopic prosthesis. J Prosthodont 2017;26: Hoffmann O, Beaumont C, Tatakis DN, Zafiropoulos GG. Telescopic crowns as attachments for implant supported restorations: A case series. J Oral Implantol 2006;32: Kochanek-Leśniewska A, Sobczyk K. Telescopic crowns as attachments for implant supported removable dentures. A literature review. Prosthodontics 2015;65: Özyemişci-Cebeci N, Yavuzyilmaz H. Comparison of the effects of friction varnish and electroforming on the retention of telescopic crowns. J Prosthet Dent 2013;109: Wagner C, Stock V, Merk S, Schmidlin PR, Roos M, Eichberger M, et al. Retention load of telescopic crowns with different taper angles between cobalt-chromium and polyetheretherketone made with three different manufacturing processes examined by pulloff test. J Prosthodont 2018;27: Kochanek-Leśniewska A, Majcher A, Mierzwińska- Nastalska E. Analysis of changes in the value of the retention force in three-part telescopic crowns system manufactured from zirconia- part II. Prosthodontics 2015;65: Gounder R, Rao PL, Kumar GA, M G, Chandrasekhar N. Full mouth rehabilitation of a patient with extracoronal attachments and telescopic prosthesis - a case report. J Clin Diagn Res 2014;8:ZD Kochanek-Leśniewska A, Ciechowicz B, Wojda M. Retention of overdentures supported on telescopic crowns. Prosthodontics 2013;63:41-8. Source of support: Nil; Conflict of interest: None Declared 2003