Tooth-supported complete dentures: Description and

clinical evaluation of a simplified technique

Robert M. Morrow, lieutenant Colonel, USAF (DC),* Joseph M. Powell,

Major, USAF (DC),** William S. Jameson, lieutenant Colonel, USAF
(DC),*** Leonard G. Jewson, lieutenant Colonel, USAF (DC),**** and
Kenneth D. Rudd, Colonel, USAF (DC)*****

Wilford Hall USAF Hospital, Aerospace Medical Division (AFSC),

Lackland Air Force Base, Texas

I t has been estimated1 that twenty million Americans are totally edentulous and
ten million more are edentulous in one arch. Nearly two thirds of all Americans
over the age of 75 years are edentulous. In one study* of the reasons for removal of
teeth in an oral surgery practice among middle-income families, 20 per cent were
clinically sound teeth but removed for “prosthetic” reasons. These statistics indicate
a need for increased efforts in preventive dentistry by all members of the dental
profession in order to significantly reduce the number of persons who become
edentulous. Patients with many teeth that are hopeless are often candidates for com-
plete dentures. They may, however, have 1, 2, or 3 retainable teeth. Frequently,
these few teeth are removed because they are considered inadequate to support
partial dentures, and complete dentures are constructed. However, such patients
can benefit from tooth-supported complete dentures.

TOOTH-SUPPORTED COMPLETE DENTURES

The variety of methods3-5 for using natural teeth to support and stabilize com-
plete dentures indicates an awareness of the need for effective techniques that will
permit the retention of teeth inadequate to support the usual prostheses.
The techniques using natural teeth vary in complexity. In some instances, the
denture is constructed for insertion directly onto the remaining recontoured, but
unprotected, natural teeth and, undoubtedly, many are successful. The disadvantages

Read before the Academy of Denture Prosthetics in Honolulu, Hawaii.

*Training Officer and Research Project Officer, Department of Prosthodontics.
**Assistant Chief, Area Dental Laboratory.
***Assistant Chairman, Department of Prosthodontics.
****Staff, Department cJf Periodontics.
*****Consultant in Prosthodontics to the Surgeon, USAFE.

414
Volume 22 Tooth-supported complete dentures 415
Number 4

of this technique include the susceptibility of the unprotected abutment teeth to

caries, the possibility of wear between the denture and abutment teeth, and e\pr-n
the possibility of denture breakage while in service.
Gold copings cemented on prepared abutment teeth prior to denture construe,-
tion provide increased protection against caries and can contribute to an impro\4
esthetic result. The preparation reduces the size of the abutment teeth and enabks
the replacements on the denture to approximate the size and contour of the ulj-
prepared teeth. Successful endodontic therapy for abutment teeth further aids m
achieving this objective, and facilitates the development of improved clinical crown /
root ratios. As with unprepared teeth, complete dentures constructed for insertion
over abutment copings are subject to wear between the gold coping and the acrylic
resin of the denture base, with a resultant shorter service life.
Milleti advocates the use of gold copings on abutment teeth and corresponding
gold copings within the completed denture. His method provides caries protection
and metal-to-metal bearing surfaces between the denture and abutment copings.
The effects are the minimizing of wear between abutment copings and the dentun:,
reduction in breakage, and more effective stress distribution to supporting structures.
In a modification of this technique, a cast metal base, rather than individual
denture copings, is incorporated within the denture. G Both methods have recei\.rd
extensive use at our facility with excellent results.

DISADVANTAGES OF TOOTH-SUPPORTED COMPLETE DENTURES

Disadvantages of both methods are the time requirement and the increased cost
associated with fabricating cast gold denture copings, or cast gold or chrome-cobalt
alloy denture bases. In addition, the flasking and packing procedures are more
complicated than for routine complete dentures, and any subsequent rebasing or
relining of the denture is more difficult. Increased cost and complex laboratory
requirements often are negative influences on the use of a given procedure, regarrl-
less of its clinical validity. The purpose of this project was to evaluate eclectically
the current techniques for constructing tooth-supported complete dentures and To
attempt to simplify the clinical and laboratory procedures incident to the technique.
A clinical study involving the objective determination of pocket depths and rhe
horizontal mobility of abutments was included to aid in evaluation.

METHODS AND MATERIALS

Careful evaluation of the advantages of placing gold copings over prepared
endodontically treated teeth resulted in their use throughout the study, but with
some design modifications. Reduced caries susceptibility, increased potential for im-
proving crown/root ratios and esthetics, as well as better stress distribution to abut-
ment teeth, justify the additional clinical and laboratory procedures for placement
of copings.
Although possessing considerable merit, metal bases or copings within the den-
ture base require additional laboratory procedures that significantly increase costs.
Laboratory expense can be reduced and positive contributions with metal ba.sc-vs
and denture copings can be retained by using prefabricated chrome-cobalt bearings
processed with the denture base.
 416 Morrow et al. J. Pros. Dent.
October, 1969

Fig . 1. The chrome-cobalt bearing provides metal-to-metal contact between the denture and
the occlusal surface of the abutment coping.

Fig. 2. A waxing tool is used to shape uniform indentations in coping patterns.

 Tooth-supported complete dentures 417

CHROME-COBALT BEARINGS
Some chrome-cobalt castings serve as metal bearing surfaces between the abut-
ment copings and the denture base (Fig. 1). They are hemispherical in shape and
have an upper surface that is roughened by coating it with retentive crystals to per-
mit its retention within the denture base resin. The convex surface of each bearing
is designed so it will function in a corresponding concavity placed in the occlusai
surface of the coping on the abutment tooth, The radius of curvature for the den-
ture bearing is slightly less than the one for the indentation in the tooth coping.
The difference in curvature between the surface of the denture bearing and the
curvature of the coping indentation permits a centralized contact to be made be-
tween the bearing surfaces, and this allows some freedom of rotation. Uniformity
of coping indentations was assured by constructing a special waxing tool (Fig. 2)
This tool is used to make indentations of known curvatures in the occlusal surfaces
of wax patterns for the abutment copings. The denture bearings are cast in :I
chrome-cobalt alloy. * The technique for constructing the denture support bearings
and the waxing tool is to be described in a later article.

CONSTRUCTING THE DENTURE

The clinical success of tooth-supported complete dentures is predicated on
thorough examination, accurate diagnosis, and a carefully formulated treatment
plan. In addition to a thorough visual and digital examination of the oral cavity, a
radiographic survey and a history are essential. The patient’s oral hygiene status
should be determined, and corrective measures should be instituted as they are indi-
cated. Maintenance of an adequate oral hygiene level is a prerequisite to success.
Hopeless teeth should be identified and prospective abutment teeth evaluated sys-
tematically from four viewpoints: periodontal, endodontic, positional consideration,
and caries susceptibility. Ideally, abutment teeth should present minimal perio-
dontal involvement, but this situation seldom prevails, Apparent horizontal mobility
can be reduced by shortening the length of the clinical crown, and pocket depths
often can be reduced by appropriate periodontal procedures. Normally, the perio-
dontal treatment is completed after the hopeless teeth have been removed and prior
to the initiation of endodontic therapy.
Endodontic treatment of abutment teeth is recommended because it facilitates
the development of more favorable clinical crown/root ratios, allows for an im-
proved esthetic result, and often permits the use of tilted or malposed abutment
teeth.
The positional consideration of prospective abutment teeth includes the deter-
mination of their number and distribution in the dental arch. Patients with four or
less retainable teeth in an arch should be considered for tooth-supported dentures.
When an arch has more than four retainable teeth, other treatment approaches mav
be indicated. Ideally, abutments should be equally distributed bilaterally, e.g., .a
cuspid and a second premolar on the left and a cuspid and a second premolar on
the right. Two abutment teeth in an arch are common and typified by a cuspid or
a premolar on each side. Cuspids and single-rooted premolars frequently are selected

*Ticonium, type 100, C.M.P. Industries, Inc., Albany, N. Y.

418 Morrow et al. J. Pros. Dent.
October, 1969

as abutments because they are amenable to endodontic and periodontal treatment.

Extensive caries involvement of a prospective abutment may contraindicate its use
unless the abutment tooth is restorable.

TREATMENT SEQUENCE
After the identification of hopeless teeth and selection of abutments, immediate-
insertion removable partial dentures are constructed. They are inserted at the time
of surgery and worn by the patient throughout the healing period. Modifications
often are necessary during this phase of treatment in order to maintain adequate
adaptation and patient comfort. The indicated periodontal and endodontic pro-
cedures can be completed during the healing period, which reduces the total treat-
ment period.
Upon completion of all prerequisite procedures, the abutment teeth are pre-
pared. They should be reduced adequately, both axially and occlusogingivally, to
achieve the objectives of abutment preparation. These objectives are as follows:
(1) reduction of clinical crown/root ratio, (2) adequate removal of tooth structure
to facilitate improved esthetics, (3) planning of tooth structure removal to permit
the use of tilted or malposed abutments, (4) contouring of abutment form to permit
axial loading of the abutment tooth during function, and (5) development of ac-
curate preparation margins.

MAKING THE COPINGS

Prepared teeth should be conical in shape and have the occlusal surface flattened.
Chamfer-type margins should be extended immediately below the free gingival
margin. Impressions of the prepared teeth are made by using rubber base or re-
versible hydrocolloid impression materials. The impression adapted for removable
dies is poured in an improved stone. After the setting, the dies are removed and
the margins are indicated by “ditching.” The wax patterns are carved and the
occlusal indentation is made with the waxing tool while the pattern is mounted in
a surveyor. Then the patterns are sprued, invested, burned out, and cast in a type
III gold alloy. The polished castings are fitted in the mouth by using disclosing wax.
Endodontically treated abutment teeth are coated with a fluoride caries-preventing
solution prior to cementing the copings. After cementation, a border-molded im-
pression is made of the copings and the residual alveolar ridges in a rubber base
material carried to the mouth in a relieved resin tray.
Opposing arch impressions are made at this time, and improved stone is poured
into the boxed impressions. The abutments on the cast are blocked out with wax
prior to constructing autopolymerizing (cold-curing) resin baseplates.
Denture bearings are placed in each abutment indentation on the cast and sealed
in position with baseplate wax, and the cast is coated with a tinfoil substitute. A
cold-curing soft resin is placed in undercut areas, and the baseplate is completed by
adding a hard type of cold-curing resin over the denture bearings and the soft resin
in order to build up the desired thickness. The denture bearings retained in the
baseplate contribute to the support and stability of the baseplate during the jaw
relation recording procedures. Jaw relation records are obtained and verified, and
the casts are mounted in an articulator by the use of a face-bow transfer.
Volume 22 Tooth-supported complete dentures 419
Number 4

Fig. 3. Resin denture teeth are hollowed out so they can be placed over the bearin: ac~i tl,,.
abutment.

The mold and shade of the teeth are selected, and the anterior teeth are po~i-
tioned in the presence of the patient by the dentist.
Baseplate resin is removed in the region of the abutment teeth to permit the
setting of denture teeth for a try-in. The denture bearings are retrieved from thr.
resin that is removed from the baseplates by heating the resin and taking them out
as the resin softens. These same denture bearings are returned to the master cast an{!
sealed in position with sticky wax. Resin denture teeth of the proper size and shad!-
are hollowed with a bur until they can be properly positioned over the abutment-~
(Fig. 3). They are waxed to the bearings and the occlusion is adjusted prior to thi*
try-in. Either anatomic or monoplane posterior teeth can be used. When constructinrc
a complete denture opposed by natural teeth, the occlusion is developed by thrb
functionally generated path technique.
After the try-in, the wax dentures are sealed to the casts, the occlusion is PC-Y-
fected, and the denture patterns are waxed. The wax is eliminated and the dentures
bearings are retrieved from the wax. Then the bearings are cleaned in boiling watt:!
and cemented to the casts with oxyphosphate of zinc cement (Fig. 4). The uppt~’
surfaces of the bearings are opaqued* prior to coating the casts with a tinfoil
substitute.
The denture flanges are tinted by placing tinting polymers on the facial surface%
of the stone in the cope (the upper half of the flask). Heat-curing polymer of thus
proper color is sifted into the abutment indentations of the upper part of the flask.
and saturated with a monomer. Denture base resin amenable to the single closurca
technique is mixed and placed into the mold, and the flasks are slowly closed in zr
hand compress. The dentures are subjected to the proper curing cycle, at the end o!
which they are bench cooled, retrieved from the flasks, and mounted in the artic:;-

*Justi Opaque, H. D. Justi Division, Williams Gold Refining Co., Inc., Philadelphia, Pa
420 Morrow et al. J. Pros. Dent.
October, 1969

Fig. 4. The chrome-cobalt bearings (arrows) are cemented to the abutments prior to packing
the denture base resin.

lator for the correction of processing changes. Then the corrected dentures are
removed from the cast and polished (Fig. 5) .
Disclosing wax is used at the time of insertion to locate contacts between the
abutment teeth and the acrylic resin of the denture base. Abutment contacts should
exist only between the convex surface of the bearing and the concave bearing surface
of the coping on the tooth. Inasmuch as contacts between the lateral walls of the
abutments and the denture are undesirable, they are removed by grinding from the
resin of the denture when the need is indicated by the disclosing wax. The com-
pleted dentures are subjected to the usual checks associated with the insertion of
dentures, and special emphasis is placed upon maintenance instructions. The need
for an adequate oral hygiene program is reemphasized to the patient, stressing the
correlation between the oral hygiene and the service life of the prosthesis. Dis-
closing tablets are used to indicate areas that require additional cleansing, and the
patient is instructed to use narrow gauze strips to clean the abutment teeth effec-
tively. The need for follow-up care is discussed, and post-insertion visits are
scheduled.

CLINICAL EVALUATION
Tooth-supported complete dentures were constructed in the manner described
for nine patients involving twenty abutment teeth. Six of the tooth-supported den-
tures were made for the maxillary arch, and three for the mandibular arch. Five of
the test dentures were opposed by natural teeth and four were opposed by a soft-
tissueborne complete denture. Both monoplane and anatomic occlusal patterns
were used. Functionally generated path occlusions were developed for the dentures
 Tooth-supported complete dentures 421

Fig. 5. The bearings are visible in a completed denture.

opposed by natural teeth. All abutment teeth were either cuspids or premolars that
had been endodontically treated. Seven of the nine dentures were supported by two
abutment teeth, and two by three abutment teeth. When two abutments were used,
they were distributed bilaterally, whereas when three were used, two were on one
side of the arch and one on the other.
Mobility of teeth and depth of the periodontal pockets are parameters that are
frequently used to assess periodontal health. When two or three teeth support a com-
plete denture, there may be a physiologically incompatible application of force to the
abutment teeth, with a concomitant alteration in mobility and pocket depth values.
The objective of this study was to determine the effect of a tooth-supported denture
on the horizontal mobility and the pocket depth of the supporting abutment teeth.
The horizontal mobility of each abutment tooth was measured with a perio-
dontometer, as described by O’Leary and Rudd.7 Pocket depths were recorded by
a staff periodontist for each tooth at eight positions. Fiducial recordings were ob-
tained for these parameters at the time of tooth coping cementation after pre-
requisite endodontic and periodontal therapy. In addition to the initial recordings,
postinsertion measurements were obtained during the first, second, third, and fourth
postinsertion weeks, and then at monthly intervals. The shortest period of observa-
tion was 80 days following insertion of the denture and the longest was 221 days.
The average postinsertion observation period was 147 days. All but four pcrio-
dontometer measurements were made by the same dentist. Measurement perjods
were scheduled at the same hour throughout the study. The measuring gauge used
to indicate the mobility of the teeth was stabilized in the mouth with acrylic resin
clutches. A 500 gram force was applied to the facial and lingual surfaces of the teeth>
and the resultant deflections of the measuring gauge were noted (Fig. 6). Index
 J. Pros. Dent.
422 Morrow et al. October, 1969

Fig. 6. The periodontometer in place on the patient.

Table I. Mean abutment mobility (mm./lOO) before and after placement of denture

No. of teeth Before placement End of test period ) Percentage change

20 15.3 15.1 1.3 Decrease

Table II. Mean pocket depth (mm.) before and after placement of denture

No. of teeth 1 Before placement ( End of test period 1 Percentage change

20 2.1 2.3 9.0 Increase

marks were placed on the teeth in a diagnostic cast in order to facilitate the applica-
tion of force at the same point on the tooth at the time of each measurement. The
total horizontal mobility was determined by adding the facial and lingual deflec-
tions. Two facial and lingual measurements were made and the average horizontal
mobility was recorded according to the schedule.

RESULTS
The horizontal mobility of the 20 abutment teeth did not vary significantly from
the fiducial recordings throughout the test period (Table I). No difference in mo-
Volume 22 Tooth-supported complete dentures 423
Number 4

bility behavior was noted between the abutment-supported dentures opposed by

complete dentures and abutment-supported dentures opposed by natural teeth. Tlrc
number of patients treated was not large enough to permit evaluation of mobilit)
differences, if any, related to the type of occlusion used.
The depths of the pockets also tended to remain near the fiducial levels (‘1 able
II). One patient had an acute periodontal abscess, which significantly increased the
pocket depth and mobility of that abutment.
Subjective observations by the patients with respect to comfort, esthetics, and
masticatory performance were uniformly favorable. Two dentures were brokru
during the study; one was dropped onto a hard surface, and the other developed a
fracture line across the labial flange, but both were repaired satisfactorily.

SUMMARY AND CONCLUSIONS

A method for constructing tooth-supported complete dentures was described
and the results of a clinical evaluation were discussed. In addition to those ad-
vantages inherent to tooth-supported dentures, the simplified construction technique
eliminated the need for cast metal bases or denture copings. Also, the small size of
the metal casting in the denture permitted its unobtrusive placement within the
denture and facilitated an esthetic result, The uniformity of the chrome-cobalt
bearings, and the waxing tool improve the stress distribution, and made possible
the construction of duplicate dentures with minimal additional time and materials.
Horizontal mobility and pocket depth were recorded for 20 abutments in 9 pa-
tients following the insertion of dentures constructed by the described method. The
horizontal mobility for abutment-teeth supported complete dentures tended to
remain at or below fiducial levels throughout the test period. With only a slight
variation, pocket depths remained consistent with initial levels. Patient acceptance
of the tooth-supported dentures was uniformly excellent, as manifested by few post-
insertion complaints and steady improvement in masticator-y performance. One
denture fractured when dropped on the floor, and another developed a fracture line
in a thin labial flange; otherwise there were no incidents of denture failure dlle to
breakage. The principal disadvantage of the technique was related to the need ~OJ
prerequisite periodontic, endodontic, and surgical procedures that, in turn, lengthenrd
the treatment period and increased the cost. This factor should be equated reaiisti-
tally with the ultimate service to the patient. Based on the objective clinical evalul-
tion, the tooth-supported complete denture remains an effective, preventive prostho-
dontic procedure.

References
1. Selected Dental Findings in Adults by Age, Race, and Sex, National Center for Health
Statistics, Series 11, Number 7, 1960-1962, Washington, D. C., U. S. Department of
Health, Education, and Welfare, 1962.
2. Krogh, H. W.: Permanent Tooth Mortality. A Clinical Study of Loss, J. A. D. A. 57:
670-675, 1958.
3. Brill, N.: Adaptation and the Hybrid Prosthesis, J. PROS. DENT. 5: 811-824, 1955.
4. Miller, P. A.: Complete Dentures Supported by Natural Teeth, J. PROS. DENT. 8: 921-
928, 1958.
5. Dolder, E. J.: The Bar Joint Mandibular Denture, J. PROS. DENT. 11: 689-707, 1961.
424 Morrow et al. J. Pros. Dent.
October, 1969

6. Morrow, R. M., Feldmann, E. E., Rudd, K. D., and Trovillion, H. M.: Tooth Supported
Compete Dentures: An Approach to Preventive Prosthodontics, J. PROS. DENT. Pending
publication.
7. O’Leary, T. J., and Rudd, K. D.: An Instrument for Measuring Horizontal Tooth Mobility,
J. Am. Sot. Periodontist 1: 249-254, 1963.

206 EASTRIDGE DR.

SAN ANTONIO, TEX. 78227