REMOVABLE PROSTHODONTICS
SECTION EDITORS
LOUIS BLATTERFEIN 5.. HOWARD PAYNE
Management of loading forces on mandibular
distal-extension prostheses. Part I: Evaluation of
concepts for design
\
Brian D. Monteith, M.Ch.D.*
Medical UniverGty of Southern Africa, Faculty of Dentistry, Medunsa, Republic of South Africa
T he two structures that support a mandibular distal-
extension removable partial denture differ markedly in
their viscoelastic response to loading. The differential
between the 500 pm resilience of the residual ridge
tissues and the 20 pm of the teeth permitted by the
periodontal ligament’ presents a disparity of support
that is in contrast to the uniform support accorded a
tooth-supported removable partial denture (Fig. 1, A).
Hence the denture tends to rotate about its most distal
abutments, inducing heavy torsional stresses on, and
possible traumatization of the ridges (Fig. 1, B).
Design philosophies aimed at minimizing this rota-
tional movement have appeared regularly in the dental
literature over the past 50 years. The fact that they
continue to do so indicates that there is no unanimity as
to what might be considered the best method of solving
the problem. These design concepts can be classified into
four basic categories.
1. The flexible denture base. This concept is represented by
stress-breaker designs.
2. The floating denture base. In this concept a mucostatical-
ly recorded denture base is related to the abutment teeth
under pressure.‘,’
3. The mucofunctional concept. This approach includes the
impression techniques that record the tissue surfaces in
the shape that the residual ridges assume under function-
al loading.
4. The endosseous implant. The proponents of this concept
seek to eliminate all movement of the denture base by
reconstituting the missing distal abutment.
The purpose of this article is to examine these
concepts in the light of recent research into the viscoelas-
tic behavior of the teeth and mucosal tissues, as well as
that of endosseous implants as reported by Wills and
Manderson4 and Picton and Wills.5*6
VISCOELASTIC BEHAVIOR OF TEETH AND
MUCOSA
Pattern of tissue response to loading
Fig. 2 illustrates the mucous membrane displacement
curve that resulted when a force of 4 N was applied to a
*Professor <andHead, Department of Prosthetic Dentistry.
THE JOURNAL OF PROSTHETIC DENTISTRY
tissue-borne denture base. In the curve on the left, the
intrusive range is about 500 pm, which is 25 times
greater than the measurement of 20 pm obtained when
the same force was applied to teeth (Fig. 3). However,
an important feature common to both curves is that the
response to load takes place in two distinct phases. Phase
1 occurs instantaneously with the application of the load
and reveals a typically elastic response. In contrast,
Phase 2 is a much stiffer phase characterized by an
alteration in the shape of the curve to a typically
viscoelastic pattern, which suggests a sudden marked
increase in tissue resistance.
In similar fashion, the recovery of the system also
takes place in two distinct phases. When the load is
removed, there is an instantaneous elastic-type recovery,
which spans about 50% of the displacement range. The
second phase is of a more viscoelastic nature; and
although abrupt in onset, it suggests a slow and pro-
tracted return to the baseline.
Effect of rate and duration of loading
The curve on the right in Fig. 2 illustrates the effect
that a change in the rate of a force application of 4 N has
on the tissue displacement pattern. When the rate of
application is increased from 4 N/set to 100 N/set, the
reduced time element results in a 20% reduction in the
amount of displacement that occurs and a much quicker
return to the baseline. Increasing the duration of the
force has just the opposite effect. The same studies
have shown that a static load applied for 10 minutes
gradually depressed the tissues further into the resis-
tant second phase. This is called tissue creep, which if
prolonged will not only push the system to its viscoelastic
limit, but will result in the phase of recovery becoming so
extended as to require 3 or 4 hours to return to its
baseline.
Effect of area of loading
Altering the unit area of load application has a
definite bearing on the amount of displacement that
takes place. One might expect, for example, that halving
the area of tissue covered by a denture base from 150
mm’ to 75 mm2 would have the arithmetic effect of
673

B
Fig. 1. A, Mesial and distal abutments provide uniform
support for tooth-borne removable partial denture or
fixed prosthesis. B, Mixed support arises from loss of
distal abutment. Because residual ridge tissues are 25
times more resilient than periodontal attachment appa-
ratus, removable partial denture under vertical load will
tend to rotate around a fulcrum point that coincides
with its most distal occlusal rest.
doubling the amount of tissue displacement under the
same load. Surprisingly the studies under review show
that halving the area of support in this way results not in
a twofold increase but a geometric fourfold increase in
tissue displacement.
FLEXIBLE DENTURE BASE CONCEPT
Hailed by some and decried by others, stressbreakers
provide a means of interposing a flexible connection
between the tooth-borne retainer portion of a removable
partial denture and its distally extended tissue-borne
base. Although many types of stressbreakers are avail-
able, the principle that underlies their use is aimed at
ensuring that all forces that fall on the denture base
portion will be directed toward the residual ridges alone
and thus protect the teeth from possible torsional effect.
The vertical movement permitted by a hinge in the
674
MONTEITH
so0 pu
RECOWZRY 400
500
n I
Fig. 2. Mucous membrane displacement curves that
result from application of a force of 4 N at rates of 4
N/set and 100 N/set, respectively. Note that displace-
ment occurs in two distinct phases and that there is less
displacement when rate of force application is 100
N/second combined with quicker return to baseline
when load is removed. (Redrawn from Manderson,
R.D., et al.‘)
TOOTH
Fig. 3. Typical displacement curve resulting from
application of axial load of 4 N at a rate of 4 N/set to
tooth. Note that both loading and recovery phases
feature distinct elastic and viscoelastic elements. (Re-
drawn from Manderson, R.D., et al.‘)
sagittal plane is such that the denture base portion, in
effect, becomes a beam that under load behaves like the
moving radius of a circle. The distal extremity of the
denture base will scribe an arc (Fig. 4), and because it is
furthest from its center of movement at the hinge will
consequently undergo more movement than any other
point along the length of the denture base. Because they
are subject to geometric principles, the arc lengths
scribed by all points along the length of the denture base
will reflect a gradient that is governed by a strictly linear
differential. As Vahid? demonstrated, the tissue dis-
placement along the crest of the mandibular residual
ridge presents a similar differential; that is, the tissues
immediately adjacent to the last abutment tooth are far
less resilient than those in the region of the retromolar
pad. The ridge tissues, however, do not behave according
to a geometric system, so it is most unlikely that the
NOVEMBER 1984 VOLUME 52 NUMBER 5
CONCEPTS FOR DESIGN
Fig. 4. Flexible denture base removable partial denture
demonstrating steep arc differential when location of
stressbreaker hinge results in short-radius beam.
J IV
Fig. 5. Long-radius design incorporating split major
connector. Locating point of resilience as far anteriorly
as possible reduces arc differential to a minimum.
tissue displacement differential along the length of the
ridge will coincide with the strictly linear differential
imposed by the denture base. The inevitable result,
therefore, will be an uneven match of stress and resil-
ience, and the areas that are least resilient will be made
to bear most of the load. In terms of the “square rule”
relating displacement to area, this limitation of the area
under load might induce tissue creep and the risk of
insidious damage to the underlying alveolar bone.
Efforts to reduce the arcing differential to less stressful
gradients have resulted in “long radius” designs such as
that of Levin.* Long radius designs seek to lengthen the
active radius of the system by ensuring that the flexible
joint is located as far anteriorly as possible. This
frequently involves the use of a split major connector that
is two separate lingual bars joined anteriorly in a
manner that will permit a degree of resilience between
the denture base and the retainer portions of the
framework to which they are attached (Fig. 5). Length-
ening the beam radius in this way could reduce the
arcing differential to a gradient more in keeping with the
inherent displa.ceability of the ridge tissues. It is more
likely, however, that clinical successes attendant on
the use of these devices are to be attributed to the in-
herent ability of biologic systems to tolerate the rudely
mechanical concepts so frequently imposed on them
by dentistry.
FLOATING DENTURE BASE CONCEPT
Recognizing that a distal-extension denture base
sinking into the underlying ridge mucosa will cause
THE JOURNAL OF PROSTHETIC DENTISTRY
I
Fig. 6. Evidence of trauma in region immediately distal
to last abutment tooth. Because it displays less compress-
ibility than tissues elsewhere, this region bears the
brunt of functional stresses of prosthesis made from
mucostatic impression.
occlusal rests to bind on their seats and transmit torque
to the abutment teeth, Hindel2 described a technique to
induce a vertical floating movement in the denture base,
in which the rest will contact the base of its seat only
when the ridge tissues that support the denture base are
maximally compressed. As a result, the masticatory load
will be divided between the ridges and the abutment
teeth. On release of the load, the mucosa will rebound,
the entire structure will move upward, and the occlusal
rests buoyed up by this movement will be prevented from
acting as fulcrums. This technique incorporates a
mucostatic impression of the ridges related by means of
finger pressure to the abutment teeth.
In measuring this philosophy against the biophysical
concepts outlined earlier, it is helpful to examine the
underlying principle of a mucostatic impression related
under pressure. Applegate9~‘o stated the futility of
mucostatic impressions for removable partial dentures.
His reasoning was that the ridge tissues are not uniform-
ly compressible and that a base made from mucostatic
impressions will result in the firmer areas doing all the
work, and the more compressible areas receiving little or
no work stimuli. Vahidi’ showed conclusively that the
ridge tissue immediately distal to the last abutment tooth
675

Fig. 7. Metal framework constructed on master cast
obtained by means of irreversible hydrocolloid impres-
sion material.
in a distal-extension prosthesis is far less compressible
than the tissues elsewhere. This means that a mucostati-
tally shaped base would tend to “ride” on this relatively
small region. As with stressbreakers, in terms of the
square rule the concentration of functional forces on so
small a region will invite stress of potentially damaging
proportions (Fig. 6).
The ideal of having the rest contact its seat at the
precise moment at which the tissues are maximally
compressed seemsto be an admirable one. Will this ideal
state be attainable through the application of arbitrary
finger pressure? Masticatory pressures have been ascer-
tained to be approximately 4 N applied at a rate of 100
N/set.’ Therefore, even if the fingers could be schooled
into consistently applying a force of 4 N, the problem of
the time factor will remain, that is, the rate and duration
of the application. With the floating denture base
concept, the force is applied through the finger holes in
the impression tray as long as it takes the impression
material to set. This will involve compression of the
mucosal tissues lasting a number of minutes: an imposi-
tion that will implicate the added danger of tissue creep.
The functional implications of this will be that a patient
who exerts compression of 4 N at a rate of 100 N/set
will find it impossible to match the amount of compres-
sion gained by finger pressure applied over a number of
minutes. The denture, therefore, would remain totally
and perpetually tissue-borne; and until ridge resorption
occurs, the occlusal rests or precision attachments of the
prosthesis will have little chance of ever contacting their
seats.
676
MONTEITH
Fig. 8. Accurately fitting clear acrylic resin denture
bases have been adapted to metal framework prior to
making corrective impression.
MUCOFUNCTIONAL CONCEPT
The rationale of this concept is that the soft tissues of
the ridge derive benefit from the massaging effect
produced by the rhythmic displacement of blood fluids
from the superficial vessels during function.9 In terms of
the tissue displacement curve (Fig. 2), this vascular
displacement coincides with the more elastic first phase
of compression prior to the sudden onset of increased
tissue resistance that marks the start of Phase 2. The
objective of the floating denture base concept was to
effect tooth support at the very moment that the ridge
tissues become maximally compressed. To take this
literally however, would presuppose that this is made to
occur at the end of Phase 2, because it is only then that
the tissues are maximally compressed. It is more logical
to time the seating of rests or attachments to coincide
with the end of Phase 1, because the beneficial massag-
ing effect will be retained without placing the event of
rest contact beyond the mucocompressive capabilities of
normal function. At first this seems almost impossible to
achieve, because the ridge is not uniformly compressible,
and the amount of movement represented by Phase 1 of
the curve will vary in magnitude from place to place. In
other words, there is not just one curve to be accommo-
dated, but an infinite number, each of which represents
the degree of tissue compressibility as it occurs at
different points over the entire ridge. Ideally, if it were
possible to capture the ridge profile at a stage at which
each curve reached the end of Phase 1 and is beginning
to feel the resistance at the start of Phase 2, this would be
the ideal point at which to introduce tooth support.
Unlikely as it may seem, this can be achieved simply by
superimposing one kind of elasticity on another through
NOVEMBER 1984 VOLUME 52 NUMBER 5
CONCEPTS FOR DESIGN
Fig. 9. Corrective impression of ridges obtained with
soft ZOE impression paste.
Fig. 10. Kidge regions are removed from uncorrected
master cast with saw.
the choice of an impression material that possesseselastic
properties similar to those of the ridge tissues. The
material should be sufficiently stiff to induce tissue
compliance over the first phase of the displacement
curve, yet not s,ostiff as to overcome the onset of tissue
resistance at the start of Phase 2.
In this manner, the entire ridge mucosa may be
optimally displaced to an extent dictated by the discrete
displaceability of its constituent regions, with the whole
reaching a state:of resistance to load at exactly the same
moment. Impression waxes have been formulated to this
end, such as those that form the basis of Applegate’s
“altered-cast technique.“‘, ‘O Other materials have been
investigated,“, “’ and zinc oxide-eugenol (ZOE) paste,
once considered to be the basis for essentially mucostatic
impressions,13 h.as viscoelasuc properties that are ideally
suited to this purpose (Figs.. 7-12).
Of the various philosophies reviewed, only the muco-
functional concept appears to satisfy the criteria against
which all three have been measured. In contrast to the
uneven stressing of isolated ridge regions that might arise
from the geometric imposition of stressbreaker designs
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 11. Metal framework with associated corrective
impression repositioned on tooth portion of master cast
prior to altering distal-extension bases.
and the arbitrary finger pressures of the floating denture
base technique, mucofunctional philosophy appears to
offer the only way in which the entire denture-bearing
region can be loaded in a uniform way. By relying
exclusively on the elastic resistance of the impression
material to achieve the required amount of tissue dis-
placement, there will be less chance of the tissues being
stressed beyond their capabilities. The even nature of the
resulting displacement and the fact that it is spread over
the entire contacting surface seemsto satisfy the require-
ments of the square rule relating tissue compression to
area in a way that seems unlikely by any other means.
ENDOSSEOUS IMPLANT CONCEPT
Another school of thought is that by reconstituting a
missing distal abutment, a uniformity of support suitable
for fixed partial dentures can be achieved that eliminates
the need for a removable partial denture. If one accepts
the precept that an endosseous implant represents a
perfect tooth analogue, this concept is attractive, partic-
ularly to those who consider a fixed prosthesis superior
to a removable partial denture. Both these assertions are
677

Fig. 12. Final altered cast with ridges corrected to
conform with functional profile.
open to debate; however, they reflect an attitude that
may underlie the enormous increase in the use of
endosseous implants.
In his review of the literature, Kapuri4 has drawn
attention to the scarcity of documented reports aimed at
establishing success or failure rates in contrast to the
profusion of articles that deal with matters of technique,
design modifications, and isolated successful experiences.
It was on the grounds of insufficient sample size and
conflicting results that the Harvard Consensus Confer-
ence15had to admit that it was unable to assessspecific
survival estimates of the free-end blade implant, even in
its simplest form. It is understandable therefore, that the
Conference advised that implants should not replace
conventional dentistry but be used only when conven-
tional dentistry is unsuitable.15 With its plea for a more
properly constituted gathering of data, this reflects a
more cautious attitude. As Armitage16 pointed out at the
Conference, “. . . many modifications have taken place to
improve blade implants. However, all have proven
inadequate to justify such widespread use of this device
today . . . . The rapid increase in the use of this implant
without documented success is alarming. . . [and its]
continued use . . . requires material and design modifica-
tions to elicit a more favorable, longstanding inter-
face.”
Significantly, the twin matters of design and materials
research, as well as the nature of the implant/bone
interface, have attracted the attention of dental research-
ers and material scientists for more than a decade.14
Design development
Design development has tended toward the empirical;
an example is the introduction of the anchor design to
678
MONTEITH
DEHISCENCE
Fig. 13. Conventional blade vent design demonstrat-
ing tendency of shoulder portion to undergo dehis-
cence.
counter an observed tendency toward bone loss around
the shoulder regions of blade vents (Fig. 13). By
permitting the shoulder to be relocated at a deeper level
within the bone (Fig. 14), the anchor form has the
arguable result of rendering bone resorption, if not less
likely, at least less apparent.*
Materials research
The efforts of the materials scientists have been
directed toward the search for substances sufficiently
biocompatible to elicit the least possible reaction when
implanted in the body. Details of this quest have been
furnished by Kapur14 and Lavelle et al.” in their succinct
yet comprehensive reviews.
A significant precept of the search for the perfect
implant material is that the attainment of a state of
ankylosis between implant and bone is consistently held
to be the characteristic sign of physiologic compatibili-
ty* ” B Y contrast, the development of a fibrous connec-
tive-tissue sheath at the implant/bone interface is viewed
as evidence of incipient failure and has served as an
incentive to further and greater scientific endeavor.
However, it is not only compatibility that is at issue in
the occurrence of this fibrous phenomenon, but also the
matter of implant loading. ‘a The appearance of fibrous
tissue at the interface suggests that biocompatibility
alone is not enough to ensure implant viability. Biocom-
patibility is a passive concept of toleration by the tissues
of something that does nothing to provoke its own
rejection. Consequently, the search has extended into the
*Mohammed, H.: Personal communication, 1981.
NOVEMBER 1984 VOLUME 52 NUMBER 5
CONCEPTS FOR DESIGN
Fig. 14. Anchor design, which by dispensing with
shoulder, ostensibly obviates possibility of dehiscence.
realms of bioreactivity for a material that goes further
than mere toleration by the tissues to one that actively
stimulates a process of biologic integration within the
bone.
One way in which this criterion has been met involves
coating metal implants with a ceramic tricalcium phos-
phate. This substance has been found to react with the
bone within a freshly prepared site in a way that results
in the implant becoming “locked” within the bone of the
jaw. ” A similar effect has been achieved with titanium
oxide.” Both methods result in a direct bone/implant
interface with the total exclusion of the unacceptable
fibrous tissue layer. The use of bioreactive materials
such as these appears to represent the most promising
advance in design and materials research.
Response to loading
It is possible that the ultimate cause of endosseous
implant failure may have little to do with design and
materials. The work done by Picton and Wills6 in the
investigation of the loading response to blade implants
suggests that it is in the realm of biomechanics that the
answers should be sought. To put it another way, the
ultimate success or failure of an endosseous implant
might depend not so much on its shape or material, but
on what the dentist puts on top of it.
Picton and Wills6 extended their work on displace-
ment determination to include blade implants. A force of
several newtons applied vertically to an implant post
produced a negligible amount of intrusion. This observa-
tion led them to conclude that from a functional point of
view, blade implants can be regarded as being ankylosed
to the surrounding alveolar bone. The application of a
horizontal load, however, resulted in an elastic deflection
THE JOURNAL OF PROSTHETIC DENTISTRY
ENDOSSEOUS IMPLANT
______ RecovERY
;No” viscous
LOAD fSN/secj
Fig. 15. Displacement curve obtained by applying hor-
izontal force of 5 N/set to endosseous implant in vivo.
Elastic nature of displacement is attributable to bending
of implant neck. Absence of viscoelastic element sup-
ports view that endosseous implants should not be
regarded as tooth analogues. (Redrawn from Picton,
D.C.A., and Wills, D.J.“)
of 1 to 2 pm (Fig. 15). Puzzled by this anomaly, Picton
and Wills6 immobilized a similar implant blade in a vise
and applied the same loads. The results were identical,
which led them to conclude that the deflection in both
instances was due to bending of the implant stem, and
that it should not be ascribed to displacement of peri-
implant tissue.
It is clear from these findings, and can be seen in a
comparison of Fig. 15 with Fig. 3, that a blade implant
does not react in the same way as a tooth when placed
under load. Consequently, it cannot be regarded as a
true tooth analogue.
This places the rationale of free-end blade implants in
serious doubt. Intended as a way to avoid the displace-
ment differential between tooth and mucosa that is so
troublesome in distal-extension removable partial den-
tures, the free-end blade as a substitute tooth merely
results in the creation of a new differential between tooth
and implant. Admittedly, the difference between the 20
km viscoelastic deflection of a tooth and the almost
negligible elastic deformation of an implant stem is
minute. However, the proportion between the two is
almost the same as that which exists between a tooth and
the tissues of the residual ridge.
The matter is further complicated when tooth and
implant are immovably united by means of a fixed
partial denture. Acting as a beam, under functional load
it becomes in effect a pernicious lever. At one end it is
anchored immovably to a tooth that is capable of an
intrusive movement of 20 pm, while at the other end it is
anchored immovably to an endosseous implant post
capable of no intrusive movement at all. On the applica-
tion of vertical load (Fig. 16), the tooth at one end of the
lever will intrude back into its socket, while at the other
679

Fig. 16. Movement differential between tooth and
free-end blade is taken up in bending of implant neck.
Resultant torsional forces are expressed as compressive
stresses in alveolar bone with probable resorptive con-
sequences in regions indicated.
end the implant is incapable of similar intrusion and will
comply by simply bending. In obedience to the third law
of Newton, the torsional stress set up within the implant
neck by this bending will elicit a reaction at the
extremities of the implant blade. The implant will
become a force transducer, and the stress built up within
itself will be transmitted to the surrounding alveolar
bone in a compressive way. The inevitable consequence
of compressive stresseson bone is osteoclastic activity, so
it is hardly surprising that regions of bone resorption are
a frequent feature of this modality.
The inference is that far from presenting a way to
avoid the problem of mixed support in a distal-extension
prosthesis, the implant-fixed partial denture-tooth com-
bination merely substitutes another form of mixed
support between the tooth and the implant.
Clinical comments
The matter of fibrous connective tissue at the interface
will remain unresolved as long as there are people who
continue to regard it in the light of an “implant-
periodontal ligament.” Weiss and Rostoker*” reported
the progress of a new type of endosseous implant in
baboons. They welcomed the appearance of a fibrous
tissue interface on their devices and observe that this
“ . . . allowed some desirable ‘micromovement’ (approxi-
mating that of a natural tooth) without causing bone
resorption.” It might be argued that the lack of further
bone change could be ascribed to the fact that none of the
functioning implants was attached to an adjacent tooth
MONTEITH
Fig. 17. Unwarranted enthusiasm for a clinical activity,
where more properly extreme caution ought to pre-
vail.
and thus were preserved from the deleterious effects of
tooth/implant differentials.
Osseous integration procedures, on the other hand,
bury abutments for an initial period to allow full
ankylosis to develop before risking exposure to function-
al forces. The implant philosophy presented by Lavelle
et al.” makes use of this preparatory measure and seeks
to preserve the resulting ankylosis through the use of an
epimobile polysulphone cone, which should be of value
in absorbing differential stresses. Having gone to such
lengths to avoid the development of fibrous tissue at the
interface, they are uncompromising in their condemna-
tion of it and state, “The notion that a layer of
disorganized connective tissue around an implant is
analogous to the highly organized periodontal ligament
is fallacious. Indeed, the presence of connective tissue
around an implant heralds its demise.”
Unfortunately and ironically, this controversy will
probably never be resolved. The Harvard Consensus
Conference (recommendation 30) ranked mobility as of
first importance in the evaluation of free-end fixed
prostheses and apportioned this criterion a value of 0.8
on a scale of l.*’
This is admirable. Unfortunately, in listing its criteria
for implant success (recommendation 15), the Confer-
ence deemed the presence of movement less than 1 mm in
any direction in an implant to be grounds for self-
congratulation. The proponents of absolute ankylosis
disagree with this concession. Should the latter be correct
in their assertion that any movement in an implant is a
harbinger of certain failure, it is unlikely that their
rectitude will ever be acknowledged. The existence of a
set of standards against which failure can be rated as
successwill give the free-end endosseousblade a respect-
ability that it has not earned and promote unwarranted
NOVEMBER 1984 VOLUME 52 NUMBER 5
CONCEPTS FOR DESIGN

enthusiasm for a clinical activity where, more properly,
extreme caution ought to prevail (Fig. 17).
SUMMARY
The viscoelastic reaction of ridge mucosa and abut-
ment teeth, by virtue of their periodontal ligaments, is a
necessary dimension in the evaluation of design concepts
for removable partial dentures for patients with distal-
extension ridges.
The possible modalities are (1) removable partial
dentures with flexible denture bases (stressbreakers), (2)
use of a fl0atin.g denture base impression technique, (3)
use of a mucofunctional impression technique to relate
the denture base to the framework, and (4) use of an
endosseous implant. An evaluation of each modality has
been made.
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1. Manderson, R. D., Wills, D. J., and Picton, D. C. A.: Biome-
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Proceedings Iof the Second International Prosthodontic Congress.
St. Louis, 1979, The C. V. Mosby Co., pp 98-101.
2. Hindels, G. ‘W.: Load distribution in extension partial dentures.
J PROSTHETDENT 2:92, 1952.
3. Hindels, G. W.: Stress analysis in distal extension partial
dentures. J PROSTHETDENT 7:197, 1957.
4. Wills, D. J.. and Manderson, R. D.: Biomechanical aspects of
the support of partial dentures. J Dent 5~310, 1977.
5. Picton, D. C. A., and Wills, D. J.: Viscoelastic properties of the
periodontal ligament and mucous membrane. J PROSTHETDEHT
40~263, 1978.
6. Picton, D. C. A., and Wills, D. J.: The mobility of horizontally
pinned teeth in monkeys and of endosseous blade implants. Br
Dent J 139:469, 1975.
7. Vahidi, F.: Vertical displacement of distal extension ridges by
dill’erent impression techniques. J PROSTHET DENT 40~374,
1978.
8. Levin, B.: Stressbreakers: A practical approach. Dent Clin North
Am 2.3~77, 1979.
9. Applegate, 0. (1.: The partial denture base. J PROSTHETDENT
5:636. 1955.
10. Applegate, 0. C.: Essentials of Removable Partial Denture
Prosthesis. Philadelphia, 1954, W. B. Saunders Co., pp 166-
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1I Holmes, J. B.: Influence of impression procedures and occlusal
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13. Kramer, H. M.: Impression technique for removable partial
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14. Kapur, K. K.: The literature on blade implants. In Schnitman, P.
A., and Shulman, L. B., editors: Dental Implants: Benefit and
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