Nonprecious Alloy vs Precious Alloy Telescopic

Crown–Retained Removable Partial Dentures:

Survival and Maintenance Needs
Karina Zierden, Dr Med Dent1/Luisa Kurzrock, Dr Med Dent2/
Bernd Wöstmann, Prof Dr Med Dent3/Peter Rehmann, Prof Dr Med Dent4

Purpose: The purpose of this retrospective clinical study was to evaluate the clinical outcomes
of nonprecious alloy (NPA) vs precious alloy (PA) telescopic crown–retained removable partial
dentures (TRPDs), the factors influencing survival, and the type and number of maintenance
procedures required during the observation period. Materials and Methods: This
retrospective clinical study is based on 462 patients with a total of 572 TRPDs on a total of
1,946 abutment teeth. The following parameters were analyzed with Kaplan-Meier analysis:
sex; alloy type; denture location; number and distribution of abutment teeth (Kennedy Class);
vitality of abutment teeth; dentition in the opposing arch; and participation in follow-up visits.
Results: The mean observation period was 3.87 ± 3.15 years (2.99 ± 2.52 years for NPA-
TRPDs and 5.36 ± 3.53 years for PA-TRPDs; maximum 11.01 years). During the observation
period, 4.2% (n = 24) of the TRPDs ceased functioning and 8.3% (n = 161) of the abutment
teeth had to be removed. The calculated 5- to 10-year survival probabilities were 96.1% and
84.0%, respectively, for the TRPDs. The number of abutment teeth was the only parameter
that significantly (P < .05) impacted this probability, whereas the vitality of the abutment teeth
and the type of alloy significantly (P < .05) impacted the survival probability of the abutment
teeth. NPA-TRPDs needed significantly earlier initial treatment than PA-TRPDs (P < .05).
Conclusion: The type of alloy seems to have no impact on TRPD survival, but seems to have
an influence on the survival of the abutment teeth. There are also differences in maintenance
between NPA- and PA-TRPDs. Int J Prosthodont 2018;31:459–464. doi: 10.11607/ijp.5820

N owadays, more and more people aged 65 years

and above are partially edentulous. Due to better
prophylactic programs, people are able to keep their
natural teeth for longer; therefore, more people in
this age require partial dentures. Telescopic crown–
retained removable partial dentures (TRPDs) are a
well-established treatment option for restoring patients
with a residual dentition,1–20 especially in Germany (ie,
“German crowns”). Parallel-sided or conical-shaped
inner and outer crowns are primarily used; in the lat-
ter group, the degree of taper is kept within a defined
range of inclination.12 TRPDs are tooth-preserving be-
cause they reduce any existing tooth mobility9 due to
1Assistant,Department of Prosthodontics, Dental Clinic,
Justus-Liebig-University, Giessen, Germany.
2Private Practice, Nordrhein-Westfalen, Germany.
3Professor and Chairman, Department of Prosthodontics,
their rigid connection to the abutment teeth and their
primarily axial loading. However, it is precisely because
of this rigid connection that there is an increased risk
for tooth fracture.10 The treatment and laboratory pro-
cedures are also demanding,3,7,11 resulting in higher
costs for the patients. Apart from their rather com-
mon need for maintenance measures,5,13–17 TRPDs of-
fer high oral comfort for patients.18 Implant-supported
dentures, as well as removable partial dentures
(RPDs) with metal clasps, show good survival rates
nearly comparable with those of TRPDs17,19,23 and are
therefore a reliable treatment option for patients with
a reduced dentition. Even though RPDs with metal
clasps are slightly lower in oral comfort compared to
TRPDs or implant-supported dentures, they still offer
functional denture stability, as well as good retention
and satisfactory esthetic results.23

Dental Clinic, Justus-Liebig-University, Giessen, Germany.

4Assistant Professor, Department of Prosthodontics, Dental Clinic,
Justus-Liebig-University, Giessen, Germany.
Correspondence to: Dr Karina Zierden, Department of Prosthodontics,
School of Dental Medicine, Justus-Liebig-University, Schlangenzahl 14,
35392 Giessen, Germany. Fax: +49 641 99 46 139.
Email: karina.zierden@dentist.med.uni-giessen.de
©2018 by Quintessence Publishing Co Inc.
T he request for cost-effective dental prostheses
has moved increasingly into focus. Therefore, it is
desirable to keep the manufacturing costs of dental
prostheses as low as possible by using nonprecious
alloys (NPAs) instead of precious alloys (PAs). NPAs
are tooth-friendly due to low thermal conductivity and
high hardness values, which allow a minimal material
thickness, and are more cost effective. However, the
manufacturing of NPA-TRPDs is more complicated

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Survival Rates and Maintenance Needs of NPA- vs PA-TRPDs
Table 1   N
 umber of TRPDs Categorized by Number of Abutment Teeth
No. of abutment teeth 1 2
No. of TRPDs (total n = 572) 21 125
Table 2   N
 umber of TRPDs Categorized by Years Under Observation
Time (y) 1 2
No. of TRPDs under observation (total n = 572) 572 447
because NPAs are more rigid (230 to 430 HV) in com-
parison to PAs (50 to 300 HV). Due to these material
properties, it is more difficult to achieve acceptable
retention between primary and secondary crowns
when manufacturing NPA-TRPDs.
Nevertheless, no information has been found re-
garding whether NPA-TRPDs show results compa-
rable with those of PA-TRPDs. Thus, it was the aim
of the present study to evaluate possible differences
between NPA-TRPDs and PA-TRPDs regarding needs
for maintenance and clinical performance. The follow-
ing null hypothesis was tested: the (1) survival rates
and (2) maintenance needs would not differ between
NPA-TRPDs and PA-TRPDs.
Materials and Methods
The data of 637 patients who received TRPDs at
the Department of Prosthodontics, Justus-Liebig-
University, Giessen, Germany, between 2004 and 2015
were included in this study. Patients with dental im-
plants (n = 152) or maxillary defects after oral cancer
surgery (n = 9), patients who never showed up after
denture placement (n = 8), and cases in which the
data about the type of alloy were missing (n = 6) were
excluded from the study. This resulted in a conve-
nience sample of 462 patients (209 women, 253 men;
mean age 61.5 ± 10.0 years) who received 572 TRPDs
on a total of 1,946 abutment teeth.
A total of 259 TRPDs were placed in the maxilla, and
313 were placed in the mandible (variable: denture lo-
cation). Kennedy Class was used to measure the vari-
able number and distribution of abutment teeth; 479
of the arches were classified as Kennedy Class I, 79 as
Kennedy Class II, and 14 as Kennedy Class III. A total
of 360 of the TRPDs were manufactured with NPAs
and 212 with PAs (variable: type of alloy). Regarding
the variable opposing dentition, 231 of the patients
had combined dentures with fixed and removable
parts opposing the restoration area, 165 had remov-
able dentures, 120 had fixed partial dentures, 42 had
no dental prosthesis or natural dentition, and 14 had
implant-supported prostheses.
There were 1,473 abutment teeth that showed vi-
tality, 249 treated by root canal (145 of these teeth
were treated with a metal core), and 224 with no data
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3 4 5 6 7 8
173 130 79 35 8 1
3 4 5 6 7 8 9 10
356 281 230 190 154 126 81 44
available (variable: vitality of abutment teeth). The
variable number of abutment teeth is shown in Table 1.
All patients with a residual dentition were offered
treatment with either TRPDs or RPDs with metal
clasps. As in Germany, TRPDs are a standard treat-
ment option for patients with three or less remaining
teeth per arch, whereas patients with more than three
remaining teeth per arch often receive RPDs with
metal clasps, often because of the costs. The TRPDs
were delivered as part of the clinical courses taught
in the department under the strict supervision of ex-
perienced full-time teachers following a standardized
protocol. The patients individually decided whether to
receive an NPA-TRPD or PA-TRPD; the costs were the
most decisive factor for most of the patients. All TRPDs
were fabricated in the same dental laboratory. After
incorporation of the TRPDs, all patients were asked to
participate in a continuous annual follow-up program.
The statistical analysis was performed using a
Kaplan-Meier estimate with 95% confidence intervals
(CIs) for survival analysis. Survival was defined as the
time between incorporation (start point value) of the
TRPDs and the time the TRPDs had to be renewed
(end point value). Maintenance was defined as ini-
tial adjustments directly following denture insertion
and maintenance needs during the functional period
starting 30 days after insertion.
The variables of sex, denture location, number and
distribution (Kennedy Class) of abutment teeth, vital-
ity of abutment teeth, type of alloy, dentition in the
opposing arch, and participation in follow-up visits
were analyzed as covariates of the survival function
(log rank test, P < .05). Additionally, a Cox regression
was carried out to analyze the impact of the covariates
on the survival probability and to calculate the hazard
ratio (HR) for the risk of TRPD ceasing function.
This study was approved by the ethics committee of
the Justus-Liebig-University, Giessen, Germany (Reg
No.164/11) and registered in the German Clinical Trials
Register (DRKS-ID: DRKS00009701).
Results
The mean observation time was 3.87 ± 3.15 years (2.99
± 2.52 years for NPA-TRPDs and 5.36 ± 3.53 for PA-
TRPDs; maximum 11.01 years). The number of TRPDs
 Zierden et al

1.0 Survival
Censored 1.0

0.8 0.8
Cumulative survival

Cumulative survival
0.6 0.6

0.4 0.4
1
2
3
0.2 0.2 4
Censored
Censored
Censored
0.0 0.0 Censored

0 2 4 6 8 10 12 0 2 4 6 8 10 12
Time (y) Time (y)

Fig 1   Outcome probability of all TRPDs (target event: renewal; n = Fig 2   Outcome probability of all TRPDs dependent on the number of
572; Kaplan-Meier). abutment teeth (target event: renewal; n = 572; Kaplan-Meier).

remaining at risk after a specific observation period is

1.0 Survival
shown in Table 2. During the observation period, 4.2% Censored
(n = 24) of the TRPDs ceased functioning, and 8.3%
(n = 161) of the abutment teeth were removed. 0.8
Cumulative survival
Survival of TRPDs 0.6

The mean ± standard deviation (SD) expected survival 0.4

time of the TRPDs was calculated to be 10.31 ± 0.14
years (95% CI: 10.04 to 10.57). The outcome probability
for all TRPDs was 96.1% after 5 years and 84.0% after
10 years (Fig 1). The reasons for renewal were loss of
abutment teeth (n = 20) and technical failures (n = 4).
The number of abutment teeth was the only pa-
rameter influencing TRPD survival that was signifi-
cant (P < .05). Thus, TRPDs with one abutment tooth
(n = 21) showed a significantly lower mean survival
time, which was 7.67 ± 0.62 years (95% CI: 6.45 to 8.88
years), in contrast to TRPDs with three abutment teeth
(n = 173), which was 10.55 ± 0.16 years (95% CI: 10.24
to 10.86 years) (Fig 2). None of the other parameters
showed any significant impact (P > .05) on the final
clinical outcome. Thus, part one of the null hypothesis
could not be rejected.
Survival of Abutment Teeth
The expected survival time of the abutment teeth was
calculated to be 9.79 ± 0.10 years (95% CI: 9.60 to 9.99
years). The outcome probability for all abutment teeth
was 92.0% after 5 years and 68.9% after 10 years (Fig
3). A total of 8.3% (n = 161) of the abutment teeth were
removed during the observation period. The reasons
for removal were: periodontal disease (n = 83), frac-
ture of the abutment teeth (n = 57), and decay (n = 21).
The type of alloy showed a significant impact on the
survival of the abutment teeth (P < .05). Abutments
with NPA primary crowns (n = 1,430) showed a mean
0.2
0.0
0 2 4 6 8 10 12
Time (y)
Fig 3   Outcome probability of all abutment teeth (target event: tooth
loss; n = 1,946; Kaplan-Meier).
survival time of 9.33 ± 0.17 years (95% CI: 8.99 to
9.67 years) in contrast to abutments with PA primary
crowns (n = 716), which showed a mean survival time
of 10.01 ± 0.12 years (95% CI: 9.78 to 10.24 years) (Fig
4). Cox regression showed that abutment teeth with
NPA-TRPDs had a significantly higher risk for remov-
al in comparison to abutment teeth with PA-TRPDs
(HR: 2.04).
A significant difference (P < .01) was observed
between mean survival time of vital abutment teeth
(n = 1,473), which was 9.91 ± 0.10 years (95% CI: 9.71
to 10.10), and that of endodontically treated abut-
ment teeth with post-and-core buildups (n = 145;
9.21 ± 0.31 years [95% CI: 8.59 to 9.83]) and those
without post-and-core buildups (n = 104; 8.34 ± 0.46
years [95% CI: 7.43 to 9.26]) (Fig 5). Cox regression
also showed a significantly higher risk for removal of
endodontically treated abutment teeth without post-
and-core buildups in comparison to vital abutment
teeth (HR: 2.9).

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Survival Rates and Maintenance Needs of NPA- vs PA-TRPDs

1.0
1.0

0.8
0.8
Cumulative survival

Cumulative survival
0.6 0.6

0.4 0.4
Vital
0.2 0.2 Endodontically treated with post-and-core build-up
NPA
PA Endodontically treated
NPA censored Censored
0.0 PA censored 0.0 Censored
Censored
0 2 4 6 8 10 12 0 2 4 6 8 10 12
Time (y) Time (y)

Fig 4   Outcome probability of all abutment teeth dependent on the Fig 5   Outcome probability of all abutment teeth dependent on abut-
type of alloy (target event: tooth loss; n = 1,946; Kaplan-Meier). ment tooth vitality (target event: tooth loss; n = 1,946; Kaplan-Meier).

Table 3   Initial Maintenance Interventions Categorized by Type of Alloy (n = 600)

No. of necessary interventions
Intervention NPA PA Total %
TRPDs
  Removal of pressure spots 119 80 199 33.2
  Adjustment of retention (lowering) 95 15 110 18.3
  Adjustment/correction of occlusion 56 52 108 10.0
  Adjustment/repair of acrylic material 27 26 53 8.8
 Relining 14 17 31 5.2
  New veneering of secondary crown 8 17 25 4.2
  Adjustment of retention (increasing) 6 1 7 1.2
  Repair of metal framework 0 1 1 0.2
Abutment teeth
  Recementation of primary crowns 32 17 49 8.2
  Insertion of dental core 7 5 12 2
  Manufacturing of new primary crowns 2 3 5 0.8
Total 366 234 600 100

Maintenance Needs maintenance more often than NPA-TRPDs. Thus, part

Almost all dentures (n = 488) needed initial adaptation
and/or later maintenance. The most frequent initial
treatment was the removal of pressure spots (33.1%),
followed by adaptation (lowering) of retention in the
NPA group (25.9%); this was only necessary in 6.3% of
the PA group (P < .05) (Table 3). NPA-TRPDs needed
significantly earlier initial treatment than PA-TRPDs
(0.038 ± 0.007 years [~14 days] vs 0.151 ± 0.110 years
[~55 days], respectively). Also, dentures located in the
mandible needed earlier initial treatment compared to
those in the maxilla (0.036 ± 0.005 [~13 days] vs 0.307
± 0.099 years [~112 days], respectively).
During the functional period, the first maintenance
was necessary after a mean time of 2.27 ± 0.13 years.
The most frequent reasons for maintenance dur-
ing the functional period were removal of pressure
spots (19.0%); adjustment/correction of the occlusion
(13.3%); recementation of the primary crowns (13.1%);
and relining (12.5%) (Table 4). PA-TRPDs needed
two of the null hypothesis could be rejected.
None of the parameters analyzed showed a signifi-
cant impact on maintenance needs.
Discussion
Using a retrospective longitudinal study design,
this study aimed to evaluate the survival probabil-
ity and maintenance needs of NPA- and PA-TRPDs.
Retrospective studies have natural shortcomings, as
they must rely on the data available; nevertheless,
they are helpful as long as data of higher evidence (eg,
RCTs) are missing. This applies to the topic investi-
gated in the currenty study in particular. The differing
group sizes (NPA-TRPDs = 360; PA-TRPDs = 212) and
the differing mean observation periods (2.99 ± 2.52
years for NPA-TRPDs and 5.36 ± 3.53 years for PA-
TRPDs) could be seen as methodical difficulties and
therefore as weaknesses of the study. Furthermore,
it would have been desirable to include other clinical

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 Zierden et al

Table 4   Maintenance Interventions During Period of Function Categorized by Type of Alloy
No. of necessary interventions
Intervention NPA PA Total %
TRPDs
  Removal of pressure spots 211 246 457 19.0
  Adjustment/correction of occlusion 133 188 321 13.3
 Relining 118 183 301 12.5
  Adjustment/repair of acrylic material 121 137 258 10.7
  New veneering of secondary crown 102 138 240 10.0
  Adjustment of retention (lowering) 112 27 139 5.8
  Repair of metal framework 57 45 102 4.3
  Adjustment of retention (increasing) 33 68 101 4.2
  Renewal of metal framework 16 26 42 1.7
Abutment teeth
  Recementation of primary crowns 160 156 316 13.1
  Insertion of a dental core 68 48 116 4.8
  Manufacturing of new primary crowns 9 5 14 0.6
Total 1,140 1,267 2,407 100.0

data (eg, periodontal parameters) in the study; un-
forutnately, the data available were inconsistent in this
regard. Nevertheless, a high degree of reproducibility
was guaranteed by the use of standard treatment pro-
tocols for the fabrication of all TRPDs, as well as by
the utilization of standardized documentation forms,
which are part of a computerized database software.
Moreover, a modified Kaplan-Meier estimate specially
designed for this type of study design was used to
increase the reliability of the results.24
The calculated 5- and 10-year survival rates for
NPA-TRPDs (95.9%) and for PA-TRPDs (96.5%;
P > .05) in the present study are comparable with
other publications.1–23 The calculated extraction rate
for the abutment teeth (8.3%) and the reasons for
removal correspond to the data found in the litera-
ture.6,8,9,13,20,22,23 The extraction rate is a good number,
especially when considering that teeth with a critical
prognosis (eg, with a reduced periodontium) are often
used as abutment teeth for TRPDs.16
Although the type of alloy showed no significant
impact on TRPD survival (P > .05), it did have an
impact on the survival of abutment teeth (P < .05).
Despite the fact that abutment teeth with NPA-TRPDs
showed a lower 10-year survival rate in comparison to
abutment teeth with PA-TRPDs (67.7% vs 71.8%, re-
spectively; P = .004), the use of NPA-TRPDs cannot be
advised against in general,8 as this result could be ex-
plained by the fact that there were differences in the
mean observation time and in group sizes. The fact
that vital abutment teeth showed a significantly higher
survival rate in comparison to endodontically treated
abutment teeth (P = .001) has also been documented
in other studies.3,4,7,11,21,22 The use of endodontically
treated teeth as abutment teeth for TRPDs should
therefore be considered critically, especially with re-
gard to the cost-benefit relationship. However, should
successful endodontically treated teeth be used as
abutment teeth for TRPDs, they should be treated
with a post-and-core build-up to achieve better sur-
vival rates for the TRPDs.
TRPDs with less than three abutment teeth showed
a lower survival rate than TRPDs with three or more
abutment teeth, which is also presumed in other stud-
ies,4,7,13,17 although there are others that have shown
contrary results.3,12,22 Nevertheless, TRPDs with only
one abutment tooth still offer a higher oral comfort in
comparison to full dentures, and their mean survival
time (7.67 ± 0.62 years) is sufficient. Therefore, they
should be considered a treatment option for elderly
patients with a reduced dentition because they can
be modified stepwise into a full denture, which is also
cost effective.
Nearly all of the observed TRPDs needed some kind
of maintenance procedure; thus, the need for mainte-
nance was a bit higher in the present study compared
to the literature.3,6,7,14,15,16 The most common mainte-
nance procedure was the removal of pressure spots,
followed by recementation of primary crowns, adjust-
ment/correction of the occlusion, and relining. These
results are comparable with other studies.7,14,15
More maintenance was necessary for PA-TRPDs.
It was apparent that NPA-TRPDs needed a reduction
of friction more often, whereas PA-TRPDs needed
increasing of the friction. This might be explained by
their differing material properties and the technical
problems resulting from trying to set an acceptable
retention between primary and secondary crowns, es-
pecially for the NPA-TRPDs. During the adaptation pe-
riod, 79.1% of the necessary measurements could be
carried out by the dentists themselves, whereas during
the period of function, 50% of the necessary mainte-
nance measurements had to be carried out by dental
laboratories, which results in extra costs. Initial adap-
tation was necessary earlier in NPA-TRPDs (13 days vs
106 days for PA-TRPDs) and in dentures located in the

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Survival Rates and Maintenance Needs of NPA- vs PA-TRPDs
mandible (14 days vs 112 days for TRPDs in the maxilla);
a reason for this could be that nearly 26% of the NPA-
TRPDs needed a reduction in retention for initial adap-
tation due to their material properties and the resulting
difficulties setting an acceptable retention. During the
period of function, only the variable opposing dentition
seemed to influence the maintenance need. Therefore,
fixed dental prostheses and natural teeth as opposing
dentition caused an earlier need for maintenance than
removable dental prostheses. This might be caused by
the fact that patients with fixed dental prostheses or
natural teeth achieve higher chewing forces than pa-
tients with removable dentures. Further studies based
on a higher level of evidence are needed to validate
the outcomes of this treatment modality.
Conclusions
Within the limitations of this retrospective study, it
can be concluded that NPA-TRPDs are a viable alter-
native to PA-TRPDs in clinical use. The type of alloy
seems to have no significant influence on the sur-
vival of the TRPDs, but did show a considerable im-
pact on the long-term success of the abutment teeth.
Though PA-TRPDs showed a slightly higher need for
maintenance in comparison to NPA-TRPDs, most of
this maintenance could be carried out by the dentists
themselves and therefore did not incur any extra costs.
According to the cost-benefit relation of both alloys
(PA and NPA), the use of NPA rather than PA saves
nearly 40% of the costs; thus, in the clinical situation of
a partial dentition with three remaining teeth, the use
of NPA should be preferred.
Acknowledgments
The authors would like to thank Dr Hermann for performing the
statistical analysis and his statistical advice. The authors report no
conflicts of interest related to this study.
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