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Prosthetic design modifications to improve esthetics in removable metal partial dentures

Prosthetic design modifications to improve

esthetics in removable metal partial
dentures
Modifications in removable partial dentures design looking for better
aesthetic results
Fernández E*, Monardes H**, Mardones F***, Acosta H****, Segovia JL****,
Román J****, Bernal G****

SUMMARY

Despite the undeniable increase in the use of integrated bone implants in the treatment of the extensive problem
of partial edentulousness, the fabrication of removable metallic prostheses continues to be the main current
therapeutic resource on a worldwide scale. However, from the patient's point of view, the recovery of esthetic
function is its main shortcoming. We propose, therefore, to extend the use of the principle of frictional retention
inherent to fixed prosthesis, through the preparation of "frictional retentive facets" in certain abutment teeth, thus
generating removable prosthetic artifacts with sufficient retention, without exhibiting metallic elements in the
anterior sectors of the oral cavity. Five clinical cases are presented that support the validity of our proposal after
a correct indication.

Keywords: Removable prosthesis, retention, esthetics, retentive facets.

SUMMARY

Despite the fact that nowadays the use of osseointegrated implants is increasing worldwide nevertheless
removable partial dentures with cast metal frameworks is still the most indicated treatment for cases of partial
edentulism. However, patients remain reluctant regarding the aesthetic impairment brought by some of the
removable partial dentures' components. Therefore we propose to apply to removable partial dentures some of
the frictional retention's principles used in fixed prostheses, preparing instead of conventional guiding planes in
some abutment teeth, a more wide and extensive platform what we called "frictional retentive facets".
Accordingly we can afford to provide enough retention to our removable devices without exposing unaesthetic
components such as vestibular retentive arms. Five clinical cases will be shown in order to sustain our proposal
keeping in mind the need of respecting the right indication.

* Degree in Dentistry. University of Chile. Specialty in Dental Prosthesis, Université Catholique de Louvain.
Professor of the V year of Integrated Clinics and Postgraduate in Oral Rehabilitation of the Faculty of
Dentistry. San Sebastian University. Santiago de Chile.
** Dental Surgeon, Universidad de Concepción. Master in Biomedical Sciences, Universidad de Talca. Professor
of the V year of Integrated Clinics and Director of the Endodontics Postgraduate Course of the Faculty of
Dentistry, Universidad San Sebastián, Santiago de Chile.
*** Dentist Surgeon, Universidad de Chile, student of the Postgraduate Course in Oral Rehabilitation, Version
2010- 2011. San Sebastian University. Santiago de Chile.
* * * * Students of V year 2011, Integrated Clinics, School of Dentistry. San Sebastian University.
Santiago de Chile.

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Key words: Removable prostheses, retention, aesthetic, retentive facets.
Date of receipt: March 23, 2012.
Accepted for publication: May 25, 2012.
Fernández E, Monardes H, Mardones F, Acosta H, Segovia JL, Román J, Bernal G. Prosthetic design
modifications to improve esthetics in metal removable partial dentures. Odontostomatol Av. 2013; 29 (4): 175-
183.
INTRODUCTION
The term guide plane refers to two or more parallel
vertical surfaces on abutment teeth designed to direct
the prosthesis during insertion and removal. This is
their main function. The guide plane surfaces should
be as parallel to the major axis of the abutment tooth
as possible (1).
The guide planes thus elaborated to determine a
single axis of insertion and removal of the es-
cheletic or metallic prosthesis provide the latter with
a certain retention by friction, generated by the
intimate or close contact of the metallic element of
the base on the dental surfaces of the abutments for
those parallelized fi- nes (guide planes).
This type of "frictional retention" (FR), which we
seek and use in a fundamental way in fixed
prostheses, (2) acquires a secondary role in
removable prostheses compared to the retention
provided b y t h e kinetic energy generated by the
flexion of a retentive arm when flanking the
prosthetic equator.
However, we believe that the secondary role of the
R.F. The results obtained in the guide planes could
acquire greater preponderance in the retention of the
removable prosthetic appliance if we were to
introduce some modifications that refer both to the
extension in the preparation and to the maxilla
and the type of reduction presented by the clinical
case to be treated (Kennedy's classification), In
this way, we could obtain a great esthetic advantage
in the prosthesis since the metal base thus made
would not place visible retentive arms in the
vestibular, anterior sections of the mouth.
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By extending to the maximum the wear we perform
on the face near the span, in an axial, cervico-
occlusal and palatal or lingual vestibule direction, we
will obtain a surface for friction much larger than
that of a small guide plane, that is to say, it
constitutes a "Frictional Retentive Facet" (F.R.F.).
MATERIAL AND METHODS
We will analyze five clinical cases in which, with
greater and lesser success (read failure), we tried to
apply these concepts for the esthetic benefit o f the
patients, without undermining the essential
requirement of safeguarding the retention of the
prosthetic appliance, capital to recover functions.
The cases were treated during 2011 by students of
the 5th year of Integrated Clinics of the USS,
Santiago campus, and a colleague, a student of the
postgraduate course of Oral Rehabilitation of the
same university.
The clinical procedures and the sequence of
diagnosis, analysis and execution of these removable
metallic prostheses do not differ from the traditional
ones, with the exception of those related to the so-
called biostatic preparation or preparation of teeth
for prosthetic purposes, which we will detail below.
DIFFERENCES IN THE DIMENSIONS OF THE
F.R.F. COMPARED TO GUIDE PLANES
According to McCracken (1), the surface of the guide
planes should be similar to a cylindrical object,
smooth, continuous and with rounded corners. As
a rule of thumb
 Fernández E, Monardes H, Mardones F, Acosta H, Segovia JL, Román J, Bernal G..
Prosthetic design modifications to improve esthetics in removable metal partial dentures

In general, the guide surfaces should span half the
width between the tips of the adjacent vestibular and
lingual cusps, or one third of the vestibulo- lingual
distance of the tooth. They should extend vertically
about two-thirds of the length of the crown enamel
from the marginal crest in the cervical direction.
2. The F.R.F. wear in the cervical occlusal/ cervical
However, the F.R.F. have the following peculiarities
in their preparation (Figs. 1 to 4):
1. In an axial direction with respect to the major
axis of the tooth, the wear should eliminate
practically all the "natural" convexity of the
intervening tooth, wear not less than 0.5 mm.
Upper and lower canines, upper premolars,
lower premolars, upper lateral and lower lateals,
in this respective order, tolerate these
preparations without major pulpal inflammatory
effects, and at the end of the procedure, if such
side effects occur, fluoride varnish (22,600
p.p.m.) can be applied.
incisor direction should occupy the maximum
possible dimension from the marginal ridge, but
maintaining a minimum distance of 1 mm from
the marginal gingiva towards the cervical, similar
in this point to what is indicated for a retentive
complex (R.C.) (3) of the R.P.I. type (4).R.) (3) of
the R.P.I. type. (4) In fixed prostheses, a
cervical/occlusal/ cervical incisor, canine and
premolar dimension of not less than 3 mm is
recommended (2).

Figure 1 Figure 3

Figure 2 Figure 4

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3. In the vestibulo-palatal or lingual direction (or as
Goodacre calls it, faciolingual), the F.R.F. should
cover the maximum possible extension on the
face subjected to wear, taking care not to
"intervene" part of the vestibular face, as this
would diminish the esthetic advantage we are
looking for by not having a metallic element
v i s i b l e on the abutment tooth.
4. When preparing the F.R.F., as with the guide
planes, special care must be taken not to create
angle lines, lingual vestibule or palatal lines,
because, among the many reasons given, the
sharp linear angles create an overconcen- tration
of stress, as well as hinder certain laboratory
procedures (2).
RESULTS
Clinical Case 1
Female patient, 4th decade, Kennedy class III,
maxillary and mandibular, frictional retentive facets
(F.R.F.) in 1.3, 2.2 and 3.3 and 4.3 (Figs. 5 to 10).

Fig. 5 Fig. 6 Fig. 6

Fig. 7

Fig. 8 Fig. 9 Fig. 10

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Prosthetic design modifications to improve esthetics in removable metal partial dentures

Clinical Case 2

Patient mascu- lino

gender, 4th decade,
maxillary Kennedy Class
II, sub-division 2, F.R.F.
at 1.3 and
2.3/Mandibular Kennedy
Class I, subdivision 1,
R.P.I. and Akers retentive
complexes (Figs. 11 to 14).

Fig. 11 Fig. 12

Fig. 13 Fig. 14

Clinical Case 3

Female patient, 7th

decade, maxillary
Kennedy's class III,
subdivision 1, F.R.F. in
1.3, 2.3
1.7 and 2.7 with
intraradicular retainers in
1.5 and 2.7 Fig. 15 Fig. 16
2.5/Mandibular Kennedy
class I (Figs. 15 to 22).

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Fig. 17 Fig. 18 Fig. 19

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Prosthetic design modifications to improve esthetics in removable metal partial dentures

Fig. 20 Fig. 21 Fig. 21 Fig. 22

Clinical Case 4 Fig. 26

Female patient, 3rd decade, Kennedy class III,

subdivision 2, maxilla. F.R.F. in 1.1, 1.3 and
2.3/lower maxilla, Kennedy class III, subdivision 1,
rehabilitated with plural fixed prosthesis, ceramo
metal, conventional (Figs. 23 to 30).

Fig. 27

Fig. 23
Fig. 28

Fig. 24 Fig. 29

Fig. 30

Fig. 25

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Clinical Case 5

Female patient, 3rd decade, Kennedy class III, subdivision 2, maxilla, F.R.F. in 1.3 and 2.3/lower maxilla,
Kennedy class I (Figs. 31 to 38).

Fig. 31 Fig. 32 Fig. 33

Fig. 34 Fig. 35 Fig. 36

Fig. 37 Fig. 38

DISCUSSION In this sense, clinical case 1 corresponds exactly to

We have stated that in order to obtain the advantages
of the F.R.F., the indication in both jaws must be
limited to Kennedy-Applegate class III, whether pure
or subdivisions.
the above, a l t h o u g h in one of the maxillary
abutments operated on, 2.2, being a lateral incisor,
the esthetic benefit is less. In the lower jaw, the
search for retention was reversed in the lower
molars, from vestibular to buccal.

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Prosthetic design modifications to improve esthetics in removable metal partial dentures
lingual, since the natural inclination of these teeth
indicated this in accordance with the selected
insertion axis. In these "posterior" abutments we did
place conventional retentive complexes, such as
those of Akers.
However, in the "anterior" abutments of the retentive
complex, we only place an occlusal or cingular
support for the transmission of masticatory loads
(support), and a minor connector, omitting the active
and containment arms, which are replaced by the
already requested F.R.Fs.
As an argument that ratifies what was stated at the
beginning of this chapter, clinical case 2 shows us
reliably that we cannot over-request the use of the
F.R.F. in Kennedy classes I and II, especially in the
upper jaw. In this particular case, the length of the
left span, without a posterior abutment, in
conjunction with the severity force, did not generate
minimum levels of retention compatible with the
recovery of function. Retention had to be
supplemented by a 0.9 mm reten- tion arm on tooth
2.3.
Clinical case 3, in the upper jaw, constitutes a
singularity in the indication of this resource, since it
allowed us to resort to the F.R.F. complementing the
function of "Sandri-type" cast intraradicular
retainers, without placing retentive complexes in any
of the abutments, thus achieving an optimal esthetic
result.
In this way the F.R.F., in canines and molars that
limit the spans, provided insertion guidance and
stabilization of the prosthesis, mostly delegating the
support to the alveolar bone and the main retention
to the intraradicular devices. Thus, we avoid the
generation of other fulcrums than the one established
in relation to these pins symmetrically located in
teeth 1.5 and 2.5. In this case, the F.R.F. will act
marginally as retention elements, since this is
essentially assumed by the intraradicular retainers.
In the lower jaw, "conventional" rehabilitation using
"Sandri" type "intraradicular attachment" on tooth 3.4
and Nally-Martinet retentive complex on tooth 4.5.
In this same perspective of complementarity of the
F.R.F., clinical case 4 demonstrates its usefulness by
indicating it in the upper jaw, as an alternative of
acceptable esthetic recovery in the anterior sector by
means of a removable partial prosthesis, which
usually results in a challenge not achieved by means
of these artifices, fundamentally due to the intrinsic
difficulty of "making compatible" the esthetic
appearance of natural teeth with that of artificial
teeth, as well as the esthetically unfortunate
"exposure" of retentive arms.
It should be noted that F.R.F. fabrication is not a
priority for natural teeth as shown in Figure 24, teeth
1.3 and 2.3 undamaged and tooth 1.1, restored in
conjunction with 1.2, by means of direct esthetic
veneers with composite resin.
Finally, clinical case 5 presents an alternative
treatment for young patients who have suffered
multiple tooth loss in the upper jaw, but the
remaining teeth a r e distributed in the upper arch in
such a way that it is possible to rehabilitate with
removable prostheses while retaining function and
esthetics. In canines 1.3 and 2.3, F.R.F. in the mesial
and distal sides and fabrication of
R.C. of the "Roach mesiodistal tongs" type (Figs. 33
and 34).
In addition, the omnipresent and unfavorable
economic variable determined to channel resources
to include in a second phase, after orthodontic
closure of diaste- mas, the rehabilitation of the lower
jaw by means of implant-retained prostheses, since
we know that in bilateral free-end edentulousness,
esthetics and function can rarely be satisfactorily
restored by means of removable prosthetic devices.
CONCLUSIONS
We believe that, in today's dentistry, the removable
partial skeletal or metallic prosthesis continues to be
a fully effective therapeutic resource for a vast
population of the planet. Therefore, we must
persevere in the search for improvements and
variation of the prosthetic design provided by the
F.R.F.,
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for Kennedy class III cases and subdivisions, it
constitutes a contribution.
This pertinent indication, hopefully with the metric
presence of posterior teeth, allows us to place
conventional retentive complexes in them, whose
thicker retentive arms will contribute and
"compensate" for the reduction of certain retention in
the anterior sector. The advantage is esthetic, since
we do not have to use active arms in the vestibular of
anterior or visible teeth.
We should not extrapolate the use of F.R.F. to cases
of edentulousness with free ends, Kennedy I and II,
since its contribution to the total retention of the
prosthetic appliance proved to be insufficient.
Kennedy class IV cases can be approached with
good esthetic and functional results by using
rotational insertion shafts that have been widely used
in our specialty since the seventies of the last
century.
BIBLIOGRAPHY .
1. Carr AB, McGivney GP, Brown DT. Principles of
Removable Partial Denture Design. In:
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McCracken Removable Partial Prosthesis. Madrid:
Elsevier España S.A, 2006:154-5.
2. Goodacre ChJ, Campagni WV, Aquilino SA. Pre-
parations dentition for full crowns: an art form
based on scientific principles, J Prosthet Dent
2001;85:363-76.
3. Grimonster J, Fernandez E, Vanzeveren Ch.
Partial removable prosthesis: the major
principles governing the design and performance
of a PAP. -Editions Techniques- Encycl. Méd.
Chir. (Paris- France), Odontologie, 23310 C10 ,
1991, 26 p.
4. Fernandez E, Grimonster J. Retention and
biome- chanics of retentive complexes Part III:
the Kratochvil School and ac- tual retentive
complexes, Av Odontoestomatol 1989;5:180-7.
CORRESPONDENCE
Enrique Fernández M.
School of Dentistry
Universidad San Sebastián
Av. Cumming, 40
Santiago de Chile
E-mail: efernandez@santotomas.cl