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Removable partial dentures: an introduction
Article in British dental journal · November 2000

DOI: 10.1038/sj.bdj.4800769a · Source: PubMed
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PRACTICE
prosthetics
Removable partial
dentures: an introduction
J. C. Davenport,1 R. M. Basker,2 J. R. Heath,3
J. P. Ralph,4 and P-O. Glantz,5
his series of articles has been selected from two new publi-
T cations replacing ‘A Colour Atlas of Removable Partial Den-
tures’, Davenport, Basker, Heath and Ralph, Wolfe Medical
Publications Ltd, 1988. The content has been much revised and
augmented, and has been reorganised into two volumes to con-
form to the format of the successful ‘Clinical Guide’ series of the
BDJ. The first volume, ‘A Clinical Guide to Removable Partial
Dentures’ focuses on the clinical aspects and techniques of remov-
able partial denture (RPD) treatment, while the second volume,
‘A Clinical Guide to Removable Partial Denture Design’ concen- The first article emphasises the important distinction between
trates on the procedures and principles of designing RPDs. the need and demand for RPD treatment. The dangers of
The series of articles commencing in this issue of the BDJ overtreatment are discussed and the management options for the
comprises a selection from both volumes. As it is not possible partially dentate patient considered. A discussion of RPDs and
within the series to include more than a fraction of the books’ the elderly includes comments on the demographic processes
contents the topics have been chosen to give a coherent account within the population and the possible significance of the reten-
of those aspects leading up to the provision of definitive RPD tion of at least some teeth into old age.
treatment, namely: Effective communication between dentist and dental techni-
cian is a cornerstone of competent RPD treatment, so present
1. Need and demand for treatment, including a consideration
shortcomings and how they may be overcome will be discussed.
of RPDs and the elderly
Although not included in this series of articles, each of the chap-
2. The removable partial denture equation of risk versus benefit
ters on the clinical stages of RPD treatment in the first volume
3. Communication between the dentist and the dental technician
conclude with checklists of instructions to the dental technician
4. Surveying
as an aide mémoire for the dentist.
5. A system of design
The process of surveying is described and the reader is taken
6. Retention
through a logical sequence for developing the final design.
7. Bracing and reciprocation
There will be several articles on various aspects of RPD
8. Principles of clasp design
design. One of these, on clasp design, is taken from a compre-
9. Indirect retention
hensive section on the principles of design in ‘A Clinical Guide
10. Connectors
to Removable Partial Denture Design’. This section was devel-
11. Initial prosthetic treatment
oped from a collection of design rules produced for a comput-
12. Tooth preparation
erised knowledge-based system1 for the design of RPDs. This
There is still limited scientific data on which to base current collection of rules was obtained initially from the literature and
concepts of RPD design. However, there is a widely held view was subsequently modified in the light of comments received
amongst prosthetic specialists that hygienic aspects of RPD design from prosthodontic specialists in all the dental schools in the
are of overriding importance compared with those design aspects UK and the Republic of Ireland. The level of support each
concerned primarily with mechanical requirements. It is the design rule received from these experts is included as a guide
authors’ intention that this series of articles should clearly reflect to the reader. Since then further significant contributions to this
this belief in the importance of basing RPD design predominantly knowledge base have been made by a number of prosthodon-
on the need to maintain the oral health of the patient. tic specialists from several different countries. Their comments
have been taken into account in the discussion that follows each
1*Emeritus Professor, University of Birmingham, UK ; 2Professor of Dental
rule. Readers are invited to use this article in an interactive way
Prosthetics, University of Leeds and Consultant in Restorative Dentistry, Leeds by first forming their own opinion on the design principles
Teaching Hospitals NHS Trust, Leeds, UK; 3Honorary Research Fellow, University
of Manchester (Formerly Senior Lecturer in Restorative Dentistry, University of listed at the beginning of the article and then comparing their
Manchester) and Consultant in Restorative Dentistry, Central Manchester opinions with those of the experts, and considering the points
Healthcare Trust, Manchester, UK; 4Consultant in Restorative Dentistry, Leeds raised in the discussions. We hope that the wealth of prostho-
Teaching Hospitals NHS Trust and Senior Clinical Lecturer, University of Leeds
and Honorary Visiting Professor, Centre for Dental Services Studies, University of
dontic knowledge and experience that this section represents
York, York, UK; 5Professor of Prosthetic Dentistry, Consultant in Prosthetic will make it of particular and lasting value to the reader.
Dentistry, Faculty of Odontology, University of Malmo, Sweden The series concludes by describing procedures for creating the
*Correspondence to: 5 Victoria Road, Harborne, Birmingham B17 0AG best possible oral environment for the provision of RPDs.
email: john.davenport@btclick.com
REFEREED PAPER
© British Dental Journal 2000; 189: 363 1 ‘RaPiD’, TMS Ltd, Aylesbury, UK.
BRITISH DENTAL JOURNAL, VOLUME 189, NO. 7, OCTOBER 14 2000 363

PRACTICE
prosthetics
Need and demand for

1 treatment
J. C. Davenport,1 R. M. Basker,2 J. R. Heath,3 J. P. Ralph,4 and P-O. Glantz,5
This article considers first, factors influencing the

In this part, we will discuss
need and demand for removable partial dentures • Factors influencing the provision of RPDs
(RPDs) and second, the particular requirements • The effect of age and extent of tooth loss
and problems of elderly patients related to such • The shortened dental arch
• Toothwear and root surface caries
treatment. • Possible treatment options for the elderly
he term ‘need’ is commonly used to describe the amount of latter may find that the effort needed to seek out that treat-
T treatment that dentists judge their patients ought to have,
whilst ‘demand’ refers to the treatment requested by the patients
ment is just too great.
Recognizing the difference between need and demand prompts
themselves. Most studies of prosthetic need and demand show the question, ‘How many teeth must be lost before a patient seeks
that the former is larger than the latter. The many reasons for this prosthetic replacement?’ Experience suggests that the answer can
difference can be considered under the following headings. vary greatly. On the one hand, the loss of one anterior tooth is
usually a powerful motivator for the patient, whereas another
· Availability of treatment
patient may have had many posterior teeth extracted before they
· Acceptability of treatment
seek the advice and help of a dentist.
· Accessibility of treatment
Although the restoration of appearance can be a powerful
motivating factor, not every patient will seek treatment follow-
Availability ing the loss of an anterior tooth. A study of elderly men living in
Availability refers to numbers of dentists, their particular skills, an area where dental treatment was readily available and afford-
their accessibility to the public and the economic realities of the able showed that one in five had at least one unrestored space
community in which they practise. towards the front of the mouth. In another study, dentists rated
the dental appearance of a group of elderly people as less attrac-
Acceptability tive than did the subjects themselves. The dentist must therefore
Acceptability describes the attitudes of people to different forms avoid preconceptions and consider the thoughts and wishes of
of treatment. These attitudes are influenced by such matters as the individual patient before recommending the provision of a
education, personal finance, and cultural background. denture. The time, effort and understanding taken to make this
judgement are likely to prevent unnecessary treatment.
Accessibility There can thus be a large difference between the perception of
Accessibility highlights important differences between peo- need and demand for a prosthesis as an aid to chewing efficiency.
ple. For example, a particular form of prosthetic treatment Nutritional status is affected by psychological, sociological and
may be equally available to young and old patients, but the economic factors as well as by the effectiveness of the dentition.

New publications:
Prosthetics, University of Leeds and Consultant in Restorative Dentistry, Leeds
All the parts which comprise this series
of Manchester (Formerly Senior Lecturer in Restorative Dentistry, University of (which will be published in the BDJ)
Manchester) and Consultant in Restorative Dentistry, Central Manchester have been included (together with a
Healthcare Trust, Manchester, UK; 4Consultant in Restorative Dentistry, Leeds number of unpublished parts) in the
and Honorary Visiting Professor, Centre for Dental Services Studies, University of book A Cinical Guide to Removable
York, York, UK; 5Professor of Prosthetic Dentistry, Consultant in Prosthetic Partial Dentures (ISBN 0-904588-599)
Dentistry, Faculty of Odontology, University of Malmo, Sweden and A Clinical Guide to Removable
*Correspondence to: 5 Victoria Road, Harborne, Birmingham B17 0AG
Partial Denture Design (ISBN 0-904588-637).
REFEREED PAPER Available from Macmillan on 01256 302699
© British Dental Journal 2000; 189: 364-368
364 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 7, OCTOBER 14 2000

PRACTICE
prosthetics
Fig. 1
Whether or not a removable partial denture (RPD) is worn by the patient 100
is dependent upon self-motivation. In a UK survey people were asked, 'If 90
you had several missing teeth at the back would you prefer to have an 80
RPD or manage without?’ The chart shows that most people would 70
Patients (%)
prefer to manage without and that the preference grows stronger with 60
increasing age. It is almost as if the longer the person has managed to 50
avoid dentures the stronger is the wish to do without them. 40
20
30
10
0
16–24 25–34 35–44 45–54 55–64 65 and
Age (yrs) over
Have RPD (%) Manage without (%)
Fig. 2
In the same study people were asked, 'Do you find the thought of having a 100
partial denture to replace some of your teeth very upsetting, a little 90
upsetting or not at all upsetting?' Overall, only 40% found the idea of 80
having dentures not at all upsetting. A breakdown of the answers by age is 70
shown in the chart. Again, there is a suggestion that older people tend to Patients (%) 60
find the thought of an RPD more upsetting than do the young. 50
40
20
30
10
0
16–24 25–34 35–44 45–54 55–64 65 and
Age (yrs) over
Very upsetting A little upsetting Not at all upsetting
For missing posterior teeth, the concept of the shortened normal function can be satisfied by the presence of natural teeth
dental arch (SDA) is relevant. Here the needs for oral health and no further distally than the second premolars.
Fig. 3
The SDA concept (see Chapter 3 in our BDJ Publication ‘A Clinical Guide
to Removable Patial Dentures’) is based on the following observations:
older people can usually function adequately with a significantly reduced
number of teeth; the provision of a distal extension RPD tends not to
contribute any significant functional benefits; the replacement of missing
posterior teeth should be driven by demand and not by need.

PRACTICE
prosthetics
Fig. 4
90 For how many people is the SDA concept a viable proposition? The
80 percentage of the UK adult population that possessed four 'good'
quadrants was found to be 54%. The relationship to age is shown in the
Patients with SDAs (%)
70
chart. The number of people who might have a functional SDA falls
60
dramatically with age. Nevertheless, there is a risk that a considerable
50 number of older people could well be provided with RPDs on the advice
40 of a dentist and yet fail to need them or even wear them.
20
30
10
0
16–24 25–34 35–44 45–54 55–64 65 and
over
Age (yrs)
In the second article in the series there is an account of the the following questions before providing an RPD for any
real benefits that can accrue from wearing RPDs, as well as patient.
illustration of the tissue damage which can occur. This ‘bio- • ‘Does the patient really want an RPD?’ (the patient’s assess-
logical price’ is particularly likely to be exacted if RPDs are ment).
not maintained adequately even if they are well-designed and • ‘Are the benefits likely to outweigh the possible damage that
constructed. It is therefore prudent for the dentist to consider may occur?’ (the dentist’s assessment).
RPDs and the elderly

People are living longer and retaining more of their teeth into old wearing of RPDs than younger individuals. It was as if the
age. This trend is likely to continue as the current middle-aged longer a person had managed to function adequately without
population, tomorrow’s elderly, is showing a dramatic improve- an RPD, the greater the reluctance to resort to such a device.
ment in oral health compared with a similar group 20 years ago. This potential barrier to the elderly accepting prosthetic treat-
A nationwide survey showed that the majority of adults pre- ment, together with the following specific problems, suggests
ferred to manage without a denture if several teeth were miss- that very careful thought is required before advising prosthetic
ing at the back of the mouth (Fig. 1). It also revealed that the treatment for the older population.
older age groups were more negatively inclined towards the
Specific problems of the elderly in relation to the

provision of RPDs
Fig. 5 — Tooth wear
Tooth wear is an increasingly common finding, particularly in older
patients. The initiating factor may be attrition, abrasion or erosion, and in
more advanced wear a combination of these agents may be involved. It is
important to establish a diagnosis if possible and institute measures to
eliminate any causative factors, thus preventing further damage to the
dentition.
There is some evidence that in those patients who are suscep- with the appearance of worn teeth in the anterior region of
tible to tooth wear, the problem may be more severe if the denti- the mouth. When the wear is moderate in extent, the teeth
tion is depleted and functional loading is concentrated on a small may be either maintained or restored with crowns and RPDs
number of contacting teeth. If it is evident that tooth loss has cre- in order to stabilise the occlusal relationship and replace miss-
ated a deficiency in occlusal support, the provision of RPDs may ing teeth. When wear is more severe, overlays may be incor-
help to stabilise the situation and prevent further deterioration. porated in the denture design to provide a satisfactory
Patients will often seek treatment because they are unhappy aesthetic and functional result.

PRACTICE
prosthetics
Fig. 6 — Tooth wear
In extreme cases it may be more appropriate to consider the reduction of
some teeth to serve as overdenture abutments. Root abutments can
make a substantial contribution to the support of RPDs, particularly when
the alternative would be an edentulous saddle area opposed by a
substantial group of natural teeth.
Fig. 7 — Root surface caries

Reference has previously been made to the tendency for RPDs to
encourage the accumulation of plaque. This factor becomes particularly
important in older patients as gingival recession may lead to the exposure
of root structure and an increased risk of root surface caries. The
situation will be aggravated further if the ability to maintain adequate
plaque control becomes impaired for any reason and if the intake of
fermentable carbohydrate increases as taste sensitivity declines and
masticatory efficiency diminishes. It is therefore particularly important to
ensure that dentures are designed to minimise contact with, or coverage
of, vulnerable areas. For example, gingivally approaching clasps which
cross and contact the exposed root surface should only be used if a
careful evaluation indicates that the risk to a particular patient is
insignificant.
Patient assessment Desire and motivation

General health status As mentioned earlier, it is important to assess the degree to which
Age by itself is an imprecise guideline in the assessment of older patients are motivated to wearing RPDs. It is not uncommon to
patients. Of much greater importance is the effect that illness may find that the request for prosthetic treatment comes from carers
have had on the ageing process. For this reason a detailed med- or members of the family, particularly if they feel that the
ical history is essential and should include a full list of any pre- patient’s recovery from severe illness is being hampered by an
scribed medications. inadequate dentition. Unless patients themselves wish to have
The state of health is an important factor to be considered RPDs and unless a high standard of plaque control can be
when deciding whether or not to advise the provision of RPDs. achieved either by the patients themselves or by the carers, treat-
Progressive infirmity or debility can have an adverse effect on the ment is unlikely to be successful.
capacity to adapt and may explain the difficulty that some
patients have in coming to terms with dentures, particularly if Domestic circumstances
they have had no previous denture wearing experience. It is thus Social factors should also be considered. For example, the absence
very important to determine what, if any, improvement in the of support from carers may pose difficulties for patients in
state of health can be expected. The effect that health factors may attending for treatment or in complying with the necessary main-
have on the ability of patients to attend for treatment and sub- tenance procedures.
sequent maintenance must also be considered.
The wearing of even the best designed RPD is likely to be Assessment of existing RPDs
accompanied by an increase in plaque accumulation. If there is The assessment of existing RPDs and an understanding of pre-
evidence of the patient having difficulty in undertaking mainte- vious denture wearing experience should follow precisely the
nance procedures, the potential for damage may outweigh the format described in Chapter 7 of our BDJ publication ‘A Clini-
likely benefits of the prosthesis in terms of function and aesthet- cal Guide to Partial Dentures’.
ics. For example, a patient may have difficulty in cleaning nat-
ural and artificial teeth because of failing eyesight. Alternatively,
a drug-induced dry mouth with its associated reduction in the
buffering capacity and volume of saliva can result in a dramatic
increase in caries and periodontal disease.

PRACTICE
prosthetics
Treatment options
For the older patient, decisions on whether or not to provide harm to the mouth may well be more critical than for a younger
RPDs and of balancing benefits of a prosthesis against potential patient.
a b
Fig. 8a and b — Treatment options

If a shortened dental arch exists particular attention must be given to the possibility of simply maintaining the status
quo rather than providing an RPD.
Fig. 9 — Treatment options

In this example the patient had no worries about appearance but had
experienced difficulties in eating. By providing a mandibular RPD to
improve masticatory ability, treatment that met the patient’s specific
concerns, it was possible to avoid an RPD in the maxillary arch.
Fig. 10 — Treatment options

Where there has been extensive tooth loss, one of the most important
decisions is whether or not to retain a selection of teeth to assist with the
wearing of an RPD. Even if it appears that such an arrangement may have
a limited life it is usually far preferable to extractions and the provision of
complete dentures. In this example the remaining natural teeth helped to
stabilise maxillary and mandibular RPDs. After a short time two of the
maxillary teeth and both mandibular teeth were converted to
overdenture abutments and continued to serve the patient faithfully for
many years. Thus an effective ‘pre-edentulous’ state was preserved.
Even if the eventual extraction of the remaining teeth is inevitable, their
retention in the short term to stabilise an RPD can make a significant
contribution to a successful transition of a patient to complete dentures.
Further reading
Need and demand RPDs and the elderly
Basker R M, O’Mullane D M. Removable prosthodontic services related to need Drummond J R, Newton J P, Yemm R. Dental care of the elderly. London: Mosby-
and demand. In Öwall B, Kayser A F, Carlsson G E. Prosthodontics: principles Wolfe, 1994.
and management strategies. pp 223-235. London: Mosby-Wolfe, 1996. Franks A S T, Hedegård B. Geriatric Dentistry. Oxford: Blackwell Scientific, 1973.
Douglas C W, Gammon M D, Atwood D A. Need and effective demand for Ralph J P, Basker R M. The partially edentulous patient. In Barnes I, Walls A (ed).
prosthodontic treatment. J Prosthet Dent 1988; 59: 94-104. Gerodontology. pp 127-134, London: Wright, 1994.
Fiske J, Davis D M, Frances C, Gelbier S. The emotional effects of tooth loss in
edentulous people. Br Dent J 1998; 184: 90-93.

PRACTICE
prosthetics
2
The removable partial
denture equation
This article describes the benefits and risks of

providing RPDs. It emphasises the importance of In this part, we will discuss
• The benefits of RPDs
co-operation between the dental team and patient • Tissue damage associated with RPDs
to ensure that the balance of this ‘equation’ is in • Preserving oral health
the patient’s favour. • The importance of teamwork
he title of this part of the series requires immediate explana- • The essential oral functions of appearance, mastication and
T tion. The term ‘equation’ refers to the balance that must be
struck between the good and the bad which can arise from the
speech.
wearing of RPDs. In this chapter we explore the benefits which It is only after this analysis has been completed that the decision
can be conferred on patients by RPDs and, at the same time, of whether or not to treat a particular patient can be taken. For
highlight the possible risks of tissue damage that can be associ- example, prosthetic treatment must not begin until it has been
ated with such prostheses. verified that there is a significant reduction in one or more of the
Every prosthetic treatment is associated with the placement of a essential oral functions. A simple determination of the number
foreign object (the prosthesis) in the mouth of the patient. As a and position of the remaining teeth is not a sufficient foundation
direct consequence of such placement the burden on the tissues in for making the decision of whether or not to initiate treatment.
the oral cavity will be increased. For example, plaque more readily If it is indicated, a treatment plan is then devised identifying the
accumulates on alloplastic materials than biologic ones. Further- various stages and the most appropriate type of prosthesis.
more, even non-toxic materials will release small amounts of their
components into the oral cavity. To justify prosthetic treatment Benefits of RPDs
and to ensure that it is beneficial to the patient, the need for such The potential benefits of RPDs which will be considered in this
treatment must be established, the patient must be appropriately section are their contribution to the following.
motivated, and the dentures properly designed, constructed and
• Appearance
maintained. Thus the initial step in determining if prosthetic
• Speech
treatment is indicated must always be the assessment of:
• Mastication
• The patient’s wishes and concerns • Maintaining the health of the masticatory system:
• The relevant dental and medical history — preventing undesirable tooth movement
• The results of the extra-oral and intra-oral examinations — improving distribution of occlusal load
• Oral hygiene habits and status • Preparation for complete dentures.
1*Emeritus Professor, University of Birmingham, UK; 2Professor of Dental

New publications:
of Manchester (Formerly Senior Lecturer in Restorative Dentistry, University of (which will be published in the BDJ) have
Manchester) and Consultant in Restorative Dentistry, Central Manchester been included (together with a number
Healthcare Trust, Manchester, UK; 4Consultant in Restorative Dentistry, Leeds of unpublished parts) in the book
and Honorary Visiting Professor, Centre for Dental Services Studies, University of A Cinical Guide to Removable
© British Dental Journal 2000; 189: 414–424

PRACTICE
prosthetics
Fig. 1 — Appearance
The restoration of the missing UR2 (12), UR1(11) and UL1(21)
undeniably benefit this patient, an 18 year-old girl, and the motivation to
wear the denture is understandably strong. Particular attention has been
paid to the appearance of the denture by the careful choice of artificial
teeth and design of the flange. A natural appearance has been created by
using a ‘veined’ acrylic, by reproducing the pre-extraction form of
alveolar ridge and by making the distal margin of the flange thin and
irregular, thus masking the transition from flange to adjacent mucosa.
a b
Fig. 2a and b — Appearance

Not only may an RPD help to restore appearance but it may actually improve it.
(a) This patient’s maxillary lateral incisors had never developed and she
was concerned about the spacing of the anterior teeth.
(b) The combination of orthodontic movement of the central incisors and the provision of RPDs improved the
appearance.
If an incisor is not replaced soon after extraction, successful treatment at
a later date may be compromised. Here, the adjacent teeth have drifted
into the unrestored UL1(21) space. The reduced space does not allow
for an artificial tooth of a realistic size to be used on a denture. If a
reasonable aesthetic result is to be obtained the space must be re-
established by orthodontic treatment.
Fig. 4 — Speech
The loss of maxillary anterior teeth may prevent the clear reproduction
of certain sounds, particularly the ‘F’ and ‘V’ which are made by the lower
lip contacting the edges of the maxillary incisors. The replacement of
missing maxillary anterior teeth will make a significant contribution to the
quality of speech.

PRACTICE
prosthetics
Fig. 5 — Mastication
With modern foods and methods of preparation it is unlikely that a
patient will suffer from malnutrition even though a large number of teeth
are missing. However, the gaps that arise through the loss of posterior
teeth reduce the efficiency of mastication: the bolus of food is allowed to
slip into the edentulous areas and thus escape the crushing and shearing
action of the remaining teeth. An RPD will prevent this escape of the
bolus and thus contribute to efficient mastication.
Maintaining the health of the masticatory system

The provision of an RPD can make a positive contribution to
oral health by preventing, or minimising, the undesirable conse-
quences of tooth loss, as described in the following paragraphs.
Fig. 6 — Preventing undesirable tooth movement

When teeth are lost from a dental arch the teeth adjacent to the
edentulous space may tilt and move into that space. This drifting of teeth
opens up further spaces which increase the opportunity for food
impaction and plaque formation, encouraging inflammation of the
periodontal tissues and decalcification of the proximal surfaces of the
teeth. Inevitably, the longer such spaces remain unrestored, the greater
the chance of tooth movement. When teeth are lost from an opposing
arch over-eruption may occur with similar deleterious effects on the oral
health. However, if tooth movement has not occurred in spite of the
teeth being lost some years previously, it can be assumed that it is not
going to occur subsequently.

The long-term absence of antagonists has resulted in over-eruption of
maxillary and mandibular teeth. The teeth are virtually contacting the
opposing edentulous ridges creating major problems if RPDs have to be
provided.

In this example, UR6 (16) has over-erupted to such an extent that it has
lost most of its bony support. Extraction of the tooth is inevitable.

PRACTICE
prosthetics
Fig. 9 — Improved distribution of occlusal load
The loss of a large number of teeth puts an increasing functional burden
on the remaining teeth. In this example there is existing periodontal
disease. The increased functional load has hastened the destruction of the
periodontal attachments of the maxillary anterior teeth, which have
become increasingly mobile and have drifted labially.
Fig. 10 — Improved distribution of occlusal load

If the periodontal attachments of the remaining teeth are healthy, the
increased load may result in excessive tooth wear or may cause damage
to existing restorations. The restoration of gross loss of tooth substance,
as in this example, is likely to involve complex and prolonged treatment.
a b
Fig. 11a and b — Improved distribution of occlusal load

Over-eruption of a tooth may place it in such a position that it bears the brunt of the load on initial contact or in excursive movements of the mandible
and therefore it may well be subjected to excessive force. In addition, where over-eruption of a tooth has created an occlusal interference (*), the
patient may modify the habitual movement patterns of the mandible in order to avoid the interfering contact. Although such a modification may reduce
the load applied to the tooth, the changed pattern in activity of the mandibular musculature may subsequently produce muscular dysfunction.
From the foregoing examples it will be appreciated that if tooth expected to retain their remaining natural teeth for a consider-
loss is restored in sufficient time to prevent tooth movement, or able number of years, thus allowing the RPD to be regarded as a
to avoid excessive stress being placed on the remaining structures, long-term restoration. But we should remember those patients
the subsequent health of the oral tissues can benefit considerably. whose remaining teeth carry a relatively poor prognosis and for
However, the point should be made that severe damage to the whom, in due course, complete dentures are inevitable. If simple
existing structures is not an inevitable consequence of tooth loss. acrylic RPDs are provided, the patient is able to serve a pros-
The implications of this statement will become apparent later in thetic ‘apprenticeship’ with appliances which receive some sta-
this section when the damaging effects of the dentures them- bility from the few remaining teeth. In the fullness of time these
selves are described. transitional dentures become more extensive as further teeth are
extracted and the patient is gradually eased into the totally artifi-
Preparation for complete dentures cial dentition. This form of transitional treatment can be of con-
Most of this book is devoted to the treatment of patients who are siderable benefit, especially for the elderly patient.

PRACTICE
prosthetics
Fig.12 — Preparation for complete dentures
The location of the remaining teeth plays an important part in the success
of such a transitional denture. It is common for the six mandibular
anterior teeth to be the last remaining teeth in the mandible. A denture
restoring the posterior teeth is frequently not worn by the patient for the
following reasons. Firstly, the denture may be unstable because there is
little resistance to its displacement in a posterior direction; secondly,
there is very little motivation to wear the denture as the anterior teeth
are still present.
Fig. 13 — Preparation for complete dentures

If, instead of extracting all the teeth, the canines are retained, the denture
will be more stable. When the denture replaces anterior teeth it is very
much more likely to be worn and thus the patient is likely to gain greater
benefit from the transitional denture.
Fig. 14 — Preparation for complete dentures

It should be remembered that the transitional RPD is being placed in a
mouth where existing dental disease is only poorly controlled or is
uncontrolled. As will be seen in the next section, the very presence of a
denture aggravates the situation. If the mouth is not inspected regularly to
identify treatment needs as they arise, there is the likelihood of
acceleration of tissue damage, which may prejudice the eventual
complete denture foundation.
In this case the inflammation and hyperplasia of the palatal mucosa was
so severe that surgery had to be performed before further prosthetic
treatment could be undertaken.
Causes of damage related to the wearing of RPDs

Harmful effects can arise from the wearing of RPDs in a variety of wearing RPDs, such as caries and periodontal disease, can be
ways: from the plaque which is likely to accumulate around any avoided. However, frequent technical maintenance of RPDs is still
RPD; from direct trauma by individual components of the den- required if optimal oral function and health are to be preserved.
ture; from excessive functional forces which will be transmitted by When tissue damage does occur it is sometimes referred to as
an ill-designed prosthesis and from errors in the occlusion. the ‘biological price’ of wearing RPDs. The possible causes of
If the patient, with the help of the dental team, can maintain damage and their sequelae are summarised in the following table
optimal plaque control the hygiene-related complications of and are discussed in more detail in the subsequent sections.

PRACTICE
prosthetics
Table 1 Summary of damage that may result from wearing an RPD
Causes Teeth Periodontal tissues Edentulous areas Muscles of mastication
Plaque accumulation Decalcification Inflammation of gingival Inflammation of mucous

and caries tissues membrane
Progression to underlying
structures
Direct trauma from Abrasion and Inflammation of gingival Localised inflammation

components fracture of tissues of mucous membrane.
teeth or Progression to underlying Denture-induced
restorations structures hyperplasia
Transmission of (a) Tooth mobility Inflammation of mucous

excessive functional (b) Aggravation of existing membrane
forces periodontal disease Resorption of bone
Occlusal error (a) Tooth mobility Inflammation of mucous Muscle dysfunction

(b) Aggravation of existing membrane
periodontal disease Resorption of bone
Increased plaque accumulation

A considerable amount of research effort has been directed affects the quantity. Not only does more plaque accumulate
towards an understanding of the relationship between plaque around the teeth in the jaw in which the denture is placed, but also
accumulation and the wearing of RPDs. It is possible that the pres- more is found around the teeth in the opposing jaw unless the
ence of a denture influences the quality of the plaque; it certainly patient is instructed in meticulous oral hygiene procedures.
a b
Fig. 15a and b — Increased plaque accumulation

The areas that tend to collect most plaque are the proximal surfaces of abutment teeth adjacent to the saddle.
(a) These surfaces are difficult to clean when using a conventional toothbrush.
(b) An interdental brush cleans the proximal surfaces more effectively.

PRACTICE
prosthetics
a b
Fig. 16a and b — Increased plaque accumulation

The design of the denture may have a significant effect on plaque accumulation. For example, it has been shown
that more plaque collects under a lingual plate than under a lingual bar.
(a) The lingual plate is well supported on the natural teeth and fits well against tooth surfaces.
(b) However, gingival inflammation has been caused by the increased accumulation of plaque.
Fig. 17 — Increased plaque accumulation

Denture
If the plaque is allowed to persist, the inflammatory process will progress
to the deeper tissues, resulting in a chronic periodontitis. The periodontal
Tooth
attachment is progressively destroyed, a periodontal pocket develops and
the investing alveolar bone is lost.
Plaque
Pocket
Bone

Unless the increased accumulation of plaque is prevented, root caries is
likely. This is a problem that will increase as more patients continue to
wear RPDs into old age. Root caries is strongly associated with gingival
recession and the use of gingivally-approaching clasps in patients who are
at risk because of a cariogenic diet and poor plaque control.

PRACTICE
prosthetics
If plaque is allowed to persist on the denture impression surface, a
generalised inflammation, called denture stomatitis, may occur. Typically
the extent of the inflammation is demarcated by the outline of the palatal
connector. This condition is discussed more fully in Part 11.
a b
Fig. 20a and b — Direct trauma from components

The oral mucosa is vulnerable to direct trauma from components of dentures.
(a) In this instance the lingual bar has been positioned too close to the gingival margin. The continuous clasp
offers only limited tooth support for the denture.
(b) The denture has sunk into the tissues, stripping away the gingival tissues on the distal and lingual aspects of
LL3 (33).
There is no evidence for the contention that a clasp arm may wear away the enamel surface to a degree that is
significant clinically. However, the movement of a clasp arm may wear the surface of restorative materials.
Transmission of excessive force

Functional forces are transmitted by an RPD to the tissues with appreciated that the forces are tensile in nature and are dissi-
which it is in contact. If a denture is supported primarily by the pated over a relatively large area. A very different state of affairs
natural teeth most of the forces will be transmitted to the alveo- exists when a denture is supported only by the mucosa. Here the
lar bone through the fibres of the periodontal ligament. Bearing forces, largely compressive in nature, are transmitted over a
in mind the orientation of most of these fibres, it will be more restricted area.

PRACTICE
prosthetics
a b
Fig. 21a and b — Transmission of excessive force

If the forces transmitted to the mucosa and bone of the edentulous area are excessive, the mucosa will become
inflamed and the bone will resorb. The obvious consequence of bone resorption is an irreversible loss of part of
the denture foundation.
(a) In this example the denture is supported only on the tissues of the edentulous area. It has caused resorption
of the bone to such an extent that the lingual bar connector has been pushed down towards the floor of the
mouth.
(b) The amount of bone that has been destroyed is apparent when the denture is removed.
Fig. 22 — Transmission of excessive force

1 2 If the design of the denture is such that it transmits excessive force to a tooth there is
every chance that the tooth will become mobile.
In this example the incorrectly designed cingulum rest (1) transmits a horizontal force
to the canine tooth. Such horizontal forces are especially damaging to the periodontal
tissues. The incisal rest (2) transmits a more favourable vertical load.
Where periodontal changes are restricted to the marginal gingivae, elimination of
excessive force will usually allow the periodontal attachment to return to a normal
healthy state. Where the supporting structures have been affected by periodontal
disease there is unlikely to be complete resolution.
1 2 3
Fig. 23 — Occlusal error

If the occlusal surface of the RPD is not designed correctly, normal jaw closure may be prevented by a
premature occlusal contact. There are three possible sequelae:
(1) If the premature contact is on a natural tooth, damage to the tooth or its periodontal ligament may occur.
(2) If the saddle bears the brunt of the force of closure, there will be localised mucosal inflammation and
resorption of the underlying bone.
(3) If the patient attempts to steer the mandible around the premature contact until a more comfortable
occlusal position is found, this abnormal closing pattern throws increased demands on certain muscles of
mastication, which may result in the patient complaining of facial pain.

PRACTICE
prosthetics
Balancing the RPD equation
A number of longitudinal clinical studies of RPDs have shown With greater understanding of the relationship between
that the types of damage itemised in the last section may be plaque and dental disease and of the importance of plaque con-
commonly found amongst wearers of RPDs. Of considerable trol, reports have appeared whose findings make for more
concern are reports that many patients expressed satisfaction encouraging reading. There is now firm evidence that the wear-
with their dentures, in spite of the fact that dental health had ing of RPDs can be compatible with continued oral health. This
deteriorated markedly. Perhaps this finding is not altogether satisfactory outcome depends upon a three-fold effort, that of
surprising when we remember the insidious nature of the pro- the clinician, the dental technician and the patient.
gression of caries and periodontal disease.
a b
Fig. 24a and b — Contribution of the clinician

The primary responsibility of the dentist and the clinical team is to ensure that the remaining teeth and
supporting tissues are restored to a healthy state and that the patient is effectively motivated and instructed in
how to maintain this state.
(a) This mouth is not in a fit state to receive an RPD. There is chronic periodontal disease and accumulation of
plaque.
(b) This patient has responded well to instruction in oral hygiene and the periodontal tissues are healthy. The
dangers of wearing the RPDs are thus minimised.
The second area of responsibility of the clinician is in relation • Clearance of gingival margins
to the design and construction of the denture. Accuracy of the • Simplicity
clinical procedures must, of course, be ensured. In addition, the • Rigid connector.
clinician should produce a design based on criteria that have
been shown to promote continued oral health: These criteria are considered in greater detail in our BDJ book
• Effective support ‘A Clinical Guide to Removable Partial Denture Design’.
Fig. 25 — Contribution of the dental technician

The dental technician’s contribution is directed towards the careful
translation of the prescribed denture design into the denture itself, and
accurate construction and positioning of the denture components. In this
instance the inaccurate fit will encourage plaque formation with
consequent periodontal disease and caries, thus introducing an
unnecessary and avoidable risk to oral health.

PRACTICE
prosthetics
Fig. 26 — Contribution of the patient
It is probably true to say that a patient who maintains immaculate plaque
control and has a good tissue resistance, or ‘host response’, can be
provided with a less than satisfactorily designed denture and still maintain
good oral health. Such is the importance of patient factors in the RPD
equation. This patient has worn a maxillary RPD for many years. The
gingival tissues are healthy and the teeth are well supported by bone; all
this in spite of the fact that there is little opportunity to provide tooth
support.
For every patient, when a denture is contemplated, it is the disadvantage it is likely that it will be in the patient’s best interest
dentist’s responsibility to assess the advantages and disadvan- that a denture is not prescribed. Of course, where a denture is
tages for that particular individual. The level of disadvantage is required to replace an anterior tooth or teeth, the demand from
influenced primarily by the patient’s dental awareness and the patient will usually be overwhelming even if the level of
plaque control. When the balance of the equation leans towards plaque control is less than satisfactory.
a b
Fig. 27a and b — Contribution of the patient

In this mouth the reasons for providing dentures are not overwhelming. There are sufficient teeth at the front of
the mouth to satisfy the demands of appearance and speech. There are certainly enough teeth to allow a varied
diet to be eaten. Most of the teeth have antagonists in the opposing arch.
If the mouth is well cared for and the patient requests dentures, the RPD equation is favourably balanced.
However, if plaque control is suspect, there is a strong argument for advising against dentures, at least for a few
months until the long-term response to oral hygiene advice is ascertained.
Further reading Renner R P. Periodontal considerations for the construction of removable partial
dentures — I and II. Quintessence Dent Technol 1985; 9: 169-72, 241-245.
RPDs and Oral Health Wagg B J. Root surface caries: a review. Comm Dent Health 1984; 1: 11-20.
Bates J F. Plaque accumulation and partial denture design. In Bates J F, Neill D J, Yap U J, Ong G. Periodontal considerations in restorative dentistry. Part 2: Prostho-
Preiskel H W (ed). Restoration of the Partially Dentate Mouth, 225-236. Chicago: dontic considerations. Dent Update 1995; 22: 13-16.
Quintessence, 1984.
Berg B. Periodontal problems associated with use of distal extension removable partial Survival of Removable Partial Dentures
dentures — a matter of construction? J Oral Rehabil 1985; 12: 369-379. Bergman B, Hugoson A, Olsson C-O. A 25 year longitudinal study of patients treated
Blinkhorn A S. Dental health education: what lessons have we ignored? Br Dent J 1998; with removable partial dentures. J Oral Rehabil 1995; 22: 595-599.
184: 58-59. Bergman B. Prognosis for prosthodontic treatment of partially edentulous patients. In:
Budtz-Jorgenson E. Oral mucosal lesions associated with the wearing of removable Owall B, Kayser A F, Carlsson G B. Prosthodontics: principles and management
dentures. J Oral Path 1981; 10: 65-80. strategies. London: Mosby-Wolfe, 1996.
Carlsson G E, Hedegård B, Koivumaa K K. Studies in partial denture prosthesis IV. Frank R P, Milgrom P, Leroux B G, Hawkins N R. Treatment outcomes with mandibu-
Final results of a 4-year longitudinal investigation of dentogingivally supported lar removable partial dentures: a population-based study of patient satisfaction.
partial dentures. Acta Odont Scand 1965; 23: 443-472. J Prosthet Dent 1998; 80: 36-45.
Chandler J A and Brudvik J S. Clinical evaluation of patients eight to nine years after Kapur K K, Deupree R, Dent R J, Hasse A L. A randomised clinical trial of two basic
placement of removable partial dentures. J Prosthet Dent 1984; 51: 736-743. removable partial denture designs. Part I: Comparisons of five year success rates
Germundsson B, Hellman M, Odman P. Effects of rehabilitation with conventional and periodontal health. J Prosthet Dent 1994; 72: 268-282.
removable partial dentures. Swed Dent J 1984; 8: 171-182. Kapur K K, Garrett N R, Dent R J, Hasse A L. A randomised clinical trial of two basic
Gray R J M, Davies S J, Quayle A A. Temporomandibular disorders. a clinical approach. removable partial denture designs. Part II: Comparisons of masticatory scores.
London: British Dental Association, 1995. J Prosthet Dent 1997; 78: 15-21.
MacEntee M I. Biologic sequelae of tooth replacement with removable partial den- Libby G, Arcuri M R, LaVelle W E, Hebl E. Longevity of fixed partial dentures. J Pros-
tures: a case for caution. J Prosthet Dent 1993; 70: 132-134. thet Dent 1997; 78: 127-13 1.
McHenry K R, Johansson O B, Christersson L A. The effect of removable partial den- Vermeulen A H B M, Kelyjens H M A M, van’t Hof M A, Kayser A F. Ten-year evalua-
ture framework design on gingival inflammation — a clinical model. J Prosthet tion of removable partial dentures: survival rates based on retreatment, not wearing
Dent 1992; 68: 799-803. and replacement. J Prosthet Dent 1996; 76: 267-272.
Orr S, Linden G J, Newman H N. The effect of partial denture connectors on gingival
health. J Clin Periodontol 1992; 19: 589-594.

PRACTICE
prosthetics
Communication between
3 the dentist and the dental
technician
J. C. Davenport,1 R. M. Basker,2 J. R. Heath,3 J. P. Ralph,4 P-O. Glantz,5 and P. Hammond,6
Factors contributing to good RPD design are In this part, we will discuss
described, including the respective inputs of the • Factors contributing to good RPD design
dentist and dental technician. Poor communication • The dentist’s input
• The dental technician’s input
in current practice is reported and an appropriate • Delegation of the dentist’s responsibility
format for a work authorisation presented. • The work authorisation
• An ability to modify the oral environment, eg by tooth

n order to obtain the best possible results from removable
I partial denture treatment, it is essential that the dentist and
dental technician work together effectively as a team. Each
preparation, periodontal and orthodontic therapy etc., to
increase the effectiveness of the RPD treatment.
• An ability to design an RPD which enhances, rather than
should have a sound understanding of the role of the other so
compromises, oral function.
that they can collaborate in an effective fashion.
• An ability to anticipate possible future oral changes which
The creation of an optimal RPD design is dependent on the
can then be taken into account when designing the RPD.
following factors:
• Clinical knowledge and training. The technician’s input is founded on:
• A thorough assessment of the patient. • The ability to translate two-dimensional design diagrams
• Appropriate treatment planning including any mouth prepa- and written instructions into the three-dimensional reality
ration. of an RPD, according to accepted biological and mechani-
• Technical expertise and knowledge of the properties of cal principles.
materials. • The knowledge of appropriate techniques and materials to
produce the finished RPD.
Clearly the dentist’s contribution is related primarily to the
first three aspects while the technician’s contribution is con- It is clearly essential that a dialogue between the two members
cerned with the fourth. of the team takes place so the expertise of both can be combined
The dentist’s input is founded on the following: to ensure that the required outcome is achieved.
• A knowledge of biological factors, pathological processes
and the possible influence of mechanical factors on the The roles of the dentist and the dental technician – the reality
masticatory system. In spite of the importance of the dentist in the RPD design
• A knowledge of the patient’s medical and dental history process, numerous studies in several countries have demon-
and an ability to appreciate, and to take account of, those strated that there is widespread delegation of the responsibility
aspects likely to be significant in RPD treatment. for design by the dentist to the technician. There are probably
• An ability to undertake a thorough clinical examination many factors involved in this abrogation of the dentist’s respon-
and analysis of the oral environment. sibility, but there is no doubt that it results in patients being pro-
vided with RPDs that do not take account of clinical and
1*Emeritus Professor, University of Birmingham, UK ; 2Professor of Dental biological circumstances.
Teaching Hospitals NHS Trust, Leeds, UK; 3Honorary Research Fellow, University New publications:
of Manchester (Formerly Senior Lecturer in Restorative Dentistry, University of
Manchester) and Consultant in Restorative Dentistry, Central Manchester
Healthcare Trust, Manchester, UK; 4Consultant in Restorative Dentistry, Leeds (which will be published in the BDJ)
Teaching Hospitals NHS Trust and Senior Clinical Lecturer, University of Leeds have been included (together with a
and Honorary Visiting Professor, Centre for Dental Services Studies, University of number of unpublished parts) in the
York, York, UK; 5Professor of Prosthetic Dentistry, Consultant in Prosthetic
Dentistry, Faculty of Odontology, University of Malmo, Sweden; 6Professor of books A Cinical Guide to Removable
Informatics, Eastman Dental Institute for Oral Health Care Sciences, University Partial Dentures (ISBN 0-904588-599)
College London, UK and A Clinical Guide to Removable
*Correspondence to: 5 Victoria Road, Harborne, Birmingham B17 0AG Partial Denture Design (ISBN 0-904588-637).
BRITISH DENTAL JOURNAL, VOLUME 189, NO. 9, NOVEMBER 11 2000 471

PRACTICE
prosthetics
The work authorisation It is obviously essential for effective communication that the
In a number of countries, including the USA and Sweden, leg- dentist and technician have a clear understanding of each oth-
islation states that the dentist has ultimate responsibility for ers terminology. Clarification of the design diagram may be
all dental treatment, including the design and material of any achieved by using a colour code to identify different RPD com-
prosthesis produced by dental laboratories. In the European ponents or functions. Since there is no universally agreed colour
Community, the Guidance Notes for Manufacturers of Dental code in existence, agreement between the dentist and the tech-
Appliances (1994) of the Medical Devices Agency state that nician on the meaning of any code is essential. One such exam-
these devices (RPDs) are made in accordance with a duly qual- ple is a system based on the function of the RPD components:
ified practitioner’s written prescription which gives, under his • Red – support.
responsibility, specific design characteristics. In the USA, State • Green – retention.
laws require a written Work Authorisation Order to accom- • Blue – bracing/reciprocation.
pany all work sent by a dentist to a dental laboratory. • Black – connection.
Fig. 1 — The design diagram

A satisfactory work authorisation for an RPD design takes the form of an
annotated diagram of the design produced after a thorough assessment of
both the patient and of surveyed, often articulated, study casts.

To be an efficient means of communication between dentist and technician,
the design diagram must be executed with skill and precision. If the diagram
is of poor quality, as in this case, misinterpretation and inappropriate
shaping and positioning of components is possible.

Good quality coloured annotated design diagrams can quickly be
produced using a computerised knowledge-based system (‘RaPiD’, TMS
Ltd, Aylesbury, UK) for RPD design. Design expertise incorporated in the
software reacts if a mistake is made and guides the user to an acceptable
design solution. The development of such computerised RPD systems
introduces the possibility of on-line discussion between dentist and dental
technician of RPD designs via the Internet. This form of tele-dentistry has
potential as a useful new communications link between these two
members of the dental team.
472 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 9, NOVEMBER 11 2000

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prosthetics
Clinician's name Instructions for all stages Laboratory name

(Date instructions and strike through
Address when obsolete.) Address
Phone No Fax
Phone N o E-mail MDD Registration No
Fax E-mail
Type of
Patient' s name
prosthesis (es)
Materials NHS Teeth Shade

U L
Independent Mould
Acrylic resin
Metal Private Make
Stages Date required Technician Quality control
Casts – [surveyed*]
Special tray – [spaced*, perforated*]
Occlusal rims
Framework try-in [with teeth*]
Re-try
Finish
*Delete as appropriate}
This is a custom made device for the exclusive

Job No use of the above named patient. When signed
in this box the device conforms to the relevant
essential requirements set out in Annex 1 of
Work reviewed and accepted by – the Medical Devices Directives (93/42/EEC)
This design is not valid until signed by a qualified clinician. unless stated otherwise in this document.
Clinician’s signature Date Technician's Signature Technician's Signature
Clinical item disinfected? (Y / N - delete as appropriate and enter date) Date Date
Y/N Y/N Y/N Y/N Y/N

Keep this device away from extremes of heat and cold. Non-sterile device.
Y/N Y/N Y/N Y/N Y/N
Shaded areas for laboratory use only.
a b
Fig. 4a and b — The design diagram

When producing a design diagram it is helpful to use a proforma, such as the example here, which includes the
following information:
• Patient – name; registration number.
• Dental practice – practice address, telephone, fax, e-mail, clinician’s name.
• Date of next appointment.
• Dental laboratory – laboratory address, telephone, fax, e-mail, job number; technician’s name.
• RPD design diagram.
• RPD components, materials, specific instructions, eg type of articulator.
• Any statement required by current legislation, eg those stipulated by the Medical Devices Agency.
The study cast

Fig. 5 — The study cast
However well the design diagram is produced, it still suffers from the
significant limitation of being a two-dimensional representation of a three-
dimensional object. Designs that appear entirely satisfactory in two-
dimensions can be obviously in need of modification when seen in three
dimensions. Also, subsequent transfer of two-dimensional information by
the technician from the paper diagram to the three-dimensional cast can
lead to errors of interpretation. Therefore, it is desirable for the dentist to
transfer at least the outline of the major connector from the diagram to
the study cast before sending both to the technician. In many cases there
can be advantages if the dentist goes further and draws on the cast details
of other components such as minor connectors, guide plates, clasps and
occlusal rests.

PRACTICE
prosthetics
Fig. 6 — The study cast
Sometimes a patient may present with an RPD that has given satisfactory
service for many years but is now ‘worn out’. A study cast obtained from
an impression of the old denture in situ will provide clear details of the
connector outline and sometimes also the location of other components
which will provide a useful reference when designing and fabricating the
replacement denture.
Verbal communication
However thorough the dentist is in providing the technician Apparently insurmountable difficulties can then evaporate.
with details of an RPD design together with all the supporting Each participant can acquire a far better understanding of the
records, it is possible that the technician will still sometimes work of the other and in the process forge stronger team links
need additional information or clarification. Under such cir- and become a significantly better healthcare worker as a result.
cumstances the value of discussing the case face-to-face, if the Increasingly, electronic links such as e-mail and the Internet are
technician works on the premises, or on the telephone if the likely to become more widely used for such communication.
laboratory is elsewhere, cannot be underestimated.

PRACTICE
prosthetics
Surveying
4
This article describes the clinical objectives and In this part, we will discuss
procedures for surveying a dental cast prior to • Surveyor attachments
designing an RPD • Guide surfaces
• Paths of insertion and displacement
• Surveying sequence
• Indications for tilting a cast
• Positioning retentive clasps
• Recording the orientation of a cast
Fig. 1 — Surveying
The surveyor was first introduced to the dental profession in 1918.
This instrument, which is essentially a parallelometer, is one of the
cornerstones of effective RPD design and construction. The
surveyor allows a vertical arm to be brought into contact with the
teeth and ridges of the dental cast, thus identifying parallel surfaces
and points of maximum contour.
Ideally the clinician, rather than the dental technician, surveys the
study cast in preparation for designing an RPD. It is this design,
produced in the light of clinical knowledge and experience, which
guides decisions on pre-prosthetic treatment and which is ultimately
sent as a prescription to the dental technician, who constructs the
denture accordingly.
There are several different attachments that may be used with the
surveyor.
Analysing rod
Fig. 2 — Analysing rod
This metal rod is placed against the teeth and ridges during the initial
analysis of the cast to identify undercut areas and to determine the
parallelism of surfaces without marking the cast.

Prosthetics, University of Leeds and Consultant in Restorative Dentistry, Leeds New publications:
Teaching Hospitals NHS Trust, Leeds, UK; 3Honorary Research Fellow, University All the parts which comprise this series
Healthcare Trust, Manchester, UK; 4Consultant in Restorative Dentistry, Leeds
Teaching Hospitals NHS Trust and Senior Clinical Lecturer, University of Leeds number of unpublished parts) in the
and Honorary Visiting Professor, Centre for Dental Services Studies, University of books A Cinical Guide to Removable
Dentistry, Faculty of Odontology, University of Malmo, Sweden
and A Clinical Guide to Removable
email: john.davenport@btclick.com Partial Denture Design (ISBN 0-904588-637).
PRACTICE
prosthetics
Graphite marker
Fig. 3 — Graphite marker
The graphite marker is moved around the tooth and along the
alveolar ridge to identify and mark the position of maximum
convexity (survey line) separating non-undercut from undercut areas.
When surveying a tooth, the tip of the marker should be level with
the gingival margin allowing the side of the marker to produce the
survey line as shown in the illustration.
Fig. 4 — Graphite marker

A false survey line will be produced if the tip of the marker is
incorrectly positioned. In this example there is not, in fact, an
undercut area on the tooth although an incorrect surveying technique
has indicated one. If this false line is used in designing an RPD, errors
will arise in the positioning of components, especially clasps.
Undercut gauge
Fig. 5 — Undercut gauge
Gauges are provided to measure the extent of horizontal undercut
and are available in the following sizes: 0.25 mm, 0.50 mm and 0.75
mm. By adjusting the vertical position of the gauge until the shank and
head contact the cast simultaneously, the point at which a specific
extent of horizontal undercut occurs can be identified and marked.
This procedure allows correct positioning of retentive clasp arms on
the tooth surface as described in Chapter 6 of our publication —
‘A Clinical Guide to Partial Denture Design’.
Other, more sophisticated, types of undercut gauge are available
such as dial gauges and electronic gauges. These attachments fulfil the
same function as the simpler type of gauge.
Trimming knife
Fig. 6 — Trimming knife
This instrument is used to eliminate unwanted undercuts on the
master cast. Wax is added to these unwanted undercut areas and
then the excess is removed with the trimmer so that the modified
surfaces are parallel to the chosen path of insertion. A duplicate cast
is then made on which the denture is manufactured. Such a
procedure eliminates the problem shown in Fig. 7.
When elimination of undercuts is required on a cast which is not to
be duplicated, a material such as zinc phosphate cement, which can
resist the boiling out procedure, is used. The surveyor is used to
shape the cement before it is fully set.
PRACTICE
prosthetics
a b
Fig. 7a and b — Trimming knife

(a) This RPD cannot be inserted in the mouth because failure to eliminate unwanted undercut on the
cast has resulted in acrylic resin being processed into the area.
(b) This denture has been processed on a correctly prepared cast and, as a result, there is no interference
with insertion.
Fig. 8 — Trimming knife

The trimming knife can also be used to prepare guide surfaces (Fig. 9)
on wax patterns of crowns for abutment teeth.
Before discussing the functions of a surveyor in more detail it is • Path of insertion.

necessary to explain the following terms: • Path of displacement.
• Guide surfaces.
Guide surfaces (or guide planes)

Fig. 9 — Guide surfaces
Two or more parallel axial surfaces on abutment teeth which can be
used to limit the path of insertion and improve the stability of a
removable prosthesis. Guide surfaces may occur naturally on teeth
but more commonly need to be prepared.
Path of insertion
The path followed by the denture from its first contact with of displacement (Fig. 15). There may be a single path or mul-
the teeth until it is fully seated. This path coincides with the tiple paths of insertion.
path of withdrawal and may or may not coincide with the path
PRACTICE
prosthetics
Fig. 10 — Path of insertion
A single path of insertion may be created if sufficient guide surfaces
are contacted by the denture; it is most likely to exist when bounded
edentulous areas are present.

Multiple paths of insertion will exist where guide surfaces are not
utilised, for example where the abutment teeth are divergent.

Multiple paths will also exist where point contacts between the
saddle of the denture and the abutment teeth are employed in the
‘open’ design of saddle. The philosophy for this approach is discussed
in Chapter 4 of ‘A Clinical Guide to Partial Denture Design’.

Two distinct paths of insertion will be employed for a sectional, or
two-part denture illustrated here by a diagram in the sagittal plane of
2
a Kennedy Class IV denture. The abutment teeth on either side of the
saddle are not shown.
PRACTICE
prosthetics
Occasionally a rotational path of insertion can be used.
Path of displacement
Fig. 15 — Path of displacement
This is the direction in which the denture tends to be displaced in
function. The path is variable but is assumed for the purpose of
design to be at right angles to the occlusal plane.
Surveying procedure Preliminary visual assessment of the study cast

This may be divided into the following distinct phases: This stage has been described as ‘eyeballing’ the cast and is a use-
• Preliminary visual assessment of the study cast. ful preliminary to the surveying procedure proper. The cast is
• Initial survey. held in the hand and inspected from above. The general form
• Analysis. and arrangement of the teeth and ridge can be observed, any
• Final survey. obvious problems noted and an idea obtained as to whether or
not a tilted survey should be employed.
Figs 16 and 17 — Assessment of the study cast

Fig. 16 shows an anterior tilt (‘heels up’)
Fig. 17 shows a posterior tilt (‘heels down’). Clinical experience indicates that these are the positions of
the cast that most commonly give the greatest benefit. However, a lateral tilt of the cast to right or left
may also be indicated on occasion.
PRACTICE
prosthetics
Initial survey
Fig. 18 — Initial survey
The cast is positioned with the occlusal plane horizontal. The teeth
and ridges are then surveyed to identify undercut areas that might be
utilised to provide retention in relation to the most likely path of
displacement. The position of the survey lines and the variations in
the horizontal extent of undercut associated with them should be
noted. The amount of undercut can be judged approximately from
the size of the ‘triangle of light’ between the marker and the cervical
part of the tooth, or measured more precisely by using an undercut
gauge. An assessment can then be made as to whether the horizontal
extent of undercut is sufficient for retention purposes.
Analysis
An RPD can be designed on a cast which has been surveyed with The analysis of the cast continues with the occlusal plane hor-
the occlusal plane horizontal (ie so that the path of insertion izontal and the following aspects, one or more of which might
equals the path of displacement). However, there are occasions necessitate a final survey with the cast tilted, are considered:
when tilting of the cast is indicated so that the paths of inser- • Appearance.
tion and displacement differ. • Interference.
Before deciding if the cast should be tilted for the final survey • Retention.
the graphite marker in the surveyor is changed for an analysing
rod so that various positions of the cast can be examined with-
out marking the teeth.
Appearance
When a maxillary cast, containing an anterior edentulous area, is
surveyed with the occlusal plane horizontal it will often be found that
there are undercuts on the mesial aspects of the abutment teeth.
If the RPD is constructed with this vertical path of insertion there will
be an unsightly gap between the denture saddle and the abutment
teeth gingival to the contact point.
This unsightly gap can be avoided by giving the cast a posterior (heels
down) tilt so that the analysing rod is parallel with the mesiolabial
surface of the abutment tooth.
PRACTICE
prosthetics
With this posterior path of insertion the saddle can be made to
contact the abutment tooth over the whole of the mesiolabial surface
and a much better appearance results.
Interference
Fig. 22 — Interference
While examining the cast with the occlusal plane horizontal, it
sometimes becomes apparent that an undercut tooth or ridge would
obstruct the insertion and correct placement of a rigid part of the
denture. By tilting the cast, a path of insertion may be found which
avoids this interference. For example, if a bony undercut is present
labially, insertion of a flanged denture along a path at right angles to
the occlusal plane will only be possible if the flange stands away from
the mucosa or is finished short of the undercut area. This can result
in poor retention as well as a poor appearance.
Fig. 23 — Interference
If the cast is given a posterior tilt so that the rod, and thus the path of
insertion, is parallel to the labial surface of the ridge it is possible to
insert a flange that fits the ridge accurately.
Fig. 24a — Interference

Lingually tilted premolars can make it impossible to place a sublingual,
or lingual, bar connector sufficiently close to the lingual mucosa. Such
a problem would occur lingually to LR4 (44).
PRACTICE
prosthetics
Fig. 24b — Interference
Giving the cast an anterior (heels up) tilt reveals a path of insertion
that avoids this interference. If interference from a tooth is present
and cannot be avoided by selecting an appropriate path of insertion,
consideration should be given to the possibility of eliminating the
interference by tooth preparation, for example by crowning to
reduce the lingual overhang.
a b c
Retention
Fig. 25a–c — Retention
To obtain retention, undercuts must be present on teeth relative to the horizontal survey. It is a
misconception to believe that changing the tilt of the cast will produce retentive undercuts if none exist
when the cast is horizontal.
a) No undercuts on the tooth when the occlusal plane (OP) is horizontal.

b) An apparent undercut created by tilting the cast laterally.
c) Clasp arms placed in this false undercut do not provide any resistance to movement along the path of
displacement.
Fig. 26 — Retention
The principle of tilting the cast to enhance retention is that by so
1
altering the path of insertion (1) a rigid part of the denture can enter
an area of the tooth surface or an area of the ridge which is undercut
relative to the path of displacement (2).
In this example, providing retention by engaging the distal
undercut ( ) of the canine may well look more pleasing than a clasp
*
arm on the same tooth.
2
The choice of tilt for the final survey of the study cast will usu- Thus a posterior (heels down) tilt would be selected for the final
ally be a compromise as the requirements of different parts of survey which favours appearance at the expense of clasp reten-
the denture may conflict. This might be the case, for example, tion. It is of course possible to create more favourable uncercuts
where the appearance of a maxillary anterior saddle needs to on the molars by tooth preparation (A Clinical Guide to Remov-
take precedence over the optimum positioning of molar clasps. able Partial Dentures, Chapter 15)
PRACTICE
prosthetics
Final Survey
Fig. 27 — Final survey
If it is decided that the cast should be tilted, the analysing rod is
exchanged for a marker different in colour from that used in the first
survey, and the final survey is carried out. It will then usually be found
that the teeth to be clasped have two separate survey lines which cross
each other. In order to obtain optimum retention it is necessary to
understand how to position the clasps correctly in relation to the two
survey lines.
The aims for optimum retention should be to provide: ways of achieving these aims are illustrated in Figures 28–31. In
each case the red survey line has been produced with the cast
• Resistance along the path of displacement.
tilted and is relative to the path of insertion and withdrawal
• Resistance along the path of withdrawal.
while the green survey line has been produced with the cast hor-
The former can be achieved by the use of guide surfaces or izontal and is relative to the path of displacement.
clasps while the latter is provided by clasps alone. The various

When guide surfaces are used to provide resistance to displacement
of the denture in an occlusal direction, the retentive portion of the
clasp needs only to resist movement along the path of withdrawal
and therefore can be positioned solely with reference to the red
survey line.

It does not matter if, as in this example, the clasp engages too deep an
undercut relative to the path of displacement. Movement of the
denture in an occlusal direction is prevented by contact with the
guide surface, therefore permanent deformation of the clasp will not
occur.
When the denture does not contact guide surfaces on the will then provide the necessary retention without being perma-
clasped tooth the clasp will have to resist movement of the den- nently deformed either by insertion and removal of the denture
ture along both the path of withdrawal and the path of dis- along the planned path, or by inadvertent displacement of the
placement. The clasp will thus need to be positioned in the denture during function. Ways of achieving this are shown in
correct depth of undercut relative to both survey lines. The clasp Figures 30 and 31.
PRACTICE
prosthetics
A gingivally approaching clasp positioned at the cross-over point of
the survey lines resists movement along both the path of withdrawal
and the path of displacement without being permanently deformed
by movement along either path.

If the survey lines converge mesially or distally, the tip of an occlusally
approaching clasp can engage the common area of undercut to
provide resistance to movement along both paths.
If the cast has been tilted for the final survey, the degree of tilt duced in the laboratory. There are two methods of recording the
must be recorded so that the position of the cast can be repro- degree of tilt.

Using the tripod method, the vertical arm of the surveyor is locked at
a height that allows the tip of the marker to contact the palatal
surface of the ridge in the molar and incisal regions. Three points are
marked with the graphite marker, one on each side posteriorly and
one anteriorly. The points will then be ringed with a pencil so that
they are clearly visible.
PRACTICE
prosthetics
Alternatively, the analysing rod is placed against one side of the base
of the cast and a line drawn on the cast parallel to the rod. This is
repeated on the other side and at the back of the cast so that there
are three widely spaced lines parallel to the path of insertion.
Summary of the clinical objectives of surveying

Surveying is undertaken to obtain information that will allow (2) The design, material and position of clasps.
decisions to be made concerning the following: Decisions on these aspects of clasps can be arrived at from mea-
(1) The optimum path of insertion of the denture. The surement of the horizontal extent of undercut on abutment
choice of a path of insertion will be influenced by: teeth and the identification of sites on the teeth to provide
• the need to use guiding surfaces to achieve a reciprocation either from guiding surfaces or from cross-arch
pleasing appearance. reciprocation (Part 7 in this series).
• the need to avoid interference by the teeth or ridges
with correct positioning of denture components.
• the need to use guide surfaces for retention.
PRACTICE
prosthetics
A system of design
5
This article describes a method of building RPD

components into an effective design and indicates
how the details of the design can be communicated • Design sequence
clearly to the dental technician. • Design examples
• Reviewing the designs
• Design prescription
t will already be appreciated that an RPD is the sum of a num- 1. Saddles.

I ber of components. In this part of the series we describe a
method of building these components into a design and empha-
2.
3.
Support.
Retention.
size the importance of clearly detailing the design to the dental 4. Bracing and reciprocation.
technician. 5. Connector.
It must of course be remembered that the design sequence is 6. Indirect retention.
but one stage of the overall treatment plan for a partially eden- 7. Review of completed design.
tulous patient and is undertaken after completing the all-impor-
tant stages of surveying the cast and selecting a path of insertion. To help with identification, the various RPD components are
The following two examples illustrate how to apply the basic illustrated in different colours.
principles of design using the following sequence:
Example 1
Fig. 1 — Example 1
This maxillary arch has two bounded edentulous areas on the right
side and a distal extension edentulous area on the left. The teeth have
small crowns. Tooth UL4 (24) is rotated disto-buccally.

New publications:
Healthcare Trust, Manchester, UK; 4Consultant in Restorative Dentistry, Leeds number of unpublished parts) in the
and Honorary Visiting Professor, Centre for Dental Services Studies, University of books A Clinical Guide to Removable
586 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 11, DECEMBER 9 2000
PRACTICE
prosthetics
Saddles (yellow) and support (red)
Fig. 2 — Saddles and support
There is no requirement for a labial flange at UR3(13). It has been
decided to use a 'closed' design for all three saddles as the short clinical
crowns offer limited prospects for clasp retention. The saddle must be
fully extended in the distal extension edentulous area. Spaced
UR4 UL4
meshwork will be requested for the two posterior saddles to enable
them to be relined when required.
Tooth support is to be gained on UR7 (17), UR4 (14) and UL4 (24).
Because UL4 (24) is rotated, a mesial rest would be very visible and
unsightly. The occlusal rest is therefore placed on the distal aspect of the
tooth. This conflicts with advice given elsewhere in our BDJ publication UR7
A Clinical Guide to Removable Partial Denture Design to support a distal
extension saddle with a mesial rest. However, as the load from a
maxillary RPD can be distributed widely over the hard palate the
problems associated with differential support are not so marked here as
they are in the mandible. Rest seat preparation is planned for the three
teeth. As it is not possible to make this denture totally tooth-supported,
additional support must be gained from palatal coverage.
Retention (green)
It is practicable to obtain clasp retention from only three teeth (UR7
(17), UR4 (14) and UL4 (24)). Thus supplementary retention must be
obtained by wide palatal coverage, full extension of the denture base
into the left buccal sulcus and around the left tuberosity, and by contact
with the guide surfaces which will be prepared on the abutment teeth.
As most of the undercut on UR7 (17) is situated on its mesiobuccal
aspect, a 'ring' clasp is a suitable design. It is not possible to use a gingivally
approaching clasp on UR4 (14) because of a bony undercut in the buccal
sulcus. As an occlusally approaching clasp is the only reasonable
alternative, wrought gold wire has been chosen because it possesses
sufficient flexibility for the short clasp arm to function efficiently. As a
prominent fraenum precludes a gingivally approaching clasp on UL4 (24), a
wrought gold occlusally approaching clasp is to be used here also.
Bracing and reciprocation (blue)

Fig. 4 — Bracing and reciprocation
It has been decided to obtain bracing from the rigid palatal arm of the
'ring' clasp on UR7 (17), by contacting the palatal aspects of UR4 (14)
and UL4 (24) with the connector and by full extension of the distal
extension saddle. In this instance the bracing components on the
teeth will also provide reciprocation to the retentive arms on the
premolars. Retention will also be assisted by the buccal placement of
all retentive arms, thus providing cross-arch reciprocation.
Connector (black) and indirect retention

Fig. 5 — Connector and indirect retention
For the reasons given already, wide palatal coverage by the connector
is needed. However, it is possible to keep the anterior border of the
palatal plate away from the anterior teeth and from the sensitive area
around the incisive papilla to promote hygiene and tolerance to the
framework.
It is necessary to plan for indirect retention to prevent the distal
extension saddle from moving occlusally. The major clasp axis is sited
through UR7 (17) and UL4 (24). The mesial occlusal rest on UR4 (14)
will be the indirect retainer to resist the displacing force.
BRITISH DENTAL JOURNAL, VOLUME 189, NO. 11, DECEMBER 9 2000 587
PRACTICE
prosthetics
Design prescription
Fig, 6 — Design prescription
A provisional RPD design, produced at the initial treatment planning
stage, should be drawn on a proforma to provide easy reference
while any other restorative treatment is being carried out. Once this
treatment has been completed the provisional design should be
reviewed and updated in the light of any changes in the treatment
plan that proved to be necessary.
Having completed the design it is important to review the result
and to check that the design satisfies the four principles that have
been shown to promote continued oral health (Part 2 of this series):
• Effective support.
• Clearance of gingival margins.
• Simplicity.
• Rigid connector.
Fig. 7 — Design prescription

The confirmed design should also be drawn on the surveyed master
cast. The use of a different coloured lead to that used in the survey
will improve clarity.
The resulting definitive RPD design prescription is given to the
dental technician with the final impression. The prescription must
include details of the materials to be used. In this case the dental
technician will be asked to construct a cobalt chromium casting with
the retentive clasps on UR4 (14) and UL4 (24) being made from
0.8 mm wrought gold wire.
Fig. 8 — The completed framework

Careful planning and clear prescription result in the required metal
framework.
Example 2
Fig. 9 — Example 2
This mandibular arch has a unilateral distal extension edentulous area.
A gap exists between LR6 (46) and the mesially tilted LR8 (48).
PRACTICE
prosthetics
Saddles (yellow) and support (red)
Fig. 10 — Saddles and support
A spaced retaining meshwork will be required to enable the saddle to
be relined following alveolar resorption. A narrow occlusal table will LR8
be used to reduce the load falling on the tissues of the edentulous area.
A closed design will be used to provide reciprocation on the distal
surface of LL4 (34). LR6
Tooth support for the saddle will be gained from a mesial occlusal
rest on LL4 (34). The greatest possible mucosa support for the saddle
is achieved by extending the denture base onto the pear-shaped pad LL4
and to the full functional depth of the lingual and buccal sulci. On the LR4
right side of the arch it is important to spread the support so that a
stable prosthesis can be produced, thus rests have been placed on
LR4 (44), LR6 (46) and LR8 (48). The occlusal rests on the molars
bridge the gap between the two teeth. Rest seat preparations will be
carried out.
Retention (green)
The distal extension saddle will be carefully shaped to enable the oral
musculature to act against the polished surface to control the denture.
Suitable undercut and sulcus shapes allow a gingivally approaching
clasp to be used on LL4 (34). This clasp will be one of the components
for the RPI system and the tooth will be prepared accordingly. On LR6
(46) the usable undercut is on the mesiolingual aspect of the tooth and
will be engaged by an occlusally approaching clasp.
Bracing and reciprocation (blue)

Fig. 12 — Bracing and reciprocation
Lateral forces will be transmitted through the minor connectors,
through the buccal bracing arm on LR6 (46) and to the tissues of the
edentulous area through the fully extended flanges. Guide surfaces
will be prepared on LL4 (34) and LR6 (46) to provide reciprocation
for the retentive clasps.
Connector (black) and indirect retention

Fig. 13 — Connector and indirect retention
There is sufficient depth in the lingual sulcus for a sublingual bar. This
connector will be rigid and will avoid coverage of the gingival margins.
The three minor connectors will be placed as unobtrusively as
possible in the embrasures between the teeth so that the framework
is well tolerated by the patient.
The occlusal rest on LR4 (44) will provide effective indirect
retention for the distal extension saddle because it is positioned well
in front of the clasp axis passing through LL4 (34) and LR6 (46).
PRACTICE
prosthetics
Design prescription
The design is reviewed as described in Fig. 6 and then given to the
dental technician on a clearly labelled proforma as described for
Example 1.
In this instance the whole casting will be constructed in cobalt
chromium alloy.

The shape of the lingual sulcus, faithfully recorded on the cast,
dictates the shape and location of the sublingual bar. Nevertheless, it
is wise to draw the outline of the connector on the cast to avoid any
misunderstanding about its required position.
Fig. 16 — The completed framework

Careful planning and clear prescription again result in the required
metal framework.
PRACTICE
prosthetics
6 Retention
This article describes the mechanisms for retaining In this part, we will discuss
RPDs and considers the different types of direct • Mechanisms of RPD retention
retainer. The factors influencing the effectiveness • Clasp types, efficiency and selection
• Attachments
of retentive clasps and governing the choice of • RPI system
clasp are discussed. • Other retentive devices
Retention of an RPD can be achieved by:
• Using mechanical means such as clasps (1) which engage undercuts on
the tooth surface.
• Harnessing the patient’s muscular control (2) acting through the
polished surface of the denture.
2 2 • Using the inherent physical forces (3) which arise from coverage of the
mucosa by the denture.
Whether reliance is placed on all, or mainly on one of these
methods, depends on clinical circumstances. Retention by mechanical
means can also be obtained by selecting a path of insertion which
1 permits rigid components to enter undercut areas on teeth or on
3 ridges (Figs 23 and 26 of Part 4).
In this particular case there are sufficient teeth with suitable undercut
areas to allow the RPD to be retained by clasps. Successful clasp
retention allows the palatal coverage to be reduced to a minimum. Not
only does the patient appreciate this limited coverage but also it reduces
the risk of damage to the oral tissues.

Manchester) and Consultant in Restorative Dentistry, Central Manchester
(which will be published in the BDJ) have
Healthcare Trust, Manchester, UK; 4Consultant in Restorative Dentistry, Leeds been included (together with a number of
Teaching Hospitals NHS Trust and Senior Clinical Lecturer, University of Leeds unpublished parts) in the books
and Honorary Visiting Professor, Centre for Dental Services Studies, University of A Clinical Guide to Removable
York, York, UK; 5Professor of Prosthetic Dentistry, Consultant in Prosthetic
Dentistry, Faculty of Odontology, University of Malmo, Sweden Partial Dentures (ISBN 0-904588-599)
*Correspondence to: 5 Victoria Road, Harborne, Birmingham B17 0AG and A Clinical Guide to Removable
email: john.davenport@btclick.com Partial Denture Design (ISBN 0-904588-637).
REFEREED PAPER
Available from Macmillan on 01256 302699
PRACTICE
prosthetics
In contrast to the previous case, this patient’s remaining teeth offer less
opportunity for clasp retention. It is necessary, therefore, to cover more
of the palate in order to harness the physical forces of retention. The
broad palatal plate connector also provides a surface that the patient’s
tongue can press against to achieve muscular control of the prosthesis.
Muscular control is of particular importance for the success of an
extensive mandibular bilateral distal extension saddle denture. Although
this denture achieves some retention from clasps its success will depend
primarily on the muscles of the tongue and cheeks acting on the correctly
designed polished surfaces of the saddles.
As will be seen later in this section, there are circumstances muscular skills that will either augment or replace the contri-
where there is a tendency for retentive clasps to lose some of bution of the clasps.
their efficiency with the passage of time. Thus, in the long term, The remainder of this section is devoted to a consideration of
successful retention may become more dependent upon the components which provide mechanical retention, namely
physical forces and muscular control. However, it is generally clasps, precision attachments and other devices.
accepted that retentive clasps are particularly beneficial during
the early stages of denture wearing as they ensure effective
mechanical retention while the patient learns the appropriate
1 2
a b
Clasps
Fig. 5a and b — Clasps
Although many designs of retentive clasps have been described, they can be considered in one of two broad
categories: the occlusally approaching clasp on UL7 (27) and the gingivally approaching ‘I’ bar clasp on UL3
(23) (Fig. 5a). Common variations in the design of clasps (Fig. 5b) that may be selected primarily according to
the distribution of tooth undercuts include:
1 the ring clasp (which is occlusally approaching).
2 the ‘L’- or ‘T’-shaped gingivally approaching clasp.
PRACTICE
prosthetics
Fig. 6 — Clasps
Whatever type of clasp is used a denture will be retained successfully only
as long as the force required to flex the clasps over the maximum
bulbosities of the teeth is greater than the force which is attempting to
dislodge the denture. The retentive force is dictated by tooth shape and
by clasp design.
Tooth shape influences retention by determining the depth and
steepness of undercut available for clasping. Clasps 1 and 2 are positioned
in the same amount of undercut and therefore provide the same overall
retentive force. However, for the same small vertical displacement, clasp
1 is deflected more than clasp 2 and therefore offers greater initial
resistance to the displacing forces.
Fig. 7 — Clasps
The flexibility of a clasp is dependant on its design.
• Section
A round section clasp will flex equally in all directions, whereas a
half round clasp will flex more readily in the horizontal than in the
vertical plane.
• Length
The longer the clasp arm the more flexible it is. Thus an occlusally
approaching clasp on a molar tooth will be more flexible than one
on a premolar.
• Thickness
Thickness has a profound effect on flexibility. If the thickness is
reduced by half the flexibility is increased by a factor of eight.
• Curvature (see Fig. 8)
• Alloy (see Fig. 9)
a b

A clasp which is curved in two planes can exhibit the so-called ‘bucket handle’ effect in which torsional move-
ment of the clasp increases flexibility of the clasp arm.
PRACTICE
prosthetics
Fig. 9 — Clasps
Flexibility is also dependent upon the alloy used to construct the clasp.
1500 The most commonly used alloy, cobalt chromium, has a value for
modulus of elasticity (stiffness) indicated by the steepness of the first part
of the black curve, which is twice that of gold alloy (the red curve). Thus,
under identical conditions the force required to deflect the cobalt
1000
Stress (N/mm2)
chromium clasp over the bulbosity of the tooth will be twice that of a
gold clasp.
Of particular importance is the proportional limit of the alloy indicated
by the solid circles on the curves. If a clasp is stressed beyond the
500 proportional limit it will be distorted permanently. Hard gold and cobalt
chromium have similar proportional limits. Hardened stainless steel wire
(blue curve) has a much higher value.
0
0 0.02 0.04 0.06
Strain
stainless steel gold alloy

cobalt chromium alloy proportional limit
It will be appreciated that the factors mentioned above interact to be somewhat bewildering. In this book we feel it is appropri-
with each other. Thus the choice of an appropriate clasp which ate to offer the following clinical guidelines which have been
will retain a denture satisfactorily and yet not stress the tooth shown to work in practice.
unduly, or be distorted permanently during service, might appear
a b

As shown in (a), a cobalt chromium clasp arm, approximately l5 mm long, clasp arm can be achieved by using a gingivally-approaching design.
should be placed in a horizontal undercut of 0.25 mm. If the undercut is Whether this choice is appropriate depends on certain clinical factors that
less the retention will be inadequate. If it is greater, the clasp arm will be will be highlighted later in this chapter. Alternatively, an alloy with a lower
distorted because the proportional limit is likely to be exceeded. A cobalt modulus of elasticity but similar proportional limit, such as a
chromium occlusally-approaching clasp engaging the same amount of platinum–gold–palladium wire, can be used. Yet another possibility is to
undercut on a premolar tooth (b) is likely to distort during function use a material with a higher proportional limit but similar modulus such as
because it is too short. In such a situation a longer wrought stainless steel or cobalt chromium (Wiptam) wires.
Fig. 11 — Clasps
Whether a gold or stainless steel clasp arm can be provided depends on
the configuration of the denture. In this example the gold clasp on
UL5(25) can be held securely within the acrylic of the saddle.
PRACTICE
prosthetics
Fig. 12 — Clasps
If a gold clasp were to be provided for UL5(25) in this case, its only means
of attachment to the remainder of the denture would be by soldering it to
the cobalt chromium framework. Such a union is possible but relatively
weak and thus is prone to fracture during use.The metal frame of an RPD
ideally consists of a single alloy. However, if different metals or alloys are
present in the same oral environment, as in the examples described
above, interactions frequently occur between these materials that reduce
their individual properties. Corrosion is the most common reaction and it
begins as soon as different metals or alloys are in contact with each other.
Fig. 13 — Clasps
A cobalt chromium ‘Wiptam’ round wire clasp can be attached to the
framework using a ‘cast-on’ technique.
Where it is necessary to add clasp retention to an acrylic transitional
denture, stainless steel wire is a relatively inexpensive solution to the
problem. Wire of 0.75 mm diameter is appropriate for premolar teeth
while 1 mm diameter wire is suitable for molar teeth.
Two final points are worth making before we leave the subject partial denture design’) and by reciprocation (Figs 12 and 13 of
of clasp construction and progress to further consideration of Part 7). Second, the variables of clasp construction have been
design and clinical use. First, the efficiency of a retentive clasp simplified by certain manufacturers producing preformed wax
is also influenced by the support of the denture (Fig. 17, patterns with dimensions that are appropriate for the proper-
Chapter 5 of our BDJ publication ‘A clinical guide to removable ties of the alloy to be used and the tooth to be clasped.
Comparison of occlusally and gingivally

approaching clasps
Retention
Only the terminal third of an occlusally-approaching clasp (stippled
section) should cross the survey line and enter the undercut area. If, in
error, too much of the clasp arm engages the undercut, the high force
required to move it over the maximum bulbosity will put a considerable
strain on the fibres of the periodontal ligament and is likely to exceed the
proportional limit of the alloy, thus distorting the clasp.
A gingivally approaching clasp contacts the tooth surface only at its tip.
The remainder of the clasp arm is free of contact with the mucosa of the
sulcus and the gingival margin.
The length of the gingivally approaching clasp, unlike the occlusally
approaching clasp, is not restricted by the dimensions of the clasped
tooth. The length of the gingivally approaching clasp arm can therefore be
increased to give greater flexibility which can be a positive advantage
when it is necessary to clasp a premolar tooth or a tooth whose
periodontal attachment has been reduced by periodontal disease.
PRACTICE
prosthetics
Bracing
Fig. 16 — Bracing
The occlusally approaching clasp is more rigid, and more of it (stippled
section) is in contact with the tooth surface above the survey line. It is
therefore capable of transmitting more horizontal force to the tooth and
is a more efficient bracing component as a result (Part 7). Whether such a
measure is appropriate depends upon the health of the periodontal
tissues and the functional requirements of the RPD.
Appearance
Either type of clasp can detract from appearance when placed on a tooth
that is toward the front of the mouth. However, the gingivally
approaching clasp has more potential for being hidden in the distobuccal
aspect of a tooth provided that there is a suitable undercut area for the
clasp.
Tooth-coloured occlusally approaching polyoxymethylene clasps are an
alternative to metal clasps where the colour of the clasp is a key factor.
However, these clasps are bulkier than metal clasps and require a deeper
undercut. Other disadvantages include lack of adjustability and increased
cost.
Hygiene Occlusion
The gingivally approaching clasp can be criticized on the An occlusally approaching clasp must begin, and have two-
grounds that it crosses a gingival margin. There does not appear thirds of its length, in the area bounded by the occlusal contacts
to be any evidence to indicate that one clasp encourages more of the opposing teeth and the survey line on the tooth to be
plaque than the other. However, it is not unreasonable to assume clasped. Provision of an adequate space for the clasp may
that if the patient does not practise good oral hygiene the gin- require tooth preparation (see Figs 7, 8, 21–22 of Part 12).
givally approaching clasp could pose a greater threat to peri- Occlusal contacts, however, have no influence on gingivally
odontal health. approaching clasps.
The gingivally approaching clasp might also increase the risk
of root caries. It should be remembered that this lesion is strongly
associated with gingival recession, which itself is age-related.
PRACTICE
prosthetics
Factors governing the choice of retentive • Length of clasp.
clasp • Appearance.
• Occlusion.
The choice of retentive clasp for an individual tooth depends
upon the:
As we have already discussed the significance of the length of
clasp, appearance and occlusion, particular attention will be
• Position of the undercut.
focused on the first three factors.
• Health of the periodontal ligament.
• Shape of the sulcus.
The position of the undercut

Fig. 19 — The position of the undercut
The diagonal survey lines on the molar and premolar teeth shown here
indicate that there is a larger undercut on that part of the tooth which is
furthest away from the edentulous area. Typical designs of retentive clasp
are the occlusally approaching clasp on the molar and the gingivally
approaching ‘I’ bar on the premolar tooth.

The orientation of the diagonal survey line on this molar creates the
larger undercut area nearer to the saddle. The design of the occlusally
approaching clasp used on the molar in Fig. 19 would be quite
inappropriate because it would prove difficult to keep the non-retentive
two-thirds of the clasp out of the undercut whilst, at the same time,
offering very little undercut for the retentive portion. An alternative
design is the ring clasp that commences on the opposite side of the tooth
and attacks the diagonal survey line from a more appropriate direction.
An ‘I’ bar would be suitable for a premolar tooth with a survey line of
similar orientation.

Buccal Lingual A low survey line (on the buccal side of the tooth) is present because the
tooth is tilted; thus there is a high survey line on the lingual side of the
tooth. Again, a ring clasp is a solution to the problem: the bracing portion
of the clasp is on the left side of the tooth and the retentive portion on
the right side.

A high survey line poses particular difficulties on a premolar tooth. If it is
not appropriate or practical to lower the survey line by altering the
crown shape, it may be possible to position a flexible gingivally
approaching clasp higher up the crown or, if an occlusally approaching
clasp is preferred, to use a more flexible platinum–gold–palladium
wrought wire clasp.
Even if the survey line is not high enough to create difficulties in
clasping there will be potential advantages in using one of these more
flexible types of clasp on a premolar tooth (Fig. 10).
PRACTICE
prosthetics
The health of the periodontal ligament
If a retentive clasp is placed on a tooth, it is inevitable that extra without suffering damage depends upon their health, the area
force will be transmitted to the supporting tissues of that tooth. of attachment and the magnitude of the force.
Whether or not these tissues are able to absorb the extra force
Fig. 23 — The health of the periodontal ligament

This canine tooth has already lost approximately half its periodontal
attachment as a result of previous periodontal disease. Although the
disease process has been arrested, there is the possibility that further
damage will occur if a relatively inflexible retentive clasp system, such as
a cast cobalt chromium occlusally approaching clasp, is provided. If it is
considered essential to rely on mechanical retention, a possible solution
is to prescribe a more flexible gingivally approaching clasp. However, this
option should be used with caution if the gingival recession is associated
with root caries in which case a wrought wire occlusally approaching
clasp might then be more suitable.
The shape of the sulcus

Fig. 24 — The shape of the sulcus
If a gingivally approaching clasp is envisaged, the shape of the sulcus must be
checked carefully to ensure that there are no anatomical obstacles. In this
example the prominent fraenal attachment would be traumatised by a
gingivally approaching clasp of correct proportions and position. If there is no
reasonable alternative to this clasp, and mechanical retention is thought to be
essential, serious consideration must be given to surgical excision of the fraenal
attachment.
Fig. 25 — The shape of the sulcus

If there is an undercut in the sulcus, the arm of a gingivally approaching
clasp would have to be spaced from the mucosa of the ridge to allow the
denture to be inserted and removed without the clasp traumatising the
bulbous part of the ridge. If the undercut is deep, the resulting
prominence of the clasp arm is likely to irritate the buccal mucosa and
trap food debris, becoming an intolerable nuisance to the patient.
The German slang prosthodontic term for a gingivally approaching
clasp, ‘Sauerkrautfänger’ (‘cabbage catcher’), graphically describes the
situation.
The RPI system

Fig. 26 — The RPI system
The RPI system is a combination of occlusal rest (R) distal guide plate (P)
and gingivally approaching I bar clasp (I) used primarily with mandibular
distal extension saddles.
The minor connector carrying the mesial rest contacts the mesiolingual
surface of the abutment tooth and, together with the distal plate, acts as a
reciprocal for the tip of the retentive clasp which is positioned on or
anterior to the midpoint of the buccal surface of the tooth.
PRACTICE
prosthetics
The distal guide plate is positioned at the gingival end of a guide surface
prepared on the distal aspect of the tooth.

The RPI system is designed to allow vertical rotation of a distal extension
saddle into the denture-bearing mucosa under occlusal loading without
damaging the supporting structures of the abutment tooth. As the saddle
is pressed into the denture-bearing mucosa, the denture rotates about a
point close to the mesial rest. Both the distal guide plate and the I bar
move in the directions indicated and disengage from the tooth surface.
Potentially harmful torque is thus avoided.
When trying in the metal framework, it is advisable to check that it is
able to rotate about the abutment tooth in the intended fashion. If this is
found not to be the case, the framework should be carefully adjusted to
allow this rotation.

A distal extension saddle should not be rigidly attached to the abutment
tooth by a combination of stiff clasp and long guide plates. If these are
incorporated the occlusal loads falling on the saddle, which is in effect a
long cantilever arm, are likely to result in the RPD acting like extraction
forceps, with consequent damage to the supporting structures of the
tooth.
Attachments
An attachment is made up of two components, one located in Dentures, Figs 3.6 – 3.12. However, it is not the purpose of this
or on the abutment tooth and the other housed in the denture. book to provide detailed information on precision attachments
When the two matched parts are linked together they produce but rather to note their existence and refer the reader to texts
very positive retention. Attachments are discussed further in that deal with this topic.
our BDJ publication A Clinical Guide to Removable Partial
PRACTICE
prosthetics
Fig. 30 — Attachments
Tooth LR6 (46) has an example of an intracoronal micro-attachment. A
slot is incorporated within the substance of a crown and is engaged by a
matching component on the removable section.
The extracoronal micro-attachment, such as the Dalbo on the right of the
figure, is attached to the outside of the crown. The matched component
on the left is held in the denture and is designed to allow rotatory
movement as the distal extension saddle sinks into the denture-bearing
mucosa, thus taking some of the stress off the abutment tooth.
With attachments like the Kurer system, the
stud is fixed to the root face of a root-filled
tooth and a retainer held in the acrylic of the
denture base snaps over the stud.
In this example the stud attachment affords positive retention in the
anterior region for the extensive saddles.
PRACTICE
prosthetics
The advantages of attachments include positive retention in sues. As the attachments tend to encourage the formation of
the absence of clasp arms. Their use necessitates extensive plaque, the standard of oral hygiene must be immaculate.
preparation of the abutment teeth and an inevitable increase Maintenance of the denture may be complicated by wear of the
in cost of treatment. The more rigid attachments require attachments, which may necessitate replacement of the com-
the abutment teeth to have particularly healthy periodontal tis- ponent parts.
Other devices
Fig. 34 — Other devices
The ZA anchor is an example of a spring-loaded attachment. The spring-
loaded nipple engages an undercut on the surface of an abutment tooth
adjacent to the saddle. It is used for retaining bounded saddles and is of
particular value for maxillary canine or premolar teeth where a
conventional clasp arm would detract from appearance.

In recent years there has been an increasing interest in the use of
magnets. The modern alloys are powerful and retain their magnetism for
a long time. Each magnetic unit has a force of attraction in the region of
200–300 g, which is maximal as soon as the denture starts to move. This
force of attraction imparts a degree of security to the denture, without
putting great demands on the periodontal tissues of the abutment teeth.
In this example the bipolar magnet will be incorporated in the denture.
The keeper is housed in a gold coping fitted to a root-filled tooth.

The two-part denture makes use of opposing undercuts. Both parts are
2 1 inserted separately using different paths of insertion. In this figure the
portion coloured blue is inserted first from a mesial direction (1) to
engage the mesial undercut on the molar. Then the yellow portion is
inserted from a distal direction (2) to engage the distal undercut on the
premolar. Once the components are fully seated they are locked
together — in this instance with a bolt. This type of RPD is discussed
further in our BDJ publication A Clinical Guide to Removable Partial Denture
Design, Statement 11.2.
PRACTICE
prosthetics
A bolt retained sectional denture is shown in situ. The patient needs to
be reasonably dextrous to successfully manage a denture of this type.

The swing-lock denture has a hinged labial bar which has extensions into
undercuts on the labial surfaces of the teeth. When the ‘gate’ is closed
and locked into position, the denture is held securely by the ‘gate’ on the
labial aspect and by the reciprocating components on the lingual aspects
of the teeth. The denture can be particularly helpful where the remaining
natural teeth offer very little undercut for conventional clasp retention.
This patient, a trombone player, required a positively retained RPD. The
swing-lock design allowed optimum use to be made of the incisors. As
this type of denture covers a considerable amount of gingival margin, the
standard of plaque control must be high.
a b
Fig. 39a and b — Other devices

There is an added advantage of the swing-lock denture in that the ‘gate’ can carry a labial acrylic veneer.
This veneer can be used to improve the appearance when a large amount of root surface has been
exposed following periodontal surgery.
PRACTICE
prosthetics
7
Bracing and reciprocation
J. C. Davenport,1 R. M. Basker,2 J. R. Heath,3 J. P. Ralph,4 P-O. Glantz,5 and P. Hammond,6
This article describes how bracing can be used In this part, we will discuss
to produce stable RPDs which distribute forces • Distribution of forces
• Bracing components
efficiently to the supporting tissues. The
• Distal extension saddle problems
contribution of reciprocation to effective • Types of reciprocation
clasping is also discussed. • Guide surfaces
1 2 3
Bracing
Fig. 1 — Bracing
Horizontal forces are generated during function by occlusal contact (1 and 2) and by the oral musculature
surrounding the denture (3). These forces tend to displace the denture in both antero-posterior and
lateral directions.

Manchester) and Consultant in Restorative Dentistry, Central Manchester (which will be published in the BDJ) have
Healthcare Trust, Manchester, UK; 4Consultant in Restorative Dentistry, Leeds been included (together with a number
Teaching Hospitals NHS Trust and Senior Clinical Lecturer, University of Leeds and of unpublished parts) in the books
Honorary Visiting Professor, Centre for Dental Services Studies, University of York,
York, UK; 5Professor of Prosthetic Dentistry, Consultant in Prosthetic Dentistry, A Clinical Guide to Removable
Faculty of Odontology, University of Malmo, Sweden; 6Professor of Informatics, Partial Dentures (ISBN 0-904588-599)
Eastman Dental Institute for Oral Health Care Sciences, University College London and A Clinical Guide to Removable
10 BRITISH DENTAL JOURNAL, VOLUME 190, NO. 1, JANUARY 13 2001

PRACTICE
prosthetics
a b
Fig. 2a and b — Bracing

The horizontal forces are resisted by placing rigid components of the denture (bracing components)
against suitable vertical surfaces on the teeth and residual ridges. Parts of a denture resting against the
stippled areas will resist the forces whose directions are shown by the arrows. It is important to
appreciate that bracing occurs only when the denture is fully seated.
Fig. 3 — Bracing
The lateral forces in particular are capable of inflicting considerable
damage on the periodontal tissues and alveolar bone in the 3
edentulous areas. Thus they have to be carefully controlled. Bracing
on teeth may be achieved by means of rigid portions of clasp arms
(1) or plates (2). Bracing on the ridges and in the palate is obtained
by means of major connectors and flanges (3).
2 1
A distal extension saddle creates particular problems, as it is widely so that tissue damage is avoided. The problems are more
capable of being displaced posteriorly and of rotating in the hor- acute in the mandibular arch.
izontal plane. Furthermore, the lateral force must be distributed
Fig. 4 — Bracing
Those components of the RPD coloured blue are capable of resisting
lateral forces coming from the direction indicated by the arrows.
Needless to say, lateral forces in the opposite direction will be
resisted by the mirror images of these components.
BRITISH DENTAL JOURNAL, VOLUME 190, NO. 1, JANUARY 13 2001 11

PRACTICE
prosthetics
Fig. 5 — Bracing
Posterior movement of the distal extension saddle is prevented by
coverage of the pear-shaped pad and by the minor connector which
contacts the mesiolingual surface of the premolar tooth.
Fig. 6 — Bracing
Effective distribution of the lateral force in the maxilla is less of a
problem as much of it can be transmitted to the bone of the palatal
vault by extensive palatal coverage. Those components of the RPD
coloured blue are capable of resisting lateral forces coming from the
direction indicated by the arrows.
Fig. 7 — Bracing
The posterior part of the distal extension saddle is capable of rotating
in the horizontal plane. If a long saddle is clasped rigidly to a single
abutment tooth the rotatory movement can transmit considerable
force to that tooth.
Fig. 8 — Bracing
The flatter the ridge (1) or the more compressible the mucosa (2),
the greater is the potential for movement. It should also be
remembered that the close fit of a denture will deteriorate following
resorption of the residual ridge. Once more the potential for rotatory
movement is increased.
1 2

PRACTICE
prosthetics
Fig. 9 — Bracing
Potential movement
Rotation can be resisted effectively by this design that incorporates
appropriately placed bracing elements and joins them with a rigid
connector. Rotation of the right saddle in the direction of the blue
arrow is resisted by the minor connector contacting the mesial
surface of LL5 (35). Movement of the saddle in the direction of the
red arrow will be resisted by the minor connector contacting the
distal surface of the same tooth.
Fulcrum Resistance
Fig. 10 — Bracing
Rotation and anteroposterior movement of bounded saddles are
resisted by contact of the saddles with the abutment teeth. It
therefore remains to design bracing elements which will safely
distribute the lateral forces acting on the denture. The bracing
elements that oppose a lateral force indicated by the arrows are
shown in this illustration.
Fig. 11 — Bracing
(1) Anterior displacement of a maxillary Kennedy Class IV denture 1 2
can be resisted by elements of the framework contacting the disto-
palatal and disto-buccal surfaces of the teeth and, in some cases, by
the connector covering the anterior slope of the palate.
(2) Posterior displacement is resisted by the labial flange, by contact
between the saddle and the mesial surfaces of UR2 (12) and UL3
(23), by contact of the minor connectors against the mesiopalatal
surfaces of UR7 (17) and UL7 (27), and by the mesio-palatal and
mesio-buccal portions of the clasp arms on UR6 (16), UR7 (17),
UL6 (26) and UL7 (27).
Reciprocation
Fig. 12
caption 1 2
overleaf

PRACTICE
prosthetics
Fig. 12 — Reciprocation
The bracing element which is in contact with the side of the tooth opposite the retentive clasp can also play an important role in the effectiveness
of the latter, and thus in the overall retention of the denture. (1) A horizontally directed force is produced as a retentive arm is displaced in an
occlusal direction over the bulbosity of a tooth. If the clasp arm is unopposed the tooth is displaced in the periodontal space and much of the
retentive capability will be lost. (2) If the retentive clasp is opposed by a rigid component which maintains contact with the tooth as the retentive
arm moves over the bulbosity of the tooth, displacement of the tooth is resisted, the retentive arm is forced to flex and thus the efficiency of the
retentive element is increased. This principle is known as reciprocation. It is thus apparent that reciprocation is required as the denture is being
displaced occlusally whilst the bracing function, as mentioned earlier, comes into play when the denture is fully seated.
1 2 3 4
(1) A clasp is effective in retention from its position when the denture is fully seated to where it escapes over the bulbosity of the tooth. This
vertical measurement may be termed the 'retention distance'. It will be appreciated that the reciprocal element on the other side of the tooth
should be in continuous contact with the tooth surface as the retentive arm traverses the 'retention distance'. Effective reciprocation can be
achieved either (2) by a clasp arm contacting a guide surface of similar height to the 'retention distance', or (3) by a plate making continuous
contact with the tooth surface as the retentive arm moves through its 'retention distance'. (4) If the reciprocating clasp is placed on a tooth
without an adequate guide surface, it will lose contact with the tooth before the retentive arm has passed over the maximum bulbosity of the
tooth and fail to provide effective reciprocation.
1 2
On rare occasions it may be possible to find a guide surface which
occurs naturally on a tooth. More often it will be necessary to create
a suitable surface by (1) minimal shaping of the enamel or (2) building
the appropriate surface into a cast metal restoration, always
supposing that such an extensive restoration is justified on that
particular tooth.
If the tooth surface on which the bracing arm is to be placed has a
survey line at the level of the gingival margin, it will not be possible to
achieve effective reciprocation on the same tooth. In such
circumstances one may use the principle of cross-arch reciprocation,
where a retentive clasp on one side of the arch opposes a similar
component on the other side. The retentive clasps can be placed
either buccal/buccal (as in the illustration) or lingual/lingual. The
disadvantage of this approach is that, as the bracing arms leave the
tooth surfaces, the teeth will move in their sockets. This 'jiggling'
action is potentially damaging to the supporting tissues and will
reduce the effectiveness of the retention.

PRACTICE
prosthetics
8
Clasp design
J. C. Davenport,1 R. M. Basker,2 J. R. Heath,3 J. P. Ralph,4
P-O. Glantz,5 and P. Hammond,6
In this article statements related to the design of

clasps are listed and discussed. The opinion of
prosthodontic experts regarding these statements
is indicated in the accompanying pie charts.
any RPD design principles are based governing metal RPD design. Numerous
M more on clinical experience than scien-
tific evidence. Under these circumstances it is
experts have expressed their opinion on these
principles as part of a survey of the depart-
advisable for a dentist, when making RPD ments of removable prosthodontics in all
design decisions, to draw on the widest possi- dental schools in the UK and the Republic of
ble range of specialist opinion rather than to Ireland. This survey was undertaken to produce
rely on the views of just one, or a few, prostho- the knowledge base for a computerised design
dontists. assistant for RPDs.1 All 17 of the departments
To this end, this article and Chapters 11-15 responded and the results of the survey are
of our BDJ publication ‘A clinical guide to given as pie charts indicating the expert group’s
removable partial denture design’ present state- level of agreement or disagreement with each
ments that have been proposed as principles design principle:
The experts’ comments on these principles able, a design statement is likely to apply to the
have been incorporated into the discussions majority, though not necessarily all, cases.
that follow. Readers can then compare their opinions with
Readers are invited to use this article in an those of the experts and consider the points
interactive way by first forming their own raised in the discussions.
opinion of each of the design principles listed
at the beginning of the article. When doing
this it should be assumed that, to be accept- 1 ‘RaPiD’, Team Management Systems Ltd, Aylesbury, UK.
1*Emeritus Professor, University of Birmingham, UK; 2Professor of Dental New publications:

Prosthetics, University of Leeds and Consultant in Restorative Dentistry, Leeds All the parts which comprise this series
(which will be published in the BDJ) have
Healthcare Trust, Manchester, UK; 4Consultant in Restorative Dentistry, Leeds of unpublished parts) in the books
Teaching Hospitals NHS Trust and Senior Clinical Lecturer, University of Leeds and A Clinical Guide to Removable
York, UK; 5Professor of Prosthetic Dentistry, Consultant in Prosthetic Dentistry, Partial Dentures (ISBN 0-904588-599)
Faculty of Odontology, University of Malmo, Sweden; 6Professor of Informatics, and A Clinical Guide to Removable
Eastman Dental Institute for Oral Health Care Sciences, University College London Partial Denture Design (ISBN 0-904588-637).
REFEREED PAPER © British Dental Journal 2001; 190: 71–81

PRACTICE
prosthetics
Design Statements
1 A clasp should always be supported by a rest. 21 Reciprocation should be provided on a clasped tooth
diametrically opposite the retentive clasp tip.
2 A molar ring clasp should have occlusal rests mesially and
distally. 22 If a reciprocating clasp, rather than a plate, is used it
should be placed at the gingival end of a guide surface on
3 A molar ring clasp, which engages lingual undercut,
the clasped tooth.
should have a buccal strengthening arm.
23 Where a plate connector is used, reciprocation can be
4 Retentive clasps can be used to provide indirect support
obtained by a guide plate on the connector.
for a distal extension saddle by being placed on the
opposite side of the support axis from the saddle. 24 Gingivally-approaching clasps are contra-indicated if the
buccal sulcus is less than 4 mm in depth.
5 A wrought wire clasp should be attached to a saddle, not
to exposed parts of the metal framework. 25 Gingivally-approaching clasps are contra-indicated if
there is a tissue undercut buccally on the alveolus more
6 An occlusally-approaching clasp should not approach
than 1mm in depth and within 3 mm of the gingival
closer than 1 mm to the gingival margin.
margin.
7 A retentive occlusally-approaching clasp should run from
26 A gingivally-approaching clasp should be used if a
the side of the tooth with the least undercut to the side
retentive cast cobalt chromium clasp is required on a
with the greatest undercut.
premolar or canine tooth, assuming that sulcus anatomy
8 Occlusally-approaching retentive clasps should have the is favourable.
terminal third of the retentive arm entering the undercut.
27 The RPI system (rest, plate, I-bar clasp) should be used on
9 A retentive clasp should engage 0.25 mm of undercut if it premolar abutment teeth for mandibular distal extension
is constructed in cast cobalt-chromium alloy. saddles if the tooth and buccal sulcus anatomy is
favourable.
10 If an undercut on a tooth that needs to be clasped for
retention is less than 0.25 mm, then composite resin 28 The RPI system (rest, plate, I-bar clasp) should be used on
should be added to the tooth to create at least this premolar abutment teeth for maxillary distal extension
amount of undercut. saddles if the tooth and buccal sulcus anatomy is
favourable.
11 A retentive clasp should be at least 15 mm in length if it is
constructed in cast cobalt-chromium alloy. 29 A distal extension saddle should have a retentive I-bar
clasp whose tip contacts the most prominent part of the
12 Occlusally-approaching retentive clasps should be buccal surface of the abutment tooth mesio-distally.
restricted to molar teeth if constructed in cast cobalt
chromium alloy. 30 If the retentive clasp for a distal extension saddle is on a
premolar or canine abutment, it should be either a cast
13 A retentive clasp should engage 0.5 mm of undercut if it is gingivally-approaching I-bar or a wrought wire occlusally-
constructed in wrought wire. approaching clasp.
14 A retentive clasp should be at least 7 mm in length if it is 31 A distal extension saddle should have a retentive clasp on
constructed in wrought wire. the abutment tooth.
15 If an occlusally-approaching retentive clasp is used on a 32 A unilateral distal extension saddle denture (Kennedy II)
premolar or canine it should be constructed in wrought should have one clasp as close to the saddle as possible
wire. and the other as far posteriorly as possible on the other
16 Retentive clasps should usually be placed buccally on side of the arch.
upper teeth. 33 Rather than making a design statement this section poses
17 Retentive clasps should usually be placed lingually on a question: 'What is the preferred number of clasps for
lower molars. RPDs restoring each of the Kennedy classes of partially
dentate arch?'
18 Retentive clasps should usually be placed buccally on
lower premolar or canine teeth. 34 Bounded saddles should have a clasp at least at one end.
19 Where there are clasps on opposite sides of the arch, the 35 A Kennedy III modification 1 denture should have 2
retentive arms are best placed on opposing tooth retentive clasps forming a diagonal clasp axis which
surfaces ie buccal/buccal or lingual/lingual. bisects the denture.
20 Retentive and bracing/reciprocating elements of a clasp 36 A Kennedy IV denture should have retentive clasps on the
should encircle the tooth by more than 180 degrees. first molars if there is suitable undercut present.

PRACTICE
prosthetics
Prosthodontic opinion on clasp design
Statement 1 — A clasp should always be supported by a rest
A clasp should be supported to maintain its vertical relationship to the tooth. Without
such support the clasp will tend to move gingivally with the following detrimental effects:
• The retentive tip of the clasp will lose contact with the tooth. It will not therefore-
provide retention for the denture until there has been sufficient movement of the-
denture in an occlusal direction to re-establish contact of the clasp with the tooth.
The denture may therefore seem loose to the patient. a
• The tip of the clasp may sink into and damage the gingivae.
This statement is not universally applicable. For example, acrylic mucosally supported
RPDs often employ wrought wire clasps without tooth support. However, even in this
situation tooth support for clasps can sometimes usefully be obtained by wrought wire
rests or clasp arms extending onto the occlusal surfaces.
It might be preferable to omit tooth support when, as shown in Fig. 1a, there are
very few teeth remaining and rests on them would produce a support axis that approx-
imately bisects the denture. In this situation tooth support can contribute to instabil-
ity of an RPD because the denture tends to rock about the support axis. b
If however, there are very few teeth remaining, but rests on them would produce a
support axis which forms a tangent to the residual ridge, tooth support can usually be
employed to advantage and the denture remain acceptably stable (Fig. 1b).
Statement 2 — A molar ring clasp should have occlusal rests mesially and
distally
Such an arrangement may:
• Contribute to more axial loading of a tilted abutment tooth as indicated by the
black arrow in the figure. This will reduce the leverage on the tooth compared with
a mesial rest used alone.
• Support the clasp arm on the tooth distally so that if the clasp arm is inadvertently
bent it is unlikely that the arm can move far enough gingivally to traumatise the peri-
odontal tissues.
However, the prosthodontic specialists do not favour this arrangement. The com-
monest method of supporting a ring clasp is with an occlusal rest adjacent to the sad-
dle. Occasionally clinical circumstances may dictate that a non-adjacent rest be used.
This results in the entire load from the saddle to the rest being transmitted along the
proximal section of the clasp. It is necessary therefore to strengthen this section, for
example by thickening it.
Statement 3 — A molar ring clasp, which engages lingual undercut, should

have a buccal strengthening arm.
A molar ring clasp has a long arm, which is vulnerable to accidental deformation through
mishandling. The addition of a buccal reinforcing arm is intended to prevent this hap-
pening. This variant is not popular with the prosthodontic specialists possibly because it
complicates the design, thereby tending to retain plaque and reduce patient tolerance.

PRACTICE
prosthetics
Statement 4 — Retentive clasps can be used to provide indirect support for a
distal extension saddle by being placed on the opposite side of the support
axis from the saddle
When an occlusal load is applied to a distal-extension saddle the displaceability of the
supporting mucosa allows the saddle to sink. The denture rotates about the ‘support
axis’ (an imaginary line passing through the occlusal rest adjacent to the saddle and
the most distal rest on the other side of the arch) so that denture components ante-
rior to the support axis move in an occlusal direction.
A clasp placed on the other side of the support axis from the distal extension saddle
will tend to resist this movement to a limited extent. This resistance is known as indi-
rect support. However, the occlusal loads tend to be high and the retentive force gen-
erated by the clasp relatively low; also the occlusal loads are usually working at a
mechanical advantage to the clasp. This arrangement is therefore ineffective.
If the clinician does judge that indirect support is justified for a particular case the
use of multiple clasps should be considered.
Rather than trying to obtain indirect support for a distal extension saddle it is nor-
mally advisable to focus on:
• Optimising direct support of the saddle through:
– full extension of the base (A Clinical Guide to Removable Partial Denture Design,
Fig. 4.2, statement 11.17);
– the altered cast technique (A Clinical Guide to Removable Partial Dentures, Chapter 9);
– the use of mesial occlusal rests (A Clinical Guide to Removable Partial Denture
Design, Figs 5.9–5.11, statement 12.15);
– regular maintenance, including relining when necessary (A Clinical Guide to
Removable Partial Dentures, Figs 10.9–10.17).
• Minimizing occlusal loads generated during mastication by reducing the area of the
occlusal table (A Clinical Guide to Removable Partial Denture Design, Fig. 4.1, state-
ment 11.16). It is particularly important to shorten the occlusal table as this
reduces the length of the cantilever arm created by the distal extension saddle.
However, reducing the width of the occlusal table also helps, in this case by allow-
ing the denture teeth to be pushed through the bolus more easily and therefore
with less load being transmitted to the supporting tissues.
Indirect support can be of value for the Kennedy Class IV denture (statement 36).
Statement 5 — A wrought wire clasp should be attached to a saddle, not to

exposed parts of the metal framework
An effective method of attaching a wrought clasp (stainless steel or gold) to a denture
is to solder the origin of the clasp to the metal base of the saddle and then cover the
solder joint with the acrylic resin of the saddle. The advantages of this are:
• The heat created by soldering is far enough away from the active part of the clasp
arm not to change the properties of the wrought alloy.
• Subsequent corrosion of the solder joint by exposure to oral fluids is prevented by
the investing acrylic resin.
These benefits are not obtained if an attempt is made to solder a wrought clasp directly
to an exposed part of the cobalt chromium framework.
The soldering of the wrought wire clasp to the metal base of the saddle is best com-
pleted before the trial insertion of the metal framework into the mouth as this allows
the adequacy of the clasp to be checked along with the other metal components.
Statement 6 — An occlusally-approaching clasp, which is supported by a

rest, should not approach closer than 1 mm to the gingival margin
If a clasp is closer than 1 mm to the gingival margin there is the likelihood of gingival
irritation.
If the clasp is not supported by a rest the separation of clasp tip and gingival
margin should be greater than 1 mm so that when the saddle sinks the clasp does not
traumatize the gingivae.

PRACTICE
prosthetics
Statement 7 — A retentive occlusally-approaching clasp should run from the
side of the tooth with the least undercut to the side with the greatest undercut
(Fig. 7a)
This usually results in:
• Most effective utilization of available undercut.
If a clasp arm runs from maximum to least undercut, the undercut might be too
little to provide effective retention in the region of the tip of the clasp.
• Optimum positioning of the clasp arm on the tooth.
Only the terminal third of the clasp arm can cross the survey line and enter the under-
cut. The remaining, more rigid proximal part of the clasp arm has to be above the
survey line. Therefore if the clasp is going the ‘wrong’ way the tip of the clasp may
have to be placed unnecessarily close to the gingival margin, and the origin of the
clasp located so high on the tooth that it might create an occlusal interference
(Fig. 7b).
There are exceptions to this statement particularly if the tooth has a long clinical crown.
In this situation the survey line may allow the clasp to run from the greater to the lesser
undercut without compromising the positioning of the proximal or distal portions of
the clasp arm or the depth of undercut engaged..
A clasp type, which does not strictly comply with the statement, is the recurved
occlusally-approaching clasp (Fig. 7c).
Statement 8 — Occlusally-approaching retentive clasps should have the

terminal third of the retentive arm entering the undercut
The flexibility of a clasp arm made of a particular alloy is related to length and thick-
ness. The clasp arm is normally manufactured with a length and taper designed to pro-
vide sufficient flexibility for the terminal third to safely enter the undercut. If the clasp
arm crosses the survey line prematurely, the arm is likely to permanently deform in
function and to apply excessive force to the tooth. It is also likely to make insertion
and removal of the denture difficult or impossible.
Statement 9 — A retentive occlusally-approaching clasp should engage

0.25 mm of undercut if it is constructed in cast cobalt chromium alloy
If a cast cobalt chromium occlusally-approaching clasp engages less than 0.25 mm, the
inaccuracies in its production will represent a significant proportion of this value and
thus the resulting retention is unpredictable.
If the clasp engages more than 0.25 mm it is likely that its proportional limit will be
exceeded when the denture is seated or removed. The clasp thus becomes permanently
deformed and therefore non-retentive.The length of a clasp is a critical factor in deter-
mining how much undercut it can safely engage (statements 11–15)
Statement 10 — If an undercut on a tooth, which needs to be clasped for

retention, is less than 0.25 mm, then composite resin should be added to the
tooth to create at least this amount of undercut
The modification of tooth contour with composite resin is a conservative, simple,
durable and effective way of creating undercut for clasping where no, or inadequate,
undercut exists (A Clinical Guide to Removable Partial Dentures, Fig. 15.25). The tech-
nique consists of creating a supragingival composite resin veneer that produces an c
undercut just detectable to the eye. A more precise check can be made by obtaining a
study cast and measuring the amount of composite resin undercut with a surveyor, but
in practice this is often not necessary. The composite resin should cover a broad area
of the tooth surface so that it can be shaped to blend smoothly with the tooth contour
(Fig. 10a, b). A small ‘button’ of composite resin is less satisfactory (Fig. 10c).
With early composite resins, the large, irregular filler particles caused significant
abrasion of the clasps resulting in loss of retention and even fracture of the clasp. This
does not occur with modern composite resins. Also, abrasion of the composite resin
by the clasp is not generally a problem, particularly, if a round section wrought wire
clasp is employed. Abrasion of composite resin sometimes occurs when a cast gingi-
vally-approaching clasp is used since the tip of the clasp can act like a chisel.

PRACTICE
prosthetics
Other ways of creating undercuts for clasp retention are:
• Enameloplasty, by using a bur to create a small dimple in the enamel which can
be engaged by the tip of a clasp (A Clinical Guide to Removable Partial Dentures,
Figure 15.24).
• Metal or porcelain veneers bonded to the enamel surface.
• The fitting of suitably contoured crowns.
Statement 11 — A retentive clasp should be at least 15 mm in length if it is

constructed in cast cobalt chromium alloy
For the retentive tip of a cobalt chromium clasp to flex 0.25 mm without deforming
permanently, it needs to be about 15 mm in length (Fig. 10, p649, Part 6). This length
can usually be achieved with an occlusally-approaching clasp on a molar tooth, and a
gingivally-approaching clasp on any tooth.
Statement 12 — Occlusally-approaching retentive clasps should be

restricted to molar teeth if constructed in cast cobalt chromium alloy
An occlusally-approaching clasp on a molar tooth will be about 15 mm in length, but
on a premolar or canine tooth will be considerably less than this. A ring clasp on a
molar tooth may be longer than 15 mm, but the increased curvature results in a cor-
responding increase in stiffness so that an undercut of 0.25 mm remains the maxi-
mum that can be engaged safely.
A gingivally-approaching clasp can be made longer than 15 mm and in such cases
the clasp can engage a depth of undercut greater than 0.25 mm.
It should be remembered that a clasp may be used for stability rather than retention
and in this case the above statement does not apply. A short cobalt chromium
occlusally-approaching clasp placed on a non-undercut area of a tooth is ideal for this
purpose. Even though such a clasp is for bracing and does not engage undercut, it may
make a contribution to retention through frictional contact with the tooth.
Statement 13 — A retentive clasp should engage 0.5 mm of undercut if it is

constructed in wrought wire
A wrought stainless steel or gold wire clasp is more flexible than a comparable design
of cast clasp in cobalt chromium alloy and therefore needs to engage a greater depth
of undercut to generate equivalent retention. As a wrought wire clasp has a higher pro-
portional limit than a cast clasp (Fig. 9, p649, Part 6) it can engage this increased under-
cut without deforming permanently.
There can be technical difficulties in the production of accurately fitting wrought
wire clasps as the required skill is not universally available.
Statement 14 — A retentive clasp should be at least 7 mm in length if it is

constructed in wrought wire
A wrought clasp of about 7 mm in length can engage 0.5 mm of undercut without
deforming permanently. However, if the wrought clasp is shorter that 7 mm, flexing
into this undercut is likely to result in permanent deformation.
Statement 15 — If an occlusally-approaching retentive clasp is used on a

premolar or canine it should be constructed in wrought wire
A premolar or canine tooth is usually wide enough mesiodistally to accept an
occlusally-approaching clasp of about 7 mm in length but not much longer. A wrought
clasp can therefore provide reliable retention in this situation whereas a cast clasp
would be too rigid.

PRACTICE
prosthetics
Statement 16 — Retentive clasps should usually be placed buccally on upper
teeth
Retentive clasps should obviously only be placed where suitable undercuts exist or can
be created. The statements 16–18 are commonly true because they reflect the usual dis-
tribution of tooth undercuts that are available for clasp retention. In the molar region
this distribution of undercuts is associated with the tilt of the teeth creating the Curve
of Monson.
Statement 17 — Retentive clasps should usually be placed lingually on lower

molar teeth.
Undercuts suitable for retentive clasping of lower molar teeth are most frequently
located lingually.
Statement 18 — Retentive clasps should usually be placed buccally on lower

premolar or canine teeth
Undercuts suitable for retentive clasping of lower premolar or canine teeth are most
frequently located buccally.
Statement 19 — Where there are clasps on opposite sides of the arch, the
retentive arms are best placed on opposing tooth surfaces, ie buccal/buccal or
lingual/lingual
This is because the retentive clasps then move along divergent paths of displacement.
This is sometimes referred to as ‘cross-arch reciprocation’ (Fig. 15, Part 7). It is not as
effective as reciprocation via guide surfaces on the clasped teeth as relative movement
of the teeth within the periodontal ligaments is not prevented.
Statement 20 — Retentive and bracing/reciprocating elements of a clasp

should encircle the tooth by more than 180 degrees
This is the principle of ‘encirclement’. Unless encirclement is achieved the clasp can
move away from the tooth (or vice versa) and thus lose its retentive and bracing func-
tions.
Encirclement can be by a combination of retentive and bracing clasp arms (Fig. 20a),
or by clasps and guide plates as in the RPI system (Fig. 20b).
Any attempt at using teeth other than the clasped tooth to provide bracing to pre-
vent the clasp ‘escaping’ is not an effective substitute for encirclement. This is because
loss of contact of the clasp with the tooth can still occur as a result of the movement
of one tooth in relation to the other (Figs 20c and d).

PRACTICE
prosthetics
Statement 21 — Reciprocation should be provided on a clasped tooth dia-
metrically opposite the retentive clasp tip
Reciprocation (Figs 12–15, Part 7 of this series of articles) is resistance to:
a) Displacement of a tooth by a direct retainer.
If a retentive clasp is not reciprocated, the clasp will apply a horizontal force to a tooth
as it moves towards the height of contour of the tooth and this will displace the tooth
within the periodontal ligament. This movement of the tooth will reduce the reten-
tiveness of the clasp.
b) Escape of a direct retainer from an undercut.
If there is no reciprocation, the clasp will be able to escape from the undercut with-
out flexing and creating a retentive force.
The most effective location for a reciprocating component is:

a) On the clasped tooth
b) Diametrically opposite the retentive tip of the clasp. However, (a) is more important
than (b) although the further that the reciprocation is from the ideal position the
greater is the potential for tooth or denture movement resulting in reduced retention.
It should be remembered that the RPI system does not conform to (b) as effective rec-
iprocation is provided by the combination of mesial and distal guide plates that are
not diametrically opposite the I-bar (Fig. 26, p653, Part 6 of this series of articles).
Statement 22 — If a reciprocating clasp, rather than a plate, is used it should

be placed at the gingival end of a guide surface on the clasped tooth
If the reciprocating clasp is placed at the gingival end of a guide surface (which is usu-
ally 2–3 mm in length), it will maintain contact with that surface as the retentive clasp
moves through the retentive distance. Reciprocation will therefore be maintained for
as long as the retentive clasp is active.
Statement 23 — Where a plate connector is used, reciprocation can be

obtained by a guide plate on the connector
a b
Where a plate major connector contacts a clasped tooth, a guide surface can be incor-
porated into it by using a surveyor to block out undercuts on the master cast prior to
fabricating the refractory cast. The guide surface is therefore made parallel to the
planned path of insertion and removal of the denture (Fig. 23a). However, reciproca-
tion will not be provided by a plate if the tooth surface contacted has no undercut
(Fig. 23b).

PRACTICE
prosthetics
Statement 24 — A gingivally-approaching clasp is contraindicated if the buc-
cal sulcus is less than 4 mm in depth
A sulcus of less than 4 mm does not have sufficient depth to accommodate a gingi-
vally-approaching clasp without much of the length of the clasp arm being placed too
close to the gingival margin (Fig. 24a).
An exception to this statement is the ‘De Van’ clasp which is a gingivally-approach-
ing clasp running along the border of the saddle to engage the disto buccal undercut a b
of the abutment tooth. It does not enter the sulcus area buccal to the clasped tooth
(Fig. 24b).
Statement 25 — Gingivally-approaching clasps are contra indicated if there

is a tissue undercut buccally on the alveolus more than 1 mm in depth within
3 mm of the gingival margin
An undercut of these dimensions results in the gingivally-approaching clasp being relieved
extensively from the attached mucosa so that the denture can be inserted without trau-
matizing the tissues. Such relief causes the arm of the clasp to be excessively prominent,
resulting in possible irritation of the buccal mucosa, and the trapping of food debris
(Fig. 25a). Alternatively, if the clasp arm is placed on the mucosa survey line it is likely
to be too prominent and too close to the gingival margin (Fig. 25b).
Statement 26 — A gingivally-approaching clasp should be used if a retentive

cast cobalt chromium clasp is required on a premolar or canine tooth,
assuming that sulcus anatomy is favourable
A gingivally-approaching clasp is an appropriate choice under such circumstances as
it can be made long enough to achieve adequate flexibility.
Canine and premolar teeth obviously vary in their mesiodistal dimension but are
generally of the order of 7 mm. A cast cobalt chromium occlusally-approaching clasp
may be a little longer than this (allowing for the curvature of the tooth surface and the
fact that the clasp passes diagonally across the tooth). However, this may not be long
enough to ensure that such a clasp has adequate flexibility and is working within its
proportional limit. Therefore, on such teeth, more effective and reliable clasping can
be obtained either by utilizing the longer gingivally-approaching clasp or by using a
more flexible material (wrought wire).
Statement 27 — A distal extension saddle should have a retentive I-bar clasp

whose tip contacts the most prominent part of the buccal surface of the
abutment tooth mesiodistally.
In the RPI system, the tip of the gingivally-approaching I-bar clasp contacts the most
prominent part of the buccal surface of the abutment tooth mesiodistally (Fig. 27a).
Thus when the distal extension saddle sinks under occlusal loads, the tip of the clasp
moves mesially out of contact with the tooth and does not apply any potentially dam-
aging torque to it (Fig. 27b).

PRACTICE
prosthetics
Statement 28 — The RPI system (Rest, Plate, I-bar clasp) should be used on
premolar abutment teeth for mandibular distal extension saddles if the
tooth and buccal sulcus anatomy is favourable
The RPI system is described in Figs 26–28, p653-654, Part 6 of this series of articles.
Statement 29 — The RPI system (Rest, Plate, I-bar clasp) should be used on
premolar abutment teeth for maxillary distal extension saddles if the tooth
and buccal sulcus anatomy is favourable
The RPI system is not such a popular choice for the maxilla as in the mandible, pos-
sibly because the potential for support from the denture-bearing area is greater in the
maxilla than in the mandible, ie the ‘support deficit’ is less. The potential for harmful
torque forces being applied to the abutment tooth is therefore reduced.
Statement 30 — If the retentive clasp for a distal extension saddle is on a

premolar or canine abutment, it should be either a cast gingivally-
approaching I-bar or a wrought wire occlusally-approaching clasp.
These are two types of clasp that minimize the chance of applying damaging torque
to the abutment teeth of distal extension saddles.
In the case of a wrought wire occlusally-approaching clasp, the ability of the round
section wire to flex in any direction also assists in avoiding potentially damaging torque.
Statement 31 — A distal extension saddle should have a retentive clasp on

the abutment tooth
When practicable it is desirable to place a retentive clasp on the abutment tooth adja-
cent to a distal extention saddle so that one end of the clasp axis is located as close to
the saddle as possible (see statement 32)
Statement 32 — A unilateral distal extension saddle denture (Kennedy II)

should have one clasp as close to the saddle as possible and the other as far
posteriorly as possible on the other side of the arch
These principles:
• Provide the most efficient direct retention for the mesial end of the saddle.
• Locate the clasp axis as far posteriorly as possible so that the most effective indi-
rect retention can be provided for the distal extension saddle.

PRACTICE
prosthetics
Kennedy Class I Kennedy Class II Kennedy Class III Kennedy Class IV
3 7% 4 7% 2 86% 3 23% 4 0% 2 77% 3 42% 4 8% 2 50% 3 8% 4 15% 2 77%
Statement 33 — Rather than making a design statement this section poses a

question: ‘What is the preferred number of clasps for RPDs restoring each of
the Kennedy classes of partially dentate arch?’
The pie charts indicate the percentage of prosthodontists preferring 2, 3 or 4 clasps for
each of the Kennedy classes.
For all of the Kennedy classes the use of two clasps is the most popular choice for
RPD retention. Two clasps are advantageous because:
• Simple denture designs are often better tolerated and minimize tissue coverage.
• Two clasps usually generate sufficient retention.
• A pair of clasps creates a clasp axis that can be positioned to bisect the denture and
allow indirect retention to be obtained.
Statement 34 — Bounded saddles should have a clasp at least at one end

This allows for the utilization of indirect retention if required (see statement 35).
Statement 35 — A Kennedy III Modification 1 denture should have two

retentive clasps forming a diagonal clasp axis which bisects the denture
If one end of a bounded saddle has a retentive clasp the other end will tend to be lifted
by displacing forces. This tilting effect can be resisted by using an indirect retainer. If
a bounded saddle has no direct retainer at either end indirect retention cannot be used
to assist in the stabilization of the saddle.
Statement 36 — A Kennedy IV denture should have retentive clasps on the

first molars if there is suitable undercut present
This is usually a good site for a pair of clasps retaining a Kennedy IV denture because:
• Normally the clasps are far enough posteriorly to be aesthetically acceptable. In
those cases, usually maxillary RPDs, where clasps on the first molars would be too
visible, it might be better to place the clasps even further back on the second molars
if suitable sites exist.
• The molar is a sufficiently large tooth for cast occlusally-approaching clasps to be
long enough to achieve adequate flexibility and resistance to permanent defor-
mation.
• The clasps are sufficiently posterior to the support axis of the saddle to efficiently
resist tipping of the denture as the result of incising forces, ie to provide indirect sup-
port for the saddle.
• If the retentive tips of the clasps can be placed mesially on the molars, the occlusal
rests on the molar teeth will provide some indirect retention for the anterior sad-
dle. In this instance the indirect retainers will be relatively close to the clasp axis
and therefore their effectiveness will be limited. However, some direct retention is
already likely to have been obtained for the anterior saddle by the saddle contact-
ing guide surfaces on the abutment teeth and by the labial flange engaging under-
cut on the ridge. Therefore the modest indirect retention provided by the molar
rests may be sufficient to stabilize the RPD.

PRACTICE
prosthetics
8
9
Indirect retention
This article explains the mechanism of indirect In this part, we will discuss
retention for RPDs and discusses the factors which • Indirect retention systems
• Clasp axis
determine its effectiveness. Examples are given of
• Importance of clasps
designs which incorporate indirect retention. • Mechanical disadvantage of RPD designs
• Support for indirect retainers
he principle of indirect retention may be explained by

T reference to the behaviour of a mandibular distal extension
saddle in function.
Fig. 1 — Indirect retention

This saddle has an occlusal rest and a clasp on the abutment tooth, and
the connector is a sublingual bar. Although normally a mesial rest might
well be preferred, a distal rest has been used in this example to simplify
the explanation which follows. When sticky foods displace the saddle in an
occlusal direction the tips of the retentive clasps engaging the undercuts
on the abutment teeth provide the only mechanical resistance to the
movement. The saddle thus pivots about the clasp tips.
In the maxilla this movement of the saddle away from the ridge
may also be caused by gravity.

If the design is modified by placing a rest on an anterior tooth, this
rest (indirect retainer) becomes the fulcrum of movement of the
saddle in an occlusal direction causing the clasp to move up the tooth,
engage the undercut and thus resist the tendency for the denture to
pivot.
F = Fulcrum — indirect retainer, a component which obtains support.
E R = Resistance — retention generated by the clasp.
E = Effort — displacing force, eg a bolus of sticky food.
It can thus be seen that to obtain indirect retention the clasp must
F R
always be placed between the saddle and the indirect retainer.

Healthcare Trust, Manchester, UK; 4Consultant in Restorative Dentistry, Leeds been included (together with a number
Teaching Hospitals NHS Trust and Senior Clinical Lecturer, University of Leeds and of unpublished parts) in the books
York, UK; 5Professor of Prosthetic Dentistry, Consultant in Prosthetic Dentistry,
A Clinical Guide to Removable
128 BRITISH DENTAL JOURNAL, VOLUME 190, NO. 3, FEBRUARY 10 2001

PRACTICE
prosthetics
Indirect retainers do not prevent displacement towards the ridge.
This movement is resisted by the occlusal rest on the abutment tooth
and by full extension of the saddle to gain maximum support from the
residual ridge. In addition, it may be necessary to compensate for the
compressibility of the denture-bearing mucosa by using the altered
cast impression technique (A Clinical Guide to Removable Partial
Dentures, Chapter 19).

In order to understand the way in which indirect retainers are
located it is necessary to consider the possible movement of the
denture around an axis formed by the clasps. This clasp axis is defined
as the line drawn between the retentive tips of a pair of clasps on
opposite sides of the arch.
Clasp axis

Where there is more than one clasp axis, as in this Kennedy Class III
denture, it is the clasps on the axis closer to the saddle in question Major clasp
which make the major contribution to indirect retention. axis
Minor clasp
axis
As the resistance to displacement in an occlusal direction of a Other factors which influence the effectiveness of indirect
saddle using indirect retention is provided by the clasps form- retention are:
ing the clasp axis, the effectiveness of these clasps is of para-
• The mechanical disadvantage of the denture design,
mount importance in determining the amount of indirect
• The support of the indirect retainers.
retention obtained.
Mechanical disadvantage of the denture

design Effort arm
Resistance arm Displacing

Fig. 6 — Mechanical disadvantage of the denture design
force
The clasp is always nearer to the indirect retainer (fulcrum) than is E
the displacing force. The clasp is therefore working at a mechanical
disadvantage relative to the displacing force.
The RPD design should strive to reduce the mechanical advantage
of the displacing force by placing the clasp axis as close as possible to F
R
the saddle and by placing the indirect retainers as far as possible from Indirect
Clasp
the saddle. retainer
BRITISH DENTAL JOURNAL, VOLUME 190, NO. 3, FEBRUARY 10 2001 129

PRACTICE
prosthetics
In this RPD design the indirect retainers (the rests on the molar teeth)
are inefficient because they are placed too close to the clasp axis.
Clasp
axis
Indirect retainers

If the clasp axis is moved closer to the saddle the effectiveness of the
indirect retention is improved.
Clasp
axis
Indirect retainers
Support for the indirect retainer

Fig. 9 — Support for the indirect retainer
Tooth support is preferable to mucosal support because the
compressibility of mucosa allows movement of the denture to occur.
Clasp If there is no alternative to mucosal support the indirect retainer
axis should cover a sufficiently wide area to spread the load and avoid
mucosal injury. This consideration effectively limits mucosally
supported indirect retainers to the maxilla where the load can be
distributed over the hard palate (shaded area of the connector).
However, this plan view is somewhat misleading as it suggests that
the indirect retention achieved is more effective than it really is.
Indirect retainer

The side view (simplified) of a similar design shows that, when the
saddle is first displaced, mucosal compression beneath the indirect
retainer allows the denture to rotate around the clasp axis (fulcrum).
The path of movement of the indirect retainer is thus directed
obliquely, rather than at right angles, to the mucosal surface. This
combination of oblique approach and mucosal compression may
allow a significant degree of movement of the denture in function.

PRACTICE
prosthetics
(1) When possible, the indirect retainer should rest on a surface at 1 2
right angles to its potential path of movement. (2) If it rests on an
inclined tooth surface, movement of the tooth might occur with
resulting loss of support for the indirect retainer.
Examples of RPD designs which include indi-

rect retention
Each design is only one of a number of possible solutions.
Fig. 12 — RPD designs which include indirect retention

Kennedy I: Indirect retention in this design is provided by incisal rests
on LR3 (43) and LL3 (33).
In this example and in Figs 13 to 15 the part of the saddle
susceptible to displacement in an occlusal direction is indicated by an
asterisk.
Clasp
axis
Indirect retainers

Clasp axis
Kennedy II: Indirect retention in this instance is provided primarily by
rests on LR4 (44) and LR3 (43) as they are furthest from the clasp
axis. The rests on LL5 (35), LR6 (46) and LR7 (47) are close to the
clasp axis and therefore contribute little to the indirect retention.
Indirect retainers

Kennedy III: In the case of a bounded saddle there is the potential for Clasp axis
direct retention from both abutments. When this can be achieved, as
for the saddle replacing UR6 (16) and UR5 (15), indirect retention is
not required. However, it is not uncommon for only one of the
abutments to be suitable for clasping. In this design a clasp on UL3
(23) has been omitted for aesthetic reasons. Under such
circumstances indirect retention can be employed, the major
contribution being made by the rest on UR7 (17).
Indirect retainers

PRACTICE
prosthetics
Kennedy IV: In a maxillary denture it is sometimes difficult to achieve
much separation of the clasp axis and indirect retainers. In this
example, clasps engage the mesiobuccal undercuts on UR6 (16) and
UL6 (26) and indirect retention has been achieved by placing the
Clasp
rests on UR7 (17) and UL7 (27) as far posteriorly as possible.
axis
Indirect retainers
An additional function of indirect retainers is to allow accurate Partial Dentures, chapter 19), or when obtaining a wash impres-
location of the RPD framework against the teeth when under- sion to rebase a distal extension saddle.
taking the altered cast procedure (A Clinical Guide to Removable

PRACTICE
prosthetics
10
Connectors
This article describes the types and functions of

connectors for RPDs. It also considers the relative In this part, we will discuss
• Major and minor connectors
merits and limitations of these connectors. • Connectors for the upper jaw
• Connectors for the lower jaw
• Non-rigid connectors
• Connectors for acrylic dentures
Fig 1 — Connectors
Connectors can be classified as either minor or major. The minor
connectors (coloured red) join the small components, such as rests and
clasps, to the saddles or to the major connector. In addition, they may
contribute to the functions of bracing and reciprocation as in the RPI
system (Figure 6.26*). The positioning of the minor connectors joining
rests to a saddle will vary according to whether an 'open' or 'closed' design is
to be used (Figure 4.9*).The number of minor connectors should be kept to
a minimum to conform to the key design principle of simplicity.
The major connector (coloured black) links the saddles and thus unifies
the structure of the denture. The remainder of this chapter is devoted to
the major connector. The major connector may fulfil a variety of functions.
In addition to its basic connecting role it contributes to the support and
bracing of a denture by distributing functional loads widely to the teeth
and, in appropriate maxillary cases, to the mucosa. It can help to retain the
denture by providing indirect retention, by contacting guide surfaces and,
in the upper jaw, by coverage of palatal mucosa.
*A Clinical Guide to Removable Partial Denture Design
Designs of connector for the upper jaw

The choice of the shape and location of connectors is greater in • Function (eg connection of components, support, retention).
the upper jaw because of the area available for coverage offered • Anatomical constraints.
by the hard palate. • Hygiene.
A decision on choice of connector type is based upon the • Rigidity.
requirements of: • Patient acceptability.

New publications:
Healthcare Trust, Manchester, UK; 4Consultant in Restorative Dentistry, Leeds of unpublished parts) in the books
Teaching Hospitals NHS Trust and Senior Clinical Lecturer, University of Leeds and
Honorary Visiting Professor, Centre for Dental Services Studies, University of York, A Clinical Guide to Removable
Eastman Dental Institute for Oral Health Care Sciences, University College London Partial Denture Design (ISBN 0-904588-637).
email: john.davenport@btclick.com Available from Macmillan on 01256 302699

PRACTICE
prosthetics
Palatal Plate
Fig. 2 — Palatal plate
The basic functional requirement of a major connector is to link the
various saddles and other RPD components. In this tooth-supported RPD
a simple mid-palatal plate has been used. This is a very satisfactory
connector for such situations as it:
• Leaves all gingival margins uncovered.
• Can be made rigid.
• Has a simple outline.
• Is well tolerated as it does not encroach unduly on the highly
innervated mucosa of the anterior palate.

In contrast, the greater extent of the saddles in this tooth–mucosa
supported RPD presents more of a support problem. The functional
forces can be shared between teeth and mucosa by using a larger
connector that extends posteriorly to the junction of hard and soft
palates. It is still possible to leave the gingival margins of the majority of
teeth uncovered.

Where two or more teeth separate adjacent saddles it is possible to keep
the border of the connector well away from the vulnerable gingival
margins. Where only a single tooth intervenes between two saddles
(eg UR4 (14)) it may not be possible to uncover the gingival margin widely
enough to avoid problems of gingival irritation and patient tolerance.
However, any opportunity to uncover the gingival margin around even a
single tooth should normally be grasped (A Clinical Guide to Removable
Partial Denture Design, Statement 15.10)

If coverage of the gingival margin by the connector is unavoidable, close
contact between the connector and gingival margin should be achieved
whenever possible. If 'gingival relief' is created, the space is soon
obliterated by proliferation of the gingival tissue; this change in shape
increases the depth of the periodontal pocket and thus makes plaque
control more difficult.

PRACTICE
prosthetics
Full palatal coverage with cobalt chromium has two disadvantages. First,
the weight of a large metal connector can contribute to displacement of
the prosthesis. Second, the position of the post-dam cannot be altered
should it prove to be poorly tolerated by the patient. An alternative
approach which may possibly be used to overcome these problems is
illustrated. The posterior part of the casting has a retaining mesh to which
an acrylic extension will be attached.
Ring connector
Fig. 7 — Ring connector
A ring connector, outlined here on a cast, may be used in cases where
there are multiple saddles widely distributed around the arch, and where
tooth support can be obtained. This connector may also be indicated
where a prominent palatal torus would contraindicate a mid-palatal plate.
Fig. 8 — Ring connector

The ring connector exhibits good rigidity for a relatively low bulk of
metal. This is because the anterior and posterior bars can be positioned
in different planes so that an 'L'-shaped girder effect is created.
Although this connector leaves a large area of the palate uncovered, it
does have the potential disadvantage that the anterior bar crosses
mucosa that is richly innervated and is contacted frequently by the tongue
during swallowing and speech. The anterior bar may interfere with these
functions and be poorly tolerated as a result. If this design is selected the
anterior bar must be carefully positioned and shaped to blend with the
contours of the palatal rugae.
Designs of connector for the lower jaw

The main anatomical constraint for connector design in the can provide indirect retention and guide surfaces.
lower jaw is the relatively small distance between the lingual gin- With gingival recession there is even less room to manoeuvre
gival margin and the functional depth of the floor of the mouth. and it may be difficult to design a connector that satisfies two of
In terms of functional requirements the mandibular connector the main requirements: maintenance of oral hygiene and rigidity.
does not contribute to support by distributing loads directly to Five of the common connectors are illustrated diagrammati-
the mucosa. It connects the RPD components and cally and clinically.

PRACTICE
prosthetics
Sublingual bar
Fig. 9 — Sublingual bar
The sublingual bar differs from the lingual bar (see below) in that its
dimensions are determined by a specialized master impression technique
that accurately records the functional depth and width of the lingual
sulcus (A Clinical Guide to Removable Partial Dentures, Figs 16.23–16.25).
These sulcus dimensions are retained on the master cast so that the
technician waxes up the connector to fill the available sulcus width at its
maximum functional depth. This results in a bar whose maximum cross-
sectional dimension is oriented horizontally.
The rigidity of a lingual bar increases by a square factor when its height
is increased and by a cube factor when its width is increased. The
increased width of the sublingual bar connector therefore ensures that
the important requirement of rigidity is satisfied. This is not invariably the
case with a conventional lingual bar.
As the vertical height of a sublingual bar is less than a lingual bar it can
be used in shallower lingual sulci and be kept further away from the
gingival margins.
Lingual bar
Fig. 10 — Lingual bar
The lingual bar, like the sublingual bar, should be placed as low as the
functional depth of the lingual sulcus will allow. The cross-section of the
lingual bar is determined by the shape of a prefabricated wax pattern,
either prescribed by the dentist or selected by the dental technician.
The maximum cross-sectional dimension of this connector is
oriented vertically.
Fig. 11 — Lingual bar

If either a lingual or sublingual bar is to be used and additional bracing and
indirect retention are required, bracing arms and rests can be
incorporated in the design.
There are anatomical constraints in the lower jaw that may pre- these connectors. A mandibular torus may be of such a size that
vent the use of sublingual or lingual bars. Mention has already a sublingual or lingual bar, sitting on top of the bony protuber-
been made of lack of space between the gingival margin and the ance, would be excessively prominent, creating major difficul-
floor of the mouth. A prominent lingual fraenum may com- ties for the patient in tolerating the prosthesis.
pound the problem and make it impossible to use either of

PRACTICE
prosthetics
Dental bar
Fig. 12 — Dental bar
On occasions, there is insufficient room between gingival margin and
floor of the mouth for either a sublingual or lingual bar. A lingual plate
should be avoided wherever possible because it might well tip the
delicate balance between health and disease in favour of the latter. An
alternative connector, where the clinical crowns are long enough, is the
dental bar. Patient tolerance inevitably places some restriction on the
cross-sectional area of this connector and thus some reduction in rigidity
may have to be accepted.

Another connector (sometimes referred to as a 'Kennedy Bar' or
continuous clasp) consists of a dental bar, combined with a lingual bar.
This combination allows the dimensions of each component to be
reduced to a limited extent without compromising the overall rigidity of
the connector. However, this is a relatively complex design and is best
avoided if any of the simpler alternatives are feasible. Tolerance of the
patient must be assessed carefully before prescribing either a dental bar
or a lingual bar and continuous clasp.

Spaces between the incisors are likely to preclude the use of the dental
bar or continuous clasp on aesthetic grounds as the metal will show
through the gaps (arrows). A sublingual or lingual bar would avoid this
problem, although a lingual plate with its superior border notched where
it passes behind the spaces is an alternative solution.
If the space is small, composite may be added to the adjacent teeth to
close it and allow a dental bar to be used.
Lingual plate
Fig. 15 — Lingual plate
The lingual plate covers most of the lingual aspects of the teeth, the
gingival margins and the lingual aspect of the ridge. The plate terminates
inferiorly at the functional depth of the sulcus. Rigidity is achieved by
thickening the lower border to a bar-like section. One of the major
drawbacks of the lingual plate is its tendency to encourage plaque
formation. Plaque control should therefore be impeccable before a
lingual plate can be prescribed with any confidence.

PRACTICE
prosthetics
Labial (or buccal) bar
Fig. 16 — Labial (or buccal) bar
Mention has already been made of lingually inclined teeth creating an
obstruction to the insertion of an RPD, and how a change in path of
insertion can sometimes avoid this obstruction (A Clinical Guide to
Removable Partial Denture Design, Figs 3.23 and 3.24). However, on rare
occasions the lingual tilt is so severe that it is impossible to use any of the
lingual connectors. Under such circumstances a labial (or buccal) bar can
be used. The cross-sectional area of the bar is severely restricted by the
limited space available and also by patient tolerance.
The combination of limited space for the bar and its increased length as
it travels around the outer circumference of the dental arch makes it
difficult to achieve rigidity although, in this example, the short spans
minimize this problem.
A summary of the functions and essential

Table 1 Summary of functions and essential qualities of connectors
qualities of the mandibular connectors is
presented in Table 1:
Connector Connect Bracing Indirect Rigidity Hygiene Tolerance
√ Present retention
? Uncertain
Sublingual ✓ ✗ ✗ ✓✓ ✓ ✓
× Absent
bar
Lingual bar ✓ ✗ ✗ ? ✓ ✓
Dental bar ✓ ✓ ✓ ? ✓ ?
Lingual plate ✓ ✓ ✓ ✓ ✗ ✓
Labial bar ✓ ✗ ✗ ? ✓ ?
Non-rigid (stress breaking) connectors

Fig. 17 — Non-rigid (stress-breaking) connectors
During loading, a component resting on a tooth will be displaced very
much less than one which rests on mucosa. If a denture is entirely tooth-
supported, the displacement differential between teeth and mucosa is
immaterial. The connector should be designed so that it is rigid and thus
distributes the functional forces throughout the structure of the denture
and thence to the supporting tissues.
Fig. 18 — Non-rigid (stress-breaking) connectors

A distal extension saddle gains some of its support from teeth and some
from the tissues of the edentulous area. This support differential can
result in tipping of the denture when it is loaded during function, causing
an uneven distribution of load over the edentulous area. It will also result
in a relatively greater share of the load being taken by the tooth. One way
of minimising the problem is to refine the impression surface of the
saddle by using the altered cast impression technique (A Clinical Guide to
Removable Partial Dentures, Chapter 19).

PRACTICE
prosthetics
Fig. 19 — Non-rigid (stress-breaking) connectors.
An alternative approach is to create a design with 'independent rear
suspension' by using a flexible connector such as this split lingual plate. If
the saddle component is able to move more than the tooth-supported
component, a greater proportion of the load will be transmitted to the
tissues of the edentulous area and will be more evenly distributed. This is
the principle on which the stress-broken denture is based and it has been
suggested that perhaps it has its greatest application in the lower jaw.
However, research evidence suggests that this desired result is not
reliably achieved in practice.
Inevitably, the stress-broken design is a more complex con- • A rigid connector.

struction and thus more costly. It may also pose greater • Control of the load distribution to the various tissues by:
demands on plaque control and be less well tolerated by the – reducing the area of the artificial occlusal table,
patient. The use of a rigid connector may make it easier to – maximising coverage of the edentulous area,
design a simple shape. For these reasons it is our preference – employing the altered cast technique,
to design distal extension saddle RPDs that incorporate the – using one of the more flexible clasp systems,
following: – instituting a regular maintenance programme.
Acrylic dentures
Although this book is primarily concerned with the design and anticipated. A transitional denture may be fitted under such
construction of dentures with cast metal frameworks, there are circumstances so that the few remaining teeth can stabilize the
occasions when it is appropriate to provide dentures made prosthesis for a limited period while the patient develops the
entirely in acrylic resin. neuromuscular skills necessary to successfully control a
The main advantages of acrylic dentures are their relatively replacement complete denture.
low cost and the ease with which they can be modified. They are 3. When a diagnostic (or interim) denture is required before a
therefore most commonly indicated where the life of the den- definitive treatment plan can be formulated. Such an appli-
ture is expected to be short or where alterations such as addi- ance may be required, for example, to determine whether the
tions or relines will be needed. Both these reasons may make the patient can tolerate an increase in occlusal vertical dimension
expense of a metal denture difficult to justify. required to allow effective restoration of the dentition.
Indications for such treatment include the following: 4. When a denture must be provided for a young patient where
growth of the jaws and development of the dentition are still
1. When a denture is required during the phase of rapid bone proceeding.
resorption following tooth loss, for example an immediate
denture replacing anterior teeth. In this case a reline followed In addition, acrylic dentures may also provide a more per-
by early replacement of the denture is to be expected. manent solution; for example, where only a few isolated teeth
2. When the remaining teeth have a poor prognosis and their remain an acrylic connector may function just as effectively as
extraction and subsequent addition to the denture is one in metal.
Fig. 20 — Acrylic dentures

Where an acrylic denture is provided as a long-term prosthesis it is
particularly important that its potential for tissue damage is minimized by
careful design. This is easier to achieve in the upper jaw where the palate
allows extensive mucosal coverage for support and retention without the
denture necessarily having to cover the gingival margins. A popular form
of design for the replacement of one or two anterior teeth in young
people is the 'spoon' denture. It reduces gingival margin coverage to a
minimum, but a potential hazard is the risk of inhalation or ingestion.

PRACTICE
prosthetics
Fig. 21 — Acrylic dentures
A more stable and therefore more widely applicable design is the
modified spoon denture. Here one has the choice of relying on frictional
contact between the connector and the palatal surfaces of some of the
posterior teeth, or of adding wrought wire clasps.
Fig. 22 — Acrylic dentures.

Another acceptable design is the 'Every' denture which can be used for
restoring multiple bounded edentulous areas in the maxillary jaw. Its
characteristics are as follows:
• All connector borders are at least 3 mm from the gingival margins.
• The 'open' design of saddle/tooth junction is employed.
• Point contacts between the artificial teeth and abutment teeth are
established to reduce lateral stress to a minimum.
• Posterior wire 'stops' are included to prevent distal drift of the poste-
rior teeth with consequent opening of the contact points. These
'stops' can also contribute to the retention of the RPD posteriorly.
• Flanges are included to assist the bracing of the denture.
• Lateral stresses are reduced by achieving as much balanced occlusion
and articulation as possible, or by relying on guidance from the
remaining natural teeth to disclude the denture teeth on excursion.
When considering whether or not to provide an RPD in acrylic gingival margins to be left uncovered.
resin, the limitations of the material should be borne in mind. Another significant disadvantage of acrylic resin is that it is
This material is weaker and less rigid than the metal alloys and radiolucent so that location of the prosthesis can prove difficult
therefore the denture is more likely to flex or fracture during if the denture is swallowed or inhaled.
function. To minimize these problems the acrylic connector has Acrylic RPDs in the mandible often lack tooth-support mak-
to be relatively bulky. This, in turn, can cause problems with tol- ing tissue damage highly probable. Such RPDs should therefore
erance and offers less scope for a design that allows the be avoided whenever possible.

PRACTICE
prosthetics
11 Initial prosthetic treatment

This article describes measures designed to In this part, we will discuss

provide short-term solutions to existing RPD • Repairs and additions
• Temporary relines
problems and to establish an optimum oral
• Occlusal adjustment
environment for the provision of definitive • Interim prostheses
prostheses. • Denture stomatitis
nitial prosthetic treatment may involve modification of an of polymers for direct use in the mouth significantly increases
I existing denture or provision of an interim prosthesis as a
preparation for the definitive course of treatment.
the number of opportunities for adopting this approach. Their
relatively short clinical life, usually measured in months rather
When modifying existing dentures the following points should than years, is not a problem where early replacement of the den-
be borne in mind. Firstly, as these dentures are commonly due ture is anticipated.
for early replacement, modifications will not have to last for very
long. Secondly, the patient will often be reluctant to part with the Repairs and additions
denture for the modifications to be carried out, particularly if it Before undertaking a repair it is essential to determine the cause
replaces anterior teeth. These considerations point to modifica- of the fracture so that appropriate corrective measures can be
tion of the denture at the chairside wherever practicable. A range undertaken.
Fig. 1 — Clasps and rests

To replace fractured clasps and rests, or to add these components to a
denture, an alginate impression in a stock tray is required of the denture
in situ. Great care must be taken to ensure that the impression material
does not displace the denture from its correct relationship to the
surrounding tissues.
Where a component is to be added and the occlusion will influence the
design or position of that component, an impression of the opposing
dentition is also needed. If it will not be possible to place the casts by hand
into the intercuspal position an interocclusal record will be required to
allow the casts to be mounted on an articulator.
Fig. 2 — Clasps and rests

1 2
A new clasp arm is usually produced by adapting a wrought stainless steel
wire to the tooth on the cast and then attaching the wire to the existing
acrylic base (1). Alternatively, an entirely new clasp assembly can be cast
and tagged into the saddle of the denture (2). This latter procedure
would normally be undertaken only if the existing denture is to be used
for a considerable time.

New publications:
Manchester) and Consultant in Restorative Dentistry, Central Manchester been included (together with a number of
Healthcare Trust, Manchester, UK; 4Consultant in Restorative Dentistry, Leeds unpublished parts) in the book
Teaching Hospitals NHS Trust and Senior Clinical Lecturer, University of Leeds and
Honorary Visiting Professor, Centre for Dental Services Studies, University of York, A Clinical Guide to Removable
Eastman Dental Institute for Oral Health Care Sciences, University College London
email: john.davenport@btclick.com Available from Macmillan on 01256 302699
BRITISH DENTAL JOURNAL, VOLUME 190, NO. 5, MARCH 10 2001 235

PRACTICE
prosthetics
Fig. 3 — Teeth
If a tooth has become detached from the denture but is still available, a
rapid chairside repair can usually be effected using cold-curing acrylic
resin. It is advisable to cut some form of mechanical retention in order to
reinforce the chemical bond.
The addition of a new artificial tooth may be required to fill a Alternatively, it may be possible to rapidly achieve an accept-
space created either by loss of a denture tooth or by extraction of able result by building up a replacement tooth by direct additions
a natural tooth. This is often best done by obtaining an alginate of tooth-coloured cold-curing acrylic resin to the denture at the
impression and interocclusal records, as described in Fig. 1, so chairside.
that the addition can be made in the laboratory.
a b
Fig. 4a and b — Teeth

The attachment of teeth to metal connectors can be achieved by the creation of mechanical retention such as
perforations or soldered wire loops. Alternatively, acrylic can be bonded to cobalt-chromium using meta adhesives.
Fig. 5 — Connectors
If the portions of a fractured acrylic denture can be relocated accurately
outside the mouth, the clinician can unite them with a wire rod held on to
the occlusal surfaces with sticky wax, or by applying a cyano-acrylate
adhesive to the fracture surfaces. If possible the assembled denture
should then be tried in the mouth for accuracy before being sent to the
laboratory for repair.
Alternatively, a chairside repair using cold-curing acrylic resin is
sometimes possible.
236 BRITISH DENTAL JOURNAL, VOLUME 190, NO. 5, MARCH 10 2001

PRACTICE
prosthetics
Fig. 6 — Connectors
If the portions of the denture do not relocate accurately outside the
mouth they should be held in the best possible relationship by an
application across the fracture line of cold-curing acrylic resin or
impression compound. The denture may then be seated in the mouth
while the bonding material is still pliable, and both portions held in their
correct relation to the ridges and teeth until the denture is rigidly united.
A laboratory repair can then be undertaken.
If apposition cannot be achieved, or if a metal connector is broken or
bent, the denture will usually have to be remade.
Fig. 7 — Flanges
The addition or extension of a flange may be achieved using a non-poly
methyl methacrylate resin, such as butyl methacrylate resin, which is
adaptable directly in the mouth. However, as the colour stability of these
resins is relatively poor, the technique is not ideal if the flange is visible and
the denture is to be worn for more than a few weeks.
For the laboratory addition of a flange, an alginate impression in a stock
tray is obtained of the denture in situ. The tray will usually need to be
extended in the area where the flange is to be added using a suitable
border-moulding material.
Fig. 8 — Flanges
Alternatively a border-moulding material, in this case tracing compound,
can be added to the denture and shaped to conform to the area to be
covered by the flange. A local wash impression is then taken within the
modified flange. An over-impression of the teeth and denture in situ using
alginate in a stock tray will facilitate the laboratory work.
Temporary relining
The acrylic base of an RPD may be relined temporarily where conditioners) is an advantage in that it distributes the load more
loss of fit has resulted in instability or mucosal injury. evenly and thus promotes healing. The hard materials have been
Temporary relining is carried out in the mouth using either mentioned in Fig. 7.
soft or hard materials. When mucosal inflammation is present, Before undertaking a temporary reline, preparatory adjust-
the cushioning effect of the short-term soft materials (tissue ment of the denture is commonly necessary.

PRACTICE
prosthetics
Fig. 9 — Temporary relining
A diagnostic alginate impression taken in the old denture is a quick and
useful aid to assessing the fit of the denture and identifies pressure points
that require adjustment before adding the reline material.

If the denture is to be relined at the chairside any areas of under-
extension should first be corrected by border moulding with a direct
application of a chairside cold-curing resin. This resin may not have a very
strong bond to the acrylic denture base and if allowed to form a feather
edge (1) at the junction between the two materials, will tend to lift after a
period of intra-oral use and will consequently traumatise the oral mucosa.
This is prevented if a butt joint (2) is produced between the two resins.

When carrying out a direct reline with a temporary material it is all too
easy to fail to seat the denture correctly. This is particularly so in the case
of a maxillary denture. If this occurs both the vertical and the horizontal
occlusal relationships will be altered. It will also result in thickening of the
connector leading to possible problems of patient tolerance and may alter
the position of an anterior saddle to an unacceptable degree. These
changes are likely to make the denture unwearable.

There are a number of precautions that can be taken to reduce the
chance of the denture being seated incorrectly. In a maxillary denture
with extensive palatal coverage the escape channel for any excess reline
material is long and tortuous and therefore the choice of a low-viscosity
material is important. In the mandible, and in individual saddles, the
escape channel is much shorter and so a higher viscosity material may be
used.

PRACTICE
prosthetics
Alternatively, when a lining material of relatively high-viscosity such as
butyl methacrylate resin is used, escape of the excess lining material from
a maxillary denture can be helped by drilling holes into the palatal
connector and sometimes the flanges.

Where the loss of fit is localised to the site of recent extractions, it is
recommended that the temporary reline is restricted to that area —
UL1 (21) and UL2 (22) in this example. The remaining, unmodified
impression surface helps to locate the denture correctly against the
residual ridges and abutment teeth. There will be a line of demarcation
between the new resin and the original impression surface but minor
smoothing of this junction is all that is usually required to achieve an
acceptable result.

If a hard reline material is being used it is important to appreciate that it
may flow into undercut areas around the teeth and that consequently the
timing of removal of the denture from the mouth is critical. Failure to
remove the denture before curing is complete will result in the denture
being locked into place. Removal of the denture will then only be possible
if the offending acrylic resin is cut away with burs, a thoroughly time-
consuming and frustrating business.

Once the denture has been relined, any excess material must be
removed from the polished surfaces and teeth. If the relining material is a
hard resin the borders are trimmed and polished (maxillary denture).
Excess short-term soft lining material is trimmed on the polished
surface of the denture so that the denture border consists of a smooth roll
of the material (mandibular denture).

PRACTICE
prosthetics
A patient who has had a denture relined with a short-term soft lining
material should be given specific instructions on how to clean the lining.
Some of these materials are damaged by the use of alkaline perborate
denture cleansers and others by alkaline hypochlorites. Unless the patient
is warned of these incompatibilities rapid deterioration of the lining will
occur.
As all these linings are added as a temporary measure, a posi- to be assessed at approximately weekly intervals and replaced
tive decision must be taken by the dentist as to the next stage of periodically until mucosal inflammation has resolved. A new
treatment. For example, a short-term soft lining material needs denture can then be constructed.
Occlusal adjustment
Fig. 18 — Occlusal adjustment
The most common occlusal deterioration in dentures that have been
worn for many years is loss of occlusal contact resulting from a
combination of occlusal wear and sinking of the denture following
alveolar resorption. Correction of the occlusion is desirable before
constructing replacement dentures as adaptive mandibular posture and
mucosal inflammation resulting from this deterioration are likely to
interfere with successful treatment.
Fig. 19 — Occlusal adjustment

After the saddles have been relined, occlusal contact can be re-
established by the addition of tooth-coloured cold-curing acrylic resin to
the posterior teeth.
The fluid resin is applied to the occlusal surfaces of one of the dentures
and allowed to reach the dough stage before the denture is inserted into
the mouth. Petroleum jelly is applied to any opposing denture teeth and
the mandible is gently guided along the retruded arc of closure until even
occlusal contact is made at the appropriate vertical dimension. The
denture is then removed from the mouth and the resin allowed to cure
before refining the occlusion by selective grinding.
Interim prostheses
An interim prosthesis may be constructed before the definitive • Improving patient tolerance.
denture for the following reasons. • Preparation for advanced restorative treatment.
• Space maintenance and aesthetics. • Modifying jaw relationships.

PRACTICE
prosthetics
Fig. 20 — Space maintenance and aesthetics
The loss of an anterior tooth may require rapid replacement with an
interim denture, both for social reasons and to prevent reduction of the
space by drifting and tilting of the adjacent teeth.
Fig. 21 — Improving patient tolerance

A small minority of patients find it very difficult, or even impossible, to
wear a denture because of a pronounced retching reflex. The provision of
a thin acrylic training base, which in the maxilla may be of horseshoe
design, is useful in overcoming the reflex. The patient wears the base for
increasing periods each day until tolerance is good enough to indicate that
conventional treatment can proceed. When a training base of horseshoe
design is used, the palatal extension can be increased in stages to allow
progressive adaptation to palatal coverage which is as close as possible to
the optimum.
In this instance the training base incorporates occlusal coverage in order
to modify the jaw relationship in preparation for advanced restorative
treatment (see below).
Preparation for advanced restorative treatment

A factor vital to the success of advanced restorative treatment is of future treatment aims and expectations, helps to create a more
the ability of the patient to maintain a high level of plaque con- realistic frame of mind and readier acceptance of the definitive
trol. The use of an interim prosthesis will permit a careful eval- prosthesis.
uation of the oral and denture hygiene over a prolonged period
before definitive treatment is commenced. Modifying jaw relationships
Advanced prosthetic treatment can fail because of a patient's Adaptive changes in the jaw relationship may result from loss of
unrealistic expectation of what a removable prosthesis can teeth, the excessive loss of tooth substance or the congenital
achieve, creating dissatisfaction and rejection of the treatment absence of teeth. These changes may require correction before
that has been undertaken. The provision of an interim prosthe- restorative treatment can be undertaken and this may be achieved
sis gives the patient experience of the limitations of such den- by the progressive occlusal adjustment of an interim prosthesis
tures; this experience, when combined with careful explanation until the optimum occlusal relationship is determined.
Fig. 22 — Modifying jaw relationships

The planning of restorations for severely worn teeth is complicated by
the uncertainty as to whether or not the increase in occlusal vertical
dimension necessary to accommodate the required restorations will be
tolerated by the patient.
An interim prosthesis is constructed to an occlusal height that appears
from the initial assessment to be appropriate. It may then be progressively
adjusted over several appointments. This allows a period in which the
patient can gradually adapt to progressive, modest increases in occlusal
height and finally confirms a height on which future treatment planning can
be based.

PRACTICE
prosthetics
An interim denture can be helpful in patients exhibiting gingival trauma as
a result of a deep incisal overbite.
A simple appliance with a palatal table can provide instant relief while a
decision is being taken on the definitive solution whether it be
orthodontic, restorative, periodontal or surgical.

In the young patient the palatal table may also improve the situation by
allowing further eruption of the posterior teeth and causing some
intrusion of the mandibular anterior teeth.

Prevention of gingival trauma should not be attempted with an onlay
appliance covering only the posterior teeth as continued eruption of the
anterior teeth may result in the original traumatic relationship becoming
re-established.
Treatment of denture stomatitis

Fig. 26 — Treatment of denture stomatitis
Denture stomatitis is a diffuse inflammation of the denture-bearing
mucosa, often of multiple aetiology.

PRACTICE
prosthetics
The commonest causes are an overgrowth of the fungus Can- cytotoxic agents, may predispose to denture stomatitis.
dida albicans encouraged by poor denture hygiene and mechan- Treatment of the condition to achieve resolution of the
ical trauma from the denture. Systemic conditions, such as inflammation and the associated mucosal swelling should be
diabetes, deficiencies of iron, vitamin B12 or folic acid, and drug carried out before working impressions are obtained.
therapy, including broad-spectrum antibiotics, steroids and
Fig. 27 — Treatment of
denture stomatitis
Some of the many aetiological and
predisposing factors, which may
play a part in the pathogenesis of
denture stomatitis are shown in
the figure. The possible interaction
of the various factors is complex
and uncertain, but a possible
scenario is as follows.
Toxins produced by the Candida cells left on the denture sur- contribute to the condition by increasing the adhesiveness of the
face by deficient hygiene measures, together with trauma from Candida cells, and thus encouraging the formation of denture
the denture, initiate an inflammatory reaction. Thinning of the plaque. As candidal proliferation occurs, the rate of production
mucosa results in increased permeability and escape of inflam- of potent toxins by the micro-organisms increases. The passage
matory exudate. The exudate, together with desquamated of these toxins into the tissues is facilitated by the thinning and
mucosal cells, forms a favourable nutrient medium, which pro- increased permeability of the mucosa. Aggravation of the inflam-
motes the growth of Candida albicans. In addition, this exudate, matory response occurs and so a vicious circle is set up. Anti-
and the sucrose-rich diet which may result from the dietary selec- candidal antibody is secreted in parotid saliva but the denture
tion sometimes associated with the wearing of dentures, may base may restrict access of antibody to the Candida cells.
Fig. 28 — Treatment of denture stomatitis 1 3 2

The aetiological factors may act alone or in combination as indicated here
diagrammatically. In patient (1) the lesion is due to a proliferation of
Candida organisms, in patient (2) to denture trauma, and in patient (3) to
a combination of these factors.
The position of each denture stomatitis patient should be estimated on Candida
this aetiological scale so that the appropriate treatment can be carried out.
Trauma
Systemic factors

If the denture plaque control is poor the dentist should demonstrate the
plaque to the patient by the use of a disclosing solution, explain the
significance of the plaque and give instruction in how best to remove it.

PRACTICE
prosthetics
To clean the denture the patient should be advised to use a small-headed
medium multi-tufted toothbrush, which gives good access to all parts of
the denture and good adaptability to the surface. Any agent used with the
brush should have a low abrasivity for acrylic resin. Soap is one such
agent. It should be noted that many proprietary toothpastes, and even
some denture pastes, contain abrasive particles which can damage acrylic
resin.

Acrylic dentures should also be immersed daily in a cleanser of the
hypochlorite type, as these have been shown to be the most effective
chemical agents for plaque removal. In this figure an acrylic plate carrying
disclosed plaque has been partially immersed for 20 minutes in such a
cleanser, rinsed and then re-disclosed. The immersed portion (right side)
has been rendered plaque-free.

Cobalt chromium dentures should not be immersed for long periods in
hypochlorite cleansers because there is a risk of corrosion of the metal.
If trauma appears to be a contributory factor to the stomati- If the lesion does not respond to these local measures the inves-
tis, appropriate adjustments, such as occlusal correction and tem- tigation of possible systemic factors should be undertaken. In
porary relining, should be made to the denture as described in such refractory cases, oral antifungal agents such as Ampho-
the earlier sections of this chapter. However, it should be borne tericin B, Nystatin or Miconazole may be beneficial. It should be
in mind that as temporary linings with tissue conditioners make noted, however, that these antifungal agents by themselves are of
it more difficult for the patient to keep the denture clean, they very limited value and unless the underlying cause of the den-
should be avoided if possible. As both plaque and traumatic fac- ture stomatitis is eradicated the condition will recur when the
tors can be eliminated by leaving the denture out the patient antifungal agents are withdrawn.
should be advised to do this as much as possible.

PRACTICE
prosthetics
12
Tooth preparation
5 J. C. Davenport,1 R. M. Basker,2 J. R. Heath,3 J. P. Ralph,4
This final article in the series describes the

modification of teeth to improve their shape for • Rest seats
the support and retention of RPDs. • Guide surfaces
• Correction of unfavourable survey lines
• Creating retentive areas
reparation may be undertaken for a number of reasons. ally undertaken with rotary diamond instruments of appropri-
P
• Provide rest seats.
ate size and shape. The resulting roughened enamel surface must
always be smoothed and polished. Special burs, stones and abra-
• Establish guide surfaces. sive-impregnated rubber wheels and points are available for this
• Modify unfavourable survey lines. purpose. Subsequent application of a topical fluoride varnish, to
• Create retentive areas. reduce the chance of carious attack of the modified enamel sur-
faces, should be carried out routinely.
In addition, occlusal adjustment may also form an important part
of tooth preparation (see Figs 7.14, 7.15 and 7.17 of A Clinical Rest seats
Guide to Removable Partial Dentures). Rest seats may need to be prepared to:
Tooth preparation for RPDs should be planned on articulated • produce a favourable tooth surface for support (Fig. 1);
study casts after they have been surveyed and a denture design • prevent interference with the occlusion (Fig. 2);
produced. • reduce the prominence of a rest (Fig. 3).
Shaping of enamel surfaces for any of the reasons listed is usu-
Fig. 1 — Rest seats

A rest placed on an inclined surface will tend to slide down the tooth
under the influence of occlusal loads (1). The resulting horizontal force
may cause a limited labial migration of the tooth with further loss of
support for the denture.
The provision of a rest seat (2) will result in a vertical loading of the
tooth, more efficient support and absence of tooth movement.
1 2

Healthcare Trust, Manchester, UK; 4Consultant in Restorative Dentistry, Leeds been included (together with a number of
Teaching Hospitals NHS Trust and Senior Clinical Lecturer, University of Leeds and unpublished parts) in the book
York, UK; 5Professor of Prosthetic Dentistry, Consultant in Prosthetic Dentistry, A Clinical Guide to Removable

PRACTICE
prosthetics
An occlusal rest placed at the arrow in (1) would create a premature
occlusal contact (2), unless a rest seat was prepared to make room for it
(3).
Space for the rest should not usually be created by grinding the
mandibular buccal cusp as this is a supporting cusp contributing to the
stability of the intercuspal position.
1 2 3

1 2 In addition, a rest placed on an unprepared tooth surface (1) will stand
proud of that surface and may tend to collect food particles and possibly
create difficulties in tolerating the denture.
The preparation of a rest seat (2) will allow the rest to be shaped so that
it blends into the contour of the tooth, is less apparent to the patient and
also harmonises with the occlusal relationship.
Fig. 4 — Rest seats on posterior teeth

1 2 The design of rest seats on posterior teeth is shown in:
1. occlusal view;
2. mesiodistal view;
3. proximal view.
It will be seen that preparation involves a reduction in the height of the

3 marginal ridge in order to ensure an adequate bulk of material linking the
occlusal rest to the minor connector.
Rest seats on posterior teeth should normally be saucer-shaped so that
a certain amount of horizontal movement of the rest within the seat is
possible. Dissipation of some of the energy developed by occlusal forces
acting on the denture can then occur.

The use of a box-shaped rest seat within a cast restoration may result in
the rest applying damaging horizontal loads on the abutment tooth.
These rest seats should be restricted to tooth-supported dentures where
the periodontal health of the abutment teeth is good.

PRACTICE
prosthetics
The rest should be at least 1 mm thick for adequate strength. To check
that sufficient enamel has been removed during rest seat preparation to
accommodate this thickness of metal, the patient should be asked to
occlude on a strip of softened pink wax. The thickness of wax in the
region of the rest seat will indicate if adequate clearance has been
achieved.
Figs 7 and 8 — Rest seats on posterior teeth

Where a clasp is to extend buccally from an occlusal rest and there is no space occlusally for it to do so, the
preparation must be extended as a channel on to the buccal surface of the tooth. In some circumstances it may also
be necessary to reduce and recontour the cusp of the tooth in the opposing arch.
Rest seats on anterior teeth

The design of rest seats on anterior teeth is shown in Figs 9 to 12.
Fig. 9 — Rest seats on anterior teeth

On maxillary anterior teeth, particularly canines, the cingulum is often
well enough developed so that modest preparation to accentuate its form
creates a rest seat without penetration of the enamel.

PRACTICE
prosthetics
A cylindrical diamond stone with a rounded tip should be used to prepare
the rest seat. A spherical instrument tends to create unwanted undercuts.

1 2 3 The lingual surface of a mandibular anterior tooth is usually too vertical
and the cingulum too poorly developed to allow preparation of a
cingulum rest seat without penetration of the enamel. Incisal rest seats
therefore have a wider application in this situation, in spite of their
inferior appearance. The preparation is shown from the labial (1), lingual
(2) and proximal (3) viewpoints.

Incisal rest seats can be prepared using a tapered cylindrical diamond.
Alternative, more aesthetic options are to produce a rest seat in
composite applied to the cingulum area of the selected tooth, or to bond
a cast metal cingulum rest seat to the tooth.
Guide surfaces
Fig. 13 — Guide surfaces
Guide surfaces (*) are two or more parallel axial surfaces on abutment
teeth, which limit the path of insertion of a denture. Guide surfaces may
occur naturally or, as is more often the case, may need to be prepared.
The advantages of guide surfaces • Increased stability.

It is widely accepted on the basis of clinical observation that • Reciprocation.
the use of guide surfaces confers a number of benefits in RPD • Prevention of clasp deformation.
construction. The benefits include the following: • Improved appearance.

PRACTICE
prosthetics
Fig. 14 — Increased stability
This is achieved by the guide surfaces resisting displacement of the
denture (red arrows) in directions other than along the planned path of
displacement.
A guide surface* allows a reciprocating component to maintain
continuous contact with a tooth as the denture is displaced occlusally.
The retentive arm of the clasp is thus forced to flex as it moves up the
tooth. It is this elastic deformation of the clasp that creates the retentive
force (Chapter 7, A Clinical Guide to Removable Partial Denture Design).
Fig. 16 — Prevention of clasp deformation

1 2
Guide surfaces ensure that the patient removes the denture along a
planned path (1). The clasps are therefore flexed to the extent for which
they were designed.
Without guide surfaces the patient may tilt or rotate the denture on
removal (2), causing clasps to flex beyond their proportional limit.
Fig. 17 — Improved appearance

A guide surface on an anterior abutment tooth permits an intimate
contact between saddle and tooth which allows the one to blend with the
other, creating a convincing, natural appearance. Guide surfaces may
occur naturally in this situation and if so, tooth preparation is not
required.

PRACTICE
prosthetics
The preparation of guide surfaces
Guide surfaces are usually prepared, somewhat imprecisely, by the guide surfaces checked using the analysing rod. If correction
eye. The position in which the handpiece must be held to pre- is found to be needed, further intra-oral adjustment can be
pare the required guide surfaces, so that they are all parallel to undertaken.
each other and to the path of insertion, should be established on A more precise approach to the preparation of guide surfaces
the study cast. can be achieved by the use of jigs constructed on a prepared study
As a check on the accuracy of the prepared guide surface, an cast and then transferred to the mouth, either to control the posi-
alginate impression may be taken to produce a second study cast. tioning of the handpiece or to check on the location and amount
This cast can then be placed on a surveyor and the parallelism of of enamel reduction.
Fig. 18 — The preparation of guide surfaces

A guide surface should extend vertically for about 3 mm and should be
kept as far from the gingival margin as possible.

A guide surface should be produced by removing a minimal and fairly
uniform thickness of enamel, usually not more than 0.5 mm, from around
the appropriate part of the circumference of the tooth (green area).
The surfaces should not be prepared as a flat plane, as would tend to
occur if an abrasive disc were used (red area). This is unnecessarily
destructive and may even lead to penetration into dentine, thus making a
restoration obligatory.

The required location of a guide surface will be dependent on its function.
The red guide surfaces on the proximal surfaces of the abutment teeth
facing the edentulous space will be needed to control the path of
insertion of the saddle. The green guide surfaces on the tooth surfaces
diametrically opposite the retentive portion of the clasp will be needed
for the latter's reciprocation.
Unfavourable survey lines

Figs 21 and 22 — Unfavourable survey lines
A high survey line on a tooth that is to be clasped is unfavourable occlusal interference is not present, a high clasp arm is more noticeable
because it requires the clasp to be placed too close to the occlusal to the patient and may interfere with mastication.
surface and may create an occlusal interference (arrows).Even if an

PRACTICE
prosthetics
Fig. 23 — Unfavourable survey lines

1 2
(1) A high survey line may also result in deformation of the clasp because,
on insertion, the clasp is prevented from moving down the tooth by
contact with the occlusal surface. If the patient persists in trying to seat
the denture, the clasp is bent upwards rather than flexed outwards.
(2) Shaping the enamel to lower the survey line will allow the clasp to be
positioned further gingivally and it also provides a 'lead-in' during insertion,
causing the clasp to flex outwards over the survey line as planned.
Retentive areas
Fig. 24 — Retentive areas
Retentive areas can be created by grinding enamel. However, the enamel
is relatively thin in the gingival third of the crown where the retentive tip
of the clasp would normally be placed, so the amount of undercut that
can be achieved by these means without penetrating the enamel is strictly
limited. It is usually better to establish improved contours for retention by
restorative methods as outlined in Chapter 14 of A Clinical Guide to
Removable Partial Dentures.
Fig. 25 — Retentive areas

Undercut areas can also be created by the use of acid-etch composite
restorations.
A broad area of attachment of the restoration to the enamel is desirable
as this will reduce the chance of the restoration being displaced and will
produce a contour more suitable for clasping.
The early composites were not suitable for this purpose as they
contained coarse filler particles that caused marked abrasion of the clasp
arm with consequent weakening of the clasp and loss of retention.
However, the use of modern ultrafine and hybrid composites results in
minimal mutual abrasion of composite and clasp so that the technique is a
durable, effective and conservative method of enhancing RPD retention.
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Removable partial dentures: an introduction

Article in British dental journal · November 2000

The user has requested enhancement of the downloaded file.

BRITISH DENTAL JOURNAL, VOLUME 189, NO. 7, OCTOBER 14 2000 363

Need and demand for

This article considers first, factors influencing the

1*Emeritus Professor, University of Birmingham, UK ; 2Professor of Dental

364 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 7, OCTOBER 14 2000

Very upsetting A little upsetting Not at all upsetting

BRITISH DENTAL JOURNAL, VOLUME 189, NO. 7, OCTOBER 14 2000 365

RPDs and the elderly

Specific problems of the elderly in relation to the

366 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 7, OCTOBER 14 2000

Fig. 7 — Root surface caries

Patient assessment Desire and motivation

BRITISH DENTAL JOURNAL, VOLUME 189, NO. 7, OCTOBER 14 2000 367

Fig. 8a and b — Treatment options

Fig. 9 — Treatment options

Fig. 10 — Treatment options

368 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 7, OCTOBER 14 2000

This article describes the benefits and risks of

1*Emeritus Professor, University of Birmingham, UK; 2Professor of Dental

414 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000

Fig. 2a and b — Appearance

BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000 415

Maintaining the health of the masticatory system

Fig. 6 — Preventing undesirable tooth movement

Fig. 7 — Preventing undesirable tooth movement

Fig. 8 — Preventing undesirable tooth movement

416 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000

Fig. 10 — Improved distribution of occlusal load

Fig. 11a and b — Improved distribution of occlusal load

BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000 417

Fig. 13 — Preparation for complete dentures

Fig. 14 — Preparation for complete dentures

Causes of damage related to the wearing of RPDs

418 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000

Table 1 Summary of damage that may result from wearing an RPD

Causes Teeth Periodontal tissues Edentulous areas Muscles of mastication

Plaque accumulation Decalcification Inflammation of gingival Inflammation of mucous

Direct trauma from Abrasion and Inflammation of gingival Localised inflammation

Transmission of (a) Tooth mobility Inflammation of mucous

Occlusal error (a) Tooth mobility Inflammation of mucous Muscle dysfunction

Increased plaque accumulation

Fig. 15a and b — Increased plaque accumulation

BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000 419

Fig. 16a and b — Increased plaque accumulation

Fig. 17 — Increased plaque accumulation

Fig. 18 — Increased plaque accumulation

420 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000

Fig. 20a and b — Direct trauma from components

Transmission of excessive force

BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000 421

Fig. 21a and b — Transmission of excessive force

Fig. 22 — Transmission of excessive force

Fig. 23 — Occlusal error

422 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000

Fig. 24a and b — Contribution of the clinician

Fig. 25 — Contribution of the dental technician

BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000 423

Fig. 27a and b — Contribution of the patient

424 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000

Special tray – [spaced, perforated]