Original article

Partial edentulism and removable partial denture design in a dental school population: a survey in Greece
Artemis P. Niarchou1, Polyxeni Chr. Ntala1, Evagelia P. Karamanoli1, Gregory L. Polyzois2 and Maria J. Frangou1
1

Private practice, Athens, Greece; 2Department of Prosthodontics, Section of Removable Prosthodontics, Dental School, University of Athens, Athens, Greece

doi: 10.1111/j.1741-2358.2010.00382.x Partial edentulism and removable partial denture design in a dental school population: a survey in Greece Objectives: To investigate the pattern of partial edentulism and the most frequent designs of cobaltchromium removable partial dentures (RPDs), constructed at the Dental School of Athens, Greece. Methods and materials: Five hundred and fty-three patients, between 42 and 81 years old, mostly males, treated by undergraduate dental students, were included. The survey was based on visual evaluation of master casts and work authorisation to dental technicians. Aspects examined were: Kennedy Classication, modication areas, major connectors, clasping, placement of rest seats and indirect retention. Results: Kennedy Class I was the most common encountered in the maxilla (50.5%) and in the mandible (70%). The most frequent major connectors were the lingual bar (92.6%) and the U-shaped palatal strap (54%). The most common clasp was the Roach (69.2%) in Class I and Class II. In Class III and IV, the most common was the occlusally approaching clasp (55% and 70%). The most frequent location of the rest was mesial of abutment teeth. On the average, 39.5% of Class I RPDs and 58.6% of Class II RPDs had indirect retainers. Conclusion: A combination of the two major philosophies of RPD design (biomechanical and hygienic) was evident in the RPDs examined in our study. Keywords: partial edentulism, removable denture design, Kennedy classication, hygienic concept. Accepted 16 January 2010

Introduction
Modern dentistry imposes the preservation of natural teeth, which leads to a progressive decline in the number of complete dentures and an increase of partial ones. Replacement of missing teeth is a common patient need and this should be accomplished by means that minimise the risks, inconveniences or problems involved1. Among these means, removable partial dentures (RPD) appropriately designed should restore the functions of speech, mastication and deglutition, enhance appearance, preserve the remaining teeth and supporting tissues of the patient and generally contribute to the normal function of the stomatognathic system2. Traditionally, to accomplish this, partial dentures have to ensure the biomechanical aspects of support, retention and stability.

In addition to these, it is important that the RPDs have to be designed in a way that minimises plaque accumulation and oral tissue damage. Such design parameters are called hygienic principles. The basic principle of open/hygienic RPD design states that if the basic elements of the RPD do not contact either teeth or periodontal tissues, they cannot cause any injuries to these structures3. According to Jacobson, the emphasis on contemporary RPD design should be placed on ensuring minimal tooth coverage by the framework and eliminating the components, whenever possible, without compromising biomechanical requirements4. As a general rule the design should be as simple as possible, with various parts of the denture avoiding contact with the free gingiva and having a space of at least 3 mm from the tooth surfaces5. Although these principles have been widely accepted among dentists and special177

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ists, there is no evidence to prove that following these standards leads to better clinical treatment or greater patient satisfaction6. Many removable partial denture classication systems have been proposed to identify potential combinations of teeth and edentulous spaces. Cummer was credited with the rst classication, followed by Bailyn and Skinner. However, the classication, originally proposed by Dr Edward Kennedy in 1925, is the most widely used. This system attempts to classify the partial edentulous arch in a manner that suggests certain principles of design for a given situation. In 1960, Applegate provided eight additional rules to Kennedys system. The main purpose of a classication system is to simplify and improve communication between dentists, students and laboratory technicians and facilitate learning and understanding the fundamentals of RPD design7. Several studies have been performed in different parts of the world concerning the different philosophies in RPD design and fabrication520. Despite the fundamental design principles, there is no unanimous opinions in RPD design and wide variations have been demonstrated among clinicians and laboratories21.Most of the surveys have been based on data gathered from dental laboratories7,10,14,15 while others took place in Dental Schools16,17. The methods followed for data collection were such as: evaluation of casts photos10,14,15, work authorisation forms7,16,17 and questionnaires9,15,19. Finally there was one houseto-house study in India which was based both on questionnaire and oral examination of patients20. The aim of this survey was to investigate (i) the prevalence of partial edentulism patterns encountered; (ii) the most frequently used designs for conventional cobalt-chromium (Co-Cr) RPDs constructed for patients attending the Dental School of Athens, Greece; and (iii) to identify whether the RPD designs followed the traditional biomechanical concepts or the more contemporary open/hygienic approach.

hundred and fty-three consecutive patients, who were provided with conventional Co-Cr RPDs, were included in this survey. The age of the patients ranged between 42 and 81 years and 62% of the participants were male. Excluded from this survey were transitional (acrylic) and swing lock RPDs, obturators or precision attachment-retained ones. The survey was based on the visual examination/evaluation of 553 master casts with and without the cast RPD frameworks and work authorisation towards dental laboratories. The information was gathered in joint sessions with the dental students and supervising staff. During those sessions any further information/clarication concerning RPDs design was obtained from the examiners. Kennedy classication was followed to identify different classes of the pattern of edentulism (Class IIV). The modication spaces were divided into ve categories: no modication area, anterior modication area, posterior modication area, combined anterior and posterior modication area and extensive RPD where only one or two teeth were present on either or both sides of the arch. Moreover, the design aspects included were: The type of major connector: the maxillary major connectors were recorded as horseshoe (Ushape), anterior-posterior palatal bar, palatal strap, palatal plate and the mandibular as: lingual bar, double lingual bar, lingual plate; The types of direct retainers: circumferential clasp, embrasure clasp, ring clasp, back-action, Roach, RPI and others (multiple clasp, half-andhalf clasp and reverse action clasp); The location of rests on abutment teeth in distal extension saddle cases; and The use of indirect retention.

Results
The results are presented through descriptive statistics. The majority of the RPDs examined for our study were fabricated for the lower arch (61%) whereas only 39% were for the upper. The distribution of RPD frameworks according to Kennedy classication is presented for the maxilla (Fig. 1) and the mandible (Fig. 2). It is obvious that the most frequent pattern of partial edentulism was Kennedy Class I (50.5% in the maxilla and 70% in the mandible) and Kennedy Class IV was the least frequently encountered pattern (3% in the maxilla and 1.5% in the mandible). For Kennedy Class II the percentages were 32% in the maxilla and 21% in the mandible and for

Materials and methods

The survey took place in the fourth and fth year undergraduate Prosthodontic and Comprehensive Dental Care Clinics at the Dental School of Athens, Greece over a period of three consecutive academic years (20032006). The dental students who treated the patients were under clinical staff (faculty/ associates) supervision. The clinical staff were certied prosthodontists and members with longterm experience in removable prosthodontics. Five

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Class III, 14.5% in the maxilla and 7.5% in the mandible. Table 1 shows the distribution of RPD according to the pattern of modication areas. The majority of Kennedy Class I in both the maxilla and mandible were without modication areas (10% in the maxilla and 25% in the mandible). In Class II and Class III the posterior modication area was the most frequently presented in both arches (5.8% in the maxilla and 5.4% in the mandible for Class II and 2% in the maxilla and the mandible for Class III).

Maxilla

IV 32.0%

I 50.5%

III 14.5% II 3.0%

Figure 1 Distribution of RPD frameworks according to Kennedy Classication in the maxilla.

III 7.5%

Mandible IV 1.5% II 21.0%

Finally, in Class IV, 0.9% in the maxilla and 0.4% in the mandible had an extensive modication area. In the upper arch the U-shape palatal strap was the most frequently designed major connector (54%), while the palatal strap was constructed for 26% of the patients, the palatal plate for 19% and the anterior-posterior palatal bar only for 1% of the patients. The distribution of the major connectors in the mandible shows the lingual bar the most prescribed mandibular major connector (92.6%) in all Classes. The other two types of major connectors (double lingual bar and lingual plate) followed with a very small percentage (6.8% and 0.6%). Details of the distribution of the clasp types on the abutment teeth in every Kennedy Class were: in Class I and II the Roach type clasp was the most frequently used (69.2%), followed the occlusally approaching clasp (29.6%) and the RPI clasp (0.4%). In Class III, the occlusally approaching clasp had a percentage of 55%, the Roach type 44% and the RPI 1%. Finally in Class IV, the occlusally approaching clasp was encountered in 70% of the cases, the Roach type in 27% and the RPI type in 3%. The distribution of the rest seats on the abutment teeth is shown in Fig. 3a-c. For Class I and II, in 28% of the cases, the rest was found placed on the mesial of the anterior teeth, in 24% mesial of the premolars, in 16% distal of anteriors or mesial of molars, in 10% distal of premolars and in 6% distal of molars. In Class III, 37% mesial of molars, 19% mesial of anterior teeth, 13% distal of premolars or mesial of premolars, 10% distal of molars and 8% distal of anterior teeth. For Class IV, 47% of the rests were seated mesially of molars, 19% distally of molars, 14% mesially of premolars, 10% distally of premolars and 5% mesially and 5% distally of anterior teeth. The incidence of indirect retention in the maxilla and in the mandible was found to be 55.6% of the RPDs in the maxilla and 39% in the mandible. On average, 39.5% of Class I RPDs and 58.6% of Class II RPDs had indirect retainers incorporated into their designs. Indirect retention was used more often in the mandibular Class I than in the maxillary Class I frameworks and the same was observed in the Class II frameworks.

Discussion
Over the last decades, increased life expectancy, enhanced awareness of periodontal health and continuous improvement in dental materials and techniques have led to a general change in denture design philosophy. This has probably impacted on a greater variety of the RPDs constructed and

I 70.0%

Figure 2 Distribution of RPD frameworks according to Kennedy Classication in the mandible.

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Table 1 Distribution of RPD classes according to pattern of modication areas by arch [values are percentage of the total number (553) of RPDs casts examined]. Anterior modication area Max % 5 1.8 2 0 Mand % 11.2 2 1.1 0 Posterior modication area Max % 0.9 5.8 2 0 Mand % 1.5 5.4 2 0 Combined modication area Max % 0.5 0 0 0 Mand % 0 1.5 0.2 0 Extensive modication area Max % 3.4 3.1 0.4 0.9 Mand % 4.3 2.4 0.2 0.4

No modication area Class Class Class Class Class I II III IV Max % 10 2.2 0.9 0.4 Mand % 25 1.8 1.3 0.4

Max,: maxilla; Mand: mandible.

consequently, there appears to be no unanimous opinion on the design principles. As there are differences among countries in the social, nancial and professional aspects of dental treatment, the RPD design can be inuenced by the provided dental education philosophy and training to be provided. In the Dental School of Athens, modern concepts of preventive dentistry are taught to the students, thus combining the open/hygienic design with the biomechanical concept. This imposes a simple shape for the prosthesis and keeps the number of components to the minimum in a way that plaque or pocket formation and inammation are prevented without compromising the retention and stability of the prosthesis. In our survey, the number of partially edentulous males (62%) outnumbered the females (38%), which is in accordance with the results of Dwairi17 and in contrast with others15,20. In the present study, the maxillary and mandibular arches treated constituted 39% and 61% of the sample respectively. Corresponding gures were 39.5% and 60.5% for Sweden9, 40.6% and 59.4% for the USA10, 51.2% and 48.8% for Poland11. In Scotland, the gures were 70.4% for the maxilla and 29.6% for the mandible15. The predominance of mandibular RPDs in most countries is probably related to the general pattern of tooth loss and the reluctance of dentists to recommend a complete mandibular denture because of the problems associated with it7. The most frequent pattern of partial edentulism in our survey was Kennedy Class I, with Kennedy Class IV being the least frequent. Similar results regarding Class I were reported by Curtis et al.7. In other studies, Class III was the most predominant, whereas Class IV was always the least encountered16,17,20. The limited use of RPDs Kennedy Class IV could be attributed to the fact that anterior

teeth, when lost are usually replaced by xed prostheses or implants for aesthetic reasons. On the other hand the higher incidence of Class I RPDs could be attributed to masticatory purposes. Among the RPDs without modications, Class I RPDs were the most common. Among the RPDs with anterior modication areas, the mandibular Class I were the most common, whereas the posterior modication areas were predominant in the maxillary Class II RPDs. Finally, RPDs with extensive modication areas were more frequently found in the Kennedy Class I followed by Class II of both the maxillary and mandibular arches. The studies by Sadig et al.16 and Dwairi17, indicate that among the RPDs without modications, Class I were the most common ones corroborating with our ndings. Concerning the major connector, the most frequently prescribed for the maxilla in our study was the U-shape palatal strap (horse-shoe) and the lingual bar for the mandible. The same results for the maxilla were reported in a North America RPDs design survey10 and another conducted by Becker et al.13. The lingual bar remains the most popular major connector for the mandible10,1517. The preference for the lingual bar depends on the depth of the lingual sulcus, the presence of tori, periodontal disease and previous experience with dentures17. The advantages and/or disadvantages of different types of clasps have not been clearly documented. Basker et al.22, presented the general philosophy for the use of the direct retainers. Although the occlusally approaching clasps minimise the risk of gingival trauma, aesthetic reasons often limit their use especially in the anterior region. This need is compensated for by the use of the gingivally approaching clasps. On the other hand, plaque formation and unfavourable anatomical factors should be taken into consideration during the

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(a)
Mesial of molars 16%

181

Class I, II
Mesial of anterior teeth 28%

Distal of molars 6%

Distal of premolars 10%

Distal of anterior teeth 16%

Mesial of premolars 24%

(b)
Mesial of premolars 13% Distal of anterior teeth 8%

Class III

Mesial of molars 37%

Distal of molars 10%

Distal of premolars 13% Mesial of anterior teeth 19%

(c)

Class IV
Distal of anterior teeth 5% Mesial of anterior teeth 5% Distal of premolars 10%

Mesial of molars 47% Mesial of premolars 14%

Distal of molars 19%

Figure 3 (ac) Distribution of rest seats on the abutment teeth by Kennedy Classication.

treatment planning5. Our ndings indicated that the most frequently used clasp for Class I and II was the gingivally approaching type, whereas for Class III and IV it was the occlusally approaching variety. On the other hand, Curtis et al.7 reported the common use of occlusally approaching clasps even in Class I and II. The survey of Sadig et al.16 showed an overwhelming preference for occlusally approaching clasps evenly distributed between

both arches, with the ring clasp dominating on mandibular RPDs. Dwairi17 was in accordance with the previous survey, but mentioned a more frequent use of the I bar clasp in the maxilla indicating a higher concern for aesthetics. Finally the survey of Fayyaz and Ghani19 in Pakistan revealed the inadequate training of the practitioners regarding the use of clasps and poor knowledge in the designing of RPDs. This corroborates the ndings of Grey and MacDonald that showed the inappropriate use of occlusally approaching clasps on premolar or canine teeth23. The optimum length of a cast Co-Cr clasp should be more than 15 mm and for this length to be achieved on canine or premolar teeth, a gingivally approaching clasp would be more appropriate23. Concerning the distribution of the rest seats on the abutment teeth of distal RPDs, our results coincide with these reported by Dwairi17 and Sadig et al.16 where the rest seat is placed mesially, conrming in this way the benets of the RPI system. During function, rotation occurs in the area of mesial rest; the I bar and the proximal plate disengage from the tooth and the abutment tooth is usually braced by the mesial adjacent tooth24. Many prosthodontists advise the use of an indirect retainer for Class I and II RPDs7.An indirect retainer minimises the risks of the denture base to move away from the supporting tissues5. According to our results, indirect retainers were incorporated into the majority of designs of Class II RPDs and more often in the mandible. The results of Curtis et al.7 and Sadig et al.16 where indirect retention was used more often in maxillary Class II RPDs were similar. On the contrary, Dwairi17 found that an indirect retainer was used more often in mandibular Class I cases. The diversity that is apparent in the results of all these studies, including our survey and the variations that exist in RPD design pattern, reect the different teaching philosophy and the educational background of the clinicians in every country. We have to emphasise that such kind of surveys are useful in many elds such as: identifying deciencies and shortcomings of dental curricula regarding RPDs, providing the necessary reforms and updates under the current knowledge and state of the art over the time; it can be the instrument to compare teaching philosophies and status on RPDs design/ construction among dental schools worldwide; explore the teaching homogeneity among staff members involved in RPDs construction driving adjustment in cases of gross deviations and nally monitoring possible disparities between academic teaching of RPDs and every day clinical practice by

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providing the necessary feedback. It must be pointed out that descriptive studies of dental school samples/populations may not be representative to what might be obtained in general dental practices. Schwarz and Barsby8 reported in a survey of 794 dentists in UK that there was a disparity between what was taught regarding the design and construction of partial dentures and what was carried out in general dental practice In addition, some aspects of partial denture treatment were discarded at an early stage in professional practice. This nding reafrmed recently in another UK survey by Allen et al.18, highlighting that for some dentists there was a divergence between knowledge and practice. This inconsistency was most apparent in decisions regarding material used, level of follow-up and designing of RPDs. All these reports emphasise the need for reorganising and reinforcing educational and training strategies related to RPDs. Furthermore, understanding, continuous communication and co-operation between clinicians and laboratory technicians is necessary in order to maximise the benets for our RPDs patients.

Conclusion
According to our study, the majority of the casts examined revealed that the most frequent pattern of partial edentulism was the Kennedy Class I and the least frequent was the Class IV both in the maxilla and mandible. A combination of the traditional biomechanical approach (mesial rest seats, indirect retention) with the open/hygienic concept (minimum tissue coverage, Roach type clasps, uncovered gingival margins) was followed at the Dental School of Athens regarding the RPD design.

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Correspondence to: Artemis P. Niarchou, 35 Vas. Konstantinou 15122, Marousi, Athens, Greece. Tel.: +30 210 8066555 Fax: 00302103452227 E-mail: artniarchou@yahoo.gr

2011 The Gerodontology Society and John Wiley & Sons A/S, Gerodontology 2011; 28: 177183