Clinical evaluation of abutment teeth of removable partial

denture by means of the Periotest method

J. H. JORGE, E. T. GI AMPAOLO, C. E. VERGANI , A. L. MACHADO, A. C. PAVARI NA
& M. R. CARDOSO DE OLI VEI RA Department of Dental Materials and Prosthodontics, Sa o Paulo State University,
Araraquara Dental School, Sa o Paulo, Brazil
SUMMARY Prosthodontics should be one of the
means of establishing conditions for the mainten-
ance of periodontal health. The forces applied to the
abutment teeth and their effects are very important
considerations in the design and construction of the
removable partial dentures. This 6-month follow-up
clinical study evaluated the degree of mobility of
abutment teeth of distal extension and tooth sup-
ported removable partial dentures by using Perio-
test. Two types of clasp design were selected for
evaluation. In cases with unilateral and bilateral
distal-extension, a clasp design including a T clasp of
Roach retentive arm, a rigid reciprocal arm and a
mesial rest were used. For the abutments of tooth-
supported removable partial dentures, a second
clasp design with a cast circumferential buccal
retentive arm, a rigid reciprocal clasp arm and a
rest adjacent to the edentulous ridges was selected.
A total of 68 abutment teeth was analysed. Periotest
values were made at the time of denture placement
(control) and at 1, 3 and 6 months after the denture
placement. The statistical analysis was performed
using Friedman test. All analysis was performed at a
005 level of signicance. The results revelled that no
signicant changes in tooth mobility were observed
during the 6-months follow-up (P > 005). In conclu-
sion, our ndings suggest that adequate oral hygiene
instructions, careful prosthetic treatment planning
and regular recall appointments play an important
role in preventing changes in abutment tooth
mobility caused by removable partial denture place-
ment.
KEYWORDS: mobility, removable partial denture,
abutment teeth, prosthodontics, design
Accepted for publication 19 June 2006
Introduction
Correct treatment planning is vital to successful partial
denture service. It involves designing and constructing
the prosthesis utilizing biological and mechanical prin-
ciples so that the prosthesis will provide the patient
with long term function, while maintaining healthy
oral structures. Removable partial denture should
ameliorate the health of remaining dentition and
surrounding oral tissue (1). However, longitudinal
studies indicated that removable partial dentures have
been associated with increased abutment mobility (2
11). These alterations were attributed to poor oral
hygiene, increased plaque accumulation and transmis-
sion of excessive forces to the abutment teeth. Other
researches demonstrated more favourable results, with
moderate injuries or practically no periodontal changes
(1, 1113). However, the results were inconclusive and
sometimes contradictory.
Adequate distribution of stresses and proper applica-
tion of forces have a direct bearing on the success and
life expectancy of a removable partial denture (11). It is
assumed that horizontal and lateral stress on abutment
teeth may cause or favour the breakdown of periodon-
tal structures and increase in tooth mobility. Frechette
(14) concluded that the loading and movement of
abutment teeth are strongly inuenced by such factors
as the number and location of rests, contour and
rigidity of connectors and extension of the denture
bases. When a removable partial denture is considered
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd doi: 10.1111/j.1365-2842.2006.01644.x
Journal of Oral Rehabilitation 2007 34; 222227
for restoration of missing posterior teeth in distal
extension edentulous ridges, the design normally is a
problem. The displacements are quite different between
the periodontal support tissues of abutments and the
residual ridge mucosa. A correct design for a removable
partial denture should prevent rotary movement in
order to protect the supporting tissues (15). It must also
be remembered that the supporting ridge area becomes
progressively smaller as the residual ridges resorb (2). It
is known that function can modify the internal struc-
ture of human bone, pressure can cause its resorption
and tension may bring about bone deposition in some
situations (16). In a tooth borne prosthesis, the occlusal
forces are transferred directly to the abutment teeth
through rests. These rests are designed so that trans-
mitted forces are directed along axis of the abutment.
Considering that forces direct parallel to the long axis of
a tooth are better tolerated than tipping or torquing
forces (17, 18), changes in abutment tooth mobility
with time are expected to be more pronounced in distal
extension than tooth supported removable partial
dentures.
Tooth mobility has been graded clinically by placing a
tooth between two metallic instrument handles and
moving the tooth in as many directions as possible (19).
This is a subjective assessment of mobility. Several
methods were devised for measuring tooth mobility
more accurately (2025). The Periotest is an electronic
device that measures the dampening characteristics of
the periodontium. The Periotest value is a biophysical
parameter in its own right of the reaction of the
periodontium to a percussive force (26). This value
depends to some extent on tooth mobility, but mainly it
depends on the damping characteristics of the perio-
dontium (26). This 6-month follow-up clinical study
evaluated the degree of mobility of abutment teeth of
distal extension and tooth supported removable partial
dentures by using Periotest.
Materials and methods
This study was approved by the Human Research Ethic
Committee of Araraquara Dental School, and informed
consent was obtained from each patient. Inclusion
criteria included patients with fully edentulous upper
jaw and partially edentulous lower jaw (Applegate
Kennedy class I, class II and class III) (27) and no
general health complications. The range of patient ages
was 5070 years. Patients with habit of cigarette smo-
king, severe bleeding disorders, diabetes, osteoporosis,
cancer, history of bruxism, abutment tooth with a
mobility degree of 3 (movement in the apical direction)
and abutment teeth with full-crown were excluded
from the study.
Prior to prosthetic treatment, all the other necessary
dental treatments such as periodontal and restorative
treatments were carried out. All subjects were rehabil-
itated with a complete upper and a partial lower
denture. Two types of clasp design were selected for
evaluation. In cases with unilateral and bilateral distal-
extension, a clasp design including a T clasp of Roach
retentive arm, a rigid reciprocal arm and a mesial rest
were used (Fig. 1). For the abutments of tooth-suppor-
ted removable partial dentures, a second clasp design
with a cast circumferential buccal retentive arm, a rigid
reciprocal clasp arm and a rest adjacent to the edent-
ulous ridges was selected (Fig. 2). The undercuts
engaged by the retentive arms were limited to
025 mm. The framework casts were made in cobalt
chrome alloy*.
All biological and mechanical principles of removable
partial denture design and construction were followed
to minimize the forces transmitted to the supporting
tissues or to decrease the movement of the prostheses in
relation to them. The size of the saddle was increased in
proportion to the stress exerted on it and the distal-
extension of the removable partial denture was made
until rst molar in acrylic resin teeth. Moreover, the
altered-cast impression technique was used to provide
adequate support. At time of placement and during the
recall visits, an alternate nger pressure was applied on
the base to check the t to the alveolar ridge. In
addition, an indicator paste was used to detect any
pressure areas, which were relieved accordingly.
After removable partial denture placement, all of the
subjects received oral hygiene instructions and a self-
educational manual. Oral instructions included
mechanical tooth cleaning three times daily using a
soft toothbrush, interproximal ossing and interspace
toothbrushing. The cleaning of removable dentures
included mechanical cleaning with a soft toothbrush.
Subjects were also instructed to keep the denture
immersed in ltered water overnight.
The mobility degree of the abutment teeth was
measured with the Periotest instrument manufactured
*Wironit, Bego Laboratories, Bremer Goldschla gerei Wilh, Herbst
GmbH & Co., Germany.
MOB I L I T Y OF AB UT ME NT T E E T H OF R E MOV AB L E P AR T I AL DE NT UR E 223
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
by Siemens

. Before measurements were taken, the

Periotest was calibrated by one examiner with the
calibration sleeve provide by manufacturer. The meas-
urement protocol developed by the manufacturer for
the Periotest instrument was followed. The Periotest
handpiece was held perpendicular to the teeth, with the
start button on the top of the handpiece. During the
measurements, an audible signal was emitted to indi-
cate correct or incorrect handpiece position, since
deviations in the horizontal plane can inuence the
measurements. Invalid measurements were recognized
as such and eliminated. The tapping head is electro-
magnetically retracted into the handpiece. In 4 s, 16
exactly dened tapping impulses are applied to the
tooth (26). Five measurements were made to each
abutment tooth. Before the experiments, the interindi-
vidual and intra-individual variabilities were tested to
determine the reproducibility of the Periotest measure-
ment. Using a volunteer, Periotest measurements were
conducted three times by four skilled experts to obtain
the three Periotest readings for each expert. Pearsons
correlation coefcient showed reliability coefcient
ranging from 093 to 096, thus indicating no evidence
of a large random error between the readings. All the
measurements were carried out by the same clinician to
avoid interexaminer variability. A total of 68 abutment
teeth was analysed in this study.
Periotest values were made at the time of denture
placement (control) and at 1, 3 and 6 months after the
denture placement. The values of the Periotest meas-
urements are calculated from the contact time between
tapping head and tooth (28) and range from )8 to +50,
corresponding to four different scores of mobility
(Table 1). For each clasp design data, Friedman test
was used to compare the mobility scores at baseline
(control) and 1, 3 and 6 months examinations. No
comparisons were made between the two clasp designs.
The statistical analyses were performed at a 005 level of
signicance.
Results
The mean Periotest values for all abutment teeth
ranged from )1 to +22, therefore, all tooth had a score
from 0 to 2. Friedmans tests performed on the score
data from each clasp design revelled that no signicant
changes in tooth mobility were observed during the 6-
month follow-up (Friedman test,P > 005). Figures 3
Fig. 2. Removable partial denture tooth supported (Applegate
Kennedy Class III).
Fig. 1. Removable partial denture unilateral or bilateral distal-
extension (ApplegateKennedy class I or II).
Table 1. Scores of mobility and Periotest values
Millers original classication
(34)
Mobility
(scores)
Periotest
value (28)
No movement distinguishable 0 )8 to +9
First distinguishable sign of
movement
1 1019
Tooth deviates within 1 mm
of its normal position
2 2029
Mobility is easily noticeable,
and the tooth moves >1 mm
in any direction or can be
rotated in its sockets
3 3050

Gulden-Medizintechnik, Bensheim, Germany.

J . H. J OR GE et al. 224
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
and 4 show the distribution of subjects (%) with
different tooth mobility scores. The majority of subjects
presented no distinguishable movement (score 0) of the
abutment teeth.
Discussion
Assessment of the state of the periodontal ligament has
proved difcult because it cannot be examined directly
in vivo. In this study, the mobility was measured with
an electro-mechanical instrument. The Periotest was
selected because it has the ability to recognize ne
gradations of clinical mobility combined with a dem-
onstrated capacity to generate highly reproducible
results (29, 30). The measurements are sensitive and
the readings are automated and therefore objectives.
Andresen et al. (31), suggested that the Periotest
measurement is more sensitive than traditional meth-
ods at detecting periodontal damage and unfavourable
sequelae.
In the present study, the scores of the mobility were
evaluated in accordance with the Millers (32) original
classication. No signicant changes in tooth mobility
were observed during the 6-months follow-up, regard-
less of the clasp designs. The results of this study are in
accord with those of Kapur et al. (33), who observed
that two designs (I-bar and circumferential clasps) did
not differ signicantly in terms of success rates after
60 months. These results are contrary to several reports
that showed moderate-to-severe damage to periodon-
tium. Fenner and Mu hlemann (34) found that signi-
cant acute or gradual tooth mobility changes were
produced by treatment with removable partial denture.
Accordingly, Zlataric et al. (4) observed that the
removable partial dentures detrimentally affected the
mobility of the abutment teeth. It was observed,
however, that an appropriate design and good oral
hygiene decreased the appearance of periodontal dis-
ease. Carlsson et al. (35) also reported an increased
mobility in the abutment teeth when the partial
denture (distal extension) was worn by the patient
and a decrease in mobility of the abutments when the
partial denture was not worn. The authors observed a
marked increase in gingival inammation after the
partial dentures had been worn for a 12-month period.
Yusof and Isa (36), found in their clinical evaluation
(158 years) that there was increased gingival inam-
mation in regions covered by the removable partial
dentures. The results also demonstrated that the wear-
ing of removable partial dentures was detrimental to
the periodontal health in patients whose oral hygiene
was less than adequate. Comparisons between the
results from the present investigation with those from
previous studies are difcult because the observations
periods are very different. In addition, the investigators
assessed the tooth mobility using traditional and sub-
jective methods such as palpation and percussion of the
teeth (35, 36). Other important differences should be
noted between this and other studies. The patients were
selected to meet fairly rigid general and periodontal
health criteria and were followed up for 6 months. A
rigid quality control system was also followed for the
fabrication of the removable partial dentures.
An important factor that may have contributed to the
favourable results from the present investigation was
the t of the distal-extension denture bases over the
residual ridge promoted by the altered-cast impression
%

S
u
b
j
e
c
t
s
17.6
23.5
58.8
0 1 3
Time in months
0 Score 1 Score 2 Score
6
50.0
41.2
8.8
20.6
32.4
47.1 47.1
35.3
17.6
Fig. 3. Degree of mobility of abutment teeth of distal extension
removable partial denture.
Time in months
0 Score 1 Score 2 Score
0 1 3 6
%

S
u
b
j
e
c
t
s
23.5
17.6
5.9
47.1
47.1 47.1
47.1
5.9
29.4
52.9
11.8
64.7
Fig. 4. Degree of mobility of abutment teeth of tooth supported
removable partial denture.
MOB I L I T Y OF AB UT ME NT T E E T H OF R E MOV AB L E P AR T I AL DE NT UR E 225
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
technique. This impression technique provides the least
movement of extension bases under an occlusal load
when compared with bases processed on an anatomic
cast (37). The advantages include increased support for
the base and decreased forces on the abutment tooth
(3840). Moreover, the distal-extension of the remov-
able partial dentures was made until rst molar in
acrylic resin teeth so that the size of the saddle was
increased in proportion to the stress exerted on it (41).
Furthermore, a mesial rest was used, transferring the
chewing forces more perpendicular to ridges than distal
occlusal rests. Hence, the gingival mucosa of the
abutment tooth was better protected (42). As opposed
to distal-extension removable partial dentures, the
movement of the base of an entirely tooth-borne partial
denture toward the edentulous ridge is prevented
primarily by rests placed on the abutment teeth located
at each end of each edentulous space. As a result, the
rotation of the tooth-borne partial denture is relatively
non-existent.
Other factors might have contributed to the stability
of the abutment teeth. The parallel guiding planes
achieved on the diagnostic casts were accurately
transferred to the natural teeth (43). It has become
accepted that parallel surfaces on the teeth, enclosed
by the framework (guiding planes), make a substantial
contribution to stability and can also aid retention (44,
45). Further, the retentive and reciprocal arms were
vertically positioned on same level on both sides of the
tooth (vertical reciprocation), encircling >180 of its
circumference (horizontal reciprocation). As a result,
the two clasp designs were able to resist lateral forces
and also to reciprocate the force exerted by the
retentive arm when the removable partial denture
was placed or removed.
In conclusion, our ndings suggest that adequate oral
hygiene instructions, careful prosthetic treatment plan-
ning and regular recall appointments play an important
role in preventing changes in abutment tooth mobility
caused by removable partial denture placement.
Despite these favourable clinical ndings, it is import-
ant to mention that future long-term investigations are
needed before denitive conclusions can be made.
Acknowledgment
This investigation was supported by The State of Sao
Paulo Research Foundation (FAPESP; grant no. 03/
06129-3).
References
1. Schwalm CA, Smith DE, Erickson JD. A clinical study of
patients 1 to 2 years after placement of removable partial
dentures. J Prosthet Dent. 1977;3:380385.
2. Carlsson GE, Hedegard B, Koivumaa KK. Late results of
treatment with partial dentures. J Oral Rehabil. 1976;3:267
271.
3. Lappalainer R, Koskenranta-Wuorinen P, Markkanen H.
Periodontal and cariological status in relation to different
combinations of removable dentures in elderly men. Gerio-
dontics. 1987;3:122126.
4. Zlataric DK, Celebic A, Peruzovic V. The effect of removable
partial dentures on periodontal health of abutment and non-
abutment teeth. J Periodontol. 2002;73:137144.
5. Drake CW, Beck JD. The oral status of elderly removable
partial denture wearers. J Oral Rehabil. 1993;20:5358.
6. Jorge JH, Pavarina AC, Varja o FM, Garcia PPSN, Machado AL.
Oral health care of partial edentulous patients in prosthetic
rehabilitation. J Dent Res. 2002;81:186.
7. Kern M, Wagner B. Periodontal ndings in patients 10 years
after insertion of removable partial dentures. J Oral Rehabil.
2001;28:991997.
8. Mojon P, Rentsch A, Butz-Jorgensen E. Relationship between
prosthodontic status, caries, and periodontal disease in a
geriatric population. Int J Prosthodont. 1995;8:564571.
9. Vanzeveren C, Dhoore W, Bercy P. Inuence of removable
partial denture on periodontal indices and microbiological
status. J Oral Rehabil. 2002;29:232239.
10. Yeung AL, Lo EC, Chow TW, Clark RK. Oral health status of
patients 5 to 6 years after placement of cobalt-chromium
removable partial dentures. J Oral Rehabil. 2000;27:183189.
11. Bergman B, Hugoson A, Olsson CO. Caries, periodontal and
prosthetic ndings in patients with removable partial den-
tures: a ten-year longitudinal study. J Prosthet Dent.
1982;48:506514.
12. Bergman B, Hugoson A, Olsson CO. Caries and periodontal
status in patients tted with removable partial dentures. J Clin
Periodontol. 1977;4:134146.
13. Bergman B, Hugoson A, Olsson CO. Periodontal and pros-
thetic conditions in patients treated with removable partial
dentures and articial crowns. A longitudinal two-year study.
Acta Odontol Scand. 1971;29:621638.
14. Frechette AR. The inuences of partial denture design on
distribution of force to abutment teeth, 1956. J Prosthet Dent.
2001;85:527539.
15. Lyons KM, Beumer J, Caputo AA. Abutment load transfer by
removable partial denture obturator frameworks in different
acquired maxillary defects. J Prosthet Dent. 2005;94:281
288.
16. Zarb GA et al. Removable partial prosthodontics: clinical and
laboratory protocol. In: Zarb GA et al., eds. Prosthodontic
Treatment for partially edentulous patients. Saint Louis:
Mosby-Year Book; 1978:408521.
17. Stewart KL, Rudd KD, Kuebker WA. Components of a
removable partial denture: major connectors, minor connec-
tors, rests and rest seats. In: Stewart KL, Rudd KD, Kuebker
J . H. J OR GE et al. 226
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd
WA, eds. Clinical removable partial prosthodontics, 2nd edn.
St Louis: Ishiyaku Euro Ame rica, Inc.; 1992:1957.
18. McGivney GP, Carr AB. Rests and rest seats. In: McGivney GP,
Carr AB, eds. McCrackens removable partial prosthodontics,
10th edn. St Louis: Mosby; 2000:7795.
19. Carranza FA, Newman MG. Clinical diagnosis. In: Carranza
FA, Newman MG, eds. Clinical Periodontology. Philadelphia:
W.B. Saunders; 1990:344362.
20. Beyeler K, Drefus J. Prinzip Einer electrodynamischen appar-
atur zur lockerungs grades der Za hne. Parodentologie.
1947;1:113.
21. Dreyfus J. Le Vitrometre Dynamique. The orie et applications
dun Nouvel instrument electrique de Me sures Mecaniques.
Schweiz Arch Angew Wiss Tech. 1949;15:338.
22. Manly RS, Yurkstas AA, Reswick JB. An instrument for
measuring tooth mobility. J Periodont. 1951;22:148155.
23. Lundquist C. Objektiva paradontala registreingsmetoder.
Odontol Revy. 1956;7:9.
24. Picton DCA. A method of measuring physiological tooth
movements in man. J Dent Res. 1957;36:814.
25. Partt GJ. Measurement of the physiological mobility of
individual teeth in an axial direction. J Dent Res.
1960;39:608618.
26. Schulte W, dHoedt B, Lukas D, Maunz M, Steppeler M.
Periotest for measuring periodontal characteristics correla-
tion with periodontal bone loss. J Periodont Res.
1992;27:184190.
27. Apllegate OC. Essentials of removable partial denture pros-
thesis, 3rd edn.Philadelphia: WB Saunders Co.; 1965: 15.
28. Lukas D, Schulte W. Periotest a dynamic procedure for
diagnosis of the human periodontium. Clin Phys Physiol
Meas. 1990;11:6575.
29. Manz MC, Morris HF, Ochi S. An evaluation of the Periotest
system. Part I: examiner reliability and repeatability of
readings. Implant Dent. 1992;1:142146.
30. Manz MC, Morris HF, Ochi S. An evaluation of the Periotest
system. Part II: reliability and repeatability of instruments.
Implant Dent. 1992;1:221226.
31. Andresen M, Mackie I, Worthington H. The Periotest in
traumatology. Part II. The Periotest as a special test for
assessing the periodontal status of teeth in children that have
suffered trauma. Dent Traumatol. 2003;19:218220.
32. Miller SC. Textbook of periodontia. Philadelphia: Blakiston
Co.; 1938:91.
33. Kapur KK, Deupree R, Dent RJ, Hasse AL. A randomized
clinical trial of two basic removable partial denture designs.
Part I: comparisons of ve-year success rates and periodontal
health. J Prosthet Dent. 1994;72:268282.
34. Fenner W, Gerber A, Muhlemann HR. Tooth mobility changes
during treatment with partial denture prosthesis. J Prosthet
Dent. 1956;6:520525.
35. Carlsson GE, Hedegard B, Koivumaa KK. Studies in partial
denture prosthesis. IV. Final results of a 4-year longitudinal
investigation of dentogingivally supported partial dentures.
Acta Odontol Scand. 1965;23:443472.
36. Yusof Z, Isa Z. Periodontal status of teeth in contact with
denture in removable partial denture wearers. J Oral Rehabil.
1994;21:7786.
37. Leupold RJ. A comparative study of impression procedures for
distal extension removable partial dentures. J Prosthet Dent.
1966;16:708720.
38. Holmes JB. Inuence of impression procedures and occlusal
loading on partial denture movement. J Prosthet Dent.
1965;15:474483.
39. Leupold RJ, Flinton RJ, Pfeifer DL. Comparison of vertical
movement occurring during loading of distal-extension
removable partial denture bases made by three impression
techniques. J Prosthet Dent. 1992;68:290293.
40. Maxeld JB, Nicholls JI, Smith DE. The measurement of
forces transmitted to abutment teeth of removable partial
dentures. J Prosthet Dent. 1979;41:134142.
41. Mizuuchi W. Theeffects of loadinglocations anddirect retainers
on the movements of the abutment tooth and denture base of
removable partial dentures. J Med Dent Sci. 2002;49:1118.
42. DeBoer J. The effects on function of distal-extension remov-
able partial dentures as determined by occlusal rest position.
J Prosthet Dent. 1988;60:693696.
43. Rudd RW, Bange AA, Rudd KD, Montalvo R. Preparing teeth
to receive a removable partial denture. J Prosthet Dent.
1999;82:536549.
44. Ali M, Waters NE, Nairn RI, West F, Sherriff M. A laboratory
investigation of the role of guide planes in the retention of cast
cobaltchromium alloy partial denture frameworks. J Dent.
2001;29:291299.
45. Sato Y, Hosokawa R. Proximal plate in conventional circum-
ferential cast clasp retention. J Prosthet Dent. 2000;83:319
322.
Correspondence: Dr Eunice Teresinha Giampaolo, Department of
Dental Materials and Prosthodontics, Araraquara Dental School, Rua
Humaita , no 1680, Araraquara, Sa o Paulo, Brazil.
E-mail: eunice@foar.unesp.br
MOB I L I T Y OF AB UT ME NT T E E T H OF R E MOV AB L E P AR T I AL DE NT UR E 227
2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd