Prosthodontics

Enhanced CPD DO C

Prashanti Eachempati

Guy Lambourn, Himanshi Agarwal, Kiran Kumar Krishnappa Salian, Ewen McColl and Devi Prasad Nooji

A Comprehensive Guide to
Removable Partial Dentures.
Part 1: Patient Selection, Design
Principles and Decision Algorithms
for Component Selection
Abstract: This two-part series provides a comprehensive guide to fabricating definitive metal partial dentures, addressing the challenges dental
practitioners face in mastering prosthesis design. Part 1 explores diagnostic procedures, indications for metal partial dentures, design principles,
and surveying techniques. It emphasizes the understanding of biomechanical forces and discusses design principles such as support, retention
and stability, along with the components that provide these functions in a metal partial denture. Decision algorithms for selecting various
components are presented to guide clinical practitioners in efficient designing. The series aims to equip dental professionals with a thorough
understanding of the theoretical foundations and practical methods for effective metal partial denture fabrication.
CPD/Clinical Relevance: This series provides essential knowledge and practical techniques for designing and fabricating effective metal
partial dentures.
Dent Update 2024; 51: 458–466

Conventional removable partial dentures is influenced by factors such as patient- fixed alternatives. Removable partial
continue to be a viable treatment option, related systemic considerations, intra-oral dentures are available in diverse types,1,2
even in the current dental scenario factors, or cost constraints that may deter encompassing interim solutions as well
dominated by dental implants. This choice patients from choosing implants or other as definitive options, which include both
metal-based and metal-free alternatives.3
Among these alternatives, mastering
Prashanti Eachempati, BDS, MDS (Prosthodontics), MSc, MPhil, DICOI, FADI, FICCDE, FAIMER, the definitive prosthetic design and
FAoME, Peninsula Dental School, University of Plymouth; Professor, Manipal University College understanding the underlying principles
Malaysia, Melaka, Malaysia. Guy Lambourn, BDS, MFDS RCPS, MClinDent, MRD, FHEA, FDS has consistently posed a challenge for
RCS, FDTFEd Associate Professor, Consultant in Prosthodontics, Peninsula Dental School, dental practitioners.
University of Plymouth. Himanshi Agarwal, BDS, MDS (Prosthodontics), Prosthodontics Historically, partial dentures were cast
Resident, Department of Restorative Sciences, School of Dentistry, University of Alabama using the lost wax technique, leading to
at Birmingham, AL, USA. Kiran Kumar Krishnappa Salian, BDS, MDS (Prosthodontics), the term ‘cast partial dentures.’ However,
Prosthodontist, Saligrama Dental Care, Karnataka, India. Ewen McColl, BSc (Hons), BDS, FDS recent advancements in fabrication, using
RCPS, FCGDent, MRD RCS Ed, MClinDent, FDS RCS(Rest Dent), FDTFEd, FFD RCSI, FHEA, Head
computer-aided design and manufacturing
of School, Director of Clinical Dentistry, Peninsula Dental School, University of Plymouth.
(CADCAM), have introduced non-cast
Devi Prasad Nooji, BDS, MDS (Prosthodontics), Professor, Department of Prosthodontics, KVG
options.4 This shift makes the use of the term
Dental College and Hospital, Sullia, Karnataka, India. email: [email protected]
‘metal partial dentures’ more appropriate

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 Prosthodontics

Type
Diagnosis Patient and extent of Patient
compliance to edentulous area willingness and
maintenance comfort

Decision making
Dentists’
Factors influencing the Condition of remaining
knowledge of designing
success of a teeth and supporting
and competence in clinical
metal partial denture tissues
procedures
Designing

Competent Number
Aesthetics
laboratory and location of
and occlusal
Delivery and maintenance support remaining teeth
considerations

Figure 1. The 4 Ds mnemonic. Figure 2. Factors influencing the success of a metal partial denture.

than ‘cast partial dentures’. Despite the Evaluation of teeth Decision making: when to
growing popularity of metal-free partial Conducting a meticulous tooth-by-tooth
dentures with newer polymer materials,3 this prognosis assessment involves evaluating
choose a cast/metal/definitive
series focuses specifically on discussing clasp- the prosthodontic, endodontic, and partial denture
retained definitive (metal) partial dentures periodontal conditions. This detailed Following initial primary disease
owing to their longstanding success. It examination forms the foundation for stabilization, the decision-making process
is essential to note that the foundational informed decision-making regarding for prosthesis selection should take into
principles of design and biomechanics for the suitability of the patient for a metal account the number of missing teeth
removable prostheses in partially dentate partial denture.5 (span length and span configuration) and
mouths remain consistent, whether the overall periodontal prognosis.7 After this
partial denture is metal or metal-free. Evaluation of edentulous spaces preliminary decision-making process, other
This two-part series serves as a guide Systematically analysing edentulous factors such as cost, treatment duration,
to fabricating definitive/metal partial spaces, both in terms of mesiodistal and patient preferences etc. will influence the
dentures. Part 1 explores key elements, inciso-cervical dimensions, ensures a final choice.
including indications, success factors, comprehensive space analysis for accurately The flow chart (Figure 3) excludes
design principles, surveying techniques, accommodating the partial denture. the modality of implants and provides
and decision algorithms. Part 2 covers guidance on determining whether a fixed
procedures for impressions, essential Evaluation of soft tissue
or removable prosthesis is an appropriate
laboratory techniques, and practical case A thorough assessment of the existing treatment option. Metal partial dentures are
examples. This structured approach aims soft tissues should evaluate the health and suitable for a wide range of partially dentate
to offer dental professionals a thorough compressibility of those tissues, and include cases. When a fixed prosthesis cannot be
understanding of theoretical foundations recording features such as high frenal provided owing to concerns about cost or
and practical methodologies for effective attachments, reduced sulcus depth, presence the preservation of tooth tissue, a metal
metal partial denture fabrication. of tori and prominent undercuts. For partially partial denture becomes a viable option.7,8
To aid in understanding and recall, we dentate cases, the use of Siebert’s system is In cases where the periodontal condition
propose the use of the following mnemonic suggested, which categorizes edentulous is poor, an interim acrylic denture may be
– the 4 Ds: diagnosis, decision-making, ridges into: initially provided until a stable periodontal
designing, and delivery and maintenance status develops.7,8 Subsequently, a metal
 Class I: loss of tissue width, normal height;
(Figure 1). partial denture can be planned for long-
 Class II: loss of height, normal width;
term prosthetic prognosis. However, if
 Class III: combined loss in
the poor periodontal condition persists,
Diagnosis both dimensions. 6
interim partial dentures may be a more
In the diagnostic stage preceding the appropriate option.
selection of a definitive/metal partial Evaluation of occlusal relationships
denture, a clinician must gather information Understanding the inter-arch relationships
including, general health, systemic becomes crucial, as variations in occlusion Design
conditions, medications, allergies as well can significantly influence the design of the The process of design requires the clinician
as patient compliance, concerns and metal partial denture.7 to have a thorough understanding of
expectations. Among all the different Moreover, various other factors require the biomechanical forces that will be
factors, intra-oral examination focuses on careful evaluation before deciding on a applied to both the prosthesis and the
four key areas: metal partial denture (Figure 2). supporting tissues.

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 Prosthodontics

Figure 3. Preliminary decision-making chart.

a c

Figure 5. Lever forces acting in different partial

denture situations.

both teeth and soft tissues. Kennedy’s

classification categorizes partially
edentulous arches into four primary classes,
 Class I (Figure 4a);
b d  Class II (Figure 4b);
 Class III (Figure 4c);
 Class IV (Figure 4d) with modifications
(Figure 4c) as described by Applegate.10
The movement of the denture during
function in Class III and even short span
Kennedy’s class IV cases are generally
minimal as they are primarily tooth
supported. In contrast, the rotational
movement of Class I and II removable
partial dentures occurs in three cranial
planes (sagittal, frontal, horizontal) due to
variations in the support characteristics
Figure 4. (a) Kennedy class I: bilateral edentulous areas positioned posterior to the natural teeth. of the abutment teeth and the soft tissue
(b) Kennedy class II: a unilateral edentulous area situated posterior to the remaining natural teeth. enveloping the residual ridge. Despite the
(c) Kennedy class III with modification: a unilateral bounded saddle with natural teeth either side of the
potential minimal actual movement of the
edentulous space and a modification space. (d) Kennedy class IV: a single bounded saddle that crosses
denture, this may introduce a lever force
the midline, anterior to the remaining natural teeth.
acting on the abutment teeth (Figure 5).9
Understanding these variations
is essential for designing an effective
Biomechanical forces in partial dentures: teeth and soft-tissue denture-bearing areas.9 partial denture, given that the nature of
impact and correlation with classification It is imperative to manage these stresses, the edentulous span and support used
Removable partial dentures, owing to their ensuring that they remain within the bounds influences the denture’s movements.10
lack of rigid attachment to teeth, necessitate of physiological tolerance without disruption
control of potential movement of the or traumatic consequences.9 Key principles of designing and
denture during function to provide optimal A crucial determinant in achieving component insights
stability, retention, and patient comfort. The optimal design lies in the distinction A partial denture prosthesis consists of
dynamic nature of prosthesis movement between partial dentures receiving support multiple components that provide support,
under functional load exerts stresses on the solely from teeth, and those relying on retention and stability, all of which are

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 Prosthodontics

Name Indication Advantages Disadvantages

Synonyms: Supra bulge/occlusally approaching/circumferential/Akers clasp designs

Simple Tooth Simple design Difficult to adjust/repair

circlet supported Provides support, Decalcification of the
(Figure 6) dentures and reciprocation tooth
modification and passivity
spaces
Figure 6. Simple circlet (circumferential clasp).
Reverse In Kennedy Reduces stresses Reduced strength at
circlet clasp class I and II transmitted to abutment shoulder of clasp assembly
situations when next to distal extension Food impaction in the
the undercut proximal plate region
is adjacent to
edentulous area

Embrasure On the Simple design Fatigue failure

clasp dentulous side Provides sSupport,
(Figure 7) in Class II, III, IV reciprocation
and passivity
The mesial rest on the
distal abutment acts as Figure 7. Embrasure clasp.
an indirect retainer in
long-span Kennedy class
IV situations

Ring clasp Mesio-lingually Maximal Distortion and fracture of

(Figure 8) tipped support, bracing, clasp assembly
mandibular retention, encirclement Demineralization of the
molar with tooth
mesiolingual Additional rest/bracing
undercut (can strut are required to
be used in other reduce the flexibility of the
situations) clasp arm

Combination In Kennedy Reduces stresses Additional laboratory

clasp class I and II transmitted to abutment steps
situations when next to distal extension Prone to fracture
the undercut is
away from the
edentulous area Figure 8. Ring clasp.

Synonyms: infrabulge/gingivally approaching/bar/Roach clasp designs

I-bar, Y-bar, Most cases of Aesthetic Cannot be used in the

T-bar, Class I and II presence of soft tissue joined together by connectors to ensure
modified when a distal undercuts function, and aesthetics, ultimately
Y-bar undercut Food lodgement leading to better patient comfort
is present and acceptance.
RPI clasp Distal extension Reduces stresses Cannot be used in the
RPD transmitted to an presence of soft tissue Support
abutment next to distal undercuts Support refers to the foundational
extension base Food lodgement area upon which a dental prosthesis
Mesial rest helps to resist rests.11 Specifically, concerning dental
rotational movements prostheses, it denotes the resistance to
of the denture base forces directed towards the basal tissue
during mastication or underlying structures. In a metal partial
denture, the primary support is provided
Table 1. Direct retainers.
by the rests being placed on the hard

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 Prosthodontics

Types Position tissues, with additional secondary support

provided by a well-adapted denture base
Preferred on canines owing to prominent contacting the soft tissues.12
Cingulum rests (Figure 9)
cingulum
Placed on the mesial occlusal surface of a Retention
Occlusal rest (Figure 10)
first bicuspid tooth Retention is the quality inherent in the
Finger extension from a premolar rest that dental prosthesis acting to resist the
Canine extensions from occlusal rests is placed on the prepared lingual slope of forces of dislodgement along the path
the adjacent canine tooth of displacement.11 Components in the
metal partial denture providing retention
Terminal rests at either end of the lingual are direct and indirect retainers. Direct
Continuous bar retainers and
plate in the form of auxiliary occlusal rests retainers consist of a clasp assembly or
lingual plates
or canine rests
precision attachments.13 These retainers
Table 2. Indirect retainers. can be categorized into two main types:
occlusally or gingivally approaching which
describe where the components originate
from the framework. Tables 1–4 include
commonly used clasp designs. However,
the material choices and specifics of the
different designs is beyond the scope of
this article.
Indirect retainers are components that
assist the direct retainer(s) in preventing
displacement of the distal-extension
denture base. They function through lever
action on the opposite side of the fulcrum
Figure 9. Cingulum rests (two indirect retainers Figure 10. Occlusal rest (one indirect retainer in line when the denture is displaced away
in Kennedy class I). Kennedy class II). from the tissues. Cingulum rests on
canines and occlusal rests on premolars
a are typical examples of indirect retainers
in distal extension cases.14 Different types
of direct and indirect retainers with their
indications and advantages are presented
in Tables 1 and 2.
A decision algorithm for selecting
the type of direct retainer is presented
in Figure 11. These decision algorithms
facilitate design, but should be used
cautiously and take into account local
patient factors.

Stability
The quality of stability for a removable
b partial denture is the resistance to
displacement by functional horizontal
or rotational forces.15 The bracing or
stabilizing elements of a metal partial
dentures are functional when the denture
is fully seated. These components
include the denture base contacting
the slopes of the residual alveolar ridge,
proximal plates contacting the guide
planes and the reciprocal arm of the
clasp assembly when placed to resist the
displacing force.15

Connectors
Figure 11. (a) Decision algorithm for selecting a direct retainer for Kennedy class I and II. (b) Decision
The parts of the metal partial denture
algorithm for selecting a direct retainer for Kennedy class III and IV.
that unite all the components are

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 Prosthodontics

Name Indication Advantages Disadvantages

Rigid design (L-Beam effect) Instances of papillary hyperplasia
Kennedys Class III and its modifications Patient acceptability due to owing to coverage
Palatal strap
(tooth-supported prosthesis only) minimum interference to tongue

Indicated in Class III situations when Minimum tissue coverage Minimum support to prosthesis
Anteroposterior anterior are posterior abutments are Bulky
palatal bar separated widely Interfere with phonetics
Presence of a tori
Rigid design. (L-Beam effect Interfere with tongue and phonetics
Indicated in class I, class II, long span class III
Anteroposterior and encirclement)
and class IV situations
palatal strap
Presence of a tori

Maximum support, retention, Maximum tissue coverage

Class I and II situations where maximum
Complete palate bracing and direct-indirect retention
support is indicated
from the palate
Class IV partially Reduced coverage of palatal tissues Flexion
Horseshoe (Figure 12) Edentulous arch May be less intrusive for tongue
Presence of tori

Name Indication Advantages Disadvantages

Kennedy class III situations Minimum interferes with function Not as rigid as other designs
Short-span Kennedy class I and II with Difficult to add additional
Lingual bar (Figure 13)
adequate lingual sulcus depth prosthetic teeth
(8 mm or more)
All Kennedy classes with inadequate lingual Good rigidity Does not provide indirect retention
Sublingual bar sulcus depth (6 mm or less) Good hygiene

All Kennedy classes with less than 8 mm of Easy to add additional May cause anterior tipping of teeth
lingual sulcus depth prosthetic teeth if not properly designed
Periodontally compromised anterior teeth Rigid and provides indirect retention Increased tooth surface coverage
Lingual plate
Inoperable tori
Modification: step back design can be used
in case of diastemas

Less coverage of teeth in the May cause anterior tipping of teeth

Kennedy bar (double Class I and II situations where anterior teeth lingual surface if not properly designed
lingual bar) have open cervical embrasures Food entrapment
Interference to the tongue
Malpositioned or lingually inclined Indicated when other major Low patient acceptance
anterior teeth connectors cannot be used due to Poor aesthetics and can alter
Labial or buccal bar lingually inclined teeth lip fullness
Large lingual tori or exostoses that cannot be
removed surgically
Large tori or exostoses that cannot be Can be used when other major Must be bulky to have sufficient
Continuous bar or removed surgically connectors cannot be used owing to rigidity and thus may be
cingulum bar Severe undercut in the lingual alveolus large lingual tori objectionable to the patient

Table 3. (a) Maxillary and (b) mandibular major connectors.

connectors. Major connectors join

the components on one side of the
arch to those on the opposite side.16
Minor connectors are the connecting
link between the major connector
and the other units of the prosthesis,
such as the clasp assembly, indirect
retainers, and denture bases.16
Different types of these connectors
with their indications and advantages
Figure 12. Horseshoe. Figure 13. Lingual bar.
are presented in Tables 3 and 4.

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 Prosthodontics

Name Characteristics/salient features

A sufficient bulk is needed to ensure rigidity

Minor connectors that join
Must be positioned to avoid irritating the oral tissues
clasp assemblies to major
Located on proximal surfaces of teeth adjacent to
connectors (Figure 14, A)
edentulous areas
Minor connectors that Positioned in lingual embrasures to disguise their bulk
join indirect retainers or and promote patient comfort
auxiliary rests to major
connectors (Figure 14, B)
Three types:
Open/lattice construction
Tooth-tissue supported cases, with limited Figure 14. (A) Minor connectors that join clasp
inter-arch space assemblies to major connectors. (B) Minor
Relining the denture base is possible connectors that join indirect retainers or auxiliary
Mesh construction rests to major connectors.
Tooth-tissue supported cases, with ample available a
Minor connectors that join inter-arch space
denture bases to major Relining the denture base is possible
connectors (Figure 15) Weaker acrylic attachment
Difficult to pack acrylic as compared to open design
Bead, wire, nail head or braided post
Short-span tooth-supported cases, where relining of
denture base may not be required
Improved hygiene and enhanced thermal stimulation
Difficult to adjust and reline
Weak acrylic attachment
b
Vertical projection/bar- They support gingivally approaching clasps
type clasps (Figure 16) Only minor connectors with some degree of flexibility

Table 4. Types of minor connectors.

Decision algorithms for selecting the  Denture tooth try-in on metal

type of maxillary and mandibular major framework supported by wax (anterior
connectors are presented in Figures 17–19. and posterior teeth try-in);
 Final processing to obtain final partial c
denture prosthesis;
Delivery
 Delivery and maintenance.
Workflow
Once a diagnosis and the decision to These steps can be either performed by
fabricate a definitive partial denture conventional method, digital method or a
has been made, it becomes crucial to combination of these methods.
comprehend the sequential steps that must Figure 15. Minor connectors that join denture
be undertaken both chairside and in the Diagnostic impressions bases to major connectors: (a) open; (b) mesh;
laboratory phases. The diagnostic impressions can be made and (c) braided.
 Primary impressions; either conventionally by using irreversible
 Survey of the diagnostic casts and hydrocolloids or digitally by using intra-oral
component design; scanners or by scanning the diagnostic
 Tooth preparation according to the cast as determined by the clinician and
specific design; appropriate to the patient case.17
 Secondary impressions; With the introduction of intra-
 Survey of the master casts; oral scanners (Ex. Cadent iTero, Align
 Anterior tooth try-in supported by wax Technology, CEREC Omnicam, Dentsply
(in cases where metal backings will be Sirona, TRIOS, 3 Shape) an alternative
incorporated into the framework design); technique for recording impressions has
 Fabrication of framework; been added. The digital process entails
Figure 16. For vertical projection/bar-type clasps.
 Framework try-in; conducting multiple scans for both arches.

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 Prosthodontics

direction. The path of displacement

(POD) is the direction in which the
denture is dislodged during function and
is assumed to be at a right angle to the
occlusal plane.18,19 Metal partial denture
design incorporates components to
limit POI, POW to a single path, and
resist POD. Guiding planes, parallel axial
surfaces of abutment teeth, define POI
and POW.18,19 The survey line delineates
the height of contour, distinguishing
between desirable undercuts (retentive
areas) and undesirable undercuts
(interferences to be eliminated or
Figure 17. Decision algorithm for selecting a maxillary major connector for Kennedy class I and II.
blocked out) (Figures 20 and 21).
Undercuts should be analysed using
undercut gauges for both depth and
location. Aesthetics are considered,
ensuring suitable positioning of
components and artificial teeth for a
pleasing appearance. The initial cast is
horizontally oriented (zero-degree tilt)
for marking survey lines and checking
interferences. Tilting the cast helps to
reduce spaces between abutments and
the framework avoiding the creation
of unaesthetic spaces in the anterior
zone or difficult to clean spaces in the
Figure 18. Decision algorithm for selecting a maxillary major connector for Kennedy class III and IV. posterior zone. Lateral tilting can be
incorporated to limit the undesirable
undercuts. Substantial tooth preparation
should be avoided when preparing guide
planes, an antero-posterior tilt will often
aid in this.
The final tilt minimizes tooth
modifications, but if it exceeds 10
degrees, then crowns with denture
features may be considered. The final
orientation of the cast is recorded
in relation to the path of placement
using reference points and tripoding
(Figure 22).19 Marking the external
surface of the cast with parallel lines is
another method to record the tilt.

Figure 19. Decision algorithm for selecting a mandibular major connector for Kennedy classes I–IV. CAD-based surveying
The process of surveying has been
digitized using specialized software.
Stereolithographic (STL) files can be
The software subsequently combines these and associated structures on diagnostic
acquired either directly by using an
scans to generate a comprehensive full- casts. Using a dental surveyor, this process intra-oral scanner or by scanning
mouth image. The Standard Tessellation identifies the path of insertion (POI) and conventional diagnostic casts. The STL
Language (.STL) file generated by the path of withdrawal (POW), determines file is then processed using specialized
scanner is imported into the designing guide planes, locates areas that may CAD software (3Shape CAD points,
software to plan and complete designing.17 provide suitable retention, assesses 3Shape, Partial Framework CAD, and
interferences, and plans for aesthetics.18 Geomatic Touch X, 3D Systems).17
Surveying The POI is the direction the denture takes Using a digital survey tool the program
The survey is a crucial step in designing when initially contacting abutment teeth, assesses undercut depth on the potential
removable partial dentures, involving aiming for minimal interference and abutments and parallelism between
analysis of the potential abutment teeth enhanced stability. The POW is the opposite teeth. Using this information, the

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org/10.3390/polym15153258
4. Akl MA, Stendahl CG. Removable partial
denture frameworks in the age of digital
dentistry: a review of the literature. Prosthesis
2022; 4: 184–201. https://doi.org/10.3390/
prosthesis4020019
5. Samet N, Jotkowitz A. Classification and
prognosis evaluation of individual teeth – a
comprehensive approach. Quintessence Int
Figure 23. Digital surveying.
2009; 40: 377–387.
Figure 20. Surveying.
6. Rana R, Ramachandra SS, Lahori M et al.
Combined soft and hard tissue augmentation
for a localized alveolar ridge defect. Contemp
Clin Dent 2013; 4: 556–558. https://doi.
org/10.4103/0976-237X.123090
7. Davenport JC, Basker RM, Heath JR et al.
Removable partial dentures. 1. Need and
demand for treatment. Br Dent J 2000;
Figure 24. Digital block-out. 189: 364–348. https://doi.org/10.1038/
sj.bdj.4800770
8. Davenport JC, Basker RM, Heath JR et al. The
Figure 21. Location of desirable undercut.
removable partial denture equation. Br Dent J
The absence of a single best design 2000; 189: 414–424. https://doi.org/10.1038/
emphasizes the decision-making complexity sj.bdj.4800787
and multiple acceptable designs for 9. Carr AB, Brown DT. Principles of removable
a partially edentulous arch may be partial denture design. In: McCracken’s
reasonable. Understanding the indications Removable Partial Prosthodontics. 13th edn. St
and contraindications for metal partial Louis, MO, USA: Elsevier, 2016; 122–115.
dentures is crucial, as overlooking these 10. Carr AB, Brown DT. Classification of partially
turns the design process into a speculative edentulous arches. In: McCracken’s Removable
endeavour rather than a methodical and Partial Prosthodontics. 13th edn. St Louis, MO,
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Figure 22. Tripoding points. Acknowledgements
https://doi.org/10.1016/j.prosdent.2016.12.001
We extend our appreciation to Dr Merlyn
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George, QA Head, and Dr Anu Ann Bussy,
McCracken’s Removable Partial Prosthodontics.
Quality Specialist of the Removable
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arranging the photographs for this article.
Virtual survey lines are generated Retention. Br Dent J 2000; 189: 646–657.
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Conflict of Interest: The authors declare that retention. Br Dent J 2001; 190: 128–132. https://
blocking out of undesired undercuts
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(Figure 24).17
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