Removable Partial Denture

Design: A Study of a Selected

Population in Saudi Arabia

Abstract

Determination of the incidence of various classes of removable partial dentures (RPDs) including their
designs and their comparison with previous studies provide clinically useful information for dental training
and continuing education. The purpose of this study is to determine the pattern of partial edentulism, the
major connector, clasping, and design of 740 cobalt chromium RPD frameworks constructed for a selected
population in Saudi Arabia. RPD framework design information and patient personal data were obtained
from the work authorization form and the dental records respectively. The relationship among age, sex,
nationality, and various Kennedy classes of the RPDs was determined by chi-square statistical analysis.
Results indicate that Kennedy Class III removable partial dentures were the most frequently constructed.
Although gender had no significant relationship, age and nationality had statistically significant relationship
with the distribution of various Kennedy classes of removable partial dentures. Lingual bars and anterior
posterior palatal straps were the most commonly used mandibular and maxillary major connectors. Lingual
and palatal plates, however, were more frequently used than any major connectors for distal extension
RPDs. Comparison with previous findings confirms the established variation in designing RPDs. The
distribution of partially edentulousness revealed the influence of the general pattern of tooth loss, which
could be modified by patient’s demands and socio-economic status. Practitioners need to avail themselves
fully of basic RPD design principles concerning the most commonly encountered classes of RPDs.

Keywords: Partial edentulism, RPD frameworks, removable partial denture design, Kennedy classification

Citation: Sadig WM, Idowu AT. Removable partial denture design: A study of a selected population in
Saudi Arabia. J Contemp Dent Pract 2002 November;(3)4:040-053.

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The Journal of Contemporary Dental Practice, Volume 3, No. 4, November 15, 2002
Introduction

Removable partial prosthodontics is a versatile,

cost effective, and reversible treatment method
for partially edentulous patients at any age. With
the changing trends in dental treatment that favor
retention of natural teeth, a decline in the number
of complete dentures with an increase in the
number of removable partial dentures (RPDs) is
anticipated.1

The objectives of RPD design have been well

established. They include the restoration of
function, enhancement of esthetic and, most
importantly, the preservation of the remaining Variations in RPD design have been demonstrated
teeth and periodontal structures.2 The primary among dentists and laboratories.5-8 Similarly,
purpose for the classification of partially variations in teaching and practice of design
edentulous arches is to identify potential concepts is also known to occur among countries
combinations of teeth to edentulous ridges as exemplified by the documented differences in
in order to facilitate communications among the types of major connectors used in Sweden
dental colleagues, students, and technicians. compared to North America.9,10 A survey of the
Such classification should allow longitudinal dental profession and dental laboratories in the
comparison of the incidence of the various United Kingdom has revealed that up to 60% of
classes of RPDs. Moreover, the trends in the casts received by laboratories has little or no input
incidence of the various classes of RPDs being from the dentists in the design of their patients’
fabricated should be reviewed periodically to dentures.12 Over the years, the concepts of RPD
serve as teaching guidelines.3 A survey by design have been predicated on many factors such
Stratton and Wiebelt included three thousand as clinical conditions, scientific research findings,
partially edentulous mandibular arches and two social acceptance, dogmatic traditions,
thousand partially edentulous maxillary arches. and philosophical axioms.3,10,11
The distribution of various Kennedy Classes of
RPDs were predominated by Kennedy Class I The patterns of tooth loss have been evaluated
in the mandibular arch (Figure 1) and Kennedy in many selected populations in different
Class III in the maxillary arch (Figure 2).4 countries.13-18 The objectives of this study were
to determine the patterns of partial edentulism

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The Journal of Contemporary Dental Practice, Volume 3, No. 4, November 15, 2002
and design frequency of cobalt chromium RPD distribution of the sample population. The mean
frameworks constructed for patients who attended age was 42 for both males and females. Out of
the clinic at the College of Dentistry, King Saud 422 patients, 319 had RPDs in both arches and
University, Riyadh, Saudi Arabia to establish a 103 had RPDs in one arch only. The total number
database for trend comparison and to what extent of RPD frameworks was 740. Their distribution
current design concepts are being followed. based on the Kennedy classification is delineated
in Table 2. Class III (40.8%) were the most
Materials and Methods frequently constructed and Class IV (5.9%) RPDs
were the least frequently constructed (Figure 3).
The work authorization forms for 650 patients
requiring RPDs from the clinics of the College
of Dentistry, King Saud University, Riyadh
written during a one-year period were reviewed
for this study. Dental students under faculty
supervision, interns, and faculty staff treated the
patients. Excluded from this study were work
authorizations for transitional RPDs (29%) and
non-conventional RPDs such as swing lock RPDs
(0.6%), obturators (1%), precision-attachment
retained RPDs (2%), and situations in which
the designs and instructions were ambiguous
(2.5%). Of the 650-work authorizations reviewed,
422-work authorizations for conventional cobalt
chromium RPD frameworks were included in
the study.

The Kennedy classification with the guidelines While maxillary Class III and Class IV RPDs were
advocated by Applegate for each partially more common than their mandibular counterparts,
edentulous arch was recorded.19,20 Categorization more mandibular than maxillary distal extension
of the modifications for the Kennedy RPD classes RPDs (Classes I and III) were found. Of the
was expanded to five categories: anticipated 16 combinations of various classes of
RPDs among the 319 patients with RPDs in both
1. No modification area arches, only the maxillary Class IV RPD opposing
2. Anterior modification area mandibular Class IV RPD combination was
3. Posterior modification area absent. The maxillary Class III RPD and opposing
4. Combined anterior and posterior modification mandibular Class III RPD combination was the
area and most common (22.5%), followed by the maxillary
5. Extensive RPD where only one or two teeth Class III RPD opposing mandibular Class II RPD
present on either or both sides of the arch. combination (13.1%). Next most common were
the maxillary Class I RPD opposing mandibular
The number of modification areas, the type of Class I RPD and the maxillary Class II RPD
major connector, the number and type of direct opposing mandibular Class II RPD combination,
retainer, the use of indirect retainer, and location both at a frequency of 11.3%.
of rest seats on distal extension RPDs were also
recorded. The age, gender, and nationality of the Among the RPDs without modifications, Class
patients were obtained from the dental records, I RPDs [maxillary (6%) and mandibular (12%)]
and their relationship with the various Kennedy were the most common, (Table 3). RPDs with
classifications was determined by chi-square combined anterior and posterior modification
statistical analysis. areas as well as extensive modifications were
more frequently found in the Kennedy Class
Results III followed by Class II of the maxillary arches
Table 1 indicates the number, age, and gender than in the mandibular arch where the posterior

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The Journal of Contemporary Dental Practice, Volume 3, No. 4, November 15, 2002
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The Journal of Contemporary Dental Practice, Volume 3, No. 4, November 15, 2002
modification areas were predominant. Of the respectively). There was a tendency for RPD
740 frameworks, 491 (approximately two-thirds) designs to increase in numerical values from
exhibited one or more modification areas. Class I to Class III between the 15-24 age group
and the 35-44 age group. On the other hand,
The relationship between age, gender, nationality, the designs tended to decrease from Class IV to
and the distribution of RPD classifications is Class I from 45-54 age group upwards to 64 years
demonstrated in Table 4. Although gender had no of age. Both Saudi (mean age 44± 12.9) and
significant relationship, age and nationality was non-Saudi Arabs (mean age: 44.9±10.4) tended
statistically significantly related to classification to have similar patterns of RPD classification
(x2=61.2 p<0.0001 and x2=33.79; p<0.0001 distribution. Both groups had more Class I RPDs

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The Journal of Contemporary Dental Practice, Volume 3, No. 4, November 15, 2002
than Class II RPDs. The Filipino patients (mean maxillary major connector. Close to two-thirds
age: 36.9 + 8.4) and other non-Arab patients (61.4%) of the total number of direct retainers
(mean age: 42.1+11.1) tended to have a steady used were circumferential clasps. This clasp
increase in the number of RPDs from Class I to type was almost evenly distributed between
Class III. both arches. Ring clasps were used to retain
mandibular RPDs approximately twice as
Table 5 indicates that lingual bars (76.9%) and frequently as were the clasps used to retain
anterior-posterior palatal straps (38.7%) were the maxillary RPDs. On the contrary, infrabulge
most commonly used mandibular and maxillary clasps were used twice as frequently for maxillary
major connectors when all classifications were RPDs compared to mandibular RPDs. Likewise,
included. The distribution of the major connectors embrasure clasps were more frequently seen in
by Kennedy classification revealed the palatal the maxillary RPDs.
strap was numerically the most prescribed single

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The Journal of Contemporary Dental Practice, Volume 3, No. 4, November 15, 2002
RPI and RPA clasp assembles were more The RPD services are provided at no charge at
frequently used in the mandibular arch than in King Saud University, College of Dentistry clinics
the maxillary arch. Figures 4 and 5 indicate the and both Saudis and non-Saudis avail themselves
distribution of the types of clasps and the locations to this opportunity. Thus, the study population is a
of rest seats on the abutment teeth of distal diverse cross section of the society.
extension RPDs. On the average, 75.6% of Class
I RPDs and 78.9% of Class II RPDs had indirect A comparison between studies where age and
retainers incorporated into their designs. Indirect gender distribution of the RPDs was indicated
retention was used more often in the mandibular reported that more Class I followed by Class
Class I than in the maxillary Class I frameworks. II RPDs were found in a study with a higher
Whereas, its use was more frequent in the proportion of females, older adults (>50 yrs),
maxillary Class II than the mandibular counterpart. and mandibular prostheses.18 On the contrary, in
a study where there were higher proportions of
Discussion males, younger adults (<50 yrs), and maxillary
RPDs, more Class III followed by Class II RPDs
were found.12 This study had higher proportions
of younger adult males and approximately equal
numbers of maxillary and mandibular prostheses.

Previous reports indicated mandibular distal

extension RPDs (Classes I and II) are more
common than maxillary distal extension RPDs
(Classes I and II).12,18 The opposite case with
Class III and Class IV RPDs is supported by this
study and is in agreement with the established
patterns of tooth loss.11,13-17 When a comparison
was made between this study and the survey
that included 3,000 partial edentulous mandibular
arches and 2,000 maxillary arches,4 there was an
agreement in the proportion of various classes of
RPDs in the maxillary arch only.

A previous study of the patterns of tooth loss

in Saudi Arabia reported that females had a
significantly higher rate of mandibular molar tooth
loss compared to males, suggesting there is a
greater likelihood of finding mandibular distal
extensions among females.16 Nevertheless, this
study did not find significant gender differences
for extension base RPDs possibly because males
outnumbered females by more than half in the
study population. Moreover, in this study, the
increase in the record number of distal extension
RPDs with advancing age was consistent with the
finding of a proportionate number of edentulous
spaces without distal abutments in patients
with a significant increase in age. This finding
is further reinforced in this study because the
Filipino patients with the lowest mean of age
had a higher proportion of Class III and Class IV
RPDs compared to nationalities that had higher
age averages. For information purposes, Filipino

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The Journal of Contemporary Dental Practice, Volume 3, No. 4, November 15, 2002
dentists may routinely extract maxillary anterior
teeth rather than to restore them because they
feel the esthetics of the anteriors are better with a
removable appliance.

Restoring Class III and Class IV partially

edentulous arches with fixed partial dentures
(FPDs) is not totally free of charge like the
RPDs services at King Saud University, College
of Dentistry clinic. However, since the FPD
service is not free of charge, this may influence
the number of partially edentulous patients with
Kennedy Class III to seek RPDs instead.

The preference for anterior–posterior palatal

strap major connectors found in the study as
opposed to the U shaped palatal strap11 or single
strap16 reported in other studies confirms the
established variation that exists in RPD design
concept. The anterior–posterior palatal strap
appears to have been used indiscriminately
especially in Kennedy Class II and III when the
simpler palatal strap was more of a logical choice
giving more comfort to the patient because there
is less tissue coverage and fewer borders to
bother the tongue.4 In this study as well as the
North American study9 the lingual bar was found
to be the most common major connector, but this
is not the case in Sweden7-8 where the dental
connector cingulum bar is the preferred choice of
mandibular major connector because of patient
comfort. Frenum attachment depth of the lingual
alveolar sulcus and the presence of tori have
been found to have the greatest influence on the
choice of mandibular major connectors, while Class I and Class II).11 In spite of the reported
compromised periodontium and existing dentures mechanical and esthetic advantages of a
were found to have less influence.21 The influence gingivally approaching clasp over an occlusally
of the clinicians preference has yet to be fully approaching clasp, many factors such as plaque
investigated. (Figure 6, 7) formation and unfavorable anatomical factors
often mitigate against its use.22
Similarly, the lingual plate was more frequently
used than the lingual bar for mandibular distal It was also anticipated that more frequent use
extension RPDs (Class I and Class II) confirming of the infrabulge clasp in the maxilla than in the
a previous finding.18 Factors such as rigidity, mandible indicates the higher priority for esthetics
support, and indirect retention probably played in the maxilla. On the other hand, the more
a significant role in influencing the choice of these frequent use of the ring clasp in the mandible
major connectors. The overwhelming preference than the maxilla may suggest the higher tendency
for circumferential clasps was demonstrated in of finding mesially inclined mandibular terminal
this study (where over 50% of the RPDs were molar abutments than the maxillary counterparts.
Class I and Class II) in accordance with a
previous study (where 73% of the RPDs were The prescription of RPI and RPA clasp assemblies
for only 55.4% of distal extension cases were not

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The Journal of Contemporary Dental Practice, Volume 3, No. 4, November 15, 2002
comparable to the reported, wherein there is a principle. A careful methodical treatment, sound
very limited use of these clasp systems for similar biomechanical concepts, preservation of oral
cases constructed in a regional commercial dental health, functions and esthetics, and lastly the use
laboratory and in a general practice set up (Figure of the simplest type of clasp and major connector
4).11,18 On the contrary, an overwhelming use of that will accomplish the treatment objectives
mesial rests (91.3%) on distal extension abutment should always dictate the type of RPD designed
teeth found in this study was noticed (Figure 5). for patients rather than to a stereotyped treatment
philosophy.
The result of this study
showed treatment Conclusions
philosophy in King
Saud University, 1. Patterns of partial
College of Dentistry edentulousness of patients who
has been effective in attended the clinics of King
teaching the benefits Saud University were similar
of the RPI/RPA and between Saudi and non-Saudi
mesial rest. During Arabs but differ compared to
function, the rotation Filipinos and other non-Arab
occurs in the area patients.
of mesial rest; the I-bar and proximal plate 2. The incidence of various classes of RPDs
disengage from the tooth and the abutment tooth may not only be a reflection of the pattern
is usually braced by a mesial adjacent tooth.2 of tooth loss but also patients demand and
affordability of alternative prosthetic treatment.
Although more mandibular Class II RPDs were 3. Kennedy Class III RPDs are most frequently
constructed than maxillary Class II RPDs in used, whereas Class IV were the least used.
this study, indirect retainers were incorporated Both classes were more common in the
more often in the maxillary Class II RPD than maxillary than their mandibular counterparts.
in the mandibular Class II RPD despite the fact 4. Younger adults had more Kennedy Class III
that indirect retention is required more on the and IV RPDs. Older adults had more distal
mandibular arch than on the maxillary arch. extension RPDs (Classes I and II).
However, there will always be a higher tendency 5. Circumferential direct retainers were the
of finding a third abutment anterior to the fulcrum most commonly prescribed. RPI and RPA
in the maxillary Class II RPDs suitable for both slightly predominated distal extention cases.
direct and indirect retention as in the case of this However, an overwhelming use of mesial rests
survey and another9 where more posterior and on distal extention abutments was noticed.
combined anterior and posterior modification 6. A infrabulge clasp was used more frequently
areas are found. in the maxilla than in the mandible. On the
other hand, the ring clasp was used more
A descriptive study of dental school samples frequently in the mandible than in the maxilla.
may not be representative to what might be 7. The most common maxillary major connector
obtained in a general dental practice. The was the anterior-posterior palatal strap
variation in conventional RPD design concepts followed by the palatal strap. On the
with international studies reflects the influence mandible, the lingual bar was used in 77% of
of teaching philosophy and diversity of faculty the cases.
members’ background. The results of this study
suggested design concepts leaning towards
the North America philosophy of a basic design

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The Journal of Contemporary Dental Practice, Volume 3, No. 4, November 15, 2002
References

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8.10. 198; 3:47-51.
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Prosthodont Restor Dent. 1994 Mar;2(3):127-9.

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About the Authors

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The Journal of Contemporary Dental Practice, Volume 3, No. 4, November 15, 2002