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BIOMECHANICS OF REMOVABLE PARTIAL DENTURE INTRODUCTION:
Biomechanics is defined as the application of the principles of mechanical engineering in the living organism.An understanding of the biological response to mechanical stimuli is of paramount importance for promoting long term success of removable partial dentures.Mechanical forces exerted on removable partial dentures during functional mandibular movements should be properly directed to the supporting tissues to elicit the most favourable response. It may also be considered as the study of the problem of distributing the energy generated by the muscles of mastication so that it will be expressed at the occlusal surface with the maximum efficiency consistent with the minimum damage to the supporting structures. The primary consideration in partial denture construction is to distribute the forces on the occlusal surfaces with the minimum damage to the supporting tissues.Partial dentures are subjected to many forces,such as chewing(vertical and lateral), lifting( sticky foods), and actions of the tongue,lips and cheeks. The manner in which alveolar bone surrounding the natural teeth responds to force differs markedly from that of the residual bone remaining after the extraction of the teeth. Fundamental to understanding partial denture design is a solid grasp to simple mechanical principles.It is necessary to understand the essential physics involved in the working of the prosthesis. Designing a removable partial denture which optimally satisfies the prosthodontics requirement of support, function and esthetics is a daunting challenge.When poorly designed without taking into
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BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

consideration of the biomechanical principles involved would make the removable partial denture as a tooth extractor especially in a distal extension removable partial denture. All removable partial dentures direct mechanical forces to bone which is the ultimate supporting tissue.The mucosa of the residual ridge transmits compressive forces through the submucosa to the underlying bone without changing the nature of the forces frequently resulting in pressure induced resorption. The natural teeth are attached to the bone by means of a periodontal ligament which converts much of the masticatory compressive forces to tensional forces favourably stimulating alveolar bone. In the oral cavity one would find a number of sources of stress generation, the human body is built in such a manner that it learns to adapt to any stressful situation. However when we try to create an artificial replacement of that natural component which is lost, we are at loss in making it fully functional and adaptable. Designing of partial denture necessitates a proper planning for the form and extent of dental prosthesis and studying of all the factors involved. The prosthesis must be designed following the most favourable biomechanical principles, as the proper design helps in reducing the harmful effects on the supporting structures. The optimal goal is to provide useful, functional removable partial denture prostheses by striving to understand how to maximize every opportunity for providing and maintaining a stable prosthesis. Because removable partial dentures are not rigidly attached to teeth, the control of potential movement under functional load is critical to providing the best chance for stability and patient accommodation. The
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consequence of prosthesis movement under load is an application of stress to the teeth and tissue that are contacting the prosthesis.It is important that the stress not exceed the level of physiologic tolerance, which is a range of mechanical stimulus that a system can resist without disruption or traumatic consequences. In the terminology of engineering mechanics, the prosthesis induces stress in the tissue equal to the force applied across the area of contact with the teeth and/or tissue. This same stress acts to produce strain in the supporting tissue, which results in load displacement in the teeth and tissue. The understanding of how these mechanical phenomena act within a biological environment that is unique to each patient can be discussed in terms of biomechanics. It is important for clinicians providing removable partial denture service to understand the possible movements in response to function and to be able to logically design the component parts of the removable partial denture to help control these movements. The following biomechanical considerations provide a background regarding principles of the movement potential associated with removable partial dentures, and the subsequent chapters explain various factors associated with removable partial denture and how they are used to control the resultant movements of the prostheses.
REVIEW OF THE LITERATURE Goodmann.J et al21(1963) stated that the design of a free-end partial denture restoration required a careful balance between the requirements of retention and the stresses that the retainers would exert on abutment teeth He founded a simple solution to reduce stress to abutment teeth through the use of Balance of force principle. Augsburger.R26 (1963)postulated that mathematical equations could be used to outline quantitative values in the design of removable partial dentures and numerical values were used to simulate forces imposed upon abutment teeth by retention and support components of the denture. He concluded that this system of analysis could be applied to designs of removable partial dentures but the factors of the patients attitude toward cosmetics and functional comfort must be considered. Maxfield et al37(1979)measured the forces applied to abutment teeth by removable partial dentures computed by applying an extension of the Pythagorean theorem,they found that the transmitted forces vary when different removable partial denture designs were used.They also suggested that improving adaptation of the extension bases to the residual ridge was an excellent means for providing maximum support, increasing patient comfort, and decreasing forces to abutment teeth. Cecconi.T.B et al32 (1975) had performed an invitro study using several types of rests to determine which type of rests transmits forces to abutment teeth in the most favourable manner. He concluded that the
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rests with gingival seats at maximum depth in abutment teeth significantly decreased abutment tooth movement and bilateral loading of a removable partial denture caused significantly less abutment tooth movement than unilateral loading. Knowles E.L16(1958) reviewed the engineering principles associated with removable partial denture and he proposed that the primary biomechanical principles to be considered were support, bracing, and retention. Seong-kyum kin et al74 (2007) had conducted an invitro study to investigate the biomechanical effects of mandibular Removable partial denture with various prosthetic designs under unilateral loading using strain gauge analysis.They concluded that splinting of two isolated abutments by bridge reduced the peri-abutment strain in comparison with unsplinted abutments under unilateral loading. Asher L.M52(1992) had proposed biomechanical consideration for the use of the rotational path removable partial denture for a patient with a tooth-bounded ridge on one side and a distal extension ridge on the opposite side.He concluded that by including a rotational path rigid retentive element in a design that accommodated rotational movement in function,exceptional stability was achieved with minimal stress to the abutments. Rachman Ardan76(2008) conducted an in vitro study about the masticatory force on the fulcrum point of first class lever on the lower jaw distal free end denture using two dimensional static model in sagital direction.He concluded that the main problem of distal free end Removable Partial Denture is lateral displacement. He also stated that
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the first class lever retainer design on distal free end RPD generated leverage to the abutment tooth and created cumulative pressure in main fulcrum point. Devan M M4 (1952) had stated that mouth needing a bilateral partial denture was in a state of mutilation.He suggested for the preservation of the partial denture foundation the horizontal forces falling on the saddles and transverse forces falling on the abutments should be reduced.He also suggested the all-out use of every available tooth and tissue bearing for preservation of partial denture foundation. Arthur.R.C1(1951)proposed that the amount of force imposed upon the denture may be reduced by maintaining the sharpness of tooth cusps and by decreasing the size of the food table. Kwin Chi Luk59(1979) had demonstrated the design of a unilateral rotational path removable partial denture to restore a single edentulous space with a tilted mandibular molar.He suggested that the stability and retention of the denture were controlled anteriorly by the buccal retentive clasp and lingual guide plate of the conventional direct retainer, and posteriorly by the rigid retainer with its buccally and lingually extended proximal plates. Theodore Berg51(1992) had compared distribution extracoronal characteristics photo elastically the stress
of maxillary bilateral distal-extension
removable partial dentures retained by light and heavy ERA attachments.He also compared the pattern of stress with one prosthesis included distribution in photoelastic model
supporting rests and the other had no rests.He concluded that there was significant difference in stress distribution.
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MC Cracken et al15(1958) discussed the design, location, and the purpose of the various components of the partial denture and pointed out that some of the violations of sound biologic and mechanical principles were committed. Lawrence W.A11(1956) had analysed the lateral force transmitted to denture base location and clasp design.He constructed an experimental model to simulate the type of tooth movement found in the mouth. He also constructed partial dentures of various designs and evaluated the torques and rotational patterns of removable partial denture. MC Cleod.S N3(1982) had shown that with a rotating retainer an axis of rotation exists about the fulcrum line on either side of the dental arch. He also concluded that lack of alignment of the rotational axis on either side of the arch produces torque on the abutments when the prosthesis was in function. Ceconi T.B29(1971) conducted an in vitro study and determined the effect of two types of partial dentures movement, stress breakers on abutment tooth movement and ridge displacement. He measured these movements when the stress breakers were both active and not active. MC Cleod34(1977) had shown that with a rotating retainer an axis of rotation existed about the fulcrum line on either side of the dental arch. He concluded that lack of alignment of the rotational axis on either side of the arch produced torque on the abutments when the prosthesis was in function. He also altered the retainers and

accomodated the lateral movements associated with the rotational axis and compensated the torque. Lammie8(1954) stated forces acting on RPD always be resolved into three components, a purely vertical force, uncomplicated by a simultaneously acting horizontal component on a lower free-end saddle.He explained the forces acting on bilateral free end saddle and the treatment options for bilateral free end saddles. McCracken7(1953) stated that two distinctly different types of partial dentures exist,tooth borne and tooth tissue borne.He further stated that the advantage of this method of classification was there exists a definite relationship between each other. Arthur R.C1(1953) had planned partial denture with special reference to stress distribution based on the physiologic rest position of the mandible. He stated that there were two major factors involved in controlling the forces of mastication.They were the reduction of the amount of force imparted to the denture during mastication and, the wide distribution of the forces to the tissues. Arthur J.Kroll20 (1963) had demonstrated clasp design on an extension based removable partial denture.He considered that the factors of stress controlled when there was minimal tooth coverage and gingival coverage. He introduced the RPI clasp that minimised tooth coverage and reduced stress on the abutment tooth. Ceconi T.B29(1971) had studied the effects of the sagittal inclination of the residual ridges.He compared bilateral vs unilateral loading on abutment tooth movement and also load vs non load side movements
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of the abutment teeth.He found out that the angulation of the residual ridge in a sagittal plane altered the direction and magnitude of abutment tooth movement. Chester Perry10(1956) stated few basic rules and few basic requirements such as support,retention,stability and esthetics must be met if the restoration had to function adequately with comfort. Kratochovil20(1963) demonstrated the effects of rest placement using a training aid. He found that as the denture base was followed posteriorly, the arc of movement became nearly perpendicular to the surface of the mucosa ZBen Ur61 (1999) had discussed the factors affecting denture design related to the position of the abutment teeth, the symmetry design,the cross sectional shape of the residual ridges and the treatment of complications of the edentulous distal extensions. Aviv.I48(1989) had proposed that an axis of rotation was created through most distally placed occlusal rests when distal-extension removable partial denture was loaded.He further stated that if the residual ridges were of unequal lengths, the axis of rotation may not be perpendicular to the residual ridges. Beckley W.R27(1969) had considered the correct distribution of stress between the abutment teeth and the denture base had been a point of contention among the three schools of thought advocating broken stress, functional bases, and wide distribution of stress. He proposed a technique that took advantage of beneficial aspects of each method.
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Weinberg28(1971) had analysed the lateral force in relation to denture base location and clasp design. He constructed an experimental model to simulate the type of tooth movement found in the mouth.He constructed partial dentures of various designs on the model and tested torque and rotation patterns. Ben-Ur et al61(1999) performed rigidity tests on maxillary major connector with different designs and mandibular major connectors of the lingual bar type with different cross sectional shape and major thickness.They concluded that the most rigid maxillary the U-shaped palatal bar. Nathan K.C. Luk49(1990) had analysed mathematically occlusal rest design for cast partial dentures.He concluded that a decrease in occlusal width had increased the bending stress and required thicker rest for compensation.He concluded by his mathematical analysis that the traditional spoon-shaped occlusal rest seat dimensions had complied with the mechanical requirements for non-precious cast metal occlusal rests in RPD. Akaltan et al72(2005) had evaluated the effects of two distal extension removable partial denture designs on tooth stabilisation and periodontal health. They concluded that RPD treatment did not damage remaining teeth and periodontal tissue if the dentures were carefully planned, the prostheses and oral hygiene were checked at regular recall appointments. Miura et al46(1992) had examined the effect of direct retainer and major connector designs on RPD dynamics under simulated loading.They
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connector was anterior-posterior palatal bar and the most flexible was

found out that rigid direct retainers and rigid major connectors decreased both RPD movement,abutment tooth displacement under loading. Their results provided the basic data that supported the importance of rigidity of the RPD components to control denture dynamics. RoyMacgregor41(1983) reviewed the literature on planning the support of bounded saddles of removable partial dentures or fixed bridges. He also used three-dimensional photoelastic analysis to examine stresses on removable partial dentures of different designs. Neil D J17(1958) discussed the problems associated with lower free end removable partial dentures,the problems associated with not restoring the dentition, the tissue damage associated with wearing of removable partial denture,the problems associated with denture design and technical consideration in fabricating lower free end removable partial denture. Beckerd L.S44(1988) had analysed the influence of saddle classification on removable partial denture.He classified distal extension saddle situation based on support it derives into class-1(tooth borne),Class-2 (mucosa borne),class -3(problem type have inadequate abutments to support the saddle and probably also inadequate mucosa support). Kelly K.E et al9(1953) explained physiologic approach to partial denture design.He advocated several methods to reduce lateral stresses by means of rigid lingual and palatal bars so these stresses would be distributed over as many abutments as practicable and by using stress breakers.
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Potter B.R24(1967) stated that lateral stresses applied to a natural tooth are so destructive to the supporting structures, whereas stresses in the direction of the long axis of the tooth were well tolerated. He proposed that the design of removable partial dentures must minimize lateral stresses by distributing these stresses over as many teeth and as much supporting tissue as possible, and occlusion that provide damaging stresses should be avoided. Avant W.E28(1971) discussed retention and fulcrum lines in planning for removable partial dentures.He described a primary retention line and compared with a primary fulcrum line. Bickley W.R27 (1969) discussed a method for constructing partial denture, removable
incorporating broad distribution of stress,the
principles of broken stress and functional bases.His technique minimised lateral stresses by keeping all the forces in a vertical direction and by allowing rotation without torquing of the teeth. Mensor C.M25(1967) suggested the rationale behind resilient hinge action stress breaker. He started with the known motion differences between anchor tooth and the free-end denture base.He also made an attempt to differentiate the entire movement complex of mastication into individual components. Davis M.M et al3(1952) had explained the design and force distribution in removable partial denture.They suggested that movement of a removable partial denture in function was rotary in that the movement takes place in three planes.They also added that the instantaneous center of rotation theory could be meaningfully
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applied to partially edentulous situations even though the theory was based on movement in one plane. Hindels W.G3(1952) discussed the load distribution in extension saddle removable partial denture.He insisted that the method used to make impressions of the supporting and retaining anatomic structures of the mouth was of basic importance for obtaining optimum distribution of the masticatory load in the construction of removable partial dentures. Blatterfein et al44(1988) evaluated loading forces on mandibular distal extension prosthesis.They classified the concepts of design into 4 basic categories the flexible denture base design,the floating denture base design,the mucofunctional concept,the enodosseous implant concept. Hirschritt et al14(1957) differentiated tooth and tissue bearing areas of the mouth and simplified the design of each individual partial denture. He said that a tooth borne unit, with its splinting and supporting ability, protected the teeth against overstressing. Deboer.J43(1988) reviewed the position of rests on occlusal surfaces of abutment teeth for distal extension removable partial denture and proposed rational alternatives to improve denture stability extension removable partial dentures. McCartney38(1980) analysed motion vector of an abutment for a distal extension removable partial denture.He determined intraorally the effect of various rest placements and clasp designs of a mandibular bilateral distal extension removable partial denture. He
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and
prognosis by the selection of sites for occlusal rests in distal

also found that the magnitude and direction of abutment tooth movement under vertical loading of the denture base. Boero.E et al30(1972) explained considerations in the design of
removable prosthetic devices with no posterior abutments. He explained that the basis of good restorative dentistry consists of establishing an equilibrium of forces so stresses were conducive to develop a physiologic continuum rather than pathosis. Marie.K.M21(1963) compared the average measurements of forces required to dislodge two kinds of circumferential clasps in different amounts of undercuts,one with a half-round retentive arm and the other with a round retentive arm under tensile load.His findings indicated the use of cast round clasps were advantageous in clinical fit and reduction of transmitted forces to the abutment. Steefel V18(1962) explained the importance of diagnosis and functions of removable partial dentures.He proposed the objectives of removable partial denture design as bilateral distribution of stresses, the various types of retainers (direct and indirect), cosmetic effects, and function. He explained certain methods to achieve these objectives. Kaires K.A12(1956) studied the effect of partial denture design on force distribution. He fabricated a mandibular model and tested partial denture to determine the effect of various denture designs on the distribution of stress. Frechette R.A2(1951) analysed lower distal extension removable partial denture. He determined the magnitude of forces imparted to abutment teeth when known loads were applied to a denture.
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Wills D J et al36(1979) performed experiments on macaque monkeys. He compared the support provided for base plates resting on groups of teeth, palatal mucosa and a combination of both. Ben Ur et al61(1999) proposed that retentive clasp components could be created to minimize torquing forces on abutment teeth incorporated in the support and retention of bilateral distal extension removable partial dentures.
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EVOLUTION OF REMOVABLE PARTIAL DENTURE Early Concepts- The construction(before 1950) band, the clasp, and sectional
The early concepts of RPD design were primarily developed by dentists who recorded the techniques that were successful in their practices.The first recorded description of an RPD was by Heister in 1711 when he reported carving a block of bone to fit the mouth(Fig1).Fauchard,' who is considered by many to be the father of modern dentistry, described the construction of a lower RPD in 1728 using two carved blocks of ivory joined together by metal labial and lingual connectors. (Fig-1). The first mention of a maxillary RPD using a palatal connector was by Balkwell in 1880.Retentive clasps were first discussed by Mouton in 1746. In 1810,Gardette described the use of the wrought band clasp.(Fig2)The bands completely encircled the tooth and often extended into the gingival sulcus. The destruction of the marginal gingiva and the tooth due to constant vertical movement of the prosthesis led tothe first description of an occlusal rest in 1817. In 1817, Delabarre" referred to "hooks" (clasps) and the use of "little spurs" (occlusal rests) to prevent irritation around the abutment teeth.In 1899, Bonwill recorded his techniques for clasping abutments
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with individually contoured gold circumferential clasps that were then soldered to "the plate" (major connector). Bonwill also advocated the use of "lugs" (rest seats) so that the prosthesis would be supported by the abutments.(Fig-3) In 1913, Roach presented a wrought wire circumferential clasp as an improvement over the wide wrought band clasp. The first mention of a bar clasp or "infra bulge" clasp was by Henrichsen in 1914,, but the bar clasp did not gain popularity until Roach"' promoted this concept in 1930. 'I'he concept of rotational factors, which the early writers called "balance," was first described by Balkwell" in 1880. Prothero" is credited with coining the term "fulcrum line." William Taggart(Fig-4) proposed the lost-wax casting technique for dentistry in 1907(Fig-5). This principle was applied to RPDs by Norman B. Nesbet.(Fig-6) In 1916,he described the technique for casting clasp assemblies for RPDs. His refinement of the alloy and prosthetic tooth attachment allowed the successful creation of short spanned unilateral RPDs. Nesbett described the inlay fit of the clasp assemblies attained afterassembling the separately cast components on a plaster cast. Chayes had developed a parallelometer(Fig-7) in 1920 to help guarantee parallel alignment both clinically and in the laboratory.The first commercially available instrument developed specifically for use in surveying models of teeth was designed by Weinstein and Roach in 1921. The leap into full-arch, one-piece RPD castings was officially made by Akers(Fig-8) when he published this technique in 1925. Although descriptions of line tracings on the teeth occur prior to this
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time, the term height of contouris credited to Edward
Kennedy.Willis(1935)was among the first to describe in writing the technique for dental model surveying and blocking out undesirable undercuts. He was the first to use the term path of insertion for RPDs in relation to a chosen plane and described tripoding. Roach, who was the first to describe reciprocation, was aware that most retentive clasps were actively exerting force on the abutment teeth. During the 1930s and 1940s, there was persistent disagreement as to how to approach the two dissimilar tissues encountered with the distal extension RPD-teeth and the mucosa covering the residual ridgeThe discussion centered around how to equalize forces placed on the hard, relatively immovable, abutment teeth and the soft, relatively movable, edentulous tissue areas According to Steiffel, the prominent clinicians of the time could be placed into the following three groups: (1) those advocating some sort of stress-breakers between the abutments and the major connector (2) those advocating broad stress distribution to multiple abutments and the edentulous area and (3) those advocating physiological or functional basing Steffel placed himself into the broad stress distribution group but conceded that all three methods could be successful if properly executed. He rejected the common practice of constructing a distal extension RPDs from a single impression.
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Before 1950, RPD concepts were mostly developed by a small group of authors who presented their theories and techniques based primarily on empirical observation. INVESTIGATIVE YEARS 1950 TO 1970 It was in 1950s that some of these clinical debates were resolved in an evidence based approach.During these years several longitudinal studies have performed that showed extensive pathological changes in the periodontium and increased caries activity for patients who wore RPDs. These studies gave credence to the then prevailing attitude of the profession, as well as of the public, that RPDs were detrimental to the existing dentition and were considered an interim appliance on the pathway to complete dentures those days. It was pointed out that in the 1950s, the partial denture concepts in Europe were vastly different from the accepted concepts in North America. In Europe, the RPDs tended to provide a flimsy design with wrought wire clasping and, usually, no rest seats. In North America, the partial denture design tended to include rigid major connectors, cast clasps, and rest seats. In 1956,Kaires showed that the lingual bar of a lower RPD should be rigid to distribute forces across the arch. Also, an increase in residual ridge coverage reduced forces to abutment teeth. In 1956, Frechette showed that multiple occlusal rests helped to distribute forces to more abutments and, thus, reduced forces to the terminal abutments. Holmes and Leupold both showed that distal extension partial dentures constructed on one-piece casts exhibit more movement of bases
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than those constructed using an altered cast procedure. The original altered cast technique was first presented to the profession by Applegate. Advantages of the altered cast procedure have more recently been confirmed by Vahidi and by Leupold et al. During the 1960s and early 1970s, two influential clinicians increased the popularity of the bar clasp concept started by Henrichsen and Roach many years before. Kratochvil promoted the use of the I-bar clasp with a mesial occlusal rest as a means of reducing the force on a clasped abutment when dealing with distal extension RPDs. Krol modified Kratochvils concept with his mesial rest proximal platc-I bar (RPI) design.(F ig-9) Some of the problems encountered included insufficient
vestibular depth, soft tissue undercut below the abutment tooth, and lack of I-bar usable undercuts. As a result of these limitations for the I-bar system, there evolved a modification that combined the I-bar and circumferential clasp designs. This clasp design is called the mesial restproximal plate-Akers clasp (RPA) and was developed by Krol and Eliason. The mesial rest and proximal plate are identical to the RPI system, but the buccal retentive arm becomes a circumferential or Akers clasp engaging a mesial undercut. The superior border of the rigid portion of the Akers clasp should contact the tooth on the survey line.Nelson et al suggested using a cast round clasp rather than the conventional half round design to form the retentive Akers clasp. RESEARCH IN EARNEST- 1970 TO PRESENT
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During the 1970s, there began to appear a large number of studies beginning with in vitro research. Cecconi et al showed that force to the abutment teeth was transmitted via the rest seats, and that this force was the same with or without retentive clasps. Robinson showed that forces to abutment teeth with distal extension RPDs are minimized with a mesial rest (as opposed to a distal rest) and that a wrought wire retentive clasp has the same force on the abutment as an I-bar design when used with a mesial rest. He also demonstrated that no clasp is passive, as had been deemed essential by nearly all theoretical concepts proposed in the past. Nally showed that a mesial rest created the least amount of abutment movement and that abutment movement increased with the removal of indirect retainers. Browning et al confirmed the value of the mesial rest with either the I-bar or the wrought wire clasp design. Frank and Nicholl showed that indirect retainers have little to do with retention of a distal extension RPD; rather, it is the guide planes that create retention in conjunction with clasping. They showed that indirect retainers do help with force distribution and, thus, are a beneficial component in RPD design. An earlier study by Fisher and Jaslows supports the findings of Frank and Nicholls. Photoelastic studies provided a new laboratory research tool for evaluating RPD design. Kratochvil and Caputo showed that an RPD framework that had been properly adjusted to fit the abutments created less force to the abutments than a framework that had not been adjusted. Thompson et al reported the most favorable force to abutments came with a mesial rest and either a wrought wire or an I-bar retentive clasp.
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Pezzoli et al confirmed the value of mesial rests, indirect retainers, and multiple rest seats on force distribution. Clayton and Jaslow measured the movement of the clasps on the corresponding abutments. Browning et al showed that the clasp moves more than the corresponding abutment. The major reasons for using wrought wire clasps are that the wire is more flexible than a cast clasp and that wire can flex in three dimensions. The fallacy in Clayton and Jaslous study is that movement of the clasp does not necessarily translate into movement of the abutment, and, thus, comparisons of the force placed on the corresponding abutment by measuring the movement of the clasp is invalid. This study has been widely misquoted as justification for using an I-bar instead of the more flexible wrought wire clasp. Clayton and Jaslow's study does confirm that there is no such thing as a passive clasp. From the increased interest in scientifically evaluating the design concepts of the past, there began to emerge the following sound basic principles for RPD design: 1. Major connectors should be rigid. 2. Multiple rest seats appear to distribute forces favorably. 3. Mesial rests appear to provide some advantage when used with distal extension RPDs. 4. Parallel guide planes are beneficial for retention and stability of a prosthesis.
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5. The I-bar or the wrought wire retentive clasp, in combination with a mesial rest, may be a superior design for the distal extension RPD 6. The altered cast procedure reducrs movement of the distal extension RPD at least initially. PERIODONTAL AWARENESS Clinical research began to gain momentum as periodontal awareness increased. More valid and reliable concepts for RPD design evolved that relied less on empirical observation. . In 1966, Rudd and O'Leary did a brief longitudinal study in which they reported that, when proper guide planes were established on periodontally treated patients, mobility to abutment teeth remained the same or improved. In 1977, Schwalm et al reported the results of a 2-year investigation in which acceptable RPD design principles were used and initial plaque control instructions and basic periodontal therapy were instituted, but there was no periodic recall. Bergman and Ericson reported that in a 3-year cross-sectional study, they found no adverse periodontal results associated with the wearing of RPDs. UNCONVENTIONAL DESIGNS Swing lock design The swinglock design was first introduced to the dental profession by Simmons in 1963(Fig-10). Simmons took advantage of the casting properties of the chrome cobalt metals to devise a hinge and lock system that allowed for a retentive labial bar that can he opcncd and closed by the patient. This radical technology alloys for successful use of
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periodontally compromised abutment teeth, as well as situations in which critical abutments are missing. Bolender and Becker have suggested certain specific indications for the swinglock design including: periodontal compromised abutments, missing key abutments,abutment mobility, limited economics, and maxillofacial prosthesis.They recommend the use of multiple rest seats and suggest placing the hinge and clasp of the labial retentive bar atleat one tooth distal to the terminal abutments. Antos, Renner, and Foerth prefer no rest seats and place the hinge and clasp of the labial retentive arm next to the terminal abutments.
The dual path or rotational path design The dual path (or rotational path) RPD(Fig-11)concept is relatively new, having been introduced by king and Graver in 1978. Initially, the dual path design arose out of the need for an RPD that would be esthetic when anterior pontics are present primarily, the desire to eliminate anterior clasping. This technique uses proximal undercuts adjacent to the edentulous spaces for retention without clasps. The first path of insertion of the framework is into these proximal undercuts. As soon as the framework has gained access to the desired undercuts, it is rotated into the second path of insertion to complete seating the prosthesis.Initially, the dual path design was limited to tooth borne situations in which anterior teeth were missing.
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The swinglock and dual path concepts are good examples of design modifications that have evolved because of a need to solve special problems. Return to Precision:Sectional construction revisited Following the introduction of Akers one-piece casting technique, several authors maintained that sectional construction was preferred due to the superior fit obtained. Several modern methods of sectional construction have been discussed. More recently, improvements in laserwelding technology have allowed predictable components. Cecconi et al described a component approach in which individual parts are fabricated and joined on the definitive cast by means of autopolymerized acrylic resin or laser welding.Brudvik et al showed that this technique reduced distortion of large castings, the cumulative effect of which is optimum control of the framework fit. Cecconi advocated the advantages of sectional casting as being Eliminating the need for time-consuming trial placement of the framework. fabrication of tooth- and tissue-supported elements can be done separately. dissimilar materials may be used. In component RPDs, cobaltchromium or nickelchromium alloys may be used for rigid major connectors, and gold unification of metal
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alloysmay be used for clasp assemblies where improved accuracy and flexibility may be required Similarly, acrylic resin denture base and acrylic resin teeth may be combined with metal or porcelain where necessary. Key turning points in RPD philosophy included Bonwills bandfree RPD design, Akers one-piece casting technique, and the ramifications of the one-piece techniques application
BIOMECHANICAL CLASSIFICATION OF REMOVABLE PARTIAL DENTURE (Based on the nature of the supporting tissues- Occlusal forces are transmitted to the teeth used as RPD abutments)
A.
TOOTH BORNE (Tooth supported /Dentoalveolar supported)(Fig-12)

1.
Abutment teeth border all edentulous areas where tooth replacement is planned. Functional forces are transmitted through abutment teeth to bone.
2. B.
TOOTH - MUCOSA BORNE (Tooth and Mucosa supported, Dentoalveolar and muco-osseous supported or extension base)(Fig-13)
1.
Exhibits one or more edentulous areas which are not bordered by

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abutment teeth (extension base RPDs).
2. 3. 4.
Forces are transmitted through abutment and mucosa to bone. The majority of these are distal extension RPDs. This category may apply to tooth bordered situations when excessive abutment tooth mobility is present or when long span tooth bordered edentulous areas are present precluding primarily tooth support.
C.
MUCOSA BORNE. (Muco-osseous supported)(Fig-14) 1. Regardless of the natural teeth present, support is derived entirely from the mucoosseous segment.
2.
This category includes prostheses fabricated from hard or combinations of resilient and hard denture base materials such as stayplates which function as interim or transitional prostheses. These prostheses usually do not contain a metal framework and usually should not be considered definitive treatment.
3.
MECHANICAL PRINCIPLES OF REMOVABLE PARTIAL DENTURE

Definition: Dental Biomechanics is defined as the relationship between the biologic behavior of oral structures and the physical influence of a dental restoration. Bio------pertaining to Caries,resorption.. ..etc) living systems(eg:inflammation, to
Mechanical----related to forces and its application objects(Eg:looseness of teeth,bone r e s o r p t i o n . . e t c )
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Mechanics may be classified into two general categories: Simple & complex. Complex machines are combination of many simple machines. There are six simple machines(Fig-15)(Fig-16)(Fig-17) 1. Lever 2. Inclined plane 3. Wedge 4. Screw 5. Wheel 6. Axle and pulley A removable partial denture in the mouth can perform actions of two simple machines,LEVER & INCLINED PLANE LEVER : The lever is a simple rigid bar supported at some point along it is length.It can be used to move objects by application of force(weight), much less than weight of object being moved.
Types of lever: Classification is based on location of load(resistance), and direction of effort (force).
fulcrum
(support),
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Note:

The load is the weight or force to be acted upon. The effort is the weight or force required to cause the action.
The fulcrum is the pivot about which these forces act.
In a perfect system which is static:

The effort the distance from the fulcrum = the load the distance from the fulcrum.
There are three fundamental levers around which the whole removable partial denture revolve.But, the first fundamental facts are
1.
A lever system works at mechanical advantage when the effort is less than the load.
Mechanical advantage =Effort arm /Resistance arm
The length of fulcrum to resistance is called resistance arm, while the length of lever from fulcrum to the point of application of force is called effort arm.
2.
A lever system works at a mechanical dis advantage when the effort is

greater than the load.
3.
To be in balance(equilibrium) the forces on either side of the fulcrum should be equal. That is the effort multiplied by its distance from the fulcrum is equal to the load multiplied by its distance from the fulcrum.
4.
Whenever the effort arm is longer than the resistance arm the mechanical advantage favors the effort arm,proportionately to the difference in length of the two arms.In other words when the effort arm is twice the length of the resistance arm a 25lb weight on the effort arm will balance a 50 lb weight at
29 the end of the resistance

arm.The opposite is also true and helps in cross arch stabilization.
The fundamental levers are

1. 2. 3.
The first class lever The second class lever The third class lever
THE FIRST CLASS LEVER:(Fig-18) The fulcrum (F) is in center of the bar, resistance (R) is at one end and the force (E) is at opposite end (called cantilever). Cantilever: It is a beam supported only at one end, when force is directed against unsupported end of beam cantilever can act as first class lever. Archimides said that Give me a lever long enough, I can lift the whole world CLINICAL APPLICATION OF CLASS-I LEVER Acastcircumferentialdirect
rest.Ifitis
retainer
engages
the
mesiobuccalundercutandissupportedbythedisto-occlusal
rigidlyattachedtotheabutmenttooth,thiscouldbe considered a cantilever design, and detrimental first class lever force may be imparted to the abutment if tissuesupportunder the extension base allow excessive vertical movement toward the residual ridge. Every effort should be made to avoid lever of Ist class as it causes more damage to the supporting structures.
THE SECOND-CLASS LEVER:(Fig-19) The fulcrum at one end, the force at opposite end & the resistance in center. This type is seen as indirect retention in removable partial denture.Works at a mechanical advantage cannot work at a mechanical
30

disadvantage as the load is always near the load. CLINICAL APPLICATION OF CLASS-II LEVER Typical examples for clinical application of class-II lever in removable partial denture is seen in indirect retention in removable partial denture and Equipose removable partial denture.In equipoise restoration the occlusal rest (F) located mesially, while the retentive tip (R) positioned distally, and the saddle(E) located distal to the retentive tip i.e.the (Resistance) located in between the (Fulcrum) & (Effort). THE THIRD CLASS LEVER:(Fig-20) The fulcrum at one end, the resistance at opposite end and the force in the center.This type is not encountered in removable partial denture.Eg: tweezers. INCLINED PLANE Inclined plane is nothing but two inclined surfaces in close alignment to one another. The direct retainers and the minor connectors slide along the guide plane of the teeth and can act as inclined planes if not prepared correctly. When a force is applied against an inclined plane it may produce two actions:
Deflection of the object, which is applying the force Movement of the inclined plane itself (tooth).These results should be prevented to avoid damage to the abutment teeth.
(Denture).
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POSSIBLE MOVEMENTS OF REMOVABLE PARTIAL DENTURE(Fig-21)

Three fundamental planes and three axis as related to the human head. I.SAGITAL PLANE The first plane is a sagittal plane. Movement in this plane occurs relative to a medio-lateral axis that is perpendicular to the sagittal plane. One movement is rotation about an axis through the most posterior
32

abutments. This axis may pass through occlusal rests or any other rigid portion of a direct retainer assembly located occlusally or incisally to the height of contour of the primary abutments This axis, known as the fulcrum line, is the center of rotation as the distal extension base moves toward the supporting tissue when an occlusal load is applied. The axis of rotation may shift toward more anteriorly placed components, occlusal or incisal to the height of contour of the abutment, as the base moves away from the supporting tissue when vertical dislodging forces act on the partial denture. These dislodging forces result from the vertical pull of food between opposing tooth surfaces, the effects of moving border tissue, and the forces of gravity against a maxillary partial denture. If it is presumed that the direct retainers are functional and that the supportive anterior components remain seated, rotation rather than total displacement should occur. Vertical tissue ward movement of the denture base is resisted by the tissue of the residual ridge in proportion to the supporting quality of that tissue, the accuracy of the fit of the denture base, and the total amount of occlusal load applied. Movement of the base in the opposite direction is resisted by the action of the retentive clasp arms on terminal abutments and the action of stabilizing minor connectors in conjunction with seated, vertical support elements of the framework anterior to the terminal abutments acting as indirect retainers. Indirect retainers should be placed as far as possible from the distal extension base, affording the best possible leverage against lifting of the distal extension base II.HORIZONTAL PLANE
33

The second is the horizontal plane. Movement in this plane occurs around a vertical axis that is perpendicular to the horizontal plane. The movement is rotation about a longitudinal axis as the distal extension base moves in a rotary direction about the residual ridge.This movement is resisted primarily by the rigidity of the major and minor connectors and their ability to resist torque. If the connectors are not rigid, or if a stressbreaker exists between the distal extension base and the major connector, this rotation about a longitudinal axis applies undue stress to the sides of the supporting ridge or causes horizontal shifting of the denture base. III.FRONTAL PLANE The final plane is a frontal plane. Movement in this plane occurs relative to an antero-posterior axis running perpendicular to the frontal plane. The movement is rotation about an imaginary vertical axis located near the center of the dental arch.This movement occurs under function because diagonal and horizontal occlusal forces are brought to bear on the partial denture. It is resisted by stabilizing components, such as reciprocal clasp arms and minor connectors that are in contact with vertical tooth surfaces. Such stabilizing components are essential to any partial denture design, regardless of the manner of support and the type of direct retention employed. Stabilizing components on one side of the arch act to stabilize the partial denture against horizontal forces applied from the opposite side. It is obvious that rigid connectors must be used to make this effect possible.
34
FORCES ACTING DENTURE
ON
REMOVABLE
PARTIAL
Removable partial dentures (RPD) have to be in a state of equilibrium, i.e., a state in which opposing forces or influences are balanced. Keeping in mind Devan's statement to preserve what
35

remains, forces should be given major consideration while designing a partial denture, to ensure the dynamics of these appliances without deleterious effects to the supporting structure. The Supporting structures for removable partial are structurally adapted to receive and absorb forces within their physiological tolerance. The ability of these structures to tolerate forces is largely dependent upon the magnitude, the duration and the direction of these forces in addition to the frequency of force application. The magnitude of forces acting on partial dentures depends on age and sex of the patient, the power of the muscles of mastication and the type of opposing occlusion.Natural teeth are better able to tolerate vertical directing forces acting on them. This is because more periodontal fibers are activated to resist the application of vertical forces. On the other hand, lateral forces are potentially destructive to both teeth and bone. Lateral forces should be minimized in order to be within the physiologic tolerance of the supporting structures. Removable partial dentures are subjected to a composite of forces arising from three principal fulcrums. One fulcrum is on the horizontal plane that extends through two principal abutments, one on each side of the dental arch, and generally is termed the principal fulcrum line.This fulcrum controls the rotational movement of the denture in the sagittal plane ( i e, denture movement toward or away from the supporting ridge). Rotational movement around this fulcrum line is the greatest in magnitude,but is not necessarily the most damaging. The resultant force on the abutment teeth is usually mesioapical or distoapical, with the greatest vector in the apical direction the fibers of
36

the periodontal ligaments are arranged so that axially aligned forces are resisted 17 times greater than the non-axial loads. Therefore, horizontal or lateral forces are of much less magnitude and can be more destructive to TYPES OF FORCES ACTING ON RPD the hard and soft tissues of the periodontium. I.Vertical forces(Fig-22) A second fulcrum line lies in the sagittal plane and extends through a.) Tissue-ward movements b.) Tissue-away movements the occlusal rest on the terminal abutment and along the crest of the II.Horizontal forces:(Fig-23) residual ridge on one side of the arch.In a Class I situation, there would be two such lines, one on each side of the arch. a.) Lateral movements b.) Antero-posterior movements. III.Rotational forces:(Fig-24) This fulcrum line controls the rotational movements of the denture They areplane due to the variation in compressibility of supporting structures, in the frontal (ie, a rocking movement over the crest of the ridge). absence of distal is abutment one end or more of denture bases, and /or This movement easier toat control than the firstends and usually not as great absence of occlusal or clasps at are anymore end of the bases. in magnitude. The rests resultant forces nearly horizontal and are not well resisted by the oral structures. Therefore, these forces can be moderately damaging and should be given thorough consideration in the a.)Rotation of the anterior and posterior extension denture base around design (transverse) process. coronal fulcrum axis: i.)Rotation the denture base towards the ridgeof around the fulcrum The third of fulcrum is located in the vicinity the midline, just axis (joining main occlusal rests)fulcrum line is oriented vertically and lingualthe to two the anterior teeth.This controls rotational in the away horizontal (ie,the flat,the arcuate ii.) Rotation ofmovement the denture base from plane the ridge around fulcrum movements of the prosthesis). Due to its orientation, the force resulting axis from this movement isof almost entirely horizontal. Consequently,these (joining the retentive tips the clasps.) forces can be extremely damaging and should receive significant attention during the design process. b.)Rotation of all bases around a longitudinal axis parallel to the crest of the residual ridge effort (Buccolingual labiolingual). Every must be or made to control or minimize the rotational movements related to these three principles c.)Rotation about an imaginary perpendicular axis, this axis either near the center of the dental arch in class I, or is the long axis of abutment tooth in class II partial denture.
37
38

I.Vertical forces a) Tissue-ward movements. Tissue-ward forces are,Vertical forces acting in gingival direction tending to move the denture towards the tissues.They occur during mastication, swallowing and aimless tooth contact. Biting forces falling on artificial teeth are transmitted to the soft tissues and bone underlying the denture base. The partial denture should be designed to resist this movement by providing adequate supporting components. This function of the partial denture is called Support. b.)Tissue-away movements Tissue-away dislodging forces are, "Vertical forces acting in an occlusal direction tending to displace and lift the denture from its position.Tissue-away forces occur due to the action of muscles acting along the periphery of the denture, gravity acting on upper dentures or by sticky foodadhering to the artificial teeth or to the denture base. The partial denture should be designed to resist this movement by providing adequate Retention. II.Horizontal forces a.)Lateral movements Lateral forces are Horizontal forces developed when the mandible moves from side to side during function while the teeth are in contact.Lateral movements have a destructive effect on teeth leading to tilting, breakdown of the periodontal ligament and looseness of abutment teeth. The application of lateral forces causes areas of compression of the
39

periodontal membrane, which leads to bone resorption. Hence lateral forces play a major role in bone resorption. Partial dentures should be designed to prevent the deleterious effects of lateral forces by using stabilizing or bracing components. The magnitude of lateral forces could also be minimized by: 1.Reducing cusp angles of artificial teeth. 2. Providing balanced occlusal contacts free of lateral interference The removable partial denture being anchored to both sides of one arch and joined by a rigid major connector can provide cross arch stabilization to forces acting in bucco-lingual direction. b.)Antero-posterior movements Antero-posterior forces are "Horizontal forces which occur during forward and backward movement of the mandible while the teeth are in contact". This may result in movement of the denture.There is natural tendency for the upper denture to move forward and for the lower denture to move backward. Forward movement of the upper denture could be resisted by: Anterior natural teeth. Palatal slope. Maxillary tuberosity. The natural teeth bounding the edentulous space. The backward movement of the lower denture could be resisted by: The slope of the retromolar pad.
40

The natural teeth bounding the saddle area. Proximal plates. III.Rotational forces Rotational forces are Forces acting on the partial denture either in vertical or horizontal direction causing rotation (torque) of the denture base around an axis.In tooth supported removable partial dentures, the abutment teeth on both sides of the edentulous area provide adequate support and resistance to rotational forces through supporting rests and clasps placed on them.In distal extension partial denture when vertical forces are applied the difference in displaceability of the supporting structures often results in rotation of the partial denture around a fulcrum axis and application of torque on abutment teeth. Rotational movements must be counteracted in the partial denture design to minimize their destructive effect on both,teeth and the residual ridge.Rotational forces acting on distal extension partial denture may result in three possible rotational movements these are i.)Rotation of the denture base around the fulcrum axis (Torque). ii.)Rotation about a longitudinal axis formed by the crest of the residual ridge (Tipping movement). iii.)Rotation about an imaginary perpendicular axis near the center of the dental arch (Fish tail movement). a.)Rotation of the anterior and posterior extension denture base around coronal (transverse) fulcrum axis:
41

Movement of the component parts of the denture lying on the opposite side of the fulcrum axis occur in a direction opposite to that of the applied force. This leads to rotation of the denture:The fulcrum axis is an imaginary line passing through teeth and component parts of the partial denture around which the distal extension partial denture rotates when a vertical force is applied.More than one fulcrum lines may be identified for the same removable partial denture depending on the direction and location for force application. i.)Rotation of the denture base towards the ridge around the fulcrum axis This movement results from occlusal stresses occurring during mastication and occlusion of teeth. The free extension denture base moves tissue-ward while other components on the opposite side of the fulcrum line moves away from the tissues.This result in rotation of the denture about a diagonal supportive fulcrum line joining two occlusal rests on the most posterior abutments on either side of the dental arch. Tissue ward movement of the base could be limited by supporting structures, which are: Supportive form of the residual ridge, Accurate and properly extended bases. Artificial teeth set on the anterior two third of the base Flexible clasps are preferred over rigid clasping to reduce stresses and torque applied on abutments. If the clasps are rigid, the abutments tend to rotate distally during tissue ward movement of the denture base resulting in periodontal breakdown and looseness of teeth. ii.) Rotation of the denture base away from the ridge.
42

This movement occurs due to the pulling effect of forces applied by sticky food, gravity on upper dentures and the elastic rebound of soft tissues covering the edentulous areas. Tissue-away rotation of denture base is counteracted by: Indirect Retainers: which are the components of partial denture located on the side of the fulcrum axis opposite to the distal extension base. The retentive tip of the clasp arm. Adequate coverage and extension of the base (direct indirect retention) Effect of gravity on mandibular bases. b.)Rotation of all bases around a longitudinal axis parallel to the crest of the residual ridge This rotation occurs due to application of vertical forces on one side of the arch only. It causes twisting of the denture base. This movement is counteracted by: Cross arch stabilization (The action of clasps on the opposite side of the arch). Broad base coverage. Proper placement of artificial teeth (teeth on the ridge or lingualized occlusion). Narrow teeth bucco-lingually The effect of rigid major connectors
43

c.)Rotation about an imaginary perpendicular axis, this axis either near the center of the dental arch Application of horizontal or off-vertical force results in rotation around an imaginary vertical axis located either about the axis of abutment in class II or near the center of the dental arch, lingual to anterior teeth in class I. It results due to the application of masticatory forces falling on distal extension bases causing buccolingual movementof the base. This rotation is called fishtail movement. This movement is counteracted by : Providing adequate bracing components in the partial denture. A rigid major connector. Broad base coverage. Balanced contact between upper and lower teeth. Forces occuring through a removable restoration can be widely distributed, directed, and minimized by the selection, the design, and the location of components of removable partial dentures and by developing a harmonious occlusion. FORCE I.Vertical Forces CAUSE OF THE COUNTERAC- FUNCTION FORCE -TION OF FORCE Functional -Rests placed on Support movements during abutments bound saddles
44
in
a.)Tissue ward mastication,

movements swallowing and lower teeth and -Rests & proper end saddles -Maxillary connectors b.)Tissue away movements Pulling gravity effect on of -Retainers & Retention
occlusion of upper coverage in free
sticky food provides -Adhesion upper cohesion
dentures and excess between denture muscle forces acting base & tissues on the periphery of the denture Side to
II.Horizontal forces a.)Lateral Forces
side -Rigid
bracing Bracing
movements of the clasp arms. mandible while teeth -Major are in contact. connectors. -Balanced occlusion. -Maximum extension of the flanges and -Abutments adjacent to of the denture. -Guiding planes.
b.)Anteroposterior forces
Forward backward movement mandible
Stabilization
while teeth are in contact III.Rotational

45

Forces a.Rotation the base the around of Functional Supporting rests Supporting and properly rests. -Properly adapted bases adapted bases denture movements towards while teeth are in ridge occlusion the Indirect retention
fulcrum axis b.Rotation of -Sticky foods gravity -Indirect the base around denture on aways dentures,elastic the under the base upper retainers -Direct retainers
from the ridge rebound of tissues fulcrum axis
46
PHILOSOPHYOF PARTIAL DENTURE DESIGN

There are four design concepts, which can be used to distribute the force evenly along the tissues and supporting tooth structure. They are : Conventional rigid design. Stress equalization. Physiologic basing. Broad stress distribution. Physiologic basing(Fig-26) The philosophy of design agrees in part with the first school about the relative lack of movement of the abutment teeth in an apical direction but denies the necessity of using stress directors to equalize the disparity of vertical movement between the tooth and the mucosa. The belief is that the equalization can best and most simply be accomplished by some form of physiologic basing, or lining, of the denture base.(Fig-26) The physiologic basing is produced either by displacing or depressing the ridge mucosa during the impression making procedure or by relining the denture base after it has been fabricated. The reason for
47

displacing the mucosa during the impression procedure is to record the soft tissue in its functioning, not anatomic, form. If the tissues are recorded in their functional state, the denture base, formed over the displaced tissue, will be better able to withstand the force that is generated. It is obvious that in such situation, the artificial teeth will be positioned above the plane of occlusion when the denture is in mouth and not in function. To permit vertical movement of partial denture from the rest position to the functioning position, the direct retainers or retentive clasps must be designed with minimal retention and the number of direct retainer must be limited. The occlusal rest and direct retainers will also be slightly unseated at rest. They will be completely seated only when the mucosa beneath the denture base is displaced to its functional form. ADVANTAGES a) The intermittent base movement has a physiologically stimulating effect on the underlying bone and soft tissue , which reduces the frequency of relining or rebasing the prosthesis (there will be less bone loss ) b) Simplicity of design and constructive because of the minimal retention requirements results in a light weight prosthesis needing minimal maintenance and repair c) An additional advantage is gained by the minimal direct retention used. The looseness of the clasp (combination clasp with wrought wire retentive arms) on the abutment tooth reduces the functional
48

forces transmitted the abutment tooth. Hence the abutment teeth are preserved for longer time duration. DISADVANTAGES 1. The denture is not stabilized against lateral forces 2. The residual ridge receives the greater proportion of forces that are transmitted by the denture, hence more chances of bone resorption 3. The load of stabilizing and supporting the denture is limited to a few teeth instead of being shared by a number of teeth as in other design philosophies 4. There will always be slight premature contacts between the opposing teeth and the denture teeth when the mouth is closed. This is an uncomfortable situation to many patients and may result a sense of insecurity 5. It is a difficult to produce effective indirect retention because of the vertical movement of the denture and the minimum retention of the direct retainer. Broad Stress Distribution(Fig-25) According to this philosophy of design, the occlusal load acting on the denture should be distributed over a wider soft tissue area and maximum number of teeth. This is achieved by increasing the number of direct retainers, indirect retainers, and rests and by increasing the area of the denture base.(Fig-25) Advantages This design with multiple clasps acts as a form of removable splinting.
49

It increases the health of the abutment teeth (due to splinting action). Easier to construct and economical. Disadvantages Less comfortable. Difficult to maintain adequate oral hygiene
Conventional Rigid Design The denture is designed with rigid component which act like a raft foundation to evenly distribute the forces on the supporting tissues. This design is used in all general cases. The flexible component of these dentures is their retentive terminal. Advantages Easy to construct and economical. Equal distribution of stress between the abutment and the residual ridge. Reduced need for relining as the ridge and abutment share the load. Indirect retainers prevent rotational movement and also stabilize the denture
50

during horizontal movements. Less susceptible to distortion. Disadvantages Increased torquing forces on the abutment teeth. Rigid continuous clasping may damage the abutment teeth. Dovetail intracoronal retainers cannot be used in these cases as tipping forces from the denture base will be directly transmitted to the abutment teeth. Tapered wrought wire retentive arm (combination clasp) cannot be used, as it is difficult to construct. Relining is difficult and inappropriate relining leads to damage of the abutment teeth.
Stress Equalization or Stress Breaker or Stress Directing Concept(Fig27) A stress breaker is defined as, A device which relieves the abutment teeth of all or part of the occlusal forces" - GPT. A stress director is a device that allows movement between the denture base and the direct retainer which may be intracoronal or extracoronal. Dentures with a stress breaker are also called as Broken stress partial dentures or Articulated prostheses.(Fig-27).
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We know that the soft tissues are more compressible than the abutment teeth. In a tooth tissue supported partial denture, when an occlusal load is applied, the denture tends to rock due to the difference in the compressibility of the abutment teeth and the soft tissue As the tissues are more compressible, the amount of stress acting on the abutments is increased. This can produce harmful effects on the abutment teeth.In order to protect the abutment from such conditions, stress breakers are incorporated into a denture. There are two types of stress breakers: Type I Here a movable joint is placed between the direct retainer and denture base. This joint may either be a hinge or a ball and socket or a sleeve and cylinder. Adding these stress breakers to the junction of the direct retainer and the denture base, allows the denture base to move independently.This decreases the amount of force acting on the abutment. The combined resiliency of the periodontal ligament and the stress director will be equal to the resiliency of the oral mucosa overlying the ridge. Examples for hinges include DALBO, CRISMANI, ASC 52 attachments. Type II It has a flexible connection between the direct retainer and the denture base. It can be a wrought wire connector, divided or split major connector or a movable joint between two major connectors.In a split major connector, the major connector is split by an incomplete cut parallel to the occlusal surface of the teeth into two units namely the
52

upper unit (more near to the tooth) and the lower unit. The denture base is connected to the lower unit and the rests and direct retainers are connected to the upper unit. Advantages The alveolar support of the abutment teeth is preserved as the stresses acting on the abutment teeth are reduced. The stress on the residual ridge and the abutment teeth are balanced. Weak abutment teeth are well splinted even during the movement of the denture base. Abutment teeth are not damaged even if relining is not done appropriately (after the denture wears out). Minimal requirement of direct retention. Movement of the denture base produces a massaging effect on the soft tissues. This avoids the frequent need for relining and rebasing
Disadvantages of stress breakers 1. The broken stress denture is usually more difficult to fabricate and therefore more expensive
53

2. Many stress breakers designs are not well stabilized against horizontal forces. 3. The effectiveness of indirect retainers and cross arch stabilization is reduced or eliminated altogether. 4. The more complicated the prosthesis, the less the patient may tolerate it. 5. Spaces between components are sometimes opened up in function, thus trapping of food and occasionally the tissue of the mouth leading to injury and periodontal problems. 6. Flexible connectors may be bent and distorted by careless handling. 7. Repair and maintenance of any stress breaker is difficult, costly and frequently required. 8. If relining is not done whenever needed, it may result into excessive resorption of residual ridge.
SUPPORT MECHANISM IN REMOVABLE PARTIAL DENTURE Support is derived from bone, for it is to the bone that all forces are ultimately transmitted, either via the mucosa and periosteum or via
54

the teeth and periodontal ligament. The mucosa is an inappropriate tissue to resist occlusal forces, as any complete denture wearer will attest to. In a partially edentulous situation, using mucosa only invites iatrogenic damage.Therefore,vertical support must always be provided by some of the remaining teeth for all removable partial dentures. CHARACTERISTICS OF SUPPORT BEARING AREAS The forces directed to the supporting tissues will be partially absorbed and partially transmitted to adjacent tissues. The percentage of force absorbed or transmitted will vary depending upon which tissue is involved. Bone is the tissue which ultimately absorbs the greatest amount of the force applied to both the muco-osseous and dento-alveolar segments. DENTO-ALVEOLAR SUPPORT
A.
TEETH.(Fig-28)
Teeth should be 1.Structurally sound and 2.Anatomically favourable.

1.
Structurally sound. Functional forces are transmitted by a partial denture to the tissues
with which it is in contact.If a denture is supported primarily by the natural teeth most of the forces will be transmitted to the alveolar bone through the fibres of the periodontal ligament.
Tooth structure:Structurally sound vital teeth are capable of withstanding normal functional forces.Excessive forces applied to the tooth may result in adverse effects such as
55

i. Tooth fracture. ii.Tooth movement. iii. Pulpal irritation.( Pulpal hyperemia or irreversible pulpitis. Structurally compromised teeth may fail in response to normal functional forces.Few examples are i.Teeth with large intracoronal restorations. ii.Endodontically treated teeth. Endodontically treated teeth are structurally weak due to dessication of dentin leading to loss of its organic content which ultimately makes the dentin brittle.This brittle dentin when subjected to occlusal forces may fracture and loss of teeth structure. 2.Anatomically favorable.
a. b. c.
Root surface area. Root morphology. Presence of multiple roots. d. Presence of divergent roots e. Crown to root ratio. f. Axial Inclination
B.PERIODONTIUM(Fig-29) These includes gingiva, crevicular

56
epithelium,
junctional

epithelium, connective tissue attachment, cementum, periodontal ligament and alveolar bone. Healthy periodontium permits force absorption without damaging effects.Excessive forces may increase the width of the periodontal ligament and result in increased tooth mobility. Health periodontium should be 1.Anatomically favorable. a. Normal epithelial and connective tissue attachment. b.Adequate zone of attached gingiva. 2.Absence of periodontal disease Plaque induced inflammation may compromise the periodontium. It can lead to apical migration of the crevicular epithelial attachment (functional epithelium) and destruction of the fibroblasts and connective tissue of the connective tissue attachment. In the presence of inflammation normal functional forces may accelerate the rate of periodontal attachment loss. The presence of plaque induced periodontal disease is associated with a loss of bone height. Moderate forces may accelerate increasedmobility of the teeth. A healthy periodontium should have a.Gingival indices within normal limits. b.Absence of mobility or hyper mobility. the disease process resulting in further bone loss, less bone support, and
C.ALVEOLAR BONE. Residual ridge support(Fig-30)

57

As has been said, the entire root surface area ot an arch ot teeth is about 45 cm2 . It is as well to consider this in terms of the area remaining when the teeth arc lost. It has been calculated that the entire denture bearing area when all teeth are lost is about 20 cm for the maxilla, and about 12 cm2 for the mandible. Hence in the partially edentulous situation, ii will always be preferable, just from this consideration alone, to use the teeth for support. It residual ridge support is to be used as well, then it follows that full use should be made of a fully extended denture base.
The residual alveolar ridge, though, has forces transmitted to it by the overlying mucoperiostium, and this too will resist forces in a manner which will depend on its morphology. There is a wide variety of thickness and type of ridge mucosa, with some areas being almost seven times thicker than others.There are three main histological types of mucosa.Buccal mucosa is partially keratinised and has underlying elastic tissue; mucosa of the floor of the mouth is similar but non-keratinised. Both these types are not firmly attached to the
58

underlying bone, in contrast to the third type, the attached ridge mucosa, which is usually keratinised and much more able to withstand loads. FORM OF RESIDUAL RIDGE The residua ridge itself is also uneven in shape, and this will affect not only resistance to loading forces, but also resistance to laterally directed forces,inother words, the stability of the denture base overlying the ridge.In A, a flat ridge will provide good support but poor stability. The varying thickness of the mucosa and the sharp and often spongy ridge in B provides poor support. In C, neither good support nor stability are present, because of the flabby and displaceable tissue over the ridge.
The ridge often becomes sharp and uneven because of the uneven resorption of bone following tooth extraction.This depends on many factors, such as the nature and health of the alveolar bone prior to extraction of the teeth, and the manner of resorption of the smooth conical bone, which varies from individual to individual. Also varying, is the type and position of the muscle attachments, which may form sharp and pointed ridges.
59

With age. some of the tendinous attachments may become calcified, and with increasing resorption, all attachment sites can become relatively prominent (this is common at the genial and mental tubercles and along the mylohyoid ridge). PRESSURE-TENSION THEORY: Bone tends to resorb in response to compressive force and to be stimulated by tensional force. In order to preserve remaining alveolar bone,it is important that functional forces be transmitted to bone primarily as tension rather than pressure whenever possible. In tooth borne situations the majority of functional forces are transmitted as tension to bone through proper rest design and rest seat preparation.In tooth mucosa borne situations some of the vertical seating forces are transmitted as tension to the bone through the rests. Horizontal forces are transmitted as a combination of compressive and tensional forces to the alveolar bone(e.g.those forces directed through bracing clasps,proximal plates and minor connectors contacting proximal tooth surfaces and guiding planes).Vertical displacing forces are transmitted to the bone as both compressive and tensional forces (e.g.sticky foods or retentive clasps engaging undercuts). BONE INDEX The response of bone to pressure varies in terms of the rate of resorption depending on genetic,nutritional, hormonal and biochemical and other intrinsic factors. The bone index is determined by analyzing the previous response of bone to force. The bone index of the alveolar bone
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surrounding natural teeth may differ from that of the bone comprising the residual ridges. CORTICAL VS. CANCELLOUS BONE The residual ridge crest is comprised mainly of cancellous bone and is less resistant to resorption. The facial and lingual inclines of the residual ridges are comprised of cortical bone and are more resistant to remodelling. The rate of cancellous bone resorption has been described as being approximately three times that of cortical bone. Excessive forces may increase the rate of bone resorption. Moderate forces may result in accelerated bone resorption when intrinsic factors, local abnormalities or systemic disorders compromise the bone index of the individual. MUCO-OSSEOUS SUPPORT A.MUCOSA. Keratinized and Firmly bound. B.SUBMUCOSA.
1. 2.
Normal sub mucosa serves as an "hydraulic cushion". Firmly bound and dense.
C.BONE.
1. 2. 3.
Cortical bone. Favorable bone index. Presence of muscle attachments which direct tension to bone (or the
equivalent in terms of resistance to pressure induced resorption). DISPLACEMENT CHARACTERISTICS OF PERIODONTIUM AND RESIDUAL RIDGE MUCOSA The previous discussion of the types and sites of support available
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for a partial prosthesis leads to a consideration of the different characteristics that the support mechanisms may have. A denture that uses both tooth and residual ridge support is dento-mucosally supported, and because the nature of the tissues varies, one must be aware of the loading characteristics of each type When load is applied to a material there are basically three ways in which the material can react, depending on its nature,as shown in figure where D is the displacement, and T-time.
A purely elastic material will be displaced immediately, and then immediately recover to its original form or position on removal of the force applied it obeys Hooke's law). When a viscous substance, such as oil, is subjected to load,it will gradually be displaced to reach a resting
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state, and will not recover on removal of the force (it behaves as a Newtonian element). A combination of these two effects occur in viscoelastic materials which behave as a voigt model.Application of the load will cause a relatively free phase of displacement or distortion, the rate of which will lessen until equilibrium is reached. Removal of the load will reveal a relatively fast recovery phase followed by a prolonged and gradual return to the original state. Hence the response depends on the rate of loading as well as the magnitude and duration of the load. Teeth and mucosa behave as viscoelastic materials, but with quite different characteristics. When a tooth is loaded,there is an initial rapid displacement as a result of movement of tissue fluids and cell distortion, followed by a stiffer more gradual response as the periodontal fibres are loaded.When the applied force is removed, the tooth recovers to its original position rapidly,within a minute or two.
The response of oral mucosa,however,is much more akin to a classical visco-elastic response, and depends far more on the magnitude and the duration of the loads applied. This has been tested by applying different loads to an acrylic plate placed on palatal mucosa.For static loading, when the load was applied suddenly there was an instantaneous elastic displacement, and as the load was maintained constantly for 10
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minutes a further gradual displacement (creep) occurred. On sudden removal of the load there was an instantaneous elastic recovery, followed by a viscoelastic recovery that can last upto four hours( the heavier the load, the longer the recovery).For dyanamic loading an increase in the loading rate reduces the amount of mucosa displacement at 4 Newtons per second the plate was displaced 500 and at 100N/sec it was displaced only 375m.
More importantly, under functional conditions in the mouth, loading varies with each chew, and the effects of simulating this have also been studied. With successive chews, there is a progressive displacement, but also a progressive failure to recover, so that an equilibrium at a displaced position relative to the starting position is reached. These displacement characteristics of mucosa can be explained by considering the structure of mucosa itself its thickness and fluid flow characteristics when depressed will cause the variety of responses, together with the general physiological tissue characteristics of the host.
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This latter becomes an important consideration when age is taken into account. It has been shown that there is a decrease in mucosa thickness with age, and a significant difference in recovery characteristics ,the tissues in elderly people take many hours to recover from the effect of moderate mechanical force, whereas the tissues of a 25 year old,for example, require much less lime to recover from the same force. In figure the mucosa of'young patients (age range 15-25 years recovered faster and further than that of older patients (age range 72-86 year).
The choice of support It should be apparent from the above discussion that oral mucosa presents a much more varied and greater response to loading than the periodontium.
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The diagram illustrates the displacement of tooth-borne and mucosa-borne plates when a load was applied and maintained for 30 seconds.The tooth-borne plate displaced the least, with a load of 1N as shown by the line A. The mucosa-borne plate at the same load displaced further, as shown by the line. B. When this plate was given a load of 4N the greatest displacement was measured, as the lineC. Under certain conditions, mucosa can be displaced up to twenty times that of the periodontium, and this can create many clinical complications especially with dento-mucosally supported dentures. The practical application of this problem will be dealt with under a number of different sections following, but it is essential to understand the biomechanical nature of the problem. It should be obvious now that it would be preferable to use the teeth for support at all times, and to avoid any loads on the mucosa at all but there are occasions when the mucosa must also be used for support, and when it is, there must be some compensation made for the difference in displacement characteristics of the mucosa and the teeth.Otherwise, at every bite, the denture will move
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in a manner such that not only will the patient will be unable to control the movement,but the movement may cause iatrogenic damage to the teeth or tissue. The most obvious situation where the residual ridge must be used is when there are no teeth distal to the gap the dento-mucosally (usually called dento-gingivally.) supported denture. The residual ridge must be used to support that part of the denture carrying the missing teeth.Less obvious, are the situations where the state of the teeth and periodontium are such that they could not carry the extra loads of a prosthesis without exceeding their physiological tolerance to do so.In this case, once again iatrogenic damage to the teeth and their supporting tissues may occur. Over the years, a variety of clinicians have offered suggestions for classifications of dentures based on support. For any classification to be useful, it should be: Consistent Unambiguous Generally accepted No one classification is ideal, and perhaps the most useful is that outlined, in one form or another, by Beckett (1953), Craddock (1956) and Osborne and Lammie (1974) Class I: Denture supported by mucosa and underlying bone Class II: Denture supported by teeth. Class III: Denture supported by a combination of mucosa and tooth-borne means.
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We consider that this classification should now be extended to include a further type, namely: Class IV: Denture supported by implants. It must be realized that this classification is not ranked in order of precedence but could perhaps be considered in order of complexity of planning. For this reason, the support options will be discussed in the above order. Class I Dentures (deriving their support from mucosa and underlying bone) Wills (1978) clarified some misconceptions on the displacement and deformation properties of oral mucosa with their research on primates. They determined that the effects of loading mucosa over a long period were to compress it by up to 45% of its original thickness and, further, that its recovery was visco-elastic in nature. The time required for recovery from the displacing forces has also been found to increase with age. What this clearly means, however, is that prostheses which derive their support from mucosa and the underlying bone will inevitably do two things: Displace mucosa Result in further loss of alveolar bone (this is perhaps of greater importance). From the above, it is clear that in mandibular dentures especially, mucosa-borne partial prostheses ought to be considered as a last resort, or possibly as a transitional phase to complete dentures.More latitude exists
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in the maxilla, however, where the hard palate affords additional support, but this is often abused. Class II Dentures (deriving their support from teeth) Tooth-supported prostheses gain their support from the teeth via the supreme qualitative and quantitative support agent, namely the periodontal membrane. Pressure down the long axis of the tooth imparts tension in the periodontal membrane, which in turn helps to maintain alveolar bone. Clearly this is the most desirable form of support and should be used whenever practical. It has traditionally been taught that dentures may gain tooth support from incisal rests, occlusal rests or cingulum rests. The statements in the foregoing paragraph indicate that, theoretically, support derived from teeth is more desirable than any other single form of support, and this is a scientifically established fact. However, on occasion the clinician has a need to be empirical and to prescribe what is most appropriate for the patient. For example, a patient who has been treated for chronic periodontal disease may have lost considerable bony support,and a cast metal framework utilizing occlusal rests and cast cobalt chromium clasp assemblies may impart inappropriate forces on a tooth. Class III Dentures (deriving their support from a combination of mucosa and tooth borne means) In tooth tissue supported RPD attention must be given to both abutment and edentulous ridge. For the abutment teeth these consideration are periodontal health, crown and root morphology, C/R
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ratio, bone index area, location of abutment in the ridge, and opposing dentition. For edematous ridge these consideration are the quality of the ridge, the extent of the ridge covered by denture base, the type and accuracy of impression technique, and the partial denture design. The greatest difficulty occur in transition area where tooth support ends and mucosa support begins ,when functional occlusal load is applied to denture base,an axis of rotation is created ,the denture tend to rotate about its most distal abutment inducing heavy torisonal stresses on the abutment teeth and possible traumatization of the ridge. The degree and direction of the denture base movement are greatly influenced by the quality of the supporting residual ridge, the design of RPD and the extent of the forces exerted on the denture during function.When RPD with both anterior and posterior denture bases present a stress problems, since the length of the ridge area extends anterior and posterior to the fulcrum clasping areas produces a double acting lever problem for the abutment teeth. It is perhaps no coincidence that clinicians and patients alike have embraced the shortened dental arch philosophy. The option to do nothing or to use a fixed prosthesis to replace one dental unit(e.g. by cantilevering one unit from the terminal abutment) is seen as being less problematic than providing a removable prosthesis to replace several missing teeth. From the clinicians viewpoint this is because of the very real and problematic differences between the two supporting elements,and from the patients perspective because of intensive tissue coverage.Extrapolating the results of Wills and Manderson (1977) and Wills et al. (1980), the clear fact emerges that, long after abutment teeth
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have returned to their resting positions (after mastication, for example), the mucosa will remain displaced; this displacement is of the order of 20 times that of the teeth even on the basis of a maximally covered saddle. It will be self-evident to state that mucosa under minimally covered saddles will be displaced even more than under maximally covered saddles.This support differential is thus problematic,and the inherent tendency for a prosthesis to demonstrate rocking (instability) has resulted in philosophies of clasping which were based on homeostatic principles of stress-breaking, whereas others were based on more biological principles(Kratochvil, 1963; Krol, 1973). Class-IV Dentures(Tissue Implant supported removable partial denture) The design and maintenance of bilateral and unilateral distal extension partial dentures (Kennedy Class I and II) present challenges for clinicians,as these dentures require support from the teeth, the mucosa and the underlying residual alveolar ridges. In particular, the distal extension removable partial denture is subjected to vertical, horizontal and torsional forces due to the different resiliencies of alveolar mucosa and periodontal ligament of abutment teeth that may have adverse effects during functional and para-functional activities. To prevent displacement of the denture, precision attachments or conventional clasps have been widely used. However, the rotational tendency of the RPD after long-term use cannot be eliminated completely, regardless of design and fit of the denture. To overcome this clinical challenge, single implants may be placed bilaterally at the distal
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extension of the denture base to minimize the potential for dislodgement of the denture. The chief goal of placing an implant under the posterior-most molar of the distal extension denture base is to stabilize the RPD in a vertical direction. Distal implants effectively convert a Kennedy Class I or II denture to a Kennedy Class III denture. Therefore, a tooth- and implant-supported RPD is cheaper (because fewer implants are needed) and more stable, and may therefore be a better option for patients with limited financial resources than an implant-supported fixed partial denture. IMPLANT CORRECTED REMOVABLE PARTIAL DENTURES The classification will always begin with the phrase "ImplantCorrected Kennedy (class)," followed by the description of the classification. It can be abbreviated as follows: (i) ICK I, for Kennedy class I situations, (ii) ICK II, for Kennedy class II situations, (iii) ICK III, for Kennedy class III situations, and (iv) ICK IV, for Kennedy class IV situations. ICK I, for Kennedy class I situations The Kennedy Class I partially edentulous arch has bilateral distal extensions. The functional load is transmitted to the teeth and the soft tissue. Implant location depends primarily on the dimensions of the residual ridge and the biomechanical considerations of the RPD design. Two distally positioned implants in the area of the second molars would
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effectively trans-form the Kennedy Class I configuration to a more favorable Kennedy Class III. Theoretically, the implants should be located as distally as possible to provide maximal support and stability. This is of special importance in the mandible because of the significant displacement of the denture base that is not supported by the major connector. The implants might be used for support only using healing caps or for retention with resilient attachments connected to the implants. A low-profile attachment is preferred to decrease the off-load forces to the implants. Note:Endodontically treated abutments would be specifically beneficial when used for support only without direct retainers applying unfavorable lateral displacing forces. Drawbacks: An inadequate posterior ridge dimension could restrict implant placement to a more anterior location. The Implant therapy is versatile In the future, the patient might select to restore the edentulous ridges with fixed implant-supported restorations(in such case the implants should be located more medially, adjacent to the existing abutments, to allow future prosthodontic use) ICK II, for Kennedy class II situations The Kennedy Class II partially edentulous arch has a unilateral distal extension. An ISRPD should be usedwhen the tooth loss is extensive.Otherwise,just as when only the molars are missing, the patient
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might not use the prosthesis. When the patient has no functional problem, a shortened dental arch concept,with no prosthesis, should be considered Placing a single implant in the posterior regionwould modify the Kennedy Class II configuration to a Kennedy Class III and increase the stability and reten-tion of the prosthesis. The same considerations discussed for the Kennedy Class I tissue ISRPD also apply. ICK III, for Kennedy class III situations The Kennedy Class III partially edentulous arch has edentulous space bounded by teeth. Therefore, implants should be used when the edentulous space is long, the abutments are compromised, and when thepatient objects to the appearance of the clasps.The implants should be placed adjacent to the abutments. ICK IV, for Kennedy class IV situations The Kennedy Class IV partially edentulous arch hasa single, anterior edentulous space that crosses the midline and is bounded by the remaining teeth. The implants should be placed as medially as possible tothe abutments to provide optimal support. The labial flange of the prosthesis might serve to restore the lip support in these ISRPDs. The use of implants inKennedy Class IV partially edentulous patients renders the use of retentive clasps and elaborated dual-path RPD designs unnecessary. Clinical guidelines for Implant Supported removable partial denture 1. Place implants in area of second molars in distalextension patients.
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2. Place implants adjacent to distal abutment in case future fixed restoration is an option, distal abutments are poor, or patient is concerned about unesthetic clasp showing. 3. Place implants medially in Kennedy Class IV arch. 4. Use short or narrow-body implants if necessary. 5. Use resilient attachments on the implants. 6. Design a simple RPD; use rest seats and guiding plates similar to conventional RPD. 7. Use rigid major connector design for maxillary arch. 8. Minimize mandibular lingual flange if difficult for patient to adjust 9. Incorporate retentive elements to denture base under functional load. 10. Schedule patient for checkups and maintenance appointments Advantages Improved esthetics by the elimination of visible clasp assemblies. Ability to change fulcrums in the arch providing more favorable biomechanics. Minimizing rotational and lateral forces on direct and indirect abutment teeth. Controlled additional vertical support especially significant in partially edentulous patients with distal extensions.
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Provide additional retention and stability to the prosthesis by incorporating an attachment mechanism. Simplify prosthesis design and base extension. Highly predictable treatment. Easy to maintain depending on prosthesis design and attachment system. Minimize excessive pressure and trauma to soft tissues and supporting ridge with alteration of the biomechanical forces. Disadvantages of using implants in removable partial prosthodontics. Additional costs for treatment. Additional surgical procedures. Extended treatment time. Involve careful treatment planning and interdisciplinary approach More technique sensitive than a conventional RPD. Additional maintenance over time depending on prosthesis design and attachment systems used. Manual dexterity can be challenged in certain patient populations, eg., rheumatoid arthritis, limited mobility. Increased costs to overall treatment.
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FACTORS INFLUENCING MAGNITUDE OF STRESSES 1) Length of the edentulous span The longer the edentulous span is, the longer the denture base will be, and the greater the leverage force transmitted to the abutment teeth will be. For each distal extension base, the fulcrum is located at or near the occlusal rest on the most posterior abutment tooth. During function, a load is applied to the artificial teeth, and the length of the lever arm (i.e,denture base) determines how much force the associated abutments must withstand. Therefore, the practitioner must always be aware of the forces that are generated as a result of removable partial denture design. Although other factors such as the thickness of the mucosa and the total area of the residual ridge may affect clinical outcomes, the length of the edentulous span remains a factor that warrants particular attention. When treatment is being planned, every effort should be made to retain an abutment posterior to the edentulous space.Preserving a posterior tooth to serve as vertical support, even as an overdenture abutment, results in improved patient service.
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Similarly, the placement of an endosseous dental implant can result in an equally valuable service. 2) Quality of support of Ridge The form of the residual ridge can play a large part in distributing forces generated by the function of the partial denture. Large, well-formed ridges are capable of withstanding greater loads than are small, thin, or knife-edged ridges. Broad ridges with parallel sides permit the use of denture bases with longer vertical surfaces. These surfaces help stabilize the removable partial denture against lateral forces. The thickness and health of the mucoperiosteuma so influence the loads transferred to abutment teeth.A healthy mucoperiosteum approximately 1mm in thickness is capable of bearing a greater functional load than is thin, atrophic mucosa. Soft,flabby, displaceable tissue contributes little to the vertical support of the denture base. This type of tissue allows excessive movement of the denture base and permits forces transmitted to the associated structures. 3) Occlusal relationship of the remaining teeth and orientation of the occlusal plane Many patients exhibit deflective occlusal contacts that generate horizontal force vectors. These vectors can be magnified by removable partial dentures and can be transmitted to the abutments and residual ridges. To prevent the transmission of destructive forces, the practitioner must be fully aware of occlusal
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conditions and of the mechanics of partial denture movement.The opposing occlusion can play an important role in determining the load generated during closure.Some individuals with natural teeth can exert closing forces of 300 pounds per square inch. In contrast, many denture wearers may not be able to exceed 30 pounds per square inch. Therefore, a removable partial denture that opposes an intact dentition may be subjected to much greater loading than a removable partial denture opposed by a complete denture. The area of the denture base against which the occlusal load is applied also influences the amount of load that is transferred to the abutment teeth and the residual ridge. If an extension base is loaded adjacent to the neighboring abutment, there will be minimal movement of the denture base. As loading moves far away from the abutment, movement of the denture base will be greater. Ideally, the occlusal load should be applied in the center of the denture-bearing area, both anteroposteriorly and faciolingually. In most mouths, the second premolar and first molar regions represent the best areas for the application of the masticatory loads. Artificial teeth should be arranged so that the bulk of the masticatory forces are applied in these areas. 4) Qualities of clasp A flexible retentive clasp arm decreases the stress that will be transmitted to the abutment tooth. A wrought wire clasp is more flexible than a vertically projection clasp, hence, it decreases the forces acting on the abutment tooth and increases the forces transferred to the
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edentulous ridge. It provides less resistance to more destructive horizontal stresses. 5) Clasp design A clasp that is designed to be passive when it is completely seated on the abutment tooth will exert less load on the tooth than will one that is not passive. As a result, the fit of a removable partial denture framework must be carefully refined to ensure that the prosthesis is completely seated. Only when the framework is completely seated will the retentive clasp arms be passive. If a clasp's retentive tip is designed and constructed to lie in a 0.010inch undercut, but the framework is not completely seated, the retentive tip will not be passive. Instead, it will exert a continuous load on the abutment.
Refinement of the framework's fit is best accomplished by uniformly coating the tooth-contacting surfaces of the framework with a disclosing wax.As the framework is seated, wax is displaced. A tooth to metal binding will show through the wax. These areas are adjusted until the framework is completely seated and the clasp arms become passive.
A clasp should be designed so that during insertion or removal of the prosthesis, the reciprocal arm con-tacts the tooth before the retentive tip passes over the greatest bulge of the abutment. This will stabilize or neutralize the load to which the
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abutment is subjected as the retentive tip passes over the greatest bulge of the tooth. 6) Length of clasp The flexibility of clasp depends on its length. Doubling the length increases the flexibility five times. This decreases the stress on the abutment tooth using a curved rather than a straight clasp on an abutment tooth will aid to increase clasp length.
7) Material used in clasp construction A clasp constructed of chrome alloy will normally exert greater stress on the abutment teeth, than a gold clasp because of its greater rigidity. To compensate for this property, clasp arms of chrome alloys are constructed with a smaller diameter than a gold clasp. 8) Surface characteristics of abutment The surface of a gold crown or restoration offers more frictional resistance to clasp arm movement than does the enamel surface of a tooth. Therefore, greater stress is exerted on a tooth restored with gold than on a tooth with intact enamel.
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STRESSES INDUCED BY THE REMOVABLE PARTIAL DENTURE

The service expectancy of a removable partial denture will be proportional to the degree of control which is exercised over the stresses induced by it. This is such an important factor especially in the success of the extension-base type of prosthesis that it should be emphasized by analyzing each stress and suggesting clinical and constructional procedures for bringing about its most effective control. Functional stress stimuli, within certain limits, are necessary for maintenance of the supporting structures. Beyond an optimal amount, which may vary to a considerable degree, stress may become an irritant, however, and may actually cause retrogressive changes to begin. In the case of the partial denture, one sure method of avoiding overload is by the reduction of functional stress loads to a minimum
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which is consistent with a conservative restoration of function. In fact, the total stress load should be well below the estimated tolerance of each patient. This provides a safety factor to accommodate a variation in the amount of stress which the structures may tolerate at different periods. Such variations are seen between one individual and another, where extreme differences may be noted, but there are also variations from one period to another in the life of the same individual. PRESERVING THE ORAL STRUCTURES Certain basic precautionary measures are indicated to assure that an oral rehabilitation program will be kept within the tolerance limits of the prosthodontic patient. The restoration of masticatory function is desired, but the degree of restoration must be adjusted to the individual's ability to sustain such increased workloads on the supportive structures. In addition to limiting the beginning functional load given to the individual, one must also provide a margin of safety to accommodate for the depression periods of reduced tolerance limits. Even for the young patient an occasional subnormal period may be expected. For older patients there is the added certainty of a slowing up in physical processes as they approach senescence. These low tolerance periods and slumps in metabolic function may come on very gradually and without the patient's recognition. One of the important reasons for scheduled, periodic rechecks, as a part of partial denture maintenance service, is to detect evidence of any stress overload and to correct for this if possible. It is strongly urged that prosthodontists concentrate less on the idea of restoring full masticatory function for the
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partially edentulous patient, and that they exhibit more concern about maintaining the oral structures which still remain. INDUCED STRESSES TO BE RECOGNIZED This is very important to determine how each component part may assist in the reduction or elimination of induced stresses. For further emphasis of this important matter of stress control, each of the following potential overloads should be analyzed,its effects upon the supportive structures noted, and measures for its control outlined. To have a better overall picture of this problem, however, the induced stresses first should be enumerated. The principal ones are: 1. Stresses resulting from an inaccurate appliance; 2. Stresses caused by an interference to appliance insertion and removal; 3. Stresses which may cause impingement of the gingival structures adjacent to the remaining teeth; 4. Stresses which develop as a result of the use of a sloping tooth surface for the support of an abutment occlusal rest; 5. Stresses resulting in impingement by a major connector; 6. Stresses which torque or twist the abutment of an extensionbase prosthesis; 7. Stresses which cause the proximal or lateral tilting of an abutment.
1.STRESS RESULTING FROM APPLIANCE INACCURACY
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When a removable partial denture (of any type) is either oversize or too small, there will be a continuous pressure on all teeth and other structures with which it makes contact. The direction of the pressure will be variable and dependent upon which unit of the prosthesis is transmitting the contact effect. The first result of this stress will be orthodontic in nature. If severe, it may induce hyperemia and discomfort. Usually, the tooth so effected will respond to the pressure, as in intentional orthodontic therapy, and will alter its position enough to release the pressure. As a result of the induced movement, a relation of malocclusion will usually be produced as a second effect of the inaccuracy of appliance fit. This has quite serious potentialities unless it is soon rectified. Unrelieved occlusal prematurities of this type can result in periodontal disturbances, not only about the tooth moved but also about those in adjacent and/or occlusal contact. Such pressures are capable of causing compression areas in the periodontal membranes of the affected teeth and may easily lead to destruction of the enveloping alveolar bone. Ramfjord has said, "Traumatic occlusion may result when
pressure contacts force a tooth into a position having an occlusal relation which in turn rocks the tooth into another position when functional or bruximatic stress is applied." A third effect of appliance distortion may be noted in the cast bases of inaccurate extension-base partial dentures. Impingement of sub-basal structures sometimes occurs in the mucosal pad over the mandibular ridge. It may occur bilaterally and apparently results from a slight "rebound" of the horseshoe-shaped casting when the sprues are cut.
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Mills refers to distortion of this nature in a very valuable study of volume change as a result of various factors concerned with the making of large bilateral removable partial denture castings. An inaccuracy as a result of volumetric change during the congealing of cast metal would be most noticeable near the free ends of the long castings, such as in a Class I mandibular appliance. This type of mucosal pad impingement would not be encountered in a partial denture of resin base construction. The resin base having been related to the cast metal framework after the casting process had been finished, there would be compensation for the former distortion as far as the ridge relationship of the base is concerned. This is another advantage of the resin base. SOME COMMON CAUSES OF APPLIANCE INACCURACIES In order to prevent the damage which may arise from a distorted appliance, the various contributing factors should be appraised. Most of these can be completely avoided, and all can be reduced to discrepancies which are quite within the average range of tissue tolerance. a.FAULTY IMPRESSION A faulty impression is the first cause of inaccuracy to be eliminated. The discrepancy may be in either the impression of the prepared dental arch or the hydrocolloid duplication impression of the master cast. Partial displacement of the impression from the tray is more frequent than is suspected. When this accident is apparent (usually at one heel of the lower tray), there is the temptation to rely upon what seems to be an accurate replacement by the repositioning of an otherwise perfect impression back into contact with the tray.
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Since the slightest failure to reseat it perfectly will result in a gross error in a casting the size of an average dental arch, the risk in making such an attempt is evident. The value of properly locking the impression material in the tray is apparent when the eventual cost of this error is taken into account. This distortion could have been avoided by proper placement of the material in the tray. It could be corrected in a very short time by retaking the impression. A second source of damage to the impression of the dental arch is from overstraining the material by forcing the impression from a deep undercut area in a direction which will result in the greatest strain. First release the surface tension seal at the periphery in the area of least undercut (let air under the impression). Then remove the impression as quickly as possible, allowing the direction of the snap removal to take the line of least resistance. This method will allow less chance of permanently deforming the elastic impression material. Improper care of the hydrocolloid impression is a common reason for the inaccuracy of the resulting appliance. A volumetric change (either shrinkage or expansion) is only one discrepancy to be guarded against. Injury to the surface of the resulting master cast by the contact of the setting stone against hydrocolloid is another danger which also must be avoided In this connection, an advantage of rubber-base material (mercaptan) is superior surface of the stone cast which can be obtained. b.ERRORS IN DUPLICATION In duplication, the hydrocolloid will have been diluted and, hence, is more easily abraded. All undercuts which are not to be used should have been blocked out (filled) to lessen the strain of removing the master
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cast. A further safety feature in this connection is to use a duplicating flask or ring which permits complete displacement of the impression from it before removal of the master cast is attempted .Mills found that one of the several factors affecting the degree of accuracy of prosthetic castings was the use of a non conducting ring of the duplicating flask. When such a flask is used,gelation of the hydrocolloid will take place from the bottom upward. This avoids the risk of internal shrinkage voids. Greater accuracy of the casting resulted, according to the Mills report. c.CASTING INACCURACIES. Incorrect proportions of water to investment can be the source of casting inaccuracies at two points in the development of a partial denture. First, the master cast may be affected in this way. The master cast must be an exact replica of the dental arch. The proper portion of water to investment should be used to produce a stone which will have minimal expansion. The amount of water to investment for the refractory cast also may be incorrect so that there will be an insufficiency of the necessary setting expansion of this cast. It takes the combined expansion which is obtained in three ways to negate the contraction of molten metal as it congeals to the desired form of the casting: 1. The setting expansion of the refractory material of the proportions found to give the maximum expansion while still having a consistency which permits proper handling; 2. The hygroscopic expansion achieved by having water contact the refractory material as soon as the impression has been filled, and before this investment begins to set;
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3. The thermal expansion of the refractory investment when it is heated to eliminate the wax pattern (1300 F. for three hours). Improper W-P ratio is one of the most critical of the several possible causes of appliance undersize or oversize. Even when every precaution is taken, it is barely possible to control this factor. It must be admitted that very often the large removable partial denture casting is not perfect in this respect the minimal goal that is accepable is one that keeps this error within the range of tissue tolerance. Larger, heavier removable partial denture castings, especially those for maxillary cases, present a need for maximum control of metal shrinkage. An effective way to accomplish this, is by altering the waterpowder ratio. For instance, from the recommended ratio of 28 cc. of water to 100 grms of powder, for the average bulk of Ticonium casting, this may be varied to amounts of water ranging as low as 25/100. A lower ratio of "Vestic," the more recent refractory investment recommended for Ticonium castings, has given excellent clinical fits. Surface abrasion of the casts used in making a partial denture may easily be responsible for a larger error in appliance.The effect of hydrocolloid on the surface of casts made of gypsum products is that of a retarder. If a soft, chalky surface is present on the master cast it will certainly be reduced by abrasion and the casting will be that much undersized. To offset this retarding action of the hydrocolloids it is possible to employ a "hardening" solution (2 per cent potassium sulfate) as a wash into which the impression is immersed for a few minutes before it is to be filled.
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The surface of the refractory cast may be more easily abraded because it is much softer than the improved stone of which master casts are most often made. A potassium sulfate solution may be used again to give a harder surface to the refractory cast. To further lessen the chances of abrading the refractory cast, at the time of removing the hydrocolloid, it is suggested that the removal of the cast be delayed for about 30 minutes after the allotted setting time. During this additional period the hydrocolloid is intentionally dehydrated by removing the duplicating impression from the flask and exposing it to air (a stream of compressed air also may be directed on the cast and exposed hydrocolloid). As the latter loses water it dries the surface of the cast by absorption. Removal of the duplicating material can be done with less abrasion by breaking it away do not attempt to withdraw the refractory cast. If a Vshaped piece is removed from the hydrocolloid impression in the palatal and lingual areas, those portions of the impression can be removed with less rubbing of the lingual surfaces of the abutment teeth. It is also an aid to use compressed air as a means of loosening these pieces. The refractory cast should not be rubbed or brushed and it should be handled with great care while it is drying and during the placement of the wax pattern. If the refractory cast has been reduced, the casting will fit neither the master cast nor the patient's dental arch. Proper thermal expansion of the casting mold will be listed here for emphasis,although it was mentioned in connection with the W-P ratio. It is usual to maintain a temperature of 1300 F. for three hours to insure an adequate temperature in the mold center. One important precaution is that the oven Pyrometer be tested frequently enough to insure its complete ac90

curacy. It occasionally happens that the temperature may be lower than the pyrometer shows. This condition will give an undersized casting. Distortion of the cast units during heat treatment or soldering operations has been reported in only a small percentage of cases tested.This should be regarded as a possible cause of discrepancy of appliance fit, particularly if the casting had shown a correct relationship when tested on the master cast, and then, after the reheating of the casting, it no longer seemed to fit as well as before. Even only two or three out of 100 appliances would seem too great a percentage of failures from this cause. These failures can be avoided by the use of alloys whose physical properties are acceptably near the ideal and do not require heat treatment, and by use of a method of construction which does not entail soldering. Excessive polishing is responsible for many misfits among partial denture castings. The reduction of the tooth surface of an occlusal rest can result in the lowering of the appliance. When some other unit (such as the suprabulge sector of a clasp) is resting on an occlusally inclined surface, it then will exert a lateral or proximal pressure on the abutment, if the appliance is allowed to settle as it would by the reduction of the undersurface of an occlusal rest. Actually, the appliance no longer fits. It should be a rule, therefore, that the tooth surfaces of a casting should be burnished and buffed lightly never ground. 2.STRESS INSERTION FROM INTERFERENCE TO APPLIANCE
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This stress, unlike that from an appliance inaccuracy, is an intermittent disturbance of tooth alignment. It occurs when a contacting rigid area of a removable prosthesis passes over a surface bulge of the abutment tooth. This interference to appliance insertion or removal results from the failure in mouth preparation to establish parallelism between the tooth surfaces with which the prosthesis is to make contact. Sometimes it is not possible or desirable to achieve a parallel relationship of the total area on which an interference is found, in which case some of the undercut will remain and must be eliminated at the stage of final survey. If the degree of interference is slight, the type of tooth disarrangement which it causes is of brief duration only. A second source of this kind of stress arises from the movement of a retentive clasp out of the infrabulge area and over the abutment height of contour. In this action, pressure develops from the temporary distortion of the clasp arm. Ideal clasp design provides a reciprocal support to counteract the force generated by the retentive clasp. The advantage of having this reciprocal terminal placed on a surface which had been made parallel to the path of appliance movement was emphasized. When this is done, the retentive stress is neutralized throughout the total period of its generation. Even when unreciprocated, this stress (retention which is generated by the retentive terminal) is also very briefly only the time that would elapse in the movement of the retentive clasp terminal on the infrabulge incline to and over the crest of abutment contour. While these two stresses are not to be desired, and can, with proper preparation of the abutments, be entirely eliminated, the potential damage
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which they may cause is undoubtedly much less than the stress generated by an appliance of inaccurate adaptation. In the first place, the stress from interference to appliance placement is brief and not continuous for the entire time that the prosthesis is in position. As compared to the above mentioned constant pressure (from a distorted or an inaccurate appliance), it certainly would be unlikely to cause any increase of trauma, and usually it would be much less. Of greater significance, however, is the fact that during the period of this stress application, the teeth cannot be in occlusal contact.Therefore, the added trauma arising from occlusal imbalance, which accompanied the stress caused by the inaccurate appliance, is completely avoided in the case of stress arising from interference. After the mouth preparation changes have given parallelism, there still will be need for the elimination of slight interferences in most instances. When the master cast is completed, the degree of improvement may be accurately measured by another study of the cast on the surveyor. Almost always there will be need to block out remaining undercuts of minor extent. When this is done,it is possible to make a refractory cast which will be almost entirely free of interference. Following the above precautions, any remaining interference should be very slight. If care is taken in studying the relationship of the casting to the master cast, these points of interference can be detected before damage to the cast surface has occurred. Relief of the appliance
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can be made to remove the final degree of interference. This method should be used only as a last resort. If relief by grinding the appliance is used excessively, the metal structure may be weakened to an objectionable degree. A more serious objection, however, is the development of space for the retention of debris and stagnant saliva between the appliance and the tooth surface. This is especially hazardous when the prosthesis is resting on an enamel surface of a caries-susceptible patient. 3.GINGIVAL APPLIANCE The gingivae are most susceptible to injury by any pressure induced by a removable prosthesis. Even minor contacts seem to promote an unfavorable reaction in these areas. Inflammation in the areas of contacts made by the units which must cross the gingivae is soon followed by edema. As these structures become distended, the pressure increases and a vicious circle of retrogressive change is established. The end result is a resorptive loss of the adjacent alveolar process with a pocket formation. Loosening of the abutment follows, and as the bone level is lowered, the tilting and twisting stresses on the abutment become more and more an overload. If the abutment tilts, the impingement of the periodontium in areas of compression will closely follow. It frequently is easier to prevent this unfortunate sequeala than to reduce the condition after it has become well established. There may be need to give the structures a rest period with the appliance removed from
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IMPINGEMENT
BY THE
REMOVABLE

the mouth for all except the periods of meals. At the time of first seeing the patient who has this situation, a careful examination subgingivally should be made to check on the possible presence of subgingival calculus. Such deposits are at times the cause of this irritation because, as the gingivae are pressed away "from the cervical area by the accumulating mass, they are pressed against the overpassing unit of the prosthesis. After the root surface is freed of deposits and has been polished, a short rest period then follows. It is best to defer any reduction of the prosthesis until the patient is again seen, when the amount of adjustment (if any is needed) can be determined more exactly. Not infrequently, the edges of the metal base or the connectors are found to be too sharp, or angular. This angularity alone is quite sufficient to initiate the process of inflammation. On the side of prevention there are certain definite precautionary measures to observe. Most important is to be sure of proper occlusal rest preparations. Without adequate occlusal rest stops, it is useless to expect the gingiva to escape impingement in these crossing areas. Some have suggested the use of clasp retainers without occlusal rests. If such unsupported clasps are under even the slightest tension (as when distortion might have occurred), there will be a cervical pressure generated enough to produce gingival impingement of increasing severity. For added emphasis, it seems well to urge again that soft alloys not be used for a restoration in which to prepare an occlusal rest seat. Silicate and resin should not be used in this way, and an amalgam filling which is in situ should not be used if it seems soft or poorly condensed. Getting the proper rest support still is not enough,it must be protected. The tooth
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surface of an occlusal rest must not be reduced in the process of polishing the prosthesis. Any reduction of the rests will allow the appliance to move toward the subbasal structures to impinge, first of all, the gingival crossings. At the time of construction a slight relief should be made at each gingival crossing. Particular care should be given to the matter of rounding the edges of the prosthesis which are adjacent to or which cross the gingivae. Each time the partial denture patient is seen for maintenance inspections, the gingival crossings should be checked again for evidence of over-contact. It is quite possible that such a condition may develop even after years without such trouble. This might come from occlusal rest wear, from intrusion of the abutment teeth apically, or as a result of subgingival calculus deposits. The consequence of gingival irritation warrants that every safeguard be utilized to avoid its beginning. Its cure is not always easy. 4.STRESS FROM OCCLUSAL RESTS PLACED ON INCLINES The frequent necessity of using a cuspid tooth for abutment service makes the problem of effecting a safe transfer of partial denture occlusal loads to one that is constantly with the prosthodontist. The lingual anatomy of the valuable cuspid abutment is frequently steeply inclined. In fact, some mandibular cuspids present almost a vertical lingual surface. To apply rests on such surfaces would produce very unfavorable leverage on the abutments, resulting in areas of impaction in the periodontal membrane. An abutment support cannot accept this destructive overload, even
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when the host is capable of normal bone maintenance under increased stress loads. A second unfortunate sequela of applying a partial denture loading on an inclined surface is the possibility that the appliance will slip as the occlusal load is applied. Appliance movement of this kind can easily induce the gingival irritation which was discussed in the preceding paragraphs. While the most serious situation pertaining to the problem of the inclined support relates to the use of a cuspid abutment, bicuspids and molars (especially those with single or fused roots) are also subject to similar damage unless the rest recess is favorably formed. In some mandibular extension base partial dentures, the placement of a distal occlusal rest on a surface which slopes cervically toward the edentulous area may result in repeated impingement of the subbasal pad at the retromolar periphery of the base. This is produced as the prosthesis slips posteriorly on the inclined surface of the abutment. Preventing stress which would be caused by locating an occlusal rest on cervically sloping abutment surfaces can be attained only by considerable clinical effort. The operator must come to evaluate this extra expenditure of time and exertion as being an excellent investment in longevity for his service, and the patient must be sufficiently aware of its potential value to accede to the considerable additional cost. There is always the temptation on the part of both to take an easier shortcut. After seeing the tragic loss of fine abutment teeth from this type of stress, the
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prosthodontist of long experience can attest to the merit of proper mouth preparation. Specific measures to be taken in the direction of avoiding damage from this source can be accomplished at the time of preparing the mouth for partial denture service. The first, and by far the most frequent, is the making of an adequate occlusal rest recess in bicuspids or molar abutments. Of primary significance in stress control is that the floor of the prepared recess must slope from the abutment margin toward its center. This form creates an angle which is less than 90 degrees between the rest floor and the vertical minor connector. Then, under stress loads, an abutment is held firmly against the vertical guiding plane of the minor connector, thus preventing lateral pressures which would cause periodontal impingement. In the situation of the cuspid abutment,the form of this tooth will seldom be such as to permit the placing of an adequate occlusal rest. The reshaping of a cuspid tooth can be done best by the placement of a threequarter veneer crown restoration, in which a groove is placed on the lingual surface just above a raised cingulum. Occasionally, for some good reason, reconstruction of the cuspid may be impossible. Than the labio-incisal (embrasure-hook) unit has been used instead of the raised-cingulum restoration. Another substitute measure may be suggested for the posterior tooth where an ideal rest recess cannot be executed for some reason. This is the use of a secondary (auxiliary) occlusal rest to compensate for any pressure in the mesial direction which would be generated by the use of the rest on a distal incline.
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As noted, however, this reciprocal action of the auxiliary occlusal rest is operative only as long as the mesial rest remains perfectly seated. Should there be a resorptive loss in the sub-basal structures which would permit rotation of an extension base prosthesis at its cross-arch fulcrum line, the compensatory action of the mesio-occlusal rest would be nullified. Thus, again, the best procedure, as in the case of the rebuilding of the cuspid, is to place a restoration which would permit the proper occlusal rest recess on the distal portion of the occlusal surface. 5.STRESSES THAT A MAJOR CONNECTOR MAY CAUSE There are three different ways in which a major connector may produce impingement of the structures over which it passes. If it is not rigid, workloads may cause it to flex. When these loads are such as to cause an extension base to move lingually, the non rigid connectors (particularly the lingual bar type) may be forced to flex toward the subbasal structures. At the weakest point in its anterior arc between the right and left abutments, the flexible bar will, because of these flexures, repeatedly press against the mucosal covering. Localized inflammation, followed by edema, increases this pressure and soon the underlying bone is involved. The lesion is not usually very painful and may escape the notice of both patient and dentist unless the area is carefully examined. If allowed to continue, this type of impingement may eventually produce a perforation of the mucosal pad. The small hole is quite smooth and well defined. Through this aperture one may probe the bone, which may be denuded with the periosteum detached in an area much larger than the tiny opening. Not infrequently a
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sequestrum may be exfoliated, and occasionally the lingual cortical plate is entirely lost in this area. A second type of major connector impingement may follow a lateral shifting of the appliance. This, too is more commonly seen in the mandibular prosthesis. It usually accompanies the property of flexibility of the lingual bar, but in this condition, the bar has a tendency to become straightened (its arc reduces). The result is that the connector moves laterally to impinge the area lingual to one or the other, but not usually both sides of the arch. This movement is quite frequently associated with an occlusal imbalance in which the prosthesis tends to move toward the side being impinged. Here, again pressure contacts lead to an inflammatory process, and this trauma may produce edema to increase the pressure and thus establish a vicious circle. In less time than one may realize, bone destruction may ensue, with definite pocket formation on that side of the abutment. Mobility of the abutment increases and its loss may be the end result of the unfavorable sequelae of this impingement. A third major-connector traumatization may be seen, but with less frequency than either of those referred to above. This condition is a generalized contact pressure which results from a change in the relationship of the connector to the underlying structures, when the tooth-borne portion of the partial denture settles or depresses. While this does not happen often, it is a situation that can be the result of several conditions, most of which fortunately can be prevented. This is another problem which is much easier to prevent than to correct.
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Actually, when impingement is found throughout a major connector, the disturbance is so painful that it will be necessary to remove the partial denture at once. This is usually seen more frequently in connection with the mandibular partial denture. There is no reason why the causes of appliance settlement cannot occur in the maxillary arch. A probable reason that it is not so frequently associated with the upper partial denture is that the anterior major connector (palatal bar) is usually much broader than a lingual bar. As a result, any impingement would be more widely spread and therefore less likely to exceed tissue tolerance. It is a clinically observed fact, that the structures of the anterior palatal area are much less likely to be irritated than those of the lower arch. a.Trauma from flexing This type of impingement most often occurs with the single lingual bar,and it is always seen in the case of a bar which is too flexible. During heavy occlusal impacts, the arc between the right and left abutments alters in such a manner that the bar springs against the mucosal pad. This will occur in the area of its greatest flexibility, or at its most acute curvature. Since length is associated with flexibility, the longer connector will be most prone to show this defect. One problem that is always encountered in the design and construction of a lower Class II prosthesis is that of overcoming the tendency for the long connector to flex. This was a constant difficulty when the use of the wrought lingual bar was common practice. It also is usual to find occlusal imbalance accompanying this situation. The type of prematurity or cuspal
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interference for which one should be most watchful is that which would carry the lower extension base appliance in a horizontal direction.
Prevention of flexure impingements: 1. Use a cast connector employ a less flexible alloy. 2. Increase the bulk, when the connector is long . 3. Alter the form (use a half-pear form instead of half-round or flat). 4. Some alloys of gold that are rigid or may be made rigid by heat treatment. 5. Add a secondary lingual bar across the cingula of the lower anterior teeth. 6. Use a linguoplate connector, which will be more rigid because of being in two planes and somewhat corrugated in form. 7. Widen the anterior palatal bar to include two planes of the palatal surface add bulk between the rugal crests. 8. When the palatal arch is high and the rugae are prominently developed to provide a corrugated undersurface then it is unnecessary to also use a posterior palatal bar. When the palate is low and flat (with a less well developed system of rugae), it is necessary to use both posterior and anterior palatal connectors. A principal reason that the assembled partial denture, utilizing a wrought connector, has proven less than satisfactory is because
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it is too flexible; this is especially true of the lingual bar. By casting this bar, it was possible to change the form and vary the bulk to remove this objection. The selection of a less flexible alloy is possible, when it is to be cast. Such choice is much more limited in the ready-formed bars. Since it is not easy to draw the less ductile alloys, they are avoided in the manufacture of the ready-made wrought bar.
b.Trauma from lateral appliance movement A lateral shift of the partial denture may tend to occur in certain conditions, with the result that there is a pinching of the tissue beneath the major connector. Such movement would be encouraged by the use of weak tooth support, especially when this condition is accompanied by the use of a flat ridge from which a base could not gain much resistance to lateral stresses. If considerable occlusal disharmony is added to these conditions, there is a probable chance that an area of thin, unyielding tissue might be pinched between the base and the surface of the bone. If this trauma continues, the chronic irritation may result in bone necrosis. Fortunately it is possible to utilize certain preventive measures. Prevention of impingements from lateral shifting: 1. Provide a slight space beneath the lingual bar by placing a thin blockout material before duplicating the master cast. 2. Employ more rigid stabilizing units (reciprocal clasp arms, auxiliary
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occlusal rests, indirect retaining units, etc. 3. Reduce the cuspal inclines of the opposing occlusal surfaces. When unused teeth present cuspal inclines that are steeper because the teeth have not been in function and have had no abrasive wear, such teeth should be adjusted. 4. The height of their cusps and the steepness of their cuspal inclines should be made to correspond to that of the remaining natural teeth. 5. Restore the best possible occlusal level of extruded teeth by grinding,or by restoration when they must be shortened so much that the dentin would be exposed. Occasionally, such teeth may have to be extracted because their malposition is so extreme. 6. Relieve the major connector in an area of anticipated impingement after the casting has been made (or when irritation has occurred); reduction by grinding may make the major connector flexible, in which case one trauma would be likely to replace another. 7. Since this type of lesion is associated with lateral appliance movement, it is doubly urgent that the mandibular base be extended to maximum flange length, especially on the lingual. If the ridge height is subnormal and there is a sharp lingual edge, surgery should be utilized to make possible a longer lingual flange by recontouring the area. 8. Splinting to provide multiple abutment support will effect more adequate stabilization and reduce the possibility of appliance movement.
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It is interesting to note that of the above measures suggested for the control of a very annoying and too frequent partial denture difficulty, all but one may be said to be preventive. Six of the seven are planned and executed before delivery of the prosthesis. Four of the seven are measures to be completed at the mouth preparation stage of the proposed service. Only one measure (relief of the casting) can be classed as remedial, and it is suggested only in a limited way. With careful attention directed toward the six preventive aids, the rehabilitation program will have improved chances of success. If it fails, it will probably do so in spite of the lone remedial measure. c.Trauma from connector settlement Removable partial denture without adequate occlusal rests is seldom encountered in modern prosthodontics. A strong plea has been made for utilizing tooth support (gained by the use of proper rest units) to prevent gingival irritations. No less forceful is the claim that inadequacy of occlusal rests can be cited as a cause of major connector impingement. Particularly in the instance of a mandibular partial denture can it be stated that even maximum extension of the bases will not alone be able to gain sufficient support to avoid an occasional appliance settlement. Even with the aid of tooth support, there still will be some situations where such settlement will occur. One such occasion is that in which one or both abutments have had no recent occlusal work loads. An abutment of this category is certain to take a position (after assuming abutment service) which will alter its relation to the alveolar walls that are to give it support. It may be
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expected that this change will result in an increasing contact between the lingual bar and the surface of structures subjacent to it. When too little free-way space has been provided for a patient with unusually heavy occlusal force loads, there may be intrusion of the supporting teeth. Hypercontact of the connector is sure to follow.A similar result is encountered when the bone of the alveolar process is subnormal. If the patient is incapable of normally maintaining his bone structure, it is certain that the bone tolerance limit will be more quickly reached. Under this condition and with too heavy occlusal loading, abutment intrusion is possible. In this connection it would be profitable to review the section on determining the probable stability of the alveolar bone. The use of unsuitable materials to support an occlusal rest is about the same as not using one. Obviously, a soft filling (such as silicate) in the area of an occlusal rest site will reduce. As the support for an occlusal rest is lowered, the appliance settles to closer contact with the mucosal surface beneath it. The same effect can be the result of grinding the supporting surface of an occlusal rest during the finishing and polishing of a removable partial denture casting. Avoiding major connector settlement: 1. The primary preventive measure to be taken is an attempt to adjust for any metabolic imbalance, when there is evident failure to maintain the alveolar bone. 2. If there has been previous loss of supportive bone, splinting of the adjacent teeth will be a major factor in avoiding overload after the
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abutment service is added. 3. Adequate occlusal rest units should be provided. In polishing the undersurface of these, no reduction is to be made burnish and polish lightly. 4. Restorations made of easily abraded materials must be avoided in locating primary occlusal rests. 5. When abutment teeth have not had recent occlusal function, digital exercise will help to reduce the amount of positional adjustment after prosthetic loading occurs. The patient should be instructed to place his finger so that an occlusal force may be simulated as to the amount and direction. Such exercises should precede the final impression by a few days, during which time the exercise should be frequently repeated. 6. In designing a removable partial denture, where the possibility of overload is suspected, auxiliary occlusal rests can profitably be included, in order to spread the work load more widely. 7. A lingual bar wax pattern should be thickened when there is a chance that later reduction may be needed. 8. A supporting base should be extended as widely in a buccal direction and over the retromolar area as possible, when an unstable condition is suspected. Include all of the basal bone surface which can be used without encroaching on moving structures. 9. Finally, reduce the occlusal table (both in width and length) to lessen the force loads which may be received in any single contact
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with a food bolus. In establishing the occlusal pattern, care also should be taken (especially in these situations) to avoid the overreduction of free-way space. Continuous occlusal pressure from muscle tension must be avoided. 10.If, in spite of the above preventive measures, major-connector settlement does occur, the impingement certainly will be of less degree and perhaps can be entirely relieved by a reduction of the under (or tissue) surface. Any such reduction, how ever, is quite definitely limitedthe bar must not be made flexible. With the exception of the first of the above corrective measures, which will often require specialist management, all are either to be done in mouth preparation procedures by the prosthodontist or are to be under his direction and executed by a technical assistant.
6.STRESSES WHICH TORQUE OR TWIST THE ABUTMENT The stresses resulting in the various impingements of the major connector, which have been discussed in the preceding paragraphs, may be caused by a tooth-borne removable prosthesis as well as by the extension-base type. However, the stresses which cause torque or twisting action will be found to operate to an exaggerated degree in the partial
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denture having an extension base and practically not at all in the toothborne appliance. This is because the prosthesis with the free end produces twisting and tilting forces because of its lever action. Since this base is supported by structures having some yield, both its lateral and vertical movement will need maximum control, even when the base is the best possible. The term "torque" is used in the following analysis to designate that stress which tends to twist or turn an abutment in its alveolus, as distinguished from a force which leads to the tilting of the abutment laterally or proximally. Conditions which encourage the lateral movement of the extension-base prosthesis make this stress a constant problem, and its control one of the reasons that this prosthesis has been called the most difficult of prosthodontic assignments. Lateral movement of the extension base becomes aggravated when the sub-basal ridge is low and flat in form. This movement results principally from inadequate flange length. It also may be increased by the presence of a flabby, movable pad of mucosal structures over the ridge. Another critical factor in the development of torque stresses is the presence of high cuspal inclines, especially if these are surfaces which are not in occlusal balance. This lack of occlusal harmony occurs frequently in the partial denture on which substitutes have been placed in relation to teeth which had migrated from normal alignment, and which had been out of occlusal function for a long period. On these unused teeth, the cuspal height and inclination are both excessive as compared to the existing condition of the remaining teeth
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that have been subjected to abrasive wear. When such teeth govern the excursive movements of the jaw, then the supplied teeth (and those with which they occlude) cannot possibly be in harmonious balance until their surfaces also have been made to conform. In addition to the above conditions, torque stresses will be most destructive When the occlusal loads are heavy; when the abutment has a round, tapered root When the abutment root is single (or fused). When there has been previous alveolar bone loss about the abutment teeth When the occlusal table is long, and the number of remaining teeth are few and When the patient has a well established habit of bruxism. Preventive measures in torque control: Surgical recontouring of flabby and hypertrophic tissue on the alveolar ridge. Splinting the adjacent teeth, if the root is short or tapered, which gives counter leverage advantage of multirooted abutment.
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Maximum extension of denture base within the physiologic limit. Use a rigid connector which extends to a remote anchorage in order to effect adequate counter leverage. Utilize a combination clasp to provide its stress breaking action.
Since torque stresses originate with lateral appliance movement, it is most important in the mandibular extension-base prosthesis to obtain a stable base before the abutment has suffered damage from torque. Very frequently the undersized lower ridge is also further handicapped by having been out of function for many years. Until it has been reconditioned, by having received work stimuli, it cannot assume the support of functional loads at once without further resorptive loss. There are two ways to handle this temporary instability. The prosthesis may be completed and then "rebased",or a prosthesis without teeth may be worn with only light digital exercise to stimulate the alveolar process to become "re-organized". Further loss of basal structures should be avoided. There is no more certain way to induce torque stress loads, and there is no stress which is more destructive. Since much of the control of torque stresses will be dependent upon the amount of force received on the occlusal table, the matter of achieving harmony in occlusion is a very vital factor in the control of this
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type of stress. The need for adjusting the occlusal anatomy of opposing unused teeth has been stressed. Another matter, equally important, is to coordinate the occlusal relations of the supplied teeth to those opposing so that there will be harmony throughout all ranges of excursive jaw movement. The method of doing this by having the patient wear an occlusal wax record,during which period jaw movements are exercised, is strongly recommended. The measures for the reduction of stresses which place a twisting force on the partial denture abutment diminish in effectiveness as the length of the occlusal table increases. The most frequently occurring partial denture situation, the mandibular Class I, must make use of the bicuspid for abutment support. This means that the appliance lever is long, while the form of most bicuspid roots is least resistant to the turning action stimulated by the torque stress. At the same time it should be recognized that in this situation (the most frequently occurring partial denture case), the measures for controlling this induced stress are less than maximum. It would seem that this unfortunate combination of circumstances attaches the greatest emphasis to the need for reducing, at its origin, that force responsible for torque. There is urgent need, then, for complete occlusal harmony, not only during the voluntary effort of masticating but also throughout an involuntary muscular contraction like bruxism.
7.STRESSES WHICH TILT AN ABUTMENT
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It has been emphasized that stress loads can be transferred to the supporting bone of the jaws most ideally, from a physiologic point of view, through the periodontal membrane. But this is true only when the force loads are received in a trajectory which is parallel to the long axis of the abutment. When the tooth is tilted by forces that are not parallel to its longitudinal axis, certain areas of the membrane fibers are compressed instead of being tensed, and impingement trauma results. Tooth-borne prosthodontic appliances often are made removable and bilateral in design in order to avoid these lateral tilting stresses. In bilateral design, the principle of cross-arch splinting can be applied to develop counter-leverage by which effective control of tilting stresses is gained. Control of forces which induce proximal (mesiodistal) tilting is not so readily accomplished in the extension-base prosthesis, however. In tooth-borne appliances there is little possibility of abutments being tilted proximally; in the extension appliance this stress is a major problem. Any slight yield of the mucosal pad structures, not to mention actual resorptive change in the sub-basal supporting bone, tends to produce varying degrees of vertical movement of the base, and proximal tilting follows. The ultimate result of compressive trauma of the periodontium is bone resorption in the area of the alveolar walls. As the tooth is tipped, it assumes a position of increasing malocclusion, with the forces generated by occlusal imbalance being added to the traumatic injury already sustained.
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As the abutment becomes mobile, lateral shifting of the prosthesis may result to produce major connector impingement which further accelerates the process of damage. Particularly in the maxillary extension partial denture (because of gravity) there may also be a mesial proximal tilting. Hence, in severely unfavorable situations, the supporting bone may be overloaded from all directions because of lateral and proximal tilting of an abutment. It has been shown that extension partial denture rotates at its crossarch fulcrum line in two directions, toward and away from the sub-basal structures.As a result, the periodontal pressure developed may be on either the mesial or the distal surfaces of the abutment alveolus. The exact location of the pressure areas will be determined by the direction of the tilting force. a.Limiting Stress Caused by Base Movement Toward Ridge Any movement toward the sub-basal structures would indicate lack of sufficient support to sustain the occlusal load. If the partial denture is of the type that is distally extended, the abutment will be tilted in that direction. The first control is that of most direct approach improve the support. There are two ways of doing this: 1. Improve the ability of the supportive structures to carry a greater load. This can be done, in many instances, by surgical procedure at the time of mouth preparation. If the mucosal pad shows excessive mobility, it frequently may be improved by excision of some of the hypertrophic mass to provide a more stable foundation. 2. If there has been prolonged lack of functional activity, a second
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way of improving the support is the program of exercise therapy. This has been found to so recondition the supporting bone that the base may not require the usual rebasing procedure later. Another effective aid in the problem of appliance instability is to increase basal coverage. The beneficial result of increasing the supportive area of the base is two fold. Not only can a greater occlusal load be borne safely, but the wider distribution of the applied load will lessen the possibility of resorptive change. Hence, proximal tilting of the abutment may be avoided more frequently and for longer periods. There is a very definite limit to extending the size of the base, especially in the mandibular edentulous ridge area. Surrounded by functionally moving structures, the peripheral limits of the base are reached much too soon before an adequate area of coverage has been attained, in many instances. One more important measure may be taken when this impasse is reached. This is to relate the base to the supportive structures in such a way that all units of the surface are giving support. Care should be taken always to keep the applied load well within the limit of the physiologic tolerance of sub-basal structures. However, distributing the functional load as uniformly as the nature of the various component structures will produces the least chance of overloading the firmer areas so as to induce resorptive change in them. As has been pointed out, these measures too frequently are not enough to insure stability of the base. The available mandibular area is too limited. There is, however, another approach which is as direct as the first
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this is to reduce the load at its source. To accomplish this, it is better to reduce the buccolingual width of the occlusal surfaces supplied on the prosthesis rather than to shorten the mesiodistal length of the occlusal table. If the most posterior of the opposing teeth is not given occlusal contact, it would tend to extrude, a condition which must be avoided. The reduction in occlusal width does not always solve the problem of overload . While it greatly diminishes the force generated by any single occlusal masticatory contact on a food bolus, it in no way eliminates the overload which occurs during bruxism. In the latter stress, only one point of contact on the occlusal table is needed to transmit the full load. Unfortunately, the bruximatic force is usually the more dangerous because it may be continued for long periods without interruption. In mastication, the occlusal forces are applied intermittently, usually with less biting pressure and for shorter intervals. There is a very dependable way to reduce the possibility of bruxism, however; this is to carefully eliminate all occlusal prematurities. Occlusal imbalance is considered to be a primary cause of the habit of bruxism. When these methods have been utilized to the limit,some curtailing induced stresses, others augmenting the quality and degree of the support then the last defense is again called into play. It is best to assume that (at least in periods of subnormal tolerance) the demand on the supportive structures may approach or exceed their maximum capability. Accordingly, every effort should be made to include some safety measure such as stress breaking type of flexible clasp as a last resort.
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b.Limiting Stress Caused by Base Movement Away From Ridge This stress does not develop in a tooth-borne prosthesis when a direct retainer is functioning at each terminal abutment. Any force tending to cause the extension-base appliance to leave its contact with the sub-basal structures does produce tilting stress on the abutment. It is suggested that the section relating to the indirect retainer be reviewed at this point, since it has a pertinent application with the problem relating to the stress being considered at this time. The amount of the force tending to induce movement of an appliance away from the supporting ridge will vary, but its magnification always will be directly proportional to the extended length of the appliance. In general, the forces which tend to move the prosthesis away from its supporting structures will be less than those of occlusal origin which move it toward them. These forces are: the pull of sticky substances (upon which one may have bitten) when the jaws are again separated; the pressing of circumjacent structures as they are in functional movement against the border or side of the prosthesis; sudden expulsions of air from the the lungs (such as coughing or sneezing); and the force of gravity in maxillary extension base appliances. The effect of this leverage stress on the abutment tooth is to cause it to be tilted proximally in its alveolus.
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The direction of the stress application will, be such as to tip the abutment away from the edentulous area. Again, this stress will cause zones of compression in the periodontal membrane, as did the stress developed by movement of the base toward the ridge surface. While this impingement may be less in magnitude, it may be more prolonged. The effect of gravity (in displacement of the maxillary appliance, for instance) is continuous for most of the time whenever the teeth are not in occlusal contact. Certain factors in the control of this stress are favorable, however. The extension-base partial denture is predominantly of the Class I or II variety. This means that a stress resulting from movement of the base away from ridge contact would tend to tilt the abutment in a mesioproximal direction. Usually, the abutment will make contact mesially with an adjacent tooth. The tilting force will, therefore, be partially shared by this contacting neighbor. There may be two or three such contacting and supporting teeth in the arch. Also, when the abutment is multiple that is, adjacent teeth are rigidly splinted not only is there wider distribution of this stress, but also a more favorable leverage advantage is developed. Both of these influences tend to reduce this type of stress now being considered. This statement is not presented to minimize the importance of seeking to reduce this type of stress, however.The end result of its continuation can be very destructive, culminating in permanent injury to the periodontium.
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In order to limit the stress caused by the free end of an extension base appliance tending to loose ridge contact: 1. Reduce the weight of the maxillary partial denture of the extension type to lessen the effect of gravity. 2. Avoid peripheral encroachment on moving circumjacent structures in the attempt to enlarge the area of the base. 3. Reduce the base peripheries, if there has been overextension. 4. Contour and finish the appliance so that there is less chance of a sticky bolus adhering to its surface. Position the supplied teeth so that the contact of tongue and cheeks will tend to displace the appliance least.(Reduce the lower teeth, if necessary, on their lingual surfaces.) 5. Employ complete palatal coverage to obtain surface tension support (as for a complete denture) as an aid to the less effective indirect retainer in extensive Class I cases 6. Utilize the most efficient indirect retention which can be obtained under the existing conditions. 7. Dissipate the remaining leverage stresses by the use of flexible retentive clasp arms as stress-breaking units. 8. If a problem is anticipated in the adequacy of the control measures, or if a weakened abutment tooth must be used, it is well to utilize a multiple abutment if splinting is possible. It would seem, then, that the most destructive stresses induced by the partial denture are those which twist or tilt an abutment tooth. This is because the functional forces produced on the occlusal table are magnified by the appliance, acting as lever, and are then passed on to the abutment.
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Certain measures can be taken to prevent this and, in fact, to accomplish a reduction of the stress load in many cases. If the various measures for controlling these stresses, as outlined in the foregoing pages, are applied with meticulous insistence at the time of mouth preparation, during design and construction of the prosthesis, and at each appointment for maintenance service, then the removable partial denture so produced will be most likely to give a long period of satisfactory service. SPLINTING TO IMPROVE STRESS CONTROL A very common predisposing cause of alveolar breakdown is a previous loss of bone support. As the bone level at the alveolar crest is reduced, so also is the surface of the alveolar wall remaining for root support. The stress assumed by each square unit of bone surface becomes greater as the depth of the alveolus decreases. If the abutment happens to be one which has a tapered root form, this decrease in percentage of area of remaining alveolar support is quite rapid. Add to this situation an unfavorable root form and it need not surprise one to find the surrounding tissue overloaded. An abutment with a single root is always more vulnerable because of its reduced area of surface support, but when this one root is round it also becomes very susceptible to torque. Often a single root is round and tapered and this form is accompanied by a previous loss of bone around it, indicating a susceptibility to alveolar atrophy. To use such teeth for abutment support is a matter of questionable wisdom to say the least.
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Stress control actually starts,at the diagnosis stage of partial denture service.The wise prosthodontist will prescribe complete denture service for a case in which he knows that it will be impossible to control the stress load which the contemplated partial denture is likely to induce. Where there are especially urgent reasons for retaining the remaining teeth under some or all of the above conditions, there is one possible way of controlling the stress load with reasonable success. This is by the use of multiple abutments. The most effective way of accomplishing a division of abutment work is by the actual union of two or more teeth. Restorations in the adjacent teeth may be soldered at their contact points to make such union.An other application of this idea is to use the fixed bridge, uniting a tooth which is standing alone to one which is separated by only a one or two tooth space. This splinting of weak teeth produces an abutment support which is comparable to that of a multirooted tooth. A molar with two or more widely separated roots is accepted as an ideal bridge abutment. By such union a great advantage is gained against torque and a favorable leverage is developed to combat proximal tilting. Damage which formerly was attributed to the rigid fixation of teeth, in the light of present-day knowledge seems to have been caused by lack of attention to some other phase of stress control. Until alveolar atrophy can be controlled through other remedial measures, the splinting of these weakened teeth offers hope for saving at least the majority of them. THE COMBINATION CLASP IN STRESS REDUCTION
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A combination clasp is one in which the retentive arm is made of a round, flexible, wrought structure. In spite of all efforts at stabilization, the base of an appliance that depends upon the subjacent structures for its major support will have a variable amount of lateral and vertical motion. Some device, therefore, is necessary to eliminate, or at least reduce, the resulting stress before it is transmitted to an abutment tooth and the surrounding area of supporting tissue.(Fig-41) Stress-breakers of varied types have be entried from time to time to reduce the work of a partial denture abutment. Most of these have incorporated an idea of a broken joint between the clasp and the appliance. This device allows some movement laterally or toward the ridge but does not let a prosthesis move away from the tissue. There is, usually, too much movement allowed, stresses are not uniformly distributed and the very valuable stabilizing leverage of the bilateral design is then lost. This type of moveable attachment is complicated to make and adds materially to the cost. A simple, inexpensive but very effective approach to the stressbreaker control of forces which escape all other means of elimination is the combination clasp.Because this clasp uses a retentive arm made of wrought alloy, it is flexible and, being fibrous, has a toughness that permits its use in very small gauges. Also, a round form of retentive arm is given to this clasp to make it equally flexible in any direction. For this reason it is as effective against a twisting stress as one which tends to tilt out of vertical. Hence, no stress which would shift the abutment can pass through this flexible arm. Any
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stress which can reach this point is simply dissipated, because the wrought arm will yield (flex) before the pressure generated against the tooth is enough to cause periodontal injury. The wrought arm of a combination clasp has the additional and very practical advantage of being adjustable. An increase or decrease in the amount of retention requires that the clasp arm be moved cervically (into the undercut) or occlusally to a level nearer the height of contour. If the arm is half-round, as the cast clasp is, the above adjustment would require an edgewise bend. This is a most difficult change to make in a cast structure without permanently injuring it.
METHODS OF STRESS ANALYSIS

BRITTLE LACQUER COATING TECHNIQUE This technique was developed by DeForest et al in the 1940s. It gives a qualitative and roughly quantitative analysis of the strain patterns in a previously deformed body. The technique is particularly useful in detecting and measuring strains at the surface of a structure as well as indicating the direction and sequence of the tensile strains. The qualitative analysis involves spraying a lacquer onto the surface of the body to be tested. This is allowed to dry and loads are applied in the desired way.(Fig-31) Cracks appear in the lacquer in areas of maximum tensile stress. Increasing the load causes cracks to form at other points where the tensile stress has exceeded that required to fracture the lacquer. The lacquer selection is critical and depends on the
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humidity,temperature and sensitivity required. The prime constituent of the lacquer used is colophony resin and spraying is carried out using the equipment specifically designed for this purpose. The major drawback with this technique is that the cracks which are relatively easily seen on load application disappears once the load is removed. Additionally as the cracks do not run out onto the surface, the top surface has to be etched away before developing with a dye. The technique is also sensitive to fluctuations in temperature and humidity and only gives a qualitative assessment of the stresses. Due to its simplicity this method has been widely used in dentistry and was first applied to examining stresses in dentures by Matthews and Wain. Qualitatively. the technique gives a quick and easy test as a guide to the need for primary modifications. It has been suggested that for quantitative measurements in dentures the brittle lacquer technique is used in conjunction with electrical strain gauges. ELECTRICAL STRAIN GAUGES Electric strain gauges have been used to give a quantitative analysis of the stresses encountered. For any material a well-defined relationship between stress and strain exists. If the strain in a certain area of the denture is measured,the value of the stress can be calculated provided the elastic modulus of the material is known. It is this principle that is utilized in employing the electrical strain gauges for the measurement of stress.(Fig-32)
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An instrument measures the strain and using the relationship described above,the stress is calculated. This instrument belongs to a class of strain gauges which depend on the alteration of some parameter associated with the flow of an electric current for the measurement of strain. When the load is applied strains in the surface of the specimen under examination are transmitted to the wire filament via a paper backing cemented onto the surface. This results in a change of resistance of the wire filament which is then measured by some associated electrical current. Three factors have to be considered before the gauges are fixed to the surface of the specimen: (1) location of the gauge. (2) size of the gauge to be used (3) orientation of the gauge with regard to the specimen. Strain gauges have been widely used in clinical research on dentures. Studies have been carried out which examine both mandibular and maxillary denture rigidity and denture deformation. Kegli and Kyddx were the first to apply the strain gauges to study mandibular base deformation. Regli and Gaskill studied the deformation of plastic denture bases using strain gauges and concluded that dentures with high ridges exhibited torsion deformation during mastication and those with flat ridges exhibited compression. They also found that the
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ability of the denture base to resist deformation was an important factor in adequate stress distribution to the supporting structures. ADVANTAGES The main advantage of using this technique is the relatively small size of the gauges which causes minimal interference during use. However the disadvantages encountered are far greater than the advantages. DISADVANTAGES The gauges have to be sealed effectively from the oral tissues. if used intraorally, to prevent short circuits and they must be adhered firmly to the surface of the appliance.They must also be placed in relevant parts of the denture as well as aligned in the correct direction. Additionally with these gauges only the surface strain at selected points is measured and although stresses may be calculated from the strain measurements,this requires time. Strain gauges have been used in conjunction with the brittle lacquer coating to overcome some of the problems discussed above. The initial analysis with the lacquer indicates the areas of high stress concentration thereby enabling location of the best areas to cement the gauges. The coating also gives the direction of the tensile stresses and hence aids in the alignment of the gauges. Wain employed a combination of the two methods. The lacquer was coated onto the denture and loads were applied. The gauges were then applied where the cracks were seen and strains measured.
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PHOTOELASTIC ANALYSIS The photoelastic method is a well-recognized engineering method of stress analysis and was first applied to dentistry in 1949 by Noonan. His study employed this method to evaluate amalgam restorations and cavity design. Since its initial application. the method has been used widely in the field of dentistry. The technique involves construction of a model of the structure to be investigated from a photoelastic material.(Fig-33) The direction and magnitude of the applied forces and the way it is supported and its shape must simulate the conditions of the actual structure to obtain a true analysis of the stresses. The temporary double refraction under stress of photoelastic materials is utilized for photoelastic analysis. The incident ray of light is resolved into two rays which travel at different velocities along the principal plane of the material and emerge retarded with respect to each other. The amount of retardation is directly proportional to the difference between the principal stresses and is measured using a polariscope. The coloured fringes obtained are used for the stress determinations. The application of the method to dentistry was reviewed by Mahler and Peyton. They concluded that the technique was particularly applicable to dental problems because of the irregular shapes encountered. Initial studies utilized two dimensional models but with
improvements in technology the three-dimensional model is being used. Despite this three dimensional photoelastic studies have been
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limited due to the complexity involved in the determination of the complete state of stress in three dimensional irregularly shaped structures. Although the photoelastic method is widely used in dentistry there is little documentation of its use in dentures. The majority of the studies relate to partial dentures and few have been reported in complete dentures. ADVANTAGES The advantage of the photoelastic method over the earlier methods discussed is that it provides a visual display for the observation and measurement of stress distribution throughout the model under investigation. However the method requires special equipment introduction method. DRAWBACKS: The specimen preparation for this method is arduous since it is critical that the model is of uniform thickness. Tanner has examined the factors that affect the design of photoelastic models for two-dimensional analysis. He concluded that the mode of support was the most important factor affecting the relationship between the experimental model and the original structure. The elastic modulus of the material used for specimen preparation may not conform to the actual material used for the
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and expertise of the
to
perform
adequately. Since of
the dental
computation
era,stress analysis
structures has been made easier with the use of the finite element

prosthesis. Additionally no absolute value for the magnitude of the stress is obtained and only the maximum shear stresses can be analysed. Separation methods have to be used to obtain other components demanding. REFLECTION PHOTOELASTICITY This is a new method of detecting stresses in prosthetic appliances. Through the observations of fringe patterns created upon loading, reflection photo elasticity gives immediate identification of stress fields in parts of the studied object accessible to normally incident light. This method has been widely used in testing industrial prototypes but experiments in dentistry are limited. FINITE ELEMENT ANALYSIS The finite element analysis is a computerized numerical method used to determine the distribution of stresses and displacements in a structure subjected to mechanical load. Initially developed for use in the aircraft industry.The method has seen widespread use not only in aerospace engineering but also in civil engineering. Prior to the advent of the computer the technique required considerable mathematical ability. However. with the availability of a number of software programs the method has become more versatile.(Fig-34) The basic concept of the method is the idealization of the actual continuum as an assemblage of a finite number of discrete structural elements,interconnected at a finite number of points called the nodal points. The finite elements are formed by figuratively cutting the
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of
the
stress
tensor which
can
be
lengthy
and

original continuum into a number of appropriately shaped sections and retaining in the elements the properties of the original material (such as the elastic modulus and poisson s ratio). In structures having a regular simple geometry relatively small numbers of elements will be adequate, however in more complex shapes a higher number of elements would be required to improve the accuracy of the analysis. The analysis process consists of satisfying compatibility within each element and equilibrium conditions at the nodal points. By concentrating the equivalent forces at the nodes, equilibrium conditions are satisfied in an overall sense. The information required to calculate the stresses is: The total number of nodal points. The total number of elements. The type of boundary conditions. Evaluation of the forces at the external nodes. Coordinates of each nodal point. The elastic modulus and poisson s ratio. Once these are specified, the displacements. as well as the stresses. can be immediately calculated with the help of the program. The validity of the finite element results depends on the precision by which the geometry, material properties and interface conditions, support and loading are in accordance with the physical reality.
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The finite element method, due to its simplicity and relative ease of use is becoming more popular for the stress analysis of dental structures. Additionally its other advantages are that the oral conditions can be simulated reasonably easily and different parameters can be altered relatively simply. Although initially used in two dimensions the popularity and improved accuracy of the three dimensional model is becoming more apparent. The threedimensional model has been used in the stress analysis of the mandible and other structures. This method has proved to be valuable in stress
analysis.However the limitations of the method lie in the validity and accuracy of the model. The latter problem can be overcome by the use of convergency tests where subsequent mesh refinements of the model make the results concerge. The validity of the analysis should be established by either comparing results with clinical observations or laboratory tests. The limitations of a two- dimensional design must be
appreciated where the analysis involves these models. Additionally in the finite element analysis it is assumed that the interfaces between different materials are in perfect adhesion, with the elements comprising different materials being joined at common nodes. Another drawback is that the computer package for the analysis can be quite costly. Despite these limitations the method seems to be promising and appears to play a valuable role in the stress analysis of all dental structures.
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In the finite element method all the stress components can be calculated and these can be calculated at each point in the model. Changes of relevant parameters and loads can be easily incorporated into the calculation and hence conducting the analysis and assimilating the results is quicker than the photoelastic method.In as much the accuracy of the calculation results can be easily increased by increasing the number of elements and the three-dimensional analysis is likewise easily within its range of possibilities. HOLOGRAPHIC INTERFEROMETRY While holography is often used to obtain recreations of 3dimensional objects, many industrial applications of holography make use of its ability to record two slightly different scenes and display the minute differences between them. This powerful technique, called interferometry,is an invaluble aid in design, testing, quality control, and stress analysis.(Fig-35) Holographic techniques are non destructive, realtime,and definitive in allowing the identification of vibrational modes, displacements, and motion geometries.If the object under study is changed or disturbed in some way during the hologram exposure or from one exposure to the next,then a pattern of fringes will appear on the image itself, making the object look striped. These fringes really represent maps of the surface displacement caused by the force or stress that disturbed the object.Such a displacement map represents an extremely sensitive picture of the actual motion the object has experienced, with a single fringe contour representing lines of equal displacement.
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Holograms can record motions and displacements, deformations and bends, and expansions and contractions on virtually any object. The typical optical laser used in holographic interferometry gives an accuracy better than a half wavelength (about 10 millionths of an inch), and both qualitative and quantitative information can be derived from the fringe patterns. This allows us to look at the effects of vibration, temperature, stress and strain,and other physical forces in an entirely nondestructive way. A powerful feature of holographic interferometry is that information is obtained over the entire illuminated surface of the object being studiedas a full and continuous field, which is important in understanding what is happening to the object as a whole. Holographic interferometry is used in vibration and modal analysis, structural analysis, composite-materials and adhesive testing, stress and strain evaluation, and flow, volume/shape, and thermal analysis.All these applications derive from one or more of the three basic methods of applied Holographic interferometry Real-time, Multiexposure, and Time average holography. Interferometric nondestructive testing can be accomplished with either continuous or pulsed lasers of almost all wavelengths.Continuous lasers are ideal for real-time studies of displacement and motion. Pulsed lasers can be synchronized with motion and also can record holograms of extremely fast transient phenomena.
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REAL-TIME HOLOGRAPHY Real-time holography allows one to observe instantaneously the effects of minute changes in displacement on, or in,an object as some stress affects it. This is done by superimposing a hologram of an object over the object itself while it is being subjected to some small force or stress. MULTIEXPOSURE HOLOGRAPHY Multiexposure holography creates a hologram by using two or sometimes more exposures. The first exposure shows an object in an undisturbed state. Subsequent exposures, recorded on the same image, are made while the object is subjected to some stress. The resulting image depicts the difference between the two states. TIME AVERAGE INTERFEROMETRY The third technique,time average holography, involves creating a hologram while the object is subjected to some periodic forcing function. This yields a dramatic visual image of the vibration pattern.All these techniques reveal the shape,direction, and magnitude of the stress induced displacements in the structure under study. An important key to holographic interferometrys success is that it allows the use of very low level, non destructive stress to gather data that once required destruction of the material.
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STRESS CONTROL BY DESIGN CONSIDERATIONS

It is often argued that the theoretical aspects of partial denture design are of primary importance. In reality,clinical observation and experience must be used to balance what should happen with what will
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happen. It has been stated that "No removable partial denture can be designed or constructed that will not be destructive in the mouth." This statement can be fully justified if all forces and movements are considered. There is no mechanism to counter all forces that may be applied to a removable partial denture. Nevertheless, a design philosophy that strives to control these forces within the physiologic tolerances of the teeth and supporting structures can be successful. Therefore,the design philosophy of this book is a combination of theoretical and clinical knowledge that a practitioner can learn and then use to achieve predictable results. Past arguments about partial denture design philosophies have resulted in noticeable confusion. As a result, many practitioners have abandoned their design responsibilities. The stresses induced by a removable cast partial denture can be managed by keeping design considerations for the various components of the partial denture in mind. They are as follows I. Direct Retention The retentive clasp arm is the element of a removable partial denture that is responsible for transmitting most of the destructive forces to the abutments. Consequently, a removable partial denture should be designed to keep clasp retention at a minimum, and yet provide adequate retention to prevent dislodgment of the denture by unseating forces. Other components of a removable partial denture may contribute to the retention of the prosthesis,thereby allowing a reduction in the amount of retention provided by clasps. Exploiting this retentive potential in
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widely separated areas of the mouth can re-sult in reduced loads on the abutment teeth. As a result, the support and stability of the prosthesis also may be improved. POTENTIAL SOURCES OF ADDITIONAL RETENTION a) Forces of adhesion and cohesion For prosthetic purposes, adhesion may be defined as the attraction of saliva to the denture base and soft tissues, and cohesion may be defined as the attraction of saliva molecules for one another. Although it is impossible to develop a peripheral seal around the borders of a removable partial denture, adhesion and cohesion can still contribute to retention. To maximize this effect, each denture base must cover the maxi-mum area of available support, and it must be accurately adapted to the underlying mucosa. b) Frictional control The partial denture should be designed so that Guide planes are created on as many teeth as possible. Guide planes are areas can the teeth that are created so that they are parallel to each other to the path of insertion and withdrawal from the mouth. These planes may be created on the enamel surfaces of the teeth or in restorations placed on the teeth. The frictional contract of the prosthesis against these parallel surfaces can contribute significantly to the retention of the denture. d) Neuromuscular control
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The innate ability of the patient to control the actions of the lips, cheeks, and tongue can be a major factor in the retention of a removable prosthesis. A patient who lacks the ability or coordination to control the movement of these structures may not be able to retain a prosthesis. The design and contour of the denture base can greatly affect the patient's ability to retain a removable partial denture. Any overextension of the denture base can contribute to displacement of the prosthesis. As a result, clasping mechanisms will no longer be passive and will apply undesirable forces to the abutments. These forces may produce noticeable tooth movement and /ordiscomfort. Properly contoured denture bases prevent such difficulties and can enhance retention and stability of a removable partial denture. d) Clasp position The position or the relation of the retentive clasp to the height of contour is more important in retention and in controlling stresses. The number of clasps used in the design will determine the type of stress developed within a denture. Removable partial dentures with four clasps are described to have a Quadrilateral configuration. Similarly RPD with three and two clasps are described to have tripod and bilateral configuration respectively. Quadrilateral configuration
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The quadrilateral configuration is indicated for Class-III arches, particularly when there is a modification space on the opposite side of the arch. A retentive clasp assembly should be positioned anterior and posterior to each edentulous space. This creates a stable mechanical situation in which leverage is effectively neutralized.(Fig-38) For a Class III arch in which no modification space exists, the goal should be to place two clasp assemblies adjacent to the edentulous space, and two clasp assemblies on the opposite side of the arch. The clasp assemblies on the intact side of the arch should be separated for additional mechanical stability. Consequently, one clasp assembly should be placed as far posteriorly as possible, and the other should be positioned as far anteriorly as space and esthetics will permit. This maintains the quadrilateral concept and represents an effective method of controlling loading. Tripod configuration This design is used primarily for class II edentulous arches. If there is a modification space on the dentulous side, the teeth anterior and posterior to the space are clasped to bring about the Tripod configuration. If the modification space is not present, one clasp on the dentulous side of the arch should be positioned as far posterior as possible, and other as far as anterior as factors. Such as interocclusal space, retentive undercut and esthetic considerations will permit.(Fig-37) The design is not effective as quadrilateral configuration but is most effective in neutralizing leverage in class II situation.
Bilateral configuration
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In case of bilateral distal extension group, or class I ideally the single retentive clasp on each side of the arch should be located near the center of the dental arch or denture bearing area. In bilateral configuration the clasp exerts little neutralizing effect on the leverage induced stresses generated by the denture base.(Fig36) e) Clasp design 1) Circumferential cast clasp The conventional circumferential cast clasp originating from a distal occlusal rest on the terminal abutment tooth and engaging a mesiobuccal retentive undercut should not be used on distal extension RPD. The terminal of this clasp reacts to movement of the denture base towards the tissue by distal tipping, or torquing forces on the abutment tooth.(Fig-39) A cast circumferential clasp that approaches a distobuccal undercut from the mesial surface of the terminal abutment tooth is acceptable. As an occlusal load is applied to the denture base, the retentive terminal is moves further gingivally into undercut area and looses contact with the abutment tooth. In this manner the torque is not transmitted to the abutment tooth. 2) Vertical projection clasp or bar clasp This clasp is used on the terminal abutment tooth on a distal extension partial denture when the retentive undercut is located on the distobuccal surface. It is never indicated when the tooth has a mesiobuccal undercut. The bar clasp functions in similar manner to reverse circumferential clasp. As the denture base is located
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towards the tissue, the retentive tip of the bar clasp rotates gingivally to release the stress being transmitted to the abutment tooth.(Fig-40) 3)Combination clasp When a mesiobuccal undercut exists on a abutment tooth adjacent to a distal extension edentulous ridge, the combination clasp can be used to reduce the stress transmitted to the abutment tooth. Wrought wire clasp by virtue of its internal structure is more flexible than a cast clasp. It can flex in any spatial plane, where as a cast clasp flexor in horizontal plane only. The wrought wire retentive arm has a stress breaking action that can absorb torsional stress in both the vertical and horizontal planes. A cast circumferential clasp under some situation would transmit most of the leverage induced stress to the abutment teeth.(Fig-41) f) Splinting of the abutment teeth Weak abutment teeth should be splinted with the adjacent teeth for strength and stability. Splinting helps to share the stresses produced in a weak abutment tooth. It will stabilize the weak teeth in mesiodistal direction. Usually splinting is done by fabricating full veneer crowns over the teeth to be splinted or by clasping more than one tooth on each side of arch with numerous rests for additional support and stabilization.(Fig-42) Guide planes helps to increase the horizontal stability of the denture. Hence, additional clasps can be used to increase the guide planes and also increase the cross arch stabilization.
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Indications Abutments with tapered or short roots. Terminal abutments located on the edentulous side of a distal extension denture base. Fixed splinting is given if there is some loss of periodontal attachment, after a periodontal disease or therapy. II. Indirect Retention An indirect retainer is a part of removable partial denture that helps direct retainer to prevent displacement of the distal extension denture by resisting the rotational movement of the denture around the fulcrum line established by the occlusal rests. The indirect retainer is located on the opposite side of the fulcrum line from the denture base.(Fig-43) Indirect retention is based on lever principle. It is produced by moving the axis of rotation of the denture away from the point of application of force. In class I situation, indirect retainers are necessary and they should be positioned as far anteriorly to the fulcrum line as possible. In class II situation, the fulcrum line runs through the most posterior abutment on the dentulous side and the terminal abutment on the distal extension side. Adding another rest perpendicular to this fulcrum line provides indirect retention. In class III situation, indirect retention is usually not required. In some case there is a buccolingual placing of the
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denture, which is prevented by placing rest on the dentulous side, perpendicular to longitudinal axis of rotation of denture. III. Denture Base The denture base should be designed to cover the maximum amount of soft tissue available. - The denture base should have long flanges, within the physiological limits of the soft tissues in order to stabilize the denture against horizontal movement. - Distal extension denture base must always extend onto the retromolar pad area in mandibular denture and cover the entire tuberosity in the maxilla. - The denture base will displace the soft tissues on the ridge during functional occlusal load. A functional impression is recorded to fabricate the denture in order to improve its adaptation and avoid excessive tissue displacement. IV. Major Connector In the mandibular arch the lingual plate major connector that is properly supported by rests can aid in the distribution of stresses to the remaining teeth. It is particularly effective in supporting periodontally weakened anterior teeth. It also contributes to the effectiveness of cross arch stabilization. In the maxillary arch the use of a broad palatal major connector that contacts several of the remaining natural teeth through lingual plating can distribute stresses over a large area.
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The major functions o the major connector includes rigidity, retention and stability. V. Minor Connector The major connector joins the major connector to the clasp assembly and the guiding planes located on the abutment tooth surface. The minor connectors used for auxillary rests aid in indirect retention. These provide horizontal stability to the partial denture against lateral forces on the prosthesis. The abutment tooth receives stabilization against lateral forces by the contact of the minor connector. VI. Rests Properly designed rests help in control the stresses, by directing the forces, acting on the denture to the long axis of the abutment tooth. The floor of the rest seat should be less than 90 to a tangent line drawn parallel to the long axis of the tooth(Fig-46). Adding rests on the additional teeth decreases the amount of occlusal load on each tooth and helps to distribute the occlusal load equally to all the abutment teeth. STRESS BREAKERS A stress breaker is defined as "A device which relieves the abutment teeth of all or part of occlusal forces" GPT-6. All vertical and horizontal forces, applied to the artificial tooth are distributed throughout the supporting portions of the
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dental arch. Broad distribution of force is accomplished through the rigidity of the major and minor connectors. In distal extensions situations, the use of rigid connection between the denture base and supporting teeth must account for the base movement without, stress on the abutment teeth and residual ridge is minimized through the use of functional basing, broad coverage, harmonious occlusion and correct choice of direct retainers. The concept of stress-breaking exists that insists on seperating the action of the retaining elements from the movement of the denture base by allowing independent movement of the denture base for its supporting framework and direct retainers Aims: 1) To direct occlusal forces in the long axis, of the abutment teeth. 2) To prevent harmful forces being applied to the remaining natural teeth. 3) To share the forces as evenly as possible between the natural teeth and distal extension area according to the ability of these different tissue to accept the forces.
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4)
To ensure that the part of the load applied to the distal extension area is distributed as evenly as possible over the whole mucosal surface. Dentures with a stress breaker are also called as a "broken
stress partial dentures". In a tooth tissue supported partial denture, when an occlusal load is applied, the denture tends to rock due to the difference in the compressibility of the abutment and soft tissues. As the tissues are more compressible, the amount of stress acting on the abutments in increased, which can produce harmful effects on the abutment teeth. To protect the abutment from such conditions, stress breakers are incorporated into the dentures. A stress breaker is a hinge like joint placed with in the denture framework, which allows the two parts of the framework on either side of the joint to move freely. I. Movable joint between the direct retainer and denture base. This group includes hinges, sleeves, and cylinders and ball and socket devices. Being placed between the direct retainer and denture base, they may permit both vertical movement and hinge action of the distal extension base. This prevents direct transmission of tipping forces to the abutment teeth as the base moves tissue-wards under function. E.g. Dalbo attachment, Crismani attachment, ASC 52 attachment.
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II. Flexible connection between the direct retainer and denture base includes the use of wrought wire connector and split major connector(Fig-47). Advantages: Vertical forces acting on the abutment teeth are minimized and alveolar support of abutment teeth is preserved. Intermittent pressure of denture bases massage the mucosa thus providing physiologic stimulation, which prevents the bone resorption and eliminates need for relining. Minimal requirement of direct retention. Weak abutment is well splinted even during the movement of the denture base. Disadvantages: easily. Difficult to repair. Design is complicated and expensive. The assembly is very weak and tends to fracture very
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STRESS BREAKERS OR STRESS EQUALISERS

Stress Breaker A stress breaker is a device which relieves the abutment teeth of all part of the occlusal forces(GPT-2005). Stress Director A stress director is a device that allows movement between the direct retainer which may be intracorornal or extra coronal.(GPT-2005) Introduction: The resiliency of the tooth secured by the periodontal ligament in an apical direction is not comparable to the greater resiliency and displaceability of the mucosa covering the edentulous ridge.Due to this forces are transmitted to the abutment teeth as the denture bases are displaced in function. It is agreed that a rigid connection between the denture and the direct retainer on the abutment tooth is damaging and that some types of stress director or stress equalizer(a flexible or movable joint between teeth and metal frame work so that the clasp) is essential to protect the vulnerable abutment teeth.It allows independent movement of the denture base and the direct retainers separates the action of the retaining elements from the movement of the denture. The need for stress breakers on free end RPDs has been recognized on the basis that the resiliency or displaceability of the mucosal tissue
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ranges between 0.4 mm to 2mm, while the vertical resiliency of a normal healthy tooth in its socket is approx. 0.1mm. This tissue resiliency differential of 20 to 40 times the axial displaceability of a normal tooth in its socket dictates the necessity for some form of stress direction in the partial denture design. TYPES OF DESIGNS: RESILIENT JOINTS AND HINGE JOINTS Joint attachments are used as retainers for unilateral and bilateral distal extension partial dentures.They allow various degrees of movement between the body of the prosthesis and the abutment teeth. The movement may be: Rotation around a transverse axis Vertical bodily movement Based on the type of movement, joints are classified either as: Resilient hinge joints that allow both vertical bodily movement and rotation around a transverse axis Pure hinge joints that only allow rotation around a transverse axis RESILIENT HINGE JOINTS Joints can be connected directly to an abutment crown through either the female or the male part. In these cases the two parts are separated in the mouth as the denture is removed. There are, however, joints in which the entire joint construction can be separated from the abutment. The male and female elements, which comprise the resilient part,are connected to the abutment tooth by
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means of a sliding attachment (sliding attachment resilient joint). Joints in which one part can be removed from the other at the abutment crown are called separable joints. Those that cannot be separated in the mouth are designated as linked joints and are connected to the abutment teeth by means of additional retainers, such as cast clasps or double crowns. Each individual form of joint is offered by the manufacturers in many variations, allowing a wide range of applications. Thus, there are special types for extracoronal installation, and for both unilateral and bilateral use. When using a jointed connection between the body of the prosthesis and the abutment teeth, the compressibility and the resilience of the mucosa must be taken into account The stress-breaker effect prevents the transmission of excessive forces to the abutment teeth during chewing. The springs built into the joints cushion the loading forces and return the denture bases to their rest positions. Dalbo attachment This attachment is one of the oldest and most successful extracoronal attachments and is classified as an adjustable, directed-hinge distal extension attachment.This system features lateral stability, vertical resiliency, and hinge movement.The advantages of the Dalbo system are the intrinsic direct retainer and excellent stability owing to the vertical beam. The attachment may be used in unilateral or bilateral applications. The unilateral configuration provides a larger vertical bar for enhanced lateral stability. The attachment is offered in two sizes, although the mini version lacks vertical resiliency.(Fig-48)
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The resilience hinge joint by Dalla Bona is available in separable (Dalbo extracoronal attachment) and linked(Dalbo-Fix) forms.With the separable variety,the ball-shaped male section is attached to the abutment crown,either by soldering or by being luted to the wax pattern beforecasting. The removable female housing with its enclosed coilspring is embedded in the denture base. The vertical resiliency is rendered through the presence of a spring and found only in the standard unilateral and bilateral designs.The difference between the standard and the mini is approximately 2 mm in clinical crown height requirement, 1.7 to 2.0 mm in preparation depth, and 1 mm in faciolingual width requirement. As in all extracoronal attachments, the amount of space required in the denture base is approximately 5.5 to 6.0 mm. This often creates difficulty with tooth placement and inadequate strength for the resin. The minimum amount of resin recommended should be strictly adhered to so as not to compromise the strength of the denture base in the region of the attachment. This extracoronal retainer offers a mechanism to "lock" the attachment for reline procedures. ASC-52 ATTACHMENTS The functional properties of the ASC 52 resilient joint attachment stressbreaker is based upon the original adaptation of the CARDAN JOINT principle. The ball screw spring joint ASC-52 from Degussa is a separable attachment, that is,it can be disconnected in the mouth. The female part is attached to the abutment crown, and the male unit, to the removableprosthesis.The male unit is made up of a ball tipped sliding bolt, enclosure, spring,and screw(Fig-49).
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It is most useful due to the following reasons: The removable part of the prosthesis can accomplish a wide variety of movements according to the specific case This removable part is well anchored to the abutment teeth, but it does not overload them. In this way a perfect retention of the partial prosthesis in the mouth is assured,the prosthesis can be easily inserted and removed without any risk for the abutment teeth. The action of the inner part can be regulated according to the specific needs. An increase or decrease in prosthesis moveability is achieved by adjusting the spring tension(screw or unscrew the small nut), It is possible to replace any detail of the inner part at any time (wear, damages, accident),dental technicians will find ther joint attachment easy to handle. DSE HINGE The DSE Hinge is intended for use on bilateral clasp retained free end removable partial dentures to reduce loading or torquing of abutments. The small size is easy to work with and eliminates multiple inventory requirements.The unique design provides for easy freeing after casting and provides total lateral stability.For patients, it allows patient comfort and abutment protection by allowing independent unilateral function eliminating torquing leverage on the abutments on the
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nonfunctioning side. The miniaturized size allows utilization in short vertical spaces and provides for good esthetics(Fig-50). The FR system The FR system for removable partial dentures is a technological revolution for what many call semi-precision or "mill-ins." A tapered,friction retained intracoronal precision attachment for removable partial dentures with a lingual arm and for segmented bridgework or nonparallel abutments in fixed bridgework.The female is actually cast against the prefabricated male for total accuracy, improved proximal wall contacts, and tremendous time and labor savings(Fig-51). This simple and inexpensive attachment uses a single investment technique, eliminates porcelain in the female due to the silicone male, allows for easy and accurate duplication, no soldering is needed, easy separation of male and female, and the miniature size allows for use in close bitesituations. Easy insertion because of the tapered male, improved esthetics (no metal on the occlusal),excellent retention and reduced wear account for this being one of the most popular attachments in dentistry. The UNOR The UNOR is a screw adjustable retention precision attachment for intracoronal use. The beveled male is adjustable so retention may be eitherincreased or decreased, allowingfor easy patient insertion and removal, thus less wear. Vertical height may also be altered for short or close bite situations. The female may be directly cast with precious or semi-precious alloys for easy fabrication.(Fig-52)
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A female ceramic former is available for creating a female in nonprecious castings. The excellent external wall contact allows for guide plane stability. The male may be connected to the cast frame by acrylic resin, composite resin, or solder.The system also allows for conversion of a fixed bridge to a removable partial denture if distal abutments are lost.
CEKA ATTACHMENT Definition: An attachment which has a patrix conical portion with a split head for activation and a matrix cap portion. Indications The Ceka attachment was developed as an extracoronal attachment. However, it can also be used for both root face abutments and bars. In the latter case it allows increased retention of the superstructure where a clip may not be provided. If the bar is short the placement of a clip may not be possible and therefore the use of such an adjustable attachment can provide the solution. Advantages The attachment can be used for many different clinical situations . The matrix ring retainer can be placed in a variety of locations and the patrix component comes in different forms allowing it to be cast, soldered or bonded into place. The patrix has a cross split allowing for activation of this attachment with wear. The Traditional Ceka and Ceka Revax systems provide hinge, vertical, and rotational movements to provide maximum abutment
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protection. Each attachment consists of three angulations of plastic female profiles with precision metal insert,male spring pin, and retention component. The three angulations allow the user to design the case for the patients needs(Fig-53)
Disadvantages The attachment requires adequate space and the correct angulation relative to the path of insertion of the denture. VERTIX The Preci Vertix and Vertix "P" provides for hinge and vertical movements. It should besupported by a broad based ridge. TheVertix is a very inexpensive and popular system that provides patient comfort and abutment protection for both mandibular and maxillary bilateral removable partial dentures. Unilateral free end removable partial dentures should be cross arch stabilized(Fig-54). The Vertix features time-saving and simple routine techniques, requires no additional tools, may be cast in any alloy to eliminate soldering and dissimilar alloys, and provides outstanding space-saving aesthetics. The plastic female absorbs negative movements to protect abutments and provide patient comfort. It requires only a routine full coverage abutment preparation and provides easy patient insertion and removal. The only servicing requirement is the occasional, fast, easy female replacement. Three different female retention clips are available to accommodate all your retention needs.
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O-SO Distal extension The OSO is a popular extracoronal attachment that provides free movement in all planes for maximum protection. A proven retentive system utilizing an easily replaceable rubber O ring. This is a resilient attachment with vertical and hinge stress-breaking action for free-end and bounded partials. Maybe used in conjunction with other attachment(Fig55). Universal Ic attachment The IC attachment is a popular spring loaded retaining attachment that provides free movement for abutment protection without requiring an abutment crown. The IC attachment requires a 180 degree reciprocal lingual arm. The attachment consists of a male anchor and female inlay.It is made of a stainless, chrome-alloy like those used for casting partials. It will not tarnish or corrode, and when properly installed,will not malfunction even after years of wear.Other benefits include no pulpal involvement,no gingival retraction before impressions, easy to adjust at the chair ,and this is a reversible procedure. Mays unilateral attachment Designed specifically for the unilateral distal extension, the Mays is the first attachment with a lingual locking arm. It can not be dislodged,but yet is easily removed for patient hygiene. Does not require a lingual or palatal arm. No cast chrome framework required or soldering; the male portion casts with the crowns. No parallelism is necessary ,even on bilateral cases.(Fig-56) HINGE JOINTS
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Hinge joints exhibit only one type of freedom of movement, namely, rotation around a transverse axis. Since there is no vertical bodily movement, they have a somewhat more favorable topographic and dynamic relationship to the distal abutment teeth than do joints with both rotation and bodily movement. There is no direct mechanical irritation of the gingival margin.Hinges that cannot be separated in the mouth (linked hinges) can only be used on removable prostheses (partial dentures and telescopic bridges). A bilateral application is also conceivable provided the two denture bases are not rigidly connected to each other. Hinges that cannot be separated in the mouth (linked hinges) can only be used on removable prostheses (partial dentures and telescopic bridges). A bilateral application is also conceivable provided the two denture bases are not rigidly connected to each other.
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SPECIAL CLASP DESIGN TO CONTROL STRESS RPI system In 1963, Kratochvil introduced the I-bar design philosophy.This philosophy was based upon use of an I-bar retentive element, a mesial rest, and a distal proximal plate. Proponents of the I-bar philosophy claimed that the resultant clasp design minimized torquing forces and directed occlusal loads parallel to the long axes of abutments.The I-bar rationale, especially the use of a mesial rest, emerged as a popular byproduct of Kratochvil's design principles(Fig-57). The RPI clasp is a current concept for bar clasp design, as the full T bar should not be used since it covers an unnecessary amount of tooth structures compared with the RPI clasp. Components of the I-bar System Kratochvil's I-bar system includes a mesial rest, I-bar retainer, and a long distal guiding plane that extends to the tooth-tissue junction. Each component must function properly to ensure success of the I-bar system. The RPI clasp fulfils the requirements of proper clasp design The practitioner must understand that the I-bar retentive clasp is only one
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element in the design equation.For this clasping system to function effectively, all components must be properly designed, constructed, and fitted. The rest, located on the mesial occlusal surface of the abutment tooth, acts as the point of rotation and exerts a mesial force on the tooth rather than a distal displacing force. Pressure exerted on the extension base moves the proximal plate tissueward without torquing the tooth. The I bar also moves mesiogingivally away from the tooth under masticatory load. Rests For distal extension base partial dentures where a bicuspid serves as the abutment tooth, a mesial rest preparation is made. For posterior teeth, where restorations are not placed,the rest seal can be prepared in the appropriate triangular fossa. Sufficient bulk of metal must be provided to permit the rest to function without fracturing or bending. Gold requires larger and deeper preparations than the non-precious metals (chrome cobalt, nickel cobalt, etc.). This preparation should be rounded and fully polished to permit some rotation when depression of the extension base occurs. If a cuspid is to serve as the abutment, a mesio lingual rest preparation is made.
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The rest seat must be deep enough to prevent the mesial rest from slipping gingivally. As a general rule, mandibular cuspids have a thin enamel covering and when preparing an adequate rest seat, penetration into the dentin is often inevitable. If dentin is exposed, the preparation should be deepened and modified to accept a gold foil, amalgam, or other restoration which can be properly contoured.
Guide Planes A guide plane is prepared on the distal surface of the abutment tooth at the occlusal one third as proposed by Potter. It should extend lingually just far enough so that the proximal plate together with the mesial minor connector will prevent lingual migration of the tooth. The guide planes should be approximately 2 to 3 mm. in height occlusogingivally. This guide plane will often permit the proximal plate and the mesial minor connector to contact the tooth simultaneously and provide proper reciprocation against the force exerted by the retentive buccal clasp arm during the seating and removal of the denture.
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If the mesial minor connector and proximal plate cannot contact simultaneously, as may occur with cuspid abutments, then the retentive I bar should engage the mesiobuccal undercut and receive its reciprocation from the proximal plate alone. Proximal Plate It is placed on a distal guiding plane, extending from the marginal ridge to the junction of the middle and gingival third of the abutment tooth. The proximal plate minor connector should contact approximately 1 mm of the gingival portion of the guiding plane in distal extension cases. The bucco-lingual width of the proximal plate is determined by the proximal contour of the tooth. The proximal plate extends lingually just far enough so that the distance between the minor connector and proximal plate is less than the mesiodistal width of the tooth. It should be 1mm thick and join the framework at right angle. The proximal plate together with the mesio-lingually placed minor connector provides stabilization and reciprocation of the assembly. I Bar The approach arm of the I bar extends from the framework so as to remain at least 3 mm from the gingival margin and then crosses the gingival margin at right angles.
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Approximately 2 mm of the I bar contacts the tooth surface, usually at the gingival one third of the tooth. The bottom ponion of the I bar contacting the tooth surface should engage 0.01 inch undercut. The I bar should taper slightly from the base to the tip. It is usually placed at the greatest mesiodistal prominence on the buccal surface or towards the mesial, but not toward the distal. Slight relief is necessary when the arms crosses the gingival margin.
Advantages Vertical masticatory force on the distal extension base causes the Ibar to move mesiogingivally away from the tooth and the proximal plate to move further into the undercut of the tooth. Thus, both the I bar and the proximal plate disengage the abutment and thereby reduce torquing of the tooth. The mesial minor connector together with the proximal plate provide the necessary reciprocation and eliminate the need for a lingual arm.
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The mesial rest eliminates the potential "pump handle" effect that a force. on the base often induces with a distal rest. The RPI clasp contacts the tooth minimally and is advantageously used on caries prone patients. The I bar itself makes very little contact with the tooth, it is usually more esthetic than most other clasp arms. Indications The RPI clasp is indicated In distal extension cases, as it provides a stress releasing action. When tissue undercuts are not severe. Contraindications The RPI clasp is contraindicated with Shallow vestibule (the base of the I-bar should be at least 3mm from the gingival margin). High floor of the mouth which necessitates the use of lingual plate. When buccal undercut is absent or only distobuccal undercut exists. In cases with severe tissue undercut to avoid food or tissue trap. If the facial surfaces of teeth are facial to the tissue surface, the RPA Clasp may be used.
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CONCLUSION
Many individuals have contributed to the progressive advancement of partial denture service and have written extensively to document their experiences and philosophies in this field. Their objective are universal, to provide means of restoring function, esthetics and comfort, which promotes the oral health.Partially edentulous arches exist in a great variety of forms.
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A thorough knowledge of the mechanical principles involved is very important and it should be understood properly because it is an integral factor in design of removable partial denture.Designing of the appliance play an important role because it is through the structure of the denture that the forces of mastication are transmitted from the occlusal surfaces of artificial teeth, natural teeth and underlying tissues. Generally it is very important that, the design which provide broad bases, rigid connectors, multiple rests and properly selected retainers are most likely to effect favourable distribution of force and maintain the integrity of remaining tissues. Hence while designing removable partial denture biological as well as physical factors should be considered.The biological factors includes the denture support, avoiding the deleterious effect on the abutment teeth, proper stress distribution and the physical factors includes the strength of the denture base used, whether it accommodates the future relining etc.
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mathematical equations J Prosthet Dent 1969;22(5):528-542. 27. Bickley W.R Combined splint-stress breaker removable partial denture J Prosthet dent 1969:21(5);509-512. 28.Avant E.W Factors that influence retention of removable partial denture J Prosthet dent 1971;25(3)265-270. 29.Cecconi T.B et al Removable partial denture abutment tooth movement as affected by inclination of residual ridges and type of loading. J Prosthet Dent 1971;23(4):375-381. 30.Boero E et al Considerations in design of removable prosthetic devices with no posterior abutments J Prosthet dent 1972:28(3):253-263. 31.Cecconi T.B Effect of rest design on transmission of forces to abutment teeth J Prosthet dent 1974:32(2);141-151.
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32.Cecconi T.B et al Stressbreakers and the removable partial denture J Prosthet dent 1975:34(2);145-151. 33.Thompson D.W Evaluation of photoelastic stress patterns
produced by various designs of bilateral distal extension removable partial denture J Prosthet Dent 1977;38(3):261-273. 34. McLeod A theoretical analysis of the mechanics of the Thompson dowel semiprecision intracoronal retainer. J Prosthet Dent 1977;37(1):19-27. 35.McDowell C.G Force transmission by indirect retainers during unilateral loading J Prosthet Dent 1978;39(6):616-621. 36.Farah W.J Stress analysis of disjunct removable partial dentures J Prosthet Dent 1979;42(3):271-275. 37.Maxfield J.B The measurement of force transmitted 1979;41(2):134-142. 38.McCartney W.J Motion vector analysis of an abutment for a distalextension removable partial denture: A pilot study J Prosthet dent 1980:43(1);15-21. 39.McLeod S.N An analysis of the rotational axes of semiprecision and precision distal-extension removable partial dentures.J Prosthet Dent 1982;48(2):130-133. 40. Boucher L.J Treatment of Partially Edentulous Patients The CV.Mosby Co.. St.Louis Toronto. London 1982. to the
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BIOMECHANICS OF REMOVABLE PARTIAL DENTURE INTRODUCTION:

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

of maxillary bilateral distal-extension

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

incorporating broad distribution of stress,the

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

prognosis by the selection of sites for occlusal rests in distal

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

TOOTH BORNE (Tooth supported /Dentoalveolar supported)(Fig-12)

Exhibits one or more edentulous areas which are not bordered by

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

MECHANICAL PRINCIPLES OF REMOVABLE PARTIAL DENTURE

Mechanical----related to forces and its application objects(Eg:looseness of teeth,bone r e s o r p t i o n . . e t c )

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

In a perfect system which is static:

A lever system works at a mechanical dis advantage when the effort is

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

The fundamental levers are

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

POSSIBLE MOVEMENTS OF REMOVABLE PARTIAL DENTURE(Fig-21)

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

FORCES ACTING DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

a.)Tissue ward mastication,

BIOMECHANICS OF REMOVABLE PARTIAL DENTURE

occlusion of upper coverage in free

sticky food provides -Adhesion upper cohesion

II.Horizontal forces a.)Lateral Forces

Forward backward movement mandible

while teeth are in contact III.Rotational