Risk Factor Assessment for Survival of

Removable Partial Dentures and Their

Abutment Teeth: A Retrospective Analysis
Jacob Nisser, DDS
Department of Prosthodontics, Faculty of Odontology, Malmö University, Malmö, Sweden.

Jenö Kisch, DDS

Department of Prosthodontics, Faculty of Odontology, Malmö University, Malmö, Sweden.

Bruno Ramos Chrcanovic, DDS, MSc, PhD

Department of Prosthodontics, Faculty of Odontology, Malmö University, Malmö, Sweden.

Purpose: To investigate the risk factors related to failure of removable partial dentures (RPDs) and to
compare the survival of RPDs when abutment teeth have good vs reduced bone support. Materials and
Methods: In this longitudinal patient record–based cohort study with a mean follow-up of 44.9 months, Cox
regression models were used to evaluate the associations between clinical covariates and abutment tooth
failure, as well as prosthesis failure. Results: A total of 142 patients and 172 RPDs were included. Of the
172 prostheses, 64 (nearly 40%) failed after a mean time of about 4 years. Loss of abutment teeth was the
main reason leading to RPD failure, followed closely by poor fit and adaptation. No factor was shown to be
statistically significant at the prosthesis level. Women (Hazard Ratio [HR] = 0.542), endodontic treatment (HR
= 3.460), presence of post and core (HR = 0.302), presence of a prosthetic crown (HR = 3.403), and abutment
tooth type (in relation to incisor: canine HR = 0.196, premolar HR = 0.449) were the risk factors statistically
significantly associated with the loss of abutment teeth. The pre-prosthesis amount of bone support of the
teeth did not affect their prognosis as abutments for RPDs. Conclusion: RPD treatment modality presented
a high failure rate after a mean follow-up of 4 years. Vital abutment teeth had a better survival rate than the
ones treated endodontically (whether restored with or without a post and core); nevertheless, the amount
of bone support did not affect their survival. Int J Prosthodont 2022 MONTH&DAYPOSTED. doi: 10.11607/
ijp.7457. Online ahead of print.

R
emovable partial dentures (RPDs) are associated with an increased prevalence of
gingivitis, periodontitis, and abutment teeth mobility.1–6 Carlsson et al1 evaluated
patients who were rehabilitated with RPDs more than 50 years ago and showed
that a significant number of abutment teeth in RPD wearers presented a tendency
for increased mobility during the 4-year follow-up period. There were no significant
changes in the mobility of the teeth for the patients who did not wear RPDs. Later
on, Rissin et al2 evaluated various factors associated with gingivitis and periodontal Correspondence to:
disease in 694 nonsmoker patients. Their results showed that the periodontal disease Dr Bruno Ramos Chrcanovic
variables manifested in the individuals with RPDs were more severe than in individuals Department of Prosthodontics,
Faculty of Odontology
without a prosthesis. Markkanen et al3 compared the periodontal conditions of 7,190 Malmö University, Carl Gustafs väg
patients with different combinations of removable dentures and observed that when 34, SE-214 21, Malmö, Sweden.
an RPD was worn in one or both arches, the periodontal condition was significantly Fax: +46 40 6658503
Email: bruno.chrcanovic@mau.se;
poorer than in those without dentures or with a complete denture. Tuominen et al4 brunochrcanovic@hotmail.com
compared the occurrence of periodontal pockets among RPD wearers and nonwear-
ers in a sample of 5,028 patients. Wearing RPDs highly significantly increased the Submitted October 27, 2020;
accepted August 17, 2021.
odds of having periodontal pockets in general (4 mm or more), as well as the odds of ©2022 by Quintessence
having deeper periodontal pockets (exceeding 6 mm). Kern and Wagner5 observed Publishing Co Inc.

doi: 10.11607/ijp.7457 1
 deterioration of probing depths and tooth mobility for a
mean of 10 years in 74 patients who received RPDs, and
these periodontal parameters were worse in abutment
teeth than in nonabutment teeth. However, no regular
recall system was provided. Zlatarić et al6 evaluated the
effect of RPDs on the periodontal health of abutment
and nonabutment teeth in 205 patients. Significant dif-
ferences were noted for plaque, gingival, and calculus
indices, as well as for probing depth, gingival recession,
and tooth mobility, between the two groups, with abut-
ment teeth showing more disease. On the other hand,
Bergman et al7 observed more favorable results with
RPDs after a period of 25 years for patients who were
enrolled in a regular oral hygiene and prosthesis check-
up program.
Despite the high survival rate in many studies, dental
prostheses are not without problems, and their longevity
is limited not only by biologic complications but also by
prosthetic maintenance requirements.8–12 As abutment
teeth are an important part of the support to RPDs, and
the loss of one or more of these abutments can jeop-
ardize oral rehabilitation, it is important to identify the
factors that may be a risk for their long-term survival. As
epidemiologic data seem to show an increasing trend
of tooth loss due to periodontal reasons rather than
caries,13 it was the aim of this longitudinal retrospective
cohort study to investigate the risk factors related to
failure of RPDs and their abutment teeth, as well as to
compare the survival of RPDs when abutment teeth have
good (radiographic bone loss < one-third of root length)
or reduced (radiographic bone loss of > one-third of
root length) periodontal support. As the null hypothesis,
it was assumed that RPDs supported by periodontally
compromised teeth would present a higher risk of failure
in comparison to RPDs supported by noncompromised
abutment teeth.
MATERIALS AND METHODS
Materials
This retrospective study included patients treated with
RPDs from 2008 to 2014 at the Faculty of Odontol-
ogy, Malmö University, Malmö, Sweden. This study
was based on data collected from patients’ dental re-
cords, and the patients were not recalled for further
examination. The treatment for RPDs was planned and
performed by dental students, general dentists, and
specialists in prosthodontics. The study was approved
by the regional Ethical Committee, Lund, Sweden (Dnr
2019/164).
Definitions
The patient ages were established with the delivery day
of the RPD as the time point for further calculations. [AU:
Sentence OK as edited?] A patient was considered a
2 The International Journal of Prosthodontics
smoker if they were a daily active smoker who did not
quit during the follow-up period.
The periodontal status of the abutment teeth was
determined from radiographs and dental records ac-
cording to the modified disease classification of Nyman
and Lindhe14:
• 0 = healthy
• 1 = gingivitis
• 2 = periodontitis levis (bone loss < one-third of root
length)
• 3 = periodontitis gravis (bone loss > one-third of
root length)
• 4 = periodontitis gravis et complicata (bone loss >
one-third of root length with vertical bone defect
and furcation involvement grade 2 or 3)
Supportive periodontal therapy (SPT) was registered if
at least one yearly supportive appointment was attended
by the patient.
The status of the dentition in the opposing arch was
divided into four categories: (1) removable complete den-
ture or overdenture; (2) partially edentulous with an RPD;
(3) natural teeth with or without a fixed dental prosthesis
(FDP), or FDPs supported by teeth and implants in the
same arch; and (4) implant-supported fixed complete
prostheses (ISFCP).
The RPD construction type according to the eden-
tulous spaces was classified into four categories: (1)
unilateral distal-extension prosthesis; (2) bilateral distal-
extension prosthesis; (3) bounded saddle prosthesis; and
(4) combination prosthesis; ie, including at least one gap
between natural teeth and a distal extension.
The RPD type according to the prosthesis structure
was classified into two categories: (1) prosthesis with the
use of clasps for retention (simple metal-framed RPD);
and (2) retained by intra- and/or extracoronal attach-
ments (complex RPD).
An abutment tooth was a tooth that served as occlu-
sal rest and/or support for clasp retention. Information
about the mobility of an abutment tooth from before
and after delivery of the RPD was retrieved from the
dental records and was graded according to Miller.15 End-
odontic treatment and posts and cores were registered
from the patients’ radiographs. Both dental laboratory–
casted and chairside–fabricated posts were included.
Only dental laboratory–fabricated crowns (excluding
acrylic crowns) were counted as a prosthetic crown.
A failed RPD was defined as a prosthesis that was no
longer in use due to loss of abutment teeth; poor fit
and adaptation; fracture of clasps in a way that would
completely compromise the stability of the prosthesis;
replacement of the RPD with another type of prosthesis;
the need for addition of more prosthetic elements to
the prosthesis; or loss of the prosthesis by the patient.

Survival of an RPD was defined as a prosthesis that was
in use but had been through modifications as a result of
some complication. Success of an RPD was defined as a
prosthesis that was in use with only minor adjustment
visits due to, for example, clasp activation or adjustments
due to irritation wounds in the oral mucosa (denture sto-
matitis or decubitus ulcer).
The complications noted were the following:
• Complications regarding the prosthesis: fracture
of clasps, fracture/loss of acrylic teeth, denture
stomatitis, need for relining, poor fit and adaptation
• Complications regarding the abutment teeth: caries,
need for endodontic treatment, increased mobility,
fracture, extraction (due to advanced periodontal
disease or extensive carious lesions)
Inclusion and Exclusion Criteria
All patients treated for severe periodontitis and rehabili-
tated with RPDs at the aforementioned institution during
the period from 2008 to 2014 were considered for inclu-
sion. The patients needed to have at least 6 months of
follow-up after delivery of the prosthesis. The exclusion
criteria consisted of patients rehabilitated with temporary
RPDs, obturators, or maxillofacial prostheses. Patients
for whom the use of RPDs was discontinued soon after
delivery of the prosthesis were not included in the study.
Selection Process
First, all patients rehabilitated with RPDs with a history
of severe periodontitis who had been under periodontal
treatment in the aforementioned period and institution
were considered for inclusion. Then a similar number
of RPD-rehabilitated patients who were not treated for
severe periodontitis were randomly selected from the
archive of patient records. The random selection of the
other half of the patients was done due to the fact that
there were many more RPD-rehabilitated patients not
treated for severe periodontitis than treated.
Data Collection
The data were directly entered into an SPSS file (SPSS
software, version 26, IBM) as the dental records of the
patients were being read. The factors noted were the
following: patient gender; patient age at delivery of the
prosthesis; smoking habits; rehabilitated arch (maxilla/
mandible); tooth abutment mobility; endodontic status
of the abutment teeth; presence or not of post and
core and/or prosthetic crown in the abutment teeth;
abutment tooth type (incisor, canine, premolar, molar);
periodontal status of the abutment teeth (the afore-
mentioned classification); location of abutment in the
arch (anterior/posterior); patient assiduity to SPT; RPD
construction type; RPD type, status of the opposing
arch; number of abutment teeth; and the clinic where
Nisser et al
the prosthetic rehabilitation was conducted (student or
specialist clinic).
Statistical Analyses
The mean, SD, and percentage were calculated for sev-
eral variables. The tests performed were the following:
Kolmogorov-Smirnov, to evaluate normal distribution;
Levene test, to evaluate homoscedasticity; Student t test
or Mann-Whitney test, for two independent groups or
continuous variables; and Pearson chi-square or Fisher
exact test for categorical variables. Wilcoxon signed-rank
test was used to compare the mean values of tooth
abutment mobility between before prosthesis delivery
and the final follow-up visit.
Cumulative survival rate (CSR) of the RPDs was calcu-
lated over the maximum period of follow-up reported
in two life-table survival analyses, one at the prosthesis
level and another at the abutment level. Abutment teeth
(instead of patients) were considered as one of the statis-
tical units of the study due to the fact that different teeth
in the same patient can present different prognoses.16
Univariate and multivariate Cox regression were used
to evaluate the associations between clinical covariates
and abutment tooth failure, as well as prosthesis failure.
Hazard ratio (HR) and 95% CI were estimated from Cox
proportional hazard models. In order to verify multicol-
linearity, a correlation matrix of all of the predictor vari-
ables with a significant odds ratio (P value cut-off point
of 0.1) identified in the univariate models was scanned
to assess whether there were high correlations among
the predictors. Collinearity statistics obtaining variance
inflation factor (VIF) and tolerance statistic were also per-
formed to detect more subtle forms of multicollinearity.
For final multivariate Cox regression models, all vari-
ables that were moderately associated (P < .10) [AU:
P < .10 correct?] with abutment teeth and prosthesis
failures were included in their respective statistical mod-
els. Clustering of multiple abutment teeth for the same
RPD and for two prostheses within each patient was
accounted for in the Cox models using the methods
outlined by Lee et al17 and Lin.18 Data were statistically
analyzed using SPSS software. The degree of statistical
significance was considered P < .05.
This observational study followed the STROBE
(Strengthening the Reporting of Observational Studies
in Epidemiology) guidelines.
RESULTS
Sample Description
A total of 165 patients with 203 RPDs were initially se-
lected. Of these, 30 RPDs were followed up for less than
6 months and 1 temporary RPD was excluded, which
resulted in 142 patients and 172 RPDs included in the
study. Of these 172 prostheses, 83 were placed in men
doi: 10.11607/ijp.7457 3
 Table 1   Life-Table Survival Analysis Showing the Cumulative Survival Rate of Removable Partial Dentures
No. with- Survival rate
drawing within each Cumulative propor-
Interval No. enter- during No. exposed Prosthesis interval tion surviving at end Standard
start time, y ing interval interval to risk failures (ISR), % of interval (CSR), % error, %
0 172 17 163.5 6 96.3 96.3 1.5
1 149 27 135.5 13 90.4 87.1 2.8
2 109 11 103.5 9 91.3 79.5 3.5
3 89 10 84 6 92.9 73.8 2.9
4 73 10 68 9 86.8 64.1 4.6
5 54 9 49.5 7 85.9 55.0 5.0
6 38 7 34.5 3 91.3 50.2 5.3
7 28 10 23 5 78.3 39.3 6.0
8 13 5 10.5 4 61.9 24.3 7.0
9 4 2 3 0 100 24.3 7.0
10 2 0 2 2 0 0 0
ISR = interval survival rate; CSR = cumulative survival rate.

Table 2   Life-Table Survival Analysis Showing the Cumulative Survival Rate of Abutment Teeth of Removable
Partial Dentures
No. with- Survival rate
drawing Abutment within each Cumulative propor-
Interval No. enter- during No. exposed tooth fail- interval tion surviving at end Standard
start time, y ing interval interval to risk ures (ISR), % of interval (CSR), % error, %
0 541 83 499.5 8 98.4 98.4 0.6
1 450 115 392.5 6 98.5 96.9 0.8
2 329 56 301 14 95.3 92.4 1.4
3 259 38 240 13 94.6 87.4 1.9
4 208 40 188 11 94.1 82.3 2.3
5 157 43 135.5 9 93.4 76.8 2.8
6 105 28 91 7 92.3 70.9 3.4
7 70 31 54.5 2 96.3 68.3 3.7
8 37 17 28.5 6 78.9 83.9 6.0
9 14 9 9.5 0 100 53.9 6.0
10 5 5 2.5 0 100 53.9 6.0
ISR = interval survival rate; CSR = cumulative survival rate.

and 89 in women. The patients had a mean ± SD GE
of 62.6 ± 11.1 years (range: 39.6 to 86.3) at the date of
prosthesis delivery and were followed up for a mean ±
SD of 44.9 ± 30.8 months (range: 6.2 to 120.5; median
37.0) after delivery of the prosthesis. Information con-
cerning smoking habits was present for patients wearing
164 of these prostheses, and for 47 (28.7%) the patient
was a smoker. Forty patients were followed up for SPT,
and the reason for this was that, although all patients
were offered SPT, not all of them were willing to come
back for SPT appointments.
Life-Table Analysis
Life-table survival analyses at the prosthesis and abut-
ment levels are shown in Tables 1 and 2, respectively.
The estimated cumulative survival rates (CSRs) after 5
years were 55.0% and 76.8% for the prostheses and
the abutment teeth, respectively.

4 The International Journal of Prosthodontics


Removable Partial Dentures
The rehabilitation of patients with RPDs was conducted
in a student clinic (82.6%, n = 142) or in a specialist clinic
(17.4%, n = 30). A total of 85 RPDs (49.4%) were made
for the maxilla, while 87 (50.6%) were mandibular. A
total of 142 (82.6%) RPDs were simple metal-framed
prostheses with the use of clasps for retention, and
30 (17.4%) were additionally retained by intra- and/or
extracoronal attachments (complex type). Concerning
the construction type, 7 RPDs (4.1%) were unilateral
distal-extension RPDs, 92 (53.5%) were bilateral distal-
extension RPDs, 23 (13.4%) were bounded saddle pros-
theses, and 50 (29.1%) were a combination of free-end
and bounded saddle prostheses. The RPDs were opposed
in the antagonist arch by a removable complete denture
or overdenture in 19 cases (11.0%), another RPD in 77
cases (44.8%), natural teeth or a combination of teeth
and FDPs on teeth in 71 cases (41.3%), and to an ISFCP
in 5 cases (2.9%).
A total of 64 prostheses failed out of the total of
172 (37.2%) after delivery in 57 patients after a mean
± SD follow-up of 47.8 ± 31.0 months (range: 6.7 to
120.5, median 45.1) after prosthesis delivery. The reasons
for failure were the following: loss of abutment teeth
(n = 26; 40.6%); poor fit and adaptation (n = 24; 37.5%);
fracture of clasps (n = 9; 14.1%); replacement with im-
plant-supported FDPs (n = 2; 3.1%); patient lost the
prosthesis (n = 2; 3.1%); and need for addition of more
prosthetic elements (n = 1; 1.6%).
Table 3 shows a comparison between failed and
surviving RPDs according to different factors and the
results of the univariate Cox proportional hazard mod-
els. As only one factor (type of clinic where the treat-
ment was conducted, student or specialist clinic) was
moderately associated (P < .10) with prosthesis failure,
a multivariate model was not attempted. In this case, a
higher failure rate was observed for when patients were
rehabilitated with RPDs in a student clinic in comparison
to a specialist clinic, although not with a statistically
significant HR.
Abutment Teeth
A total of 541 teeth were used as RPD abutments.
There was a mean ± SD of 3.1 ± 1.0 abutment teeth
(range: 1 to 6) for the prostheses. These teeth con-
sisted of 71 incisors (13.1%), 161 canines (29.8%), 206
premolars (38.1%), and 103 molars (19.0%). Of these
541 teeth, 103 (19.0%) were endodontically treated,
58 (10.7%) had a post and core, and 158 (29.2%) were
restored with a prosthetic crown. The percentage of
abutment teeth that were endodontically treated was
44.3% (70/158) restored with a prosthetic crown and
8.6% (33/383) not restored with a crown. The peri-
odontal status of the abutment teeth was as follows:
category 0 = 1 tooth (0.2%); category 1 = 23 teeth
Nisser et al
(4.3%); category 2 = 234 teeth (43.4%); category 3 =
264 teeth (49.0%); and category 4 = 17 teeth (3.2%).
This information was unknown for 2 abutment teeth.
The mean ± SD tooth abutment mobility before pros-
thesis delivery was 0.27 ± 0.58 [AU: mm?] (range: 0
to 2; n = 512) in comparison to 0.52 ± 0.90 (range:
0 to 3; n = 381) at the final follow-up visit (P < .001;
Wilcoxon signed-rank test).
A total of 76 of the 541 abutment teeth failed (14.0%)
in 44 patients, after a mean ± SD time of 47.9 ± 26.5
months (range: 2.1 to 104.6, median: 45.5) after pros-
thesis delivery. In 18 out of these 44 patients, the loss
of a tooth did not result in failure of the prosthesis; in
these cases, the gap left by the lost teeth was replaced
via the addition of acrylic teeth to the prosthesis. Table
4 shows a comparison between failed and surviving
abutment teeth according to different factors and the
results of the univariate Cox proportional hazard mod-
els. Several factors presented a moderate association
(P < .10) with tooth failure in the univariate model, of
which the following showed a statistically significant
HR in the multivariate model (Table 5): patient gender
(women with lower HR in comparison to men); end-
odontic treatment (endodontically treated abutments
with higher HR); presence of post and core (teeth with
post and core with lower HR); presence of a prosthetic
crown (teeth restored with a crown with higher HR);
and abutment tooth type (canines and premolars with
lower HR than incisors). It is worth noting that none
of the abutment teeth with mobility 2 had a post and
core. Teeth were more often restored with a post and
core if they were classified with less mobility: 8.6% of
the abutment teeth with mobility 1, and 12.0% of the
teeth with mobility 0.
Complications
A total of 46 RPDs (26.7%) presented complications
that did not lead to prosthesis failure. Besides the loss of
abutment teeth (18 out of the 44 patients who presented
with tooth loss did not lose the prosthesis because of
that, as aforementioned elsewhere in the text), there was
also the occurrence of fracture of clasps (in these cases
not leading to prosthesis failure; n = 8), loss/fracture of
prosthetic acrylic teeth (n = 5), need for relining of the
prosthesis base (n = 4), fracture of the RPD framework
(n = 3), denture stomatitis (n = 2), and caries of one
abutment tooth with the need for endodontic treatment
(n = 1). In some cases, the patients had more than one
complication, such as the fracture of clasps and of acrylic
teeth (n = 2), the loss of natural teeth and the fracture
of acrylic teeth (n = 2), and the loss of natural teeth and
the fracture of clasps (n = 1).
doi: 10.11607/ijp.7457 5
 Table 3   Comparison Between Failed and Surviving Removable Partial Dentures According to Different Factors
and Univariate Cox Proportional Hazard Models for Prosthesis Failure
Failed prostheses, Surviving prostheses,
Factor n (%) n (%) Hazard ratio (95% CI) P value
Sex
Men 33 (39.8) 50 (60.2) 1
Women 31 (34.8) 58 (65.2) 0.771 (0.467, 1.271) .308
Age 1
Increase by 1 y – – 1.003 (0.979, 1.027) .812
Smoker
No 48 (41.0) 69 (59.0) 1
Yes 16 (34.0) 31 (66.0) 1.122 (0.629, 2.001) .697
Arch
Maxilla 31 (36.5) 54 (63.5) 1
Mandible 33 (37.9) 54 (62.1) 1.319 (0.798, 2.180) .281
Periodontal class
2 14 (34.1) 27 (65.9) 1
3 or 4 50 (38.2) 81 (61.8) 0.848 (0.467, 1.540) .589
Supportive periodontal therapy
No 55 (41.7) 77 (58.3) 1
Yes 9 (22.5) 31 (77.5) 0.927 (0.455, 1.890) .835
Restoration type
Unilateral distal-extension RPD 3 (42.9) 4 (57.1) 1
Bilateral distal-extension RPD 32 (34.8) 60 (65.2) 1.181 (0.345, 4.046) .791
Bounded saddle prosthesis 10 (43.5) 13 (56.5) 1.181 (0.315, 4.433) .805
Combination prosthesis 19 (38.0) 31 (62.0) 1.707 (0.479, 6.082) .409
Prosthesis type
Simple metal-framed RPD 54 (38.0) 88 (62.0) 1
Complex RPD 10 (33.3) 20 (66.7) 0.989 (0.501, 1.954) .975
Opposing arch
Denture/overdenture 7 (36.8) 12 (63.2) 1
Partially dentate with RPD 27 (35.1) 50 (64.9) 0.710 (0.308, 1.637) .422
Natural teeth w/wt FDP 28 (39.4) 43 (60.6) 1.141 (0.494, 2.636) .757
ISFCP 2 (40.0) 3 (60.0) 1.227 (0.252, 5.972) .800
No. of abutment teeth 1
Increase by 1 abutment – – 0.891 (0.704, 1.128) .337
Clinic
Student clinic 58 (40.8) 84 (59.2) 1
Specialist clinic 6 (20.0) 24 (80.0) 0.449 (0.193, 1.046) .063
FDP = fixed dental prosthesis; w/wt = with/without; ISFCP = implant-supported fixed complete prosthesis.

DISCUSSION The periodontal disease classification used for the

The null hypothesis of the present study was rejected,
as the pre-prosthesis amount of bone support of the
teeth did not affect their prognosis as abutments for
RPDs.
present study14 was not the most recent19; however, it
was the one used in the clinical setting for the patients
of the present study, and trying to transform or adapt
the classification that was used to clinically assess the

6 The International Journal of Prosthodontics

 Nisser et al

Table 4   Comparison Between Failed and Surviving Abutment Teeth for Removable Partial Dentures According
to Different Factors and Univariate Cox Proportional Hazard Models for Abutment Tooth Failure
Factor Failed tooth, n (%)a Surviving tooth, n (%)a Hazard ratio (95% CI) P
Sex
Men 43 (16.3) 221 (83.7) 1
Women 33 (11.9) 244 (88.1) 0.682 (0.433, 1.074) .099
Age 1
Increase by 1 y – – 1.027 (1.004, 1.050) .019
Smoker
No 51 (14.0) 312 (86.0) 1

Yes 24 (15.7) 129 (84.3) 1.638 (0.992, 2.704) .054

Arch
Maxilla 47 (17.5) 222 (82.5) 1
Mandible 29 (10.7) 243 (89.3) 0.684 (0.430, 1.088) .108
Tooth abutment mobilityb,c
0 48 (11.8) 360 (88.2) 1
1 15 (21.4) 55 (78.6) 1.500 (0.838, 2.686) .172
2 8 (23.5) 26 (76.5) 2.085 (0.984, 4.420) .055
Periodontal disease classificationd
0, 1, 2 27 (10.5) 231 (89.5) 1
3, 4 49 (17.3) 234 (82.7) 1.598 (0.998, 2.559) .051
Supportive periodontal therapy
No 65 (15.8) 346 (84.2) 1
Yes 11 (8.5) 119 (91.5) 0.831 (0.437, 1.581) .573
Endodontically treated abutment
No 46 (10.5) 392 (89.5) 1
Yes 30 (29.1) 73 (70.9) 2.948 (1.859, 4.673) < .001
Abutment with post and core
No 65 (13.5) 418 (86.5) 1
Yes 11 (19.0) 47 (81.0) 1.952 (1.027, 3.710) .041
Abutment restored with prosthetic crown
No 42 (11.0) 341 (89.0) 1
Yes 34 (21.5) 124 (78.5) 2.568 (1.628, 4.050) < .001
Abutment tooth type
Incisor 18 (25.4) 53 (74.6) 1
Canine 17 (10.6) 144 (89.4) 0.288 (0.148, 0.559) < .001
Premolar 32 (15.5) 174 (84.5) 0.546 (0.306, 0.974) .041
Molar 9 (8.7) 94 (91.3) 0.303 (0.136, 0.675) .003
Abutment position in the jawe
Anterior 35 (15.1) 197 (84.9) 1
Posterior 41 (13.3) 268 (86.7) 1.019 (0.648, 1.603) .935
FDP = fixed dental prosthesis; w/wt = with/without; ISFCP = implant-supported fixed complete prosthesis.
aFor when the information was available.
bAccording to Miller15; before prosthesis delivery.
cThere was only one abutment tooth classified as having mobility 3 (the tooth did not fail). Due to the small number, this class was not included in this

analysis.
dAccording to the modified disease classification of Nyman and Lindhe.32
eIncisors and canines were considered anterior teeth, and premolars and molars were considered posterior teeth.

doi: 10.11607/ijp.7457 7
 Table 4   Comparison Between Failed and Surviving Abutment Teeth for Removable Partial Dentures According
to Different Factors and Univariate Cox Proportional Hazard Models for Abutment Tooth Failure
(continued)
Factor Failed tooth, n (%)a Surviving tooth, n (%)a Hazard ratio (95% CI) P
Construction type
Unilateral distal-extension 1 (5.0) 19 (95.0) 1
RPD
Bilateral distal-extension RPD 38 (15.6) 205 (84.4) 3.901 (0.535, 28.460) .179
Bounded saddle prosthesis 6 (6.3) 89 (93.7) 1.319 (0.159, 10.971) .798
Combination prosthesis 31 (16.9) 152 (83.1) 5.760 (0.784, 42.316) .085
Prosthesis type
Simple metal-framed RPD 57 (12.9) 384 (87.1) 1
Complex RPD 19 (19.0) 81 (81.0) 1.753 (1.034, 2.969) .037
Opposing arch
Denture/overdenture 9 (16.7) 45 (83.3) 1
Partially dentate with RPD 41 (16.2) 212 (83.8) 0.699 (0.339, 1.442) .332
Natural teeth w/wt FDP 25 (11.2) 198 (88.8) 0.789 (0.368, 1.692) .543
ISFCP 1 (9.1) 10 (90.9) 0.799 (0.100, 6.371) .833
Number of abutment teeth 1
Increase by 1 abutment – – 0.860 (0.700, 1.057) .152
Clinic
Student clinic 60 (13.6) 380 (86.4) 1
Specialist clinic 16 (15.8) 85 (84.2) 0.951 (0.545, 1.660) .861
FDP = fixed dental prosthesis; w/wt = with/without; ISFCP = implant-supported fixed complete prosthesis.
aFor when the information was available.
bAccording to Miller15; before prosthesis delivery.
cThere was only one abutment tooth classified as having mobility 3 (the tooth did not fail). Due to the small number, this class was not included in this

analysis.
dAccording to the modified disease classification of Nyman and Lindhe.32
eIncisors and canines were considered anterior teeth, and premolars and molars were considered posterior teeth.

patients to the more recent one may raise the risk of
not reflecting the original periodontal diagnosis.
Nearly 40% of the prostheses failed after a mean time
of about 4 years. Life-table survival analyses showed that
the CSRs after 5 years were 55.0% and 76.8% for the
prostheses and the abutment teeth, respectively. These
4- to 5-year results should be interpreted with caution, as
the numbers for each interval are low and the censored
numbers are proportionally high, reducing the confi-
dence of the outcomes.20 The most recent observations
are the least reliable because of the decreasing number
of patients at risk for the event of interest.21
The loss of abutment teeth was the main reason lead-
ing to RPD failure (40.6% of the failures), followed closely
by poor fit and adaptation (37.5%). The loss of teeth
could be, to some degree, a result of the negative ef-
fect of this type of prosthesis on the periodontal status
of abutment teeth,1–6 as already reported in detail in
the present study. According to the regression model
at the prosthesis level, five variables were suggested to
influence the failure of abutment teeth.
Patient gender was one of these five factors. It was
observed that women presented a lower risk than men
for losing their abutment teeth. Population data from
Sweden have shown that men over the age of 60 are
more prone to having teeth extracted than women.22
It has also been shown that men more frequently have
periodontal disease than women,23,24 and the destruc-
tion of the periodontium influences whether teeth are
retained or extracted.25 Moreover, women floss more,
are more embarrassed by tooth loss, and are more aware
of the importance of oral health than men.26
Endodontically treated abutment teeth (but not nec-
essarily restored with post and core) presented a higher
risk for failure than those not treated endodontically,
in agreement with the results of a similar study.27 It is
hypothesized that a retainer for an RPD might deterio-
rate the survival of endodontically treated teeth, as the
mechanical stress from the RPD increases the fracture
risk of abutment teeth.27
Abutments restored with a prosthetic crown pre-
sented a higher risk of failure than the ones without a

8 The International Journal of Prosthodontics

 Nisser et al

crown, and this could be related to Table 5   Multivariate Cox Proportional Hazard Model for Abutment
the fact that 44.3% of the crown- Tooth Failure
restored abutments were also end- Factor Hazard ratio (95% CI) P
odontically treated, in comparison Sex
to only 8.6% of the abutments not Men 1
restored with crowns. The higher risk Women 0.542 (0.322, 0.912) .021
for endodontically treated teeth, as
Age 1
aforementioned, would apply here.
The lower risk of failure for abut- Increase by 1 y 0.992 (0.962, 1.022) .580
ment teeth with a post and core in Smoker
comparison to teeth without them No 1
was initially a surprise. However, Yes 1.471 (0.827, 2.614) .189
further analysis of the data showed Tooth abutment mobilitya
that abutment teeth were more of-
0 1
ten restored with a post and core if
they were classified with less initial 1 1.563 (0.834, 2.928) .163
mobility before prosthesis delivery. 2 2.233 (0.972, 5.130) .058
Incisors presented the highest risk Periodontal disease classification
of failure in comparison to other 0, 1, 2 1
types of teeth (canine, premolar, 3, 4 1.152 (0.653, 2.032) .624
molar) when used as an abutment
Endodontically treated abutment
for RPDs. This could be related to
the fact that incisors, in particular the No 1
mandibular ones, have the shortest Yes 3.460 (1.858, 6.443) < .001
roots among all permanent teeth28 Abutment with post and core
and consequently present less total No 1
area of periodontal support. This Yes 0.302 (0.122, 0.745) .009
makes incisors more vulnerable to
Abutment restored with prosthetic crown
failure if submitted to load forces in
RPDs that are not properly balanced. No 1
Regarding tooth mobility, the Yes 3.403 (1.643, 7.050) .001
difference in the mean values of Abutment tooth type
tooth abutment mobility between Incisor 1
before prosthesis delivery and the Canine 0.196 (0.090, 0.427) < .001
final follow-up visit was statistically
Premolar 0.449 (0.227, 0.889) .022
significant. Abutment teeth are sub-
mitted to continuous and repetitive Molar 0.442 (0.183, 1.064) .068
mechanical (which includes the ro- Construction type
tational and settling movements of Unilateral distal-extension RPD 1
the RPD) and bacterial stress from Bilateral distal-extension RPD 4.332 (0.529, 35.492) .172
RPDs and therefore have a higher risk Bounded saddle prosthesis 1.260 (0.138, 11.477) .838
of damaging the periodontal tissue
Combination prosthesis 6.366 (0.770, 52.644) 0.086
than nonabutment teeth.27 This can
contribute to an increase in tooth Prosthesis type
mobility with time, which can even- Simple metal-framed RPD 1
tually lead to complete compromise Complex RPD 1.056 (0.504, 2.213) 0.886
of periodontal support of the abut- Only the factors that were considered statistically significant (P < 0.1) [AU: P < .10 correct here, or
ment teeth.29 should it be P < .01?] in the univariate model and did not present multicollinearity were included in
the multivariate model.
The initial amount of bone sup- aAccording to Miller15; before prosthesis delivery.

port of the teeth did not affect

their prognosis when used as an
abutment for RPDs. This could have
been a result of the limitation of the
classification14 used for the present
study, which focuses mainly on the
radiographic level of bone loss in relation to the root length, with no de-
tailed periodontal examination—namely, no probing depth, no bleeding on
probing, and no clinical attachment level. Moreover, it is a matter of debate
whether the lack of statistical significance in the particular case may also

doi: 10.11607/ijp.7457 9
 reflect a lack of clinical significance. Other researchers30
observed that the frequency of maintenance care was
associated with the deterioration of the periodontal con-
dition of the remaining teeth, although they evaluated
more parameters to assess the periodontal condition.
Although none of the predictor variables was shown
to be statistically significant at the prosthesis level model,
two factors concerning the prosthesis failure rate need
to be stressed here.
The first factor is the prosthesis failure rate at the stu-
dent clinic, which was higher than in the specialist clinic.
A dentist who has engaged in practice at the specialist
level has considerably more didactic and clinical instruc-
tion compared to a student’s experience31; therefore,
one would argue that in the student clinic, students
make more mistakes, hence the higher failure rate.
The second factor worth noting is the patient at-
tendance to SPT. Patients regularly attending an SPT
program did not show a significantly lower prosthesis
failure HR when compared to patients not willing to
participate in the program, although it is important to
stress here that the patients’ cooperation and plaque
index were not taken into account, which may have
more influence on these results than just their assidu-
ity to an SPT program. Earlier studies have shown that
tooth-supported FDPs can work well in patients with very
advanced periodontal disease,32 but there is very limited
scientific documentation about the effects of RPDs in
patients with reduced periodontium.33 [AU: Sentence
OK as edited?] Studies have shown that regular SPT
and effective plaque control are strong patient-related
factors for preventing tooth loss,34 even in patients with
periodontally compromised dentition.35
Besides the already considerable number of cases of
prosthesis and abutment failures, 26.7% of the prosthe-
ses presented complications that did not lead to pros-
thesis failure. This leads to the reasonable understanding
that patients rehabilitated with RPDs need to be closely
followed up with regular check-ups for SPT and adjust-
ments in order to minimize failure of both abutment
teeth and RPDs.
The limitations of the present study include the fact
that this is a retrospective study, and therefore gaps in
information and incomplete records are present. More-
over, since this was not a prospective study, treatment
was not standardized. There was also no standardization
or calibration when the periodontal examination was
performed by different clinicians, and the periodontal
disease classification used was not the most recent one.
As several professionals were involved, there must have
been some variability in the prosthetic approaches and
dental laboratory techniques applied. Furthermore, no
information was retrieved about the RPD design, how
many clasps were placed, where they were placed rela-
tive to the axis of rotation, what type of clasps were
10 The International Journal of Prosthodontics
used, and how those clasps were designed to preserve
the abutment teeth.
CONCLUSIONS
Nearly 40% of the RPDs failed after a mean time of
about 4 years. The loss of abutment teeth was the main
reason leading to RPD failure, followed closely by poor fit
and adaptation. The initial amount of bone support of
the teeth does not affect their prognosis when used as
an abutment for RPDs. Patient gender, tooth abutment
mobility, endodontic treatment, presence of a post and
core, presence of a prosthetic crown, and abutment
tooth type were the risk factors statistically significantly
associated with the loss of abutment teeth.
ACKNOWLEDGMENTS
This research received no specific grant from any funding agency in
the public, commercial, or not-for-profit sectors.
The authors declare no conflicts of interest.
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