R E M O V A B L E P R O S T HPOR D

O O
S TNHTOI DCOS N T I C S

A Clinical Overview of Removable

Prostheses: Introduction
J. FRASER MCCORD, NICK J.A. GREY, RAYMOND B.WINSTANLEY AND ANTHONY JOHNSON

Abstract: This series of articles has been written with the intention of simplifying beneath their dignity to design RPDs
the processes involved in the prescription of removable partial dentures. The scene is or find that designing them is
set in this introduction, and the first article addresses basic clinical and patient- problematic. Whatever the reason,
related factors involved in decision-making before commencing active prosthodontic many clinicians devolve the
treatment. The second paper will outline a variety of impression techniques for responsibility of denture design to the
primary and definitive impressions, while the third discusses designing principles. technician.
The fourth article is a brief overview of some technological aspects of removable Most textbooks on what to do when
partial denture-making and the fifth attempts to provide a useful guide showing how a patient presents with missing teeth
to diagnose and manage common clinical problems associated with removable partial are aimed at undergraduates and
dentures.
assume the role of either a textbook on
Dent Update 2002; 29: 375 fixed prostheses or a textbook on
RPDs. The intention of this series of
Clinical Relevance: The provision of satisfactory removable prostheses is an articles is to serve as a clinical manual
important aspect of dental practice. for graduate clinicians who are
operating at a non-specialist level,
with the following purposes:

l to share our views on how to plan

he decision to replace missing or
T extracted teeth may be made for a
variety of reasons. The ultimate
decision, however, will in all
probability be predominantly, but not
exclusively, patient-driven.
Clearly, the clinician has a
considerable part to play in advising
the patient on the merits or otherwise
of restoring missing teeth and, further,
J. Fraser McCord, BDS, DDS, FDS, DRD RCS
(Edin.), FDS RCS (Eng.), CBiol, MI Biol,
Professor and Head of Unit of Prosthodontics,
University Dental Hospital of Manchester,
Nick J.A. Grey, BDS, MDSc, PhD, FDS, DRD,
MRD RCS (Edin.), Consultant/Honorary Senior
Lecturer in Restorative Dentistry, Edinburgh
Dental Institute, Raymond B.Winstanley, BDS,
MDS, FDS RCS (Edin.), Senior Lecturer/
Honorary Consultant in Restorative Dentistry,
Charles Clifford Dental School, Sheffield, and
Anthony Johnson, MMedSci, PhD, Lecturer in
Dental Technology, Charles Clifford Dental
School, Sheffield.
has a leading part to play in how to
replace teeth. This subject becomes a
matter of debate among clinicians and
technicians and, while most clinicians
may agree on whether a prosthesis
should be fixed or removable, the
nature of the design will often be
subject to considerable variation. This
is particularly true in the case of
removable partial dentures (RPDs) or,
more accurately, removable
prostheses. As Watt and Macgregor
stated,1 this is because many features
that are desirable in RPDs ‘are
mutually exclusive and the process of
designing is a journey through a maze
of compromises’.
It is not difficult to understand why
student clinicians struggle over the
intricacies of RPD design given their
relative inexperience in the treatment
of patients; it is a matter of frustration
to teaching prosthodontists, however,
that most clinicians either find it
and organize treatment;
l advise on how to structure
decision making; and, when these
two qualifying rounds are
completed;
l to discuss rationales of design
principles for RPDs.
We will also address technical
aspects of RPD treatment and, in
conclusion, address problem solving.
We are firmly of the view that the
clinician should lead the dental team
and that this leadership should include
responsibility for designing RPDs
appropriate to the needs of each
patient.
R EFERENCES
1. Watt DM, MacGregor AR. Designing Partial
Dentures. Bristol: Wright, 1984.

Dental Update – October 2002 375

 P R O S TRHEOMD O
O VN A
TBI CL SE P R O S T H O D O N T I C S

A Clinical Overview of Removable

Prostheses: 1. Factors to Consider in
Planning a Removable Partial Denture
J. FRASER MCCORD, NICK J.A. GREY, RAYMOND B.WINSTANLEY AND ANTHONY JOHNSON

Abstract: This is the first article in a series on the prescription of removable partial expecting; at this stage it may be
dentures. It addresses basic clinical and patient-related factors involved in decision- obvious that their demands are
making before commencing active prosthodontic treatment. Further papers will outline unrealistic or might result in a situation
a variety of impression techniques for primary and definitive impression, discuss that compromises other factors relevant
designing principles, give an overview of some technological aspects of removable to denture-wearing success.
partial denture-making and provide guidelines on how to diagnose and manage The following aspects of aesthetics
common clinical problems associated with removable partial dentures. should be considered when planning
any prosthesis:1
Dent Update 2002; 29: 376-381

Clinical Relevance: Good planning is essential for the satisfactory removal of l colour;
partial dentures. l contour;
l proportion;
l symmetry;
l outline form;
l soft-tissue harmony; and
l position of the teeth.

T he need to restore teeth in

edentulous space depends on a
variety of clinical issues and the wishes
l psychological factors.

Unless any one of the above reasons

of the patient, which may relate to:
l aesthetic factors;
l function;
l occlusal stability;
l comfort;
l speech;
l prevention of further disease/
deviations from normal;
J. Fraser McCord, BDS, DDS, FDS, DRD RCS
(Edin.), FDS RCS (Eng.), CBiol, MIBiol, Professor
and Head of Unit of Prosthodontics, University
Dental Hospital of Manchester, Nick J.A. Grey,
BDS, MDSc, PhD, FDS, DRD, MRD RCS (Edin.),
Consultant/Honorary Senior Lecturer in
Restorative Dentistry, Edinburgh Dental
Institute, Raymond B.Winstanley, BDS, MDS,
FDS RCS (Edin.), Senior Lecturer/Honorary
Consultant in Restorative Dentistry, Charles
Clifford Dental School, Sheffield, and Anthony
Johnson, MMedSci, PhD, Lecturer in Dental
Technology, Charles Clifford Dental School,
Sheffield.
can clearly be justified, there is little
reason to provide interventive treatment.
It is often said of removable partial
dentures (RPDs) that ‘the best kind of
partial denture is no partial denture’, as
many studies have demonstrated the
untoward effects of their presence in the
mouth. The need to provide treatment
(RPD) will therefore be explored within
each of the above subject headings.
AESTHETICS
The old adage ‘beauty is in the eye of
the beholder’ is often recounted and,
unless the wishes of the patient are
considered at the outset of planning, the
potential for failure is very high, with
consequent ill-feeling between patient
and clinician, and sometimes the
technician. At the initial consultation,
therefore, care should be taken to
determine exactly what the patient is
RPDs have the potential to control
aesthetics significantly better than fixed
prostheses (either tooth-supported or
implant-supported) as all of the above
aspects may be addressed. To avoid
aesthetic problems, the clinician must
plan where the teeth are to be placed in
the prosthesis in advance of planning
the other components of the denture,
especially if a cast cobalt chromium
framework is being prescribed. If this
planning is not performed the
morphology of the framework may
dictate tooth position, which may in turn
compromise the appearance of the
denture and be at variance with the
patient’s wishes. This will be discussed
in a later article.
Another helpful stage during denture
construction is that of allowing the patient
to take the trial insertion prosthesis (or a
wax-up of the proposed prosthesis) home
to allow a longer evaluation with family
and/or friends. This gives the patient
greater input during his/her treatment,

376 Dental Update – October 2002


Figure 1. Placement of an ‘I’ bar on the
distobuccal aspect of the abutment tooth
diminishes the unsightly nature of the clasp.
which reduces the need to alter the
appearance of the denture after fitting.
The situation of having to alter the
denture in any way after delivery of the
denture is disappointing for all
concerned, and any opportunity to avoid
doing so should be taken.
Visibility of Clasps
A common problem with the aesthetics
of RPDs relates essentially to what is
often perceived as the unsightly display
of clasps. Wherever possible, the more
posterior a clasp can be placed, the more
unlikely it will be that appearance is
compromised. However, this is not
always a realistic option and therefore
clasping should be disguised as much
as possible – Figure 1 shows the
distolabial placement of an ‘I’ bar to
minimize the display of metal. Other
methods described have been those of
utilizing materials for clasping which are
tooth-coloured and potentially ‘more
aesthetic’. One such system is the
‘Dental D’ clasp system (Figure 2). This
system would appear to be well
Figure 2. The ‘Dental D’ clasp. Note the proximity
of the clasp arm to the gingivae. The authors do
not recommend this type of clasp: hence this is a
laboratory model and not a clinical case.
Dental Update – October 2002
P R O S T H O D O N T I C S
accepted by patients but does require
rather long, thick clasps, which are often
inappropriately close to the gingival
margin. In addition, repair of these clasp
arms is more technically demanding and
this has of necessity a cost implication.
The use of precision attachments can
also be considered; however, this
requires a significant amount of
interocclusal space, which is often not Figure 3. By planning the path of insertion, the
present. In addition, maintenance of flange on |2 merges imperceptibly with the
gingivae of the canine.
precision-retained prostheses is
exceedingly problematic. Although
precision attachments are undoubtedly
useful components, conventional
wisdom would suggest that the clinician
and the technician have some experience
in their usage and (of great importance)
their maintenance.
A very useful method of dispensing
with or reducing the number of clasps is
to use hard or soft-tissue contours
(undercuts relative to paths of survey) Figure 4. A resilient lining was incorporated into
this training denture to engage the undercut in
that may be present in the anterior part the distal aspects of the abutment teeth. It
of the mouth. For example, where an provided retention, stability and avoided the
anterior bounded saddle exists, the unsightly presence of clasps.
clinician and dental technician should
survey the casts to consider the
possibility of using an anterior path of
insertion by tilting the casts upwards in Matching Artificial to Natural
the anterior region, enabling the Teeth
prosthesis to engage that undercut and Problems may be encountered when
resist displacement relative to the attempting to match the colour of
occlusal path of displacement. Retention artificial teeth to the natural ones.
may be enhanced and the overall The greatest area of difficulty is often
appearance improved as the denture/ with respect to differences in crown
tooth interface may be better managed, heights and the careful selection of
avoiding unwelcome gaps (Figure 3). denture teeth is advised to avoid a
Similar problems exist in the presence of ‘step’ (Figure 5) caused by the denture
other saddles in the arch, although teeth having shorter clinical crowns
appearance may not be as critical. than the natural teeth.
Another technique for avoiding the
use of clasps is to utilize a resilient
material adjacent to the dental undercuts.
This may engage the undercut and gain
retention (Figure 4). However, although
this technique is useful, the long-term
stability of such materials is less ideal
than hard acrylic, and the clinician and
patient need to be aware of the need to
replace the material periodically. This
clearly has cost and social implications as
the patient will be without his/her
denture for at least a working day to Figure 5. No thought had been given to the
enable the technician to effect the gingival architecture adjacent to the necks of the
replacement. teeth.
377
 P R O S T H O D O N T I C S
FUNCTION
The decision as to whether treatment is
needed to satisfy efficient masticatory
function is often dictated by the patient
and a number of studies have
investigated patient satisfaction with
respect to the remaining number of
teeth. Kayser2 and Witter et al.3
introduced the concept of accepting a
shortened dental arch rather than
providing interventive treatment if
periodontal health and tooth position
are deemed to be stable. Other studies
have investigated patient satisfaction of
shortened dental arches and it is
apparent that there is not always a need
to replace teeth to increase the number
of occluding units.
In situations where, for example, first
premolar to first premolar teeth exist in
opposing arches, appearance may be
compromised more than function. The
placement of distally cantilevered
pontics from the first premolars has
been described;4 the success of such a
technique is reportedly high, and it is
therefore worthy of consideration (as an
alternative to doing nothing or
providing an RPD) during treatment
planning.
The delivery of treatment that will do
no harm to the patient is of great
importance and the practitioner must
balance the likelihood of an appliance
increasing function against the potential
for it to be an agent of iatrogenesis.
When planning an RPD, mouth or
tooth preparation may be required and
there is a risk that, should the patient be
unable to tolerate the appliance, he or
she has undergone unnecessary
treatment which may render them worse
Figure 6. Patient needs (e.g. ripping action of the
chipped incisors on food) ought to be determined
before any tooth tissue is removed.
378
off. An example may be seen in Figure
6. In this case, the worn anterior teeth
were reduced before making master
impressions for an upper overdenture.
It transpired that the patient could not
tolerate the appliance and did not wear
the overdenture. With respect to
function, the patient perceived the
treatment a failure, as previously he
had used the sharp edges of the worn Figure 7. The mucosa-borne denture which was
anterior teeth to ‘rip up’ his food. One worn has resulted in further loss of the alveolar
way of avoiding such an outcome bone. In addition, the lower incisors have over-
erupted.
would have been to fabricate a
diagnostic appliance before resorting
to irreversible measures such as tooth restore without resorting to
reduction. If the patient had accepted orthodontics.
the diagnostic appliance the clinician
could have proceeded with greater
confidence about the outcome of the COMFORT
treatment. If a patient presents with pain or
discomfort, a non-interventional
approach obviously cannot be
OCCLUSAL STABILITY considered and the treatment strategy
Although it is often discussed, the should be to address the difficulty.
concept of what constitutes occlusal Disease control and its management is
stability is not well defined and well reported and requires little further
instability can often be diagnosed only discussion; however, there are several
when difficulties arise from occlusal options for management of discomfort
changes. In this respect, the from an RPD. The advantages and
philosophy of restoring a recently disadvantages of each option should
created space to maintain occlusal be discussed with the patient so that
stability (especially in the opposing he or she can make an informed
arch) merely to avoid the potential for decision on how to proceed with
unwanted tooth movements has no treatment.
evidence base. We would urge that the
clinician monitors each case and
consider intervention only when Modification of the Existing
changes appear to be occurring. Prosthesis
Should occlusal changes be noticed, Modification of an existing prosthesis
the nature of the prosthesis to effect may often appear attractive to both the
further change must also be taken into dentist and the patient as the number
account. For example, a mucosa-borne of visits is considerably reduced.
prosthesis may ultimately sink into the
tissues and be out of occlusal contact,
therefore proving ineffective both as a
preventive measure and as a
functioning prosthesis (Figure 7).
There is always the potential for
teeth to tilt or drift following tooth
extraction and such changes are
probably of more concern where
appearance is compromised. Figure 8
shows a situation where, following
tooth extraction, no prosthesis was Figure 8. Before definitive treatment could be
worn and tooth movements have performed, the space for the canine had to be
resulted in a space more difficult to increased orthodontically.
Dental Update – October 2002
 P R O S T H O D O N T I C S
Where alveolar resorption has
occurred, a reline procedure may
effectively rejuvenate the impression or
‘fitting’ surface of an otherwise
satisfactory appliance. However, great
care needs to be taken before
modifying a previously worn prosthesis
as the changes made might not result in
an improvement as far as the patient is
concerned – and may even make the
situation worse (e.g. the patient may
have a problem relating to tissue
support in the denture-bearing saddle
areas). At this stage, the dentist and
patient may have reached an impasse
as the situation is irreversible.
Changing the Design of the
Appliance or Technique of
Fabrication
A later article in this series will attend
to the diagnosis of partial denture
problems, and the importance of making
an accurate diagnosis cannot be
overemphasized. Good diagnosis
should lead to appropriate treatment
planning. The maxim ‘no diagnosis, no
treatment’ is entirely true here.
Consideration of a Fixed
Appliance
If a removable partial denture has been
worn by the patient but was
unsatisfactory in terms of comfort
(although the denture, normatively
speaking, was acceptable) then
consideration could be given to the use
of a fixed partial denture. The clinician
must balance the relative benefits of
resorting to a fixed option against the
potential disadvantages. The
preparation of teeth for ‘conventional’
bridgework tends, per se, to be
destructive of tooth tissue, whereas
resin-retained bridges are much less so,
and the clinician should determine
which form of fixed prosthesis is most
appropriate for the patient.
Consideration of an Implant-
retained and/or Supported
Prosthesis
The use of dental implants should be
380
taken into consideration when the
strategy for treatment is being
developed, and in most cases should
feature in the list of options presented
to the patient before obtaining
informed consent. Further details of
considerations of implant therapy are
contained in appropriate textbooks, but
obviously multiple-bounded saddles,
medical reasons or cost might indicate
that RPDs are selected over implants.
Rendering the Patient
Edentulous
In some circumstances, the number and
anatomical distribution of the remaining
teeth is such that the wearing of an
RPD with comfort is rendered more
difficult. This situation often exists
when only a few teeth remain in the
arch. These teeth may offer little benefit
in terms of support for the prosthesis
and the opportunity for retention
offered by these teeth may often be
less satisfactory than if a complete
denture was provided with the full
benefits of a complete peripheral seal.
From this perspective, therefore,
although this option may appear
destructive, extraction of the remaining
teeth may be beneficial, although the
patient’s perceptions must be taken
into account.
If the patient has some standing
teeth in the mandibular arch plus a
mandibular RPD, then the possibility of
achieving predictable success
(combination syndrome) is
problematic.5
Factors Relating to Comfort
of RPDs
Several factors relating to comfort may
be considered.
Impression Technique
Discomfort may be related to the ability
of the denture-bearing area to support a
prosthesis. Thin and friable mucosa,
flabby ridges and the presence of
undercuts present particular difficulties.
As a later article in this series describes
techniques to take into account the
different problems to be considered, the
subject is listed here only for
thoroughness.
Design of the Framework
The design of the major connector may
be important for the comfort of the
patient. The extent of palatal coverage
may compromise this if there is a
susceptibility to gagging.
In addition, the way the prosthesis is
perceived by the soft tissues,
especially the tongue, may affect
patient tolerance. Opinions differ as to
the optimum design of major
connectors, but in our view the
decision on the major connector should
be reached only after thorough
assessment of the patient and taking
his or her wishes into account.
Materials Used
Cobalt chromium (in definitive
prostheses) is generally better
accepted by patients than acrylic, as
transmission of heat and less bulk have
been deemed preferable.6
The presence of an allergy to a dental
material is important and, although rare,
often makes the treatment problematic
for the dentist as confirmation of the
allergy may prove difficult. Allergies to
acrylic (PMMA) and nickel appear to
be the most common and manufacturers
offer alternative materials for such
cases.
The Need for Mouth Preparation
The patient may present with discomfort
that requires management before an
impression can be made. Denture
stomatitis may best be managed by
asking the patient to abstain from
wearing the appliance. This suggestion,
however, is rarely welcomed by the
patient and may result in considerable
social distress; it is therefore not always
a sensible option. In such
circumstances, the use of (for example)
miconazole gel on the fitting surface of
the denture can be employed – but this
is contraindicated for patients taking
anticoagulants (e.g. warfarin).
Further Considerations
On a historical basis, pre-prosthetic
Dental Update – October 2002

Figure 9. The palatogram indicates where the
tongue contacts the denture base and teeth.
surgery was often considered in the
hope that the denture-bearing area
could be improved. The use of such
procedures is now quite rare as the
outcome is not predictable and
subjecting a patient to surgery where
this is the case must be difficult to
justify. (For the purposes of this series
of articles, alteration in form to the
natural teeth is not considered pre-
prosthetic surgery, but preparation of
the mouth.)
Whenever the dentist has concerns
about the state of health of the oral
tissues it is wise to refer the patient for
an oral medicine consultation to ensure
that no underlying disease exists. This
is especially pertinent where an
apparent denture-related ulcer fails to
heal 1 week after leaving a denture out
of the mouth.
SPEECH
Speech difficulties appear to be quite
uncommon in dentistry and, in the
authors’ experience, have constituted a
small percentage of new patient referrals
to consultation clinics in the Dental
Hospitals of Edinburgh, Manchester and
Sheffield. Although they are
exceedingly rare, speech difficulties can
cause the dental practitioner much
difficulty. Several studies have
described the phonetic determinants of
speech in dentistry, paying particular
attention to the clinician’s awareness as
to the significance of sibilant sounds
and labiodental sounds.7,8
Many potential difficulties of both
fixed and removable prosthodontics can
be overcome by using a provisional
appliance to assess the acceptability of
Dental Update – October 2002
P R O S T H O D O N T I C S
the prosthesis to the patient before
embarking on a definitive solution.
When speech difficulties do occur
they are often transient, but if persistent
soft wax or pressure-indicating paste
may be applied to the prosthesis as a
diagnostic tool. This may reveal what
features of the appliance need to be
altered in order to identify tongue
contact areas and help determination of
the effect of decreasing the space on
airflow in anterior consonant phonetics
(e.g. S, Ch, Th; Figure 9).
PREVENTION OF FURTHER
DISEASE/DEVIATION FROM
NORMAL
The need to place a restoration is more
straightforward when it is quite apparent
that by not doing so a worse scenario
would ensue. For instance, it could be
that teeth, after a period of time of
monitoring, are over-erupting and at that
stage provision of an appliance may be
appropriate. Furthermore, if toothwear is
progressive, resulting in shorter crown
heights, the eventual provision of full-
coverage restorations is made more
difficult. In such circumstances the
placement of a removable restoration
would be justified.
Overall plaque control is a basic
prerequisite of all preventive regimens.9,10
With prevention in mind, therefore, the
clinician should always remember the
maxim of Watt and MacGregor:11 ‘the
design of partial dentures should avoid
the intricate and complex in favour of the
tidy and simple’.
PSYCHOLOGICAL FACTORS
There are many reasons other than
obvious dental difficulties that may
make the provision of a satisfactory
removable prosthesis difficult or even
impossible. Most commonly, gagging
represents a difficult situation to rectify.
Various methods of addressing this
issue have been reported, such as
desensitization programmes, hypnosis,
the use of relative analgesia and even
acupuncture. Another problem is that
some patients reject the idea of wearing
a removable appliance because they
perceive such a situation as socially
unacceptable. In such cases, he or she
may demand a fixed solution such as the
placement of dental implants.12
Where such psychological difficulties
exist, management should involve
consultation with appropriately trained
personnel, although the dental
practitioner might have problems if
access to such personnel is limited. The
dental practitioner should try to take on
this role only with great caution.
SUMMARY
This article has outlined whether
interventional treatment for a patient
with edentulous spaces is warranted.
Generally, unless the practitioner can
confidently be assured that one of the
above-noted categories necessitates
treatment, little should be done.
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1. Cassidy M, McLaughlin WS, Grey NJA. Aesthetics
and porcelain veneers. Restor Dent 1989; 5: 42–
45.
2. Kayser AF. Limited treatment goals – shortened
dental arches. Periodontology 2000 1994; 4: 7–14.
3. Witter DJ, van Palenstein Heldeman WH, Creugers
NH, Kayser AF. The shortened dental arch concept
and its implications for oral health care. Community
Dent Oral Epidemiol 1999; 4: 249–258.
4. Al-Wahadni A, Linden GJ, Hussey DL. Periodontal
response to cantilevered and fixed-fixed resin
bonded bridges. Eur J Prosthodont Restor Dent 1999;
7: 57–60.
5. Kelly E. Changes caused by a mandibular
removable partial denture opposing a maxillary
complete denture. J Prosthet Dent 1972; 27: 140–
150.
6. Anusavice KJ. Phillips’ Science of Dental Materials,
10th edn. Philadelphia: WB Saunders, 1996.
7. Lawson A, Bond EK. Speech and its relation to
dentistry. Dent Pract 1968; 19: 113–118.
8. McCord JF, Firestone H, Grant AA. Phonetic
determinants of tooth placement in complete
dentures. Quintess Int 1994; 25: 341–345.
9. Bergman B, Hugoson A, Olsson CO. Caries,
periodontal and prosthetic findings in patients
with removable dentures: A ten-year longitudinal
study. J Prosthet Dent 1982; 48: 506–514.
10. Mullally BH, Linden GJ. Periodontal status of
regular dental attenders with and without
removable partial dentures. Eur J Prosthodont
Restor Dent 1994; 2: 161–163.
11. Watt DM, MacGregor AR. Designing Partial
Dentures. Bristol: Wright, 1984; p.201.
12. British Society for the Study of Prosthetic
Dentistry. Guidelines in Prosthetic and Implant
Dentistry. London: Quintessence Publishing,
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