R E M O V A B L E

R ES M
AB
RO
S TS H O D O N T I C S
P R O
T OHVO
DLOE NP T
I C

The Distal Extension Base Denture

BRENDAN J.J. SCOTT AND PAULINE MAILLOU

Abstract: The distal extension base denture may be indicated in situations in which
the edentulous area to be restored is without a terminal abutment tooth. There may be
significant challenges in providing a prosthesis with sufficient support and retention to
make it comfortable without damaging the intra-oral tissues. This can be a greater
problem in the mandible as the denture-bearing area is usually much smaller than in
the maxilla. This paper considers how distal extension removable prostheses can be
designed to restore edentulous spaces.
Dent Update 2003; 30: 139-144

Clinical Relevance: Distal extension removable prostheses can be designed so that

they are comfortable to wear, stable in function and do not damage the intra-oral
tissues.

he provision of a distal extension

base denture is a common treatment
for patients who have lost their natural
posterior teeth. The prosthesis is used
in situations where there are no terminal
abutment teeth (i.e. free-end saddles). In
these situations, particularly where the
saddle is long, a removable prosthesis is
the only realistic treatment option as,
with the exception of implant-supported
fixed bridgework, conventional or
adhesive cantilevered restorations using
the anterior abutment teeth may be
inappropriate. Although this pattern of
tooth loss is common, the distal
extension prosthesis is amongst the
most difficult to wear due to inherent
problems of retention and stability.
An increasing percentage of the
Brendan J.J. Scott, BDS, BSc, FDS, PhD, Senior
Lecturer/Honorary Consultant, and Pauline
Maillou, BDS, BMSc, FDS, PhD, Lecturer/Honorary
Specialist Registrar, Unit of Restorative Dental
Care and Clinical Dental Sciences, Dundee Dental
Hospital and School.

Dental Update April 2003

population is managing to retain their

natural teeth for longer and the
proportion of edentulous patients
appears to be falling. However, this does
not mean that intact natural dentitions
will be retained over the whole lifetime.
For this reason, well designed and
constructed removable distal extension
prostheses will continue to play an
important role in the restoration of
posterior edentulous spaces. In this
paper, the design principles of such
prostheses will be discussed.
Loss of the natural posterior teeth
does not necessarily mean that they
should be replaced by a prosthesis. The
amount of plaque in the mouth is
increased when a prosthesis is present1
and therefore denture wearing could
compromise the health of other oral
structures. Furthermore, many patients
appear to be able to function
satisfactorily with reduced dentitions.2
For these reasons, it may not be
appropriate to provide a denture for
every patient with missing posterior

teeth. The patients stated desires

related to chewing ability and
appearance also need to be considered
carefully in making a decision.

PLANNING PROSTHETIC
TREATMENT
A careful assessment will need to be
made of the patient and his/her
suitability for rehabilitation with a
removable prosthesis. The dental and
medical history should be recorded,
paying particular attention to the
patients account of any previous
denture-wearing experience. There may
be factors in the medical history that are
relevant to difficulties in denture
wearing: for example, a dry mouth may
result in an increased susceptibility to
dental caries. Full extra-oral and intraoral examinations should be carried out.
Further investigations, such as
radiographs of the abutment teeth, may
be required to assess their use for the
support of the denture.
Before treatment is undertaken the
patient must develop and maintain a
high standard of oral hygiene. If this
cannot be achieved, the potential for
further plaque-related disease affecting
the teeth and periodontal tissues
remains, and could progress even more
rapidly when a partial denture is present
than if one was not provided at all.

DESIGNING THE
PROSTHESIS
To work up a definitive design the
dentist will need to use all of the
information gathered from the history,
examination, and other investigations.
Surveyed and articulated study casts
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Figure 1. Casts to show the support area available (shaded in green) on the tissues in the
maxilla and mandible related specifically to the distal extension saddles. (a) The denture base
can be extended over a wide area for a bilateral distal extension saddle in the maxilla. Further
support may be gained by extending the prosthesis anterior to the shaded area. (b) The
morphology of the mandible restricts the available base coverage for a lower bilateral distal
extension saddle denture.

will be useful to the dentist in the design

process. Factors that need to be
considered in the denture design
include:
l saddles to be replaced;
l path of insertion of prosthesis;
l support tooth/mucosa or mucosa
only;
l retention direct and indirect;
l bracing;
l connectors;
l overview for prosthesis stability
and hygienic design.
At this stage any sites at which tooth
preparations are necessary should be
identified before making the working
impressions. Such preparations may be
required to form appropriate contours to
some tooth surfaces for siting particular
components of a partial denture e.g.
preparation of occlusal rest seats. It may
also be necessary to carry out tooth
preparation in the arch opposing the
one for which a denture is planned, in
order to create sufficient space to
ensure that the components of a partial
denture do not interfere with the
occlusion. Examples of such
modifications include modest reductions
of overerupted teeth.

Saddles
The saddles are the parts of the denture
that carry the artificial teeth. The base of
the saddle will rest on the underlying
tissues and will need adequate
extension over the denture-bearing area
140

(see below). The artificial teeth should

be sited to ensure that the denture will
not tip under occlusal loading. The
polished surfaces should be designed
so that the denture is well retained and
tolerated. The shape of the denture base
becomes more critical when teeth have
been missing for many years with
associated resorption of bone.
Furthermore, in some circumstances, the
space available for a lower prosthesis
may be limited because of changes in
activity of the tongue musculature
(tongue spread). It may therefore be
necessary to narrow the denture teeth or
even omit one or more (e.g. second
molars) to allow the patient to tolerate
the prosthesis more easily.
It is important to consider the status
and prognosis of the teeth that will act
as abutments to the saddles. Critical
abutment teeth are those that are
essential to the stability of the
prosthesis: for example, the most
posterior tooth in the arch that would
offer support, retention and bracing
against posterior movement of the
prosthesis. If a single distal abutment
tooth remains on the side of the mouth
opposite to a distal extension saddle, all
efforts must be made to retain it. Loss of
such a tooth would result in an arch that
was originally a unilateral distal
extension saddle becoming one with
bilateral distal extension saddles.
Almost certainly this would result in any
prosthesis becoming significantly less
stable as there would no longer be any
posterior teeth present.
The patient should be advised of the

particular importance of cleaning

abutment teeth at the posterior aspects
of the arch areas that can easily be
neglected. Aids such as a finger
bandage may be useful in cleaning
single standing posterior abutment
teeth.

Support
Unlike a bounded saddle prosthesis, in
which it is possible to gain full support
from the abutment teeth, occlusal
loading of the saddle area of a distal
extension denture will result in some
force being directed towards the tissues
of the edentulous ridge directly
underneath. The size and shape of the
ridge, as well as the thickness and
density of the overlying fibrous
connective tissue and mucosa, will also
influence the support offered. Generally
these factors are more favourable in the
maxilla, where the soft tissues may be
thicker and less displaceable than those
in the mandible. The amount and type of
the underlying alveolar bone should
also be considered.
The opportunity in the maxilla to
achieve greater coverage of the
prosthesis on the alveolar ridges and
across the hard palate allows more
favourable loading than in the mandible,
where the available support area is
reduced (Figure 1). Therefore distal
extension dentures are potentially less
damaging in the maxilla.
Support becomes a much greater
problem if there is a knife-edge form to
the ridge or if the pattern of alveolar
resorption results in mobile fibrous tissue
overlying the alveolar bone, particularly
in the mandibular denture-bearing area. In
a distal extension base denture, optimum
support is gained by using the natural
teeth where possible. However, all distal
extension base dentures will derive at
least part of their support from the
tissues underlying the saddle.
When considering the component of
mucosal support the objective is to
minimize the load per unit area being
transferred to the underlying ridge.
This is usually done by extending the
denture base maximally without
interfering with structures that
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Figure 2. A design for a bilateral distal extension

mandibular denture with the occlusal rests
(shown by the arrows) sited on the mesial
aspects of the mandibular teeth.

influence movement of the border

tissues. 3
l In the mandible the base should
extend over the alveolar ridge, on to
the buccal shelf and retromolar pad
and fully into the functional sulci.
l In the maxilla, base extension over a
wide area of the alveolar ridge and
palate will allow the most favourable
load distribution. The force to the
ridge from occlusal loading can be
minimized by reducing the size of the
occlusal table by omitting denture
teeth (e.g. second molars), using
smaller teeth or by narrowing their
buccolingual width.
It may be that the denture will be
supported only on the soft tissues
overlying the alveolar ridge (mucosal
support). This is generally less damaging
in the maxilla as it is usually possible to
gain adequate support from the palatal
mucosa. Great care should be taken when
embarking on this course in the mandible
as further alveolar ridge resorption could
result in this becoming a gum stripper
denture. However, there are occasions in
which this may be the only option for
example, for a transitional partial denture.
Tooth support should be used where
possible on the distal extension denture,
especially in the mandible. Clearly this
will depend on the periodontal support of
the natural teeth being satisfactory:
where possible, there should be support
on the abutment tooth adjacent to the
saddle. There is less chance of distal
tipping of the abutment tooth if the rest is
Dental Update April 2003

placed on the mesio-occlusal aspect

(Figure 2), although this assumption has
been challenged.4 In a unilateral saddle,
cross-arch tooth support on the opposite
side is desirable.
Even if support is shared between the
teeth and mucosa, occlusal loading may
result in displacement of the distal
extension saddle. As the underlying
mucosa may be much more displaceable
than a tooth supported by its periodontal
ligament, the denture may rotate around
the occlusal rest on the abutment tooth in
function. In the mandible this can be a
particular problem and may be
exacerbated if there is further alveolar
ridge resorption. The approaches used to
address this range from specific
impression techniques for the saddle (e.g.
altered cast technique) to allowing the
saddle part of the denture to move
independently by means of a flexible
connector (stress broken design). Stress
broken designs are rarely used as it is
very difficult to predict how the position
of the hinge joint or flexible connector
will influence the loading on the tissues
of the edentulous area.5

The Altered Cast Technique

The aim of the altered cast technique is
to produce an impression of the mucosa
of the saddle area such that movement
of the denture base in function will be
minimized.6 Detailed accounts of the
clinical and laboratory stages are given
elsewhere.68 The procedure is usually
carried out when the casting is fitted. A
close-fitting, non-spaced impression
tray is attached to the cobalt chromium
a

framework. A mucodisplacement
impression can be recorded with the
close-fitting impression tray and an
appropriate impression material (e.g. zinc
oxide/eugenol). Following the
impression, in which care should be
taken to avoid any direct pressure to the
tray while ensuring the casting is seated
properly around the teeth, the saddle is
sectioned away from the original master
cast. The metal framework and
associated impression are seated and a
new area of the cast formed by casting
stone into the impression (Figure 3). The
use of this technique may help prevent
the denture from tilting when the saddle
is loaded occlusally.

Retention and Stability

Retentive forces are those that resist
vertical movement of the denture away
from the underlying ridge. When
designing a partial denture the objective
is to provide components that resist the
displacing forces that may be applied to
the denture during function. In the case
of the distal extension prosthesis, this is
usually achieved by siting retentive
components close to (direct retention)
and distant to (indirect retention) the
saddle. Additional ways of achieving
retention include physical forces from
the denture base coverage of the
mucosa, and the design of the polished
surfaces to harmonize with a patients
muscular control.5
In the maxilla the opportunity to
spread the denture base widely can help
the retention of the prosthesis.
However, retention problems may be
b

Figure 3. The laboratory stages of the altered cast technique. An impression has been recorded in
a close-fitting impression tray attached to the casting.The original distal extension saddle area of
the master cast has been sectioned. (a) The casting secured to the original dentate portion of the
master cast by means of yellow wax overlying the occlusal rests on teeth /5 and 5/. (b) The
impression surface to which new stone will be poured.

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Figure 4. A design for a unilateral distal

extension mandibular denture to show the
principle of indirect retention.The tendency of the
distal part of the saddle to lift away from the
tissues rotating around the fulcrum axis (AA) is
resisted by the premolar occlusal rest (B) and
the lingual plate connector (C).

encountered with a mandibular distal

extension denture: adhesive and
cohesive forces between the mucosa,
saliva and denture base may not make a
major contribution to retention, especially
if the available denture-bearing area is
small. Furthermore, there is only one
abutment tooth at the anterior end of the
saddle that can offer direct retention
often either a premolar or a canine, which
have small mesiodistal dimensions. If an
occlusally approaching clasp is used it
will need to be made from a material that
is sufficiently flexible (e.g. stainless steel)
to allow the undercut to be engaged but
this may distort compared with a cast
material (e.g. cobalt chromium). Where
aesthetics are important, gold or toothcoloured acetyl resin may be the material
of choice.
The position of the survey line,
together with the patients feedback on
aesthetics, will determine whether the
clasp will be occlusally approaching or
gingivally approaching. A gingivally
approaching clasp may have less
potential for causing unwanted
movement of the abutment tooth when
the saddle moves under occlusal load as
it will disengage from the undercut.
The RPI system is a form of
component design with the objective of
preventing or minimizing the potential
for damage to the abutment tooth during
loading of the distal extension saddle.
The occlusal rest (R) is placed on the
142

mesial aspect of the abutment tooth.

The plate (P) is in contact with a small
guide plane on the distal aspect of the
abutment tooth and is designed so that it
is able to move towards the tissues,
therefore disengaging from the tooth
surface, when the saddle is loaded.
Similarly the I-bar, which engages an
undercut on the buccal surface of the
tooth, will move towards the tissues and
away from the tooth when the saddle is
loaded. This system of design has the
advantage of reducing the potentially
damaging torquing forces to the
abutment tooth due to occlusal loading
of the saddle. More detailed descriptions
of this concept are given in the
literature.5,9
The absence of a distal abutment tooth
may cause the saddle to lift away from
the tissues during function. For this
reason components that offer indirect
retention need to be included in the
denture. An indirect retainer is a support
component that rests on a firm structure
on the side of the clasp axis opposite to
the saddle (Figure 4). When the distal
extension saddle attempts to lift during
function, the supporting components
become the fulcrum of movement instead
of the clasp axis, increasing the force
required to dislodge the denture. The
support component should be positioned
as far from the axis of rotation through
the clasps as possible to optimize the
indirect retention. In addition, the clasp
axis should be as close to the saddle as
possible.
It may be necessary to change tooth
contours to achieve more effective
retention. The addition of composite

resin to the buccal aspect of a tooth

provides a simple solution to the problem
of an unsuitable abutment shape. In some
circumstances it may be necessary to
construct a crown for an abutment tooth,
in which case the crown can be designed
to optimize the components on the
prosthesis. Features include siting an
appropriate rest seat, a well shaped
bulbosity for clasping, and parallel
surfaces to avoid undercuts between the
prosthesis and abutment tooth (Figure 5).
However, some consideration should be
given to the possible torquing forces that
might arise around the tooth from
occlusal loading on a distal extension
base denture. This could compromise the
abutment, e.g. if there is associated
periodontal attachment loss.
The occlusal relationships will need to
be considered in relation to the stability
of the prosthesis. The denture should be
designed so that no interferences with
the relationship of the natural teeth are
created. Eccentric interferences during
lateral or protrusive excursions of the
mandible could destabilize the prosthesis.
Overerupted, drifted and tilted teeth can
contribute to this type of problem and
therefore the occlusion should be
carefully assessed before commencing
treatment.

Additional Methods of Securing

Retention
Swinglock dentures (Figure 6) can be
constructed if there are particular
difficulties in retention.10 These consist
of a hinged labial bar and locking device.
Some patients may not tolerate the labial

Figure 5. Features that can be incorporated into a crown on an abutment tooth adjacent to a
distal extension saddle. (a) The occlusal rest seat and a mesiobuccal undercut on the crown. (b)
A cobalt-chromium-based denture in place.The occlusal rest fits over the rest seat and the
terminal part of the gold clasp is sited in the undercut area.

Dental Update April 2003

R E M OVA B L E P R O S T H O D O N T I C S

Figure 6. A mandibular swinglock denture. (a) The hinged labial flange and locking segment. (b)
The prosthesis in place to show the position of the hinge.

to be carefully planned. As well as the

features considered above, it is
important that the patient is comfortable
in function and is able to clean the teeth
and dentures well. Patients should be
reviewed at regular intervals to identify
any early signs of damage to intra-oral
tissues. This allows the opportunity for
appropriate modifications to be made
before more serious problems arise.

ACKNOWLEDGEMENTS
We would like to thank Dr Kenneth Tyson for
composing the line drawings for Figures 2 and 4.

REFERENCES
1.

Figure 7. A mandibular distal extension denture retained by extracoronal precision attachments

on the abutment teeth.The prosthesis had been worn for over 10 years. (a) The extracoronal
attachment linked to a crown on the abutment tooth. (b) The locking pin in the denture that
engages the attachment.

bar and every attempt should be made to

keep the bulk of the appliance to a
minimum. It is also possible that large
forces will be applied to the natural teeth
during occlusal loading. This problem
would be exacerbated if further alveolar
resorption in the saddle areas takes place
as there would be a greater tendency for
the appliance to rock.
An alternative approach is to use
precision attachments on the abutment
teeth into which matching components in
the prosthesis can engage. Again there
may be the potential for damage to the
abutment tooth, although these can
function for many years (Figure 7).
Very careful thought is necessary
before embarking on these types of
designs. They are contraindicated if the
tooth structure or periodontal tissues are
compromised and unless the patient has
excellent plaque control.

CONNECTING THE
COMPONENTS OF THE
DENTURE
An appropriate major connector is
required to link the distal extension
saddle with other components of the
144

prosthesis. Factors that will determine a

suitable connector design include:
l the space available in the anterior
part of the mouth;
l the health of the teeth and
periodontal tissues; and
l the need to consider its use in
indirect retention.
Many types of connector are
described (e.g. palatal plate, anterior
palatal bar, lingual plate, lingual bar,
dental bar).5,8 To maintain periodontal
health it is preferable that the connector
avoids coverage of the gingival tissues
(Figure 8). Some connectors, such as
lingual bars, are an ineffective source of
indirect retention on their own, even
though there are advantages in leaving
the gingival margins of teeth remote from
the saddle uncovered. In such cases,
other sources of indirect retention need
to be found, provided that there are
already components on the prosthesis to
provide effective direct retention.

CONCLUSIONS
A distal extension base denture needs

Bates JF, Addy M. Partial dentures and plaque

accumulation. J Dent 1978; 6: 285293.
2. Elias AC, Sheiham A. The relationship between
satisfaction with mouth and number and position
of teeth. J Oral Rehabil 1998; 25: 649661.
3. McGivney GP, Carr AB. Support for the distal
extension base. In: McCrackens Removable Partial
Prosthodontics, 10th ed. St. Louis: Mosby, 2000;
pp.337354.
4. Feingold GM, Grant AA, Johnson W. The effect of
partial denture design on abutment tooth and
saddle movement. J Oral Rehabil 1986; 13: 549557.
5. Davenport JC, Basker RM, Heath JR, Ralph JP,
Glantz PO. A Clinical Guide to Removable Partial
Denture Design. London: British Dental
Association, 2000.
6. Barsby MJ, Schwarz WD. Partial dentures with
free-end saddles: the altered cast technique. Dent
Update 1987; 14: 101110.
7. Feit DB. The altered cast impression technique
revisited. J Am Dent Assoc 1999; 130: 14761481.
8. Davenport JC, Basker RM, Heath JR, Ralph JP,
Glantz PO. A Clinical Guide to Removable Partial
Dentures. London: British Dental Association, 2000.
9. Krol AJ. RPI (Rest, Proximal Plate, I Bar) clasp
retainer and its modifications. Dent Clin North Am
1973; 17: 631649.
10. Chan MFW-Y, Adams D, Brudvik JS. The swinglock removable partial denture in clinical practice.
Dent Update 1998; 25: 8084.

Figure 8. A dental bar connector which avoids

coverage of the gingival margins.These can be
well tolerated by the patient and may have a
role in indirect retention.
Dental Update April 2003