Removable Partial Prosthodontics

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PARTIAL DENTURE CLASSIFICATIONS

The Kennedy classification of partially edentulous arches:

  • Class I – bilateral distal extensions posterior to the remaining natural teeth.
  • Class II – unilateral distal extension located posterior to the remaining natural teeth.
  • Class III – unilateral edentulous area with natural teeth anterior and posterior to it. A Kennedy Class III denture is tooth supported.
  • Class IV – single bilateral edentulous area located anterior to the remaining teeth, which crosses the midline.
Kennedy class 1
Kennedy class 1 mod 1
Kennedy class 1 mod 2
Kennedy class 2
Kennedy class 2 mod 1
Kennedy class 2 mod 2
Kennedy class 3
Kennedy class 3 mod 1
Kennedy class 4

Applegate’s rules for the Kennedy classification system:

  • The most posterior edentulous area is the one that determines the classification.
  • The classification is determined by the teeth remaining after any planned extractions.
  • A posterior tooth, whether second or third molar, that is not going to be replaced in the denture is not included in the Kennedy classification. However if it is to be replaced or to be used as an abutment, it is included. 
  • Any edentulous areas other than the one determining the classification are called “modifications”. Modifications only indicate the number of additional edentulous areas, not the extent of each.
  • There are no modifications in a Kennedy Class IV denture.

The Craddock Classification is based on the denture type:

  • Type I – supported by mucosa only (full denture).
  • Type II – supported by teeth (Kennedy Class III and IV).
  • Type III – supported by a combination of mucosa and teeth (Kennedy Class I and II).

MAXILLARY MAJOR CONNECTORS

Major connectors link the components of the two sides of the arch. They need to be rigid enough to provide stability and should not impinge on gingival tissues. Bony and soft tissue prominences need to be avoided during placement and removal. 

Anterior-posterior palatal strap connectors provide the most rigidity for the amount of tissue covered. They can be useful for any Kennedy classification, especially Class IV and Class II, and can be fabricated to avoid a maxillary torus. 

Single palatal strap connectors are mostly used in Class III cases, where one or two teeth are being replaced on either side and the need for palatal support is minimal. They are useful for short span areas. Increasing the width of the palatal strap connector increases the rigidity. The anterior border of the major connector should sit posterior to the rugae. 

Palatal plate connectors are the most rigid of all major connectors and are indicated when all posterior teeth are missing bilaterally. The large area of tissue coverage is more likely to lead to soft tissue inflammation or hyperplasia, and problems with phonetics may occur. A palatal plate cannot be used when there is a palatal torus. They can be useful when there is a compromising situation: 

  • periodontally compromised teeth.
  • small mouth.
  • shallow vault.
  • flabby ridges.
  • cleft palate.

U-shaped palatal strap (horseshoe) connectors are the least rigid major connector, only used when no other design is feasible. A patient with a large palatal torus that cannot be removed may benefit from this design. It can also be used when several anterior teeth are to be replaced or when the patient is unable to tolerate palatal coverage (exaggerated gag reflex). 

Single palatal bar connectors are less than 8mm in width. A connector with a width of more than 8mm would be classified as a strap connector. This connector lacks strength and rigidity and its use is limited to a tooth borne prosthesis replacing one or two teeth on either side of the arch. They are not to be used for distal extensions, and not often selected for definitive treatment. Volume can be added to the bar to increase its strength.

Anterior-posterior palatal bar connectors are similar to the AP strap but less than 8mm in width. The main disadvantage is the bulkiness of the connector. It is indicated when support is not a major concern and when anterior and posterior abutments are widely separated. It can also skirt a palatal torus and be useful if the patient strongly opposes palatal coverage. This major connector does not provide good palatal support and may inhibit speech.

Maxillary connector – Anterior posterior palatal strap
Maxillary connector – horseshoe
Maxillary connector – palatal plate
Maxillary connector – Single palatal strap

MANDIBULAR MAJOR CONNECTORS

Lingual bar connectors have a half pear shaped cross-section, with the tapering end oriented superiorly. The depth of the vestibule needs to exceed 7-8mm, 5mm for the width of the bar and 2-3mm space between the bar and the gingival margins. It is the simplest and most commonly used mandibular major connector, with minimal soft tissue coverage and minimal contact with oral tissues. A lingual bar is not used if the patient presents with an inoperable lingual tori, high frenum attachment, or when there is interference from the floor of the mouth. 

Sublingual bar connectors are modifications of the lingual bar, essentially a lingual bar rotated horizontally. This major connector can be useful when there is not enough space for a lingual bar. The superior border of the bar should be kept 3mm from the gingival margins. A sublingual bar cannot be used when teeth are lingually tilted, there are inoperable tori, or in cases with a high lingual frenum attachment.

Lingual plate (Linguoplate) connectors are lingual bar connectors that have been extended upwards to cover the lingual surfaces of the mandibular anterior teeth. Lingual plates are used when the lingual vestibule depth is less than 7mm (shallow floor of mouth or high frenum), when further loss of anterior teeth are anticipated, or when all posterior teeth are to be replaced. They can also be used when patients have inoperable mandibular tori or to stabilize periodontally compromised anterior teeth. Lingual plate connectors are very rigid and provide more support and stabilization compared to other mandibular major connectors, but can be unaesthetic if there are gaps in between anterior teeth, and may also lead to poor cleaning. Lingual plates are not used in cases of severe crowding.

Labial bar (rigid or swing-lock) connectors consist of a fixed or hinged continuous bar located buccal/labial to the teeth. They are used in cases with large inoperable lingual tori or severely lingually inclined lower anterior teeth. Labial bars are rarely used.

Cingulum bar (continuous bar) connectors exert no pressure on the gingival tissues with the movement of the RPD, provide indirect retention, and repairs are easy when further anterior teeth are lost. But the metal bar can be bulky, and esthetics poor if there are spaces in between the teeth. 

A combination (Kennedy bar, double lingual bar, continuous bar) connector is a mandibular lingual bar combined with a continuous bar/cingulum bar. They can add rigidity, stability, and indirect retention.

COMPONENTS AND DESIGN

Support for partial dentures can be tooth borne or from a combination of abutment teeth, residual ridges, adjacent soft tissues, and the fibrous connective tissues covering the alveolar ridges. A healthy tooth can move about 0.2mm, accommodated by the periodontal ligament space. Soft tissue on the other hand can move 1mm or more. This is not a problem for tooth-supported Class III dentures, but becomes important for distal extensions bases. The alveolar ridge resorption under distal extension RPD can be minimized by maximal coverage of supporting areas.

Rests prevent vertical displacement towards the softs tissue and transmit occlusal forces to the supporting teeth. Their main function is direct support, but are also important in indirect retention. Rests are often included in a retentive clasp assembly. Routine denture design will see teeth next to a denture space receiving a rest, usually on the incisal, lingual or occlusal surfaces. 

Occlusal rests are rounded (semicircular or spoon shaped) with the apex pointing towards the tooth’s center. They are designed to take up one third of the facial-lingual width, and are about 1.5mm deep for adequate strength. 

A cingulum rest is usually an inverted V or U shape, used when a tooth’s lingual anatomy lends itself to preparation for a positive seat (usually only maxillary canines). Mesio-distal length is 2.5-3mm, labio-lingual width about 2mm, depth about 1.5mm. A cingulum rest is rarely recommended for mandibular central and lateral incisors, and the lingual surface of a mandibular canine is usually too steep. 

An incisal rest is used when other rests are not available. It is a rounded notch at the incisal angle, 2.5mm wide and 1.5mm deep. An incisal rest provides direct support and indirect retention. They are rarely used since they lead to poor aesthetics. 

Direct retainers prevent RPD movement away from the hard and soft tissues. They can be intra-coronal (precision attachments, semi-precision attachments) or extra-coronal, which are generally clasp assemblies. Only the terminal part of the retentive arm sits below the contour line of the tooth and engages the undercut. 

Intra-coronal attachments derive their function from closely fitting, coupling parts. One component is attached to the removable partial denture and the connecting component is traditionally incorporated into a cast crown or a fixed partial denture, sometimes referred to as patrix and matrix. Intracoronal attachments allow for the placement of torquing forces close to the long access of the tooth and eliminates the need for visible external clasps. They are generally more hygienic. However, more tooth reduction is required, they are more expensive and technically difficult to fabricate, and more difficult to repair. Intra-coronal attachments are fine for tooth-borne dentures but not appropriate in patients with distal extension bases since the functional movement will result in abutment tooth torquing

Precision attachments are prefabricated and incorporated in a denture design. Semi-precision attachments show a similar design but are made of wax, and replaced by metal during the casting process. 

Indirect retention counters the lifting of the denture base away from the soft tissue during function. Indirect retainers take the form of rests and are placed on the opposite side of the fulcrum line from the denture base, as anteriorly as possible. Common locations include the lingual surface of the canines or mesial surfaces of lower premolars. They provide retention, but also protect soft tissues from impingement by the major connector. Indirect retainers may not be included in some designs (e.g. tooth borne Kennedy Class III appliances). 

Reciprocation is included in denture design to counter the effects created by another part of the prosthesis. In an RPI design, reciprocation is achieved by rigid plating, minor connectors and guide planes. A minimum of 180° encirclement is recommended for adequate reciprocation.

A reciprocal clasp/stabilizing clasp is usually positioned on the lingual side of the assembly. Originating from the minor connector, the reciprocal clasp should contact the tooth above the height of contour. During insertion the reciprocal arm should engage the tooth at the same time as the retentive clasp arm to counter any unwanted lateral forces on the tooth. 

Minor connectors link components of the removable partial denture to the major connector. They must be rigid to transmit functional stresses evenly throughout the mouth.

Stress-breakers can be incorporated to relieve abutment teeth of excessive forces during function. When a stress-breaker is used next to a free-end distal extension RPD, the majority of the functional stress is directed onto the residual ridge with only minimal force transfer to the abutment tooth. This protects the tooth and supporting structures, but will likely result in increased ridge resorption, requiring more frequent relines. Types of stress breakers include:

  • Wrought-wire clasps – the simplest form of stress relief, providing a flexible connection between the direct retainer and the denture base. Compared to cast clasp arms, wrought-wire clasps exhibit greater flexibility, adjustability, ductility, toughness, and tensile strength. But the yield strength can be negatively impacted by excessive heat or long term cyclic loading. The terminal end of the wrought-wire clasp is usually placed in the middle of the gingival third of the clinical crown, but positioning is dictated by the location of the undercuts. When seated the arm should be passive. 20-gauge wire is twice as flexible as thicker 18-gauge. 
  • Split-bar major connectors – flexible connections between the direct retainer and the denture base.
  • Stress-breaker with a moveable joint – connecting the direct retainer and denture base. Examples include Distal Extension Hinge (DE hinge), Crismani attachment, ASC-52 attachment, and Dalbo attachment. 

Bracing occurs when rigid components are placed on the RPD to sit against non-undercut areas. A bracing component resists horizontal forces. 

Guidance is obtained by incorporating rigid components that brace against teeth during insertion and removal. Guiding surfaces are parallel to the path of insertion.

Beading is the procedure of scribing a rounded trench 0.05 mm deep following the anterior and posterior borders of a maxillary major connector. Beading an RDP adds strength (volume) to the major connector and ensures proper tissue contact to prevent food impaction.

The dental surveyor is an instrument used to determine the relative parallelism of oral anatomy. With a dental surveyor a clinician can determine the path of insertion, position of guide planes, and the location of undercuts. Areas used for support cannot be determined by surveying. Tilting the cast will change the path of insertion, position of survey lines, and the location of undercuts and non-undercut areas. When surveying casts the dentist/technician places tripod marks on the cast to record and reproduce the cast’s orientation on the surveyor.

CLASP DESIGN

Clasps are used for retention. A suprabulge clasp arm originates from a minor connector and approaches the retentive undercut from an occlusal direction. Examples include:

  • Circumferential (Akers clasp, circle clasp or C-clasp) – the most commonly used suprabulge clasp, composed of a buccal and lingual arm originating from a common body. One arm is retentive, the other bracing (provides reciprocation). They usually engage mesial or distal undercuts opposite to the side of the rest.
  • Ring clasp – surrounds the tooth to engage an undercut located on the same side as the rest. They can be unaesthetic and may predispose the tooth to caries. The length makes them more difficult to adjust and more easily distorted.
  • Embrasure clasp (Double Akers) – two Aker’s clasps back to back, originating from a common minor connector. It is used in a quadrant where no edentulous area exists, or where a distal approach clasp cannot be used on the most posterior tooth (when another clasp is not available). It must cross the marginal ridges of two teeth, and requires adequate tooth preparation.
  • Reverse-action clasp (hairpin clasp) – doubles back on itself and can be used to engage an undercut on the same side of the abutment as the rest. They can be unaesthetic, may predispose the tooth to caries, and are very difficult to adjust. 
  • Extended arm clasp – a circumferential clasp that extends to a second tooth to provide additional splinting and to engage a more favorable undercut.
  • Half and half clasp – one circumferential clasp with an additional arm extending from a second minor connector on the opposite side.

An infrabulge clasp arm originates from a minor connector and approaches the retentive undercut from the gingival direction. It can be referred to as a roach or bar (I-bar, J-bar, T-bar, L-bar, etc.). Infrabulge clasps are not placed into a tissue undercut and do not engage the tooth apart from at the specified undercut, usually in the gingival third of the tooth. The arm should be at least 3-4mm below the gingival margin, turning 90° at the abutment margin. Infrabulge clasps can provide more efficient retention with less distortion, are easier to clean, and less prone to caries. Since they emerge from the sulcus they also tend to be more esthetic. But infrabulge clasps can irritate vestibular tissues and can be aesthetically unsatisfactory in patients with a high lip line or gummy smile. 

Changing the length, diameter, shape, taper and type of metal will alter the physical properties of the retentive arm. Wrought wire is more flexible than cast metal. It should be at least 7 mm in length and can engage 0.5 mm (0.02 in.) of the undercut without deforming permanently. Wrought wire clasps can be soldered, included in the wax pattern before casting, or embedded in acrylic during processing. Less flexible cast metal clasp arms can engage 0.25mm (0.01 in.) undercuts.

  • Increasing the taper increases the flexibility. 
  • Increasing the diameter increases the rigidity by a cube factor.
  • Increasing the length increases the flexibility by a cube factor. 

A removable partial denture clasp assembly refers to a combination of four components:

  • Retentive arm.
  • Reciprocal arm.
  • Rest.
  • Guiding plate.

A RPI is one type of retentive clasp assembly design that incorporates:

  • a mesial Rest and minor connector.
  • proximal guide Plate designed to disengage during loading (and helps slightly with reciprocation).
  • I-bar which sits at least 3mm from the gingival margin and engages a mesial undercut. 

A RPI clasp assembly is used in Kennedy Class I and II cases to clasp an abutment tooth adjacent to a free saddle area. It provides retention and stability while avoiding unwanted forces on this abutment tooth. During function soft tissue displaces more than periodontal ligament which creates a levering action on a tooth. With the RPI rest seat and clasp located on the mesial aspect of the abutment tooth, the mesial I-bar will move away from the tooth during function preventing potentially damaging levering or torquing forces. 

In some instances an RPI design cannot be used, perhaps because of an obstructive frenum, lack of vestibular space, or deep soft tissue undercuts. In these cases a RPA (or RPC) design is utilized, where the I-bar is replaced with an Aker’s clasp (C-clasp). A combination clasp can be used instead of an RPI in cases where a mesial rest cannot be used, for example:

  • A mesial rest would cause rotation.
  • Heavy centric contact on the mesial surface.
  • Large amalgam restoration on the mesial surface.

The clasp assembly should encircle 180° or more of the tooth and be passive until a dislodging force is applied to the denture. The rest only provides vertical support. In a Kennedy Class III case the rests can be placed on the side of the tooth adjacent to the edentulous space since the denture is entirely tooth supported.