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Clinical Application of Removable Partial Dentures Using Thermoplastic Resin-Part I: and Indication of Non-Metal Clasp Dentures
Clinical Application of Removable Partial Dentures Using Thermoplastic Resin-Part I: and Indication of Non-Metal Clasp Dentures
ScienceDirect
Position Paper
* Corresponding author at: Section of Removable Partial Prosthodontics, Department of Masticatory Function Rehabilitation, Graduate
School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, 113-8549 Tokyo, Japan.
Tel.: +81 3 5803 5514; fax: +81 3 5803 5514.
E-mail address: kunfu.rpro@tmd.ac.jp (K. Fueki).
1883-1958/$ – see front matter # 2013 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
http://dx.doi.org/10.1016/j.jpor.2013.12.002
4 journal of prosthodontic research 58 (2014) 3–10
p
Department of Prosthodontics, Division of Oral Functional Science and Rehabilitation, School of Dentistry, Asahi
University, Japan
q
Division of Occlusion and Removable Prosthodontics, Health Sciences University of Hokkaido, Japan
r
Department of Prosthodontics, Gerodontology and Oral Rehabilitation, Osaka University Graduate School of
Dentistry, Japan
s
Department of Prosthodontics and Oral Implantology, Iwate Medical University, Japan
t
Department of Oral & Maxillofacial Rehabilitation, Removable Prosthetics, Kanagawa Dental College, Japan
u
Department of Prosthodontics, Showa University, Japan
v
Division of Fixed Prosthodontics, School of Dentistry, Meikai University, Japan
w
Section of Implant and Rehabilitative Dentistry, Division of Oral Rehabilitation Faculty of Dental Science, Kyushu
University, Japan
x
Department of Fixed Prosthodontics, Osaka University Graduate School of Dentistry, Japan
Article history: This position paper proposes a definition and naming standard for removable partial
Received 11 November 2013 dentures (RPDs) using thermoplastic resin, and presents a guideline for clinical application.
Accepted 5 December 2013 A panel of 14 experts having broad experience with clinical application of RPDs using
Available online 22 January 2014 thermoplastic resin was selected from members of the Japan Prosthodontic Society. At a
meeting of the panel, ‘‘non-metal clasp denture’’ was referred as the generic name of RPDs
Keywords: with retentive elements (resin clasps) made of thermoplastic resin. The panel classified non-
Removable partial denture metal clasp dentures into two types: one with a flexible structure that lacks a metal
Thermoplastic resin framework and the other having a rigid structure that includes a metal framework. Accord-
Non-metal clasp denture ing to current prosthetic principles, flexible non-metal clasp dentures are not recommended
Resin clasp as definitive dentures, except for limited cases such as patients with a metal allergy. Rigid
Metal allergy non-metal clasp dentures are recommended in cases where patients will not accept metal
clasps for esthetic reasons. Non-metal clasp dentures should follow the same design
principles as conventional RPDs using metal clasps.
# 2013 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2. Preparation of position paper . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
3. Term and definition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
4. Indications and contraindications for NMCDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
4.1. Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
4.2. Contraindications and cases in which use requires caution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
4.2.1. Type of partially edentulous arch and occlusal relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
4.2.2. Anatomical factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
4.2.3. State of oral hygiene. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
5. Advantages and disadvantages of NMCDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
5.1. Advantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
5.1.1. Esthetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
5.1.2. Feel during use of NMCDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
5.1.3. Metal allergy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
5.2. Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
5.2.1. Discoloration and degradation of thermoplastic resin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
5.2.2. Difficulty of polishing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
5.2.3. Breakage of resin clasp, difficulty of adjusting retention capacity and repair. . . . . . . . . . . . . . . . . . . . . . 9
5.2.4. Design of retentive parts and periodontal condition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
5.2.5. Ineligibility for insurance coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
6. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
journal of prosthodontic research 58 (2014) 3–10 5
reasons; this is one explanation for patients disliking the use Polyester EstheShot Bright i-Cast
of RPDs. Conventionally, attachments have been used in EstheShot i-Cast
patients who place emphasis on esthetics, but the need to Polycarbonate Reigning N Toushinyoukou
remove large quantities of tooth structure and the require- Reigning Toushinyoukou
ment for specialist skills means that at present, this is not a JET CARBO-S HIGH DENTAL JAPAN
generally viable choice. In the United States, since the 1950s, JET CARBO RESIN HIGH DENTAL JAPAN
polyamide resin (nylon) has been used to fabricate RPDs that Acrylic resin ACRY TONE HIGH DENTAL JAPAN
do not contain any metal elements. Since 2007, a number of
Polypropylene UNIGUM WELDENZ
thermoplastic resins have also been approved for use as
denture bases in Japan (Table 1). The use of RPDs made either
from resin alone or a combination of resin and metal is now in 2008, JPS stated that ‘‘Application of flexible dentures solely
rapidly gaining popularity among general dentists and is from the viewpoint of anterior esthetics is not recommended.’’
considered to be superior to conventional metal-clasp The second problem identified by prosthodontists is that
retained RPDs with metal clasps in terms of both esthetics there is no set definition or name for RPDs using thermoplastic
and comfort [1]. Changes in public awareness have led to resin, which are commonly known as flexible dentures, non-
increasingly strong demands from patients with respect to clasp dentures, clasp-free dentures, and metal-free dentures.
esthetic aspects when fitting prostheses, with an increasing Recently, ‘‘non-clasp dentures’’ has become the generally
number of patients avoiding RPDs because they are associated used term, but according to the definition in the US GPT-8
with growing old. The need for dentists to respond to this Glossary of Prosthodontic Terms [3], the resin part that
demand from patients may be a cause of the increasing extends from the denture base to include the abutment teeth
popularity of such RPDs. and which is responsible for retention is a structural element
RPDs using thermoplastic resin have some limitations as that should be called a clasp, and the term ‘‘non-clasp’’ is
revealed by prosthodontists [2]. The first issue is that some therefore inappropriate.
RPDs using thermoplastic resin do not conform to the In light of this situation, the Clinical Guideline Committee
principles regarding the standard RPD design in Japan, and responded to a request from the Social Insurance and Dental
that the use of such RPDs may seriously affect the periodontal Service Problem Committee and considered correcting the
tissues of abutment teeth and the residual ridge. As this guideline. They first searched the literature in PubMed and
procedure is simple and is not covered by national health Igaku Chuo Zasshi (ICHUSHI, Japan Medical Abstracts Society)
insurance, if patients’ demands and desires for a good esthetic to collect the latest clinical evidence, and found that there
appearance are given precedence and such RPDs are used were a limited number of studies: as of August 2011, only one
outside the scope of their intended use, this would be a serious original paper had been published based on clinical research
disadvantage for patients. It has also been pointed out that on RPDs using thermoplastic resin [4]. Then, a questionnaire
depending on the material, problems including fracture of the was sent to a panel of prosthodontists on how to formulate a
resin clasp, roughening of the polished surface of the denture guideline (dentures to be covered, types of defect, design,
base, or discoloration of denture base resin may occur, and whether or not to limit them to thermoplastic resin materials).
treatment such as reline or repair may be difficult. In practice, The results revealed that most prosthodontists wanted to
various problems do occur after denture fitting in at least some formulate a guideline on the different types of thermoplastic
patients, and while the evidence from clinical trials is limited, resin currently in use, cases in which their use is indicated,
there is a possibility that the inappropriate use of RPDs using and denture design. Given the lack of evidence, however, it
thermoplastic resin may become a social issue. If this situation was considered that it would be difficult to formulate a
is left unaddressed, it may decrease public trust in dental guideline for such a wide diversity of patients using standard
treatment and dentistry. In light of these circumstances, the methods. The decision was therefore made to select an expert
Japan Prosthodontic Society (JPS) has cautioned against the panel from among JPS members who had clinical experience
regular clinical use of RPDs using thermoplastic resin, stating with RPDs using thermoplastic resin in order to form a
that ‘‘Although so-called non-clasp dentures have the positive consensus based on clinical experience, and to publish the
advantage of being effective in restoring external appearance, results as a position paper. The objectives of this position
they have the disadvantage that if they are used in the wrong paper were (1) to propose an official term and definition for
patients they may cause major damage, including abnormal RPDs using thermoplastic resin, and (2) to provide guidelines
resorption of the residual ridge and increase of movement of for prosthodontists and general dentists on points to note with
the abutment teeth, and their indications should be scienti- respect to the indications and contraindications, design, and
fically verified in the future’’. In a clinical guideline formulated clinical use of such dentures.
6 journal of prosthodontic research 58 (2014) 3–10
Fig. 3 – A non-metal clasp denture with a framework (Reigning NW). (a) Basal surface of the denture; (b) metal rest and resin
clasp.
Fig. 4 – A non-metal clasp denture using different denture base resins for retentive elements and a denture base. (a) Resin
clasp on working cast; (b) delivered denture.
Fig. 5 – A non-metal clasp denture without metal framework replacing missing maxillary bilateral frontal teeth (ValplastW).
(a) Labial view on working cast; (b) palatal view on working cast.
patients who do not consent to the preparation of abutment 4.2.1. Type of partially edentulous arch and occlusal
teeth (Fig. 5). NMCDs that include a metal structure and are relationship
rigid are basically indicated in a wide range of cases (Figs. 2–4). NMCDs may be designed with a metal rest or framework to
control displacement of the dentures while in use, and designs
4.2. Contraindications and cases in which use requires that incorporate metal may be used with almost all types of
caution partially edentulous arches. Their use is difficult, however, in
patients with non-vertical stop occlusion or those with few
Contraindications for NMCDs depend on the type of partially remaining teeth, in whom good treatment results cannot be
edentulous arch and occlusal relationship, anatomical factors expected even with the use of metal clasp-retained RPDs. For
that affect the design and fabrication of RPDs, or a state of oral patients with non-vertical stop occlusion in particular,
hygiene that may affect the maintenance and management of rotation and sinking of the denture base, changes in occlusal
RPD treatment. position, and resorption of the residual ridge tend to occur,
8 journal of prosthodontic research 58 (2014) 3–10
Fig. 7 – Deterioration of thermoplastic resin used for non-metal clasp dentures. (a) Loss of burnish on polished surface
(ValplastW); (b) discoloration and decolorization of thermoplastic resin (Lucitone FRSW).
5.1.2. Feel during use of NMCDs rubbery form, and the heating effect of polishing may also be
The resins currently in use have a lower elastic modulus detrimental.
and a softer surface compared with acrylic resin [10–13],
meaning that patients feel better when worn. There also 5.2.3. Breakage of resin clasp, difficulty of adjusting retention
appears to be no problem with fit [14,15]. As there is a low capacity and repair
risk of breakage of dentures made solely of resin, which are No guidelines have been indicated for the design of resin
highly elastic and not at all rigid, the denture base can be clasps of NMCDs. Therefore, the width, thickness, and length
made thinner. This makes them lighter and thinner than are designed via trial and error. Design guidelines based on
RPDs using an acrylic resin or metal framework to ensure differences in materials’ physical properties would therefore
rigidity. be desirable [26]. Frequent breakage of the retentive elements
in the early years has led to improvement in their physical
5.1.3. Metal allergy properties. Clasp wires were buried in the retentive parts with
Dentures that contain no metal at all eliminate concerns about the aim of ensuring continued retention and preventing
metal allergy. Historically, the first NMCDs in the 1950s were breakage. If the material is one that adheres to self-curing
made of polyamide resin, which was developed to deal with resin, then the retentive capacity may be recovered to some
the allergic reaction to residual monomers after the poly- extent, but if not then it is difficult to adjust. We will address
merization of acrylic resin [16]. This advantage has also been adhesion to self-curing resin in the context of repair and reline
utilized subsequently for avoiding metal allergy [17]. of different materials in Part II. Materials to which self-curing
resin does not adhere must be repaired in a laboratory.
5.2. Disadvantages
5.2.4. Design of retentive parts and periodontal condition
5.2.1. Discoloration and degradation of thermoplastic resin In NMCDs, the resin clasp covers the cervical area of the
Surface roughening after a few months of denture delivery abutment teeth over a wide area on both the crown and root
was identified in all but a few materials [18]. As the surface is sides, being designed to be part of the gingiva. This means that
not as hard as that of acrylic resin, the depths and the widths the area covered by the resin clasp is large, and the undercut
of marks were greater than the acrylic resins by the scratch and relief regions may easily become dead space, with the risk
test [19], thus the polished surface loses its luster. Discolora- of exacerbating periodontal conditions. Meticulous cleaning is
tion and loss of color are also seen [20–22] (Figs. 6 and 7). therefore essential.
Candida growth is not a concern as long as denture
maintenance is possible, but if adequate cleaning cannot be 5.2.5. Ineligibility for insurance coverage
performed then more caution would be required than for NMCDs using thermoplastic resin are not covered by national
acrylic resin [23]. health insurance in Japan. The cost of NMCDs consisting
entirely of resin is different from that of dentures that utilize a
5.2.2. Difficulty of polishing metal framework for rigidity. Their ineligibility for insurance
Toothbrush friction experiments (measuring the decrease in coverage means that patients must pay a greater amount, but
volume) on the denture base material used in NMCDs have as mentioned in the opening sentences of this paper, many
shown that it loses less than one fifth of the volume lost by people prefer to use NMCDs, and this is based heavily on the
acrylic resin [24]. Nevertheless, although the surface is easily improved esthetics of RPDs.
damaged, as described above, these materials are regarded as
not susceptible to surface loss even when damaged. This
property means that compared with acrylic resin they may be 6. Recommendations
difficult to polish at the chairside [25], and a special polish is
required. When the glass transition point is exceeded in the In this position paper, within the current restricted scope,
non-crystalline portion of a polymer material, it takes on a non-rigid NMCDs cannot be recommended as definitive
10 journal of prosthodontic research 58 (2014) 3–10
dentures in light of current prosthetic principles, with the [10] Sano M, lto K, Nomura A, Kohno S. Properties of
exception of patients with metal allergies and some others. thermoplastic polymers used for non-clasp dentures. J Jpn
Soc Dent Products 2009;23:28–34 [in Japanese].
NMCDs that include a metal framework to provide rigidity
[11] Yokoyama N, Machi H, Hayashi K, Uchida T, Ono T, Nokubi
may be recommended in cases in which the patient is
T. Physical properties of polyamide resin (nylon group) as a
uncomfortable with a metal clasp running through areas that polymeric material for dentures: Part 2. Surface hardness
would affect esthetic appearance. Methods of reline and and tensile strength. J Nippon Acad Dent Technol
maintenance should be understood with reference to the 2004;25:87–92 [in Japanese].
properties of the different materials used. [12] Kawara M, Suzuki H, Ishikawa S. Progress of EstheShot1 for
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Conflicts of interest [13] Ucar Y, Akova T, Aysan I. Mechanical properties of
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Prosthodont 2012;21:173–6.
The preparation of this position paper was funded by JPS. JPS [14] Hayashi K, Yokoyama N, Machi H, Uchida T, Ono T, Nokubi
does not receive support from any specific group or T. Physical properties of polyamide resin (nylon group) as a
corporation. No funding from any group or corporation polymeric material for dentures: Part 1. Characteristics of
absorbent and dimensional change. Journal of Nippon
was used for the preparation of this position paper. The
Academy of Dental Technology 2004;25:80–6 [in Japanese].
members of the expert panel and clinical guideline commit-
[15] Hishimoto M, Katou Y, Akita Y, Murakami Y, Iida S.
tee involved in the preparation of this position paper did not Physical properties of polyester copolymer for denture
receive any support from any specific group or corporation materials. J Nippon Acad Dent Technol 2008;29:196 [special
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had contributed to the development of or lectured on a [16] Stafford GD, Huggett R. The use of nylon as a denture-base
specific resin were not involved in writing about the resin material. J Dent 1986;14:18–22.
[17] Kuwahara K, Nagahama F, Kitahara K, Wada M, Makimura
concerned.
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Acknowledgement [18] Yatabe M. How to deal with non-clasp denture? Its
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