Journal of Oral Rehabilitation 2005 32; 823–829
An evaluation of the effects of two distal extension
removable partial denture designs on tooth stabilization and
periodontal health
F. AKALTAN* & D. KAYNAK† Departments of *Prosthodontics and †Periodontology, Faculty of Dentistry, University of
Ankara, Ankara, Turkiye
SUMMARY A 30-month follow-up study was conduc-
ted on 36 patients to evaluate the effects of the
lingual plate as a major connector in distally exten-
ded removable partial dentures (RPDs) on tooth
stabilization. At the same time, the study evaluated
the effects of lingual plate-type RPDs and lingual
bar-type RPDs on periodontal health. The most
striking finding of the study was that, with the
exception of gingival recession (GR), periodontal
conditions improved with both types of RPDs.
At the end of 30 months, there were significant
differences in plaque index, GR and tooth mobility
(TM) values between treatment groups (P < 0Æ05).
Plaque accumulation was greater in the lingual plate
treatment group; however, this did not result in
periodontal breakdown. There were no statistically
significant differences between treatment groups
with respect to pocket depth, gingival index or
Introduction
Previous longitudinal studies and cross-sectional
surveys have established the long-term effects of
removable partial dentures (RPDs) on the periodontal
health and caries incidence of abutment teeth (1–8).
Studies have shown that partial dentures promote an
increase in plaque accumulation, not only on tooth
surfaces in direct contact with the denture, but also
on teeth in the opposing arch, and, in some cases, on
teeth buccal surfaces as well (8). Most studies have
also shown a continuation of or increase in perio-
dontal breakdown in patients fitted with RPDs (5, 9).
However, these negative effects on the periodontium
may be reduced through regular maintenance
ª 2005 Blackwell Publishing Ltd
attachment loss (P > 0Æ05). Moreover, patients trea-
ted with lingual plate-type RPDs demonstrated less
TM when compared with patients treated with
lingual bar-type RPDs at the end of 30 months
follow-up.Overall study findings established that
with adequate checks on oral and denture hygiene
at regular intervals, patients with RPDs may even
experience improved periodontal health. Moreover,
the clinical interpretation of decreased TM observed
in patients treated with lingual plate-type RPDs
may be questionable as the plaque accumulation
was greater in the lingual plate treatment group
inspite of periodic recalls.
KEYWORDS: removable partial denture, tooth mobil-
ity, splinting
Accepted for publication 10 February 2005
therapy, including specialized oral hygiene instruction
(1).
Clinical studies on the effectiveness of RPDs and their
designs have to date been limited, focusing mainly on
direct retainers and their load distribution on abutment
teeth (6, 7, 10–12). Looked at as a whole, studies of
RPD design suggest that insertion of a partial denture
constitutes a risk factor for periodontal health. One
particular problem may be the relationship of the
denture connector to the gingival margin. One study
concluded that in cases where tooth approximation was
necessary, the gingival margin should be relieved by
ensuring a space underneath the denture base (13). In
contrast, another study concluded that the appliance
should be very closely fitted to the gingival margin (14),
823
824 F. AKALTAN & D. KAYNAK
and yet another study concluded that regardless of the
degree of relief, coverage of the gingival margin had a
detrimental effect on gingival health (8).
None of the studies on RPD design in the current
literature examine the effects of major connectors on
the support of remaining teeth. The lingual bar is by far
the most frequently used major mandibular connector.
Because of its simplicity, it should be used if no
contraindications are evident. Because the bar has
minimal contact with oral tissue and no contact with
teeth, it does not cause decalcification of tooth surface
as a result of the collection of food or plaque around the
major connector.
In cases where most of the posterior teeth have been
lost, as, for example, in the case of bilateral distally
extended arches, there is a need for additional indirect
retention. Although the lingual plate itself is not an
indirect retainer, it contributes to indirect retention
when it is supported by rests at each end of the anterior
teeth. Because the flat residual ridges offer little
resistance to the horizontal rotational tendencies of a
denture, the remaining teeth must be depended upon
to resist such rotation. A correctly designed lingual plate
will, in fact, utilize the remaining teeth to resist
horizontal rotation. While less effective than fixed
splinting, lingual splinting with a lingual plate is
recognized to be of considerable value when used with
definite rests on sound adjacent teeth. This stabilization
with a removable prosthesis is not a new concept (15,
16); however, the splinting effect of a lingual plate has
not received much attention in dental literature.
The lingual plate is by far the most controversial of
the mandibular connectors. Criticism usually centres
around the fact that coverage by the metal plate inhibits
the physiologic stimulation of lingual gingival tissue
and the self-cleansing of mandibular anterior teeth
lingual surfaces by the saliva and tongue. When the
connector is prescribed, the patient is advised to remove
the prosthesis from the mouth for at least 8 out of 24 h
and to keep the mouth scrupulously clean (17).
Admittedly, erosion of lingual surfaces of teeth is not
unknown when the prosthesis is worn continuously
without adequate oral hygiene.
The misapplication of splinting techniques has been
reported when performed without adequate knowledge
of oral diagnostic, periodontal analysis, occlusal analysis
or basic restorative dentistry techniques. When restor-
ative procedures are not carried out properly, further
damage can result (18). With this in mind, the present
ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 823–829
study was designed to evaluate whether the lingual
plate in a distally extended RPD could provide a
stabilizing effect on natural teeth. The study also
evaluated the periodontal status in two groups of
patients treated with RPDs with either a lingual plate
or lingual bar over a 30-month period.
Materials and methods
The study population consisted of 36 elderly patients
(mean age: 55) for whom bilateral distally extended
lower arches had been prescribed. All patients had their
natural six anterior teeth and an intact maxillary arch,
and none of the patients displayed any occlusal abnor-
malities. None had received fixed dentures or previ-
ously worn a removable appliance, and none had any
medical condition which contraindicated their inclu-
sion in the study. All patients agreed to use their
dentures both day and night and to follow oral hygiene
instructions based on twice-daily mechanical tooth
cleaning using a toothbrush supplemented with inter-
dental cleaning using toothpicks and an interspace
toothbrush.
All patients received the following periodontal treat-
ment: (i) motivation for their oral hygiene; (ii) instruc-
tion in oral hygiene procedures; (iii) scaling and root
planing; (iv) incisal adjustment of the dentition, where
necessary; (v) scaling and polishing with pumice and
rubber cups.
Following periodontal treatment, patients were ran-
domly divided into two equal groups, one of which was
treated with lingual plate RPDs and the other with
lingual bar RPDs. This included the preparation of
cingulum rest seats on the enamel surfaces of canine
abutments and the conventional fabrication of RPDs
comprised of a cobalt–chromium framework, cingulum
rests, I-bar-type cast clasps in distobuccal undercuts and
distal proximal plates on canine abutments.
After an initial post-prosthodontic treatment exam-
ination (‘day zero examination’), five additional recall
appointments were conducted at 6-month intervals
over a period of 30 months. The ‘day zero examination’
was conducted 6 weeks following treatment to ensure
that patients had adapted to their new prosthetic
conditions with regard to oral hygiene. At each of the
follow-up appointments, selected parameters were
carefully recorded, and the teeth and denture profes-
sionally cleaned, including subgingival scaling. Pros-
thetic adjustments were also performed, as necessary.
 TOOTH STABILIZING EFFECT OF RPD DESIGNS 825

Periodontal parameters included the following: Table 1. Comparative periodontal indexes for lingual Plate
1. Plaque Index (PI), according to Silness and Löe (19). removable partial dentures (RPDs) and lingual Bar RPDs

2. Gingival Index (GI), according to Löe and Silness

RPD with RPD with
(20).
Lingual plate Lingual bar
3. Probing Pocket Depth (PD), as measured from the (LP) (LB) P value
gingival margin to the bottom of the clinical pocket on Periodontal Index for
for two periods Mean s.d. Mean s.d. LP-LB
mid-buccal, mid-palatal, mesio and disto-palatal tooth
surfaces using a thinned William’s periodontal probe PI day 0 1Æ99 0Æ68 1Æ71 0Æ52 >0Æ05
with a 0Æ5 mm tip diameter and gentle pressure. PI 30 months 1Æ03 0Æ38 0Æ70 0Æ38 <0Æ05*
4. Gingival Recession (GR), as measured from the P-value for periods <0Æ001* <0Æ001*
GI day 0 1Æ74 0Æ77 1Æ70 0Æ65 >0Æ05
cemento-enamel junction to the gingival margin on
GI 30 months 0Æ79 0Æ34 0Æ59 0Æ25 >0Æ05
mid-buccal, mid-palatal, mesio and disto-palatal tooth P-value for periods <0Æ001* <0Æ001*
surfaces. PD day 0 4Æ05 0Æ79 3Æ42 0Æ74 >0Æ05
5. Attachment Loss (AL), as measured from the base of PD 30 months 2Æ77 0Æ62 2Æ36 0Æ78 >0Æ05
the pocket to the cemento-enamel junction on mid- P-value for periods <0Æ001* <0Æ001*
GR day 0 2Æ99 0Æ57 3Æ34 0Æ76 >0Æ05
buccal, mid-palatal, mesio and disto-palatal tooth sur-
GR 30 months 3Æ23 0Æ56 3Æ81 0Æ82 <0Æ05*
faces. P-value for periods <0Æ001* <0Æ001*
6. Tooth Mobility (TM), as measured with a Periotest AL day 0 7Æ04 1Æ08 6Æ76 0Æ99 >0Æ05
Instrument (German Patent 2617779, 11 February AL 30 months 6Æ00 0Æ72 6Æ17 1Æ05 >0Æ05
1982) and classified according to Miller Periotest values P-value for periods <0Æ001* <0Æ001*
(21). TM day 0 20Æ63 2Æ65 20Æ54 3Æ27 >0Æ05
TM 30 months 14Æ82 1Æ63 16Æ81 2Æ47 <0Æ05*
All patients met the following periodontal criteria
P-value for periods <0Æ001* <0Æ001*
prior to receiving RPDs: PI: £2; GI: £2; PD: £4 mm; TM:
£25; GR: £4 mm. PI, Plaque Index; GI, Gingival Index; PD, Pocket Depth; GR,
Gingival Recession; AL, Attachment Loss; TM, Tooth Mobility.

Statistical analysis
ANOVA was conducted for both the lingual plate and
lingual bar groups to analyse differences between ‘day-
zero’ and 30-month values of selected parameters.
Differences in ‘day-zero’ values between the lingual
plate and lingual bar groups as well as in 30-month
values between the lingual plate and lingual bar groups
were evaluated using either Student’s t-test or Mann–
Whitney U-test. Differences between ‘day-zero’ and
30-month values for lingual plate and lingual bar
groups were compared using either paired t-tests or
Wilcoxon signed ranks test, as appropriate.
Results
Table 1 shows comparative values for periodontal
indexes of the lingual plate RPD and lingual bar RPD
treatment groups. With the exception of GR, both
groups showed significant reductions in index values
from day 0 to 30 months (P < 0Æ001).
No statistically significant differences were observed
between the lingual bar and lingual plate groups for
any of the periodontal indexes at the day 0 examination
(P > 0Æ05). At 30 months there were still no statistically
significant differences in PD, GI or AL between groups.
However, statistically significant differences between
groups (P < 0Æ05) were found for PI which was higher
in the lingual plate group, and for GR and TM values
which were higher in the lingual bar group.
Discussion
When designing an RPD, each component should be
added for a good reason and to serve a definite purpose.
No component should be used arbitrarily or conven-
tionally. Reasons for adding a component include
stabilization against horizontal rotation, retention, sup-
port, patient comfort, preservation of tissue health and
aesthetics. The dentist alone should be responsible for
the choice of design used and should have good
biological and mechanical reasons for making this
choice (22).
The biomechanical aspects of RPD design have
always been a matter of concern in the literature.
Support for bilateral and unilateral distal extension
RPDs is shared between the abutment teeth and the

ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 823–829

826 F. AKALTAN & D. KAYNAK
edentulous ridges. Differences in resilience between
these supporting elements have prompted examination
of numerous laboratory and clinical models and their
effects on the forces exerted on abutment teeth. While
studies have reported that RPD design does affect the
distribution of force on abutment teeth and residual
alveolar ridges (23–26), most studies have involved the
use of laboratory rather than clinical models, and there
is still no clear consensus as to the ideal RPD design.
Although some studies (10) have concluded that there
are no significant differences between I-bar and cir-
cumferential clasp retainers in terms of success rates,
maintenance care and effects on periodontal health,
most studies (27, 28) claim that the typical ‘RPI’
retainer design (with mesial rest seat and buccal I-bar)
produces the least torquing on abutment teeth. In order
to achieve the most favourable load distribution on
abutment teeth, the RPDs used in the present study
were designed with I-bar retainers located in the
distobuccal undercuts on canine teeth, distal proximal
plates and cingulum rests fitted in rest seats.
A number of studies conducted in the 1960s looked
at the effects of RPDs on the stabilization of periodon-
tally mobile teeth (29, 30); however, none of them
focused on the splinting effect of a lingual plate in
distally extended RPDs, and none included proper
control groups or statistical analyses. The present study
was designed to evaluate whether or not a lingual plate
could be effective in providing tooth stabilization or in
improving periodontal conditions.
In bilateral distally extended lower arches, the lingual
plate must frequently be called upon to serve as an
indirect retainer, especially in cases where only the six
anterior teeth exist. A continuous bar retainer – which
is, in fact, the superior border of a lingual plate, without
the gingival apron – may also be used as a mandibular
major connector for the same purpose. While it
provides the same stabilization and other advantages
of a lingual plate, it is frequently more objectionable to
the patient’s tongue and is certainly more of a food trap
than the contoured apron (17); therefore, it was not
evaluated by this study.
The lingual plate may create dead-end tunnels
between teeth that trap food entering from the labial
side and prevent its passage lingually (17). A number of
epidemiologic studies and clinical and experimental
trials have shown that both caries and periodontitis are
caused by bacterial growth on tooth surfaces. It has also
been shown that there is a relationship between caries
ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 823–829
and diet, as well as a strong association between dental
plaque and the severity of periodontal disease, with the
severity increasing with age (31, 32). In this study,
although there was greater plaque retention on dental
surfaces in the lingual plate group than the lingual bar
group at the end of a 30-month follow-up period,
surprisingly, the increased plaque accumulation did not
result in any periodontal breakdown. In fact, there was
actually a decrease in PI values from day 0 to
30 months, which can be attributed to regular recall
appointments for professional plaque control, including
subgingival scaling and root planing.
The RPDs have been reported to lead to increased
plaque accumulation, mainly on tooth surfaces in
contact with the denture (33, 34), but also on other
tooth surfaces (35, 36). In one clinical study (3),
patients wearing RPDs were reported to have experi-
enced more harmful effects on periodontal tissue when
compared with controls; however, the authors noted
that the oral hygiene of patients in the study was less
than optimal, as they were not seen at regular intervals
by the same examiners and received no reinforcement
of oral hygiene instruction. In line with this comment,
we again suggest that the negative periodontal effects of
RPDs can be diminished by home-care procedures and
professional plaque control recall appointments, as
demonstrated by the present study.
Motivation, instruction and professional oral hygiene
care can prevent the progress of and even reduce
periodontal disease and caries to a minimum (8, 37, 38).
A number of previous clinical studies on RPDs (4, 16,
37) have also mentioned that incorporating a preventive
program into follow-up examinations makes it possible
to maintain a high standard of oral hygiene in adults and
elderly individuals over a prolonged period of time. One
study conducted over a 10-year period showed that with
the maintenance of proper plaque control, forces trans-
mitted from the denture to abutment teeth did not
induce periodontal damage (1). Moreover, it should be
noted that it is the type rather than quantity of plaque
that is considered to be pathogenic and to cause
periodontal breakdown (39, 40).
In the present study, there was no statistically
significant difference in the GI scores between groups.
Both groups also exhibited regressions in PD values;
however, in the lingual bar group, decreases in PD
values were due in part to increases in GR, which were
greater in the lingual bar group than in the lingual plate
group. This GR was seen most frequently in the teeth
 TOOTH STABILIZING EFFECT OF RPD DESIGNS
supporting the denture, a finding that is contrary to
most previous studies (5, 6, 41), which have reported
that RPDs cause the most adverse affects on gingival
health where the appliance was in close contact with
the gingival margin.
Despite increases in GR, there was still a time-
dependant decrease in mean TM values for the lingual
bar group. However, beginning at 12 months and
continuing to 30 months, the lingual bar group showed
greater TM than the lingual plate group. This finding is
indicative of a reorganization of the supra-alveolar
connective tissue. This result is also consistent with the
findings reported by Lindhe and Nyman in 1975 and
Persson in 1980 and 1981 (42–45).
Because of the effects of force distribution, use of an
RPD will inevitably lead to degenerative changes such as
resorption and differentiation of trabecular sequences,
especially in distally extended cases. However, a properly
designed RPD may provide a homogenous distribution of
occlusal forces, create regular adaptation of periodontal
tissue and an obvious decrease in TM, especially when
supported by a strict oral hygiene routine and frequent
recalls. Moreover, used as a major connector in an RPD,
the lingual plate may simulate occlusal adjustment by
interfering with or altering the direction of occlusal
forces. Thus, decreases in TM values may be attributable
to the stabilizing effects of the lingual plate.
Some clinical research has shown that healing
following treatment of periodontal disease is greater at
non-mobile teeth than at mobile teeth (46, 47). As a
result of this finding, it has been hypothesized that
tissue formation and maturation is better at non-mobile
than at mobile teeth, and therefore splinting may be a
suitable means of slowing down the breakdown of
attachment apparatus in cases of periodontitis. This
hypothesis is supported by the current survey’s finding
of statistically significant improvements in TM values in
the lingual plate group between day 0 and 30 months.
It may be concluded that the forces applied to teeth
used to support the RPD lingual plate had a positive
affect on the attachment levels of connective tissue.
There are numerous factors that play a role in TM,
even in patients with a healthy periodontium. Changes
in TM values following periodontal therapy may be
related to the number and morphology of roots, the
amount of root surface area occupied by the alveolar
bone, host-specific defense situations, as well as pres-
sure applied by the clinician in measuring values (45).
However, the authors of the present study remain
ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 823–829
827
convinced that the synergy between periodontal treat-
ment and the splinting effect of the lingual plate in
lingual plate-type RPDs results in decreases in TM at the
end of 30 months follow-up.
In conclusion, our findings suggest that RPD treat-
ment will not lead to increased damage of remaining
teeth and periodontal tissue if dentures are carefully
planned, plaque control is established and the pros-
theses and oral hygiene are checked at regular recall
appointments. Moreover, patients treated with a lingual
plate RPD were not found to experience any deterior-
ation during 30 months follow-up and, in fact, experi-
enced decreases in TM values, indicating that lingual
plate-type RPDs may play an important role in minim-
izing the negative effects resulting from loss of support.
When ideal oral hygiene is maintained, the lingual plate
may be used as a major connector in distally extended
cases, especially when there are few remaining teeth to
support the indirect retention of the prosthesis. How-
ever, as experienced in the present study the plaque
accumulation was greater in the lingual plate treatment
group inspite of periodic recalls and this still stands to be
a risk factor for the deterioration of the periodontal
status of our patients treated with RPDs. Under these
circumstances the long-term clinical interpretation of
decreased TM observed in patients treated with lingual
plate-type RPDs may be questionable.
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46. Burgett FG, Ramfjord SP, Nisle R, Morrison R, Charbeneau Correspondence: Funda Akaltan, Dis¸ Hekimliği Fakültesi, Ankara
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ª 2005 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 32; 823–829