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ProstheticsThe removable partial denture equation

Article  in  British dental journal · October 2000

DOI: 10.1038/sj.bdj.4800787

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PRACTICE
prosthetics

2
The removable partial
denture equation
J. C. Davenport,1 R. M. Basker,2 J. R. Heath,3 J. P. Ralph,4 and P-O. Glantz,5

This article describes the benefits and risks of

providing RPDs. It emphasises the importance of In this part, we will discuss
• The benefits of RPDs
co-operation between the dental team and patient • Tissue damage associated with RPDs
to ensure that the balance of this ‘equation’ is in • Preserving oral health
the patient’s favour. • The importance of teamwork

he title of this part of the series requires immediate explana- • The essential oral functions of appearance, mastication and
T tion. The term ‘equation’ refers to the balance that must be
struck between the good and the bad which can arise from the
speech.

wearing of RPDs. In this chapter we explore the benefits which It is only after this analysis has been completed that the decision
can be conferred on patients by RPDs and, at the same time, of whether or not to treat a particular patient can be taken. For
highlight the possible risks of tissue damage that can be associ- example, prosthetic treatment must not begin until it has been
ated with such prostheses. verified that there is a significant reduction in one or more of the
Every prosthetic treatment is associated with the placement of a essential oral functions. A simple determination of the number
foreign object (the prosthesis) in the mouth of the patient. As a and position of the remaining teeth is not a sufficient foundation
direct consequence of such placement the burden on the tissues in for making the decision of whether or not to initiate treatment.
the oral cavity will be increased. For example, plaque more readily If it is indicated, a treatment plan is then devised identifying the
accumulates on alloplastic materials than biologic ones. Further- various stages and the most appropriate type of prosthesis.
more, even non-toxic materials will release small amounts of their
components into the oral cavity. To justify prosthetic treatment Benefits of RPDs
and to ensure that it is beneficial to the patient, the need for such The potential benefits of RPDs which will be considered in this
treatment must be established, the patient must be appropriately section are their contribution to the following.
motivated, and the dentures properly designed, constructed and
• Appearance
maintained. Thus the initial step in determining if prosthetic
• Speech
treatment is indicated must always be the assessment of:
• Mastication
• The patient’s wishes and concerns • Maintaining the health of the masticatory system:
• The relevant dental and medical history — preventing undesirable tooth movement
• The results of the extra-oral and intra-oral examinations — improving distribution of occlusal load
• Oral hygiene habits and status • Preparation for complete dentures.

1*Emeritus Professor, University of Birmingham, UK; 2Professor of Dental

New publications:
Prosthetics, University of Leeds and Consultant in Restorative Dentistry, Leeds
Teaching Hospitals NHS Trust, Leeds, UK; 3Honorary Research Fellow, University
All the parts which comprise this series
of Manchester (Formerly Senior Lecturer in Restorative Dentistry, University of (which will be published in the BDJ) have
Manchester) and Consultant in Restorative Dentistry, Central Manchester been included (together with a number
Healthcare Trust, Manchester, UK; 4Consultant in Restorative Dentistry, Leeds of unpublished parts) in the book
Teaching Hospitals NHS Trust and Senior Clinical Lecturer, University of Leeds
and Honorary Visiting Professor, Centre for Dental Services Studies, University of A Cinical Guide to Removable
York, York, UK; 5Professor of Prosthetic Dentistry, Consultant in Prosthetic Partial Dentures (ISBN 0-904588-599)
Dentistry, Faculty of Odontology, University of Malmo, Sweden and A Clinical Guide to Removable
*Correspondence to: 5 Victoria Road, Harborne, Birmingham B17 0AG
email: [email protected]
Partial Denture Design (ISBN 0-904588-637).
REFEREED PAPER Available from Macmillan on 01256 302699
© British Dental Journal 2000; 189: 414–424

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Fig. 1 — Appearance
The restoration of the missing UR2 (12), UR1(11) and UL1(21)
undeniably benefit this patient, an 18 year-old girl, and the motivation to
wear the denture is understandably strong. Particular attention has been
paid to the appearance of the denture by the careful choice of artificial
teeth and design of the flange. A natural appearance has been created by
using a ‘veined’ acrylic, by reproducing the pre-extraction form of
alveolar ridge and by making the distal margin of the flange thin and
irregular, thus masking the transition from flange to adjacent mucosa.

a b

Fig. 2a and b — Appearance

Not only may an RPD help to restore appearance but it may actually improve it.
(a) This patient’s maxillary lateral incisors had never developed and she
was concerned about the spacing of the anterior teeth.
(b) The combination of orthodontic movement of the central incisors and the provision of RPDs improved the
appearance.

Fig. 3 — Appearance
If an incisor is not replaced soon after extraction, successful treatment at
a later date may be compromised. Here, the adjacent teeth have drifted
into the unrestored UL1(21) space. The reduced space does not allow
for an artificial tooth of a realistic size to be used on a denture. If a
reasonable aesthetic result is to be obtained the space must be re-
established by orthodontic treatment.

Fig. 4 — Speech
The loss of maxillary anterior teeth may prevent the clear reproduction
of certain sounds, particularly the ‘F’ and ‘V’ which are made by the lower
lip contacting the edges of the maxillary incisors. The replacement of
missing maxillary anterior teeth will make a significant contribution to the
quality of speech.

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Fig. 5 — Mastication
With modern foods and methods of preparation it is unlikely that a
patient will suffer from malnutrition even though a large number of teeth
are missing. However, the gaps that arise through the loss of posterior
teeth reduce the efficiency of mastication: the bolus of food is allowed to
slip into the edentulous areas and thus escape the crushing and shearing
action of the remaining teeth. An RPD will prevent this escape of the
bolus and thus contribute to efficient mastication.

Maintaining the health of the masticatory system

The provision of an RPD can make a positive contribution to
oral health by preventing, or minimising, the undesirable conse-
quences of tooth loss, as described in the following paragraphs.

Fig. 6 — Preventing undesirable tooth movement

When teeth are lost from a dental arch the teeth adjacent to the
edentulous space may tilt and move into that space. This drifting of teeth
opens up further spaces which increase the opportunity for food
impaction and plaque formation, encouraging inflammation of the
periodontal tissues and decalcification of the proximal surfaces of the
teeth. Inevitably, the longer such spaces remain unrestored, the greater
the chance of tooth movement. When teeth are lost from an opposing
arch over-eruption may occur with similar deleterious effects on the oral
health. However, if tooth movement has not occurred in spite of the
teeth being lost some years previously, it can be assumed that it is not
going to occur subsequently.

Fig. 7 — Preventing undesirable tooth movement

The long-term absence of antagonists has resulted in over-eruption of
maxillary and mandibular teeth. The teeth are virtually contacting the
opposing edentulous ridges creating major problems if RPDs have to be
provided.

Fig. 8 — Preventing undesirable tooth movement

In this example, UR6 (16) has over-erupted to such an extent that it has
lost most of its bony support. Extraction of the tooth is inevitable.

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Fig. 9 — Improved distribution of occlusal load
The loss of a large number of teeth puts an increasing functional burden
on the remaining teeth. In this example there is existing periodontal
disease. The increased functional load has hastened the destruction of the
periodontal attachments of the maxillary anterior teeth, which have
become increasingly mobile and have drifted labially.

Fig. 10 — Improved distribution of occlusal load

If the periodontal attachments of the remaining teeth are healthy, the
increased load may result in excessive tooth wear or may cause damage
to existing restorations. The restoration of gross loss of tooth substance,
as in this example, is likely to involve complex and prolonged treatment.

a b

Fig. 11a and b — Improved distribution of occlusal load

Over-eruption of a tooth may place it in such a position that it bears the brunt of the load on initial contact or in excursive movements of the mandible
and therefore it may well be subjected to excessive force. In addition, where over-eruption of a tooth has created an occlusal interference (*), the
patient may modify the habitual movement patterns of the mandible in order to avoid the interfering contact. Although such a modification may reduce
the load applied to the tooth, the changed pattern in activity of the mandibular musculature may subsequently produce muscular dysfunction.

From the foregoing examples it will be appreciated that if tooth expected to retain their remaining natural teeth for a consider-
loss is restored in sufficient time to prevent tooth movement, or able number of years, thus allowing the RPD to be regarded as a
to avoid excessive stress being placed on the remaining structures, long-term restoration. But we should remember those patients
the subsequent health of the oral tissues can benefit considerably. whose remaining teeth carry a relatively poor prognosis and for
However, the point should be made that severe damage to the whom, in due course, complete dentures are inevitable. If simple
existing structures is not an inevitable consequence of tooth loss. acrylic RPDs are provided, the patient is able to serve a pros-
The implications of this statement will become apparent later in thetic ‘apprenticeship’ with appliances which receive some sta-
this section when the damaging effects of the dentures them- bility from the few remaining teeth. In the fullness of time these
selves are described. transitional dentures become more extensive as further teeth are
extracted and the patient is gradually eased into the totally artifi-
Preparation for complete dentures cial dentition. This form of transitional treatment can be of con-
Most of this book is devoted to the treatment of patients who are siderable benefit, especially for the elderly patient.

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Fig.12 — Preparation for complete dentures
The location of the remaining teeth plays an important part in the success
of such a transitional denture. It is common for the six mandibular
anterior teeth to be the last remaining teeth in the mandible. A denture
restoring the posterior teeth is frequently not worn by the patient for the
following reasons. Firstly, the denture may be unstable because there is
little resistance to its displacement in a posterior direction; secondly,
there is very little motivation to wear the denture as the anterior teeth
are still present.

Fig. 13 — Preparation for complete dentures

If, instead of extracting all the teeth, the canines are retained, the denture
will be more stable. When the denture replaces anterior teeth it is very
much more likely to be worn and thus the patient is likely to gain greater
benefit from the transitional denture.

Fig. 14 — Preparation for complete dentures

It should be remembered that the transitional RPD is being placed in a
mouth where existing dental disease is only poorly controlled or is
uncontrolled. As will be seen in the next section, the very presence of a
denture aggravates the situation. If the mouth is not inspected regularly to
identify treatment needs as they arise, there is the likelihood of
acceleration of tissue damage, which may prejudice the eventual
complete denture foundation.
In this case the inflammation and hyperplasia of the palatal mucosa was
so severe that surgery had to be performed before further prosthetic
treatment could be undertaken.

Causes of damage related to the wearing of RPDs

Harmful effects can arise from the wearing of RPDs in a variety of wearing RPDs, such as caries and periodontal disease, can be
ways: from the plaque which is likely to accumulate around any avoided. However, frequent technical maintenance of RPDs is still
RPD; from direct trauma by individual components of the den- required if optimal oral function and health are to be preserved.
ture; from excessive functional forces which will be transmitted by When tissue damage does occur it is sometimes referred to as
an ill-designed prosthesis and from errors in the occlusion. the ‘biological price’ of wearing RPDs. The possible causes of
If the patient, with the help of the dental team, can maintain damage and their sequelae are summarised in the following table
optimal plaque control the hygiene-related complications of and are discussed in more detail in the subsequent sections.

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Table 1 Summary of damage that may result from wearing an RPD

Causes Teeth Periodontal tissues Edentulous areas Muscles of mastication

Plaque accumulation Decalcification Inflammation of gingival Inflammation of mucous

and caries tissues membrane
Progression to underlying
structures

Direct trauma from Abrasion and Inflammation of gingival Localised inflammation

components fracture of tissues of mucous membrane.
teeth or Progression to underlying Denture-induced
restorations structures hyperplasia

Transmission of (a) Tooth mobility Inflammation of mucous

excessive functional (b) Aggravation of existing membrane
forces periodontal disease Resorption of bone

Occlusal error (a) Tooth mobility Inflammation of mucous Muscle dysfunction

(b) Aggravation of existing membrane
periodontal disease Resorption of bone

Increased plaque accumulation

A considerable amount of research effort has been directed affects the quantity. Not only does more plaque accumulate
towards an understanding of the relationship between plaque around the teeth in the jaw in which the denture is placed, but also
accumulation and the wearing of RPDs. It is possible that the pres- more is found around the teeth in the opposing jaw unless the
ence of a denture influences the quality of the plaque; it certainly patient is instructed in meticulous oral hygiene procedures.

a b

Fig. 15a and b — Increased plaque accumulation

The areas that tend to collect most plaque are the proximal surfaces of abutment teeth adjacent to the saddle.
(a) These surfaces are difficult to clean when using a conventional toothbrush.
(b) An interdental brush cleans the proximal surfaces more effectively.

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a b

Fig. 16a and b — Increased plaque accumulation

The design of the denture may have a significant effect on plaque accumulation. For example, it has been shown
that more plaque collects under a lingual plate than under a lingual bar.
(a) The lingual plate is well supported on the natural teeth and fits well against tooth surfaces.
(b) However, gingival inflammation has been caused by the increased accumulation of plaque.

Fig. 17 — Increased plaque accumulation

Denture
If the plaque is allowed to persist, the inflammatory process will progress
to the deeper tissues, resulting in a chronic periodontitis. The periodontal
Tooth
attachment is progressively destroyed, a periodontal pocket develops and
the investing alveolar bone is lost.
Plaque

Pocket

Bone

Fig. 18 — Increased plaque accumulation

Unless the increased accumulation of plaque is prevented, root caries is
likely. This is a problem that will increase as more patients continue to
wear RPDs into old age. Root caries is strongly associated with gingival
recession and the use of gingivally-approaching clasps in patients who are
at risk because of a cariogenic diet and poor plaque control.

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Fig. 19 — Increased plaque accumulation
If plaque is allowed to persist on the denture impression surface, a
generalised inflammation, called denture stomatitis, may occur. Typically
the extent of the inflammation is demarcated by the outline of the palatal
connector. This condition is discussed more fully in Part 11.

a b

Fig. 20a and b — Direct trauma from components

The oral mucosa is vulnerable to direct trauma from components of dentures.
(a) In this instance the lingual bar has been positioned too close to the gingival margin. The continuous clasp
offers only limited tooth support for the denture.
(b) The denture has sunk into the tissues, stripping away the gingival tissues on the distal and lingual aspects of
LL3 (33).

There is no evidence for the contention that a clasp arm may wear away the enamel surface to a degree that is
significant clinically. However, the movement of a clasp arm may wear the surface of restorative materials.

Transmission of excessive force

Functional forces are transmitted by an RPD to the tissues with appreciated that the forces are tensile in nature and are dissi-
which it is in contact. If a denture is supported primarily by the pated over a relatively large area. A very different state of affairs
natural teeth most of the forces will be transmitted to the alveo- exists when a denture is supported only by the mucosa. Here the
lar bone through the fibres of the periodontal ligament. Bearing forces, largely compressive in nature, are transmitted over a
in mind the orientation of most of these fibres, it will be more restricted area.

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a b

Fig. 21a and b — Transmission of excessive force

If the forces transmitted to the mucosa and bone of the edentulous area are excessive, the mucosa will become
inflamed and the bone will resorb. The obvious consequence of bone resorption is an irreversible loss of part of
the denture foundation.
(a) In this example the denture is supported only on the tissues of the edentulous area. It has caused resorption
of the bone to such an extent that the lingual bar connector has been pushed down towards the floor of the
mouth.
(b) The amount of bone that has been destroyed is apparent when the denture is removed.

Fig. 22 — Transmission of excessive force

1 2 If the design of the denture is such that it transmits excessive force to a tooth there is
every chance that the tooth will become mobile.
In this example the incorrectly designed cingulum rest (1) transmits a horizontal force
to the canine tooth. Such horizontal forces are especially damaging to the periodontal
tissues. The incisal rest (2) transmits a more favourable vertical load.
Where periodontal changes are restricted to the marginal gingivae, elimination of
excessive force will usually allow the periodontal attachment to return to a normal
healthy state. Where the supporting structures have been affected by periodontal
disease there is unlikely to be complete resolution.

1 2 3

Fig. 23 — Occlusal error

If the occlusal surface of the RPD is not designed correctly, normal jaw closure may be prevented by a
premature occlusal contact. There are three possible sequelae:
(1) If the premature contact is on a natural tooth, damage to the tooth or its periodontal ligament may occur.
(2) If the saddle bears the brunt of the force of closure, there will be localised mucosal inflammation and
resorption of the underlying bone.
(3) If the patient attempts to steer the mandible around the premature contact until a more comfortable
occlusal position is found, this abnormal closing pattern throws increased demands on certain muscles of
mastication, which may result in the patient complaining of facial pain.

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Balancing the RPD equation
A number of longitudinal clinical studies of RPDs have shown With greater understanding of the relationship between
that the types of damage itemised in the last section may be plaque and dental disease and of the importance of plaque con-
commonly found amongst wearers of RPDs. Of considerable trol, reports have appeared whose findings make for more
concern are reports that many patients expressed satisfaction encouraging reading. There is now firm evidence that the wear-
with their dentures, in spite of the fact that dental health had ing of RPDs can be compatible with continued oral health. This
deteriorated markedly. Perhaps this finding is not altogether satisfactory outcome depends upon a three-fold effort, that of
surprising when we remember the insidious nature of the pro- the clinician, the dental technician and the patient.
gression of caries and periodontal disease.

a b

Fig. 24a and b — Contribution of the clinician

The primary responsibility of the dentist and the clinical team is to ensure that the remaining teeth and
supporting tissues are restored to a healthy state and that the patient is effectively motivated and instructed in
how to maintain this state.
(a) This mouth is not in a fit state to receive an RPD. There is chronic periodontal disease and accumulation of
plaque.
(b) This patient has responded well to instruction in oral hygiene and the periodontal tissues are healthy. The
dangers of wearing the RPDs are thus minimised.

The second area of responsibility of the clinician is in relation • Clearance of gingival margins
to the design and construction of the denture. Accuracy of the • Simplicity
clinical procedures must, of course, be ensured. In addition, the • Rigid connector.
clinician should produce a design based on criteria that have
been shown to promote continued oral health: These criteria are considered in greater detail in our BDJ book
• Effective support ‘A Clinical Guide to Removable Partial Denture Design’.

Fig. 25 — Contribution of the dental technician

The dental technician’s contribution is directed towards the careful
translation of the prescribed denture design into the denture itself, and
accurate construction and positioning of the denture components. In this
instance the inaccurate fit will encourage plaque formation with
consequent periodontal disease and caries, thus introducing an
unnecessary and avoidable risk to oral health.

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Fig. 26 — Contribution of the patient
It is probably true to say that a patient who maintains immaculate plaque
control and has a good tissue resistance, or ‘host response’, can be
provided with a less than satisfactorily designed denture and still maintain
good oral health. Such is the importance of patient factors in the RPD
equation. This patient has worn a maxillary RPD for many years. The
gingival tissues are healthy and the teeth are well supported by bone; all
this in spite of the fact that there is little opportunity to provide tooth
support.

For every patient, when a denture is contemplated, it is the disadvantage it is likely that it will be in the patient’s best interest
dentist’s responsibility to assess the advantages and disadvan- that a denture is not prescribed. Of course, where a denture is
tages for that particular individual. The level of disadvantage is required to replace an anterior tooth or teeth, the demand from
influenced primarily by the patient’s dental awareness and the patient will usually be overwhelming even if the level of
plaque control. When the balance of the equation leans towards plaque control is less than satisfactory.

a b

Fig. 27a and b — Contribution of the patient

In this mouth the reasons for providing dentures are not overwhelming. There are sufficient teeth at the front of
the mouth to satisfy the demands of appearance and speech. There are certainly enough teeth to allow a varied
diet to be eaten. Most of the teeth have antagonists in the opposing arch.
If the mouth is well cared for and the patient requests dentures, the RPD equation is favourably balanced.
However, if plaque control is suspect, there is a strong argument for advising against dentures, at least for a few
months until the long-term response to oral hygiene advice is ascertained.

Further reading Renner R P. Periodontal considerations for the construction of removable partial
dentures — I and II. Quintessence Dent Technol 1985; 9: 169-72, 241-245.
RPDs and Oral Health Wagg B J. Root surface caries: a review. Comm Dent Health 1984; 1: 11-20.
Bates J F. Plaque accumulation and partial denture design. In Bates J F, Neill D J, Yap U J, Ong G. Periodontal considerations in restorative dentistry. Part 2: Prostho-
Preiskel H W (ed). Restoration of the Partially Dentate Mouth, 225-236. Chicago: dontic considerations. Dent Update 1995; 22: 13-16.
Quintessence, 1984.
Berg B. Periodontal problems associated with use of distal extension removable partial Survival of Removable Partial Dentures
dentures — a matter of construction? J Oral Rehabil 1985; 12: 369-379. Bergman B, Hugoson A, Olsson C-O. A 25 year longitudinal study of patients treated
Blinkhorn A S. Dental health education: what lessons have we ignored? Br Dent J 1998; with removable partial dentures. J Oral Rehabil 1995; 22: 595-599.
184: 58-59. Bergman B. Prognosis for prosthodontic treatment of partially edentulous patients. In:
Budtz-Jorgenson E. Oral mucosal lesions associated with the wearing of removable Owall B, Kayser A F, Carlsson G B. Prosthodontics: principles and management
dentures. J Oral Path 1981; 10: 65-80. strategies. London: Mosby-Wolfe, 1996.
Carlsson G E, Hedegård B, Koivumaa K K. Studies in partial denture prosthesis IV. Frank R P, Milgrom P, Leroux B G, Hawkins N R. Treatment outcomes with mandibu-
Final results of a 4-year longitudinal investigation of dentogingivally supported lar removable partial dentures: a population-based study of patient satisfaction.
partial dentures. Acta Odont Scand 1965; 23: 443-472. J Prosthet Dent 1998; 80: 36-45.
Chandler J A and Brudvik J S. Clinical evaluation of patients eight to nine years after Kapur K K, Deupree R, Dent R J, Hasse A L. A randomised clinical trial of two basic
placement of removable partial dentures. J Prosthet Dent 1984; 51: 736-743. removable partial denture designs. Part I: Comparisons of five year success rates
Germundsson B, Hellman M, Odman P. Effects of rehabilitation with conventional and periodontal health. J Prosthet Dent 1994; 72: 268-282.
removable partial dentures. Swed Dent J 1984; 8: 171-182. Kapur K K, Garrett N R, Dent R J, Hasse A L. A randomised clinical trial of two basic
Gray R J M, Davies S J, Quayle A A. Temporomandibular disorders. a clinical approach. removable partial denture designs. Part II: Comparisons of masticatory scores.
London: British Dental Association, 1995. J Prosthet Dent 1997; 78: 15-21.
MacEntee M I. Biologic sequelae of tooth replacement with removable partial den- Libby G, Arcuri M R, LaVelle W E, Hebl E. Longevity of fixed partial dentures. J Pros-
tures: a case for caution. J Prosthet Dent 1993; 70: 132-134. thet Dent 1997; 78: 127-13 1.
McHenry K R, Johansson O B, Christersson L A. The effect of removable partial den- Vermeulen A H B M, Kelyjens H M A M, van’t Hof M A, Kayser A F. Ten-year evalua-
ture framework design on gingival inflammation — a clinical model. J Prosthet tion of removable partial dentures: survival rates based on retreatment, not wearing
Dent 1992; 68: 799-803. and replacement. J Prosthet Dent 1996; 76: 267-272.
Orr S, Linden G J, Newman H N. The effect of partial denture connectors on gingival
health. J Clin Periodontol 1992; 19: 589-594.

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