Compendium of Continuing Education in Dentistry

March 2006, Volume 27, Issue 3

Published by AEGIS Communications

Designing Successful Removable Partial Dentures

Abstract: In today's busy dental offices, removable partial denture design is often abdicated by dentists, both as a result of a lack of experience and consensus of design and because of educational failure on the part of dental schools. The result is delegation of the clinical design process to the lab technician. The lack of clinical data provided to the dental technician jeopardizes the quality of care. This article will focus on a logical and simple approach to this problem, making removable partial denture design simple and predictably achievable. The clinical evidence related to removable partial denture design will be described, along with a checklist to simplify the process and make it practical and applicable to everyday clinical practice. Abstract: In todays busy dental offices, removable partial denture design is often abdicated by dentists, both as a result of a lack of experience and consensus of design and because of educational failure on the part of dental schools. The result is delegation of the clinical design process to the lab technician. The lack of clinical data provided to the dental technician jeopardizes the quality of care. This article will focus on a logical and simple approach to this problem, making removable partial denture design simple and predictably achievable. The clinical evidence related to removable partial denture design will be described, along with a checklist to simplify the process and make it practical and applicable to everyday clinical practice

In 1969, Atkinson and Elliot1 showed that over half of all dental school graduates could not design a removable partial denture (RPD) that could be successfully fabricated by a dental technician and worn by a patient. A 1984 survey of removable prosthodontic laboratories2 showed that 78% of RPDs are designed by dental technicians at the dentists request. Dental education has failed to adequately address this problem. A 2002 study by Hummel and colleagues3 demonstrated that RPD problems are significant, and will continue to impact dentistry in the future. A decrease in the curriculum time allocated to removable prosthodontics may be in-appropriate.3 At least a quarter of a million people in the United States under the age of 40 wear RPDs, and of those, at least one third report RPD defects, indicating that there is a great need to improve RPDs.3 Improvements should include new materials that are easy to use, repair, and maintain; simplified designs and fabrication that enable most dentists to provide well-fitting and functioning RPDs with an emphasis on patient education, and need for follow-up care.3

Many prosthodontists consider RPD fabrication to be a complete mouth rehabilitation, and that it should be taught at the proficiency level, not on a competency level. This has resulted in dental school graduates who are more likely to delegate RPD design to lab technicians and less likely to know the benefits of prosthodontic specialty referral. Thus, the quality of dental care is compromised. This article presents a simplified educational approach to teaching RPD design that leads to predictable results. The lack of a consensus on the design of a conventional RPD is noticeable in the dental literature. Many variations of RPD design have been used for the same clinical situation.4 Several published books concur that RPD design begins by surveying the study cast using a dental surveyor, marking survey lines, and selecting the RPD components.5-9 The most logical approach to determine the design of any RPD is to focus on a clinical approach based on clinical evidence, rather than a laboratory decision-making approach. The following checklist will simplify the process and make it predictable. 1. Analyze the total oral environment. 2. Draw the RPD design. 3. Survey the cast and modify the design.

Step 1: Analyze the Total Oral Environment

Designing an RPD starts with a complete analysis of the total oral environment. The dentist must determine how to establish an optimum plane of occlusion, occlusal vertical dimension, occlusal scheme, and esthetics for a proper prosthetic restoration. To do so, adequate prosthodontic data must be collected, including personal, medical, dental, and prosthetic histories; necessary radiographs; articulated dental casts; and a visual and digital extraoral and intraoral clinical exam.5 Many dentists often underestimate the practical usefulness of articulated dental casts. This results in unforeseen future treatment problems and poor outcomes (Figures 1, 2A through 2D). These preliminary study casts are articulated at the correct therapeutic occlusal vertical dimension in a retruded contact position, on a semiadjustable articulator using an adjusted facebow and often a protrusive record. When the plane of occlusion and/or the vertical dimension of occlusion are not in harmony with the dental arches, placement of denture teeth, restoration of the abutment teeth, and creation of a functional occlusion becomes difficult or impossible to accomplish.6 The dentition in both arches must be analyzed before designing the RPD. The treatment plan should include restoring the plane of occlusion and the vertical dimension, and what type of occlusal scheme is needed for an optimum clinical result.

The responsibility for the ultimate success of the RPD is often placed solely on the dentists shoulders. This responsibility should be shared by both the dentist and the patient. In reviewing many periodontal research studies related to prosthodontics, it can be concluded that RPDs contribute to oral health if above-average oral hygiene is practiced, adequate preprosthetic periodontal therapy is executed, minimal standards for RPD design are upheld, and periodic care is maintained.10-13 A minimal standard for RPD design should be simple and within the comprehension of every practicing dentist. The dentist should note whether the patient has an anterior edentulous space in addition to a posterior edentulous space. Anterior edentulous spaces are best treated with fixed prosthodontics because it is easier to achieve adequate esthetics, and it will decrease the leverage effect of the forces generated during function on the RPD.7 In a case where soft tissue is lost, anterior edentulous spaces are best replaced with an RPD if surgical correction is contraindicated. The presence of anterior replacement teeth for RPDs was found to be a significant positive influence on denture wearing.14 Next, the dentist must determine if the clinical situation is dentoalveolar-supported (tooth-borne), dentoalveolar and muco-osseous-supported (tooth/tissue-borne), or muco-osseous-supported (tissue-borne).8 Each of these possible biomechanical situations will respond differently to occlusal forces.9 Before designing any dental prosthesis, the dentist must understand the types of forces directed on the prosthesis. When the extension base of a tooth/tissue-borne RPD with no guiding plates is subjected to occlusal forces, many fulcrum lines come into play. These fulcrum lines exist only with a poorly fitted RPD. Unfortunately, though many published research articles study the effects of vertical forces on RPDs,15-18 there is a dearth of published research on forces directed on RPDs other than vertical forces. It is certainly helpful to the dentists to understand how an extension base of an RPD will respond to vertical forces,19 but the forces placed on prostheses can produce vertical, horizontal, rotational, or twisting movements, or a combination of all 4.9 Ultimately the patient wants a stable, well-fitting prosthesis,19 devoid of all movement, not just vertical movement. A tooth-borne prosthesis can be considered a "removable fixed bridge" because it is the easiest to design, most accepted by patients, and has a longer survival rate than the tooth/tissue-borne prosthesis.7,20 The tooth/tissue-borne RPD is not well understood by many dentists, and its complexity depends on the span length of the edentulous area and type of arch involved. Patients have a tendency to function and use the areas where the prosthesis is stable (for example, the tooth-borne side of a tooth/tissue-borne prosthesis). Therefore, dentists can turn a tooth/tissue-borne situation into a tooth-borne situation by the use of a dental implant on the edentulous side away from the abutment tooth,21 (Figures 3A and 3B) or can opt to not replace the missing teeth at the extension base with a prosthesis. In addition to this previous mechanical advantage, placing an implant under the RPD distal extension base has a physiological advantage. The amount of bone loss of the distal edentulous area is reduced as a result of its physiological stimulation by the implant.22

If these choices are not feasible, the dentist can create multiple opposing guiding surfaces for the control of these forces and make an altered cast impression procedure for the mandibular RPD. This will limit any possible RPD movements. At least 3 abutments should be selected and set as wide apart as possible (Figure 4A). The biomechanical forces are resisted by a good selection of sound abutment teeth. At least 3 positive rests must be placed on 3 sound abutments. Then, as many guiding surfaces as possible must be established on the abutment teeth. This is an important step in the support, stability, and retention of the future prosthesis. However, using more than 5 abutments compromises the accuracy and fit of the prosthesis.17 If one of the RPD abutments is compromised, it is wise to consider creating a contingency design. A contingency design is defined as an RPD framework design that takes into consideration the presence of a compromised tooth so that, should it be lost, the RPD will not have to be refabricated.7 Remaking an RPD is costly; repairing or adding teeth is a more reasonable expense (Figures 5A and 5B).

Step 2: Draw the RPD Design After thoroughly analyzing the oral environment, the optimal design should be drawn on the preliminary cast. The authors believe that it is necessary to draw the optimum RPD design on the cast before it is surveyed (Figures 4A and 4B). The RPD design sequence begins by drawing the most important features of the RPD framework.5 First the rests and minor connectors are drawn (Figure 4A), followed by the major and denture base connectors, and finally the clasps or attachments (Figure 4B). Rests and Guiding Minor Connectors The first step is to draw the rests and the minor connectors at the same time. A minimum of 3 positive rests are selected on good abutments as widely apart as possible. A positive rest5 is defined as: one that directs the occlusal forces parallel to the long axis of the teeth one that is strong enough to resist breakage. A strong rest is when it is thick enough, at least 1 mm, for chrome-cobalt alloy framework. There should be a rounded line angle between the rest and minor connector. The thickness of the minor connector must be half the width of the rest, and excessive rest inclination must be avoided.23 Positive rests and guiding plates will keep the RPD from moving and exerting excess pressure on the edentulous ridges. Common rests used in modern RPD design are cingulum rests and occlusal rests. Many other forms of positive rests exist, but are rarely used because they are not taught in most dental schools. Minor connectors, or guiding plates, are strong and are rigid parts of an RPD framework, such as proximal, lingual, or buccal-vertical connectors. Their role is to

guide the RPD during placement and removal, and to connect other units, such as rests, with the major connector or the denture base connectors. Guiding minor connectors play an important role in modern RPDs. Their functions are to: distribute the occlusal load to both sides of the arch limit the number of paths of placement and removal ensure stability against lateral forces and retention of the prosthesis by their frictional retentive properties against dislodgement forces during function. Thus they maintain arch integrity by anterior-posterior and lateral bracing action. The buttressing action5 of well-fitted multiple opposing guiding surfaces, in conjunction with positive occlusal rests, provides support, stability, and retention for the prosthesis. An objective in RPD design is to maximize the number of opposing surfaces.24 Any minor connector that connects an occlusal rest, to the major connector is made to contact 2 "mini guiding surfaces" prepared in the lingual occlusal embrasure of 2 adjacent teeth (Figures 4A and 4B). For this reason, the authors prefer to place the rest on the mesial fossa of a RPD distal abutment. Major and Denture Base Connectors Cross arch stabilization is provided by a rigid major connector. A main requirement for adequate major connectors is rigidity.25 Also, they must be placed in proper location to minimize the impingement on the oral tissues.8 The difference between maxillary and mandibular major connectors for RPDs is support.8 The horizontal portion of the palate will resist vertical forces and thus play an important role in the support of the tissue/tooth-borne RPD. The vertical portion of the RPD intaglio surface plays a role in the stability of the prosthesis. The maxillary and mandibular major connectors differ in shape but not in function as a result of the different type of oral anatomy. In the authors opinion, the maxillary major connector should not cover the anterior rugae, "the playground of the tongue," or the posterior soft palate. The broad central palatal connector or strap is most accepted by patients.26 Single straps are not rigid unless they are wide enough or cover 2 different planes of the hard palate.25 An anterior-posterior (A-P) palatal connector is indicated when a palatal torus is present and its surgical removal is contraindicated. Mechanically speaking, the double strap A-P connector provides maximum rigidity for the least amount of metal bulk present.5 Its major disadvantage is that it has 4 borders that the patient can feel with the tongue inside the mouth.26 Whenever possible, the border of the anterior strap of the A-P major connector should end in the valleys of the incisal rugae, making it less obtrusive. Complete coverage of the palatal connector is rarely used, and in clinical situations where it is needed, the authors prefer acrylic coverage for practical reasons. Selecting a major connector for the mandibular arch is limited to either a lingual bar or a lingual plate. In the authors opinion, the lingual bar is the better choice because it covers the minimum amount of soft tissues.26 A lingual plate or a sublingual bar are acceptable alternatives to a lingual bar when the vertical lingual space is not available.27 Lingual plates are widely used when the height of the anterior

lingual vestibule is minimal as a result of the common presence of lingual gingival recession, high lingual frenum, and/or periodontally treated anterior teeth.5 The presence of diastemas on the mandibular anterior teeth and the lack of adequate height of the lingual vestibule dictate the use of the sublingual bar. Labial or buccal bars are used when the mandibular teeth are severely tilted lingually, or when large tori are present and surgery is contraindicated. The purpose of the denture base connector is to connect the denture acrylic base to the framework. Large openings supply stronger resin attachments,28 and they should be located parallel or lingual to the crest of the residual ridge so that they do not interfere with the length of the buccal surfaces of the denture teeth.5 They start and end in a butt joint in the major connector at the internal and external acrylic finish lines. In a narrow edentulous area or in the anterior edentulous area, posts must be placed to retain the anterior teeth. When it is certain that a narrow edentulous area will need to be relined, or in areas of recent extractions, ladder retention must be used. A minimum of 1 thickness of baseplate wax should be used as the relief pad rather than the usual 24- to 28-gauge wax.7 In every other instance, a metal base with appropriate retentive lugs or loops is indicated.5 Direct Retainers Retainers in modern RPDs must be passive in placement and passive at rest.5 Retainers can be either clasps or attachments. Popular clasps used currently are circumferential, I-bar, and wrought wire.29 In the authors experience, I-bar or circumferential clasps are good choices for almost any clinical situation. Wrought wire clasps are technique-sensitive, easily deformed by the patient, and costly. Direct retainers are the least important component of the RPD because their retentive quality is impaired in 6 months because of permanent deformation.30 In the authors clinical experience, clasps used in a situation with multiple opposing guiding surfaces will not easily lose retention. I-bars are considered the best option because they are more retentive than a circumferential clasp for the same undercut, and because they require only minimal tooth coverage.31,32 On the other hand, circumferential clasps are preferred over I-bars when there is a lack of vestibular depth, or when undercuts, exostoses, or labially inclined abutments exist.5 Many clasp assemblies are used on the distal abutment of an extension base RPD, such as distal rest and circumferential clasp assemblies, I-bar system,6 Rest-Proximal Plate-I Bar,9 Rest-Proximal plate-Ackers Clasp,18 combination clasps,33 or rigid clasp assemblies with split major connectors.34 The efficiency of these various clasp assemblies is described using photoelastic studies in the vertical plane. The purpose of all clasp assemblies is to avoid the tilting and torque of abutment teeth. However, no clinical evidence has been presented that RPDs cause tilting forces on abutment teeth in the long term.35,36 A retrospective study comparing the effectiveness of 2 clasp designs, the distal rest and circumferential clasps system and the I-bar system, found that the success rate of either design is 74%.37 This study emphasized that a well-fabricated RPD is an acceptable modality, no matter what type of retainer is used. Tebrock and colleagues35 and Maxfield and colleagues38 attempted to measure abutment mobility in the mouth with different clasp designs and different rest

placements. They reported no measurable mobility, regardless of rest position and clasp design, when the altered cast procedure had been used. Good base adaptation, good oral hygiene, and adequate occlusion are the critical factors that minimize the need to design a stress-releasing clasp assembly. In the past, indirect retention was a vital element in the design of an RPD. Frank and Nicholls39 showed that indirect retainers have little to do with retention of tooth/tissue RPDs; they found that the guiding surfaces create retention and stability in an RPD. In the authors opinion, fabrication of indirect retainers should not be included when teaching RPD design. Placing 1 or 2 additional rests and their corresponding guiding plates as far as possible from the abutment rests will help with force distribution over a wider area, thus improving the support, stability, and retention of the RPD. This will eliminate the need for a so-called "indirect retainer." In addition, the additional rest(s) could be considered as points of reference and visual cues during altered cast impression and reline procedures.

Step 3: Survey the Cast and Modify the Design The purpose of surveying the cast is to check the feasibility of the optimum selected drawn design. Surveying the cast with the RPD design drawn on it will help to identify the intraoral preparation needed to meet the selected RPD design. The optimum RPD path of placement approximates the perpendicular to the plane of occlusion.40 In rare clinical situations and during the cast survey, it is necessary to modify the optimum selected design to minimize the intraoral preparation. The dentist has 2 options in this area. Either the dentist locates a surveyor and surveys the cast, or consults with the laboratory technician during the surveying procedure to identify areas requiring intraoral modification. Once this step is completed, the dentist or the lab technician tripods the cast for future use and makes a preparation guide that will be used in the mouth to shape the guiding surfaces and tooth contours, and to eliminate undesirable undercuts on the abutment teeth. The preparation guide is formed in 2 different ways on the cast using the surveyor: 1. Select 2 adjacent teeth situated equidistant to all guiding surfaces. Block out cervical and embrasure tooth undercuts with pink base plate wax, then trim excess wax with the surveyor. Lubricate the selected area with petroleum jelly, apply a small amount of autopolymerizing acrylic, and embed a friction grip bur, using the surveyor (Figure 6A). Allow the acrylic to set, then finish and polish. The bur direction is parallel to the selected path of insertion of the designed RPD. The device is placed in the mouth and used as a reference to align the handpiece bur to execute the shaping of the selected guiding surfaces. 2. Select a tooth surface that is parallel to the path of placement, mark it on the cast as a reference, and use it in the clinical situation to align the bur direction during the intraoral preparation procedures (Figure 6B).

The second approach will save the practicing dentist time and result in a more successful prosthesis.

Conclusion This article has focused on a simplified, organized approach to designing modern RPDs. Three steps are enumerated: analyze the total environment, draw the RPD design, and check the feasibility of the design using the surveyor. This article also describes the different RPD components and their function, and relates some clinical evidence to their use.