P S R E M O V A B L E RP E M S T V A B O N T I CR O S T H O D O N T I C S RO O HOD L E

A Clinical Overview of Removable Prostheses: 5. Diagnosis and Treatment of RPD Problems

J. FRASER MCCORD, NICK J.A. GREY, RAYMOND B.WINSTANLEY AND ANTHONY JOHNSON
Abstract: This, the fifth and final article in the series, addresses the diagnoses and
treatment of problems which may arise following provision of removable partial dentures (RPDs). These include difficulties seating the denture, pain and discomfort, looseness and functional problems. Dent Update 2003; 30: 8897

Clinical Relevance: Satisfactory diagnoses of problems is central to the provision

of successful RPDs.

roblems related to RPDs may be associated with errors in diagnosis and treatment planning, including inadequate mouth preparation. Other errors relate to mechanical deficiencies, such as inappropriate denture design or poor choice of component materials. There may also be problems in relation to physical and psychological aspects of the patient, and these may contribute either directly or indirectly to a patients inability to accept RPDs. None of these problems is new.1 In this article, a review of the common problems associated with RPD treatment is presented. In the interests of clarity,
J. Fraser McCord, BDS, DDS, FDS, DRD RCS (Edin.), FDS RCS(Eng.), CBiol, MIBiol, Professor and Head of Unit of Prosthodontics, University Dental Hospital of Manchester, Nick J.A. Grey, BDS, MDSc, PhD, FDS, DRD, MRD RCS(Edin.), Consultant/Honorary Senior Lecturer in Restorative Dentistry, Edinburgh Dental Institute, Raymond B.Winstanley,BDS,MDS,FDS RCS (Edin.), Senior Lecturer/Honorary Consultant in Restorative Dentistry, Charles Clifford Dental School, Sheffield, and Anthony Johnson, MMedSci, PhD, Lecturer in Dental Technology, Charles Clifford Dental School, Sheffield.

each problem is identified and the cause, diagnosis, treatment and means of avoidance discussed. Despite advances in materials, plus careful treatment planning and improved technological and clinical expertise, there is little doubt that many patients experience difficulties in wearing RPDs. Many of these problems are biological/ biomechanical in nature and relate to faulty or inappropriate diagnosis or treatment planning. Other problems, however, have their origin in technical deficiencies associated with inappropriate prosthesis design and/or selection of component materials. Less quantifiable are those problems of a psychological nature which, unless catered for, may lead to patient rejection of otherwise acceptable prostheses. Previous authors2,3,4 have stressed that denture treatment should not normally be undertaken unless the mouth is in a healthy state, possible exceptions being immediate dentures or the provision of transitional dentures in the short-term management of elderly, partially dentate patients. Failure to observe this maxim will inevitably result in problems at

insertion and post-insertion of RPDs. Similarly, the importance of proficient impression techniques and appropriate denture design should not be underemphasized as deficiencies in those aspects of RPD prescription may contribute to problems. The purpose of this paper is to review problems associated with RPD wearing, which may be immediate, short-term or long-term. These problems relate, potentially, to a multitude of factors. In the interest of simplicity, these factors may be grouped, collectively, as follows: difficulty seating the RPD; pain/discomfort; looseness; functional problems; appearance; miscellaneous/general, e.g. intolerance and personality factors. In order that appropriate treatment can be dispensed, an accurate diagnosis of the cause(s) of each complaint must be made before remedial treatment may be effected. For each of the categories of complaints listed above, therefore, a list of causes will be presented, followed by diagnosis and suggested treatment options with hints on avoiding the problems.

DIFFICULTY SEATING THE RPD

This complaint may be encountered at the time of insertion or after a period of time in use, the difficulty/ies here may be clinician-related or patient-related. In addition, the difficulty may involve pain/
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Figure 1. Disclosing material (graphite) has been removed as the RPD was inserted.

Figure 2. Trays supported in such a way as to prevent the heels of the impression material lifting away from the trays. Failure to avoid this tends to result in the impression lifting off the trays and this results in a faulty cast.

procedures (vide infra) have been followed and that any metal framework fitted satisfactorily at try-in, then the problem will relate to surplus of acrylic resin which has flowed into undercut areas. The excess acrylic may be detected by use of disclosing paste, aerosol spray (e.g. Occlude, Pascal Co. Inc., Belleview, WA, USA), or graphite (e.g. pencil) and the excess specifically removed (Figure 1). Where frameworks do not fit, as a result of poor impression technique or impression management (Figure 2), the definitive impressions should be re-recorded. The same scenario is applicable if the teeth, not the cast, have fractured or if the cast has been abraded. avoidance: meticulous clinical preparation and impression recording plus integrated teamwork with technician. Cause 2: Design Error This may result in a cast metallic framework/acrylic being made to insert over undercuts. Either inappropriate or insufficient blocking out has been provided or no defined path of insertion was decided upon at the time of designing the RPD (Figure 3). Occasionally, where teeth exhibit mobility or, for example, where cast occlusally-approaching clasp arms have been provided on premolar teeth, the patient may complain of pain/ discomfort on insertion/removal of the RPD. diagnosis: always examine the fit of a casting/RPD on a duplicate of the master cast; check how the prosthesis locates on the model and attempt to follow this intraorally. If the denture does not fit the arch in a similar way to that on the model, then either the impression was faulty or the design needs to be modified. treatment: in this case, re-recording of definitive impressions is generally recommended. avoidance: as for Cause 1. Cause 3: Laboratory Error This may be a result of poor technology or poor administration.

Poor administration may result in delivery of the wrong denture or a denture which is not as per the prescription card. Poor technology may be a result of distortion of framework or retainer or may be a result of damage to the cast. diagnosis: request/insist that all dentures are delivered on a duplicate of the master model. If the denture does not fit the cast, or if the cast is damaged, this will be apparent. N.B. If the RPD does fit the (undamaged) cast but not the mouth, perhaps the impression was not accurate. treatment: retake definitive impressions and remake denture! avoidance: use a laboratory in which careful techniques are practised and which pursues a quality control system. If no such system is practised, use a laboratory which does, although this is an important cost issue! Cause 4: Patient Inability to Manipulate This is not uncommon with the more complicated RPD designs or those where a single path of insertion has not been provided. diagnosis: obvious from the history. It is bad practice to discover at insertion that the patient does not have the dexterity to manipulate, insert or remove the RPD at the insertion visit. treatment: pre-emptive by assessing a patients manual dexterity at a preliminary visit by asking the patient to manipulate demonstration models similar to the planned RPD (Figure 4).

discomfort or may relate to problems of dexterity.

Difficulty at Time of Provision of RPD

Cause 1: Clinical Error This may be caused by trying to insert the wrong denture (see also laboratory error Cause 3), faulty impression techniques or poor treatment planning, e.g. placement of restorations on abutment teeth after the recording of definitive impressions and insertion of the RPD. Another reason may be the failure to eliminate interferences arising from engagement of interproximal undercuts, etc. causing the impression material to tear or to be distorted. diagnosis: compare master cast to patients mouth noting form and angulation of teeth related to the RPD. treatment: as wrong denture delivery should be identified prior to placement, it will not be discussed further. Assuming that appropriate laboratory
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Figure 3. This lower framework will not locate unless the planned path of insertion is used. 89

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Figure 4. Model of sectional denture on acrylic model to enable patient to gain operational skills to insert/remove the denture.

them and re-locate the denture in the mouth. Record an impression with the denture in place and send the impression (with the denture included) to the laboratory for a replacement clasp. Where the major connector is distorted, a remake of the framework is indicated. avoidance: patient instruction into good prosthesis management should be given by demonstration on a model plus written instructions as back-up. Cause 3: Altered Oral Status This usually involves the restoration of abutment teeth and/or teeth in the opposing arch. diagnosis: usually easily elicited from sound questioning and an approach similar to that described in Cause 2 of the Difficulty at Time of Provision of RPD section. treatment: either replace the retainers as for Cause 2 of this section, or remake denture. avoidance: careful planning of the RPD with future treatment in mind. Sometimes some alterations in status are unpredictable and devastatingly rapid, e.g. root caries in elderly patients.

teeth not in connection with the RPD; teeth intimately related to the RPD (via clasp assembly, major or minor connector); mucosa covered by the RPD or mucosa at some distance from the RPD. Teeth not in Connection with the RPD treatment: routine assessment of pulpal integrity plus periodontal health should be performed as per accepted clinical practice. As with all general investigations of pain/discomfort, the clinician should be mindful of referred pain or psychogenic pain (vide infra). avoidance: as for Cause 3 in the Difficulty after RPD has been in Use for a Time section. Teeth Intimately Related to the RPD treatment: as for Cause 2 in the Difficulty after RPD has been in Use for a Time section: ensure that the RPD locates satisfactorily. If pain/ discomfort is experienced, the clinician should ensure that the clasp assembly is not overloading the tooth/teeth. This may relate to insertion/removal forces, rotational forces or functional forces as the clasp assembly may be causing a premature occlusal contact. If the fault is related to the clasp assembly causing excessive forces during insertion/removal of the RPD, then clasp replacement as for Cause 2 of the Difficulty at Time of Provision of RPD section is recommended. If the clasp assembly is interfering with the occlusion, then occlusal

Figure 5. The clasp arms are not now engaging undercuts. This is a result of the patient removing the RPD by using the clasp arm.

avoidance: design RPD appropriate for each patient.

Difficulty after RPD has been in Use for a Time

Cause 1: Design Error As for Cause 2 above. Cause 2: Patient Abuse This commonly results when the patient repeatedly removes the RPD using direct retainers as handles and/or attempts to tighten the RPD him/herself diagnosis: ask the patient to remove the RPD and note mode of removal (Figure 5). Alternatively, leave the RPD in situ for a few minutes and note the relation of the clasp arms to the abutment teeth. Similarly, frameworks may become distorted if the major connector is not sufficiently rigid and the patient grips both saddles of Kennedy I bases when cleaning the RPD. treatment: it can be difficult to effect an acceptable repair at the chairside. If direct retainers are distorted, remove
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PAIN/DISCOMFORT
With these symptoms, much may be determined by sound questioning. These symptoms may need to be coupled to those encountered when a patient has problems when seating or removing the RPD. diagnosis: in essence, the clinician should determine whether the pain is located/relevant to: the jaw in which the RPD is located or the opposing jaw.

Jaw in which the RPD is Located

Four factors must be considered here, namely:
Figure 6. Highlighted occlusal prematurity. Dental Update March 2003

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Figure 7. Under-extended saddle area of denture may be extended at chairside prior to relining.

adjustment or alteration of clasp assembly/design is indicated (Figure 6). avoidance: select type of retainer and material of retainer appropriate for the type of tooth and with its periodontal status in mind. Mucosa Covered by the RPD diagnosis: pain here may arise from the morphology of the impression surface of the saddle, underextension of the denture-bearing area or occlusal prematurities. With regard to the extension of the flanges, place silicone putty or tracing compound on the distal aspect of the base to ensure that the retromolar pad(s) are covered. Then add pressure-indicating paste to the addition and ask the patient to carry out routine chewing and talking (closed and open-mouth) movements. If the addition is not wiped off, then the base has been under-extended. In some instances, the acrylic of the saddle does not support the buccinator muscle appropriately and the putty/tracing stick should be placed on the buccal aspect of the flange. The patient is then asked to perform a range of functional movements to mould the buccinator muscle into contact with the moulding material. When this has been completed satisfactorily, the saddle should be processed in acrylic resin (PMMA). (N.B. The latter does not normally present as pain) treatment: in the case of overextension, the use of pressure92

relief cream will identify nonfunctional pressure points; these may be removed by means of an acrylic bur. For under-extension (Figure 7), the use of tracing compound or a chairside-relining material, such as Tokuso Rebase (Tokuyama Corp. Tokyo, Japan), will assist the diagnosis; relining of the denture base should correct the deficiency. For free-end saddles, a method similar to that of the altered cast technique described by Applegate 5 should be used. avoidance: follow sound prosthodontic principles relating to length and form of saddle areas. Mucosa at Some Distance from the RPD diagnosis: the commonest cause of this relates to trauma of the cheek in relation to the tip of a clasp arm. Another problem may relate to cheek-biting arising from poor extension of the flanges of a distalextension upper denture and/or poor placement of the posterior replacement teeth in a cusp-tocusp relation without buccal overjet. treatment: for the trauma by clasp arm, this is usually self-evident and the cure is effected by modifying die clasp arm appropriately. Diagnosis of under-extension of the denture base may be carried out as for Mucosa Covered by the RPD above. Occlusal problems may be corrected by occlusal adjustment or, where necessary, resetting the teeth of one or both sides as required. avoidance: careful recording of impressions and careful evaluation of occlusal and muscular function at trial insertion visit.

be checked thoroughly for the presence of dentinal/pulpal or periodontal problems and treated appropriately. treatment: if the pain is associated with teeth which are otherwise healthy and which occlude with the RPD, then the clinician should check the occlusion for any prematurities against the RPD. This may be done by using pressureindicating paste or a proprietary pressure-indicating spray (e.g. Occlude). The clinician should also be aware of the potential of pain arising from inappropriate clasping of an abutment tooth (e.g. a cast occlusallyapproaching cobalt chromium clasp arm on a premolar tooth). Similarly, the potential for the RPD to traumatize the mucosal of the opposing jaw should not be overlooked. avoidance: as for Mucosa at Some Distance from the RPD above.

LOOSENESS
Some aspects relating to this may relate to Difficulty Seating the RPD. In general, looseness is reported either: immediately or after some time in use.

Immediate
This is attributable to non-functioning of, or absence of, a retainer, poor extension of the denture base, or poor occlusion, sometimes two or all three reasons may be present. diagnosis: the non-functioning of the

Opposing Jaw
Here, again, the clinician should assess for local and general/systemic causes (e.g. burning mouth syndrome). diagnosis: the teeth opposing the RPD, and particularly those occluding with the denture, should

Figure 8. A sectional denture with a resilient component which will require replacement after 12 months or so. Dental Update March 2003

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provide appropriate undercut depth (Figure 11). Activation or replacement of a precision attachment should be done in accordance with the manufacturers recommendations. Poor base extension has been referred to previously, as have occlusal factors. avoidance: careful planning prior to recording of working impression(s) and definitive recording of intermaxillary relationships.

using, for example, an altered cast technique.

FUNCTIONAL PROBLEMS
Included in this section are problems relating to eating difficulties, including food impaction, speech problems, salivation and taste.

Eating Difficulties
Here, difficulties may arise from problems related to retention, stability and support, occlusal imbalance, including lack of freeway space (where the OVD has been re-established) and miscellaneous factors, e.g. food impaction, etc. diagnosis: the factors relating to under-extension and overextension and excessively rigid retainers may produce pain and the management of these factors and associated symptoms have been described earlier. Similarly, problems of decreased retention and stability may produce looseness. The diagnosis and treatment of this complaint has been itemized previously. While problems relating to occlusal imbalance have been discussed, they have not, as yet, included lack of freeway space. In addition to causing pain/discomfort, which increases as the day progresses, this condition may result in an impairment of eating. Patients often complain that there is not enough room in their mouths for eating utensils, let alone food. A lack of freeway space may be identified by determining the resting facial height with the RPD(s) out of the mouth and measuring the vertical dimension of occlusion with the RPD(s) in occlusion. The normal range lies between 2 mm and 5mm, although older patients may require greater amounts, as may patients with atrophic mucosa overlying edentulous areas. treatment: while excessive freeway space is less likely to produce this complaint, insufficient freeway space may well be a significant factor in eating difficulties. To
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Figure 9. This precision attachment will require regular maintenance.

After Some Time in Use

This may be a result of reduction in function of a direct retainer or indirect retainer, loss of a direct retainer or altered oral conditions. The reduction in function of direct or indirect retainers may arise out of wear of dental hard tissues or by patient abuse. diagnosis: by examining, closely, the RPD in situ and relating the tips of the clasp arms/indirect retainers to their respective planned locations. Similarly, some wear of (particularly plastic) precision attachment components is inevitable and their regular replacement ought to be a standard process of planned patient maintenance (Figure 9). Loss of a direct retainer may arise out of fatigue of a component of the RPD or via abuse by the patient. treatment: addition of composite to abutment teeth (see above); minimal adjustment of clasp arms (stainless steel principally); in some cases, patients will have assumed a neuro-muscular control of their RPD and decline remedial action. avoidance: altered oral conditions may relate to loss of tooth surface, by wear or plaque-associated disease (see above) or may arise from residual ridge resorption (RRR) in free-end saddles. This should be accounted for in the design stage to enable relining

retainer may relate to the fact that no effective undercuts are present on a tooth being used as an abutment or else a precision attachment requires to be activated (Figures 8, 9). Poor extension of the base may relate to poor planning/ laboratory procedures (Figure 10). Looseness related to occlusal imbalance is normally associated with poor function of a retainer in addition to a rocking caused by an occlusal prematurity. treatment: it is normally considered prudent to attend to any other factor(s) first before adjusting the occlusion. If no undercuts are present on a tooth, then they may be introduced by adding acidetching microfilled composite material to the tooth surface, or by providing a crown in order to

Figure 10. Note poor planning in that the base on the (right) saddle is not fully extended. Also, note poor location of the retainer on the (left) second premolar tooth. Dental Update March 2003

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avoidance: proficient planning for, and design of, each RPD.

registration and trial insertion visits.

Salivation Speech Problems

These may be related to unfamiliarity with a prosthesis, placement of teeth/RPD components in an inappropriate position and, as was mentioned earlier, when insufficient freeway space exists. diagnosis: unfamiliarity with a prosthesis may be transient or long term. The former usually disappears within a few days and is not uncommon when the patient has not worn a prosthesis previously. If the form of the RPD is not in harmony with the patients speech patterns, then problems may arise and these may be identified at the trial insertion visit. The speech may be assessed with the patient being asked to speak without any prosthesis in place, with any present prosthesis in place, and with the intended replacement RPD in place. If the patient has a phonetic problem without any denture in place, it is unlikely that the replacement denture will correct it, but it can be determined that it has not caused the speech problem. The diagnosis and treatment of insufficient freeway space has been discussed previously. treatment: minor problems will tend to be transient; more serious problems involving tooth placement will often involve resetting the affected teeth, whereas problems relating to major connectors will perforce require redesigning and recasting of the denture base, e.g. using a copy technique of the present denture if speech with that appliance is acceptable to the patient lack of freeway space may also be associated with lack of a dynamic speaking space and this treatment regime has been discussed previously. avoidance: careful determination of requirements at planning, This may be divided into hypersalivation and hyposalivation. diagnosis: the clinician must determine if these symptoms are real or imagined and this points to the importance of determining salivary status of a patient and recording it at the examination visit. Hyposalivation is unlikely to be directly related to RPD wearing, although the provision of a RPD may induce salivation. Similarly, RPD-induced soft tissue damage may induce excess salivary flow, as may some generalized disease states. treatment: the transient hypersalivation associated with a foreign body response to RPDs tends to resolve naturally. The exception may be when the RPD is overextended distally, especially an upper RPD. Trauma to soft tissues should always be looked for at review visits. avoidance: this problem is not always avoidable, but should be reduced if prosthodontic norms are followed.

Figure 11. In addition to poor aesthetics, this denture design will facilitate food impaction. Retention will also be problematic.

increase the freeway space, the teeth and/or clasp assembly may require to be reduced by grinding. Where this is not feasible, generally where less than a 0.5 mm increase is available, replacement dentures are indicated. The problem is best avoided by judicious treatment planning and confirmation of the prescription at trial-insertion stage. avoidance: careful planning and attention to detail at trial insertion visit.

Food Impaction
This tends to occur when the denture base is not well adapted to the abutment teeth (Fig. 11 ), when the denture base is not well extended or is under-contoured, and when direct retainers are of inappropriate design (Fig. 10). diagnosis: poor adaptation to abutment teeth generally occurs where no recognition and awareness is made of the presence of restored teeth and vertical paths of insertion have been incorporated. This may occur posteriorly, or anteriorly, with obvious limitations to appearance, in addition to the problems which accompany plaque retention. Diagnosis is by assessment of path of insertion and anamnestic reports from patients (these may include indiscriminate grinding by clinicians, technicians or patients!). treatment: in these cases, only relining and utilizing determined paths of insertion will eliminate food traps.
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Altered Taste (Dysgeusia)

This may be symptomatic of a large number of conditions, some of which may have serious health implications. Patients often complain of little or no taste; some complain of a constant metallic taste when food is in the mouth. Other patients relate altered taste to palatal coverage. diagnosis: careful history (may require haematological investigations) and referral of the patient to an oral medicine clinic. Examination should include determination of possible components of galvanic cells (e.g. dissimilar metal restorations connected by metallic minor/major connector(s), gold inlays opposed by amalgam restorations, etc. treatment: in cases of galvanism, this often resolves in a few days, as a result of formation of an oxide layer.
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insertion visits, ensure tooth position and appearance are functionally acceptable to both the clinician and patient, especially the patient.

Metallic Base
Figure 12. Poor aesthetics arising from poor placement of 1| in addition to non-restoration of the interdental papillae.

Figure 13. Poor appearance, arising from an over-mechanistic approach to stability.

Where this does not resolve, alternative restorations may be required and, indeed, in some cases, planned treatment in conjunction with a physician/specialist in oral medicine may be indicated. avoidance: this problem is not always avoidable, but should be reduced if prosthodontic norms are followed.

diagnosis: again the patient usually complains of the base being too obvious, either because the major connector is too obvious when a patient smiles or because one or more minor connectors and/or clasp assemblies are too obvious (Figure 13). treatment: either by avoidance of the problem at planning stage or by the the masking of the base alloy (e.g. via bonding to composite or acrylic by the use of a chemical mediator, e.g. 4-META). avoidance: patient education, and when an appreciation of the patients wishes has been established, discussion of design at the planning stage.

teeth will require to be reset and retried to ensure that the patient is happy with the proposed form of the wax work and then processed appropriately. avoidance: compliance with sound prosthodontic practice and also by the clinician seeking to determine each patients wishes and thereafter attempting to work with these in mind. If the expectations are unrealistic, the clinician is not obliged to provide treatment.

Perceptions of Appearance
This is often overlooked by clinicians until the time of insertion, when it may be too late. Perceptions of appearance and function (of the patients and their families) may well influence adaptation to the wearing of a RPD and therefore this important factor should be determined prior to commencing active clinical treatment. diagnosis: usually obvious. treatment: prior to undertaking prosthodontic treatment where more than a little alteration to facial form is planned, the clinician would be advised to explain what is proposed and, if need be, plan for transitional treatment. If this is not pursued, the wisdom of undertaking drastic changes quickly may be questioned. In other cases, resetting of the teeth or even remaking the dentures may be necessary. avoidance: compliance with sound prosthodontic practice and by determining the patients wishes and attempting to work with these in mind.

Non-metallic Base Component

This may relate to poor wax work which, when processed in PMMA, results in unsightly gingival contouring. It may also relate to the overall design of the denture base (e.g. rugae may have been incorporated and the patient does not like the feel of them or it may relate to the colouring of the denture base resin (Figures 14a and b). diagnosis: this tends to be obvious from the patients comments. treatment: in most cases, the denture

APPEARANCE
Problems of appearance, intrinsically, relate to choice of teeth, metallic base, non-metallic base component and the patients (or his/her familys) perception of appearance. A variety of factors may be involved here and some of the common ones are as follows.

Choice of Teeth
diagnosis: usually obvious from the patients criticism. This may not necessarily be attributable to the tooth choice per se but to inappropriate tooth position (Figure 12). treatment: resetting of the affected teeth. avoidance: at registration and trial
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Figure 14 (a). Poor appearance both teeth and gingivae are of poor aesthetic quality. (b) The same case as (a) but with a more aesthetic result.

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MISCELLANEOUS
Included in this category are factors such as general intolerance, personality and psychological factors, including depressive disorders. General intolerance may be immediate and may be attributable to discomfort, looseness or functional problems (see above), or may be a consequence of personality factors.

Personality Factors
Clinicians must accept that dental visits are often stressful to essentially normal people. It is thus evident that patients must be given adequate time to express their concerns, feelings and perceptions. In this way, a rapport of understanding between clinician and patient may be established. This understanding is essential if trust and understanding are to be achieved as both contribute significantly to

acceptance and successful wearing of RPDs. Equally, the time spent in listening to the patient may be beneficial in that it may indicate that the patient has unrealistic expectations for treatment and therefore it would be unwise to commence treatment. diagnosis: principally via structured interview. Look out for poor fear control, as this may lead to responses such as avoidance, irritability, gagging or excessive reactions which are directed at the oral attack and not at the clinician personally. In addition, the clinician should be patient and must conceal any frustration. Other components of a psychological nature include rejection of any removable prosthesis and atypical facial pain. Often, referral to a physician or clinical psychologist is required if depressive disorders are suspected. treatment: by improved communication

between clinician and patient and patient awareness and understanding of routine prosthodontic procedures. avoidance: the main feature here is diagnosis of the presence of underlying psychological problems and included in this must be poor patient perceptions towards maintenance of good oral health.

REFERENCES
1. 2. Guerini V. A History of Dentistry.Philadelphia: Lea Febiger, 1909: pp.4561. Grant AA, Johnson W. An Introduction to Removable Denture Prosthetics, 2nd ed. London: Churchill Livingstone, 1983: pp.3247. Davenport JC, Basker RM, Heath JR, Ralph JP. A Colour Atlas of Removable Partial Dentures. London: Wolfe, 1988: pp.3641. Stewart KL, Rudd KP, Kueber WA. Clinical Removable Partial Prosthodontics. St Louis: C.V. Mosby Co., 1983: pp.113157. Applegate OC. The rationale of partial denture choice. J Prosthet Dent 1960; 10: 891907.

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