prosthetics 2 The removable partial denture equation - Clinical clinicaljude- removable partial ... and A Clinical Guide to Removable Partial Denture Design ... transitional dentures become more extensive as further teeth are
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<ul><li><p>414 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000</p><p>PRACTICE prosthetics</p><p>The removable partialdenture equation</p><p>The title of this part of the series requires immediate explana-tion. The term equation refers to the balance that must bestruck between the good and the bad which can arise from thewearing of RPDs. In this chapter we explore the benefits whichcan be conferred on patients by RPDs and, at the same time,highlight the possible risks of tissue damage that can be associ-ated with such prostheses.</p><p>Every prosthetic treatment is associated with the placement of aforeign object (the prosthesis) in the mouth of the patient. As adirect consequence of such placement the burden on the tissues inthe oral cavity will be increased. For example, plaque more readilyaccumulates on alloplastic materials than biologic ones. Further-more, even non-toxic materials will release small amounts of theircomponents into the oral cavity. To justify prosthetic treatmentand to ensure that it is beneficial to the patient, the need for suchtreatment must be established, the patient must be appropriatelymotivated, and the dentures properly designed, constructed andmaintained. Thus the initial step in determining if prosthetictreatment is indicated must always be the assessment of:</p><p> The patients wishes and concerns The relevant dental and medical history The results of the extra-oral and intra-oral examinations Oral hygiene habits and status</p><p> The essential oral functions of appearance, mastication andspeech.</p><p>It is only after this analysis has been completed that the decisionof whether or not to treat a particular patient can be taken. Forexample, prosthetic treatment must not begin until it has beenverified that there is a significant reduction in one or more of theessential oral functions. A simple determination of the numberand position of the remaining teeth is not a sufficient foundationfor making the decision of whether or not to initiate treatment.If it is indicated, a treatment plan is then devised identifying thevarious stages and the most appropriate type of prosthesis.</p><p>Benefits of RPDsThe potential benefits of RPDs which will be considered in thissection are their contribution to the following.</p><p> Appearance Speech Mastication Maintaining the health of the masticatory system:</p><p> preventing undesirable tooth movement improving distribution of occlusal load</p><p> Preparation for complete dentures.</p><p>2J. C. Davenport,1 R. M. Basker,2 J. R. Heath,3 J. P. Ralph,4 and P-O. Glantz,5</p><p>In this part, we will discuss The benefits of RPDs Tissue damage associated with RPDs Preserving oral health The importance of teamwork</p><p>This article describes the benefits and risks ofproviding RPDs. It emphasises the importance ofco-operation between the dental team and patientto ensure that the balance of this equation is inthe patients favour.</p><p>1*Emeritus Professor, University of Birmingham, UK; 2Professor of DentalProsthetics, University of Leeds and Consultant in Restorative Dentistry, LeedsTeaching Hospitals NHS Trust, Leeds, UK; 3Honorary Research Fellow, Universityof Manchester (Formerly Senior Lecturer in Restorative Dentistry, University ofManchester) and Consultant in Restorative Dentistry, Central ManchesterHealthcare Trust, Manchester, UK; 4Consultant in Restorative Dentistry, LeedsTeaching Hospitals NHS Trust and Senior Clinical Lecturer, University of Leedsand Honorary Visiting Professor, Centre for Dental Services Studies, University ofYork, York, UK; 5Professor of Prosthetic Dentistry, Consultant in ProstheticDentistry, Faculty of Odontology, University of Malmo, Sweden*Correspondence to: 5 Victoria Road, Harborne, Birmingham B17 0AGemail: email@example.comREFEREED PAPER</p><p> British Dental Journal 2000; 189: 414424</p><p>New publications:All the parts which comprise this series(which will be published in the BDJ) havebeen included (together with a numberof unpublished parts) in the book A Cinical Guide to Removable Partial Dentures (ISBN 0-904588-599)and A Clinical Guide to Removable Partial Denture Design (ISBN 0-904588-637).Available from Macmillan on 01256 302699</p></li><li><p>BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000 415</p><p>PRACTICE prosthetics</p><p>Fig. 2a and b AppearanceNot only may an RPD help to restore appearance but it may actually improve it.(a) This patients 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</p><p>appearance.</p><p>Fig. 3 AppearanceIf an incisor is not replaced soon after extraction, successful treatment ata later date may be compromised. Here, the adjacent teeth have driftedinto the unrestored UL1(21) space. The reduced space does not allowfor an artificial tooth of a realistic size to be used on a denture. If areasonable aesthetic result is to be obtained the space must be re-established by orthodontic treatment.</p><p>Fig. 4 SpeechThe loss of maxillary anterior teeth may prevent the clear reproductionof certain sounds, particularly the F and V which are made by the lowerlip contacting the edges of the maxillary incisors. The replacement ofmissing maxillary anterior teeth will make a significant contribution to thequality of speech.</p><p>a b</p><p>Fig. 1 AppearanceThe restoration of the missing UR2 (12), UR1(11) and UL1(21)undeniably benefit this patient, an 18 year-old girl, and the motivation towear the denture is understandably strong. Particular attention has beenpaid to the appearance of the denture by the careful choice of artificialteeth and design of the flange. A natural appearance has been created byusing a veined acrylic, by reproducing the pre-extraction form ofalveolar ridge and by making the distal margin of the flange thin andirregular, thus masking the transition from flange to adjacent mucosa.</p></li><li><p>416 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000</p><p>PRACTICE prosthetics</p><p>Fig. 5 MasticationWith modern foods and methods of preparation it is unlikely that apatient will suffer from malnutrition even though a large number of teethare missing. However, the gaps that arise through the loss of posteriorteeth reduce the efficiency of mastication: the bolus of food is allowed toslip into the edentulous areas and thus escape the crushing and shearingaction of the remaining teeth. An RPD will prevent this escape of thebolus and thus contribute to efficient mastication.</p><p>Maintaining the health of the masticatory systemThe provision of an RPD can make a positive contribution tooral health by preventing, or minimising, the undesirable conse-quences of tooth loss, as described in the following paragraphs.</p><p>Fig. 6 Preventing undesirable tooth movementWhen teeth are lost from a dental arch the teeth adjacent to theedentulous space may tilt and move into that space. This drifting of teethopens up further spaces which increase the opportunity for foodimpaction and plaque formation, encouraging inflammation of theperiodontal tissues and decalcification of the proximal surfaces of theteeth. Inevitably, the longer such spaces remain unrestored, the greaterthe chance of tooth movement. When teeth are lost from an opposingarch over-eruption may occur with similar deleterious effects on the oralhealth. However, if tooth movement has not occurred in spite of theteeth being lost some years previously, it can be assumed that it is notgoing to occur subsequently.</p><p>Fig. 7 Preventing undesirable tooth movementThe long-term absence of antagonists has resulted in over-eruption ofmaxillary and mandibular teeth. The teeth are virtually contacting theopposing edentulous ridges creating major problems if RPDs have to beprovided.</p><p>Fig. 8 Preventing undesirable tooth movementIn this example, UR6 (16) has over-erupted to such an extent that it haslost most of its bony support. Extraction of the tooth is inevitable.</p></li><li><p>BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000 417</p><p>PRACTICE prosthetics</p><p>Fig. 10 Improved distribution of occlusal loadIf the periodontal attachments of the remaining teeth are healthy, theincreased load may result in excessive tooth wear or may cause damageto existing restorations. The restoration of gross loss of tooth substance,as in this example, is likely to involve complex and prolonged treatment.</p><p>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 mandibleand therefore it may well be subjected to excessive force. In addition, where over-eruption of a tooth has created an occlusal interference (*), thepatient may modify the habitual movement patterns of the mandible in order to avoid the interfering contact. Although such a modification may reducethe load applied to the tooth, the changed pattern in activity of the mandibular musculature may subsequently produce muscular dysfunction.</p><p>From the foregoing examples it will be appreciated that if toothloss is restored in sufficient time to prevent tooth movement, orto avoid excessive stress being placed on the remaining structures,the subsequent health of the oral tissues can benefit considerably.</p><p>However, the point should be made that severe damage to theexisting structures is not an inevitable consequence of tooth loss.The implications of this statement will become apparent later inthis section when the damaging effects of the dentures them-selves are described.</p><p>Preparation for complete denturesMost of this book is devoted to the treatment of patients who are</p><p>expected to retain their remaining natural teeth for a consider-able number of years, thus allowing the RPD to be regarded as along-term restoration. But we should remember those patientswhose remaining teeth carry a relatively poor prognosis and forwhom, in due course, complete dentures are inevitable. If simpleacrylic RPDs are provided, the patient is able to serve a pros-thetic apprenticeship with appliances which receive some sta-bility from the few remaining teeth. In the fullness of time thesetransitional dentures become more extensive as further teeth areextracted and the patient is gradually eased into the totally artifi-cial dentition. This form of transitional treatment can be of con-siderable benefit, especially for the elderly patient.</p><p>a b</p><p>Fig. 9 Improved distribution of occlusal loadThe loss of a large number of teeth puts an increasing functional burdenon the remaining teeth. In this example there is existing periodontaldisease. The increased functional load has hastened the destruction of theperiodontal attachments of the maxillary anterior teeth, which havebecome increasingly mobile and have drifted labially.</p></li><li><p>418 BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000</p><p>PRACTICE prosthetics</p><p>Fig.12 Preparation for complete denturesThe location of the remaining teeth plays an important part in the successof such a transitional denture. It is common for the six mandibularanterior teeth to be the last remaining teeth in the mandible. A denturerestoring the posterior teeth is frequently not worn by the patient for thefollowing reasons. Firstly, the denture may be unstable because there islittle resistance to its displacement in a posterior direction; secondly,there is very little motivation to wear the denture as the anterior teethare still present.</p><p>Fig. 13 Preparation for complete dentures If, instead of extracting all the teeth, the canines are retained, the denturewill be more stable. When the denture replaces anterior teeth it is verymuch more likely to be worn and thus the patient is likely to gain greaterbenefit from the transitional denture.</p><p>Fig. 14 Preparation for complete denturesIt should be remembered that the transitional RPD is being placed in amouth where existing dental disease is only poorly controlled or isuncontrolled. As will be seen in the next section, the very presence of adenture aggravates the situation. If the mouth is not inspected regularly toidentify treatment needs as they arise, there is the likelihood ofacceleration of tissue damage, which may prejudice the eventualcomplete denture foundation.</p><p>In this case the inflammation and hyperplasia of the palatal mucosa wasso severe that surgery had to be performed before further prosthetictreatment could be undertaken.</p><p>Causes of damage related to the wearing of RPDsHarmful effects can arise from the wearing of RPDs in a variety ofways: from the plaque which is likely to accumulate around anyRPD; from direct trauma by individual components of the den-ture; from excessive functional forces which will be transmitted byan ill-designed prosthesis and from errors in the occlusion.</p><p>If the patient, with the help of the dental team, can maintain optimal plaque control the hygiene-related complications of </p><p>wearing RPDs, such as caries and periodontal disease, can beavoided. However, frequent technical maintenance of RPDs is stillrequired if optimal oral function and health are to be preserved.</p><p>When tissue damage does occur it is sometimes referred to asthe biological price of wearing RPDs. The possible causes ofdamage and their sequelae are summarised in the following tableand are discussed in more detail in the subsequent sections.</p></li><li><p>BRITISH DENTAL JOURNAL, VOLUME 189, NO. 8, OCTOBER 28 2000 419</p><p>PRACTICE prosthetics</p><p>Fig. 15a and b Increased plaque accumulationThe 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.</p><p>a b</p><p>Increased plaque accumulationA considerable amount of research effort has been directedtowards an understanding of the relationship between plaqueaccumulation and the wearing of RPDs. It is possible that the pres-ence of a denture influences the quality of the plaque; it certainly </p><p>affects the quantity. Not only does more plaque accumulatearound the teeth in the jaw in which the denture is placed, but alsomore is found around the teeth in the opposing jaw unless thepatient is instructed in meticulous oral hygiene procedures.</p><p>Periodontal tissues</p><p>Inflammation of gingival tissuesProgression to underlying structures</p><p>Inflammation of gingival tissuesProgression to underlying structures</p><p>(a) Tooth mobility(b) Aggravation of existing periodontal disease</p><p>(a) Tooth mobility(b) Aggravation of existing periodontal disease</p><p>Edentulous areas Muscles of mastication</p><p>Inflammation of mucous membrane </p><p>Localised inflammation of mucous membrane.Denture-induced hyperplasia</p><p>Inflammation of mucous membraneResorption of bone </p><p>Inflammation of mucous Muscle dysfunction membraneResorption of bone</p><p>Table 1 Summary of damage that may result from wearing an RPD</p><p>Causes Teeth</p><p>Plaque accumulation Decalcification and caries</p><p>Direct trauma from Abrasion and components fracture of</p><p> teeth or restorations</p><p>Transmission of...</p></li></ul>
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