BEREPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.

COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC.PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.NO PART OF THIS ARTICLE MAY

Bengt Öwall, LDS, Odont Dr/PhDa

Ejvind Budtz-Jörgensen, DDS, Dr Odontb
John Davenport, BDS, FDSRCS, PhDc
Eiko Mushimoto, DDS, Dr Med Dent, PhDd
Removable Partial Denture Design: Sigvard Palmqvist, LDS, Odont Dr/PhDe
Robert Renner, DDSf
A Need to Focus on Hygienic Afrodite Sofou, DDS, Dr Dentg
Principles? Bernd Wöstmann, Dr Med Denth

Purpose: The purpose of this study was to critically analyze important hygienic/secondary
prophylactic and biomechanical aspects of removable partial denture (RPD) design.
Materials and Methods: The literature related to traditional biomechanical design and
open/hygienic design of RPDs was discussed by the authors at a 2.5-day workshop. The
written report was circulated among the authors until a consensus was reached. Results:
There is little scientific support for most of the traditional design principles of RPDs, nor has
patient satisfaction shown any correlation with design factors. However, there is evidence
that an open/hygienic design is more important than biomechanical aspects for long-term
oral health. The biomechanical importance of some components is questioned, eg, indirect
retention and guiding planes. Alternative connector designs that reduce risks of tissue injury
are described. Direct retainers and pontics are discussed in relation to the possibilities they
offer for gingival relief. Conclusion: Greater attention should be paid to RPD design
principles that minimize the risks of tissue injury and plaque accumulation in accordance
with modern concepts of preventive dentistry. Int J Prosthodont 2002;15:371–378.

T raditionally, removable partial denture (RPD) de-

sign has focused on biomechanical aspects such
as stability, retention, loading of supporting tissues,
and mechanical durability. However, in addition to
these considerations, it is of fundamental importance
that RPDs be designed so that they interfere as little
aProfessor and Chair, Department of Prosthetic Dentistry, Faculty
as possible with plaque control and do not damage
of Health Sciences, University of Copenhagen, Denmark.
bProfessor and Chair, Division of Gerodontology and Removable
the oral tissues. Such design parameters are termed
Prosthodontics, Section of Dental Medicine, University of Geneva, the secondary prophylactic aspects by Marxkors.1
Switzerland. They are also called hygienic principles.
cProfessor Emeritus, University of Birmingham, School of Dentistry,
Several studies of the outcomes of RPD treatment
St Chad’s Queensway, Birmingham, United Kingdom. have been performed in different parts of the world.
dAssociate Professor, Department of Removable Prosthodontics,
There appears to be, however, no unanimous opinion
Iwate Medical University College of Dentistry, Japan.
eAssociate Professor, Department of Prosthetic Dentistry, Faculty on RPD design principles, although one national sur-
of Health Sciences, University of Copenhagen, Denmark. vey demonstrated that many principles receive the sup-
fProfessor Emeritus, University at Stony Brook School of Dental
port of a majority of prosthodontic specialists.2 The RPD
Medicine, New York. design principles are not based on clinical research and
gAssistant Professor, Department of Removable Prosthodontics,
therefore are not evidence based. However, there are
Aristotle University, Thessaloniki, Greece.
hProfessor, Department of Prosthodontics, Justus Liebig University, a number of reports of adverse effects on the oral tis-
Giessen, Germany. sues and a high frequency of patient dissatisfaction.
The aim of this article is to critically analyze, in the
Reprint requests: Prof Bengt Öwall, Department of Prosthetic
Dentistry, University of Copenhagen, 20 Nørre Alle, DK-2200 light of current preventive concepts, some important
Copenhagen N, Denmark. Fax + 4535326739. e-mail: hygienic and related biomechanical aspects of RPD
[email protected] design.

Volume 15, Number 4, 2002 37 The International Journal of Prosthodontics

371
 RPD Design and Hygienic Principles Öwall et al

Materials and Methods

BEREPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC.PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.NO PART OF THIS ARTICLE MAY

to prescribe them and to adopt the shortened dental

arch concept whenever acceptable.6,15,16 Alterna-
The literature on the biomechanical aspects and hy- tively, other treatment options may be employed,
gienic requirements of RPD design was reviewed by such as fixed partial dentures (FPD).17,18
an international group of prosthodontists, the au-
thors, at a workshop in Copenhagen, Denmark, in Open Design/”Hygienic Design”
June 1999. Attention was paid in particular to possi-
ble conflicts of interest between these two approaches The basic principle of open hygienic RPD design is
to design. The discussions leading to a preliminary presented in a German standards document that
agreement were written down and circulated among states in translation, “If the base elements of the RPD
the authors until consensus was achieved. Literature do not contact either teeth or periodontium, it can-
brought forward during the discussions was included not cause any injuries to these stuctures.”19 Open de-
in the report, as was as any new literature that ap- sign for gingival and periodontal health is frequently
peared during the writing period. mentioned in the literature, and its advantages have
been demonstrated in a number of publications.20,21
Results Jacobson22 presents guidelines for designing RPDs
and states that, “Although some patients can maintain
It was concluded from the discussions that the open/ meticulous levels of home care regardless of the pros-
hygienic aspects of RPD design should be collected thesis design, partial dentures should be fabricated
and documented in a form suitable for coherent pre- along guidelines that benefit the majority of patients,
sentation to the prosthodontic community. including those who demonstrate less-than-ideal lev-
els of plaque control.” He also stated, regarding tradi-
Success with RPD Treatment tional RPD construction, that, “Such designs incorpo-
rate many framework components and result in the
RPD treatment can be evaluated with regard to various undesirable coverage of hard and soft tissues.”22 The
parameters, such as denture survival, patient satisfac- conclusion was that, “The emphasis in contemporary
tion, functional efficiency, and effects on oral health. RPD design should be placed on minimal tooth cov-
erage by framework components and on the elimina-
Survival of RPDs tion of components whenever possible without com-
promising biomechanical requirements.”22
Metal-framework RPDs have been shown to have a Longitudinal studies of RPD patients found that
relatively short survival time. Vermeulen3 reported a those who did not use their dentures had better pe-
50% survival time of about 10 years for clasp-re- riodontal conditions than those who did. 23–25
tained metal-framework RPDs, and a very short 50% Remarkably good long-term periodontal and gingival
survival time, about 3 years, for acrylic resin RPDs conditions were, however, maintained in controlled
without metal frameworks. That study did not give studies of RPD patients where the patients were wear-
any details about design or adverse effects of RPDs, ing RPDs of the open hygienic type and were on a
but it did underline the need to focus on the long-term regular maintenance program26–29 or were wearing
effects. A large study of metal-framework RPDs con- RPDs of the open hygienic design.30
cluded that with a simple design and regular moni- Yeung et al21 examined 87 patients who had been
toring of the patient, the results are predictably suc- treated with cobalt chromium RPDs 5 to 6 years pre-
cessful.4 The term “simple design” was, however, viously. Significantly more tooth sites adjacent to
not defined. narrow embrasures with RPDs harbored plaque than
those adjacent to wide embrasures. The same was
Patient Satisfaction true for gingival bleeding and loss of periodontal at-
tachment, measured as loss of 4 mm or more of mar-
Patient satisfaction with RPDs is relatively low.5–14 The ginal attachment. The association between root caries
figures in these studies are similar even though they and narrow embrasures was also statistically signifi-
originate from different countries with different design cant. The authors concluded that RPD components
philosophies. Constructional or design aspects that should be designed to uncover the gingival margins
can explain the low success rates have, however, not as often as possible.21
been identified. This combination of frequent rejec- Severe gingival reactions have been observed
tion of RPDs and high risk of adverse effects provides when the gingiva is covered, whereas an open design
a strong motive to consider new approaches.6 One of minor connector is less conducive to an increase
way to reduce the oral health risks from RPDs is not in crevicular temperature, plaque formation, gingival

The International Journal of Prosthodontics 37 Volume 15, Number 4, 2002

372
 Öwall et al RPD Design and Hygienic Principles

inflammation, and pocket depth.31–33 “Therefore, as

BEREPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC.PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.NO PART OF THIS ARTICLE MAY

their seats so that rotation about an axis occurs. If total

a general rule, the design of removable partial den- displacement of the direct retainer occurs, there will
tures should be as simple as possible with denture be no rotation about the fulcrum and so no indirect
bases, major connectors, and minor connectors retention.38 However, it has not been demonstrated
avoiding contact with the free gingiva and contact- that occlusal rests are held in their seats during func-
ing the alveolar ridge or the palate at least 3 mm from tion, rather the opposite.
tooth surfaces . . .”34 In a survey of prosthodontic spe- There are divided opinions regarding the value of
cialists, the majority supported use of the open design indirect retention. For example, Grant and Johnson40
when plaque control was poor.2 stated that, “The improved stability which can be
Spiekermann and Gründler,35 when discussing pe- achieved in a partial denture by placement of indirect
riodontal prophylaxis in RPD design, emphasize that retainers needs to be weighed against their possible
clasps should be placed as far as possible from gingi- disadvantages. The latter include the biological dis-
val margins and that the number of minor connectors advantages arising from increased coverage of soft and
should be kept to a minimum. They suggest direct hard tissues of the mouth, and the fact that they may
minor connectors approaching from the base areas, give rise to irritation of the tongue or other oral tissues.”
with open proximal spaces, instead of palatally or lin- Similarly, Marxkors41 questioned the overall benefit of
gually approaching minor connectors and mention indirect retention, as the indirect retainer lifts off the
that gingival relief can be further achieved by design- abutment tooth and becomes a potential source of ir-
ing the first replacement tooth of a base as a pontic.35 ritation when the distal extension base is loaded.
Adopting a simple shape for the prosthesis and Indirect retainers are often connected to the denture
keeping the number of components to a minimum base by minor connectors that, if they make contact
have major advantages as far as hygiene is con- “with axial tooth surfaces, aid in stabilization against
cerned.36 A survey of expert prosthodontic opinion horizontal movement of the denture. Such tooth sur-
showed that the majority are in favor of a maximum faces, when made parallel to the path of placement,
of two direct retainers and a major connector of sim- may also act as auxiliary guiding planes.”38 Indirect
ple shape.37 There is significant support in the liter- retainers and their minor connectors make the denture
ature for the view that gingival/periodontal health is more complex, and as the minor connectors cross the
favored by the open/hygienic design. gingival margins, they increase the risk of damage to
the gingiva. Therefore, a modified, more hygienic de-
Risk Factors in Traditional Design sign has been introduced by extending the minor con-
nector around the lingual aspect of the abutment
The majority of prosthodontic textbooks have con- tooth and onto the next tooth, thus avoiding the need
centrated on the RPD design principles of force dis- to cross the gingival margin.22,42–44
tribution, support, stability, and retention. The most An indirect retainer is supposed to reduce the risk
widely disseminated general design rules are the ones of the denture base moving away from the mucosa.45,46
described and advocated in McCracken’s textbook of However, clinical studies do not confirm that this hap-
removable partial prosthodontics.38,39 The basic prin- pens in practice. A cineradiographic study of the move-
ciples are, however, founded on ideas that are not sci- ments of bilateral distal extension mandibular RPDs
entifically proven. during chewing showed lifting of the bases even
though indirect retainers were provided.47
Direct and Indirect Retention It has been argued that there is a risk of lever action
on the clasped mesial tooth in extension base RPDs if
Direct and indirect retention feature prominently in a direct retainer is placed on the opposite side of the
the relevant design principles. The distal extension fulcrum line.38,39,44 Most design philosophies indicate
denture is assumed to rotate around a fulcrum line that such constructions are inappropriate, and this
when bases are subjected to forces directed toward seems to be a common worldwide view found in text-
or away from the residual ridge.38 books.34,35,43,48–50 In the textbook by Bergman et al,43
Indirect retainers are “rigid units of the partial den- this principle is named the “Cummer rule.”49,50 How-
ture framework that are located on definite rest seats ever, examples that do not conform to the Cummer rule
on the opposite side of the fulcrum line from the dis- can be found.37,51 In fact, a critical analysis of the lit-
tal extension base” and “should be placed as far as erature did not find any evidence that a reduction of
possible from the distal extension base affording the torquing forces transmitted to abutment teeth is nec-
best possible leverage advantage against the lifting of essary.52
the distal extension base.”38 For indirect retention to In spite of the fact that there is little or no scientific
operate, the rests on the fulcrum line must be held in evidence for most of the basic biomechanical design

Volume 15, Number 4, 2002 37 The International Journal of Prosthodontics

373
 RPD Design and Hygienic Principles Öwall et al
BEREPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC.PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.NO PART OF THIS ARTICLE MAY

principles described above, there is a high level of esthetics may be compromised), lingually inclined
agreement about many of them among prosthodon- teeth, and long dental arches, as the rigidity of the
tic experts from dental schools in the United connector may be unsatisfactory. The dimensions
Kingdom.37 For example, all agreed that indirect re- recommended are 4-mm height and 1.5- to 2.5-mm
tention should be used for distal extension bases. thickness.34,70 The dental bar has a long history, al-
though the early use was not motivated by gingival
Guiding Planes/Surfaces health considerations.71,72
The sublingual bar, which maximizes the clear-
Guiding planes are believed to increase retention by ance of the gingival area, has also been described by
increasing the efficiency of the direct retainers. They a number of authors.69,73–76 Food trapping has been
are used differently throughout the world. If em- reported and is made worse if the superior border of
ployed, the gingival relief is reduced. Guiding planes the bar is in contact with the mucosa.76–78 Therefore,
are frequently advocated in the US,38,39,53,54 and clearance between the alveolar mucosa and the sub-
sometimes extensively.55 lingual bar is now suggested.22,34,44 The recom-
The European literature recommends the prepara- mended cross-sectional dimensions of the sublin-
tion of planes less strongly than in the US. It tends to gual bar are 4 mm
2 mm.34
suggest specific justifications for the recontouring of
abutment teeth, eg, to eliminate occlusally high sur- Minor Connectors
vey lines.1,43,44,51,56 British textbooks seem to be of
the opinion that guiding surfaces are advantageous Minor connectors can, in most situations, be ex-
from a mechanical viewpoint, but that there are often tended directly from the base onto the proximal as-
contraindications to their use.40,48,57–59 When abut- pect of the abutment tooth, allowing an open em-
ment teeth are to be crowned, a German textbook brasure to be created. The direct minor connector
recommends that distinct guiding planes be incor- principle is easily accomplished for the mandibular
porated into the restoration, but a more conservative dental bar by continuing it directly into the connec-
approach is advised when removal of natural tooth tor (Figs 1 and 2). In molar regions, the minor direct
substance is involved.35 connector can be extended and shaped similarly to
The conclusions from the London International a sanitary pontic in an FPD. Where a minor con-
Prosthodontic Symposium 1982 still hold true: “It is nector has to enter a dental arch without any re-
clear that all partial dentures encourage a severe placement tooth or denture base, it can cross the gin-
ecological change, but until studies are conducted on gival margin at the midpoint of the lingual/palatal
larger samples of subjects having both similar needs tooth surface.35,38,39,65,66,68,70,79–81
for prosthetic replacement and measured assessment
of response to previous periodontal disease, the sig- Pontics
nificance of guiding planes cannot readily be as-
sessed.”60 The use of pontics in RPD design is described by a
number of authors. McGivney and Castleberry38
Clinical Examples and Recommendations mention that replacement teeth can be abutted to the
residual ridge for better esthetics, and Davenport et
The open/hygienic design principles that emphasize al57 show the use of a “cleansable” pontic. The pon-
simplicity and uncovering of gingival margins have tic was introduced into the hygienic RPD design
mostly been presented in national publications, not concept by Karlsen.30,65 It was later advocated and
always easily available. Some illustrative examples described in other publications.41,66–68,82 The pontic
are therefore discussed below. is not very often presented in the literature and is
therefore exemplified in Figs 1 to 4.
Mandibular Major Connector
Direct Retainers
Alternatives to the lingual bar are the sublingual
bar, dental bar, and linguoplate. It is clear that the Occlusally approaching retainers minimize the risk of
choice is geographically related.61–64 Many authors physical injury to the gingival tissues. They may, how-
consider the linguoplate disadvantageous from a hy- ever, have drawbacks related to esthetics. A common
gienic and gingival health viewpoint. alternative is a gingivally approaching bar retainer, but
The dental bar has been described by several this creates a risk of irritation to the facial gingival mar-
authors.20,30,65–70 Limiting factors mentioned are short gin and, in cases of shallow sulci, to the mucosa.82 An
clinical crowns, diastemas (in situations where alternative retainer design is a buccal/facial retentive

The International Journal of Prosthodontics 37 Volume 15, Number 4, 2002

374
 Öwall et al RPD Design and Hygienic Principles
BEREPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC.PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.NO PART OF THIS ARTICLE MAY

Pontic
Retention for pontic

Fig 1 Dental bar can continue distal of the abutment tooth and Fig 2 Alternative retention for acrylate.30,65
be designed to retain a pontic.

Pontic

Maxillary pontic
with metal backing

Fig 3 Lingual (or sublingual) bar can extend distal of the first Fig 4 In a situation of high risk for breakage or wear, the whole
replacement tooth and a pontic placed in the junction area. lingual and/or occlusal surface should preferably be metal.

arm approaching horizontally and proximally directly A critical analysis of the literature revealed that no
from the denture base or pontic across the embrasure clinical studies provide evidence to support the well-
and well relieved from the gingival tissue (Figs 5 and established “biomechanical” design principles.
6).81 However, adverse effects from RPDs are com-
mon.21,23,25 In addition, patient satisfaction with
Discussion RPDs is low5–14 in spite of the constructions being de-
signed for biomechanics, which basically aims at pa-
From the outset, when planning the workshop on tient comfort and denture function. Although these
which this article is based, it was decided that the problems have been known for many years, they do
topic should be RPD design, with a particular em- not seem to have influenced RPD design much,
phasis on prevention. The participants very quickly when judged from recent textbooks.39 It was, how-
came to the unanimous opinion that there was a ever, clear that the evidence for the benefits of
need to critically analyze traditional RPD design con- open/hygienic design was also weak and indirect.
cepts in the light of contemporary preventive den- There seemed, though, to be reason enough to ques-
tistry. It was apparent that most RPD literature focused tion some generally accepted design rules, and to
primarily on design related to biomechanical as- stimulate clinical studies about alternative con-
pects, while design approaches related to hygiene structional principles that could reduce risk factors.
and prevention were mostly described as “alternative” The group was aware of the possibility of being con-
constructions, if at all.37–40,48 A coherent presentation sidered revolutionary, but found good grounds to
of hygienic/preventive aspects could thus be benefi- promote the open/hygienic designs found in the re-
cial to the prosthodontic community. cent literature. It was also apparent that these design

Volume 15, Number 4, 2002 37 The International Journal of Prosthodontics

375
 RPD Design and Hygienic Principles Öwall et al
BEREPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC.PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.NO PART OF THIS ARTICLE MAY

Pontic

Pontic

Figs 5 and 6 Wrought-wire S-bar retainer83 approaches the retentive area directly from the base
or pontic without crossing the gingival margin. In cases of long clinical crowns and shallow sulci,
it is especially indicated. The length relates to the depth of the undercut and the flexibility needed.
It is free from the pontic buccal surface. Rest seats at cingulum or as incisal hooks.

aspects can be applied without invariably compro- 7. Riber E, Öwall B. Patient use of removable partial dentures.
mising the requirements of biomechanics. Results from the dental schools in Copenhagen and Århus.
Tandlægebladet 1998;102:936–940.
8. Frank RP, Milgrome P, Leroux BG, Hawkins N. Treatment out-
Conclusion come with mandibular removable partial dentures: A population-
based study of patient satisfaction. J Prosthet Dent 1998;80:36–45.
The literature indicates that gingival coverage and 9. Nylin J, Gunne J. Opinions and wearing habits among patients new
a close relationship between parts of the RPD and to removable partial dentures. An interview study. Swed Dent J
1989;13:89–93.
the gingival tissues are risk factors for the long-
10. Nakazawa I. A clinical survey of removable partial dentures:
term success of an RPD. The RPD components that Analysis of follow-up examinations over a 16-year period. Bull
especially need to be considered from a hygienic Tokyo Med Dent Univ 1977;24:125–137.
viewpoint are direct retainers, indirect retainers, 11. Redford M, Drury A, Kingman A, Brown LJ. Denture use and tech-
guiding planes, minor connectors, and mandibular nical quality of dental prostheses among persons 18–74 years of
age: United States, 1988–1991. J Dent Res 1996;75:714–725.
major connectors. A critical analysis of RPD design
12. Cowan RD, Gilbert JA, Elledge DA, McGlynn FD. Patient use of
carried out in the light of modern concepts of pre- removable partial dentures: Two- and four-year telephone in-
ventive dentistry favors open/hygienic design prin- terviews. J Prosthet Dent 1991;65:668–670.
ciples rather than biomechanical considerations. 13. Germundsen B, Hellman M, Ödman P. Effect of rehabilitation
There is accordingly a need to focus on minimiz- with conventional removable partial dentures on oral health—
A cross-sectional study. Swed Dent J 1984;8:171–182.
ing risks of oral tissue injury in RPD treatment and
14. Jokovic A, Locker D. Dissatisfaction with oral health status in an
design. older adult population. J Public Health Dent 1997;57:40–47.
15. Käyser AF. Shortened dental arch: A therapeutic concept in re-
References duced dentitions and certain high-risk groups. Int J Periodontics
Restorative Dent 1989;9:426–429.
1. Marxkors R. The Partial Denture with Metal Framework. Bremen, 16. Witter DJ, van Elteren P, Käyser AF, van Rossum GM. Oral com-
Germany: BEGO, Bremer Goldschlägarei Wilhelm Herbst, 1984. fort in shortened dental arches. J Oral Rehabil 1990;17:137–143.
2. Davenport JC, Hammond P, deMattos MG. The acquisition and 17. Budtz-Jörgensen E, Isidor F. A 5-year longitudinal study of can-
validation of removable partial dentures design knowledge. II. tilevered fixed partial dentures compared with removable partial
Design rules and expert reactions. J Oral Rehabil 1996;23:811–824. dentures in a geriatric population. J Prosthet Dent 1990;64:42–47.
3. Vermeulen A. Een Decennium Evaluatie van Partiele Prothesen. 18. Jepson NJA, Allen PF. Short and sticky options in the treatment
Een Beschrijvend Klinisch Longitudinal Onderzoek [thesis]. of the partially dentate patient. Br Dent J 1999;187:646–652.
Nijmegen, the Netherlands: University of Nijmegen, 1984. 19. Marxkors R. Kriterien für die Zahnärztliche Prothetik. Partielle
4. Vermeulen AHBM, Keltjens HMAM, van’t Hof MA, Käyser AF. Prothese. Studienhandbuch des Projektes: Qualitätssicherung in
Ten-year evaluation of removable partial dentures: Survival der Zahnmedizin. Würzburg, Germany: Gesellschaft für Strahlen-
rates based on retreatment, not wearing and replacement. J und Umweltforschung. München: Im Aufbau für das Bundes-
Prosthet Dent 1996;76:267–272. ministerium für Forschung und Technologie, 1988:25–26.
5. Wöstmann B. Tragedauer von klammerverankerten Einstückguss- 20. Mäkilä E, Koivumaa KK, Jansson H. Clinical investigation of skele-
prothesen in überwachten Gebrauch. Dtsch Zahnarztl Z 1997;52: tal partial dentures with lingual splint (continuous clasp). 1.
100–104. Periodontal and dental changes. Suom Hammaslaak Toim 1971;
6. Jepson NJA, Thomason JM, Steele JG. The influence of denture de- 67:312–324.
sign on patient acceptance of partial dentures. Br Dent J 1995;178:
296–300.

The International Journal of Prosthodontics 37 Volume 15, Number 4, 2002

376
 Öwall et al RPD Design and Hygienic Principles

21. Yeung ALP, Chow TW, Clark RKF. Oral health status of patients 46. Cummer WE. Partial denture service. In: Anthony LP (ed).
BEREPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC.PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.NO PART OF THIS ARTICLE MAY

5–6 years after placement of cobalt-chromium removable par- American Textbook of Prosthetic Dentistry, ed 7. Philadelphia: Lea
tial dentures. J Oral Rehabil 2000;27:183–189. & Febiger, 1942:782.
22. Jacobson TE. Periodontal considerations in removable partial 47. Hedegård B, Lundberg M, Wictorin L. Denture mobility during
denture design. Compend Contin Educ Dent 1987;8:530–539. chewing. Svensk Tandläkare-Tidskrift 1966;59:403–415.
23. Koivumaa KK, Hedegård B, Carlsson GE. Studies in partial den- 48. Lechner SK, MacGregor AR. Removable Partial Prosthodontics.
tal prosthesis. I. An investigation of dentogingivally supported A Case-Oriented Manual of Treatment Planning. London: Wolfe,
partial dentures. Suom Hammaslaak Toim 1960;56:248–306. 1994.
24. Carlsson GE, Hedegård B, Koivumaa KK. Studies in partial dental 49. Diakoyianni-Mordohai IH. Azaria’s Partial Dentures.
prosthesis. II. An investigation of mandibular partial dentures with Thessaloniki: University of Thessaloniki, 1994.
double extension saddles. Acta Odontol Scand 1961;19:215–237. 50. Haruyasu M. Removable Partial Dentures for Students, ed 3.
25. Carlsson GE, Hedegård B, Koivumaa KK. Studies in partial den- Tokyo: Ishiyaku, 1999.
tal prosthesis. IV. Final results of a 4-year longitudinal investiga- 51. Kaaber S. A review of design of RPD frameworks and the clini-
tion of dentogingivally supported partial dentures. Acta Odontol cal procedure. Aarhus, Denmark: Department of Prosthetic
Scand 1965;23:443–472. Dentistry and Stomatognathic Physiology, University of Aarhus,
26. Bergman B, Hugoson A, Olsson C-O. Periodontal and prosthetic 1995.
conditions in patients treated with removable partial dentures 52. Berg E. Periodontal problems associated with use of distal ex-
and artificial crowns. Acta Odontol Scand 1971;29:621–638. tension removable partial dentures—A matter of construction?
27. Bergman B, Hugoson A, Olsson C-O. Caries and periodontal sta- J Oral Rehabil 1985;12:369–379.
tus in patients fitted with removable partial dentures. J Clin 53. Renner RP, Boucher LJ. Removable Partial Dentures. Chicago:
Periodontol 1977;4:134–146. Quintessence, 1987.
28. Bergman B, Hugoson A, Olsson C-O. Caries, periodontal and 54. Stratton RJ, Wiebelt FJ. An Atlas of Removable Partial Denture
prosthetic findings in patients with removable partial dentures: Design. Chicago: Quintessence, 1988.
A ten-year longitudinal study. J Prosthet Dent 1982;48:506–514. 55. Brudvik J. Advanced Removable Partial Dentures. Chicago:
29. Bergman B, Hugoson A, Olsson C-O. A 25-year longitudinal Quintessence, 1999.
study of patients treated with removable partial dentures. J Oral 56. Marxkors R. Mastering the removable partial denture. Part two:
Rehabil 1995;22:595–599. Connection of partial denture to the abutment teeth. J Dent
30. Karlsen K. Partielle proteser. Norske Tandlegeforen Tidende 1964; Technol 1997;14:24–30.
74:47–52. 57. Davenport JC, Basker RM, Heath JR, Glantz PO. A Clinical
31. Chandler JA, Brudvik J. Clinical evaluation of patients eight to nine Guide to Removable Partial Dentures. London: British Dental
years after placement of removable partial dentures. J Prosthet Dent Dental Association, 2000.
1984;51:736–743. 58. Watt DM, MacGregor AR. Designing Partial Dentures. Bristol,
32. Runov J, Kroone H, Stoltze K, Maeda T, El Ghamrawy E, Brill N. UK: Wright, 1984.
Host response to two different designs of minor connectors. J Oral 59. Bates J, Huggett R, Stafford GD. Removable Denture Construction,
Rehabil 1980;7:147–153. ed 3. London: Wright, 1991.
33. Nada M, Gharrphy S, Badawy MS. A two-year longitudinal 60. Zarb G, Watson, RM, Hobkirk, J. Guide planes. In: Bates JF, Neill
study on the effect of removable partial denture design on the DJ, Preiskel HW (eds). Restoration of the Partially Dentate Mouth.
health of the remaining teeth. Egypt Dent J 1987;33:85–95. Proceedings of the International Prosthodontic Symposium 1982.
34. Budtz-Jörgensen E. Prosthodontics for the Elderly. Diagnosis London: Quintessence, 1984:193–201.
and Treatment. Chicago: Quintessence, 1999. 61. Toremalm H, Öwall B. Partial edentulism treated with cast frame-
35. Spiekermann H, Gründler H. Die Modellguss-Prothese. Ein Leitfa- work removable partial dentures. Quintessence Int 1988;19:
den für Zahnartzt und Zahntechniker. Berlin: Quintessence, 1977. 493–499.
36. Brill N, Tyde G, Stoltze K, El Ghamrawy EA. Ecologic changes 62. Öwall B, Taylor R. A survey of dentitions and removable partial
in the oral cavity caused by removable partial dentures. J Prosthet dentures constructed for patients in North America. J Prosthet Dent
Dent 1977;38:138–148. 1989;61:465–470.
37. Davenport JC, Basker RM, Heath JR, Ralph JP, Glantz PO, 63. Öwall B, Bieniek KW, Spiekermann H. Removable partial den-
Hammond P. A Clinical Guide to Removable Partial Denture ture production in western Germany. Quintessence Int 1995;26:
Design. London: British Dental Association, 2000. 621–627.
38. McGivney GP, Castleberry DJ. McCracken’s Removable 64. Öwall B, Junggren L, Yemm R. Removable partial denture pro-
Prosthodontics, ed 9. St Louis: Mosby, 1995. duction in Scotland. Quintessence Int 1996;27:809–815.
39. McGivney GP, Carr AB. McCracken’s Removable Prosthodontics, 65. Karlsen K. Removable partial dentures. In: Holst J-J, Nygaard-
ed 10. St Louis: Mosby, 2000. Østby B, Osvald O (eds). Nordisk Klinisk Odontologi.
40. Grant AA, Johnson W. Removable Denture Prosthodontics, ed Copenhagen: A/S Forlaget for Faglitteratur, 1973:1–24.
2. Edinburg: Churchill Livingstone, 1992. 66. Öwall B. Hygienic removable partial denture. Boxholm, Sweden:
41. Marxkors R. Mastering the removable partial denture. Part one: Dentala Proteslaboratoriet and Tandteknikertjänst, 1986.
Basic reflections about construction. J Dent Technol 1997;14: 67. Öwall B, Sofou A. Dental connector for mandibular removable
34–39. partial dentures [in Greek]. Stoma 1999;28:147–153.
42. Derry A, Bertram U. A clinical survey of removable partial den- 68. Mushimoto E. Design of removable partial denture and con-
tures after 2 years of usage. Acta Odontol Scand 1970;28:581–598. struction of metal frame. In: Mitani H (ed). Removable Partial
43. Bergman B, Gunne J, Ekenbäck J, Ödman P. Partiell Plattprotetik. Dentures for Dental Students. Tokyo: Ishiyaku, 1979.
Stockholm: Investodont, 1994. 69. Walter JD. Alternative major connectors for mandibular partial
44. Budtz-Jörgensen E, Bochet G. Alternative framework design for dentures. Restorative Dent 1986;2:80–84.
removable partial dentures. J Prosthet Dent 1998;80:58–66. 70. Meeuwissen R, Keltjens HMAM, Battistuzzi PGFCM. Cingulum
45. Cummer WE. Theory and Practice of Partial Denture Service, bar as a major connector for mandibular removable partial den-
with Special Reference to a Method of Design. (Bulletin No. 5.) tures. J Prosthet Dent 1991;66:221–223.
Toronto: The Canadian Dental Research Foundation, 1922:1–27.

Volume 15, Number 4, 2002 37 The International Journal of Prosthodontics

377
 RPD Design and Hygienic Principles Öwall et al

71. Spreng M. Über partiellen Prothesen, die den Restzähnen 78. Hansen CA, Campbell DJ. Clinical comparison of two mandibu-
BEREPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
COPYRIGHT © 2002 BY QUINTESSENCE PUBLISHING CO, INC.PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.NO PART OF THIS ARTICLE MAY

aufgestützt werden. Dtsch Zahnartzl Z 1956;11:1327–1333. lar major connector designs: The sublingual bar and the lingual
72. Gasser F. Spätergebnisse: Partielle Prothesen im Unterkiefer mit plate. J Prosthet Dent 1985;54:805–809.
fortlaufenden klammern. Schweiz Monatsschr Zahnheilk 1969;79: 79. Öwall B, Sofou A. Hygienic aspects in removable partial den-
342–354. tures [in Greek]. Stomatologia 1998;55:173–177.
73. Tryde G, Brantenberg F. The sublingual bar. Tandlægebladet 80. Radford DR, Walter JD. A variation in minor connector design
1965;69:873–885. for partial dentures. Int J Prosthodont 1993;6:50–54.
74. Basker R, Tryde G. Connectors for mandibular partial dentures: 81. Fuhr K. Modellgussprothesen. In: Hupfauf L (ed). Teilprothesen.
Use of the sublingual bar. J Oral Rehabil 1977;4:389–394. München: Urban & Schwarzenberg, 1988:117–162.
75. Brunner T, Marinello C. Der Sublingualbügel nach Tryde und 82. Budtz-Jörgensen E, Bochet G, Grundman M, Borgis S. Aesthetic
Brantenberg—Eine noch wenig bekannte Form des grossen considerations for the treatment of partially edentulous patients
Verbindungselements im Unterkiefer. Schweiz Monatsschr with removable dentures. Pract Periodontics Aesthet Dent 2000;
Zahnheilk 1983;93:352–361. 12:765–772.
76. Stilwell C. Sublingual bars: Prescription and technique. 83. Öwall B. S-bar clasp in wrought noble metal wire. Tandteknikern
Quintessence Int 1988;19:555–558. 1983;52:57–60.
77. Marinello C, Brunner T. Nachkontrolle von Unterkiefergerüst-
prothesen an der Zürcher Volkzahnklinik. Erste Erfahrungen mit
dem Sublingualbügel nach Tryde und Bratenberg. Schweiz
Monatsschr Zahnheilk 1983;93:423–440.

Literature Abstract

No association between incisal tooth wear and temporomandibular disorders.

This study investigated the relation between anterior tooth wear and TMD; 208 TMD patients
and 172 asymptomatic control subjects were selected. Individuals with more than one missing
premolar or molar in opposite arches and subjects with missing or extensively restored anterior
teeth were excluded. There were 154 TMD patients and 120 control subjects included (age 31.2
± 13.4 years). Anterior tooth wear was assessed on dental casts with a 0 to 5 scale. A multiple lo-
gistic regression analysis was performed to study the association between tooth wear and TMD.
Incisal tooth wear was not significantly associated with TMD when the influence of age and gen-
der was controlled. Substantial tooth wear, which might be regarded as a sign of bruxism, does
not yield a higher risk for the development of TMD. Based on the presented evidence, a clinically
relevant risk for TMD from incisal tooth wear can be excluded. The findings of this investigation
do not support the notion that treatment of incisal tooth wear is indicated to prevent TMD.

John MT, Frank H, Lobbezoo F, Drangsholt M, Dette KE. J Prosthet Dent 2002;87:197–203.
References: 41. Reprints: Dr Mike T. John, 4747 30th Avenue NE, #A 102, Seattle, Washington 98105.
Fax: + (206)522-8345. e-mail: [email protected]—Ansgar C. Cheng, Toronto

The International Journal of Prosthodontics 37 Volume 15, Number 4, 2002

378