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Titanium alloy removable IN BRIEF

Reviews the difficulty of the bilateral


partial denture framework free-end saddle and metal allergy.

PRACTICE
Discusses the clinical and laboratory
advantages and disadvantages of

in a patient with a metal allergy: titanium alloy in removable partial


denture frameworks.
Emphasises the usefulness of titanium

a case study alloy in patients with metal allergies.


Increases awareness of titanium alloy
removable partial denture frameworks
among general dental practitioners.
F. Oluwajana1 and A.D. Walmsley2

VERIFIABLE CPD PAPER

This article describes a mandibular bilateral free-end saddle case in a 63-year-old female with a metal allergy. Conventional
denture alloys are contraindicated and acrylic mucosa-borne dentures were not tolerated. The use of a titanium alloy
framework is shown to be a successful alternative in this case.

CASE REPORT Diagnosis was of a non-retentive, unsup-


The patient presented with a Kennedy portive mandibular distal extension RPD,
Classification 1 partially dentate mandib- with bone resorption leading to a promi-
ular arch and a distal extension remov- nent mylohyoid ridge resulting in trauma
able partial denture (RPD). Her complaint to the overlying mucosa. Moderate chronic
was of looseness, instability and pain. The generalised periodontitis exacerbated by
patients existing acrylic mucosa-borne chronic smoking was also present.
denture had wrought gold occlusally
approaching clasps on the abutment teeth TREATMENT Fig. 1 The titanium casting, which shows
similar appearance to traditional metal designs
and lacked retention, support and stability. Provision of a new acrylic RPD with a dif-
At 63years of age the patient had con- ferent design to the patients former RPD
trolled hypertension, was a long-term was first undertaken but this was unsuc-
smoker and reported a history of metal cessful. The necessary 3mm thickness of
allergy. Patch testing revealed allergy to acrylic connector was incompatible with
nickel, cobalt chloride, palladium chlo- the tongue due to the amount of spread
ride and gold sodium thiosulphate. The that had occurred. Any movement of the
remaining mandibular dentition com- tongue also caused displacement of the
prised of LR4, LR3, LR2, LR1 and LL1, LL2, denture. The option of using titanium alloy
LL3; the maxillary arch was edentulous as the RPD framework was then explored
and the upper prosthesis was being worn after a patch test revealed no allergy of the Fig. 2 The titanium casting placed clinically.
In spite of the dental staining as a result of
successfully. Clinically, the edentulous patient to titanium alloy. smoking and use of chlorhexidine mouthrinse,
free-end saddles had undergone marked The conventional clinical and design the casting shows good adaptation and was
bone resorption with the bony anatomi- stages were followed and the result- comfortable for the patient
cal features becoming prominent. The ing framework was well adapted to the
periodontal status of the remaining den- ridge, with excellent retention, support well identified as an inert, biocompatible
tition was poor, with the central incisors and stability (Fig. 1). metal but its use in removable prostheses
being grade 3 mobile. Lateral spread of is relatively limited, due to casting difficul-
the tongue had occurred due to loss of the DISCUSSION ties,2 and lack of clinical studies.
posterior dentition. This case study combines a patient with a The use of conventional casting alloys
metal allergy and a difficult lower distal such as cobalt chrome was not undertaken
extension denture. The impact of metal due to patch testing revealing allergy to
1
*Fourth year BDS student, 2Professor of Restorative allergy in practice has received limited chromium and other metals.
Dentistry, School of Dentistry, St Chads Queensway,
Birmingham, B4 6NN;
clinical report despite the fact that all den- Success of titanium in implantology
*Correspondence to: Funmi Oluwajana tal cast alloys release ions into the oral has been widely proven although titanium
Email: fxo853@bham.ac.uk
environment and thus, have the potential implant allergy is likely to become more
Refereed Paper to interact with the tissues.1 Allergy to commonly reported as its use increases.3
Accepted 19 April 2012
DOI: 10.1038/sj.bdj.2012.667
nickel, gold, cobalt and palladium are the However, as a partial denture framework
British Dental Journal 2012; 213: 123-124 most commonly stated.1 Titanium has been it has the advantages of better accuracy

BRITISH DENTAL JOURNAL VOLUME 213 NO. 3 AUG 11 2012 123


2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

of fit, light weight, increased patient used.3 Radiographic examination of the than conventional denture alloys so it is
comfort, high strength and excellent bio- framework will help determine the pres- important to inform the patient that good
compatibility.3 The biocompatibility of ence of porosities,4 although these have oral hygiene standards must be kept.3 The
the alloy is its most important feature in not been reported as a factor in caus- patient was encouraged to keep up with
metal allergy cases. Sensitivity reactions ing fracture of the titanium framework.2 her denture hygiene regime of soaking in
to metal only occur when a given metal Titanium clasps must also be designed and water overnight but was encouraged to
releases ions into the environment as a planned well, as the alloy is more flex- additionally brush the denture after meals.
result of corrosion. Titanium is known to ible than cobalt-chrome (CoCr), to prevent
be highly corrosion resistant due to its permanent deformation.3 The clasps func- CONCLUSION
ability to form thermodynamically stable tioned well in the patients mouth; they Titanium alloys are now becoming an
and adherent oxide layers on its surface.4 provided adequate retention to prevent acceptable material for the construction
The better accuracy of fit stems from the displacement of the denture and exhib- of RPDs. Their main disadvantage is cost,
materials ability to be formed into thin ited good elastic recovery. Economically, although this is likely to change as their
plates but still maintain high strength;3 the high cost of a titanium framework popularity increases. The use of titanium
this is reflected in the patients comments was once a disadvantage to the use of is ideal in patients who report a history of
about the framework being tight, com- the metal when compared with conven- allergies to conventional metal alloys used
fortable and the perfect fit for her mouth. tional metals. However, liaison with lab- for casting denture frameworks.
The patient also commented on how light oratory technicians will reveal that this
1. Schmalz G, Garhammer P. Biological interactions
the denture felt which is due to the low is no longer the case as titanium alloy of dental cast alloys with oral tissues. Dent Mater
density and therefore light weight of the now has a similar cost to that of cobalt 2002; 18: 396406.
2. Takayama Y, Takishin N, Tsuchida F, Hosoi T. Survey
alloy when cast (Fig. 2). However, the low chrome. Specific maintenance instruc- on use of titanium dentures in Tsurumi University
density of the alloy presents a significant tions on how to care for the denture are Dental Hospital for 11years. J Prosthodont Res
2009; 53: 5359.
problem to the casting process, as does required as titanium frameworks have 3. Ohkubo C, Hanatani S, Hosoi T. Present status of
the high melting point. The melting point been reported to show surface discol- titanium removable dentures a review of the
literature. J Oral Rehabil 2008; 35: 706714.
of titanium is 1,700C resulting in a long ouration with the use of strong alkaline 4. Knnen M, Rintanen J, Waltimo A, Kempainen P.
burn-out process and porosities appear- denture cleansers.3 Therefore, their use is Titanium framework removable partial denture used
for patient allergic to other metals: a clinical report
ing in the cast alloy if the alloy is insuf- best avoided. Plaque has also been shown and literature review. J Prosthet Dent 1995;
ficiently melted or inadequate pressure is to adhere more easily to titanium alloy 73: 47.

124 BRITISH DENTAL JOURNAL VOLUME 213 NO. 3 AUG 11 2012


2012 Macmillan Publishers Limited. All rights reserved.
PRACTICE

of fit, light weight, increased patient used.3 Radiographic examination of the than conventional denture alloys so it is
comfort, high strength and excellent bio- framework will help determine the pres- important to inform the patient that good
compatibility.3 The biocompatibility of ence of porosities,4 although these have oral hygiene standards must be kept.3 The
the alloy is its most important feature in not been reported as a factor in caus- patient was encouraged to keep up with
metal allergy cases. Sensitivity reactions ing fracture of the titanium framework.2 her denture hygiene regime of soaking in
to metal only occur when a given metal Titanium clasps must also be designed and water overnight but was encouraged to
releases ions into the environment as a planned well, as the alloy is more flex- additionally brush the denture after meals.
result of corrosion. Titanium is known to ible than cobalt-chrome (CoCr), to prevent
be highly corrosion resistant due to its permanent deformation.3 The clasps func- CONCLUSION
ability to form thermodynamically stable tioned well in the patients mouth; they Titanium alloys are now becoming an
and adherent oxide layers on its surface.4 provided adequate retention to prevent acceptable material for the construction
The better accuracy of fit stems from the displacement of the denture and exhib- of RPDs. Their main disadvantage is cost,
materials ability to be formed into thin ited good elastic recovery. Economically, although this is likely to change as their
plates but still maintain high strength;3 the high cost of a titanium framework popularity increases. The use of titanium
this is reflected in the patients comments was once a disadvantage to the use of is ideal in patients who report a history of
about the framework being tight, com- the metal when compared with conven- allergies to conventional metal alloys used
fortable and the perfect fit for her mouth. tional metals. However, liaison with lab- for casting denture frameworks.
The patient also commented on how light oratory technicians will reveal that this
1. Schmalz G, Garhammer P. Biological interactions
the denture felt which is due to the low is no longer the case as titanium alloy of dental cast alloys with oral tissues. Dent Mater
density and therefore light weight of the now has a similar cost to that of cobalt 2002; 18: 396406.
2. Takayama Y, Takishin N, Tsuchida F, Hosoi T. Survey
alloy when cast (Fig. 2). However, the low chrome. Specific maintenance instruc- on use of titanium dentures in Tsurumi University
density of the alloy presents a significant tions on how to care for the denture are Dental Hospital for 11years. J Prosthodont Res
2009; 53: 5359.
problem to the casting process, as does required as titanium frameworks have 3. Ohkubo C, Hanatani S, Hosoi T. Present status of
the high melting point. The melting point been reported to show surface discol- titanium removable dentures a review of the
literature. J Oral Rehabil 2008; 35: 706714.
of titanium is 1,700C resulting in a long ouration with the use of strong alkaline 4. Knnen M, Rintanen J, Waltimo A, Kempainen P.
burn-out process and porosities appear- denture cleansers.3 Therefore, their use is Titanium framework removable partial denture used
for patient allergic to other metals: a clinical report
ing in the cast alloy if the alloy is insuf- best avoided. Plaque has also been shown and literature review. J Prosthet Dent 1995;
ficiently melted or inadequate pressure is to adhere more easily to titanium alloy 73: 47.

124 BRITISH DENTAL JOURNAL VOLUME 213 NO. 3 AUG 11 2012


2012 Macmillan Publishers Limited. All rights reserved.