Dual-path design for removable partial dentures

Gordon E. King, D.D.S.* National Naval Dental Center, Bethesda, Md.

The concept of a dual path of insertion has been .applied to removable partial dentures for many years. Unfortunately, few illustrations of its applications have appeared in the literature. The purpose of this article is to describe situations in which use of a dual-path concept can improve esthetics, cleanliness, and retention of removable partial dentures. TECHNIQUE OF PLACEMENT The designation "dual path of insertion" can be misleading, for it implies two separate and complete paths of insertion, an impossibility with a single framework. In the dual-path concept, the first path, or approach of the framework to the teeth, is a maneuver to gain access to undercuts otherwise inaccessible from a single path of insertion. As soon as the framework has gained access to these desired undercuts, it is rotated to its fully seated position, the second and completed path of insertion. SIGNIFICANCE OF DUAL-PATH DESIGN When the framework is positioned firmly as a result of the final seating, it is literally locked in place. However, no active pressure other than the weight of the prosthesis is exerted on the abutment teeth. That portion of the framework positioned in the first-path undercuts cannot be removed without lifting the entire framework from its fully seated position and rotating it out and away from tile teeth. Only a minor connector, a guiding plane, or a small rigid extension of the framework into a desired under-cut is required for retention. Elimination of conventional clasps considerably improves the self-

cleansing and esthetic characteristics of removable partial dentures. SPECIAL C O N S I D E R A T I O N S All of the fundamentals of removable partial dentures must be observed to achieve success with this technique. T h e characteristics of a dual-path design require a few special considerations: I. The dual-path design should be limited to tooth-supported situations to prevent torquing of abutment teeth by nonparallel guiding planes. tJowever, in some unilateral extension base dentures the dual-path principle can be applied to the toothsupported side. 2. Positive occlusal rests on abutment teeth are particularly important to prevent gingival movement of the framework and thereby break the "locked-in" effect of the framework in the first-path undercuts. 3. Rotation of the framework from its first-path position to its fully seated, second path makes it essential to contour the supporting teeth or prepare them to meet the arc of this rotation. This requirement is met ideally and naturally by the combination of a long endentulous span and short guiding planes, or by establishing the longest possible anteroposterior distance between the first-path and secondpath abutment teeth. POSTERIOR APPLICATION OF DUAL-PATH DESIGN The dual-path design can be especially useful when a patient has lost a large number of mandibular posterior t e e t h ' b u t h~/s retained a second or third molar. Conventional clasping can be a problem, for frequently the mandibular molars are inclined mesially (Fig. 1). Tile mesial proximal surface is undercut in relation to the occlusal plane (Fig. 2). However, it is an ideal source of retention for a dual path of insertion design. When the edentulous space anterior to the distal

The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Navy or the Department of Defense. *Captain (DG) USN; Chairman, Prosthodontic Department, and Chief, Maxillofacial Division.

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VOLUME39

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DUAL-PATH DESIGN FOR REMOVABLE PARTIAL DENTURES

abutment tooth is long enough for two or more teeth, and the distal proximal surface of the anterior abutment tooth is short or inclined anteriorly, the framework can be rotated to its fully seated second path after being moved posteriorly into the proximal undercut of tile molar abutment teeth. The guiding plane and long occlusal rest are moved posteriorly into the mesial undercut and over the rest seat of the molar (the first path, Fig. 3). Then the framework is rotated onto the teeth to its fully seated position (the second path, Fig. 4). A conventional clasp is used on the anterior abutment tooth to keep the removable partial denture in place, but none is required On the molar abutment. The long, positive occlusal rest provides support and bracing. Placing the guiding plane along the mesially inclined proximal surface of the molar affords strong but passive retention posteriorly. Eliminating clasp arms increases the selfcleansing char~/eteristics of the design and aids the plaque-control efforts of the patient. ANTERIOR APPLICATION OF DUAL-PATH DESIGN The dual-path ddsign is ideal when multiple anterior teeth are missing in a single edentulous space. Usually, a single tooth replacement is not practical because of lack of access of the cingulum abutment rests to their seats from an anterior direction. The larger the edentulous span, the better the access to the desired undercuts will be on the first path of insertion. When the four incisors are missing and, particularly, if one or both canines also are missing, the first path of insertion can be nearly parallel to the oeelusal plane. The anterior guiding planes will be almost in position when the framework is rotated. This seats the framework completely posteriorly and locks it into the undercuts anteriorly? DETERMINING ANTERIOR R E T E N T I O N Success of the dual-path design usually depends upon gaining access to tile mesial proximal undercuts with guiding planes that approximate the abutment teeth adjacent to the edentulous space. This access is limited by the access of the anterior occlusal rests to their rest seats. Retention is determined by surveying a diagnostic cast, generally perpendicular to the oeclusal plane in the manner used for a single path of insertion. When the second-path rest seats, retentive areas, and guiding planes (ideally as far posteriorly as possible) have been selected, evaluate the undercuts on t h e

Fig. 1. The mesially inclined molar abutment presents an undercut to a path of insertion perpendicular to the occlusal plane.

Fig. 2. The undercut mesial surface of the molar abutment is inaccessible to a removable partial denture following a path of insertion perpendicular to occlusal plane.

Fig. 3. The first path of insertion is placement of distal guiding plane and occlusal rest posteriorly into the mesial undercut and over the molar rest seat.

..j-Fig. 4, After gaining access to the mesial undercut the framework is rotated onto the teeth-the second path.

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Fig. 5. Large undercut on proximal surface of an abutment, when surveyed in a direction approximately perpendicular to occlusal plane; generally favorable for dual path of insertion. Fig. 6. Access to anterior proximal undercut is determined by rotating cast on the surveyor. This indicates the direction of the first path of insertion. Fig. 7. Application of dual path of insertion principle is more difficult in a small edentulous space. Fig. 8. Anterior access to cingulum rest seat by the framework is limited to a path parallel to the lingual surface of the abutment.

Fig. 9. Closely adapted yet diverging guiding planes. A path of insertion other than one perpendicular to the occlusal plane had to be used. Fig. 10. Framework outline illustrates positive anterior cingulum rests. Fig. 11. Lack of anterior clasps enhances esthetics and self-cleansing characteristics of t h i s removable partial denture.

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DUAL-PATHDESIGN FOR REMOVABLEPARTIALDENTURES

mesial proximal surface of the anterior abutment teeth (Fig. 5), and decide whether or not to use the dual-path design. If the undercuts and the access to them are favorable, the first path of insertion is the approach required to gain access of the framework into the undercuts prior to rotating and seating the removable partial denture (Fig. 6). Surveying and applying the dual-path design are relatively simple when the anterior edentulous space is large and the access is ample. However, application of the design is more difficult in a small edentulous space, i.e., less than 3 teeth (Fig. 7). T h e first path of insertion is determined on the surveyor by the most anterior access to seating the cingulum rests of the abutment teeth. This path, which is parallel to the lingual surface of the abutment tooth (Fig. 8), will dictate the amount of retentive undercut available from that tooth. With the diagnostic cast ori the surveyor, the amount of retentive undercut is the space between the height of the contour lines marked on the proximal surface of the

abutment tooth when the cast is rotated from the first to the second path of insertion. Closely adapted and divergent guiding planes are seen in Fig. 9. Their insertion came from a more anterior direct i o n - t h e first path of insertion. The framework design is shown in Fig. 10 and the completed esthetic prosthesis in Fig. 11. SUMMARY The application of the dual path of insertion concept to posterior and anterior edentulous situations has been described. REFERENCES
I. King, G. E., Barco, M. T., and Olson, R.J.: Inconspicuous retention for removable partial dentures. J PROSTHETDENT. (In press)
Reprint requests to: DR. GORDON E. KING

NATIONALNAVALDENTALCENTER BETllESDA,I~D. 20014

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