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Paulami Bagchi
CLASSIFICATION
REMOVABLE PROSTHODONTICS is devoted to replacement of missing
teeth and contiguous tissues with prostheses designed to be removed by
the wearer. It includes two disciplines:
Removable complete and removable partial prosthodontics
Removable partial denture prosthesis may be extracoronal or intracoronal
depending on what type of retention is used to keep it in the mouth.
CLASSIFICATION OF PARTIALLY EDENTULOUS ARCHES
For a classification to be acceptable it should be able to deal with the
following things:
Allow visualization of the type of partially edentulous arch being
considered
Permit differentiation between tooth-supported and tooth-tissue-
supported partial dentures
Serve as a guide to the type of design to be used
Be universally accepted
One simple system classifies the prostheses according to the type of
support they receive from the dental arch:
Soft tissue supported prostheses
Tooth supported prostheses
Tooth tissue supported prostheses
However, the most widely used method of classification of the partially
edentulous dental arch is the one originally proposed in 1923 by Dr.
Edward Kennedy of New York. Although simple, the system can easily be
applied to nearly all semi edentulous conditions, and it suggests the main
design problems that must be considered.
Kennedys original classification contains the following four classes with
certain modifications.
CLASS 1
Bilateral edentulous areas located posterior to the remaining natural teeth
CLASS 2
Unilateral edentulous area located posterior to the remaining natural teeth
CLASS3
Unilateral edentulous area with natural teeth both anterior and posterior to
it
CLASS 4
Single, bilateral edentulous area located anterior to the remaining natural
teeth
Each of the classes, except class 1, refers to a single edentulous area in
each arch. Since these types of edentulous arches not in the majority,
Kennedy referred to each additional edentulous area, not each additional
missing tooth, as a modification area and included them in the
classification by the number of such areas.
Dr. O.C. Applegate (1960) later attempted to expand the Kennedy system
by adding classes 5 and 6, however, acceptance has not been universal.
CLASS 5 is described as an edentulous area bounded anteriorly and
posteriorly by natural teeth in which the anterior abutment (the lateral
incisor) is not suitable for support.
CLASS 6 is an edentulous situation in which the teeth adjacent to the
space are capable of total support of the required prosthesis.
CLASS 5 AND 6 are not truly indicative of special design considerations.
Applegate also provided the following eight rules to govern the application
of the Kennedy system.
RULE 1
Classification should follow rather than precede extractions that might alter
the original classification.
RULE 2
If the third molar is missing and not to be replaced it is not considered in
the classification.
RULE 3
If a third molar is present and is to be used as an abutment, it is
considered in the classification.
RULE 4
If a second molar is missing and is not to be replaced (that is, the opposing
second molar is also missing and is not to be replaced), it is not
considered in the classification.
RULE5
The most posterior edentulous area or areas always determine the
classification.
RULE 6
Edentulous areas other than those determining the classification are
referred to as modification spaces and are designated by their number.
RULE 7
The extent of the modification is not considered, only the number of
additional edentulous areas.
RULE 8
There can be no modification areas in class 4 arches. Any edentulous area
lying posterior to the single bilateral area determines the classification.
The numeric sequence of the classification system is based partly on the
frequency of occurrence, with Class 1 arches being most common and
Class 4 arches being least common.
The sequence is also based on the principles of design: Class 1 partial
denture is designed as a tooth-tissue-supported prosthesis, the Class 3 as
a wholly tooth-supported partial denture, and the Class 2 as a combination
of Classes 1 and 3(partly tooth-tissue supported and partly tooth
supported).
The major connectors connect the parts of the prosthesis located on one
side of the arch with those on the opposite side. All other parts of the
partial denture are attached to it either directly o indirectly.
All major connectors must:
Be rigid:
This quality allows stresses that are applied to be effectively distributed
over the entire supporting area (abutment teeth, other teeth included in the
design, underlying bone, soft tissue).
Other components such as retentive clasps, occlusal rests, and indirect
retainers can be effective only when the major connector is rigid.
Should be rigid because flexibility will allow forces to be concentrated on
individual teeth or the edentulous teeth causing damage to the periodontal
support of the teeth, resorption of the bony ridge and impingement and
injury to the soft tissue beneath the major connector.
LINGUAL PLATE
Structure is basically that of a pear-shaped lingual bar with a thin solid
piece of metal extending upward from the superior border of the bar onto
the lingual surfaces of the teeth. The lingual bar, which constitutes the
lower portion of the lingual plate, is positioned as low in the mouth as
possible without interfering with the functional activity of the floor of the
mouth. There must be adequate block out and relief for both soft tissues
undercuts in the proximal area of the teeth-that are included under the
plate. The free gingival margin and the sulcus must be relieved. The
superior border of the plate must be contoured to intimately contact the
lingual surfaces of the teeth above the cingula and to completely close off
the spaces between the teeth upto the contact points. Sealing of the
embrasures from the lingual aspect prevents food from being packed into
this area.
ADVANTAGES
It is indicated when most posterior teeth have been lost and there is a
need for additional indirect retention. The double lingual bar is indicated
primarily when some degree of indirect retention is required and when
periodontal disease and its treatment have resulted in large interproximal
embrasures. The upper bar should be positioned at th contact points of the
teeth: therefore it is well hidden from view.
DISADVANTAGES
Patients frequently feel more tongue annoyance with the double lingual bar
than is usually encountered with the lingual plate. The major disadvantage
is the entrapment of gross portions of food debris, arises from the marked
crowding that mandibular anterior teeth frequently exists.
MINOR CONNECTORS
The primary function of a minor connector is to join other units of the
prosthesis such as clasps, rests, indirect retainers, and denture bases to
the major connectors. The minor connector is also responsible for
distributing the stresses that occur against certain components of the
partial denture to other components, thus preventing any build up of force
at a single point. The need for rigidity is emphasized by this function. If the
minor or major connector were to flex, stresses could not be distributed
evenly throughout the prosthesis.
The minor connector also distributes forces on the edentulous ridge to the
ridge and the remaining teeth. Occlusal force on the minor connector that
attaches the denture base to the major connector is passed to several
other minor connectors that serve as attachments for clasps, rests or
indirect retainers. This broad distribution of force prevents any one tooth or
one portion of the edentulous ridge from bearing a destructive amount of
force.
DIRECT RETAINERS
The component that engages an abutment tooth and in so doing
resists dislodging forces applied to a removable partial denture is called
the direct retainer. The amount and location of this retention on an abut-
ment tooth must be carefully controlled to prevent damage to the
supporting structures of the tooth.
There are two types of direct retainers currently in use, intracoronal
and extracoronal.
Intracoronal Retainers
The intracoronal retainer, or internal attachment, was developed by
Dr. Herman E. S. Chayes in 1906. It consists of two units which is a
receptacle that is built into a crown or inlay constructed for an abutment
tooth. The second unit is an insert that is attached to the removable partial
denture.
Extracoronal Retainers
The extracoronal direct retainer (or clasp) operates on the principle
of the resistance of metal to deformation. It is designed so that one
terminal of each clasp is located on an external surface of a tooth that con-
verges apically to produce an undercut. When two or more of these clasp
terminals engage undercuts, the partial denture will resist dislodging
forces. The amount of retention can be varied by the depth of the undercut
and the flexibility of the clasp arm positioned in the undercut.
It has a definite path of insertion into and removal from the mouth.
The areas used for extracoronal retention must be undercut in relation to
this path or there will be no retention. Dislodging forces such as sticky
foods or the force of gravity that tend to unseat the partial denture in func-
tion act at right angles to the plane of occlusion; to resist them, the
undercut areas must be present when the cast is viewed with the occlusal
surfaces of the teeth parallel to the floor.
The line at which the two converging cones meet (or more
practically, the line at which occlusally sloping surfaces meet cervically
sloping surfaces) is called the height of contour, a term first used by
Kennedy. It represents the greatest bulge or diameter of a crown when
viewed from a specific angle. The height of contour of a tooth will change
as the vertical position of the tooth is changed. Tipping or tilting a cast will
cause the height of contour to move accordingly.
Devan (1955) used some clarifying terms to describe retention. He
referred to the surface of a tooth that is occlusal to the height of contour as
suprabulge, and the surface inclining cervically as infrabulge. A tooth
surface may be said to be retentive if it is cervical to its height of contour,
or infrabulge.
There are two basic categories of clasps:
1. circumferential, or Akers, clasps and
2. vertical projection, or bar or Roach, clasps.
Circumferential Clasp
circumferential clasp has two clasp arms that partially encircle the
abutment tooth. The clasp, with the exception of the retentive clasp
terminal, is always located occlusal to the height of contour. Thus, the
retentive tip approaches the undercut from above the greatest bulge of the
tooth. This is the principal difference between the two basic categories of
clasps; circumferential clasps approach the undercut from above the
height of contour, whereas vertical projection clasps approach it from
below the height of contour.
1. retention
2. support
3. stability
4. reciprocation
5. encirclement
6. passivity.
Ring Clasp:
The ring clasp is most often indicated on tipped molars.
C, Fishhook, or Hairpin Clasp:
The C clasp is essentially a simple circlet clasp in which the
retentive arm, after crossing the facial surface of the tooth from its point of
origin, loops back in a hairpin turn to engage a proximal undercut below its
point of origin.
Onlay Clasp.
The onlay clasp is an extended occlusal rest with buccal and lingual
clasp arms. The clasp may originate from any point on the onlay that will
not create occlusal interferences. This clasp is generally indicated when
the occlusal surface of the abutment tooth is below the occlusal plane, us-
ually as a result of the tooth being tipped or rotated.
Combination Clasp:
The combination clasp consists of a wrought round wire retentive
clasp arm and a cast reciprocal clasp arm. The cast reciprocal arm is
normally a circumferential clasp, but a bar clasp may be used. The wrought
wire retentive arm is a circumferential clasp arm.
The combination clasp is most often indicated on an abutment tooth
adjacent to a distal extension space when the usable undercut on the tooth
is on the mesiobuccal surface. The greater flexibility of the wrought wire
acts as a stress equalizer, preventing the undesirable forces created by the
lever action of the retentive clasp tip from lifting or torquing the abutment
tooth as downward forces occur on the denture Base. The partial denture
tends to rotate around a fulcrum, the occlusal rest, producing potentially
damaging stresses to the abutment tooth. For this reason a cast
circumferential clasp must never be used to engage a mesiobuccal
undercut adjacent to a distal extension space. The greater flexiblity of the
combination clasp allows it to be placed in a greater, or deeper, undercut
area. It can frequently be placed in the gingival third of the clinical crown of
the abutment tooth, resulting in a more acceptable esthetic appearance. It
is often used on maxillary canines or premolars for this reason.
The main disadvantage of the combination clasp is that it does
require extra steps in laboratory fabrication. It is also more prone to
breakage or damage than a cast clasp. It can be easily distorted by
careless handling by patients, who tend to remove the partial denture from
the mouth by lifting on the retentive portion of the wrought wire clasp. This
leads to the clasp's coming out of adjustment.
INDIRECT RETAINERS
A removable partial denture, which is supported entirely by
remaining natural teeth usually, does not require additional support other
than that furnished by the primary abutment teeth. If positive direct
retainers are located on the abutment teeth, forces will not tend to rotate or
dislodge the prosthesis.
If the partial denture is not supported by natural teeth at each end of
the edentulous space or spaces (that is, if covers a unilateral or bilateral
distal extension ridge or a long-span anterior edentulous space), some
provision must be made for the denture to resist rotational forces to which
it will be subjected. In the case of a bilateral distal extension partial
denture, the occlusal rests on the terminal abutment teeth act as fulcra,
and an imaginary line drawn between the occlusal rests will be the fulcrum
line. Rotational movement around this fulcrum line, either toward the tissue
or away from the tissue or ridge, may occur as forces are applied to the
artificial teeth on the denture base. Movement toward the supporting ridge
will be limited by the supporting ridge and will be equal to the amount of
compressible mucosa or the amount of bone resorption that has taken
place since the partial denture was constructed. This vertical component of
the rotating motion toward the ridge can be controlled only by stable
denture base support. An indirect retainer does not control the movement.
Vertical movement also occurs in the direction away from the
supporting ridge. Sticky foods or other substances may exert a pull on the
artificial teeth that tends to lift the denture base away from the ridge.
Tissues adjacent to the borders of the denture base, such the tongue or
buccinator muscle, may also lift the denture base from the underlying ridge
when they are activated by speech, chewing, or swallowing. In addition,
gravity exerts an unseating force on a maxillary prosthesis. The principle
reason for using the indirect retainer is to counteract the movement
produced by these forces.
When the bilateral or unilateral distal extension partial denture is
under occlusal loading, the fulcrum line runs between the most posterior
rests. When the denture is subjected to dislodging forces such as sticky
food, the fulcrum line runs through the retentive tip of the direct retainer
(clasps). The indirect retainer in the distal extension partial denture uses
the mechanical advantage of leverage by moving the fulcrum line farther
from the force.
The indirect retainer has several additional functions. It contributes
to the support and stability of the partial denture, particularly in
counteracting horizontal forces applied to the denture. When a long-span
mandibular lingual bar major connector is used, even if tooth-supported, an
indirect retainer provides additional support and rigidity for the lingual bar.
It also prevents impingement of the lingual bar on the mucosa during
function.
The indirect retainer also acts as a third point of contacting tooth
structure to ensure accurate repositioning of the framework on the teeth
during relining or rebasing, Occlusal rests on the terminal abutment Teeth
act as the other two of the three points of the tripod. If final impressions are
to be made with the framework as a support for the impression tray, this
accurate repositioning is absolutely essential.
TOOTH REPLACEMENTS
The majority of artificial teeth on a removable partial denture are
positioned on a denture base. However, there are instances (for example,
single missing tooth, confined space, small interocclusal distance) in which
facings, tube teeth, reinforced acrylic pontics (RAP), or metal pontics have
a more favorable prognosis. The characteristics of the various tooth
replacements are considered following this discussion of denture bases.
DENTURE BASES
Plastic (acrylic resin) and metal denture bases are available. The
acrylic resin denture base may be used when denture teeth are indicated
as replacement teeth except when the edentulous span is too great for
other forms of replacement teeth and the interarch space is restricted. In
the latter situation extra strength to prevent breakage is required, and a
metallic denture base must be used. The main drawback to a metal
denture base, particularly on a distal extension edentulous ridge, is the
inability to reline it in the event of ridge resorption. The metal base is more
indicated for tooth-supported edentulous areas. The metal is somewhat
easier for the patient to clean and is not subject to breakage as acrylic
resin is. Because the denture base is metal, thermal changes are more
quickly transferred to the underlying mucosa, stimulating the soft tissue in
a manner not possible with a plastic base.
If a metal denture base is planned for the partial denture, extreme
care must be used in the impression making procedure. Overextension of
the denture base borders must be avoided because adjusting the metallic
borders is not an easy office procedure. Underextension of the denture
must also be avoided because the forces generated by function of the
partial denture must be distributed over as large an area as possible to
prevent the edentulous ridge from being over-stressed, which could lead to
ridge resorption. In addition, esthetics restricts use of the metal denture
base to the placement of posterior teeth.
The use of characterized acrylic resin to duplicate the soft tissue
tones of each individual patient can permit the placement of esthetically
acceptable denture bases in the anterior part of the mouth. One of the
great advantages of an acrylic resin denture base is that the artificial teeth
may be positioned exactly where the original teeth were, regardless of the
loss of ridge that may have occurred, thus restoring the normal contour of
the edentulous ridge. This cannot be done with other forms of tooth
replacement. In selected cases the resin of the denture base may be used
as a "plumper" to fill out or reestablish the normal contours of the lips or
cheeks. Care must be taken in this instance not to overstress the abutment
teeth.
Methods
There are basically four methods of replacing anterior teeth with
removable partial dentures. Other replacement forms exist but can be
considered to be modifications of these four.
1. Porcelain or plastic denture teeth on denture base
2. Facings
3. Tube teeth
4. Reinforced acrylic pontics (RAP)
Facings
Advantages
1. May be used as a single tooth replacement when interocclusal
space is limited and strength is required.
2. May be used when a broad, well-healed ridge is present with little
resorption having taken place..
Limitations
1. Difficult to obtain a good esthetic result.
2. Opposing occlusion is against metal.
3. Cannot be relined.
4. Little or no support is derived from the underlying ridge.
5. Cannot be used on resorbed ridge.
Tube Teeth
Advantages
1. Provides good esthetic replacement for a single tooth where space
is available.
2. Opposing teeth will occlude against the acrylic resin tooth.
3. Not necessary to invest and process the denture after the
framework has been finished.
Limitations
1. Must have ample space mesiodistally and occlusogingivally.
2. Requires a well-healed, nonresorbed ridge; even moderate
resorption of the ridge contraindicates its use.
3. Derives no support from the soft tissue and cannot be relined.
The tube tooth also makes an excellent single tooth posterior
replacement, particularly in the premolar area.
RAPs
Advantages
1. Excellent strength and esthetics.
2. Can be designed so that occlusion is confined to the plastic.
3. Can be used in a restricted space.
Limitations
1. Unhealed ridge or resorbed ridge contraindicates use.
2. Little support can be gained from the ridge.
3. Cannot be relined.