Community Dent Oral Epidemiol 1999; 27: 249–58 Copyright C Munksgaard 1999

Printed in Denmark . All rights reserved

ISSN 0301-5661

Commentary
Dick J. Witter1,
The shortened dental arch concept Wim H. van Palenstein Helderman2,
Nico H. J. Creugers1 and
Arnd F. Käyser1
and its implications for oral health 1
Department of Occlusal Reconstruction and
Oral Function, College of Dental Science,
Medical Faculty, University of Nijmegen,

care 2
WHO Collaborating Centre for Oral Health
Care Planning and Future Scenarios,
Nijmegen, the Netherlands

Witter DJ, van Palenstein Helderman WH, Creugers NHJ, Käyser AF: The short-
ened dental arch concept and its implications for oral health care. Community
Dent Oral Epidemiol 1999; 27: 249–58. C Munksgaard, 1999

Abstract – The minimum number of teeth needed to satisfy functional demands

has been the subject of several studies. However, since functional demands – and
consequently the number of teeth needed – can vary from individual to individ-
ual, this minimum number cannot be defined exactly. In general, occlusion of a
complete dental arch is preferable. However, this goal might be neither attaina-
ble, for general, dental or financial reasons, nor necessary. Many studies demon-
strate that shortened dental arches comprising the anterior and premolar regions
can meet the requirements of a functional dentition. Consequently, when priorities
have to be set, restorative therapy should be aimed at preserving the most strate-
Key words: community dentistry; dental
gic parts of the dental arch: the anterior and premolar regions. This also implies
arches; occlusion; oral health care; removable
that in cases of a shortened dental arch, the prompt replacement of absent poster- partial denture
ior molars by free-end removable partial dentures leads to overtreatment and dis-
D. J. Witter, Department of Occlusal
comfort. The shortened dental arch concept is based on circumstantial evidence: Reconstruction and Oral Function, University
it does not contradict current theories of occlusion and fits well with a problem- of Nijmegen, P.O. Box 9101, 6500 HB,
solving approach. The concept offers some important advantages and may be Nijmegen, the Netherlands
considered a strategy to reduce the need for complex restorative treatment in the e-mail: secroof/dent.kun.nl
posterior regions of the mouth. Accepted for publication 22 January 1999

With the exception of developmental disorders,
every individual develops 28 (32) teeth or 14 (16)
functional units, i.e. pairs of opposing teeth. This
occlusal system is not stable during life, as changes
occur as a result of physiologic as well as patho-
logic processes, such as occlusal wear, caries, perio-
dontal disease and traumatic injuries. In spite of
intervention in the form of preventive and restor-
ative care, changes may accumulate, leading to
badly decayed or periodontally involved teeth or
to a reduced number of functional units.
A fundamental problem in complex restorative
care in broken-down dentitions is the decision on
how many teeth should be saved or replaced in
order to guarantee satisfactory oral function. Pres-
ervation of complete dental arches in many cases
is possible, but should be weighed against factors
such as cost and the real need for complete dental
arches (1, 2).
The traditional approach in restorative dentistry
stresses idealized morphological criteria and me-
chanically oriented concepts. Many textbooks em-
phasize the importance of molar support to pre-
vent temporomandibular joint problems and occlu-
sal instability. This compulsion to save or replace
every absent tooth may lead to overtreatment (3,
4). Drawing on clinical observation, Ramfjord (5)
stated that ‘‘replacement of lost molars is a com-
mon source of iatrogenic periodontal disease, and
should be avoided if requirements to aesthetics and
functional stability can be satisfied without such re-
placements’’.
The so-called restorative repair cycle (3, 6) (more
than 50% of dental restorative work consists of re-

249
Witter et al.
pairing previous restorations) is related partic-
ularly to molars, since they are the most susceptible
to dental diseases. The traditional restorative con-
cepts subject the dentition to an intensive repair cy-
cle of consecutively restoring ‘‘permanent’’ restora-
tions.
The shortened dental arch (SDA) concept is
based on the considerations that (i) it fits well with
current criteria for a healthy occlusion; (ii) an SDA
can meet the requirements of normal oral function;
(iii) molars are high-risk teeth for caries and perio-
dontal diseases, and (iv) possibilities for complex
restorative treatment are often limited.
The aim of this paper is to review the possible
role of the shortened dental arch concept in restor-
ative dentistry. Evidence is presented that an SDA
provides adequate oral function.
Criteria for a healthy occlusion
The prime aim of dental care is to maintain a natu-
ral functional dentition throughout life, including
all the social and biological functions, such as self-
esteem, aesthetics, speech, chewing, taste and oral
comfort (7–10). Since 1970 the orientation of occlu-
sal concepts has shifted from dogmatically mor-
phological and mechanical towards physiologic
criteria. The current criteria and underlying as-
sumptions for a healthy or physiologic occlusion,
as developed by Mohl et al. (11) and Ramfjord &
Ash (12) reflect this shift clearly:
– Absence of pathologic manifestations
– Satisfactory function (aesthetics, chewing, oral
comfort)
– Mandibular stability
– Variability in form and function of the stoma-
thognatic system
– Adaptive capacity of the stomathognatic system
to changing situations.
This physiological and functional approach as-
sumes a variety of forms of the dentition which are
still compatible with healthy occlusion and satisfy-
ing oral function. An important implication is that
the number of teeth may vary and thus may be less
than 28.
The need for 28 teeth
Social and functional impact of a reduced
number of posterior dental units
With respect to the social and functional impact on
daily life and satisfaction with a reduced number
of teeth, especially posterior dental units, the
250
following four research papers provide compre-
hensive information.
Cushing et al. (13) investigated the social impact
(or problems) of dental disease as experienced by
individuals. They reported on the extent of socio-
dental problems and the relationship of these prob-
lems to clinical oral status. They distinguished four
impact categories, namely: (i) functional (related to
eating); (ii) social interaction (related to communi-
cation, such as speech, smiling and kissing); (iii)
comfort (related to toothache) and well-being (re-
lated to tooth sensitivity, food impaction and den-
ture discomfort); and (iv) self-image (related to aes-
thetics). They computed self-assessment by ques-
tionnaires completed by 414 individuals (aged 16–
60 years) of an industrial population in the north of
England. It was found (in a dentate group without
removable partial dentures) that individuals re-
porting eating problems had an average of 17.8
functioning teeth, while the group with no eating
problems had 21.1 functioning teeth (functioning
teeth were defined as ‘‘the aggregate of sound plus
filled, otherwise sound, teeth’’). The group with
communication problems had an average of 18.5
functioning teeth; the group with no problems an
average of 20.8. The perception of pain and dis-
comfort appeared not to be related with the
number of functioning teeth. Furthermore, the
group reporting problems with dental aesthetics
had an average of 17.7 functioning teeth and the
group with no aesthetic problems an average of
21.0. When the separate impacts or problems were
added to a ‘‘total impact’’, the group of subjects
with one or more problems had an average of 19.2
functioning teeth, whereas the group with no prob-
lems had an average of 21.9 functioning teeth.
Rosenoer & Sheiham (14) studied 195 employees
in London (aged 35–64), with all anterior teeth
present (or replaced by bridges) and a varying
number of functional posterior occluding pairs.
The mean number of teeth present in the total
population was 22.8∫4.5. They found a very poor
association between reported satisfaction with
teeth and the number of standing teeth. There was
little difference in satisfaction with dental and
mouth status and the number of functional poster-
ior occluding pairs.
Leake et al. (15) examined the relationship be-
tween oral function and the number of opposing
pairs of posterior teeth. They identified 261 Ontario
adults aged 50 years and over with complete ante-
rior dentitions and with a varying number of func-
tional units (pairs of opposing posterior teeth), all

without a partial denture. Their interview con-
tained questions with respect to chewing ability,
mandibular (dys)function and questions on socio-
psychological impacts (finding appearance of teeth
embarrassing, avoiding laughing or smiling, avoid-
ing conversation, worrying about appearance/
health of the teeth). It was concluded ‘‘that oral
function problems increased with decreasing func-
tional units, being markedly more prevalent
among subjects with 2 or less functional units’’,
suggesting a turning point from adequate to insuf-
ficient function at 3 or 4 functional units (opposing
pairs of posterior teeth).
On the basis of these and other studies, Elias &
Sheiham (16) concluded in an extensive review pa-
per on the relationship between satisfaction with
the mouth and number and position of teeth that
‘‘missing posterior teeth are not very important
from a subjective aspect’’.
Consideration
It is assumed that in ancient times the possession
of complete dental arches (32 or 28 teeth) may have
had some survival value. However, in the evolu-
tion of the human species the hands took over the
grasping and touching functions of the snout, and
the brain took over part of the chewing function by
inventing and producing refined food. Communi-
cation became more important than chewing. In re-
cent times, the studies mentioned above (13–16)
and other epidemiological studies (17–21) have
shown a lack of strict correlation between a re-
duced number of occlusal posterior units and per-
ceived oral function. Open spaces in the premolar
and molar region are accepted to a high degree by
individuals of different ages in countries with a
highly developed dental care system. Most cited
studies indicate a shift from adequate oral function
to insufficient oral function when less than 20
‘‘well-distributed’’ teeth are present.
Shortened dental arches (SDA)
An SDA is a specific type of a dentition with a re-
duced number of posterior dental units, namely a
dentition with a reduction of teeth starting posteri-
orly. In order to quantify the length of the dental
arch, the number of pairs of occluding posterior
teeth can be used (22). In this model one molar unit
is considered to be equal to two premolar units
(Fig. 1). Although the arch length of SDA can vary,
the scope of this paper is limited to these types of
SDA.
Shortened dental arch concept and oral health care
Fig. 1. Representation of shortened dental arches, comprising
an intact anterior region and a variation of arch length, ex-
pressed in occlusal units (OU), i.e. pairs of occluding poster-
ior teeth; one molar unit is considered to be equal to two
premolar units.
In a 6-year longitudinal study (22, 23) on SDAs
with the anterior teeth and between three and five
occlusal units (OU) (Fig. 1), it has been shown that
there is sufficient adaptive capacity to ensure dura-
ble acceptable oral function. The main conclusions
of that study, comparing subjects with SDAs and
subjects with complete dental arches, were:
(i) SDAs provide sufficient oral function and oral
comfort in terms of chewing function, aesthet-
ics, and signs and symptoms of temporoman-
dibular disorder (TMD) for a long-term period
(6 years).
(ii) SDAs provide sufficient mandibular stability:
the absence of molar support is not a risk fac-
tor for the development of TMD problems.
(iii) SDAs provide sufficient occlusal stability: mi-
nor changes in interdental spacing occur short-
ly after extractions leading to an SDA, but a
new occlusal equilibrium remains stable and
these changes do not pose any problem to the
oral function. Although in SDAs a trend is
found to more occlusal contacts in the anterior
region in intercuspal position (in comparison
to complete dental arches), vertical overbite is
not influenced by the SDA.
(iv) Occlusal attrition in SDAs does not differ sig-
nificantly from that of complete dental arches.
(v) Alveolar bone height scores in SDAs tend to
decrease in the same degree as in complete
dental arches.
The anterior teeth in SDA have more occlusal
contacts in intercuspal position, compared to com-
plete dental arches, whereas neither interdental
spacing in the anterior region nor vertical overbite
increases (22, 24). This makes it plausible that the
anterior teeth eventually can assist in absorbing oc-
clusal forces, which is not possible in severe Angle
251
Witter et al.

Class II or Angle Class III relations. This makes it
obvious that the SDA concept is related to normal
occlusal relationships.
The finding that perceived masticatory function
in SDAs (comprising 10 occluding pairs of teeth) is
generally sufficient is not surprising as other re-
view papers (16, 25) conclude that as a rule a mini-
mum of 20 ‘‘well-distributed teeth’’ are needed for
adequate masticatory function. Although the
‘‘masticatory performance’’ (objectively measured
by pulverization tests of test food in laboratory in-
vestigations) decreases linearly with the ‘‘mastica-
tion platform area’’, the ‘‘perceived masticatory
ability’’ (assessed by interviews or questionnaires)
remains sufficient as long as the dental arch length
comprises the anterior teeth and 3–5 occlusal units
(Fig. 2), a so-called ‘‘premolar dentition’’ with some
variations. This finding is in agreement with the
study of Aukes (26), who found only small differ-
ences in perception and food selection between
subjects with shortened dental arches and subjects
with complete dental arches.
It is generally agreed in industrialized countries
that the problem of overnutrition and malnutrition
in present-day society is far greater than the prob-
lem of undernutrition. Moreover, economical and
sociopsychological factors are believed to be more
important regarding food selection and intake than
physiological factors, such as the state of the denti-
tion. Only in cases of severe masticatory impair-
ment, when only a few teeth remain, or in subjects
who have not adapted to complete or removable
partial dentures, can a shift in food selection
towards soft and easily chewed foods be expected
(25).
In a review paper on the relation of occlusal fac-
tors and TMD, Seligman & Pullinger (27) conclud-
ed that a presumed association between loss of
posterior support and osteoarthrosis is minimal or
absent when the effects of age are controlled for;
the suggested association may not be the result of
lost teeth, but of increasing age. Occlusion cannot
be considered the unique or dominant factor in de-
fining TMD populations (28).
As depicted in Table 1, the molars do not have
any exclusive function. It appears that all separate
functions performed by the molars are also pro-
vided by the premolar and anterior teeth (1, 24).
Iatrogenic effects of prosthodontic
devices
For decades, arch lengthening by free-end remov-
able partial dentures (RPD) in cases of SDA was
the standard recommendation and treatment op-
tion. It was thought that such an RPD, replacing
molars, was necessary to provide occlusal stability
(preventing anterior bite collapse and overeruption
of non-opposed posterior teeth), to support the
temporomandibular joint (TMJ), consequently to
prevent TMD, and to restore chewing function.
However, the presumed positive effects of RPDs
replacing molars could never be supported by con-
clusive research. One of the reasons is that in the
case of an SDA it is not quite clear which function

Table 1. Assessment of the function of different tooth types

Anteriors Premolars Molars

Biting π ª ª
Chewing ª π π
Speech π ª ª
Aesthetics π π ∫
Stability of :
– TMJ (mandibular
stability) π π π
– Dental arch (occlusal
Fig. 2. Schematic representation of the relation between stability) π π π
masticatory function and dental arch length (expressed in Preservation of alveolar
occlusal units). 1. masticatory ability (perceived ease of process π π π
chewing); 2. masticatory performance; A. area of sufficient
masticatory function; B. borderline range; C. area of insuffi- πΩprime involvement.
cient masticatory function. ªΩno or secondary involvement.

252

has to be improved and to what extent. On the
other hand, the negative effects of free-end RPDs
have been underestimated (4, 29). Generally, RPDs
are considered to be appliances with potential neg-
ative side-effects which to a certain extent can be
counteracted by regular recall to maintain proper
oral and denture hygiene (30–35).
Moreover, two additional problems are related
especially to the free-end type of RPD: instability
due to resorption of the alveolar bone under the
saddles (36, 37) and discomfort which often leads
to patients not wearing the RPD (14, 16, 30, 38, 39).
These, and other studies, especially among elderly
people (15, 40–43) have shown a large discrepancy
between professionally assessed need and subjec-
tive treatment demand. This is most probably the
main reason that free-end RPDs replacing molars
are often not worn by patients. In addition, free-
end RPDs are a frequent cause of re-treatment
because of fractures (of clasps and minor connec-
tors) and rebasings (23, 39).
It has also been shown that prosthetic replace-
ment of lost molars solely to prevent TMJ os-
teoarthrosis (44) or to prevent clinical signs and
symptoms of TMD (18, 23, 45, 46) cannot be a gen-
eral principle in treatment planning.
Thus, in cases of SDAs such as a ‘‘premolar den-
tition’’, the molars should not in the first instance
be replaced by for example metal frame RPDs. This
option should be considered only in exceptional
cases: when the SDA condition has evoked special
problems (which still persist after an adaptation
and ‘‘wait-and-see’’ period), and when these prob-
lems can be eliminated with a metal frame RPD.
Replacement by non-tooth supported acrylic RPD
is even more contra-indicated (37, 39) since this
type of appliance does not stabilize the occlusion
at all.
The SDA concept
Besides the evidence that SDAs can meet oral func-
tional demands, the SDA concept is based on some
other considerations.
First, with regard to dental diseases, high-risk
teeth as well as high-risk subjects (47) can be iden-
tified. In comparison with other tooth types, mo-
lars are at high risk. They have the highest plaque
deposits (48, 49) and consequently are the teeth
most affected by caries (50–55) as well as periodon-
tal disease (56). They have the lowest alveolar bone
height scores (57, 58) and the lowest periodontal
attachment levels (59–64) compared with other
Shortened dental arch concept and oral health care
teeth. Molars show a poor response to periodontal
treatment, and ‘‘looser sites’’ are more frequently
detected at molar sites than at other tooth types
(65–71). Clinical dentistry (in general practice) has
frequently solved this problem with extraction:
molars, particularly mandibular molars, are the
most frequently extracted teeth and at an earlier
stage (72–78). Many studies demonstrate the con-
tinued retention of the anterior part of the dentition
in contrast to the early loss of molars (17, 79–84).
Secondly, loss of teeth results in a tooth-bounded
open space (interrupted dental arches) or in an
SDA. Tooth-bounded open spaces offer more pos-
siblities for migration of the adjacent teeth than
SDAs, namely mesially and distally into the open
space. The most frequent and most serious migra-
tion reported is the mesial tilting of the distally re-
maining teeth, followed by distal tilting of the me-
sially located teeth (85). Based on clinical observa-
tion the impression exists that overeruption of non-
opposed teeth is seen more often in tooth-bounded
spaces than in SDAs. This may be explained by the
role of the tongue. It is assumed that in SDAs inter-
position of the tongue prevents overeruption. In
tooth-bounded spaces interposition of the tongue
is often hindered by the teeth, resulting in more
horizontal and vertical migration of adjacent and
opposing teeth. The finding that in SDAs migration
of the teeth is small (22, 24), adaptive and self-
limiting means that occlusal interferences rarely oc-
cur. This is in contrast with the consequences of
migration in tooth-bounded spaces, which lead to
a higher risk of occlusal interferences, necessitating
treatment (86).
Clinical research has shown that in SDAs minor
and self-limiting interdental spacing occurs shortly
after the extractions leading to an SDA, especially
in the (lower) premolar regions (22, 24). Neverthe-
less, spacing in itself does not indicate a pathologi-
cal condition. Silness & Røynstrand (87) found
more favourable periodontal conditions and fewer
restorations in proximal surfaces without interden-
Table 2. Oral functional level needed in relation to age, ex-
pressed in minimum number of occluding teeth. (SDAΩ
shortened dental arch, ESDAΩextreme shortened dental
arch.)
Age Functional level Occluding teeth
20–50 I–optimal 24
40–80 II–suboptimal 20 (SDA)
70–100 III–minimal 16 (ESDA)
253
Witter et al.
Table 3. Traditional treatment approach vs current approach
Traditional
Aim O Preservation of complete dental arches
Basis O Mechanical and morphological concepts
Characteristics O Always replace absent teeth
O Always restore absent molar support
O May lead to overtreatment
O Options for fixed appliances usually costly
tal contact than in surfaces with contact. Jernberg et
al. (88) found less debris at open contacts; however,
increased probing depth (0.27 mm) and more at-
tachment loss (0.48 mm) were also found at open
contacts. On the contrary, local crowding predis-
poses to increased alveolar bone loss, especially in
periodontal patients (89).
An advantage of the SDA is that the remaining
anterior and premolar regions are easily accessible
for oral hygiene (which might be important for el-
derly patients, especially those with psychomotor
impairment) and for restorative procedures.
Rationale of the SDA concept
In general, complete natural dental arches are pre-
ferable to any form of SDA since the molars con-
tribute to the long-range occlusal stability of the
anterior and premolar regions. This means that in
dental care programmes molars should get the
same priority as anterior teeth and premolars as
long as there are no limiting factors. However, if
limiting factors exist in situations where adequate
care for all the teeth is neither possible nor afford-
able, priorities have to be set (9, 86, 90, 91). This
implies concentrating the best available quality
care on the strategic regions of the dentition, the
anterior and premolar regions, in order to maintain
a suboptimal but still satisfactory functional level
(Table 2). In other words, to maintain a healthy,
natural, functioning dentition for life means the ul-
timate preservation of a premolar dental arch, and
the preservation of molar support until a certain
age. In Table 2 it is suggested that (reduced) molar
support (24 occluding teeth) should be maintained
at least until 40 or 50 years of age if possible. For
elderly and older elderly, some studies (15, 42, 92)
support the SDA concept in that they indicate that
even an extreme shortened dental arch (ESDA, 16
occluding teeth) can provide an adequate, though
minimal, functional level.
254
Current
O Preservation of functional dental arches
O Functional concepts and problem-solving strategies
O Consider treatment goals using:
– Problem-solving approach
– SDA concept
O Avoid overtreatment
O Less need for fixed appliances, hence less costly
When considering the SDA concept as a treat-
ment approach to simplify a complex treatment
plan, the clinician should assess whether subjects
meet the following criteria:
(i) Major problems (caries, periodontal disease,
severe tipping and drifting as a result of in-
terrupted dental arches) confined mainly to the
molar region.
(ii) Good prognosis of the anterior and the premo-
lar regions.
(iii) Limited possibilities for restorative care.
All things considered, reservations about apply-
ing the concept may be: young age, unfavourable
occlusal relationship of the upper and lower anteri-
or teeth (severe Angle Class II or Angle Class III),
and intensive occlusal activity (bruxism).
‘‘Pure’’ SDA conditions (such as a premolar den-
tition) are seen infrequently. In many cases some
non-opposed (non-occluding) teeth are present
posteriorly. This is to be expected as the loss of
teeth does not follow a strict standard pattern ac-
cording to a ‘‘natural history of the dentition’’. Re-
Fig. 3. Characteristics of restoring complete or reduced dental
arches in a broken-down dentition.

duced dentitions show morphologic variability and
are in reality more complex than the SDA concept
assumes.
Overeruption of non-opposed (non-occluding)
posterior teeth in SDAs might occur. But, as al-
ready mentioned, in most cases this is limited by
interposition of the tongue, resulting in pressure to
the occlusal surfaces that keeps these teeth in posi-
tion. Tooth loss and its sequelae have been overdra-
matised in the past, resulting in ‘‘preventive’’ pros-
thodontic tooth replacement instead of adopting a
‘‘wait and see’’ strategy (86). This approach was
prompted by traditional theories of occlusion that
neglected the adaptive capacity of the stomatog-
nathic system.
Healthy non-opposed posterior teeth in SDAs
should be saved. They can be useful for oral func-
tion (aesthetics, chewing function), for the preser-
vation of the alveolar process and for a reserve
function as a potential abutment tooth.
Implications for oral health care
Studies based on questionnaires among dentists
showed that the SDA concept is widely accepted,
but not widely practised (93, 94). However, from a
public health point of view it is impracticable and
uneconomical to preserve complete dental arches
when complex restorative treatment in the molar
regions is required. As argued above, preservation
of the molars at all costs is in many cases not neces-
sary. In such cases alternative treatment options,
for example maintaining an SDA, should be con-
sidered in order to simplify the treatment plan.
Then treatment goals are changing from the preser-
vation of complete dental arches towards the pres-
ervation of functional dental arches, which results
in less (over)treatment (Table 3). In a problem-solv-
ing approach, the patient’s dental problems are in-
ventoried and the treatment is then directed
towards solving these problems (7), leading to a
functional dentition, which could be an SDA (Fig.
3). In complex treatment plans this means a move
towards less treatment that also has the advantages
of being less complicated, less time-consuming and
less expensive. There is no evidence that the out-
come (in terms of the maintainance of a natural
dentition throughout life) of this treatment ap-
proach is inferior to the preservation of complete
dental arches. Concentrating on the functionally
strategic and sustainable parts of the dentition in
an effort to preserve a reduced natural, functional
dentition such as an SDA can in fact give even
Shortened dental arch concept and oral health care
better results. Then all available maintenance and
restorative care can be utilized for those parts of
the dentition that contribute most to the oral func-
tion.
Conclusions
Research indicate that SDAs consisting of the ante-
rior teeth and the premolar teeth can meet oral
functional demands such as aesthetics, chewing
ability, occlusal stability and mandibular stability
for a long-term period. However, the exact relation
between arch length, oral function, and cost-effec-
tiveness can only be clarified in prospective stud-
ies, which are difficult to conduct from an ethical
point of view. Nevertheless, as substantiated
above, there is an accumulation of circumstantial
evidence pointing out that the SDA concept offers
a realistic treatment strategy to reduce complex re-
storative treatment in the molar regions. Secondly,
by deduction, the concept indicates that in cases of
SDA absent posterior teeth should not be replaced.
The emphasis should be on preserving the func-
tionally strategic parts of the dentition, and avoid-
ing overtreatment with the associated costs and
questionable benefits.
Acknowledgement
The first three authors owe their gratitude to the late Prof.
Arnd Käyser, co-author of the manuscript of this article. He
passed away last year. We dedicate this article to him; the
man who inspired all of us in his department, and initiated
and led studies in the field of oral function in reduced denti-
tions and the shortened dental arch concept.
References
1. Käyser AF. The shortened dental arch: a therapeutic con-
cept in reduced dentitions and certain high-risk groups.
Int J Periodontics Restorative Dent 1989;9:427–50.
2. Kalk W, Käyser AF, Witter DJ. Needs for tooth replace-
ment. Int Dent J 1993;43:41–9.
3. Elderton RJ. Overtreatment with restorative dentistry:
when to intervene? Int Dent J 1993;43:17–24.
4. Käyser AF, Witter DJ, Spanauf AJ. Overtreatment with
removable partial dentures in shortened dental arches.
Aust Dent J 1987;32:178–82.
5. Ramfjord SP. Periodontal aspects of restorative dentistry.
J Oral Rehabil 1974;1:107–26.
6. Dawson AS, Makinson OF. Dental treatment and dental
health. Part 2. An alternative philosophy and some new
treatment modalities in operative dentistry. Aust Dent J
1992;37:205–10.
7. Käyser AF. Limited treatment goals – shortened dental
arches. Periodontol 2000 1994;4:7–14.
255
Witter et al.
8. Pilot T. Analysis of the overall affectiveness of treatment
of periodontal disease. In: Shanley DB, editor. Efficacy
of treatment procedures in periodontics. Chicago:
Quintessence; 1980. p. 213–31.
9. Sheiham A. Public health aspects of periodontal diseases
in Europe. J Clin Periodontol 1991;18:362–9.
10. World Health Organization. Recent advances in oral
health. Geneva: WHO Technical Report Series 826, 1992.
p. 16.
11. Mohl ND, Zarb GA, Carlsson GE, Rugh JD. A textbook
of occlusion. Chicago: Quintessence; 1988. p. 22–3.
12. Ramfjord SP, Ash MM. Occlusion. 4th ed. Philadelphia:
WB Saunders; 1995. p. 83–5.
13. Cushing AM, Sheiham A, Maizels J. Developing socio-
dental indicators – the social impact of dental disease.
Community Dent Health 1986;3:3–17.
14. Rosenoer LM, Sheiham A. Dental impacts on daily life
and satisfaction with teeth in relation to dental status in
adults. J Oral Rehabil 1995;22:469–80.
15. Leake JL, Hawkins R, Locker D. Social and functional
impact of reduced posterior dental units in older adults.
J Oral Rehabil 1994;21:1–10.
16. Elias AC, Sheiham A. The relationship between satisfac-
tion with mouth and number and position of teeth. J Oral
Rehabil 1998;25:649–61.
17. Liedberg B, Norlén P, Öwall B. Teeth, tooth spaces, and
prosthetic appliances in elderly men in Malmö, Sweden.
Community Dent Oral Epidemiol 1991;19:164–8.
18. Helöe B, Helöe LA. The occurrence of TMJ-disorders in
an elderly population as evaluated by recording of ‘‘sub-
jective’’ and ‘‘objective’’ symptoms. Acta Odontol Scand
1978;36:3–9.
19. Björn A, Öwall B. Partial edentulism and its prosthetic
treatment. Swed Dent J 1979;3:15–25.
20. Imperiali D, Grunder U, Lang NP. Mundhygienege-
wohnheiten, Zahnärztliche Versorgung und subjektive
Kaufähigkeit bei sozioökonomisch unterschiedlichen Be-
völkerungsschichten in der Schweiz. Schweiz Mo-
natsschr Zahnmed 1984;94:612–24.
21. Battistuzzi P, Käyser AF, Kanters N. Partial edentulism,
prosthetic treatment and oral function in a Dutch popu-
lation. J Oral Rehabil 1987;14:549–55.
22. Witter DJ, De Haan AFJ, Käyser AF, van Rossum GMJM.
A 6-year follow-up study of oral function in shortened
dental arches. Part I. Occlusal stability. J Oral Rehabil
1994;21:113–25.
23. Witter DJ, De Haan AFJ, Käyser AF, van Rossum, GMJM.
A 6-year follow-up study of oral function in shortened
dental arches. Part II. Craniomandibular dysfunction and
oral comfort. J Oral Rehabil 1994;21:353–66.
24. Käyser AF. Shortened dental arches and oral function. J
Oral Rehabil 1981;8:457–62.
25. Witter DJ, Cramwinckel AB, Van Rossum GMJM, Käyser,
AF. Shortened dental arches and masticatory ability. J
Dent 1990;18:185–9.
26. Aukes JNSC, Käyser AF, Felling AJA. The subjective ex-
perience of mastication in subjects with shortened dental
arches. J Oral Rehabil 1988;15:321–4.
27. Seligman DA, Pullinger AG. The role of intercuspal oc-
clusal relationships in temporomandibular disorders: a
review. J Craniomand Disord Facial Oral Pain 1991;5:96–
106.
28. Pullinger AG, Seligman DA, Gornbein JA. A multiple
logistic regression analysis of the risk and relative odds
of temporomandibular disorders as a function of com-
mon occlusal features. J Dent Res 1993;72:968–79.
256
29. Witter DJ, van Elteren P, Käyser AF. The effect of remov-
able partial dentures on the oral function in shortened
dental arches. J Oral Rehabil 1989;16:27–33.
30. Chandler JA, Brudvik JS. Clinical evaluation of patients
eight to nine years after placement of removable partial
dentures. J Prosthet Dent 1984;51:736–43.
31. Bergman B, Hugoson A, Olsson C. Caries, periodontal
and prosthetic findings in patients with removable par-
tial dentures: a ten-year longitudinal study. J Prosthet
Dent 1982;48:506–14.
32. Berg E. Periodontal problems associated with use of dis-
tal extension removable partial dentures – a matter of
construction? J Oral Rehabil 1985;12:369–79.
33. Rissin L, Feldman RS, Kapur KK, Chauncey HH. Six-
year report of the periodontal health of fixed and remov-
able partial denture abutment teeth. J Prosthet Dent
1985;54:461–7.
34. Lappalainen R, Koskenranta-Wuorinen P, Markkanen H.
Periodontal and cariological status in relation to different
combinations of removable partial dentures in elderly
men. Gerodontics 1987;3:122–4.
35. Isidor F, Budtz-Jørgensen E. Periodontal conditions
following treatment with distally extending cantilever
bridges or removable partial dentures in elderly patients.
A 5-year study. J Periodontol 1990;61:21–6.
36. Bergman B. Periodontal reactions related to removable
partial dentures: a literature review. J Prosthet Dent
1987;58:454–8.
37. Plotnick IJ, Beresin VE, Simkins AB. The effects of varia-
tions in the opposing dentition on changes in the par-
tially edentulous mandible. Part I. Bone changes ob-
served in serial radiographs. J Prosthet Dent 1975;33:278–
86.
38. Cowan RD, Gilbert JA, Elledge DA, McGlynn FD. Patient
use of removable partial dentures: two- and four-year
telephone interviews. J Prosthet Dent 1991;65:668–70.
39. Vermeulen AHBM, Keltjens HMAM, van‘t Hof MA,
Käyser AF. Ten-year evaluation of removable partial den-
tures: survival rates based on retreatment, not wearing
and replacement. J Prosthet Dent 1996;76:267–72.
40. Tervonen T. Condition of prosthetic constructions and
subjective needs for replacing missing teeth in a Finnish
adult population. J Oral Rehabil 988; 15:505–13.
41. Vehkalahti M, Paunio I. Dental conditions of the elderly:
the teeth available for use. Gerodontics 1988;4:146–9.
42. Meeuwissen JH. Perception of oral function of dentate
elderly. A descriptive study of 329 elderly subjects [the-
sis]. The Netherlands: Univ Nijmegen; 1992.
43. Steele JG, Ayatollahi SMT, Walls AWG, Murray JJ. Clin-
ical factors related to reported satisfaction with oral func-
tion amongst dentate older adults in England. Com-
munity Dent Oral Epidemiol 1997;25:143–9.
44. Holmlund A, Axelsson S. Temporomandibular joint os-
teoarthrosis. Correlation of clinical and arthroscopic
findings with degree of molar support. Acta Odontol
Scand 1994;52:214–8.
45. De Boever JA, Adriaens PA. Occlusal relationship in pa-
tients with pain-dysfunction symptoms in the temporo-
mandibular joints. J Oral Rehabil 1983;10:1–7.
46. Witter DJ, Van Elteren P, Käyser AF. Signs and symptoms
of mandibular dysfunction in shortened dental arches. J
Oral Rehabil 1988;15:413–20.
47. Elderton RJ, Davies JA. Restorative dental treatment in
the general dental service in Scotland. Br Dent J 1984;
157:196–200.
48. Shanley DB, Ahern FM. Periodontal disease and the in-

fluence of socio-educational factors in adolescents. In:
Frandsen A, editor. Public health aspects of periodontal
disease. Chicago: Quintessence; 1984. p. 109–20.
49. Silness J, Røynstrand T. Partial mouth recording of
plaque, gingivitis and probing depth in adolescents. J
Clin Periodontol 1988;15:189–92.
50. Katz RV, Hazen SP, Chilton NW, Mumma RD. Prevalence
and intraoral distribution of root caries in an adult popu-
lation. Caries Res 1982;16:265–71.
51. Dünninger P, Naujoks R. Karieszuwachs in 10 Jahren.
Longitudinalstudie an 100 ehemaligen Oberschülern.
Dtsch Zahnrärztl Z 1986; 41: 836–40.
52. Arneberg P, von der Fehr FR, Bjertness E. Caries and de-
fective restorations in elderly faculty patients. A follow-
up study. Gerodontics 1988;4:224–8.
53. Fure S, Zickert I. Prevalence of root surface caries in 55,
65, and 75-year-old Swedish individuals. Community
Dent Oral Epidemiol 1990;18:100–5.
54. Willemsen WL, Truin GJ, Kalsbeek H, Mulder J. Caries
prevalence in Dutch elderly people. Community Dent
Health 1991;8:39–44.
55. Sheiham A. Impact of dental treatment on the incidence
of dental caries in children and adults. Community Den-
tistry Oral Epidemiol 1997;25:104–12.
56. Brown LJ, Oliver RC, Löe H. Periodontal diseases in the
U.S. in 1981: prevalence, severity, extent, and role in
tooth mortality. J Periodontol 1989;60:363–70.
57. van Steenberghe D. The influence of oral health delivery
systems on the awareness and prevalence of periodontal
breakdown in the Belgian population. In: Frandsen A,
editor. Public health aspects of periodontal disease. Chi-
cago: Quintessence; 1984. p. 99–107.
58. Salonen LWE, Frithiof L, Wouters FR, Helldén LB. Mar-
ginal alveolar bone height in an adult Swedish popula-
tion. A radiographic cross-sectional epidemiologic study.
J Clin Periodontol 1991;18:223–32.
59. Schei O, Waerhaug J, Lovdal A, Arno A. Alveolar bone
loss as related to oral hygiene and age. J Periodontol
1959;30:7–16.
60. Löe H, Anerud A, Boysen H, Smith M. The natural his-
tory of periodontal disease in man. The rate of periodon-
tal destruction before 40 years of age. J Periodontol
1978;49:607–20.
61. Tal H. The prevalence and distribution of infrabony de-
fects in dry mandibles. J Periodontol 1984;55:149–54.
62. Björn A, Halling A. Periodontal bone height in relation
to number and type of teeth in dentate middle-aged
women. Swed Dent J 1987;11:223–33.
63. Okamoto H, Yoneyama T, Lindhe J, Haffajee A, Socran-
sky S. Methods of evaluating periodontal disease data in
epidemiological research. J Clin Periodontol 1988;15:430–
9.
64. Yoneyama T, Okamoto H, Lindhe J, Socransky SS, Haf-
fajee AD. Probing depth, attachment loss and gingival
recession. J Clin Periodontol 1988;15:581–91.
65. McFall WT. Tooth loss in 100 treated patients with perio-
dontal disease. A long-term study. J Periodontol 1982;
53:539–49.
66. Nordland P, Garrett S, Kiger R, Vanooteghem R, Hutch-
ens LH, Egelberg J. The effect of plaque control and root
debridement in molar teeth. J Clin Periodontol 1987;
14:231–6.
67. Loos B, Claffey N, Egelberg J. Clinical and microbiologi-
cal effects of root debridement in periodontal furcation
pockets. J Clin Periodontol 1988;15:453–63.
68. Lindhe J, Okamoto H, Yoneyama T, Haffajee A, Socran-
Shortened dental arch concept and oral health care
sky SS. Periodontal loser sites in untreated adult subjects.
J Clin Periodontol 1989;16:671–8.
69. Wood WR, Greco GW, McFall WT. Tooth loss in patients
with moderate periodontitis after treatment and long-
term maintenance care. J Periodontol 1989;60:516–20.
70. Yokota M, Kubo K, Matsuyama K, Sueda T. Pocket depth
reduction by tooth types and sites after initial treatment.
Dent Jpn (Tokyo) 1990;27:127–33.
71. Schroer M, Kirk C, Wahl T, Hutchens L, Moriarty J, Ber-
genholtz B. Closed versus open debridement of facial
grade II molar functions. J Clin Periodontol 1991;18:323–
9.
72. Papapanou PN, Wennström JL, Gröndahl K. Periodontal
status in relation to age and tooth type. A cross-sectional
radiographic study. J Clin Periodontol 1988;15:469–78.
73. Jackson D, Murray J. The loss of permanent teeth in den-
tate populations. Dent Pract 1972;22:186–8.
74. Halse A, Molven O, Riordan PJ. Number of teeth and
tooth loss of former dental school patients. Follow-up
study after 10–17 years. Acta Odontol Scand 1985;43:25–
9.
75. Cahen PM, Frank RM, Turlot JC. A survey of the reasons
for dental extractions in France. J Dent Res 1985;64:1087–
93.
76. Meeuwissen R, Eschen S. Twenty years of dental treat-
ment in the Dutch armed forces. Community Dent Oral
Epidemiol 1985;13:123–4.
77. Hand JS, Hunt RJ, Kohout FJ. Five-year incidence of
tooth loss in Iowans aged 65 and older. Community Dent
Oral Epidemiol 1991;19:48–51.
78. Eckerbom M, Magnusson T, Martinsson T. Reasons for
and incidence of tooth mortality in a Swedish popula-
tion. Endod Dent Traumatol 1992;8:230–4.
79. Loftus ER, Alman JE, Feldman RS, Wayler AH, Kapur
KK, Chauncey HH. Cross-sectional and longitudinal
tooth survival characteristics of a healthy male popula-
tion. Spec Care Dentist 1982;2:8–16.
80. Österberg T, Hedegård B, Säter G. Variation in dental
health in 70-year old men and women in Göteborg, Swe-
den. A cross-sectional epidemiological study including
longitudinal and cohort effects. Swed Dent J 1984;8:29–
48.
81. Hugoson A, Koch G, Bergendal T et al. Oral health of
individuals aged 3–80 years in Jönköping, Sweden, in
1973 and 1983. II. A review of clinical and radiographic
findings. Swed Dent J 1986;10:175–94.
82. Battistuzzi P, Käyser AF, Peer P. Tooth loss and remaining
occlusion in a Dutch population. J Oral Rehabil
1987;14:541–7.
83. Meskin LH, Brown LJ. Prevalence and patterns of tooth
loss in U.S. employed adult and senior populations,
1985–86. J Dent Educ 1988;52:686–91.
84. Toremalm H, Öwall B. Partial edentulism treated with cast
framework removable partial dentures. Quintessence Int
1988;19:493–9.
85. Kirschbaum E, Kirschbaum H, Lenz E. Das reaktiv func-
tionelle Verhalten des Lückengebisses aus der Sicht klin-
isch-experimenteller Untersuchungen. Zahn Mund Kief-
erheilkd 1987;75:270–5.
86. Käyser AF. Teeth, tooth loss and prosthetic appliances.
In: Öwall B, Käyser AF, Carlsson GE, editors. Prosth-
odontics – principles and management strategies. Lon-
don: Mosby-Wolfe; 1996. p. 35–48.
87. Silness J, Røynstrand T. Effect on dental health of spacing
in the anterior segments. J Clin Periodontol 1984;
11:387–98.
257
Witter et al.
88. Jernberg GR, Bakdash MB, Keenan KM. Relationship be-
tween proximal tooth open contacts and periodontal
disease. J Periodontol 1983;54:529–33.
89. Jensen BL, Solow B. Alveolar bone loss and crowding in
adult periodontal patients. Community Dent Oral
Epidemiol 1989;17:47–51.
90. Pilot T. Economic perspectives on diagnosis and treat-
ment planning in periodontology. J Clin Periodontol
1986;13:889–93.
91. Käyser AF, Witter DJ. Oral functional needs and its con-
sequences for dentulous older people. Community Dent
Health 1985;2:285–91.
258
92. Tzakis M, Österberg T, Carlsson GE. Masticatory func-
tion in 90-year-olds. Gerodontology 1994;11:25–9.
93. Allen PF, Witter DJ, Wilson NHF, Käyser AF. Shortened
dental arch therapy: views of consultants in restorative
dentistry in the United Kingdom. J Oral Rehabil
1996;23:481–5.
94. Witter DJ, Allen PF, Wilson NHF, Käyser AF. Dentists’
attitudes to the shortened dental arch concept. J Oral Re-
habil 1997;24:143–7.