Unilateral removable partial dentures

Removable partial dentures (RPDs) are widely used to replace missing teeth in order to restore
both function and aesthetics for the partially dentate patient. Conventional RPD design is
frequently bilateral and consists of a major connector that bridges both sides of the arch. Some
patients cannot and will not tolerate such an extensive appliance. For these patients, bridgework
may not be a predictable option and it is not always possible to provide implant-retained
restorations. This article presents unilateral RPDs as a potential treatment modality for such
patients and explores indications and contraindications for their use, including factors relating to
patient history, clinical presentation and patient wishes. Through case examples, design, material
and fabrication considerations will be discussed. While their use is not widespread, there are a
number of patients who benefit from the provision of unilateral RPDs. They are a useful
treatment to have in the clinician’s armamentarium, but a highly-skilled dental team and a
specific patient presentation is required in order for them to be a reasonable and predictable
prosthetic option.

Introduction
Partial edentulism is a growing issue. In 2009, 6% of adults in the UK were fully edentulous and
40% of dentate adults in the UK had fewer than 27 natural teeth. There were 14% who had fewer
than 21 natural teeth, which is believed to be the minimum requirement for a functional
dentition. In the UK there is an ageing population, who are retaining their natural teeth for
longer, combined with a ‘heavy-metal generation’ who have many heavily-restored teeth. It may
not be possible to maintain these heavily-restored teeth long term. Therefore dentists are likely to
become more frequently involved in the management of the partially dentate patient.

Partial edentulism problems

Functional
Missing teeth can lead to reduced masticatory efficiency. Loss of teeth may also cause issues
with speech. Dental problems can include over-eruption, drifting and loss of space. It has been
suggested that a loss of posterior teeth may result in an unfavourable distribution of occlusal
loads, occlusal interferences and periodontal breakdown. A systematic review by Van’t Spijker
et al. found no evidence suggesting that loss of posterior support leads to increased attrition.
Aesthetic
The degree of impact on appearance depends on both the site and number of missing teeth, along
with the attitude of the patient. There is a social stigma that comes with a loss of visible teeth,
especially anteriorly. Decreased occlusal face height and a lack of lip support can also change
facial features.
Psycho-social
Dental health is of great concern to many patients and losing teeth can have a detrimental impact
on a person’s self-esteem.
Treatment options
Some patients are accepting of their edentulous spaces and do not want or need restorations.
Others have active disease and poor oral hygiene, which precludes them from some treatment
options. Those who are suitable and desire replacement often have multiple options.
Fixed prostheses (bridges) tend to be limited to short spans, and patients with acceptable
abutments and suitable occlusal schemes. Conventional bridgework requires extensive
preparation of abutment teeth and evidence suggests that 29.2% of these teeth will lose vitality
after ten years. Resin-bonded bridges (RBBs) offer a less destructive, reversible alternative, with
minimal or no tooth preparation. RBBs have higher failure rates than conventional bridges, but
tend to fail less catastrophically. Metal-framed RBBs have an estimated survival rate of 80.8% at
five years.
Implants can be used to retain a single crown or larger prostheses. These are limited to patients
with a clinical presentation appropriate for implant placement. Certain patient factors are
associated with poorer outcomes with implants including smoking, poorly-controlled diabetes,
bisphosphonate use and radiotherapy to the jaws. Patients need to be willing to undergo a
surgical procedure and be able to meet the costs of treatment. Walton and MacEntee’s study
found that 36% of edentulous patients refused implants to retain lower dentures, even when
offered at no financial cost to the patient.
Orthodontic space closure may be a possibility but spaces are often unsuitable for this method
due to their size, position and asymmetry.
Few contraindications exist for removable partial dentures (RPDs); these include intolerance of
major connectors and patients with psychiatric disorders or repeated loss of consciousness. RPDs
carry a risk of increasing plaque accumulation and therefore increase the risk of caries and
periodontal disease. If designed appropriately, conventional RPDs can be an effective way to
restore large and/or multiple, bilateral edentulous spaces at a reasonable cost. It is recognised that
some patients may struggle to tolerate the bulk and wide coverage of such an appliance. In these
cases, where a single bounded saddle exists and implants and bridges are neither suitable nor
acceptable options for the patient, an alternative prosthetic option may be a unilateral RPD.

The unilateral RPD

The potential advantages of a small unilateral design over a conventional RPD include:
 Avoidance of palatal coverage and the need for a major connector. Lesser impact on
speech, gag reflex and generally more tolerable
 Lower biological costfewer surfaces for plaque accumulation, candida colonisation and
fewer natural teeth recruited as abutments
 Decreased bulk
 Does not feel like a conventional denture. Potential for less stigma and improved self-
confidence.

The disadvantages and limitations of unilateral RPDs include:

 Rarely suitable for restoring masticatory function, as they may transmit damaging lateral
forces to abutment teeth and oral tissues if placed in occlusal function during excursive
movements. This is due to the lack of cross-arch stabilisation, which may also lead to easy
displacement
 Restricted to bounded saddles
 Complex designs require more maintenance and can restrict patients to certain practices,
laboratories and hospitals
 Require good manual dexterity to take in and out of the mouth
 May require preparation of adjacent teeth to provide guide planes, rest seats and
undercuts in order to ensure good retention and stability
 Risk of inhalation and swallowing.

Smaller denture designs are more likely to be swallowed or inhaled. These events can have
serious consequences and therefore other prosthetic options must be appropriately considered
and discounted before a unilateral RPD is provided. Justifications for choosing this prosthesis
over others must be reasonable and recorded, as otherwise an adverse incident involving the
denture could leave the dentist undefendable. The enhanced stability provided by a bilateral
RPD, due to cross-arch bracing, means this design should be prioritised over a unilateral design
where possible to minimise the impact of functional forces on the oral tissues and reduce the risk
of inhalation or swallowing.

When to provide a unilateral RPD

There is currently a paucity of literature relating to the provision of unilateral RPDs and many
clinicians do not recommend their use. Davenport et al. asked a group of prosthodontists and
found that 50% agreed with the statement ‘bounded edentulous areas should not be restored with
a unilateral denture’. The authors believe these prostheses provide a viable option for the
replacement of missing teeth, but only in specific, appropriate situations. They are potentially
advantageous for single, shorter-span, bounded saddles, but it is not always necessary to restore
these bounded saddles and the patient should also consider the benefits of not doing so. Eighty-
eight percent of the prosthodontists consulted by Davenport et al. disagreed with the statement
that ‘bounded edentulous saddles should always be restored’.
Unilateral RPDs are a useful alternative when abutments are unsuitable or the span is too long
for a bridge, implant-retained restorations are not an option and a conventional RPD is not
acceptable for the patient. The patient’s concern must be primarily aesthetic and space must be
available to allow artificial teeth to be placed out of occlusal contact during excursive
movements. The lack of cross-arch stabilisation means unilateral RPDs should be limited to
areas where occlusal forces are lesser. Flatter alveolar ridges and more compressible mucosa
would be potential contraindications, as these would limit stability further, even in a well-
designed, tooth-supported prosthesis. The patient must have good manual dexterity and no
contraindicating medical or social history for a unilateral RPD. Contraindications would include
a history of psychiatric conditions, repeated loss of consciousness or alcohol and drug intoxica-
tion; these factors appear to increase the risk of inhalation or swallowing of foreign bodies.
Accidental ingestion or inhalation of foreign bodies is more common in the very young or the
elderly, therefore unilateral RPDs are best avoided in these age groups. These events are
generally uncommon however.
It is the authors’ opinion that maxillary unilateral RPDs are more successful than mandibular
unilateral RPDs. Patients tend to prioritise restoring maxillary spaces and, due to the functional
limitations of these appliances, the authors would not recommend their use in the lower arch.
Design and material options
The three main base material options are:
 Acrylic
 Cobalt-Chrome (Co-Cr)
 Nylon-based (flexible).

Acrylic unilateral RPDs gain their support from the mucosa. They can, however, be constructed
to gain additional tooth support by incorporating pre-formed (stainless steel) occlusal rests.
Stainless steel clasps may also be added to improve retention.
Cobalt-Chrome designs are tooth-borne and may be single-part or sectional. A sectional
denture is composed of two or more parts, each utilising different paths of insertion. Sectional
dentures have the advantage of combining intra-orally to engage opposing undercuts and aid
retention via a wedging effect. Locking components, such as bolts, can keep the parts together
and increase the security of a sectional denture. Retention for both types of Co-Cr design is
typically gained from clasps that engage the undercut surfaces of teeth. These may be cast in Co-
Cr as part of the metal substructure or added later if other materials are used such as gold,
stainless steel or polyoxymethylene. Precision attachments are an alternative to clasps for
achieving direct retention, but their use is not commonplace. Precision attachments are two-part
connectors; one part is connected to the tooth, root or implant and the other to a prosthesis.
Defined according to the tooth- or implant-connected element, precision attachments may be
intra-coronal (embedded in a restoration), extra-coronal (extending outside the contour of the
tooth) or radicular (connected to a root preparation). Examples include rod and tube designs,
magnets and stud-type attachments.
Nylon-based RPDs are mucosa-borne. They obtain their retention via clasps which are an
extension of the denture base material. The nylon resin allows the denture to be flexible, with
enough elasticity to be manipulated into the edentulous space.
Table 1 summarises the benefits and drawbacks of each option.

Acrylic
Advantages
Economic, quickly fabricated and little technical ability required in design or construction
Ease of insertion and removal
May be easily added to in the case of additional tooth loss
No preparation of adjacent teeth required

Disadvantages
Limited retention and stability
Increased risk of inhalation/swallowing and difficulty locating should this occur due to lack of radio
opacity. For this reason alone, the provision of small unilateral dentures made of plastic material may be
difficult to defend in front of the GDC or a court
May act as a gum stripper and accelerate alveolar bone resorption
Requires greater mucosal coverage to gain retention more bulk, greater risk of plaque accumulation and
candida colonisation
Mechanically weak and more prone to fracture
Co-Cr
Advantages
Tooth-borne and therefore less detrimental to soft tissues
Rigid and strong; can be made more hygienic and less bulky
Greater retention and stability from direct retainers eg clasps or precision attachments
Radio-opaque

Disadvantages
Often requires preparation of abutment teeth (more invasive)
Abutment teeth need to be sound healthy periodontium, ideally vital
More expensive than non-metal options
Clasps may interfere in the aesthetic zone and cause direct trauma to soft tissues

Sectional Co-Cr
Advantages
Allows opposing undercuts to be engaged to improve retention, eliminate food packing and avoid black
triangles between the teeth and denture base
May reduce the amount of tooth preparation required and need for clasping (improving aesthetics)
Excellent stability due to the close contact with the undercuts of abutment teeth

Disadvantages
Higher cost
High clinical and technical skill required to design and fabricate
Requires regular maintenance as components require regular re-activation. Therefore restricts patients to
the dental surgeries, hospitals and laboratories who manage these appliances
Requires the patient to have excellent manual dexterity

Co-Cr with precision attachments

Advantages
Greater aesthetics as clasps are not required
Improved retention, support and stability

Disadvantages
Higher cost
More destructive as abutment teeth require preparation. Often require crowns or copings to house the
attachments
Magnets are less retentive and less stable
Specific space requirements for attachments
High clinical and technical skill required to design and fabricate
Certain attachments require regular maintenance. This restricts patients to the dental surgeries, hospitals
and laboratories who manage these appliances
Requires the patient to have good manual dexterity

Flexible nylon dentures

Advantages
 Good aesthetics. Able to hide recession defects in adjacent teeth with flexible, gingival coloured clasp
arms
Resistant to fracture
Requires no tooth preparation
Can be fabricated quite thin
Easy to fabricate requires only three clinical appointments

Disadvantages
Not suitable for flabby ridges or less than 4 mm of inter-arch space
Unhygienic due to proximity to gingival margins and inability to brush the appliance without causing
scratches
Difficult to repair and re-line. Additions are rarely possible
Denture teeth are only retained mechanically (via diatorics) and tooth loss can be an issue
Aesthetics deteriorate quickly due to ease of staining and scratching
Radiolucent and therefore difficult to locate if inhaled or swallowed. For this reason alone, the provision
of small unilateral dentures made of plastic material may be difficult to defend in front of the GDC or a
court
Loss of elasticity over time, becoming more rigid

Clinical cases
The following two cases exemplify the use of unilateral RPDs to restore a single edentulous
bounded saddle. Both patients were treated in the Charles Clifford Dental Hospital, Sheffield
Teaching Hospitals NHS Foundation Trust.
Case 1
This 57-year-old female was unhappy with the appearance of the edentulous area of teeth 23 and
24 and requested replacement. Traumatic failure of a fixed-fixed bridge 22 to 24 led to
sectioning of this bridge and the extraction of tooth 24. Subsequently the 22 became non-vital
and was successfully root-treated. The patient reported a history of unsuccessful partial dentures
before the placement of this bridge.
Following stabilisation of her periodontal condition, the patient had excellent plaque control. Her
medical history was not a contraindication to any prosthesis.
On clinical examination, the patient had a porcelain-fused-to-metal (PFM) crown tooth 22
(previous bridge retainer through which endodontic access had been gained) and the tooth 25
was un-restored (Figs 1a and 1b). The patient had group function on lateral excursions and
anterior guidance in protrusion.
The options for restoring the edentulous space were discussed with the patient at length. An
implant-retained bridge was proposed but financial considerations made this option unfeasible.
Conventional RPDs were rejected as the patient had previously been unable to tolerate any
palatal coverage. A bridge was deemed unsuitable due to the length of span, the un-restored
tooth 25 and root-treated tooth 22. A Co-Cr unilateral RPD was the other option and this was the
treatment of choice.
The compromised tooth 22 crown was replaced with a milled PFM crown to be integrated with
the RPD design (Fig. 1c). The tooth 25 had a mesial rest seat and palatal guide plane prepared,
along with the addition of composite buccally to provide an undercut for engaging a retentive
clasp. The use of composite restorations to enhance RPD retention has been suggested by
Davenport et al.
The tooth 22 crown was designed with a palatal rest seat and guide plane parallel to the mesial
surface of tooth 25, in order to provide a single, altered path of insertion. A precision attachment
on the tooth 22 crown was considered to avoid using an anterior clasp, but there was insufficient
inter-occlusal space to allow for housing an intra-coronal attachment. Additionally, an extra-
coronal attachment would have been irritating and clearly visible when the patient was not
wearing the RPD. One benefit of using a removable appliance is that it is reversible, therefore the
tooth 22 crown was designed considering when the patient was and was not wearing the RPD.
The unilateral Co-Cr RPD was designed with an occlusally-approaching clasp, mesial rest and
palatal reciprocating plate on tooth 25 (Fig. 1d). The design included a palatal plate and rest to
engage the milled aspect of the tooth 22 crown and a gingivally-approaching I-bar clasp
anteriorly. As the tip would be visible in the smile-line, this clasp was fabricated in gold at the
patient’s request. A tooth-coloured, polyoxymethylene I-bar was considered for aesthetics but
the patient preferred the appearance of gold; polyoxymethylene clasps tend to be bulkier.
The casts were mounted on a semi-adjustable articulator and this was used throughout the
fabrication of the crown and RPD. The patient was very satisfied with the final result (Figs 1e–
g).

Case 2
This 41-year-old female had a history of poor tolerance of conventional RPDs with palatal
coverage. The edentulous space of teeth 14, 15 and 16 was of aesthetic concern to the patient.
The patient had good plaque control, a moderately-restored dentition and was partially
edentulous (Fig. 2a). Her medical history was not a contraindication to any forms of treatment to
replace these missing teeth. The bounded saddle in the upper right quadrant was too long to
predict success with fixed bridgework and preparation of the un-restored tooth 13 would have
been destructive. The patient was not receptive to provision of an implant-retained prosthesis.
The treatment of choice was a Co-Cr unilateral RPD.
The tooth 17 was heavily-restored with composite and amalgam. These restorations were
replaced with a composite core build-up and a full gold crown. The crown was designed with
sufficient buccal undercut to engage a clasp tip. A composite addition was also made labially to
tooth 13 to aid retention via a gingivally-approaching clasp, which was provided in Co-Cr due to
the shallow undercut available and need for a stiff clasp to maximise retention (Figs 2b–d). An
anterior precision attachment may have been more aesthetic, but it would likely have involved
irreversible preparation of the virgin tooth 13.
A Co-Cr unilateral RPD was provided bearing two denture teeth. This was designed with an
occlusally-approaching clasp, reciprocating arm and occlusal rest on tooth 17, along with a
cingulum rest and gingivally-approaching clasp on tooth 13 (Fig. 2e). The patient was delighted
with the final result (Fig. 2f).

Recommendations for success

All other prosthetic options must be considered and deemed unsuitable before a unilateral RPD is
offered. Even then, a critical element when deciding if a unilateral RPD is appropriate is to
consider the individual patient. Suitable candidates are well-motivated and have good oral
hygiene. Good manual dexterity is also necessary, especially if considering a sectional design.
Evidence suggests that very young or elderly patients and those with a history of psychiatric
conditions, repeated loss of consciousness or alcohol and drug intoxication are more likely to
swallow or inhale foreign bodies.16 Therefore it is best to avoid unilateral RPDs for such
patients.
The authors would only recommend Cobalt-Chrome unilateral RPDs. These are tooth-supported
and the metal framework is rigid and strong, providing stability and resistance to deformation.
The metalwork allows adequate strength to be obtained from a thin cross-section of material; this
reduces bulk and the need for wide gingival coverage, which could cause difficulties with plaque
control and soft tissue trauma. Effective, direct retention is essential and retentive components
must be designed carefully. Abutment teeth should have good periodontal support, sufficient
clinical crown length and adequate undercut. Davenport et al. suggest that conventional clasps,
magnets and attachments relying on frictional retention may be insufficiently reliable for
unilateral RPDs. The authors have found that clasps can be reliable if correctly designed; guide
planes and reciprocating elements are essential to ensure effective retention. Stability should be
maximised by incorporating bracing components and extending the framework and flanges to
cover as much vertical height of the alveolar ridge as possible. Effective retention and stability
reduces the risk of inhalation and swallowing and the radio-opaque nature of the Co-Cr would
make the appliance easily identifiable should this problem occur.
Deciding on a single-part or sectional design depends on the angulations of abutment teeth. If
opposing undercuts are significant then the potential for utilising these for retention makes a
sectional design more attractive. However, if opposing undercuts are less significant, it may be
more prudent to modify the teeth to provide parallel guide planes and use a single-part RPD. If
the abutment teeth have no opposing undercuts, a single-part RPD would be more appropriate.
Designs should be kept as simple as possible to promote continued oral health, with clearance of
gingival margins where practical.
The patient must be made aware of the need for regular follow-up and maintenance of such
appliances. It is essential that any faults in the prosthesis are identified and corrected early, as
retentive elements may lose some of their efficiency over time. A loss of retention in a unilateral
RPD could lead to inhalation or swallowing and cause serious health problems including
asphyxiation, tissue perforation and infections. For this reason, the dentist and dental technician
must be highly competent in partial denture design and fabrication before providing unilateral
RPDs. For example, if a clasp is designed incorrectly and the proportional limit of the material
exceeded during insertion and removal, permanent clasp distortion and a loss of retention could
occur.
Unilateral RPDs can be a safe, effective and predictable option for replacing missing teeth, but
careful case selection, appropriate design and high-quality fabrication are essentials for success.