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Katherine Chiu-Man Leung*

BDS, MDS, PhD, FRACDS, FCDSHK


(Prosthodontics), FHKAM (Dental Surgery)

Edmond Ho-Nang Pow*

BDS, MDS, PhD, FRACDS, FCDSHK


(Prosthodontics), FHKAM (Dental Surgery)

DENTAL PRACTICE

Hong Kong Dent J 2009;6:39-45

Oral rehabilitation with removable partial


dentures in advanced tooth loss situations

* Oral Rehabilitation, Faculty of Dentistry, The


University of Hong Kong, Hong Kong

ABSTRACT
There is a global trend for people to retain more teeth later in life. For this reason, it is
common to see patients seeking treatment to replace the loss of a considerable number of
teeth. Removable partial dentures are frequently prescribed for these patients. This paper
summarizes the effects of tooth loss on quality of life and provides a clinical guide to the
management of patients with advanced tooth loss with removable partial dentures.
Key words: Dentures; Quality of life; Tooth loss

Introduction
In the past, total edentulism was believed to be a natural consequence of the process
of ageing. With rapid improvements in oral health, there is a global trend for people to
retain more teeth later in life. In spite of this, tooth loss is still a problem in elderly people,
and in individuals compromised by certain medical conditions 1. The 2001 Hong Kong
Oral Health Survey revealed that tooth loss is still very prevalent, especially among elderly
people. More than half of the 65- to 74-year-old non-institutionalized population had
retained less than 20 teeth. Of these, 34% were wearing partial dentures and 37% were
assessed as needing partial dentures 2. For these patients, fixed prostheses with or without
implant support may not be feasible for various reasons, e.g. lack of suitable abutments,
general health problems, and financial constraints. Removable partial dentures (RPDs) can
be useful in such a situation. A recent Finnish study 3 found that offering good-quality
removable dentures can alleviate the problems caused by having a high number of
missing teeth. Nevertheless, many of these cases can be rather complex and difficult to
rehabilitate.

Tooth loss and quality of life


Correspondence to:
Dr. Katherine Chiu-Man Leung
Oral Rehabilitation, Faculty of Dentistry,
The University of Hong Kong, 34 Hospital
Road, Hong Kong
Tel
: (852) 2859 0307
Fax
: (852) 2856 6114
e-mail : kcmleung@hku.hk

It is common knowledge that tooth loss brings with it problems of esthetics, function,
and socialization. To the dentists, the main aim of providing dentures may be to restore
the physical functions that have been impaired by tooth loss. However, to the patients, it
is much more than that. They focus more on the social meanings of the mouth 4. A study 5
of the emotional effects of tooth loss among partially dentate populations in the UK and
Hong Kong found that 49% of the study population had difficulty accepting tooth loss,
and 35% of them felt unprepared for the effects that tooth loss had upon them. A similar

Hong Kong Dental Association

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Leung and Pow

study 6 conducted on community-dwelling elderly people


in Hong Kong also found that people with considerable
tooth loss experienced significant disability because of the
restrictions it imposed on their daily living activities, food
choices, and enjoyment of food in particular.
A paradigm shift in outcome measures within medical
and dental fields, from a disease-centered biomedical
approach to a patient-centered biopsychosocial approach,
has occurred. Quality of life (QoL) has emerged as an
important parameter for evaluating quality and outcome
of health care. Enhancement of QoL has become one of the
main goals in clinical medicine and dentistry. Oral health,
being an integral part of general health, contributes to QoL.
In a survey of older people in the UK 7, it was found that
people perceived oral health as being important to their
life quality in a variety of different ways. Most frequently its
impact on function (eating) and symptoms (comfort) were
considered most important.
It is well documented that tooth loss compromises oral
healthrelated QoL (OHRQoL) regardless of age and general
health status 8,9. People with a reduced number of remaining
teeth 10 or a decreased number of occluding pairs of teeth 9,11
were found to have a deterioration in OHRQoL. In a study 12
assessing the association between the oral state and general
health in relation to QoL, it was found that the devastating
effects on life quality of tooth loss without replacement were
comparable to those caused by major medical diseases such
as cancer or renal diseases. It was also noticed that tooth
loss in the maxilla had a stronger impact on the reduction
of OHRQoL than that in the mandible, probably due to
poor communication and reduced masticatory function
limiting social participation. Oral rehabilitation by means
of removable or fixed prostheses significantly improves the
OHRQoL in partially dentate and edentate people 13-15. On the
other hand, people with considerable tooth loss but without
recourse to removable dental prostheses were found to have
a reduced OHRQoL 16.

Rehabilitation of extensive tooth loss


Patient preparation
People with extensive tooth loss are likely to have further
tooth loss. Provision of prostheses to replace missing

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Hong Kong Dent J Vol 6 No 1 June 2009

teeth without taking the underlying cause of tooth loss


into consideration is undesirable. Likewise, provision
of prostheses in people with uncontrolled diseases can
be detrimental to oral health and can compromise the
benefit of tooth replacement, if no attempts are made to
control disease progress in the first instance. Since dental
caries and periodontal disease (or their sequelae) are the
two major diseases leading to tooth loss, risk assessment
becomes highly critical so that risk factors can be identified,
controlled, modified, or reduced. Reduced saliva flow,
frequent sugar intake, inadequate oral hygiene, and the
presence of partial dentures are some of the more common
risk factors 17. Periodontal disease is a multifactorial disease
and a number of local, systemic, and environmental factors
act as important modifiers of the development and progress
of the disease. Some of the prominent and confirmed risk
factors include race, age, gender, socioeconomic status,
diabetes mellitus, smoking, genetics, host response factors,
oral hygiene level, occlusion, presence of caries lesions, and
presence and quality of restorations 18.
Studies have been carried out to identify predictors
of tooth loss. In a 10-year longitudinal study of adults in
the US 19, the percentage of teeth with restorations, mean
probing pocket depth score, age, tobacco use, alcohol
consumption, number of teeth present, and male gender
were reported to be significant predictors. In two other
European studies 20,21, social class and level of education
were also found to be significant predictors of tooth loss.
In mainland Chinese, age, high number of teeth with caries
lesions, presence of teeth with attachment loss of 7 mm,
presence of mobile teeth, and a low percentage of sites
with subgingival calculus deposits have been proposed as
significant predictors 22. Given the results of these studies,
it is apparent that tooth loss is the result of complex
interactions among a number of predictors, and no single
factor is a dominant predictor. Furthermore, the set of tooth
loss predictors may vary by population and by gender.
About one in five people felt unprepared for the
effects of tooth loss, and more than half said that better
communication would have helped, according to a study
of Hong Kong elderly people 6. By the same token, patients
have to be psychologically prepared to receive RPD
treatment, first-time denture wearers in particular. They
should be well informed about the treatment procedures,

Oral rehabilitation with removable partial dentures

Figure 1
Inadequate support results in inflamed oral mucosa and
displaceable, flabby tissue in the anterior maxilla

Figure 2
Poor support of the future prosthesis will be resulted if
the mandibular left molar is extracted

duration, outcome, and plausible complications. Treatment


expectations must also be carefully discussed.

be achieved in the absence of any occlusal/cingulum rests,


and no other components of the dentures contact the teeth
above the survey line. To maximize support, the extension of
the denture base for a tissue-borne RPD has to be optimal
with the posterior boundary of the maxillary denture lying
at the vibrating line, while that for the mandibular denture
lies at the retromolar pad, and the buccal extension of the
mandibular denture rests on the buccal shelf. A mobile tooth
or a tooth with uncertain prognosis is not suitable for use as
a support. The denture base should, however, be extended
to cover its palatal/lingual surface as contemplation of its
future loss.

It has to be emphasized that there are situations where


the number of remaining teeth is inadequate or their poor
distribution around the edentulous arch makes provision
of RPDs a poor choice. A failed denture does not enhance
QoL and may even be the cause of patients psychological
difficulties during their remaining denture wearing years.

Construction of removable partial dentures


Replacement of missing teeth can restore the patients
appearance, speech and masticatory function as well as
improve QoL as described earlier. Compared with other
treatment options, RPDs have the advantage of being
relatively simple, reversible, less costly, and allow further
tooth loss to be more easily managed. They can also replace
multiple missing teeth and supporting tissues. On the other
hand, because the remaining dentition is often impaired in
people with advanced tooth loss, there are special problems
that must be considered in the construction of RPDs.
Support
Support of an RPD can be derived entirely from natural teeth
(tooth-borne), entirely from underlying soft tissue (tissueborne), or both. In advanced tooth loss circumstances, there
are quite often inadequate numbers of suitable abutments,
or the distribution of the remaining teeth restricts the RPD
to being a tissue-borne one. Total tissue support can only

Inadequate support results in overloading of the


mucosa and underlying bone, which can lead to pain and
inflammation of the mucosa and more rapid resorption of
the alveolar ridge (Figure 1). In some patients, a displaceable
flabby ridge may be induced. The RPD becomes ill-fitting
and rocks during function which leads to further trauma
of the supporting tissues. Alternatively, support can be
derived from a decoronized tooth modified into an overdenture abutment. It would therefore seem prudent during
treatment planning to take into consideration poor support
of the future prosthesis when the decision about tooth
extraction is made (Figure 2).
To achieve close adaptation to the mucosal tissues,
tissue-borne RPDs are generally acrylic resinbased.
Acrylic resin is vulnerable to fracture if it is in thin section.
Hence, these dentures are rather bulky and uncomfortable.

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Leung and Pow

teeth, it can also protect the remaining tooth structure


and correct for overeruption or tilting. Unfortunately, the
use of surveyed crowns is often not possible due to the
compromised condition of the remaining teeth.

(a)

Clasping anterior teeth for retention may be


inevitable. Stainless steel or gold clasps are often used in
these situations. These clasps have several advantages over
cobalt-chromium clasps. They are smaller in diameter and
engage at a deeper undercut and in a less exposed region,
which is more esthetically pleasing and better accepted
by patients. They are more flexible, therefore less leverage
is exerted on the abutments. They are less abrasive which
makes them more suitable for use in exposed root areas.
However, although these clasps are laboratory-drawn by
the dental technicians to adapt as closely as possible to
the abutment teeth, many a time the fit is less than ideal.
The flexible nature of stainless steel and gold also means
that less retentive force can be obtained. Dentures can be
rather easily displaced from the undercuts, although total
dislodgement is uncommon.

(b)

Figure 3
(a) Surveyed crowns constructed to provide ideal
contours for denture abutments; and (b) removable partial denture
retained and supported by surveyed crowns on abutment teeth

Coverage of the gingival margin can be inevitable due


to strength limitations. Plaque accumulation, as well as
adhesion of pathogenic microorganisms, and subsequent
colonization of the denture base and abutment surfaces
in contact with it can jeopardize gingival and mucosal
health 23,24.
Retention
In advanced tooth loss situations, the remaining teeth can be
so compromised that finding suitable abutments for clasping
is a problem. They may be mobile or heavily restored due
to previous diseases. Suitable undercuts for clasping may be
absent or modified due either to poor contour of the teeth,
such as exposed roots, or to unwanted tooth movement after
extraction of the neighboring teeth. These problems may
be solved in part by re-contouring, using composite buildups or construction of surveyed crowns. A surveyed crown
(Figure 3) is a cast restoration that has incorporated the
ideal contours of a denture abutment 25. For heavily restored

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Stability
Stability is the ability of an RPD to be firm, steady, or
constant, and resist displacement by functional horizontal
or rotational stresses 26. As described above, retention of
RPDs in advanced tooth loss situations is generally less
than ideal. Stability becomes highly critical. In an RPD, good
stability relies primarily on a well-fitting denture base, which
means a good impression has to be obtained in the first
instance. Guiding planes restrict the paths of insertion and
removal into a single one that can improve and assist the
retention and stability of a denture. They work in pairs, and
are more effective when the edentulous saddle between
the pair of guiding planes is short, and the proximal surface
of the abutment teeth prepared as guiding planes is long.
Unfortunately, effective pairs of guiding planes are often
absent in advanced tooth loss cases.
Occlusion has a significant role in RPD stability. After
considerable tooth loss the remaining teeth might have
drifted, shifted, or overerupted, making the establishment
of appropriate occlusal planes difficult. If the occlusal
planes of the residual dentition are unaltered, there will be
occlusal interferences at protrusive and excursive positions.
Planned occlusal adjustments are therefore required.

Oral rehabilitation with removable partial dentures

(a)

(b)

Figure 4
(a) Loss of occlusal vertical dimension; and (b) occlusal
vertical dimension restored. Artificial stain added to mimic exposed
root surfaces

Moreover, the setting of artificial teeth has to take into


account the equilibrium of the forces exerted from various
directions during function as well as the position with
respect to the alveolar ridge. For instance, the occlusal
plane of the mandibular denture has to be set where the
border of the tongue can rest on the lingual cusps. This is of
critical importance with long distal extension bases, where
opportunities for direct and indirect retention are limited and
retention and stability are serious problems. Similarly, overextension of the denture borders is undesirable because it
can cause unseating of the RPDs during normal soft tissue
functioning.
Vertical dimension and occlusion
Loss of the occlusal vertical dimension (OVD) is often
encountered in people with advanced tooth loss (Figure 4a).
As a consequence, occlusion becomes unstable and there
is limited interocclusal distance available for restoration.

In these cases, re-establishment of the OVD at the centric


relation is often necessary (Figure 4b). There are a number
of ways to assess OVD clinically 27. The more popular
clinical methods include measuring the distance between
two arbitrary facial points, assessing esthetic appearance,
and using phonetics. It has to be emphasized that no
one method is absolutely reliable, thus several methods
are normally used for this purpose. Measurement of the
distance between two arbitrary facial points depends on
accurate determination of the physiological rest position
of the mandible. However, this position is not a stable one
but is affected by factors such as head and body posture,
as well as the presence of teeth 28. Although judgment of
esthetics is subjective, it is often clinically reliable. When
using the phonetic method to determine OVD, a number
of sounds have to be tested, typically /ch/, /m/, and /s/
sounds. Sentences or passages have been developed to
test the closest speaking space 29. Nevertheless, it seems
more natural and convenient to chat with the patients in
a casual and relaxed manner. Questions such as What do
you like to do in your spare time? and What is your favorite
food/TV program/music? are useful means of initiating
conversations.
After determining the appropriate OVD, a trial denture
can be constructed with reference to this dimension. A
period of several weeks is allowed for patient adaptation
or to allow further modifications. Using mounted study
models, the dental technician can do a diagnostic wax-up of
the occlusion at this dimension, and occlusal adjustments
can then be planned. This planned occlusal adjustment
aims to establish even occlusion across the arches at
centric and eccentric jaw positions at the appropriate
OVD, with reference to the ideal occlusal planes. It can be
as straightforward as simple tooth grinding or as complex
as using cast restorations such as palatal shelves 30, onlays,
and crowns. The trial denture is then used as a guide for the
restoration of the remaining dentition to the new OVD.
Esthetics
Esthetics can be the most important reason motivating
patients to seek treatment for replacement of their missing
teeth 31. It has also been found to contribute significantly
to their general satisfaction with prostheses 32. However,
patients and dentists can judge esthetics very differently.
There is no reliable, objective scale available to quantify

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esthetics in RPDs. Therefore, it is very important to have an


understanding of the patients personality, attitude, previous
denture experience and expectations, etc. Assessment of
the patients general well-being is also warranted as people
in a depressed state may have a negative self-assessment of
their dental appearance 33.
An esthetic denture is one that does not look like a
denture in the patients mouth. In other words, it harmonizes
with the patients remaining dentition. To achieve this,
the shade and shape as well as the characteristics of the
remaining teeth have to be assessed and well-matched.
However, it is commonly observed in advanced tooth loss
situations that the remaining dentition is badly damaged
or is malaligned. Re-contouring by simple tooth grinding
or by using extensive restorations, such as cast restorations,
might be warranted. Furthermore, attention should also be
paid to the shade and contour of the denture flanges so that
they mimic the oral mucosa. Good lip and cheek support are
important, particularly when the patients are being viewed
at a distance. These can be achieved by careful positioning
of the artificial teeth using an appropriate thickness for the
denture flanges. Soft tissue support can be clinically verified
by unobstructed performance of oral functions such as
smiling and deglutition.

where full incorporation of prosthetic reconstructions to


the stomatognathic system may be independent of the
clinical and laboratory management 34. In a retrospective
investigation of factors affecting adaptation to removable
prostheses, it was shown that men adapt to removable
dentures more readily than women 35. It has also been
observed that the number of follow-up visits for denture
adjustment was similar in new and experienced denture
wearers. More adjustment visits were provided to patients
whose muco-osseous tissues were atrophic and to those
who suffered from systemic diseases.
Despite the fact that RPD itself does not cause dentogingival disease, there is a biological cost of prosthetic
intervention. Gingivitis and gingival recession are prevalent
at sites in close proximity to the dentures, as revealed by
a clinical study of Hong Kong patients who had received
RPDs 5 years previously 36. Caries, especially root caries,
are frequently detected at surfaces in contact with RPDs.
There is evidence showing a significant association with and
potentially a large contribution made by the wearing of RPD
to having new or untreated root caries lesions 37. Hence, it
may be prudent to take active precautionary measures such
as the application of fluoride varnish on sites in contact with
the dentures during recall appointments.

Maintenance and follow-up visits

Conclusions

Regular recall programs are crucial for successful dental


treatment. These programs have to be customized to suit the
patients individual needs. Likewise, the frequency of recall
varies depending on the patients condition. Some patients
may benefit from quarterly reviews whilst for others annual
recall is sufficient.

Removable partial dentures are commonly provided to


patients with advanced tooth loss. The patients have to
be physically and psychologically prepared to receive this
treatment. The construction of RPDs for these patients
poses special problems caused by the rather impaired
remaining dentition and the lack of suitable abutments.
Successful oral rehabilitation relies on careful treatment
planning, and good knowledge of and skill with prosthetic
dentistry.

The process of adaptation to RPDs is complex. It


has been explained by a psychosomatic phenomenon

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