J Indian Prosthodont Soc (December 2014) 14(Suppl.

1):S232–S237
DOI 10.1007/s13191-013-0302-6

CLINICAL REPORT

Strategic Use of Telescopic Retainers and Semi-rigid Precision

Attachments in a Geriatric Patient: A Case Report
Bhavita Wadhwa • Veena Jain • Gunjan Pruthi

Received: 21 March 2013 / Accepted: 8 July 2013 / Published online: 23 July 2013
Ó Indian Prosthodontic Society 2013

Abstract The rehabilitation of medically compromised Keywords Multiple missing teeth

elderly patients with long span partially edentulous arches Fixed removable prosthesis
Telescopic prosthesis

has been a tremendous challenge for dentists. Proper dental Semi-precision attachment
management requires a commitment to provide the best
treatment despite the compromised oral conditions. The
aim of this paper is to describe the prosthetic rehabilitation Introduction
of an elderly patient who presented with chief complaints
of gagging sensation while using upper denture, loose Partial edentulism is defined as the absence of some but not
upper and lower dentures and difficulty in eating food. all of the natural teeth in a dental arch. The management of
Patient was rehabilitated using removable partial denture long span partially edentulous arches in medically com-
with semi-rigid attachments in the maxillary arch and promised elderly patients is a daunting task. Although the
telescopic prosthesis in the mandibular arch. Use of semi management is complex but the rewards can be satisfying
precision attachments helped in increasing the retentive [1]. Various treatment modalities are available for
ability of the maxillary prosthesis, even in the presence of replacement of multiple missing teeth such as fixed partial
only few abutments. Fabrication of a telescopic denture is a denture, Implants supported dentures, removable cast par-
technique sensitive procedure but it offers advantages like tial dentures, over dentures, telescopic prosthesis and dif-
bilateral splinting effect in long span partially edentulous ferent attachments etc., but there are certain limitations to
arches, reduced effective crown–root ratio, maintenance of each of these.
proprioception and transfer of forces along the long axis of In many clinical situations, periodontal status and
the abutments. Although the management was complex but location and position of remaining teeth is such that it
it improved patient’s esthetics, oral function and social precludes the use of fixed partial dentures [2]. Implant
confidence. supported dentures can be fabricated in such cases, but
adequate width and height of bone at the prospective
implant site is a primary requisite along with other factors
like absence of any local or systemic risk factor and good
financial status of the patient [3].
Implants and other current innovations do not make
B. Wadhwa
V. Jain (&)
G. Pruthi telescopic retainer obsolete; on the contrary, they can
Department of Prosthodontics, Centre for Dental Education
enhance each other and expand the range of viable treat-
and Research, All India Institute of Medical Sciences,
New Delhi 29, India ment alternatives. Telescopic retainers provide a modality
e-mail: [email protected] of treatment that can facilitate maintenance and enhance
B. Wadhwa the survival of natural abutments and also provide addi-
e-mail: [email protected] tional option for the restoration of a partially edentulous
G. Pruthi mouth [4–7]. Therefore telescopic prosthesis provides a
e-mail: [email protected] high degree of intraoral comfort and long term viability.

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J Indian Prosthodont Soc (December 2014) 14(Suppl. 1):S232–S237 S233

Intracoronal and extracoronal attachments may be used

in treatment of long span partially edentulous arches
requiring removable partial dentures. Use of a precision
attachment provides advantages like better retention,
esthetics, patient comfort, maintainable periodontal health
and longevity of abutment teeth [8–10]. The present report
describes oral rehabilitation using removable partial den-
ture with semi-rigid attachment in maxillary arch and
telescopic prosthesis in mandibular arch, in a geriatric
patient having history of breast carcinoma and high gag
reflex.

Outline of the Case

A 65-year-old partially-dentate female patient reported

with chief complaints of looseness of upper and lower
partial dentures, gagging sensation with the use of upper
denture which led to difficulty in chewing food. Medical
history revealed that the patient had undergone surgery
followed by chemotherapy and radiotherapy for treating
breast cancer 3 years ago. Dental history revealed that
patient had removable partial dentures but she was not
using them as they were loose and she felt gagging sen-
sation whenever she tried to wear them.
Extra oral examination revealed concave facial profile
with reduced vertical facial height, poor tone of the facial
tissues, thin and short upper lip and reduced lip support
(Fig. 1a).
Intraoral examination: 15, 16, 17, 18, 25, 26, 28, 32, 35,
44, 46, 47 and 48 were present. Teeth 15, 16, 32 were
mobile. 17, 44, 48 were root stumps and 35, 47 were car-
ious (FDI tooth numbering system).
Examination of old prosthesis revealed that both max- Fig. 1 a Pre-treatment extra oral view. b Pre-treatment panorex
illary and mandibular partial dentures were not retentive view. c Diagnostic casts
and maxillary prosthesis had full palatal coverage.
Radiographic examination revealed only 18, 25, 26, 35, attachment in the maxillary arch and telescopic removable
46 and 47 had good quality of supporting bone and con- prosthesis for mandibular arch.
tinuous lamina dura (Fig. 1b). Remaining teeth and root
stumps had poor quality of supporting bone. Fabrication Procedure

Preprosthetic Phase Maxillary and mandibular diagnostic impressions were

made with irreversible hydrocolloid (Zelgan, Dentsply India
Teeth with guarded prognosis (15, 16 and 32) and root Ltd.) and casts were poured with type III gypsum product
stumps (17, 44, and 48) were extracted and amalgam res- (Fig. 1c). Occlusal rims were fabricated and adjusted
toration was done in 35 and 47. Teeth 18, 25, 26 and 28 according to the phonetics and esthetics. Vertical dimension
were left in maxillary arch (Kennedy’s class IV) and 35, 46 was assessed by using physiological and mechanical meth-
and 47 were left in mandibular arch (Kennedy’s class II ods. Maxillary and mandibular casts were mounted on a
mod I). semi adjustable articulator (Whip Mix Corporation 361
Farmington Ave. Louisville, KY USA) with the help of
Treatment Executed facebow (Quick mount facebow) and centric relation record.
Artificial resin teeth were set following the landmarks for
Treatment option that appeared most suitable to restore this establishing occlusal plane. The wax up was done on the
case was removable partial prosthesis with semi-rigid abutments also to develop a bilateral balanced occlusion.

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In the maxillary arch, teeth were prepared for fabrication included a lingual bar placed 3 mm away from the mar-
of metal ceramic crowns. Left maxillary third molar was ginal gingiva and overlay copings on 35, 46 and 47
not prepared due to inaccessibility in that region as it was (Fig. 3a). The pattern was invested using phosphate bonded
bucally tilted. Mandibular teeth were prepared for the investment (Wirovest BeGo, Germany) and casted using
fabrication of telescopic copings. Co–Cr alloy (Bellabond plus BeGo, Germany). Framework
Impression of prepared abutments was made with putty try-in was done to verify its fit (Fig. 3b). Porcelain appli-
reline technique and was poured in type IV die stone cation was done on the overlay copings according to the
(Kalrock, Kalabhai Karson Pvt Ltd., Mumbai, India). diagnostic wax up.
Maxillary cast was mounted with the help of face bow
record and mandibular cast was mounted in centric rela- Try-in and Delivery of Maxillary and Mandibular
tion. Then, the wax patterns for telescopic copings in the Removable Prosthesis
mandibular arch were fabricated with cut back technique to
achieve 0.5–1 mm wide shoulder. These copings were Master casts were mounted on semi adjustable articulator
surveyed to achieve near parallel axial walls. Maxillary with the help of facebow and centric relation record.
copings were fabricated and the male components of Artificial resin teeth were set following the established
semirigid precision attachments (BeGo precision elements occlusal plane. Try-in was taken in the patient’s mouth to
Ancora Profile rod attachment dimensions: bar length verify fit, esthetics and to take patient’s consent before
6 mm, head diameter 1.75 mm, Germany) were attached to acrylization of the final prosthesis (Fig. 4a, b).
copings with the help of surveyor to achieve parallelism. Finally, after curing, remounting, finishing and polish-
These wax patterns were invested and casted in Ni–Cr ing, female component was attached to the maxillary
alloy (Bellabond plus, BeGo, Germany). denture with self-cured tooth coloured acrylic resin. Max-
Cast metal copings were finished and surveyed again to illary and mandibular dentures were delivered to the patient
check parallelism. Porcelain was applied on maxillary after occlusal adjustments (Fig. 5a, b, c).
copings against the mandibular trial denture. After required
adjustments, crowns and copings were polished and
cemented with Glass Ionomer cement (3 M ESPE,
KetacTM Cem Easymix, Bangalore, India) (Fig. 2).
Maxillary and mandibular final impressions were made
with dual impression technique. This helped to record the
complete border extensions of the residual ridge within the
physiological limits and to record the anatomic details of
the metal copings. Master casts were obtained.

Fabrication of Overlay Metal Framework

for Mandibular Teeth

After surveying, wax up for framework was done on the

refractory mandibular cast. The design of the framework

Fig. 2 Cemented metal copings Fig. 3 a Wax pattern on refractory cast. b Metal framework try- in

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dental restorations, is based on a double crown design. The

primary coping protects the abutment tooth from caries and
thermal irritations and provides the basic element for
retention and stabilization of the outer part. The secondary
crown, being an integral part of the removable superstruc-
ture serves as a unit and it anchors the rest of the dentition
[12, 13]. Telescopic crowns provide dental restorations with
many of the advantages of both fixed and removable pros-
theses [14–18]. Yalisove and Dietz showed that in telescopic
crown-sleeve-coping restorations, the effective crown-to-
root ratio is reduced at the point where the telescopic over
crown rotates. Inclusion of weak abutments is also possible,
because the loss of a weak abutment does not compromise
the entire prosthesis [19]. Telescopic dentures provide
bilateral splinting effect in long span partially edentulous
arches. Removability of superstructure enables the use of
pink base material to replace lost bone and restore the soft
tissue, achieving a more aesthetic appearance. By removing
the over prosthesis, the gingival tissues are easily accessible
around the entire marginal circumference of the abutment
thus permitting easy home care and oral hygiene. Hence,
patient can maintain good periodontal health around abut-
ments. Also, the overdenture maintains teeth as a part of
residual ridge. This gives the patient a denture that has far
Fig. 4 a Try-in (Right lateral view). b Try-in (Left lateral view)
more support than any conventional appliance. Instead of
soft movable mucous membrane, the denture literally sits on
Post Insertion Instructions and Recall teeth ‘pilings’, enabling the denture to withstand a much
greater occlusal load without movement [4, 20]. In addition
Post insertion instructions were given to the patient that to this, reduction of lateral stress on abutments by using
included maintenance of meticulous oral hygiene and she telescopic retainer has been well documented. Pezzoli et al.
was put on a six month follow up regimen. At each follow [21] evaluated load transmission in distal extention partial
up visit, patient was evaluated for effectiveness of oral dentures and found that telescopic retainers ‘‘produced less
hygiene, retention and stability of the prosthesis. stress in the edentulous region and transmits loads more
equally to the abutments’’.
On the other hand, the application of the double crowns
Discussion requires considerable clinical skill and experience. In the
past, telescopic retainers were perceived as having disad-
In the present case, rehabilitation was done with telescopic vantages of increased bulk, expensive and complex labo-
removable prosthesis in mandibular arch and removable ratory procedures which contribute to the high cost of
partial prosthesis with semi-rigid attachment in the max- treatment.These obstacles are not significant any more, as
illary arch. Fixed dental prosthesis was not thought to be a new light cure resin materials, bonding techniques that
good option for this particular case as it would have allow these resin materials to be bonded directly to the
resulted in excessive forces on the remaining teeth. Cast metal crown frames, and less expensive casting alloys have
partial denture was also excluded as number and distribu- substantially removed the difficulty in this modality of
tion of the remaining teeth were not suitable to provide the treatment [22].
desired amount of direct and indirect retention. Further, the Retention of the maxillary denture is one of the most
patient’s unwillingness for any surgical procedure ruled out important concerns for the patients as it affects their
the option of implant supported prosthesis too. function as well as social confidence. But this was difficult
The Glossary of Prosthodontic Terms defines a telescopic to achieve in our case because of few remaining teeth to act
crown as ‘‘an artificial crown constructed to fit over a coping as abutments. Therefore, extracoronal attachments were
(framework). The coping can be another crown, a bar, or any used to enhance the retention of maxillary partial denture
other suitable rigid support for the dental prosthesis [11]. as they offer different path of insertion from the pull of
The telescopic unit, serving as anchorage in removable muscles and the action of tongue and gravity [8–10].

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Fig. 5 a Final maxillary

prosthesis (occlusal view).
b Final mandibular prosthesis
(occlusal view). c Final
prosthesis

Such prosthesis leads to cross arch load transfer and thus oral function and social confidence. Periodic follow ups
leads to better prosthesis stabilization. As compared to and meticulous prosthesis maintenance by the patient will
conventional clasp retained partial denture, it is less liable hold the key for the ultimate success of this type of
to fracture, less bulky, provides better retention and sta- rehabilitation.
bility, aesthetics and leads to less food stagnation [9].
Crown contour is better achieved in the gingival area with Financial support None.
laboratory fabricated precision attachment. All these fac-
tors lead to elevated psychological acceptance by the
patients.
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