journal of dentistry 41 (2013) 1175–1180

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Multifactorial risk assessment for survival of

abutments of removable partial dentures based on
practice-based longitudinal study

Sayaka Tada, Kazunori Ikebe *, Ken-ichi Matsuda, Yoshinobu Maeda

Department of Prosthodontics, Gerodontology and Oral Rehabilitation, Osaka University Graduate School of Dentistry,
Japan

article info abstract

Article history: Objectives: Predicting the tooth survival is such a great challenge for evidence-based den-
Received 25 May 2013 tistry. To prevent further tooth loss of partially edentulous patients, estimation of individ-
Received in revised form ualized risk and benefit for each residual tooth is important to the clinical decision-making.
18 July 2013 While there are several reports indicating a risk of losing the abutment teeth of RPDs, there
Accepted 23 July 2013 are no existing reports exploring the cause of abutment loss by multifactorial analysis. The
aim of this practice-based longitudinal study was to determine the prognostic factors
affecting the survival period of RPD abutments using a multifactorial risk assessment.
Keywords: Methods: One hundred and forty-seven patients had been previously provided with a total of
Abutment 236 new RPDs at the Osaka University Dental Hospital; the 856 abutments for these RPDs
Removable partial denture were analyzed. Survival of abutment teeth was estimated using the Kaplan–Meier method.
Survival rate Multivariate analysis was conducted by Cox’s proportional hazard modelling.
Multifactorial risk assessment Results: The 5-year survival rates were 86.6% for direct abutments and 93.1% for indirect
Longitudinal study abutments, compared with 95.8% survival in non-abutment teeth. The multivariate analysis
showed that abutment survival was significantly associated with crown-root ratio (hazard
ratio (HR): 3.13), root canal treatment (HR: 2.93), pocket depth (HR: 2.51), type of abutments
(HR: 2.19) and occlusal support (HR: 1.90).
Conclusion: From this practice-based longitudinal study, we concluded that RPD abutment
teeth are more likely to be lost than other residual teeth. From the multifactorial risk factor
assessment, several prognostic factors, such as occlusal support, crown-root ratio, root
canal treatment, and pocket depth were suggested.
Clinical significance: These results could be used to estimate the individualized risk for the
residual teeth, to predict the prognosis of RPD abutments and to facilitate an evidence-based
clinical decision making.
# 2013 Elsevier Ltd. All rights reserved.

the prosthesis for the residual teeth. In planning dental

1. Introduction treatment for patients with tooth loss, the potential impact of
replacement prostheses on dental health must be considered
When designing and providing dental prosthesis, it is very carefully. The concept of ‘‘biological price’’1 is frequently
important to estimate the individualized risk and benefit of described, and the replacement of missing teeth should be

* Corresponding author at: Department of Prosthodontics, Gerodontology and Oral Rehabilitation, Osaka University Graduate School of
Dentistry, 1-8 Yamadaoka Suita, Osaka 565-0871, Japan. Tel.: +81 6 6879 2956; fax: +81 6 6879 2957.
E-mail address: ikebe@dent.osaka-u.ac.jp (K. Ikebe).
0300-5712/$ – see front matter # 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jdent.2013.07.018
1176 journal of dentistry 41 (2013) 1175–1180
balanced with the potential for a prosthesis to contribute to
dental and periodontal diseases. This is particularly relevant
to the teeth used as abutments for fixed and removable partial
dentures (RPDs).
Various reports have referred to the association between
replacement prostheses, particularly RPDs, and dental dis-
eases.2 The abutment teeth of RPDs were reported to be at
higher risk of periodontitis,3,4 dental caries5,6 and root
fracture7 than other teeth. Longitudinal studies have also
shown that RPD abutments were at the increased risk of
loss.8,9
Tooth loss, especially in the case of abutment teeth, is
intrinsically involved in complex relationship with many
factors in the long term. However, while this mandates a
multifactorial analysis using practice-based research to exam-
ine the significant risk factors determining tooth loss, such
analysis has not been reported yet for RPD abutment teeth.
As long as RPDs remain a common treatment option for
partially edentulous patients, it is imperative to know the
specific prognostic factors dictating the survival of RPD
abutments, and their relative contribution to the duration of
tooth survival. This knowledge facilitates the development of
prosthodontic treatment strategy and the evidence-based
prediction of long-term prognosis for those abutment teeth.
The absence of any such risk assessment denies us a practical
way for predicting the survival period of each abutment
depending on their individual characteristics.
This longitudinal retrospective cohort study aimed to fill
this void by examining the survival of RPD abutments in
longitudinal clinical cases, and exploring the prognostic
factors dictating survival and their relative contribution to
tooth loss.
2. Methods
2.1. Study population
We targeted all patients provided with RPDs between January
2002 and December 2003 in Removable Prosthodontics
department of Osaka University Dental Hospital, Japan. The
protocol of this study was approved by the School of Dentistry
Ethics Committee (No. H22-E2). Patients were included if they
had been provided with a clasp-retained, cobalt–chromium-
designed and tooth-supported RPD which is covered by
Japanese medical insurance and had used it for 2 years or
more, and were excluded if their dentures were immediate
RPDs that required fixing, and dentures with complex designs
such as maxillofacial prostheses, attachment-retained or
lingual-plate-connected dentures. In addition, we excluded
patients who had not received conservative periodontal
intervention or maintenance at least once a year during the
observation period.
RPDs were provided by prosthodontists certificated by
Japan Prosthodontic Society. Periodontal maintenance was
performed by dentists in the preventive or periodontal
departments. Data were gathered from the dental records,
and patients were examined by the attending prosthodontists
at the time of RPD provision. These data included general and
oral status, and RPD’s design.
2.2. Variables
Variables set as patient-related factors were: gender (male/
female), age (<65 or 65 years), lifestyle-related disease
(with: having a medical history of at least one of hyperten-
sion, diabetes mellitus or dyslipidemia/without: having no
medical history of these diseases) and occlusal support
(A + B1/B2/B3/B4/C, based on the Eichner classification10,11).
Tooth-related factors were: jaw (upper/lower), type of tooth
(incisor/canine/premolar/molar), existing root canal treat-
ment (with/without), pocket depth (PD: 3 mm/4 mm/
5 mm/6 mm), crown-root ratio (<1.0/1.0–1.5/1.5) and type
of abutment (direct: abutment in contact with direct
retainer/indirect: abutment in contact with indirect retain-
er). Root canal treatment and crown-root ratio were
determined from the radiographs taken at the time of prosthetic
diagnosis.
2.3. Statistical analysis
Kaplan–Meier survival analysis12 was performed to show the
survival curve of direct and indirect abutments, as well as the
other residual teeth. The survival distribution was then
compared with a log-rank test. p-values less than 0.05 were
considered to be statistically significant. The Bonferroni
correction methods for counteracting the problem of multiple
comparisons were used.
Cox’s proportional hazard analysis was used to test
bivariate and multivariate associations between each variable
and the abutment survival time. For the multivariate model,
variables for which the bivariable p-value less than 0.25 were
considered as prognostic variables by the stepwise backward
selection (adoption criterion: p < 0.05, exception criterion:
p < 0.10). Cases where data for the prognostic variables were
missing were deleted.
We defined the entry-point as the date of provision
of RPDs and the end-point as either the date of the last
visit to the hospital, which was treated as a censoring, or
the date of abutment tooth loss (defined as extraction of the
tooth or changes to metal or resin coping of the over
denture).
Data were analyzed using PASW Statistics 18 software
(formerly SPSS; IBM Company, Tokyo, Japan).
3. Results
3.1. Demographics
One hundred and forty-seven patients satisfied the inclusion
criteria and had been provided with a total of 236 RPDs. The
total numbers of RPD abutments were 856 and the study
sample contained a further 1114 residual (non-abutment)
teeth (Table 1).
3.2. Clinical outcomes
During the observation period, 13.7% of the abutments were
lost (in contrast to 4.4% of non-abutment teeth), including
17.9% of direct and 8.5% of indirect abutments.
 journal of dentistry 41 (2013) 1175–1180 1177

Table 1 – Characteristics of patients and removable

partial dentures.
Patients Total number 147
Gender (male/female) 55 (37%)/92 (63%)
Age (year) 64.2  8.7 (SD)
Occlusal support A = 13, B1 = 27,
(Eichner classification) B2 = 34, B3 = 32,
B4 = 28, C = 13

Dentures Total number 236

Upper/lower 113 (48%)/123 (52%)
Mean usage period 5 year 5 months
(64.8  16.9 (SD) months)
Mean number of 5.3  2.7 (SD)
artificial teeth/a RPD
Mean number of 3.7  1.1 (SD)
abutment teeth/a RPD

Abutments Total number 856

Type (direct/indirect) 469 (55%)/387 (45%)
SD, standard deviation; RPD, removable partial denture.

3.3. Survival curves

The Kaplan–Meier survival curve is shown in Fig. 1. The 5-year

survival rate was 95.8% for non-abutment teeth, 93.1% for Fig. 1 – Kaplan–Meier survival curves for non-abutment,
indirect abutments and 86.6% for direct abutments. In the log- indirect abutment and direct abutment teeth.
rank test, significant differences between these three groups
were observed by multiple comparison tests.

3.4. Bivariate analysis
Bivariate analysis by using Cox’s proportional hazard
modelling indicated that significant variables were occlusal
support, root canal treatment, pocket depth, crown-root ratio
and type of abutment (Table 2). In the case of occlusal support,
because the statistical difference between A-B2 and B3-C was
apparent, we divided subjects into two groups and re-
analyzed. For the same reason, in the section of pocket depth
and crown-root ratio, subjects were also divided into two
groups, respectively. Results for these analyses are also
shown in Table 2.
3.5. Multivariate analysis
Variables selection for the multivariate model was performed
by the backward selection technique. The final Cox’s propor-
tional hazard model indicated that crown-root ratio (hazard
ratio (HR): 3.13), root canal treatment (HR: 2.93), pocket depth
(HR: 2.51), type of abutments (HR: 2.19) and occlusal support
(HR: 1.90), and were significant prognostic factors in the
abutment survival period (Table 3).
4. Discussion
This longitudinal prospective cohort study indicates the
expected survival trends of RPD abutments, identifies several
significant prognostic factors related to their survival and
generates numeric hazard ratio (HR) values to quantitatively
estimate the extent to which these factors influence their
survival. These novel findings can help us to predict the
survival prospects for abutment teeth at the time of diagnosis
based on their individual characteristics.
The result of the Kaplan–Meier analysis showed that the
survival rate of abutment teeth was significantly lower than
that of non-abutment teeth. A recent clinical study, following
100 patients after periodontal therapy over 10 years, showed
that 18% of RPD abutment teeth were lost, compared with only
6% of non-abutment teeth.13 Other previous research has
suggested that being an abutment of RPDs was a significant
risk factor for tooth loss.8,9,13,14 This is likely due to the
continuous and repetitive mechanical stress with which these
teeth are loaded, the attendant higher risk of damage to the
periodontal tissue. It was also reported that the presence of
RPD retainers can contribute to deterioration in dental hygiene
around abutment teeth.6,15–18
However, survival curves of RPD abutments based on large
number of longitudinal clinical cases have not previously been
reported. Much of the published clinical research19–22 evalu-
ated only the frequency with which abutment teeth are lost,
but this type of censored data do not provide a good prognostic
indication of tooth survival. The Kaplan–Meier method and
Cox’s proportional hazard regression analysis used in this
study are representative ways of performing survival analysis
using the censoring.23
In the multivariate analysis of our data by using Cox’s
proportional hazard regression model, we collected the
objective information about potential factors (both patient-
related and tooth-related), which can be evaluated easily and
correctly by any dentist. This multivariate regression analysis
indicated several independently significant prognostic factors.
Occlusal support area was one of the significant prognostic
factors. In a 28-year follow-up survey, it was indicated that the
1178 journal of dentistry 41 (2013) 1175–1180

Table 2 – Bivariate analysis for prognostic factors affecting survival of RPD abutments using the Cox’s proportional hazard
model.
Variable Reference Number of teeth Loss of teeth HR 95% CI p-Value
Gender Male 359 46 1
Female 497 71 1.06 0.73–1.53 0.775

Age Under 65 393 55 1

65 or more 497 62 0.98 0.68–1.41 0.910

Lifestyle-related Diseases Without 521 64 1

With 335 53 0.30 0.91–1.88 0.154*

Occlusal support A and B1 203 16 1

B2 199 17 0.90 0.45–1.78 0.759
B3 219 42 2.33 1.31–4.15 0.004*
B4 156 28 2.04 1.10–3.77 0.023*
C 79 14 2.18 1.06–4.47 0.033*

A-B2 402 33 1
B3-C 454 84 2.33 1.56–3.48 <0.001*

Upper/lower Lower 454 61 1

Upper 402 56 1.06 0.74–1.52 0.761

Type of teeth Canine 212 27 1

Premolar 462 56 0.94 0.60–1.49 0.806
Molar 161 28 1.48 0.87–2.50 0.149*
Incisor 21 6 2.85 1.17–6.90 0.021*

Type of abutment Indirect 387 33 1

Direct 469 84 2.16 1.44–3.23 <0.001*

Root canal treatment Without 462 38 1

With 394 79 2.52 1.71–3.72 <0.001*

Pocket depth 3 mm or less 510 48 1

4 mm 130 13 1 0.58–1.99 0.814
5 mm 56 15 3.04 1.70–5.42 <0.001*
6 mm or more 76 25 4.14 2.55–6.71 <0.001*

4 mm or less 640 61 1
5 mm or more 132 40 3.59 2.41–5.34 <0.001*

Crown-root ratio Less than1.0 486 48 1

1.0–1.5 195 20 1.09 0.65–1.83 0.756
More than 1.5 105 39 4.64 3.04–7.08 <0.001*

Less than 1.5 681 68 1

1.5 or more 105 39 4.53 3.05–6.72 <0.001*
HR, hazard ratio; CI, confidence interval.
Occlusal support was classified based on the Eichner classification.
*
Variables with p < 0.25 were considered as potential prognostic factors.

number of residual teeth at baseline significantly influenced
tooth loss, with fewer residual teeth tending to increase tooth
loss.24 In another report, patients using free-end-saddle-type
RPDs tended to experience more abutment loss. Moreover,
the survival period of abutments was shorter for bilateral
free-end-saddle-type RPDs than for unilateral ones.20 Both
results may indicate that a decrease in the number of residual
teeth, and therefore in the occlusal support area, has the
potential to cause occlusal instability, increasing the occlusal
load on the abutment teeth, and damaging the underlying
periodontal tissue. In addition, our findings suggest that the
presence of bilateral premolar occlusal support may be
crucial for the stability of the occlusal position, as indicated
by the large statistical difference between the A-B2 and B3-C
groups.
Both the crown-root ratio and pocket depth (PD) were
prognostic factors affecting the survival period. The estima-
tion of crown-root ratio is achieved simply through objective
measurement of a radiographic image. In general, we consider
the crown-root ratio an important criterion in selecting
suitable abutment teeth for RPDs.25 Teeth are adjudged to
be unsuitable as abutments if there is alveolar bone resorption
of over half of the total root length. However, from the result of
this bivariate analysis, there was little difference between
the ‘‘<1.0’’ and ‘‘1.0–1.5’’ groups (HR: 1.08, p = 0.756). So far,
there were quite few reports about the relationship between
 journal of dentistry 41 (2013) 1175–1180
Table 3 – Multivariate analysis for prognostic factors
affecting survival of RPDs abutments using Cox’s pro-
portional hazard model.
Variable Reference HR 95% CI p-Value
Crown-root Under 1.5 1 sample, it is possible that other prognostic factors could arise
ratio Over 1.5 3.13 2.00–4.90 <0.001
Root canal Without 1
treatment With 2.93 1.85–4.63 <0.001
Pocket depth 4 mm or less 1
5 mm or more 2.51 1.61–3.91 <0.001
Type of Indirect 1 mouth for RPD treatment by suitably qualified dental profes-
abutment Direct 2.19 1.36–3.52 0.001
Occlusal A-B2 1 odontal maintenance, including scaling, root planning and
support B3-C 1.90 1.17–3.10 0.010
HR, hazard ratio; CI, confidence interval.
Occlusal support was classified based on the Eichner classification.
Variables with p < 0.25 in the bivariate analysis were considered as
prognostic variables by stepwise backward selection (adoption
criterion: p < 0.05, exception criterion: p < 0.10).
26
crown-root ratio and the tooth survival time. PD is another
reliable objective index for evaluating periodontal condition.
Matuliene et al. reported that, from multivariate analysis of
the association between PD and tooth loss, PD of 5 mm and
over represented a significant risk factor, compared with PD of
3 mm or less.27 The corresponding odds ratios in that study for
PD = 4, 5, 6 and 7 mm and more were 1.6 ( p = 0.034), 3.0
( p < 0.0001), 2.7 ( p = 0.005) and 9.9 ( p < 0.0001), respectively.
Consistent with this previous work, we showed that abut-
ments with 5 mm PD and more were statistically at higher risk
of teeth loss. Our bivariate analysis showed that the HR of
4 mm PD compared with 3 mm PD was 1.00 ( p = 0.814),
suggesting no difference in the risk of tooth loss.
The existence of previous root canal treatment also
independently affected the survival time of abutment teeth.
So far it has been reported that the 4-year survival rate of 759
teeth following primary root canal treatment were 95%.28
Conversely, in case of the 410 abutment teeth of RPD after root
canal treatment, the 5-year survival rate was only 51%.29 This
difference suggests that a retainer for RPD might deteriorate
survival of endodontically treated teeth, rather than existence
of root canal treatment itself. The mechanical stress from the
RPD must increase the risk of that tooth fracturing.
There was a significant difference of the survival rates
between direct and indirect abutment teeth, indicating that the
type of abutments was also a prognostic factor. No existing
reports have compared direct and indirect RPD abutment teeth.
RPD abutments continuously loaded the mechanical and
bacterial stress from RPDs and have a higher risk to damage the
periodontal tissue than non-abutment teeth. Especially, direct
abutment teeth experience continuous and repetitive mechan-
ical loading (including the rotational and settling movements of
the RPD) much more directly than indirect abutment teeth.
This study also calculated the HR of each factor. For
instance, the HR of the type of abutment showed that indirect
abutments were likely to survive 2.19 times longer than direct
abutments after controlling for other factors. Importantly, by
using Cox’s hazard regression model, we can also calculate the
individual survival probability of the abutment teeth at any
1179
given point in time under each specific condition, giving us
previously unprecedented prognostic power.
As the patients in this study were limited to those attending
a university hospital, and might therefore be a selective
in other trials, or that the quantitative differences determined
here might change. However, we included all the patients
satisfying appropriate selection criteria over a 2-year period:
this type of continuous sampling minimizes any selection bias.
All RPDs were provided by a limited number of operators with
advanced training in prosthodontics, after preparation of the
sionals. The patients visited the hospital regularly for peri-
tooth polishing, throughout the observation period. Therefore,
we are confident that the significant prognostic factors found in
this research are an accurate reflection of those affecting the
survival of RPD abutments in general population.
5. Conclusion
We conclude that RPD abutment teeth are more likely to be
lost than other residual teeth. Occlusal support, crown-root
ratio, root canal treatment, pocket depth and type of abutment
are related to the survival time of RPD abutments. These
results will help us to estimate the individualized risk and
benefit of the prosthodontic treatment for the residual teeth,
to evaluate the prognosis of RPD abutments and also to
develop evidence-based dentistry in practice.
Conflict of interest
There is no conflict of interest.
Acknowledgments
We would like to express our deepest gratitude to Professor
Finbarr P. Allen, for providing carefully considered feedback
and valuable comments. We are also indebted to Professor
Hirofumi Yatani for his invaluable comments and warm
encouragements. This research was supported by a Grant-in-
Aid for Scientific Research (No. 22592149) from the Japan
Society for the Promotion of Science.
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