Survey of partial removable dental prosthesis (partial RDP) types in a distinct patient population

Deo K. Pun, DMD, MS,a Michael P. Waliszewski, DDS, MsD,b Kenneth J. Waliszewski, DDS, MS,c and David Berzins, PhDd Marquette University, Milwaukee, Wis
Statement of problem. Current demographic information on the number and types of removable partial dentures is lacking in the prosthodontic literature. Purpose. This study was designed to investigate patterns of tooth loss in patients receiving removable partial dentures (RPDs) in eastern Wisconsin. Material and methods. Digital images (1502) of casts at 5 dental laboratories in eastern Wisconsin were collected. Any prescription requesting fabrication of a removable partial denture was photographed twice. The first photograph was made immediately upon arrival at the laboratory, while the second photograph was made immediately before being returned to the prescribing dentist for the first time. A calibrated investigator analyzed all the photographs for Kennedy Classification, type of RPD, major connector, and other details. Data were analyzed with descriptive statistics. Fishers exact test was used to confirm repeatability. Results. Kennedy Class I was the most common RPD with a frequency of 38.4%. More than 40% of prescriptions had no design input from the dentist. One in 3 RPDs used acrylic resin or flexible frameworks. One in 5 RPDs had no rests. The horseshoe major connector was the most common maxillary major connector, while the lingual plate was the most common in the mandible. Conclusions. RPDs remain a common prosthodontic treatment in this region. Non-metal RPD frameworks are a common treatment type and rarely include rests. These data indicate a changing partially edentulous patient population and a variable commitment to standard levels of prosthodontic care. (J Prosthet Dent 2011;106:48-56)

Clinical Implications

The inclusive nature of this analysis helps demonstrate details of current RPD treatment that are rarely discussed in dental education or literature. The lack of dentist input, use of nonmetal frameworks, bulky major connectors, and lack of adequately supported RPD designs indicates the potential for poor RPD outcomes in this sample.
Recent investigations analyzed trends in demand for prosthodontics in the United States.1,2 More than 95 years ago Hillyer3 noted that as the edentulous condition decreases, the use of removable partial dentures (RPDs) increases. Despite decreasing rates of tooth loss, the need for removable prosthodontic treatment remains high.4-6 One consequence
a b

of the professions improved preventive measures has been an increase in the number of patients who require prosthodontic treatment with RPDs.7-9 Conservative treatment types such as dental implants are expensive. This may limit their availability to lower socioeconomic groups in whom the highest rates of tooth loss occur.10-12 Conventional removable prosthodon-

tic treatment types, therefore, continue to outnumber implant tooth replacements in general practice.13 Multiple RPD classification systems have been proposed.14-20 The Kennedy Classification system is currently the system described in 2 RPD textbooks,21,22 and was found to be the most commonly used system according to an older analysis.19 This

Private practice, Sterling, Ill. Adjunct Assistant Professor, School of Dentistry. c Adjunct Professor, School of Dentistry. d Associate Professor and Graduate Program Director, Dental Biomaterials.

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system also meets criteria of the principles, concepts, and practices in prosthodontics (PCPP).23 Several attempts to analyze specific trends in the frequency of various RPDs have been presented.24-39 Most of these studies are of European or middle-eastern populations with few studies from the United States.6,40-43 Curtis et al42 surveyed the incidence of various classes of RPDs fabricated at a single dental laboratory in California. Interim RPDs were excluded, leaving 327 of the 400 work authorizations for inclusion. Forty percent of these RPDs were Kennedy Class I, while 33% were Class II, 18% Class III, and 9% Class IV. The most common mandibular RPD was Class I (49%), and the most common maxillary RPD was Class II (38%). Using 5 commercial dental laboratories from different regions of North America, wall and Taylor43 investigated the frequency of different types of RPDs. While information regarding number and distribution of teeth was presented, there was no classification. Ninety-five percent of 1,363 RPDs analyzed had cast metal frameworks. Redfords group found that 8% of the 7,374 examined subjects were using an RPD.6 The prevalence increased with age to 22% at 55 to 64 years old. This finding did not include acrylic resin framework RPDs. In the United States, no recent analysis of incidence or prevalence of types of RPDs or Kennedy Classification was identified. The previously mentioned studies evaluated data pertaining only to cast metal framework RPDs. This may not reflect the demographics of the average clinical practice. While valid longterm outcome data is lacking, acrylic resin framework RPDs continue to be used with great frequency.44,45 Acrylic resin framework RPDs are far more common than cast metal framework RPDs in several other countries.46-50 As a group, these surveys demonstrated significant differences in patient treatment among institutions, government subsidized clinics, and private practice. Insurance reimbursement, capabilities of dental laboratory support, education, and location and extent of missing teeth all appear to influence whether a cast metal framework or acrylic resin RPD is fabricated.49 In addition, newer types of flexible RPDs have received much attention in dental advertisements over the past decade. However, no peer-reviewed study or incidence data for these different RPD framework materials was identified. Without the strength and established design principles of cast metal framework RPDs, it is believed that alternative RPD frameworks have reduced longevity and significant periodontal consequences. Clinical reports describe methods to improve their performance.51,52 Studies demonstrating poor periodontal or dental response to RPDs have investigated acrylic resin framework RPDs.53-57 The authors found that teeth in contact with acrylic resin frameworks were more likely to have dental disease. Carlson57 confirmed that acrylic resin RPDs had a high incidence of fracture or need for repair. In contrast, it is interesting to note that studies with positive long term clinical results used cast metal framework RPDs.40,41,58,59 The authors concluded that there is no direct evidence of well made and maintained RPDs significantly contributing to periodontal disease. In a rare direct comparison of RPD material and design, Bissada et al60 found that inflammation was greater when acrylic resin contacted the gingival tissue than when metal was used. These projects seem to confirm a preference for metal framework RPDs in terms of clinical performance and periodontal health. While metal frameworks may be preferred, modern RPD framework fit continues to be less than ideal.61-65 There is evidence that the average clinician understands and is taught less about the RPD framework fabrication process than in previous generations.66-69 Surveys of dental laboratories and dentists continue to find poor communication between the two.27,28,49,70-78 In addition, the majority of RPD procedures are selected based on their efficiency and economy rather than on the standard of care.75-78 Poor communication and standardization has not been found within the prosthodontic community.79 These quality issues help explain the high frequency of failed treatment in the non-institutionalized U.S. population.6,80-82 Further analysis of the type of prostheses requested, design instructions given, and quality of material provided to the laboratory, may clarify some of the sources of defective RPDs. Considering the previously mentioned factors, an analysis of the incidence of various classes of RPDs would be of interest. It also provides an opportunity to investigate some of the existing trends in non-institutionalized RPD services. The purpose of this study was to investigate patterns of tooth loss in patients receiving RPDs and to present details regarding how this treatment is provided.

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MATERIAL AND METHODS

Five regional commercial dental laboratories located in eastern Wisconsin, were chosen for data collection. Laboratories were selected if they were willing to participate, were regionally located, and they fabricated large numbers of RPDs. RPD was defined as any prosthesis that replaced teeth in a partially dentate arch, and could be removed from the mouth and replaced at will.83 The proposed study was approved by all laboratories and the Institutional Review Board of Marquette University School of Dentistry, Milwaukee, Wis. Data were collected by the laboratories using handheld point and shoot digital cameras. Any prescription presenting to the laboratory requesting fabrication of a RPD was included. Therefore, repairs and relines were excluded. Two photographs were made of laboratory box contents with prescriptions meeting the previously mentioned criteria. The first was made immediately upon receipt at the labo-

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ratory and the second immediately prior to being returned to the prescribing dentist for the first time. Images were standardized by placing all contents of a particular incoming box on a 30.5 cm x 40.5 cm background. If received articulated, the articulator or mounting rings were disassembled to allow imaging of the occlusal surfaces of the casts. Personal identifiers such as the patient and dentist name were blocked out prior to photographing using blank pieces of paper. The edges of the background were aligned perpendicular to and within the edges of the camera view screen. The second photograph was made using the same technique as the first, except that all contents leaving the laboratory were placed on the background. Frameworks being returned for trial evaluation were placed upon their definitive casts, and processed RPDs without casts were placed with the polished surface facing up. Calibration of laboratories was conducted on 2 separate occasions. After demonstration, discussion, and practice photography, the laboratory technician in charge of photography was observed during a photographic session. Once calibrated, a summary of instructions was left as a reference. A minimum of 1 follow-up visit to each laboratory was conducted during the initial 2 weeks of data collection. Data collection was planned to continue for a minimum of 4 weeks with a minimum sample size goal of 500. The Kennedy Classification with appropriate modification space enumeration was listed according to Applegates modifications.18 Dental implants were considered abutments based on the Kennedy Classification.84 Anterior teeth were considered missing if the prosthesis replaced an anterior tooth. However, third molars, fixed prosthesis pontics, and closed spaces were not considered missing teeth. If an immediate prosthesis was requested, the total number of missing teeth was recorded based on the modified cast. Design input was considered to

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1 Sample images of prescription for acrylic resin framework RPD. have 4 areas of information: major connector, rests, guiding planes, and clasps. Three levels of design input were considered. Multiple design input communicated at least 2 of the 4 basic areas of design through the written prescription. Credit was given if reference was made to a design cast drawing. Minimal design input communicated 1 of the 4 basic areas of design. No written design input communicated 0 of the 4 basic areas of design. Who designed the frameworks in these instances is unknown. The RPD was considered completed if it was returned after processing with all prescribed prosthetic teeth and components attached. An RPD was considered to be a metal framework if the major connector was cast. The RPD was considered to be acrylic resin if the major connector was processed in acrylic resin. The flexible type RPD was determined by the laboratory prescription, by visualization of non-metal clasp assemblies, or by the differing appearance of the base material. An extension of the RPD onto either a prepared rest seat or over the occlusal or incisal surface of a tooth or dental implant, was considered to meet the definition for a rest.83 Lingual plates, minor connectors, and claps arms were not considered rests, unless they covered an actual rest seat or they involved an occlusal or incisal surface. Major connectors were classified according to calibrated definitions. Less frequent designs were listed as other when identified. As images were collected, the first and second photographs of each subject were matched and numbered according to the laboratory routing number (Fig. 1). The first 10 image sets from each laboratory were viewed by 3 of the investigators independently to confirm data collection criteria (Fig. 2). Once calibrated, 10 new image sets from each laboratory were independently reviewed by the investigators. This group of data collection forms was tested using Fishers exact test to confirm reliability and accuracy. In addition, the lead investigator selected and reviewed an additional 10 subject sets. One week later, these same subject sets were again reviewed and the data collection forms were compared using Fishers exact test to confirm repeatability. The lead investigator completed review of the remaining image sets. Once transferred to data collection forms, information was tabulated using a computerized spreadsheet (Microsoft Excel 2010; Microsoft, Redmond, Wash). The totals where then analyzed using descriptive statistics.

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RPD Data Recording Form
1. Dental Laboratory: 2. Laboratory serial number: 3. Lab received: 4. Prescription: a. Design: _________ Multiple design input _________ Minimal design input _________ No written design input b. State of return: 5. Pre-prosthesis information: a. Classification: _________ c. Distribution: a. Type of RPD: Modification spaces: _________ _____ Posterior only _____ Both Ant & Post Yes or No TBD Palatal plate Horseshoe b. Total # of missing teeth: _________ _____ Anterior only Notation: Metal framework Acrylic resin Flexible (Valplast) b. Total # of prosthetic teeth: _________ c. Type of major connector: Max: Mand: A-P strap A-P bar Lingual bar Palatal strap Palatal bar Lingual plate Other (specify): ______________________ Other (specify): ______________________ 6. Prosthesis information: _________ Completed _________ For trial evaluation _____________________ Cast Impression Arch: Maxilla / Mandible [Alginate] [Rubber]

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2 Data recording form.

RESULTS
A total of 1502 images were collected. Images with matched photographs (1146) resulted in a total of 573 complete subject sets. The remaining 356 images were unmatched. Twenty-six of these images were unreadable or requested a reline or repair and were excluded. The other 330 images could be used for determining Kennedy Classification resulting in a total of 903 individual subjects (Table I). The modification spaces for Class II and III subjects are summarized in Tables II and III. Sixty percent of Class I RPDs lacked any modification spaces, while only 21.7% of Class II RPDs lacked the same. Eighty percent of Class III RPDs had either a single modification space or no space indicating a large majority of unilateral or single bilateral edentulous spaces. Overall, there were 377 RPDs fabricated with-

out any modification spaces. Three hundred and twenty-four of the unmatched images (n=897) could be used for the design input data (Table IV). Forty-two percent (377/897) of the total prescriptions did not provide any design information. Of the unmatched images, 319 (n=892) were used to determine the material type (Table V). For every 2 metal frameworks, there was 1 nonmetal framework. Analysis of the 573 matched images demonstrated additional details. Seventy-two percent (414/573) of the RPDs were planned for trial evaluation. Ninety-seven percent (408/421) of the metal frameworks requested return for trial evaluation. According to the images, 515 casts and 58 impressions were received at the laboratory. Nearly 7% (38/573) of RPDs replaced anterior teeth only, 47.3% (271/573) replaced posterior only,

and 46.1% (264/573) replaced both anterior and posterior. Nineteen percent (110/573) of RPDs were missing between 1 to 3 teeth, The mean number of teeth replaced was 6. According to the criteria discussed, 78.7% (451/573) of RPDs were considered to have rests (Table V). Tables VI and VII show the major connector types in the matched sample. Overall, the horseshoe (72.5%) was the most frequently used maxillary major connector, while the lingual plate (59.4%) was the most frequent mandibular. When analyzed separately, 95.3% of non-metal maxillary major connectors were a horseshoe design. Likewise, 91.1% of non-metal mandibular major connectors were a lingual plate. The P-values from Fishers exact test for investigator versus decision, replication of investigator 1, and replication of investigator 2 were .55, .62, and 1 respectively. This indicates

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Table I. Kennedy Classification distribution of RPDs

Arches
Maxilla Mandible Total Percentage

Class I
107 240 347 38.4%

Class II
103 123 226 25.0%

Class III
212 70 282 31.2%

Class IV
35 13 48 5.4%

Total
457 446 903 100%

Table II. Kennedy Classification II distribution with Applegates modification

Arches
Maxilla Mandible Total Percentage

Modification 0
23 26 49 21.7%

Modification 1
41 56 97 42.9%

Modification 2
30 36 66 29.2%

Modification 3+
9 5 14 6.2%

Total
103 123 226 100%

Table III. Kennedy Classification III distribution with Applegates modification

Arches
Maxilla Mandible Total Percentage

Modification 0
97 24 121 42.9%

Modification 1
74 30 104 36.9%

Modification 2
29 16 45 16.0%

Modification 3+
12 0 12 4.2%

Total
212 70 282 100%

Table IV. Prescription information on design input

Overall Design Input
Multiple Minimal None Total

Metal Frame Only Maxilla Mandible %

61.8 8.9 29.3 41.6%

Frequency
380 140 377 897

%
42.4 15.6 42.0 100

Frequency
152 22 72 246/592

Frequency
219 24 103 346/592

%
63.3 6.9 29.8 58.4

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Table V. Frequency of RPDs and use of rest

RPD Type
Metal Acrylic Flexible Total

Total Sample
596 250 46 892 66.8% 28.0% 5.2%

Matched Sample
421 128 24 573 73.3% 22.4% 4.2%

Rest - Present
416 35 0 451 78.7%

Rest - Absent
5 93 24 122 21.3%

Table VI. Distribution of major connectors according to Kennedy Classifications in maxilla

Maxilla
AP strap Palatal strap Palatal plate Horseshoe AP bar Others Total

Class I
8 3 9 55 0 1 76

Class II
8 13 3 39 1 0 64

Class III
8 11 2 97 1 4 123

Class IV
3 0 2 16 0 1 22

Frequency
27 27 16 207 2 6 285

Percentage
9.5 9.5 5.6 72.6 0.7 2.1 100

Table VII. Distribution of major connectors according to Kennedy Classifications in mandible

Mandible
Lingual bar Lingual plate Others Total

Class I
65 96 0 161

Class II
34 46 1 81

Class III
12 25 3 40

Class IV
0 5 1 6

Frequency
111 172 5 288

Percentage
38.6 59.7 1.7 100

no significant difference between investigators or in either repeatability case. Thirty RPDs used attachments, usually extracoronal. One framework was fabricated from gold alloy. Four metal frameworks could not be classified based on the definitions used in this study. Eight unilateral prostheses were also found, 4 of which were made from flexible materials. A single swing-lock RPD was found.

DISCUSSION
Previous research from the United States on this topic has been minimal

and does not use as strict a RPD definition. With 903 RPDs fabricated by 5 laboratories within a 4-month period, for a metropolitan area estimated at 1.7 million people, demonstrates the continued demand for this treatment type. While the Kennedy Class I continued to be the most common RPD configuration, the difference between classes was reduced.24,40-42 Class III proved more common than in any previous analysis. Inclusion of acrylic resin RPDs, reduced rates of tooth loss, and changes in therapeutic strategies for dental disease are all possible explanations. Table VIII com-

pares the current data overall, and with metal frameworks only, to previous analyses. While the nearly even number of maxillary versus mandibular RPDs could be seen as a positive, the increased incidence of maxillary Class III (46.4%) compared to Curtis et al42 (23%) may signal a lack of progress towards controlling dental disease or the patients ability to afford fixed prostheses. The reduced incidence of Class IV RPDs (5.4%) and RPDs replacing anterior teeth only (6.6%) may demonstrate rejection of removable prostheses in favor of fixed prostheses for improved esthetics.

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When only metal RPDs were considered, Class I was the most common followed in order by Class II, III, and then IV. This is similar to previous studies.24,42 A method similar to Allen and Lynch75 was used to collect prescription input. Other methods left room for interpretation of drawings, writing, or the various prescription forms. This method identified if minimal information was given and still demonstrated how little input many dentists have upon the RPD design. It must also be noted that the RPDs from the laboratory servicing the dental school had a bias towards multiple design input. If only private practice RPDs were analyzed, the rate of no input increased. This confirms previous findings of the lack of prescribing dentist input,27,28,49,70-74 as well as varying RPD design philosophies.75-78 This study revealed that 66.8% of all RPDs were fabricated with cast metal frameworks. The remaining 33.2% were fabricated with non-metal major connectors. The incidence of non-metal RPDs found in the current study is higher than the 5% found by wall and Taylor43 using similar inclusion/exclusion criteria. However, this number is less than that reported by several recent international studies.46,48,49 The standard design feature meant to minimize soft tissue damage from RPDs is the rest. Despite a broad definition, only 78.7% of RPDs used any rest. Therefore, 1 in 5 RPDs were completely tissue-borne prostheses. In addition, many RPDs that received credit for a rest were lacking in adequate support due to design and modification shortcomings. When non-metal RPDs were evaluated, only 23% were considered to have a rest. This may explain the frequent observation of periodontal tissue damage with these prostheses and RPDs in general. With the amount of advertising promoting flexible RPD frameworks, it was somewhat surprising to find only 5.2% of these within the sample. None of these RPDs were considered to have a rest. Perhaps this was due to the manufacturer claims of superior stability and retention of frameworks made from these materials. The authors were unable to locate any peer-reviewed or manufacturer-sponsored research in regards to the clinical performance of these materials. The majority of maxillary major connectors in this study (72.5%) were of the horseshoe design. Only 27 (9.5%) palatal straps were found. This is disappointing considering it was shown to be the most comfortable maxillary major connector and generally covered the least amount of gingival tissue.85 wall and Taylor43 found 56% of maxillary major connectors to be horseshoes, while Curtis et al42 did not find any. This demonstrates the necessity to define clearly each major connector type as well as potential regional differences in RPD design. It is believed that the definitions used were clear, easy to use, and based upon the prosthodontic consensus despite room for debate. The definition for a lingual bar was a mandibular major connector located lingual to the dental arch with visible gingival tissue lingual to any anterior tooth. Essentially, a lingual plate was required to cover the gingiva lingual to all remaining anterior teeth. Despite this, a majority of lingual plate major connectors was still found (59.4%). This is greater than in other studies.42,43 The large majority of horseshoe and lingual plate major connectors was likely due to nonmetal RPD strength requirements. Bulky, wide versions of the horseshoe and lingual plate were selected nearly all of the time when non-metal major connectors were used. However, when only metal frameworks were considered, the majority were horseshoes and lingual plates. Despite calibration, high laboratory volumes and study deadline were the likely reasons for missing the second image. In a few instances, it was noticed that the incoming photograph was made after completion of the RPD. This was an issue for some criteria since the laboratory may have

Volume 106 Issue 1

done a design drawing or made a cast prior to the initial image. One solution was to have the research investigators collect the images themselves. This was not considered logistically possible when using multiple laboratories for an extended time period. While a single image was adequate for most data, several questions required both images. Considering this, it was understood that the 330 accepted but unmatched images provided reliable and usable information. Only RPDs for patients already in treatment were tabulated. Therefore, these numbers do not reflect the prevalence of RPDs or tooth distribution within the general population. However, by including all RPD types a broad picture of the partially edentulous population receiving this type of care was analyzed. Overall, the encountered limitations proved minor considering the large number of RPDs collected and the simplistic nature of the critical data analyzed. The findings support the need for continued periodic regionally specific analysis. In addition, clinicians, insurers, and public health professionals in the state of Wisconsin should be mindful of the quality of removable prosthodontic care being delivered in this region. Considering how frequently acrylic resin and flexible type RPDs are used in the general community, it is disappointing that no clinical studies for these treatments could be found for patients in the United States.

CONCLUSIONS
This study evaluated images of 903 RPDs made at 5 dental laboratories located in eastern Wisconsin. The Kennedy Classification according to Applegates modification, material, and major connector type, as well as other information was identified. The following conclusions were drawn from the study: 1. RPDs of all types continue to be a common treatment type with equal incidence in the maxillary and mandibular arch.

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2. Kennedy Class I RPDs remain the most common (38.4%) with Class III RPDs demonstrating an increased incidence (31.2%) at the expense of the other classifications. 3. Dentist input into RPD designs and fabrication continues to be minimal. 4. The incidence of non-metal frameworks (33.2%) in this region of the U.S. is higher than previously reported. 5. There is a high incidence of RPDs lacking any tooth support (21.3%) in this region. 6. An increased incidence of the bulkiest major connectors was seen in this sample when compared to previous data.
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53.Zlataric DK, Celebic A, Valentic-Peruzovic M. The Effect of Removable Partial dentures on Periodontal Health of Abutment and Non-Abutment Teeth. J Periodontol 2002;73:137-44. 54.Tuominen R, Ranta K, Paunio I. Wearing of removable partial dentures in relation to periodontal pockets. J Oral Rehab 1989;16:119-26. 55.Carlsson GE, Hedegrd B, Koivumaa KK. Studies in partial dental prosthesis, III. A longitudinal study of mandibular partial dentures with double extension saddles. Acta Odontol Scand 1962;20:95-119. 56.Carlsson GE, Hedegrd B, Koivumaa KK. Studies in partial dental prosthesis. IV. Final results of a 4-year longitudinal investigation of dentogingivally supported partial dentures. Acta Odont Scand 1965;23:443-72. 57.Carlsson GE, Hedegrd B, Koivumaa KK. Late results of treatment with partial dentures. An investigation by questionnaire and clinical examination 13 years after treatment. J Oral Rehabil 1976;3:267-72. 58.Bergman B, Hugoson A, Olsson CO. Caries, periodontal and prosthetic findings in patients with removable partial dentures: A ten-year longitudinal study. J Prosthet Dent 1982;48:506-14. 59.Bergman B, Hugoson A, Olsson CO. A 25 year longitudinal study of patients treated with removable partial dentures. J Oral Rehabil 1995;22:595-9. 60.Bissada NF, Ibrahim SI, Brasoum WM. Gingival response to various types of removable partial dentures. J Periodontol 1974;45:651-9. 61.Stern MA, Brudvik JS, Frank RP. Clinical evaluation of removable partial denture rest seat adaptation. J Prosthet Dent 1985;53:658-62. 62.Dunham D, Brudvik JS, Morris WJ, Plummer KD, Cameron SM. A clinical investigation of the fit of removable partial dental prosthesis clasp assemblies. J Prosthet Dent 2006;95:323-6. 63.Firtell DN, Muncheryan AM, Green AJ. Laboratory accuracy in casting removable partial denture frameworks. J Prosthet Dent 1985;54:856-62. 64.Brudvik JS, Reimers D. The tooth-removable partial denture interface. J Prosthet Dent 1992;68:924-7. 65.Keltjens HM, Mulder J, Kyser AF, Creugers NH. Fit of direct retainers in removable partial dentures after 8 years of use. J Oral Rehabil 1997;24:138-42. 66.Akers PE. A new and simplified method of partial denture prosthesis. J Am Dent Assoc 1925;12:711-7. 67.van Minden F. Fitting, placing, and maintenance of cast partial dentures. J Amer Dent Assoc 1931;18:442-9. 68.Lynch CD, Allen PF. Why do dentists struggle with removable partial denture design? An assessment of financial and educational issues. Br Dent J 2006;200:277-81. 69.Taylor TD, Aquilino SA, Matthews AC, Logan NS. Prosthodontic survey. Part II: Removable prosthodontic curriculum survey. J Prosthet Dent 1984;52:747-9. 70.Sykora O, Calikkocaoglu S. Maxillary removable partial denture designs by commercial dental laboratories. J Prosthet Dent 1970;23:633-40. 71.McCracken WL. Survey of partial denture designs by commercial dental laboratories. J Prosthet Dent 1962;12:1089-110. 72.Frantz WR. Variability in dentists designs of a removable maxillary partial denture. J Prosthet Dent 1973;29:172-82. 73.Frantz WR. Variations in a removable maxillary partial denture design by dentists. J Prosthet Dent 1975;34:625-33. 74.Schwarz WD, Barsby MJ. Design of partial dentures in dental practice. J Dent 1978;6:166-70. 75.Lynch CD, Allen PF. Quality of written prescriptions and master impressions for fixed and removable prosthodontics: a comparative study. Br Dent J 2005;198:17-20. 76.Taylor TD, Matthews AC, Aquilino SA, Logan NS. Prosthodontic survey. Part I: removable prosthodontic laboratory survey. J Prosthet Dent 1984;52:598-601. 77.Cotmore JM, Mingledorf EB, Pomerantz JM, Grasso JE. Removable partial denture survey: clinical practice today. J Prosthet Dent 1983;49:321-7.

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78.Hardy F, Stuart LM. A critique of materials submitted by dentists to dental laboratories for the fabrication of removable partial dentures. Quintessence Dent Technol 1983;7:93-5. 79.Burns DR, Ward JE, Nance GL. Removable partial denture design and fabrication survey of the prosthodontic specialist. J Prosthet Dent 1989;62:303-7. 80.Hummel SK, Wilson MA, Marker VA, Nunn ME. Quality of removable partial dentures worn by the adult U.S. population. J Prosthet Dent 2002;88:37-43. 81.Frank RP, Brudvik JS, Leroux B, Milgrom P, Hawkins N. Relationship between the standards of removable partial denture construction, clinical acceptability, and patient satisfaction. J Prosthet Dent 2000;83:521-7. 82.Frank RP, Milgrom P, Leroux BG, Hawkins NR. Treatment outcomes with mandibular removable partial dentures: a populationbased study of patient satisfaction. J Prosthet Dent 1998;80:36-45. 83.The Academy of Prosthodontics. The Glossary of Prosthodontic Terms. J Prosthet Dent 2005;94:10-92. 84.Al-Johany SS, Andres C. ICK classification system for partially edentulous arches. J Prosthodont. 2008;17:502-7. 85.Campbell LD. Subjective reactions to major connector designs for removable partial dentures. J Prosthet Dent 1977;37:507-16. Corresponding author: Dr Michael P. Waliszewski 13780 W. Greenfield Ave #780 Brookfield, WI 53005 Fax: 262-782-7720 Email: michael.waliszewski@mu.edu Acknowledgments The authors thank all participating laboratories, as well as Cole Stockheimer, a 4th year dental student, for assistance with data collection. Copyright 2011 by the Editorial Council for The Journal of Prosthetic Dentistry.

The Journal of Prosthetic Dentistry

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