VERIFIABLE CPD PAPER PRACTICE

Unilateral removable partial dentures

W. A. Goodall,*1 A. C. Greer2 and N. Martin3

In brief
Explores the risks associated with Reassures readers that unilateral RPDs Discusses important design and Provides a succinct summary of the
unilateral RPDs and emphasises how to are an acceptable and achievable material considerations. available options for replacing missing
avoid or minimise those risks. option. teeth.

Removable partial dentures (RPDs) are widely used to replace missing teeth in order to restore both function and aesthetics
for the partially dentate patient. Conventional RPD design is frequently bilateral and consists of a major connector that
bridges both sides of the arch. Some patients cannot and will not tolerate such an extensive appliance. For these patients,
bridgework may not be a predictable option and it is not always possible to provide implant-retained restorations.
This article presents unilateral RPDs as a potential treatment modality for such patients and explores indications and
contraindications for their use, including factors relating to patient history, clinical presentation and patient wishes. Through
case examples, design, material and fabrication considerations will be discussed. While their use is not widespread, there are
a number of patients who benefit from the provision of unilateral RPDs. They are a useful treatment to have in the clinician’s
armamentarium, but a highly-skilled dental team and a specific patient presentation is required in order for them to be a
reasonable and predictable prosthetic option.

Introduction Partial edentulism problems Treatment options

Partial edentulism is a growing issue.1,2 In 2009,
6% of adults in the UK were fully edentulous
and 40% of dentate adults in the UK had
fewer than 27 natural teeth.3 There were 14%
who had fewer than 21 natural teeth, which
is believed to be the minimum requirement
for a functional dentition.3 In the UK there is
an ageing population, who are retaining their
natural teeth for longer,3,4 combined with
a ‘heavy-metal generation’ who have many
heavily-restored teeth.5 It may not be possible
to maintain these heavily-restored teeth long
term. Therefore dentists are likely to become
more frequently involved in the management
of the partially dentate patient.
1
The Dental Practice, New Street, Dinnington, S25 2EX; 2De-
partment of Restorative Dentistry, Charles Clifford Dental
Hospital, 76 Wellesley Road, Sheffield, S10 2SZ; 3Academic
Unit of Restorative Dentistry, School of Clinical Dentistry,
Claremont Crescent, University of Sheffield, S10 2TA
*Correspondence to: Mr Wayne Goodall
Email: waynegoodall_6@hotmail.com
Refereed Paper. Accepted 14 November 2016
DOI: 10.1038/sj.bdj.2017.70
©
British Dental Journal 2017; 222: 79-84
Functional
Missing teeth can lead to reduced masticatory
efficiency.2 Loss of teeth may also cause issues
with speech. Dental problems can include over-
eruption, drifting and loss of space.6 It has been
suggested that a loss of posterior teeth may
result in an unfavourable distribution of occlusal
loads, occlusal interferences and periodontal
breakdown.6 A systematic review by Van’t Spijker
et al.7 found no evidence suggesting that loss of
posterior support leads to increased attrition.
Aesthetic
The degree of impact on appearance depends
on both the site and number of missing teeth,
along with the attitude of the patient. There is
a social stigma that comes with a loss of visible
teeth, especially anteriorly.2 Decreased occlusal
face height and a lack of lip support can also
change facial features.2
Psycho-social
Dental health is of great concern to many
patients and losing teeth can have a detrimen-
tal impact on a person’s self-esteem.4
Some patients are accepting of their edentu-
lous spaces and do not want or need restora-
tions. Others have active disease and poor oral
hygiene, which precludes them from some
treatment options. Those who are suitable and
desire replacement often have multiple options.
Fixed prostheses (bridges) tend to be limited
to short spans, and patients with acceptable
abutments and suitable occlusal schemes.
Conventional bridgework requires extensive
preparation of abutment teeth and evidence
suggests that 29.2% of these teeth will lose
vitality after ten years.8 Resin-bonded bridges
(RBBs) offer a less destructive, reversible alter-
native, with minimal or no tooth preparation.9
RBBs have higher failure rates than conven-
tional bridges, but tend to fail less catastrophi-
cally.10 Metal-framed RBBs have an estimated
survival rate of 80.8% at five years.9
Implants can be used to retain a single
crown or larger prostheses. These are limited to
patients with a clinical presentation appropriate
for implant placement. Certain patient factors
are associated with poorer outcomes with
implants including smoking, poorly-controlled

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diabetes, bisphosphonate use and radiotherapy
to the jaws.11 Patients need to be willing to
undergo a surgical procedure and be able
to meet the costs of treatment. Walton and
MacEntee’s study found that 36% of edentu-
lous patients refused implants to retain lower
dentures, even when offered at no financial
cost to the patient.12
Orthodontic space closure may be a pos-
sibility but spaces are often unsuitable for
this method due to their size, position and
asymmetry.
Few contraindications exist for removable
partial dentures (RPDs); these include intol-
erance of major connectors and patients with
psychiatric disorders or repeated loss of con-
sciousness. RPDs carry a risk of increasing
plaque accumulation and therefore increase
the risk of caries and periodontal disease.13,14
If designed appropriately, conventional RPDs
can be an effective way to restore large and/
or multiple, bilateral edentulous spaces at a
reasonable cost.1,14 It is recognised that some
patients may struggle to tolerate the bulk and
wide coverage of such an appliance. In these
cases, where a single bounded saddle exists and
implants and bridges are neither suitable nor
acceptable options for the patient, an alterna-
tive prosthetic option may be a unilateral RPD.
The unilateral RPD
The potential advantages of a small unilateral
design over a conventional RPD include:
• Avoidance of palatal coverage and the need
for a major connector.13,15 Lesser impact
on speech, gag reflex and generally more
tolerable
• Lower biological cost – fewer surfaces for
plaque accumulation, candida colonisa-
tion and fewer natural teeth recruited as
abutments
• Decreased bulk
• Does not feel like a conventional denture.
Potential for less stigma and improved
self-confidence.
The disadvantages and limitations of unilat-
eral RPDs include:
• Rarely suitable for restoring masticatory
function, as they may transmit damaging
lateral forces to abutment teeth and oral
tissues if placed in occlusal function during
excursive movements. This is due to the
lack of cross-arch stabilisation, which may
also lead to easy displacement13
• Restricted to bounded saddles
• Complex designs require more mainte-
nance and can restrict patients to certain
practices, laboratories and hospitals
• Require good manual dexterity to take in
and out of the mouth13
• May require preparation of adjacent teeth
to provide guide planes, rest seats and
undercuts in order to ensure good retention
and stability
• Risk of inhalation and swallowing.13,16
Smaller denture designs are more likely
to be swallowed or inhaled.16 These events
can have serious consequences and therefore
other prosthetic options must be appropriately
considered and discounted before a unilateral
RPD is provided. Justifications for choosing
this prosthesis over others must be reason-
able and recorded, as otherwise an adverse
incident involving the denture could leave the
dentist undefendable.16 The enhanced stability
provided by a bilateral RPD, due to cross-arch
bracing,2 means this design should be priori-
tised over a unilateral design where possible
to minimise the impact of functional forces on
the oral tissues and reduce the risk of inhala-
tion or swallowing.
When to provide a unilateral RPD
There is currently a paucity of literature
relating to the provision of unilateral RPDs and
many clinicians do not recommend their use.
Davenport et al.17 asked a group of prostho-
dontists and found that 50% agreed with the
statement ‘bounded edentulous areas should
not be restored with a unilateral denture’. The
authors believe these prostheses provide a
viable option for the replacement of missing
teeth, but only in specific, appropriate situa-
tions. They are potentially advantageous for
single, shorter-span, bounded saddles,13,15,17
but it is not always necessary to restore these
bounded saddles and the patient should also
consider the benefits of not doing so. Eighty-
eight percent of the prosthodontists consulted
by Davenport et  al.17 disagreed with the
statement that ‘bounded edentulous saddles
should always be restored’.
Unilateral RPDs are a useful alternative when
abutments are unsuitable or the span is too long
for a bridge, implant-retained restorations are
not an option and a conventional RPD is not
acceptable for the patient. The patient’s concern
must be primarily aesthetic and space must be
available to allow artificial teeth to be placed out
of occlusal contact during excursive movements.
The lack of cross-arch stabilisation means
unilateral RPDs should be limited to areas
where occlusal forces are lesser. Flatter alveolar
ridges and more compressible mucosa would
be potential contraindications, as these would
limit stability further,18 even in a well-designed,
tooth-supported prosthesis. The patient must
have good manual dexterity and no contrain-
dicating medical or social history for a unilat-
eral RPD. Contraindications would include a
history of psychiatric conditions, repeated loss
of consciousness or alcohol and drug intoxica-
tion; these factors appear to increase the risk
of inhalation or swallowing of foreign bodies.16
Accidental ingestion or inhalation of foreign
bodies is more common in the very young or
the elderly,19 therefore unilateral RPDs are best
avoided in these age groups. These events are
generally uncommon however.16
It is the authors’ opinion that maxillary
unilateral RPDs are more successful than
mandibular unilateral RPDs. Patients tend to
prioritise restoring maxillary spaces and, due
to the functional limitations of these appli-
ances, the authors would not recommend their
use in the lower arch.
Design and material options
The three main base material options are:
• Acrylic
• Cobalt-Chrome (Co-Cr)
• Nylon-based (flexible).
Acrylic unilateral RPDs gain their support
from the mucosa. They can, however, be
constructed to gain additional tooth support
by incorporating pre-formed (stainless steel)
occlusal rests.14 Stainless steel clasps may also
be added to improve retention.
Cobalt-Chrome designs are tooth-borne and
may be single-part or sectional. A sectional
denture is composed of two or more parts,
each utilising different paths of insertion.1
Sectional dentures have the advantage of
combining intra-orally to engage opposing
undercuts and aid retention via a wedging
effect.1,20 Locking components, such as bolts,
can keep the parts together and increase the
security of a sectional denture.17 Retention for
both types of Co-Cr design is typically gained
from clasps that engage the undercut surfaces
of teeth.14 These may be cast in Co-Cr as part
of the metal substructure or added later if other
materials are used such as gold, stainless steel
or polyoxymethylene. Precision attachments
are an alternative to clasps for achieving direct

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Table 1 Advantages and disadvantages of the various types of unilateral RPD (cnt on p82)

Acrylic

Economic, quickly fabricated and little technical ability required in design or construction

Ease of insertion and removal

Advantages
May be easily added to in the case of additional tooth loss

No preparation of adjacent teeth required

Limited retention and stability

Increased risk of inhalation/swallowing and difficulty locating should this occur due to lack of radio-opacity. For this reason alone,
the provision of small unilateral dentures made of plastic material may be difficult to defend in front of the GDC or a court16
Disadvantages
May act as a gum stripper and accelerate alveolar bone resorption

Requires greater mucosal coverage to gain retention – more bulk, greater risk of plaque accumulation and candida colonisation

Mechanically weak and more prone to fracture

Co-Cr

Tooth-borne and therefore less detrimental to soft tissues

Rigid and strong; can be made more hygienic and less bulky
Advantages
Greater retention and stability from direct retainers eg clasps or precision attachments

Radio-opaque

Often requires preparation of abutment teeth (more invasive)

Abutment teeth need to be sound – healthy periodontium, ideally vital

Disadvantages
More expensive than non-metal options

Clasps may interfere in the aesthetic zone and cause direct trauma to soft tissues

Sectional Co-Cr

Allows opposing undercuts to be engaged to improve retention, eliminate food packing and avoid black triangles between the teeth and
denture base1,20,24
Advantages
May reduce the amount of tooth preparation required and need for clasping (improving aesthetics)1,20

Excellent stability due to the close contact with the undercuts of abutment teeth1,20

Higher cost

High clinical and technical skill required to design and fabricate1

Disadvantages
Requires regular maintenance as components require regular re-activation.1 Therefore restricts patients to the dental surgeries, hospitals
and laboratories who manage these appliances

Requires the patient to have excellent manual dexterity1

Co-Cr with precision attachments

Greater aesthetics as clasps are not required21

Advantages
Improved retention, support and stability21

Higher cost21

More destructive as abutment teeth require preparation.21 Often require crowns or copings to house the attachments

Magnets are less retentive and less stable

Specific space requirements for attachments21,25

Disadvantages
High clinical and technical skill required to design and fabricate

Certain attachments require regular maintenance.25 This restricts patients to the dental surgeries, hospitals and laboratories who manage
these appliances

Requires the patient to have good manual dexterity25

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Table 1 Advantages and disadvantages of the various types of unilateral RPD (cnt from p81)

Flexible nylon dentures

Good aesthetics.23,26 Able to hide recession defects in adjacent teeth with flexible, gingival-coloured clasp arms23

Resistant to fracture23,26

Advantages Requires no tooth preparation23

Can be fabricated quite thin26

Easy to fabricate – requires only three clinical appointments

Not suitable for flabby ridges or less than 4 mm of inter-arch space23

Unhygienic due to proximity to gingival margins and inability to brush the appliance without causing scratches23

Difficult to repair and re-line.23 Additions are rarely possible

Denture teeth are only retained mechanically (via diatorics) and tooth loss can be an issue26
Disadvantages
Aesthetics deteriorate quickly due to ease of staining and scratching23

Radiolucent and therefore difficult to locate if inhaled or swallowed. For this reason alone, the provision of small unilateral dentures made of
plastic material may be difficult to defend in front of the GDC or a court16

Loss of elasticity over time, becoming more rigid

retention, but their use is not commonplace.21
Precision attachments are two-part connec-
tors; one part is connected to the tooth, root
or implant and the other to a prosthesis.22
Defined according to the tooth- or implant-
connected element, precision attachments may
be intra-coronal (embedded in a restoration),
extra-coronal (extending outside the contour
of the tooth) or radicular (connected to a root
preparation).21 Examples include rod and tube
designs, magnets and stud-type attachments.
Nylon-based RPDs are mucosa-borne. They
obtain their retention via clasps which are an
extension of the denture base material.23 The
nylon resin allows the denture to be flexible,
with enough elasticity to be manipulated into
the edentulous space.
Table  1 summarises the benefits and
drawbacks of each option.
Clinical cases
The following two cases exemplify the use of
unilateral RPDs to restore a single edentulous
bounded saddle. Both patients were treated in
the Charles Clifford Dental Hospital, Sheffield
Teaching Hospitals NHS Foundation Trust.
Case 1
This 57-year-old female was unhappy with
the appearance of the edentulous area of
teeth 23 and 24 and requested replacement.
Traumatic failure of a fixed-fixed bridge
22 to 24 led to sectioning of this bridge and
the extraction of tooth 24. Subsequently the
22 became non-vital and was successfully
root-treated. The patient reported a history
of unsuccessful partial dentures before the
placement of this bridge.
Following stabilisation of her periodontal
condition, the patient had excellent plaque
control. Her medical history was not a con-
traindication to any prosthesis.
On clinical examination, the patient had
a porcelain-fused-to-metal (PFM) crown
tooth  22 (previous bridge retainer through
which endodontic access had been gained)
and the tooth 25  was un-restored (Figs  1a
and 1b). The patient had group function on
lateral excursions and anterior guidance in
protrusion.
The options for restoring the edentulous
space were discussed with the patient at length.
An implant-retained bridge was proposed but
financial considerations made this option
unfeasible. Conventional RPDs were rejected
as the patient had previously been unable to
tolerate any palatal coverage. A bridge was
deemed unsuitable due to the length of span,
the un-restored tooth 25  and root-treated
tooth 22.  A Co-Cr uni­lateral RPD was the
other option and this was the treatment of
choice.
The compromised tooth 22 crown was
replaced with a milled PFM crown to be inte-
grated with the RPD design (Fig. 1c). The tooth
25 had a mesial rest seat and palatal guide plane
prepared, along with the addition of composite
buccally to provide an undercut for engaging
a retentive clasp. The use of composite
restorations to enhance RPD retention has
been suggested by Davenport et al.27
The tooth 22 crown was designed with a
palatal rest seat and guide plane parallel to the
mesial surface of tooth 25, in order to provide
a single, altered path of insertion. A precision
attachment on the tooth 22 crown was con-
sidered to avoid using an anterior clasp, but
there was insufficient inter-occlusal space to
allow for housing an intra-coronal attachment.
Additionally, an extra-coronal attachment
would have been irritating and clearly visible
when the patient was not wearing the RPD.
One benefit of using a removable appliance
is that it is reversible, therefore the tooth 22
crown was designed considering when the
patient was and was not wearing the RPD.
The unilateral Co-Cr RPD was designed
with an occlusally-approaching clasp, mesial
rest and palatal reciprocating plate on tooth
25 (Fig. 1d). The design included a palatal plate
and rest to engage the milled aspect of the tooth
22 crown and a gingivally-approaching I-bar
clasp anteriorly. As the tip would be visible
in the smile-line, this clasp was fabricated in
gold at the patient’s request. A tooth-coloured,
polyoxymethylene I-bar was considered for
aesthetics but the patient preferred the appear-
ance of gold; polyoxymethylene clasps tend to
be bulkier.29
The casts were mounted on a semi-adjust-
able articulator and this was used throughout
the fabrication of the crown and RPD. The
patient was very satisfied with the final result
(Figs 1e–g).

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Case 2
This 41-year-old female had a history of poor
tolerance of conventional RPDs with palatal
coverage. The edentulous space of teeth 14,
15  and 16  was of aesthetic concern to the
patient.
The patient had good plaque control,
a moderately-restored dentition and was
partially edentulous (Fig.  2a). Her medical
history was not a contraindication to any
forms of treatment to replace these missing
teeth. The bounded saddle in the upper right
quadrant was too long to predict success with
fixed bridgework and preparation of the un-
restored tooth 13 would have been destructive.
The patient was not receptive to provision of an
implant-retained prosthesis. The treatment of
choice was a Co-Cr unilateral RPD.

Fig. 1 (a & b) Case 1: Pre-treatment views showing the edentulous space of teeth 23 and
24; (c) Case 1: Milled PFM crown cemented on tooth 22 (designed specifically to aid support,
retention and stability of the unilateral RPD provided); (d) Case 1: The Co-Cr unilateral RPD
provided; (e-g) Case 1: Post-treatment views showing the unilateral RPD in situ

Fig. 2 (a) Case 2: Pre-treatment view showing the edentulous space of teeth 14, 15 and 16; (b-d) Case 2: Post-treatment views showing
the Co-Cr unilateral RPD in situ and the integrated restorative elements; (e) Case 2: The Co-Cr unilateral RPD provided; (f) Case 2: Post-
treatment extra-oral view with the unilateral RPD in situ

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The tooth 17  was heavily-restored with
composite and amalgam. These restorations
were replaced with a composite core build-up
and a full gold crown. The crown was designed
with sufficient buccal undercut to engage a clasp
tip. A composite addition was also made labially
to tooth 13  to aid retention via a gingivally-
approaching clasp, which was provided in Co-Cr
due to the shallow undercut available and need
for a stiff clasp to maximise retention (Figs 2b–d).
An anterior precision attachment may have been
more aesthetic, but it would likely have involved
irreversible preparation of the virgin tooth 13.
A Co-Cr unilateral RPD was provided
bearing two denture teeth. This was designed
with an occlusally-approaching clasp, recipro-
cating arm and occlusal rest on tooth 17, along
with a cingulum rest and gingivally-approach-
ing clasp on tooth 13 (Fig. 2e). The patient was
delighted with the final result (Fig. 2f).
Recommendations for success
All other prosthetic options must be consid-
ered and deemed unsuitable before a unilateral
RPD is offered. Even then, a critical element
when deciding if a unilateral RPD is appro-
priate is to consider the individual patient.
Suitable candidates are well-motivated and
have good oral hygiene. 13 Good manual
dexterity is also necessary,1,13 especially if con-
sidering a sectional design. Evidence suggests
that very young or elderly patients and those
with a history of psychiatric conditions,
repeated loss of consciousness or alcohol and
drug intoxication are more likely to swallow or
inhale foreign bodies.16 Therefore it is best to
avoid unilateral RPDs for such patients.
The authors would only recommend Cobalt-
Chrome unilateral RPDs. These are tooth-sup-
ported and the metal framework is rigid and
strong, providing stability and resistance to
deformation. The metalwork allows adequate
strength to be obtained from a thin cross-sec-
tion of material; this reduces bulk and the need
for wide gingival coverage, which could cause
difficulties with plaque control and soft tissue
trauma. Effective, direct retention is essential
and retentive components must be designed
carefully. Abutment teeth should have good
periodontal support, sufficient clinical crown
length and adequate undercut.17 Davenport
et  al. 17 suggest that conventional clasps,
magnets and attachments relying on frictional
84
retention may be insufficiently reliable for
unilateral RPDs. The authors have found that
clasps can be reliable if correctly designed;
guide planes and reciprocating elements are
essential to ensure effective retention.18 Stability
should be maximised by incorporating bracing
components and extending the framework and
flanges to cover as much vertical height of the
alveolar ridge as possible. Effective retention
and stability reduces the risk of inhalation
and swallowing and the radio-opaque nature
of the Co-Cr would make the appliance easily
identifiable should this problem occur.
Deciding on a single-part or sectional design
depends on the angulations of abutment teeth.
If opposing undercuts are significant then the
potential for utilising these for retention makes
a sectional design more attractive.1 However, if
opposing undercuts are less significant, it may
be more prudent to modify the teeth to provide
parallel guide planes and use a single-part
RPD. If the abutment teeth have no opposing
undercuts, a single-part RPD would be more
appropriate. Designs should be kept as simple as
possible to promote continued oral health, with
clearance of gingival margins where practical.28
The patient must be made aware of the need
for regular follow-up and maintenance of such
appliances. It is essential that any faults in the
prosthesis are identified and corrected early,
as retentive elements may lose some of their
efficiency over time.29 A loss of retention in
a unilateral RPD could lead to inhalation or
swallowing and cause serious health problems
including asphyxiation, tissue perforation and
infections.16 For this reason, the dentist and
dental technician must be highly competent
in partial denture design and fabrication before
providing unilateral RPDs. For example, if a
clasp is designed incorrectly and the propor-
tional limit of the material exceeded during
insertion and removal, permanent clasp dis-
tortion and a loss of retention could occur.29
Unilateral RPDs can be a safe, effective and
predictable option for replacing missing teeth,
but careful case selection, appropriate design and
high-quality fabrication are essentials for success.
1. Karir N, Hindocha V, Walmsley A D. Sectional dentures
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Mosby Inc, 2005.
3. Fuller E, Steele J, Watt R, Nuttall N. Oral health and
function – a report from the Adult Dental Health Survey
2009. The Health and Social Care Information Centre,
2011.
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