The removable partial denture equation

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1 2 The removle prtil denture eqution J. C. Dvenport, 1 R. M. Bsker, 2 J. R. Heth, 3 J. P. Rlph, 4 nd P-O. Glntz, 5 This rticle descries the enefits nd risks of providing RPDs. It emphsises the importnce of co-opertion etween the dentl tem nd ptient to ensure tht the lnce of this eqution is in the ptient s fvour. In this prt, we will discuss The enefits of RPDs Tissue dmge ssocited with RPDs Preserving orl helth The importnce of temwork The title of this prt of the series requires immedite explntion. The term eqution refers to the lnce tht must e struck etween the good nd the d which cn rise from the wering of RPDs. In this chpter we explore the enefits which cn e conferred on ptients y RPDs nd, t the sme time, highlight the possile risks of tissue dmge tht cn e ssocited with such prostheses. Every prosthetic tretment is ssocited with the plcement of foreign oject (the prosthesis) in the mouth of the ptient. As direct consequence of such plcement the urden on the tissues in the orl cvity will e incresed. For exmple, plque more redily ccumultes on lloplstic mterils thn iologic ones. Furthermore, even non-toxic mterils will relese smll mounts of their components into the orl cvity. To justify prosthetic tretment nd to ensure tht it is eneficil to the ptient, the need for such tretment must e estlished, the ptient must e ppropritely motivted, nd the dentures properly designed, constructed nd mintined. Thus the initil step in determining if prosthetic tretment is indicted must lwys e the ssessment of: The ptient s wishes nd concerns The relevnt dentl nd medicl history The results of the extr-orl nd intr-orl exmintions Orl hygiene hits nd sttus The essentil orl functions of ppernce, mstiction nd speech. It is only fter this nlysis hs een completed tht the decision of whether or not to tret prticulr ptient cn e tken. For exmple, prosthetic tretment must not egin until it hs een verified tht there is significnt reduction in one or more of the essentil orl functions. A simple determintion of the numer nd position of the remining teeth is not sufficient foundtion for mking the decision of whether or not to initite tretment. If it is indicted, tretment pln is then devised identifying the vrious stges nd the most pproprite type of prosthesis. Benefits of RPDs The potentil enefits of RPDs which will e considered in this section re their contriution to the following. Appernce Speech Mstiction Mintining the helth of the mstictory system: preventing undesirle tooth movement improving distriution of occlusl lod Preprtion for complete dentures. 1* Emeritus Professor, University of Birminghm, UK; 2 Professor of Dentl Prosthetics, University of Leeds nd Consultnt in Restortive Dentistry, Leeds Teching Hospitls NHS Trust, Leeds, UK; 3 Honorry Reserch Fellow, University of Mnchester (Formerly Senior Lecturer in Restortive Dentistry, University of Mnchester) nd Consultnt in Restortive Dentistry, Centrl Mnchester Helthcre Trust, Mnchester, UK; 4 Consultnt in Restortive Dentistry, Leeds Teching Hospitls NHS Trust nd Senior Clinicl Lecturer, University of Leeds nd Honorry Visiting Professor, Centre for Dentl Services Studies, University of York, York, UK; 5 Professor of Prosthetic Dentistry, Consultnt in Prosthetic Dentistry, Fculty of Odontology, University of Mlmo, Sweden *Correspondence to: 5 Victori Rod, Hrorne, Birminghm B17 0AG emil: john.dvenport@tclick.com REFEREED PAPER British Dentl Journl 2000; 189: New pulictions: All the prts which comprise this series (which will e pulished in the BDJ) hve een included (together with numer of unpulished prts) in the ook A Cinicl Guide to Removle Prtil Dentures (ISBN ) nd A Clinicl Guide to Removle Prtil Denture Design (ISBN ). Aville from Mcmilln on BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER

2 Fig. 1 Appernce The restortion of the missing UR2 (12), UR1(11) nd UL1(21) undenily enefit this ptient, n 18 yer-old girl, nd the motivtion to wer the denture is understndly strong. Prticulr ttention hs een pid to the ppernce of the denture y the creful choice of rtificil teeth nd design of the flnge. A nturl ppernce hs een creted y using veined crylic, y reproducing the pre-extrction form of lveolr ridge nd y mking the distl mrgin of the flnge thin nd irregulr, thus msking the trnsition from flnge to djcent mucos. Fig. 2 nd Appernce Not only my n RPD help to restore ppernce ut it my ctully improve it. () This ptient s mxillry lterl incisors hd never developed nd she ws concerned out the spcing of the nterior teeth. () The comintion of orthodontic movement of the centrl incisors nd the provision of RPDs improved the ppernce. Fig. 3 Appernce If n incisor is not replced soon fter extrction, successful tretment t lter dte my e compromised. Here, the djcent teeth hve drifted into the unrestored UL1(21) spce. The reduced spce does not llow for n rtificil tooth of relistic size to e used on denture. If resonle esthetic result is to e otined the spce must e reestlished y orthodontic tretment. Fig. 4 Speech The loss of mxillry nterior teeth my prevent the cler reproduction of certin sounds, prticulrly the F nd V which re mde y the lower lip contcting the edges of the mxillry incisors. The replcement of missing mxillry nterior teeth will mke significnt contriution to the qulity of speech. BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER

3 Fig. 5 Mstiction With modern foods nd methods of preprtion it is unlikely tht ptient will suffer from mlnutrition even though lrge numer of teeth re missing. However, the gps tht rise through the loss of posterior teeth reduce the efficiency of mstiction: the olus of food is llowed to slip into the edentulous res nd thus escpe the crushing nd shering ction of the remining teeth. An RPD will prevent this escpe of the olus nd thus contriute to efficient mstiction. Mintining the helth of the mstictory system The provision of n RPD cn mke positive contriution to orl helth y preventing, or minimising, the undesirle consequences of tooth loss, s descried in the following prgrphs. Fig. 6 Preventing undesirle tooth movement When teeth re lost from dentl rch the teeth djcent to the edentulous spce my tilt nd move into tht spce. This drifting of teeth opens up further spces which increse the opportunity for food impction nd plque formtion, encourging inflmmtion of the periodontl tissues nd declcifiction of the proximl surfces of the teeth. Inevitly, the longer such spces remin unrestored, the greter the chnce of tooth movement. When teeth re lost from n opposing rch over-eruption my occur with similr deleterious effects on the orl helth. However, if tooth movement hs not occurred in spite of the teeth eing lost some yers previously, it cn e ssumed tht it is not going to occur susequently. Fig. 7 Preventing undesirle tooth movement The long-term sence of ntgonists hs resulted in over-eruption of mxillry nd mndiulr teeth. The teeth re virtully contcting the opposing edentulous ridges creting mjor prolems if RPDs hve to e provided. Fig. 8 Preventing undesirle tooth movement In this exmple, UR6 (16) hs over-erupted to such n extent tht it hs lost most of its ony support. Extrction of the tooth is inevitle. 416 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER

4 Fig. 9 Improved distriution of occlusl lod The loss of lrge numer of teeth puts n incresing functionl urden on the remining teeth. In this exmple there is existing periodontl disese. The incresed functionl lod hs hstened the destruction of the periodontl ttchments of the mxillry nterior teeth, which hve ecome incresingly moile nd hve drifted lilly. Fig. 10 Improved distriution of occlusl lod If the periodontl ttchments of the remining teeth re helthy, the incresed lod my result in excessive tooth wer or my cuse dmge to existing restortions. The restortion of gross loss of tooth sustnce, s in this exmple, is likely to involve complex nd prolonged tretment. Fig. 11 nd Improved distriution of occlusl lod Over-eruption of tooth my plce it in such position tht it ers the runt of the lod on initil contct or in excursive movements of the mndile nd therefore it my well e sujected to excessive force. In ddition, where over-eruption of tooth hs creted n occlusl interference (*), the ptient my modify the hitul movement ptterns of the mndile in order to void the interfering contct. Although such modifiction my reduce the lod pplied to the tooth, the chnged pttern in ctivity of the mndiulr musculture my susequently produce musculr dysfunction. From the foregoing exmples it will e pprecited tht if tooth loss is restored in sufficient time to prevent tooth movement, or to void excessive stress eing plced on the remining structures, the susequent helth of the orl tissues cn enefit considerly. However, the point should e mde tht severe dmge to the existing structures is not n inevitle consequence of tooth loss. The implictions of this sttement will ecome pprent lter in this section when the dmging effects of the dentures themselves re descried. Preprtion for complete dentures Most of this ook is devoted to the tretment of ptients who re expected to retin their remining nturl teeth for considerle numer of yers, thus llowing the RPD to e regrded s long-term restortion. But we should rememer those ptients whose remining teeth crry reltively poor prognosis nd for whom, in due course, complete dentures re inevitle. If simple crylic RPDs re provided, the ptient is le to serve prosthetic pprenticeship with pplinces which receive some stility from the few remining teeth. In the fullness of time these trnsitionl dentures ecome more extensive s further teeth re extrcted nd the ptient is grdully esed into the totlly rtificil dentition. This form of trnsitionl tretment cn e of considerle enefit, especilly for the elderly ptient. BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER

5 Fig.12 Preprtion for complete dentures The loction of the remining teeth plys n importnt prt in the success of such trnsitionl denture. It is common for the six mndiulr nterior teeth to e the lst remining teeth in the mndile. A denture restoring the posterior teeth is frequently not worn y the ptient for the following resons. Firstly, the denture my e unstle ecuse there is little resistnce to its displcement in posterior direction; secondly, there is very little motivtion to wer the denture s the nterior teeth re still present. Fig. 13 Preprtion for complete dentures If, insted of extrcting ll the teeth, the cnines re retined, the denture will e more stle. When the denture replces nterior teeth it is very much more likely to e worn nd thus the ptient is likely to gin greter enefit from the trnsitionl denture. Fig. 14 Preprtion for complete dentures It should e rememered tht the trnsitionl RPD is eing plced in mouth where existing dentl disese is only poorly controlled or is uncontrolled. As will e seen in the next section, the very presence of denture ggrvtes the sitution. If the mouth is not inspected regulrly to identify tretment needs s they rise, there is the likelihood of ccelertion of tissue dmge, which my prejudice the eventul complete denture foundtion. In this cse the inflmmtion nd hyperplsi of the pltl mucos ws so severe tht surgery hd to e performed efore further prosthetic tretment could e undertken. Cuses of dmge relted to the wering of RPDs Hrmful effects cn rise from the wering of RPDs in vriety of wys: from the plque which is likely to ccumulte round ny RPD; from direct trum y individul components of the denture; from excessive functionl forces which will e trnsmitted y n ill-designed prosthesis nd from errors in the occlusion. If the ptient, with the help of the dentl tem, cn mintin optiml plque control the hygiene-relted complictions of wering RPDs, such s cries nd periodontl disese, cn e voided. However, frequent technicl mintennce of RPDs is still required if optiml orl function nd helth re to e preserved. When tissue dmge does occur it is sometimes referred to s the iologicl price of wering RPDs. The possile cuses of dmge nd their sequele re summrised in the following tle nd re discussed in more detil in the susequent sections. 418 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER

6 Tle 1 Summry of dmge tht my result from wering n RPD Cuses Teeth Periodontl tissues Edentulous res Muscles of mstiction Plque ccumultion Declcifiction nd cries Inflmmtion of gingivl tissues Progression to underlying structures Inflmmtion of mucous memrne Direct trum from components Arsion nd frcture of teeth or restortions Inflmmtion of gingivl tissues Progression to underlying structures Loclised inflmmtion of mucous memrne. Denture-induced hyperplsi Trnsmission of excessive functionl forces () Tooth moility () Aggrvtion of existing periodontl disese Inflmmtion of mucous memrne Resorption of one Occlusl error () Tooth moility () Aggrvtion of existing periodontl disese Inflmmtion of mucous memrne Resorption of one Muscle dysfunction Incresed plque ccumultion A considerle mount of reserch effort hs een directed towrds n understnding of the reltionship etween plque ccumultion nd the wering of RPDs. It is possile tht the presence of denture influences the qulity of the plque; it certinly ffects the quntity. Not only does more plque ccumulte round the teeth in the jw in which the denture is plced, ut lso more is found round the teeth in the opposing jw unless the ptient is instructed in meticulous orl hygiene procedures. Fig. 15 nd Incresed plque ccumultion The res tht tend to collect most plque re the proximl surfces of utment teeth djcent to the sddle. () These surfces re difficult to clen when using conventionl toothrush. () An interdentl rush clens the proximl surfces more effectively. BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER

7 Fig. 16 nd Incresed plque ccumultion The design of the denture my hve significnt effect on plque ccumultion. For exmple, it hs een shown tht more plque collects under lingul plte thn under lingul r. () The lingul plte is well supported on the nturl teeth nd fits well ginst tooth surfces. () However, gingivl inflmmtion hs een cused y the incresed ccumultion of plque. Denture Tooth Plque Fig. 17 Incresed plque ccumultion If the plque is llowed to persist, the inflmmtory process will progress to the deeper tissues, resulting in chronic periodontitis. The periodontl ttchment is progressively destroyed, periodontl pocket develops nd the investing lveolr one is lost. Pocket Bone Fig. 18 Incresed plque ccumultion Unless the incresed ccumultion of plque is prevented, root cries is likely. This is prolem tht will increse s more ptients continue to wer RPDs into old ge. Root cries is strongly ssocited with gingivl recession nd the use of gingivlly-pproching clsps in ptients who re t risk ecuse of criogenic diet nd poor plque control. 420 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER

8 Fig. 19 Incresed plque ccumultion If plque is llowed to persist on the denture impression surfce, generlised inflmmtion, clled denture stomtitis, my occur. Typiclly the extent of the inflmmtion is demrcted y the outline of the pltl connector. This condition is discussed more fully in Prt 11. Fig. 20 nd Direct trum from components The orl mucos is vulnerle to direct trum from components of dentures. () In this instnce the lingul r hs een positioned too close to the gingivl mrgin. The continuous clsp offers only limited tooth support for the denture. () The denture hs sunk into the tissues, stripping wy the gingivl tissues on the distl nd lingul spects of LL3 (33). There is no evidence for the contention tht clsp rm my wer wy the enmel surfce to degree tht is significnt cliniclly. However, the movement of clsp rm my wer the surfce of restortive mterils. Trnsmission of excessive force Functionl forces re trnsmitted y n RPD to the tissues with which it is in contct. If denture is supported primrily y the nturl teeth most of the forces will e trnsmitted to the lveolr one through the fires of the periodontl ligment. Bering in mind the orienttion of most of these fires, it will e pprecited tht the forces re tensile in nture nd re dissipted over reltively lrge re. A very different stte of ffirs exists when denture is supported only y the mucos. Here the forces, lrgely compressive in nture, re trnsmitted over more restricted re. BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER

9 Fig. 21 nd Trnsmission of excessive force If the forces trnsmitted to the mucos nd one of the edentulous re re excessive, the mucos will ecome inflmed nd the one will resor. The ovious consequence of one resorption is n irreversile loss of prt of the denture foundtion. () In this exmple the denture is supported only on the tissues of the edentulous re. It hs cused resorption of the one to such n extent tht the lingul r connector hs een pushed down towrds the floor of the mouth. () The mount of one tht hs een destroyed is pprent when the denture is removed. 1 2 Fig. 22 Trnsmission of excessive force If the design of the denture is such tht it trnsmits excessive force to tooth there is every chnce tht the tooth will ecome moile. In this exmple the incorrectly designed cingulum rest (1) trnsmits horizontl force to the cnine tooth. Such horizontl forces re especilly dmging to the periodontl tissues. The incisl rest (2) trnsmits more fvourle verticl lod. Where periodontl chnges re restricted to the mrginl gingive, elimintion of excessive force will usully llow the periodontl ttchment to return to norml helthy stte. Where the supporting structures hve een ffected y periodontl disese there is unlikely to e complete resolution Fig. 23 Occlusl error If the occlusl surfce of the RPD is not designed correctly, norml jw closure my e prevented y premture occlusl contct. There re three possile sequele: (1) If the premture contct is on nturl tooth, dmge to the tooth or its periodontl ligment my occur. (2) If the sddle ers the runt of the force of closure, there will e loclised mucosl inflmmtion nd resorption of the underlying one. (3) If the ptient ttempts to steer the mndile round the premture contct until more comfortle occlusl position is found, this norml closing pttern throws incresed demnds on certin muscles of mstiction, which my result in the ptient complining of fcil pin. 422 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER

10 Blncing the RPD eqution A numer of longitudinl clinicl studies of RPDs hve shown tht the types of dmge itemised in the lst section my e commonly found mongst werers of RPDs. Of considerle concern re reports tht mny ptients expressed stisfction with their dentures, in spite of the fct tht dentl helth hd deteriorted mrkedly. Perhps this finding is not ltogether surprising when we rememer the insidious nture of the progression of cries nd periodontl disese. With greter understnding of the reltionship etween plque nd dentl disese nd of the importnce of plque control, reports hve ppered whose findings mke for more encourging reding. There is now firm evidence tht the wering of RPDs cn e comptile with continued orl helth. This stisfctory outcome depends upon three-fold effort, tht of the clinicin, the dentl technicin nd the ptient. Fig. 24 nd Contriution of the clinicin The primry responsiility of the dentist nd the clinicl tem is to ensure tht the remining teeth nd supporting tissues re restored to helthy stte nd tht the ptient is effectively motivted nd instructed in how to mintin this stte. () This mouth is not in fit stte to receive n RPD. There is chronic periodontl disese nd ccumultion of plque. () This ptient hs responded well to instruction in orl hygiene nd the periodontl tissues re helthy. The dngers of wering the RPDs re thus minimised. The second re of responsiility of the clinicin is in reltion to the design nd construction of the denture. Accurcy of the clinicl procedures must, of course, e ensured. In ddition, the clinicin should produce design sed on criteri tht hve een shown to promote continued orl helth: Effective support Clernce of gingivl mrgins Simplicity Rigid connector. These criteri re considered in greter detil in our BDJ ook A Clinicl Guide to Removle Prtil Denture Design. Fig. 25 Contriution of the dentl technicin The dentl technicin s contriution is directed towrds the creful trnsltion of the prescried denture design into the denture itself, nd ccurte construction nd positioning of the denture components. In this instnce the inccurte fit will encourge plque formtion with consequent periodontl disese nd cries, thus introducing n unnecessry nd voidle risk to orl helth. BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER

11 Fig. 26 Contriution of the ptient It is proly true to sy tht ptient who mintins immculte plque control nd hs good tissue resistnce, or host response, cn e provided with less thn stisfctorily designed denture nd still mintin good orl helth. Such is the importnce of ptient fctors in the RPD eqution. This ptient hs worn mxillry RPD for mny yers. The gingivl tissues re helthy nd the teeth re well supported y one; ll this in spite of the fct tht there is little opportunity to provide tooth support. For every ptient, when denture is contemplted, it is the dentist s responsiility to ssess the dvntges nd disdvntges for tht prticulr individul. The level of disdvntge is influenced primrily y the ptient s dentl wreness nd plque control. When the lnce of the eqution lens towrds disdvntge it is likely tht it will e in the ptient s est interest tht denture is not prescried. Of course, where denture is required to replce n nterior tooth or teeth, the demnd from the ptient will usully e overwhelming even if the level of plque control is less thn stisfctory. Fig. 27 nd Contriution of the ptient In this mouth the resons for providing dentures re not overwhelming. There re sufficient teeth t the front of the mouth to stisfy the demnds of ppernce nd speech. There re certinly enough teeth to llow vried diet to e eten. Most of the teeth hve ntgonists in the opposing rch. If the mouth is well cred for nd the ptient requests dentures, the RPD eqution is fvourly lnced. However, if plque control is suspect, there is strong rgument for dvising ginst dentures, t lest for few months until the long-term response to orl hygiene dvice is scertined. Further reding RPDs nd Orl Helth Btes J F. Plque ccumultion nd prtil denture design. In Btes J F, Neill D J, Preiskel H W (ed). Restortion of the Prtilly Dentte Mouth, Chicgo: Quintessence, Berg B. Periodontl prolems ssocited with use of distl extension removle prtil dentures mtter of construction? J Orl Rehil 1985; 12: Blinkhorn A S. Dentl helth eduction: wht lessons hve we ignored? Br Dent J 1998; 184: Budtz-Jorgenson E. Orl mucosl lesions ssocited with the wering of removle dentures. J Orl Pth 1981; 10: Crlsson G E, Hedegård B, Koivum K K. Studies in prtil denture prosthesis IV. Finl results of 4-yer longitudinl investigtion of dentogingivlly supported prtil dentures. Act Odont Scnd 1965; 23: Chndler J A nd Brudvik J S. Clinicl evlution of ptients eight to nine yers fter plcement of removle prtil dentures. J Prosthet Dent 1984; 51: Germundsson B, Hellmn M, Odmn P. Effects of rehilittion with conventionl removle prtil dentures. Swed Dent J 1984; 8: Gry R J M, Dvies S J, Quyle A A. Temporomndiulr disorders. clinicl pproch. London: British Dentl Assocition, McEntee M I. Biologic sequele of tooth replcement with removle prtil dentures: cse for cution. J Prosthet Dent 1993; 70: McHenry K R, Johnsson O B, Christersson L A. The effect of removle prtil denture frmework design on gingivl inflmmtion clinicl model. J Prosthet Dent 1992; 68: Orr S, Linden G J, Newmn H N. The effect of prtil denture connectors on gingivl helth. J Clin Periodontol 1992; 19: Renner R P. Periodontl considertions for the construction of removle prtil dentures I nd II. Quintessence Dent Technol 1985; 9: , Wgg B J. Root surfce cries: review. Comm Dent Helth 1984; 1: Yp U J, Ong G. Periodontl considertions in restortive dentistry. Prt 2: Prosthodontic considertions. Dent Updte 1995; 22: Survivl of Removle Prtil Dentures Bergmn B, Hugoson A, Olsson C-O. A 25 yer longitudinl study of ptients treted with removle prtil dentures. J Orl Rehil 1995; 22: Bergmn B. Prognosis for prosthodontic tretment of prtilly edentulous ptients. In: Owll B, Kyser A F, Crlsson G B. Prosthodontics: principles nd mngement strtegies. London: Mosy-Wolfe, Frnk R P, Milgrom P, Leroux B G, Hwkins N R. Tretment outcomes with mndiulr removle prtil dentures: popultion-sed study of ptient stisfction. J Prosthet Dent 1998; 80: Kpur K K, Deupree R, Dent R J, Hsse A L. A rndomised clinicl tril of two sic removle prtil denture designs. Prt I: Comprisons of five yer success rtes nd periodontl helth. J Prosthet Dent 1994; 72: Kpur K K, Grrett N R, Dent R J, Hsse A L. A rndomised clinicl tril of two sic removle prtil denture designs. Prt II: Comprisons of mstictory scores. J Prosthet Dent 1997; 78: Liy G, Arcuri M R, LVelle W E, Hel E. Longevity of fixed prtil dentures. J Prosthet Dent 1997; 78: Vermeulen A H B M, Kelyjens H M A M, vn t Hof M A, Kyser A F. Ten-yer evlution of removle prtil dentures: survivl rtes sed on retretment, not wering nd replcement. J Prosthet Dent 1996; 76: BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER

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