BIOMECHANICS OF DISTAL EXTENSION BASE REMOVABLE PARTIAL DENTURE

DR.SHARAZ SHAIK DEPT. OF PROSTHODONTICS GOVT.DENTAL COLLAGE AND HOSPITAL HYDERABAD

INDEX
1. Introduction 2. Definitions 3. Review of literature 4. Bio-mechanical problems Forces acting on distal extension base Factors influencing magnitude of stress Transmission to abutments 5. Stress control (remedies) Theories of stress control 6. Design considerations 7. Conclusion

INTRODUCTION

It is axiomatic in prosthodontics that a properly fabricated FPD is superior to a RPD. The reason for this is that the FPD does not move in function, and forces against it from any direction are directed down the long axis of the abutment teeth. This is in direct contrast to what happens to forces directed against a RPD Devan in 1952 has said that in partial denture prosthetics our
objective must be the perpetual preservation of what remains rather than the meticulous restoration of what is missing. The achievement of this ideal is

generally more difficult in the case of the free end saddle than the bounded saddle RPD. Tylman correctly stated, great caution and reserve are essential whenever
an attempt is made to interpret biological phenomenon entirely by mathematical computation. However, an understanding of certain things mechanical

and of simple machines should enhance our rationalization of the design of RPD to accomplish the objective of preservation of oral structures. A RPD can be, and often is an unknowingly designed destructive machine. Maxwell stated common observation clearly indicates that the ability of living
things to tolerate force is largely dependent upon the magnitude or intensity of the force. The supporting structures for RPD are living things and are

subjected to forces. In consideration of maintaining the health of these supporting structures, the dentist must also consider direction, duration, and frequency of force application as well as magnitude of the force. Machines may be classified into two general categories a simple and complex. Complex machines are combination of many simple machines. These are six simple machines. Lever, wedge, screw, wheel and axle, pulley, and an inclined plane. The lever and the

inclined plane most deserve our consideration in designing RPD. A consideration based on avoiding lever and inclined plane designs to the greatest extent possible. Of all partial dentures, an all tooth supported, (or) class iii partial denture can best resist forces. The reasons for this are as follows (a) It is supported by abutment teeth, (b) rarely subjected to induced stresses and leverage type forces (c) there are no fulcrums around which the partial denture may rotate. (d) Inclined planes are also not a factor when RPD is tooth supported. It is in distal extension RPD that the type of prosthesis controlling stress is important. Class i, ii, and iv RPD are subjected to greater stresses because their support is a combination of both tooth and soft tissue. The distal extension RPD is subjected to rotation around three principal fulcrums. Movement usually takes place around all three fulcrums simultaneously. Components of the RPD may then be positioned to counteract or prevent as much of the rotation as possible. Forces must be controlled by maximum coverage of soft tissue, by proper use of direct retainers and by placement of the components in the most advantageous position. A better and logical understanding of the forces and the methods to control these forces on a RPD is essential. This is what has been highlighted in this seminar.

DEFINITION
According to glossary of prosthodontic terms, a distal extension RPD is defined as A removable partial denture that is supported and retained by natural teeth only at one end of the denture segment and in which a portion of the functional load is carried by the residual ridge.

BIO-MECHANICAL PROBLEMS
FORCES ACTING ON PARTIAL DENTURE (DISTAL EXTENSION)
The forces acting on a partial denture are a result of a composite of forces arising from three principal fulcrums 1. One fulcrum is on the horizontal plane that extends through two principal abutments, one on each side of the dental arch and is termed the horizontal fulcrum line. This fulcrum controls the rotational movement of the denture in the sagittal plane (denture movement toward or away from the supporting ridge.). Rotational

movement around this horizontal fulcrum line or axis is of the greatest magnitude of all the three fulcrums, but not necessarily the most damaging. The resulting force on the abutment teeth is usually mesioapical or disto-apical, with the greatest vector in the apical direction. 2. A second fulcrum is on the sagittal plane and extends through the occlusal rest on the terminal abutment and along the crest of the residual ridge on one side of the arch. In class I situation, there would be two of these fulcrums, one on each side of the arch. This fulcrum controls the rotational movements of the denture in the vertical plane (rocking or side to side, movements over the crest of the ridge). This movement, although easier to control than the first and

usually not of greater magnitude, can be damaging, the main direction of the resulting force is more nearly horizontal and not well resisted by the tissues.

3. The third fulcrum is located in the vicinity of the midline just lingual to the anterior teeth. This fulcrum line is vertical, and it controls the rotational movement of the denture in the horizontal plane or the flat circular movements of the denture. The intensity, magnitude, direction, and time duration of the force application are of particular importance to the clinician. Every effort must be made in the design of a RPD to control or minimize the rotational movements related to these three principal fulcrums. FACTORS INFLUENCING MAGNITUDE OF STRESSES TRANSMITTED TO ABUTMENT TEETH

Patient factors
1. Length of the edentulous span: The longer the edentulous span, the longer will be the occlusal surface and the greater will be the force transmitted to the abutment teeth. 2. Quality of edentulous ridge: (a) Form of the residual ridgelarge, well formed ridges are capable of absorbing greater amount of stress than are small, thin, or knife edged ridges. Broad ridges with parallel sides permit the use of longer flanges on the denture base, which helps stabilize the denture against lateral forces.
(b) Type of mucoperiosteum: -- a healthy mucoperiosteum approx. 1mm

thick is capable of bearing a greater functional load than is a thin atrophic mucosa. Soft, flabby, displaceable tissue contributes little to

the vertical support of the denture and nothing to lateral stability of the denture base. This type of tissue allows excessive movement of the
denture, with resultant transmission of stress to the adjacent abutment tooth.

(c) Type of bone: - dense compact bone can withstand greater forces without unfavorable results and resorption than cancellous bone. 3. Condition of the abutment teeth: Teeth with long bifurcated and multiple roots with an acceptable crown to root ratio acts as better abutments than teeth with single, conical, and small root. The better the periodontal support the better service the abutment will render.

Design factors
4. Clasp: Quality of the clasp: - the more flexible the retentive arm of the clasp, the less stress is transmitted to the abutment tooth. On the other hand a flexible clasp arm contributes less resistance to the destructive horizontal stresses. Therefore, as the flexibility of the clasp increases, both the lateral and vertical stresses transmitted to the residual ridge increase. On the basis of findings made during the patient examination phase a decision has to be made as to whether the ridge or the abutment tooth requires the most protection. If the periodontal support of the abutment

tooth is good, a less flexible clasp such as a vertical projection clasp would be indicated because the tooth would more likely be able to with stand a
greater amount of stress. If on the other hand, the periodontal support has been weakened, a more flexible clasp such as the combination clasp with a

wrought wire retentive arm should be used so that the residual ridge
would share more of the resistance to horizontal forces acting on the partial denture. Clasp design: -a clasp should be designed so that it is passive when it is completely seated on the abutment tooth. A passive clasp will exert less stress on the abutment tooth than one that is not passive .

A clasp should be designed so that during insertion or removal of the

prosthesis the reciprocal arm contacts the tooth before the retentive tip passes over the greatest bulge of the abutment tooth. This will stabilize
and neutralize the stress to which abutment tooth is subjected. Length of the clasp: - lengthening the clasp can increase flexibility. Doubling the length of a clasp will increase its flexibility five times.

Diameter of the clasp: - flexibility is inversely proportional to the diameter of the clasp. As the diameter of the clasp increases, the flexibility decreases. Taper of the clasp: -clasp arm tapered both length wise and width wise is more flexible than arm of the same dimensions tapered only length wise. Cross sectional form of the clasp arm: - The only universally flexible form is the round form, which is practically impossible to obtain by casting and polishing of the half round form. Since all cast clasps are half round they may flex away from the tooth but edgewise flexing is limited. A retentive clasp arm on an abutment adjacent to a distal

extension base must not only flex during placement and removal but also must be capable of flexing during functional movement of the distal extension base.
Material used in clasp construction: - a clasp constructed of chrome alloy will normally exert greater stress on abutment tooth than a gold clasp, all other factors being equal, because of the greater rigidity of the chrome alloy.

5. Abutment tooth surface: The surface of a gold crown or restoration offers more frictional resistance to clasp arm movement than does the enamel surface of a tooth. Therefore, greater stress is exerted on a tooth restored with gold than on a tooth with intact enamel. 6. Occlusal harmony A disharmonious occlusion generates horizontal forces that, when magnified by the factor of leverage can transmit destructive forces to both the abutment teeth and residual ridges. Type of opposing occlusion :A partial denture constructed to oppose a complete denture will be subjected to much less occlusal stress (30psi) than one opposed by natural dentition (300psi) Area of the denture base against which occlusal load is applied: if the occlusal load is applied to the base adjacent to the abutment tooth, there will be less movement of the denture base and less stress transmission than if the load is applied at the distal end of the denture base. (lever arm is increased)Ideally, the occlusal load should be applied in the center of the denture bearing areas, both antero posteriorly and buccolingually. Cutting efficiency of the cusps: 33*and 20* cusped teeth have better cutting efficiency than zero degree teeth. As the sharpness of the cusps increases, the cutting efficiency increases, and hence less force is transmitted to the residual alveolar ridge during mastication.

STRESS CONTROL [REMIDIES]

Theories of controlling stress Dr. A.H. Schmidt first expounded the basic principles of RPD construction in 1956. There are three basic, underlying approaches to distributing the forces acting on a partial denture between the soft tissue and the teeth. 1. Stress equalization theory 2. Physiologic basing theory 3. Broad stress distribution theory

STRESS EQUALIZATION THEORY [STRESS BREAKERS] Philosophy

The resiliency of the tooth secured by the periodontal ligament in an apical direction is not comparable to the greater resiliency and displaceability of the mucosa covering the edentulous ridge. Because of this great disparity, forces are transmitted to the abutment teeth as the denture bases are displaced in function (in cases of distal extension RPD). The rigid connection between the denture bases and the direct retainer on the abutment teeth is damaging and that some type of stress direct /equalizer /breaker is essential to protect the

vulnerable abutment teeth.

Stress breaker /director may take several forms /types

1. Those having a movable joint between the direct retainer and denture base e.g. hinges, sleeves and cylinders, and ball and socket devices (some of which are spring loaded). The various hinges are

Swiss made Dalbo attachment, the Crismani attachment and the ASC 52 attachment. 2. The second group constitutes of the articulated partial denture designs having a flexible connection between the direct retainer and the denture base. These include the use of wrought wire connector, divided major connectors, and other flexible devices for permitting movement of the distal extension base. Included also in this group are those using a movable joint between two major connectors e.g. Lingual bars of wrought metal Advantages of stress breakers a) Stress director design usually calls for minimal direct retention. b) Internal attachment can be widely used c) Less bone resorption and hence the alveolar support is preserve. d) Stress between the abutment teeth and residual ridge can be balanced. e) Intermittent pressure of the denture bases massages the mucosa, thus providing physiologic stimulation, which prevents bone resorption and eliminates the need for relining. f) If relining is needed but not done, the abutment teeth are not damaged as quickly g) Splitting of the weak teeth by the denture is made possible despite the movement of a distal extension base.

Disadvantages of stress breakers a) The broken stress denture is usually more difficult to fabricate and therefore more expensive b) Many stress breakers designs are not well stabilized against horizontal forces. c) The effectiveness of indirect retainers and cross arch stabilization is reduced or eliminated altogether.

d) The more complicated the prosthesis, the less the patient may tolerate it. e) Spaces between components are sometimes opened up in function, thus trapping of food and occasionally the tissue of the mouth leading to injury and periodontal problems. f) Flexible connectors may be bent and distorted by careless handling. g) Repair and maintenance of any stress breaker is difficult, costly and frequently required. h) If relining is not done whenever needed, it may result into excessive resorption of residual ridge.

Physiologic basing theory

Philosophy

The philosophy of design agrees in part with the first school about the relative lack of movement of the abutment teeth in an apical direction but denies the necessity of using stress directors to equalize the disparity of vertical movement between the tooth and the mucosa. The belief is that the equalization can best and most simply be accomplished by some form of physiologic basing, or lining, of the denture base. The physiologic basing is produced either by displacing or depressing the ridge mucosa during the impression making procedure or by relining the denture base after it has been fabricated. The reason for displacing the mucosa during the impression procedure is to record the soft tissue in its functioning, not anatomic, form. If the tissues are recorded in their functional state, the denture base, formed over the

displaced tissue, will be better able to withstand the force that is

generated. It is obvious that in such situation, the artificial teeth will be positioned above the plane of occlusion when the denture is in mouth

and not in function. To permit vertical movement of partial denture from the rest position to the functioning position, the direct retainers or retentive clasps must be designed with minimal retention and the number of direct retainer must be limited. The occlusal rest and direct retainers will also be slightly unseated at rest. They will be completely seated only when the mucosa beneath the denture base is displaced to its functional form. ADVANTAGES a) The intermittent base movement has a physiologically stimulating effect on the underlying bone and soft tissue , which reduces the frequency of relining or rebasing the prosthesis (there will be less bone loss ) b) Simplicity of design and constructive because of the minimal retention requirements results in a light weight prosthesis needing minimal maintenance and repair c) An additional advantage is gained by the minimal direct retention used. The looseness of the clasp (combination clasp with wrought wire retentive arms) on the abutment tooth reduces the functional forces transmitted the abutment tooth. Hence the abutment teeth are preserved for longer time duration. DISADVANTAGES 1. The denture is not stabilized against lateral forces 2. The residual ridge receives the greater proportion of forces that are transmitted by the denture, hence more chances of bone resorption 3. The load of stabilizing and supporting the denture is limited to a few teeth instead of being shared by a number of teeth as in other design philosophies 4. There will always be slight premature contacts between the opposing teeth and the denture teeth when the mouth is closed. This is an uncomfortable situation to many patients and may result a sense of insecurity

5. It is a difficult to produce effective indirect retention because of the vertical movement of the denture and the minimum retention of the direct retainer.

BROAD STRESS DISTRIBUTION THEORY philosophy

Advocates of this theory believe that excessive trauma to the remaining teeth and residual ridge can be prevented by distributing the forces of occlusion over as many teeth and as much of the available soft tissue as possible. This is accomplished by the use of additional rests, indirect retainers, clasps and broad coverage denture bases. ADVANTAGES 1. The forces of occlusion are reduced on any one tooth or area of the ridge leading to physiologic stimulation, less resorption and a state of health. 2. Lateral forces are distributed over as many teeth as possible and are better tolerated. 3. This approach constitute a form of removable splinting and can be very helpful in instances where fixed splinting is not indicated because of a guarded prognosis or for economic reasons. 4. The prostheses are easier and less expensive to fabricate. 5. There are no flexing or moving parts, so there is less danger of distorting the denture. It is also less subjected to breakage. 6. Excellent horizontal stabilization can be achieved. 7. The prostheses do not require frequent relining DISADVANTAGES 1. Increased bulk may cause the prosthesis to be less comfortable and less well accepted by the patient.

2. Preventive dental programs to monitor caries must be instituted and carefully followed by the patient. 3. Less conservative approach.

DESIGN CONSIDERATION
Direct retention Indirect retention Occlusion Denture base considerations Major connector minor connector Rests

Direct retention
A RPD (distal extension) should always be designed to keep clasp retention to a minimum yet provide adequate retention to prevent dislodgment of the denture by the unseating forces. Direct retention is provided by the retentive clasps. Other components of the denture should also be used to contribute to the retention of the prosthesis so that the amount of retention provided by clasps can be reduced.

Other factors of retention:

Forces of adhesion and cohesion: the denture base should cover maximum area of available support and must be accurately adapted to the underlying mucosa to secure maximum possible retention through the use of forces of adhesion and cohesion. Frictional control: guide planes should be created on as many teeth as possible. The planes may be created on enamel surfaces of teeth

or in restorations placed on the teeth. The frictional contact of the prosthesis against these parallel surfaces can contribute significantly to the retention of the denture. Neuromuscular control: any over extension of the denture base either facially, lingually, or posteriorly onto the soft palate will contribute to the loss of retention, and the abutment teeth bearing the direct retainers will be overly stressed because of constant dislodgment of the RPD. A properly contoured denture base can aid the patients neuromuscular control of the prosthesis.

Clasp retention
Configuration:
In a class I situation, bilateral configuration is followed. In the bilateral configuration the clasps exert little neutralizing effect on the leverage-induced stresses generated by the denture base. These stresses must be controlled by other means. In a class ii situation, tripod configuration is followed. The largest possible area of the denture should be enclosed in the triangle formed by the retentive clasps. This design is not as effective as the quadrilateral configuration, but is most effective in neutralizing leverage in class ii situations

Clasp position
Retentive clasp tip should engage the retentive undercut which lies below the height of contour and it can be maintained for a desirable depth (either reduced by tilting or created by enameloplasty) all other portions of the clasp assembly must lie above the height of contour. Usually the position of the retentive clasp to the height of contour is more important in retention and in controlling stress than is the number of clasps

Clasp design

Circumferential cast clasp:

The conventional c-clasp originating from a distal occlusal rest on the terminal abutment tooth and engaging a mesiobuccal retentive undercut should not be used on a distal extension RPD. The terminal of this clasp reacts to movement of the denture base toward the tissue by placing a distal tipping, or torching force on the abutment tooth. This particular force is the most destructive force a retentive clasp can exert. This clasping concept must be avoided at all costs. The reverse circlet clasp It approaches a distobuccal undercut from the mesial surface of a terminal abutment tooth is acceptable. As an occlusal load is applied to the denture base, the retentive terminal moves further gingivally into an area of greater undercut and looses contact with the abutment tooth. Thus, the torque is not transmitted to the abutment tooth. Vertical projection or bar clasp

It is indicated when a retentive undercut isolated on the distobuccal surface. It is never indicated when the tooth has a mesiobuccal undercut. It functions in a manner similar to C-clasp except that it has gingival direction of approach. Combination clasp:

When a mesio-buccal retentive undercut exists on an abutment tooth adjacent to a distal extension edentulous ridge, the combination clasp can be employed to reduce the stress transmitted to the abutment tooth. It has a wrought wire retentive arm that has a stress breaking action and can absorb torsion stress in both the vertical and horizontal planes.

Splinting of abutment teeth

Adjacent teeth may be splinted by means of crowns to control stress transmitted to a weak abutment tooth. Fixed splinting is indicated when some loss of periodontal attachment has occurred after periodontal disease or therapy. Splinting is indicated whenever stabilization is required in a mesio-distal or antero posterior direction. Splinting is also indicated when the proposed abutment tooth has either a tapered root or short roots such that there is not an adequate periodontal membrane attachment. It is also indicated when the terminal abutment tooth on the distal extension side of the arch stands alone, as edentulous space exists both anterior and posterior to it.

INDIRECT RETENTION
The indirect retention is essential in the design of classes ii and I partial dentures. By using the mechanical advantage of leverage, it counteracts the forces attempting to move the denture base away from the residual ridge by moving the fulcrum farther from the force. In a class I prosthesis, the fulcrum line would be moved from the tips of the retentive clasp to the most anteriorly located component, the indirect retainer. The indirect retainer must be placed in a rest seat. It also contributes, to a lesser degree, to the support and stability of the denture. The indirect retainer in a class I arch, must be located as far anterior to the fulcrum line as possible. Although it is not as critical in class ii arch as in class I arch, it is still required. In a class ii arch, the situation is reverse. The lever arm is anterior to the fulcrum line, so the indirect retainer must be located as for posterior as possible on the other side of the arch.

OCCLUSION
A smoothly functioning harmonious occlusion with the movements of TMJ and the neuro-musculature will decrease the stress transferred to the abutment teeth and residual ridge. Maximum intercuspation (MR) and CR should coincide. These should be no occlusal prematuries. Food table of artificial teeth should be reduced in buccolingual width and the number of teeth to be replaced can also be minimized. Artificial posterior teeth should possess sharp cutting surfaces and sluiceways for the escape of food so that masticatory load on residual ridge can be minimized and efficiency of mastication can be increased. Steep cuspal inclines should be avoided. DENTURE BASE CONSIDERATION The denture base should be designed to cover as extensive an area of supporting tissue as possible. The denture base flanges should be made as long as possible for increasing stability The distal extension denture bases must always extend onto the retromolar pad area of mandible and cover the entire tuberosity of maxilla. Both structures are capable of absorbing more stress than the rest of alveolar ridge anterior to them. Borders should not be overextended other wise more functional displacement of the prosthesis will occur which will exert more forces on the abutment teeth. Gagging may occur and patient will be more uncomfortable. There should be an accurate adaptation of the denture base to the residual ridge. Impression technique should be carefully selected after considering the mucosa and bone. The contours of the polished surface of the denture base needed to be developed to aid/assist in denture retention and stability.

MAJOR CONNECTOR It must be hard (rigid). Rigidity contributes to the effectiveness of cross arch stabilization. Design should be simple. Maximum area should be covered. In maxilla, broad palatal coverage is desired, as far as possible and in mandible, lingual plating (periodontally weak teeth) .the major connector should not hamper the tongue movements. In maxilla, it should be placed 6mm away and in mandible 3mm away from the sulcus depth. That way, free gingival circulation and hygiene can be effectively maintained. MINOR CONNECTOR It must be rigid. It should be positioned to enhance comfort, cleanliness, and the placement of artificial teeth. It should be placed in intimate contact to the tooth surface so that better horizontal and lateral stabilization can be achieved. RESTS Rest seat should be prepared so that stresses are directed along the long axis of the tooth. It should be saucer shaped. The deepest portion should make an acute angel with long axis of the tooth and the line angel to avoid inclined plane effect. Rests are to be placed next to edentulous space except for few exceptions e.g.. In class I situations mesio occlusal rest is preferred. Teeth should be selected for rest preparation to provide maximum possible support for the prosthesis. All sharp line angles and point angles are rounded off to avoid stress concentration. The rest must be free to move in rest seat. The more teeth that bear seats the less will be the stress on each individual tooth.

CONCLUSION Most of the edentulous conditions existing in the patients mouth, fall in the category of class I and ii and need to be replaced with distal extension RPD It is a Hercules task to fabricate a good distal extension RPD The motto should always be the perpetual preservation of what exists in the oral cavity and not the meticulous replacement of what is missing. A detailed history, diagnosis, treatment planning and proper execution of the bio-mechanically principles with excellent clinical and lab skills, is required for rehabilitation of the patient with distal extension RPD.