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Deo K. Pun, DMD, MS,a Michael P. Waliszewski, DDS, MsD,b Kenneth J. Waliszewski, DDS, MS,c and David Berzins, PhDd Marquette University, Milwaukee, Wis
Statement of problem. Current demographic information on the number and types of removable partial dentures is lacking in the prosthodontic literature. Purpose. This study was designed to investigate patterns of tooth loss in patients receiving removable partial dentures (RPDs) in eastern Wisconsin. Material and methods. Digital images (1502) of casts at 5 dental laboratories in eastern Wisconsin were collected. Any prescription requesting fabrication of a removable partial denture was photographed twice. The first photograph was made immediately upon arrival at the laboratory, while the second photograph was made immediately before being returned to the prescribing dentist for the first time. A calibrated investigator analyzed all the photographs for Kennedy Classification, type of RPD, major connector, and other details. Data were analyzed with descriptive statistics. Fisher’s exact test was used to confirm repeatability. Results. Kennedy Class I was the most common RPD with a frequency of 38.4%. More than 40% of prescriptions had no design input from the dentist. One in 3 RPDs used acrylic resin or flexible frameworks. One in 5 RPDs had no rests. The horseshoe major connector was the most common maxillary major connector, while the lingual plate was the most common in the mandible. Conclusions. RPDs remain a common prosthodontic treatment in this region. Non-metal RPD frameworks are a common treatment type and rarely include rests. These data indicate a changing partially edentulous patient population and a variable commitment to standard levels of prosthodontic care. (J Prosthet Dent 2011;106:48-56)
The inclusive nature of this analysis helps demonstrate details of current RPD treatment that are rarely discussed in dental education or literature. The lack of dentist input, use of nonmetal frameworks, bulky major connectors, and lack of adequately supported RPD designs indicates the potential for poor RPD outcomes in this sample.
Recent investigations analyzed trends in demand for prosthodontics in the United States.1,2 More than 95 years ago Hillyer3 noted that as the edentulous condition decreases, the use of removable partial dentures (RPDs) increases. Despite decreasing rates of tooth loss, the need for removable prosthodontic treatment remains high.4-6 One consequence
of the profession’s improved preventive measures has been an increase in the number of patients who require prosthodontic treatment with RPDs.7-9 Conservative treatment types such as dental implants are expensive. This may limit their availability to lower socioeconomic groups in whom the highest rates of tooth loss occur.10-12 Conventional removable prosthodon-
tic treatment types, therefore, continue to outnumber implant tooth replacements in general practice.13 Multiple RPD classification systems have been proposed.14-20 The Kennedy Classification system is currently the system described in 2 RPD textbooks,21,22 and was found to be the most commonly used system according to an older analysis.19 This
Private practice, Sterling, Ill. Adjunct Assistant Professor, School of Dentistry. c Adjunct Professor, School of Dentistry. d Associate Professor and Graduate Program Director, Dental Biomaterials.
The Journal of Prosthetic Dentistry
Pun et al
S. This may not reflect the demographics of the average clinical practice. and could be removed from the mouth and replaced at will.59 The authors concluded that there is no direct evidence of well made and maintained RPDs significantly contributing to periodontal disease. Clinical reports describe methods to improve their performance. no peer-reviewed study or incidence data for these different RPD framework materials was identified.79 These quality issues help explain the high frequency of failed treatment in the non-institutionalized U. It also provides an opportunity to investigate some of the existing trends in non-institutionalized RPD services. In the United States. were chosen for data collection. acrylic resin framework RPDs continue to be used with great frequency. Without the strength and established design principles of cast metal framework RPDs. education. modern RPD framework fit continues to be less than ideal. and they fabricated large numbers of RPDs. population. Using 5 commercial dental laboratories from different regions of North America. However.28.51.40. and 9% Class IV. The first was made immediately upon receipt at the labo- Pun et al . and quality of material provided to the laboratory. This finding did not include acrylic resin framework RPDs. Any prescription presenting to the laboratory requesting fabrication of a RPD was included.23 Several attempts to analyze specific trends in the frequency of various RPDs have been presented. leaving 327 of the 400 work authorizations for inclusion.6. Therefore. Insurance reimbursement. Redford’s group found that 8% of the 7.363 RPDs analyzed had cast metal frameworks. design instructions given.40-43 Curtis et al42 surveyed the incidence of various classes of RPDs fabricated at a single dental laboratory in California. While metal frameworks may be preferred. These projects seem to confirm a preference for metal framework RPDs in terms of clinical performance and periodontal health.83 The proposed study was approved by all laboratories and the Institutional Review Board of Marquette University School of Dentistry.374 examined subjects were using an RPD. Data were collected by the laboratories using handheld point and shoot digital cameras. The most common mandibular RPD was Class I (49%). and location and extent of missing teeth all appear to influence whether a cast metal framework or acrylic resin RPD is fabricated. Milwaukee. and the most common maxillary RPD was Class II (38%). it is believed that alternative RPD frameworks have reduced longevity and significant periodontal consequences.July 2011 system also meets criteria of the principles.61-65 There is evidence that the average clinician understands and is taught less about the RPD framework fabrication process than in previous generations. Laboratories were selected if they were willing to participate. While information regarding number and distribution of teeth was presented. and private practice. while 33% were Class II.46-50 As a group.24-39 Most of these studies are of European or middle-eastern populations with few studies from the United States. government subsidized clinics.58. these surveys demonstrated significant differences in patient treatment among institutions. repairs and relines were excluded. concepts. Interim RPDs were excluded. 49 MATERIAL AND METHODS Five regional commercial dental laboratories located in eastern Wisconsin. newer types of flexible RPDs have received much attention in dental advertisements over the past decade. may clarify some of the sources of defective RPDs. and practices in prosthodontics (PCPP).44. Carlson57 confirmed that acrylic resin RPDs had a high incidence of fracture or need for repair.41. The previously mentioned studies evaluated data pertaining only to cast metal framework RPDs.53-57 The authors found that teeth in contact with acrylic resin frameworks were more likely to have dental disease.75-78 Poor communication and standardization has not been found within the prosthodontic community. In a rare direct comparison of RPD material and design. it is interesting to note that studies with positive long term clinical results used cast metal framework RPDs. Ninety-five percent of 1. an analysis of the incidence of various classes of RPDs would be of interest. no recent analysis of incidence or prevalence of types of RPDs or Kennedy Classification was identified. the majority of RPD procedures are selected based on their efficiency and economy rather than on the standard of care. were regionally located. there was no classification.66-69 Surveys of dental laboratories and dentists continue to find poor communication between the two. Considering the previously mentioned factors. Bissada et al60 found that inflammation was greater when acrylic resin contacted the gingival tissue than when metal was used.52 Studies demonstrating poor periodontal or dental response to RPDs have investigated acrylic resin framework RPDs. While valid longterm outcome data is lacking.45 Acrylic resin framework RPDs are far more common than cast metal framework RPDs in several other countries.6 The prevalence increased with age to 22% at 55 to 64 years old. 18% Class III. RPD was defined as any prosthesis that replaced teeth in a partially dentate arch.70-78 In addition.80-82 Further analysis of the type of prostheses requested.49 In addition.27. The purpose of this study was to investigate patterns of tooth loss in patients receiving RPDs and to present details regarding how this treatment is provided. In contrast.6. Forty percent of these RPDs were Kennedy Class I. Öwall and Taylor43 investigated the frequency of different types of RPDs. Two photographs were made of laboratory box contents with prescriptions meeting the previously mentioned criteria. Wis.49. capabilities of dental laboratory support.
The second photograph was made using the same technique as the first. and processed RPDs without casts were placed with the polished surface facing up. and claps arms were not considered rests. The RPD was considered to be acrylic resin if the major connector was processed in acrylic resin.5 cm background. Images were standardized by placing all contents of a particular incoming box on a 30. Design input was considered to Volume 106 Issue 1 1 Sample images of prescription for acrylic resin framework RPD. If received articulated. by visualization of non-metal clasp assemblies. If an immediate prosthesis was requested. rests. or by the differing appearance of the base material. Frameworks being returned for trial evaluation were placed upon their definitive casts. Minimal design input communicated 1 of the 4 basic areas of design. and closed spaces were not considered missing teeth. discussion. the articulator or mounting rings were disassembled to allow imaging of the occlusal surfaces of the casts. Once calibrated. Calibration of laboratories was conducted on 2 separate occasions. In addition. A minimum of 1 follow-up visit to each laboratory was conducted during the initial 2 weeks of data collection. An RPD was considered to be a metal framework if the major connector was cast. 1). the lead investigator selected and reviewed an additional 10 subject sets. these same subject sets were again reviewed and the data collection forms were compared using Fisher’s exact test to confirm repeatability. except that all contents leaving the laboratory were placed on the background. guiding planes. 10 new image sets from each laboratory were independently reviewed by the investigators. Major connectors were classified according to calibrated definitions. Microsoft. and practice photography. fixed prosthesis pontics. Wash). The Kennedy Classification with appropriate modification space enumeration was listed according to Applegate’s modifications. The first 10 image sets from each laboratory were viewed by 3 of the investigators independently to confirm data collection criteria (Fig. The lead investigator completed review of the remaining image sets. The RPD was considered completed if it was returned after processing with all prescribed prosthetic teeth and components attached. the total number of missing teeth was recorded based on the modified cast. Credit was given if reference was made to a design cast drawing. Once transferred to data collection forms. Redmond. third molars. Who designed the frameworks in these instances is unknown. information was tabulated using a computerized spreadsheet (Microsoft Excel 2010. After demonstration.5 cm x 40. Three levels of design input were considered. An extension of the RPD onto either a prepared rest seat or over the occlusal or incisal surface of a tooth or dental implant. minor connectors. have 4 areas of information: major connector. Less frequent designs were listed as ‘other’ when identified. Once calibrated. unless they covered an actual rest seat or they involved an occlusal or incisal surface.84 Anterior teeth were considered ‘missing’ if the prosthesis replaced an anterior tooth. However. the laboratory technician in charge of photography was observed during a photographic session. Personal identifiers such as the patient and dentist name were blocked out prior to photographing using blank pieces of paper. The flexible type RPD was determined by the laboratory prescription.50 ratory and the second immediately prior to being returned to the prescribing dentist for the first time. the first and second photographs of each subject were matched and numbered according to the laboratory routing number (Fig. a summary of instructions was left as a reference. The Journal of Prosthetic Dentistry Pun et al . and clasps. 2). was considered to meet the definition for a rest. As images were collected. Data collection was planned to continue for a minimum of 4 weeks with a minimum sample size goal of 500. This group of data collection forms was tested using Fisher’s exact test to confirm reliability and accuracy. The totals where then analyzed using descriptive statistics. The edges of the background were aligned perpendicular to and within the edges of the camera view screen.18 Dental implants were considered ‘abutments’ based on the Kennedy Classification. Multiple design input communicated at least 2 of the 4 basic areas of design through the written prescription. No written design input communicated 0 of the 4 basic areas of design. One week later.83 Lingual plates.
319 (n=892) were used to determine the material type (Table V). According to the images. State of return: 5.4%) was the most frequent mandibular. Total # of prosthetic teeth: _________ c. Likewise. Analysis of the 573 matched images demonstrated additional details. Type of RPD: Modification spaces: _________ _____ Posterior only _____ Both Ant & Post Yes or No TBD Palatal plate Horseshoe b.62. Of the unmatched images. Prescription: a. Pre-prosthesis information: a. Overall. Twenty-six of these images were unreadable or requested a reline or repair and were excluded. 78. Overall.3% (271/573) replaced posterior only. and replication of investigator 2 were . Dental Laboratory: 2. For every 2 metal frameworks.7% of Class II RPDs lacked the same. the horseshoe (72. The other 330 images could be used for determining Kennedy Classification resulting in a total of 903 individual subjects (Table I). 47.1% of non-metal mandibular major connectors were a lingual plate. RESULTS A total of 1502 images were collected.1% (264/573) replaced both anterior and posterior. The mean number of teeth replaced was 6. Three hundred and twenty-four of the unmatched images (n=897) could be used for the design input data (Table IV). Type of major connector: Max: Mand: A-P strap A-P bar Lingual bar Palatal strap Palatal bar Lingual plate Other (specify): ______________________ Other (specify): ______________________ 6. Nearly 7% (38/573) of RPDs replaced anterior teeth only. 515 casts and 58 impressions were received at the laboratory. Total # of missing teeth: _________ _____ Anterior only Notation: Metal framework Acrylic resin Flexible (Valplast) b. Images with matched photographs (1146) resulted in a total of 573 complete subject sets.55. Eighty percent of Class III RPDs had either a single modification space or no space indicating a large majority of unilateral or single bilateral edentulous spaces. . When analyzed separately. Classification: _________ c. Seventy-two percent (414/573) of the RPDs were planned for trial evaluation.July 2011 RPD Data Recording Form 1. Tables VI and VII show the major connector types in the matched sample. Laboratory serial number: 3. Forty-two percent (377/897) of the total prescriptions did not provide any design information. 95. Design: _________ Multiple design input _________ Minimal design input _________ No written design input b. The P-values from Fisher’s exact test for investigator versus decision. Prosthesis information: _________ Completed _________ For trial evaluation _____________________ Cast Impression Arch: Maxilla / Mandible [Alginate] [Rubber] 51 2 Data recording form. there was 1 nonmetal framework.7% (451/573) of RPDs were considered to have rests (Table V). Distribution: a. According to the criteria discussed. there were 377 RPDs fabricated with- out any modification spaces. and 46. The modification spaces for Class II and III subjects are summarized in Tables II and III. while the lingual plate (59. replication of investigator 1. and 1 respectively. This indicates Pun et al . The remaining 356 images were unmatched. 91.3% of non-metal maxillary major connectors were a horseshoe design. Nineteen percent (110/573) of RPDs were missing between 1 to 3 teeth. Lab received: 4. while only 21.5%) was the most frequently used maxillary major connector. Ninety-seven percent (408/421) of the metal frameworks requested return for trial evaluation. Sixty percent of Class I RPDs lacked any modification spaces.
3 6.4 The Journal of Prosthetic Dentistry Pun et al .0% Modification 3+ 12 0 12 4.9% Modification 2 29 16 45 16.0 100 Frequency 152 22 72 246/592 Frequency 219 24 103 346/592 % 63.2% Modification 3+ 9 5 14 6.2% Total 212 70 282 100% Table IV.8 8.9 29.6% Frequency 380 140 377 897 % 42.4 15.9% Modification 1 74 30 104 36.3 41.2% Total 103 123 226 100% Table III.52 Volume 106 Issue 1 Table I.6 42. Kennedy Classification distribution of RPDs Arches Maxilla Mandible Total Percentage Class I 107 240 347 38.2% Class IV 35 13 48 5.4% Total 457 446 903 100% Table II. Kennedy Classification II distribution with Applegate’s modification Arches Maxilla Mandible Total Percentage Modification 0 23 26 49 21.7% Modification 1 41 56 97 42.8 58.9 29.9% Modification 2 30 36 66 29.0% Class III 212 70 282 31. Kennedy Classification III distribution with Applegate’s modification Arches Maxilla Mandible Total Percentage Modification 0 97 24 121 42. Prescription information on design input Overall Design Input Multiple Minimal None Total Metal Frame Only Maxilla Mandible % 61.4% Class II 103 123 226 25.
Inclusion of acrylic resin RPDs.40-42 Class III proved more common than in any previous analysis.4%) and RPDs replacing anterior teeth only (6.2% Matched Sample 421 128 24 573 73. Pun et al .7% Rest . Four metal frameworks could not be classified based on the definitions used in this study.Absent 5 93 24 122 21.3% Table VI. for a metropolitan area estimated at 1. the difference between classes was reduced. DISCUSSION Previous research from the United States on this topic has been minimal and does not use as strict a RPD definition.5 5.6 59. Thirty RPDs used attachments. Table VIII com- pares the current data overall.4%) compared to Curtis et al42 (23%) may signal a lack of progress towards controlling dental disease or the patient’s ability to afford fixed prostheses.Present 416 35 0 451 78. While the nearly even number of maxillary versus mandibular RPDs could be seen as a positive.6 72.July 2011 53 Table V. the increased incidence of maxillary Class III (46. to previous analyses. reduced rates of tooth loss. One framework was fabricated from gold alloy. and with metal frameworks only.7 2. and changes in therapeutic strategies for dental disease are all possible explanations.6 0.1 100 Table VII. Frequency of RPDs and use of rest RPD Type Metal Acrylic Flexible Total Total Sample 596 250 46 892 66.8% 28. A single swing-lock RPD was found. 4 of which were made from flexible materials. With 903 RPDs fabricated by 5 laboratories within a 4-month period.7 1. The reduced incidence of Class IV RPDs (5. Distribution of major connectors according to Kennedy Classifications in mandible Mandible Lingual bar Lingual plate Others Total Class I 65 96 0 161 Class II 34 46 1 81 Class III 12 25 3 40 Class IV 0 5 1 6 Frequency 111 172 5 288 Percentage 38.3% 22. Eight unilateral prostheses were also found. demonstrates the continued demand for this treatment type.2% Rest . Distribution of major connectors according to Kennedy Classifications in maxilla Maxilla AP strap Palatal strap Palatal plate Horseshoe AP bar Others Total Class I 8 3 9 55 0 1 76 Class II 8 13 3 39 1 0 64 Class III 8 11 2 97 1 4 123 Class IV 3 0 2 16 0 1 22 Frequency 27 27 16 207 2 6 285 Percentage 9.7 million people.6%) may demonstrate rejection of removable prostheses in favor of fixed prostheses for improved esthetics.24.0% 5.7 100 no significant difference between investigators or in either repeatability case.5 9. While the Kennedy Class I continued to be the most common RPD configuration. usually extracoronal.4% 4.
The following conclusions were drawn from the study: 1. the rate of no input increased. Overall.27. It is believed that the definitions used were clear. material. many RPDs that received credit for a rest were lacking in adequate support due to design and modification shortcomings.42 A method similar to Allen and Lynch75 was used to collect prescription input. a majority of lingual plate major connectors was still found (59. Despite a broad definition.70-74 as well as varying RPD design philosophies.8% of all RPDs were fabricated with cast metal frameworks. Perhaps this was due to the manufacturer claims of superior stability and retention of frameworks made from these materials. This is greater than in other studies. only 78.24. Therefore.42. it was understood that the 330 accepted but unmatched images provided reliable and usable information. or the various prescription forms. This was not considered logistically possible when using multiple laboratories for an extended time period. several questions required both images. Considering how frequently acrylic resin and flexible type RPDs are used in the general community. when only metal frameworks were considered. However. The majority of maxillary major connectors in this study (72. RPDs of all types continue to be a common treatment type with equal incidence in the maxillary and mandibular arch. The Kennedy Classification according to Applegate’s modification. easy to use. Therefore. This demonstrates the necessity to define clearly each major connector type as well as potential regional differences in RPD design. Other methods left room for interpretation of drawings. The findings support the need for continued periodic regionally specific analysis. In addition.2% were fabricated with non-metal major connectors. CONCLUSIONS This study evaluated images of 903 RPDs made at 5 dental laboratories located in eastern Wisconsin. Despite calibration. these numbers do not reflect the prevalence of RPDs or tooth distribution within the general population. When non-metal RPDs were evaluated. The authors were unable to locate any peer-reviewed or manufacturer-sponsored research in regards to the clinical performance of these materials.5%) were of the horseshoe design. and then IV. This may explain the frequent observation of periodontal tissue damage with these prostheses and RPDs in general. The Journal of Prosthetic Dentistry Pun et al .54 When only metal RPDs were considered. 1 in 5 RPDs were completely tissue-borne prostheses. while Curtis et al42 did not find any. only 23% were considered to have a rest. This is similar to previous studies. However. This is disappointing considering it was shown to be the most comfortable maxillary major connector and generally covered the least amount of gingival tissue. a lingual plate was required to cover the gingiva lingual to all remaining anterior teeth.48. Considering this.4%). This method identified if minimal information was given and still demonstrated how little input many dentists have upon the RPD design. the encountered limitations proved minor considering the large number of RPDs collected and the simplistic nature of the critical data analyzed. and based upon the prosthodontic consensus despite room for debate.28. Bulky. high laboratory volumes and study deadline were the likely reasons for missing the second image.’ If only private practice RPDs were analyzed.85 Öwall and Taylor43 found 56% of maxillary major connectors to be horseshoes.7% of RPDs used any rest. Only 27 (9.49 The standard design feature meant to minimize soft tissue damage from RPDs is the rest. Despite this. While a single image was adequate for most data. This confirms previous findings of the lack of prescribing dentist input. and major connector type. The definition for a lingual bar was a mandibular major connector located lingual to the dental arch with visible gingival tissue lingual to any anterior tooth. as well as other information was identified. It must also be noted that the RPDs from the laboratory servicing the dental school had a bias towards ‘multiple design input. it was somewhat surprising to find only 5. and public health professionals in the state of Wisconsin should be mindful of the quality of removable prosthodontic care being delivered in this region.43 The large majority of horseshoe and lingual plate major connectors was likely due to nonmetal RPD strength requirements. writing. clinicians. The remaining 33. insurers.49. the majority were horseshoes and lingual plates.46. by including all RPD types a broad picture of the partially edentulous population receiving this type of care was analyzed. III. This was an issue for some criteria since the laboratory may have Volume 106 Issue 1 done a design drawing or made a cast prior to the initial image. With the amount of advertising promoting flexible RPD frameworks. However. this number is less than that reported by several recent international studies. wide versions of the horseshoe and lingual plate were selected nearly all of the time when non-metal major connectors were used.2% of these within the sample. None of these RPDs were considered to have a rest. One solution was to have the research investigators collect the images themselves. it is disappointing that no clinical studies for these treatments could be found for patients in the United States. Class I was the most common followed in order by Class II.5%) palatal straps were found. In addition. In a few instances. Essentially. it was noticed that the ‘incoming’ photograph was made after completion of the RPD. The incidence of non-metal RPDs found in the current study is higher than the 5% found by Öwall and Taylor43 using similar inclusion/exclusion criteria. Only RPDs for patients already in treatment were tabulated.75-78 This study revealed that 66.
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