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Journal of Prosthodontic Research 57 (2013) 109–112

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Original article
Effect of implant support on mandibular distal extension removable
partial dentures: Relationship between denture supporting area and
stress distribution
Maki Sato DMD, PhDa,*, Yasunori Suzuki DMD, PhDb, Daisuke Kurihara DMD, PhDa,
Hidemasa Shimpo DMD, PhDa, Chikahiro Ohkubo DMD, PhDa
a
Department of Removable Prosthodontics, Tsurumi University School of Dental Medicine, Yokohama, Japan
b
Division of Oral and Maxillofacial Implantology, Tsurumi University School of Dental Medicine, Yokohama, Japan
Received 1 April 2011; received in revised form 29 October 2012; accepted 8 January 2013
Available online 10 April 2013

Abstract
Purpose: This study explored the relationship between implant support and the denture-supporting area by comparing the stability of an implant-
supported distal extension removable partial denture and a conventional distal extension removable partial denture.
Methods: A model simulating a mandibular bilateral distal extension missing (#34–37 and #44–47) was fabricated using silicone impression
material as soft tissue (2 mm thick) on an epoxy resin bone model. The denture base was reduced by 5 mm cutting part of both the retromolar pad
and the lingual border. Loads of up to 5 kg were applied, and the pressure and displacement of the RPDs were simultaneously measured and
analyzed using the Wilcoxon test (a < 0.05).
Results: The pressure on the bilateral first molar and the middle areas of the implant-supported distal extension removable partial denture (ISRPD)
was significantly less than on the conventional RPD (CRPD). As the supporting area of the denture base decreased, the pressure and the denture
displacement of the CRPD were greater than for the ISRPD.
Conclusion: This study indicated that implant placement at the distal edentulous ridge can prevent denture displacement of the distal extension
bases, regardless of the supporting area of the denture base.
# 2013 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.

Keywords: Implant denture; Edentulous patient; Pressure distribution; Denture displacement

1. Introduction of distal extension RPDs. As a solution to this clinical problem,

In general, clinical observation seems to indicate that the
extraction of teeth and ridge resorption can occur after the long-
term use of distal extension RPDs, particularly in cases of
Eichner Classification C1 [1–4]. There are cases in which the
maxillary and mandibular teeth remain across from each other,
and there is no vertical occlusal stop preventing contact of the
upper and lower teeth. Serious problems, such as ill-fitting
retainers, occlusal disharmony and pain of the soft tissue under
the connector or denture base, may occur from the displacement
* Corresponding author at: Department of Removable Prothodontics, Tsur-
umi University School of Dental Medicine, 2-1-3 Tsurumi, Tsurumi-ku,
Yokohama 230-8501, Japan. Tel.: +81 45 581 1001; fax: +81 45 573 9599.
E-mail address: sato-maki@tsurumi-u.ac.jp (M. Sato).
implants placed bilaterally at the distal extension of the denture
base minimize the resultant denture displacement [5–8]. The
main purpose for an implant located under the most posteriorly
placed of the distal extension denture base is to stabilize the
RPD vertically. Implants placed distally would effectively
change the Kennedy Class I or II situation to that of the Class
III. As a result, less bone resorption, less rebasing and less
tension for precision attachments are expected. The ideal
situation is that in which fewer implants are needed to achieve a
successful distal extension RPD [9,10].
Partially edentulous patients with missing mandibular
premolars and molars, especially the combination syndrome,
have been rehabilitated successfully using the implant-
supported distal extension removable partial denture (ISRPD)
approach [11–14]. Suzuki et al. reported that mandibular
implant-supported dentures were exceedingly reliable for

1883-1958/$ – see front matter # 2013 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
http://dx.doi.org/10.1016/j.jpor.2013.01.002
[(Fig._1)TD$IG]
110 M. Sato et al. / Journal of Prosthodontic Research 57 (2013) 109–112

Fig. 1. The simulation model and the experimental denture.

[(Fig._2)TD$IG]
rehabilitation with a high survival rate and showed a good
prognosis [15].
The implant should be placed under the posterior molar of
the distal extension base to prevent denture displacement. If
there is insufficient bone in this area, the implant can be placed
more medially although this is not an ideal position. However,
there is a paucity of evidence-based research concerning the
implant position and the supporting area of the denture base.
Particularly, little is known about the effect of the decrease in
pressure on the soft tissue under the denture base, denture
displacement, and reduction of the supporting area of the
denture base.
The purpose of this in vitro study was to analyze the
relationship between implant support and the denture-support-
ing area on the stability of mandibular distal extension RPDs.

2. Materials and methods

A model simulating a mandibular bilateral distal extension

missing (#34–37 and #44–47) was fabricated using silicone
impression material (Fit Checker1, GC Corporation, Tokyo,
Japan) as soft tissue (2.0 mm thick) on an epoxy resin bone
model (Fig. 1). The six remaining anterior teeth (from right
canine to left canine) had an artificial periodontal membrane
made with silicone impression material (Fit-checker) [16,17].
Five small pressure sensors (4.2 mm diameter, PS-10KA,
PS-10KB, Kyowa, Tokyo, Japan) were attached near the left
and right first molars, first premolars and mesio-lingual alveolar
ridge (ML). The sensor at the median was positioned beneath
the lingual bar when the RPD was set on the modified models.
As soft tissue, silicone impression material (2.0 mm thick)
was amply applied between the denture base and the sensor
embedded in the resin bone.
Five bilateral distal extension RPDs with a lingual bar and
Akers clasps on both canines were designed and formed an
occlusion rim without any denture teeth. Co–Cr frameworks
were conventionally cast, and then heat-cured denture base
resin was packed and polymerized. Implants (ITI Strauman, RP
Fig. 2. Pressure distribution of CRPD.
8 mm) were placed at the bilateral second molar areas (#37 and
#47), and healing caps (4.5 mm high) were mounted. The
denture base of the ISRPD was connected to the healing caps
using autopolymerized resin according to the overdenture
technique. The conventional RPD (CRPD) simulating a
mandibular bilateral distal extension missing was mounted
using a cover screw, and this screw was covered with a silicone
impression material. Thus, the healing screws of the CRPD
were placed without being connected to the implants. The
measurement was carried out to decrease the denture base by
5 mm cutting part in following order: the retromolar pad,
retromolar pad and the lingual border. After a brass plate for
loading was attached on the occlusion rim of each RPD,
[(Fig._3)TD$IG]
M. Sato et al. / Journal of Prosthodontic
Fig. 3. Pressure distribution of ISRPD.
loads up to 5 kg were applied at the intersection of the
median line and the right and left mesial contact points of the
first molars on the plate using a constant loading apparatus.
The displacement sensor (DT-A30) and load cell (LM-20KA)
were set up on the loading rod in the apparatus. The pressure
at five different areas of the soft tissue and the displacement
of the RPDs (n = 5) were simultaneously measured using a
personal computer (PS-9000 model 310C, TEAC, Tokyo,
Japan). The data (ISRPD and CRPD) were analyzed using
the Wilcoxon test (a < 0.05).
3. Results
The pressure value at five regions and the denture
displacement of the ISRPD and CRPD are indicated in
Figs. 2–4. The pressure on #36 and #46 of the ISRPD was
significantly less than on the CRPD, regardless of the
supporting area of the denture base ( p < 0.05). In addition,
the denture displacement was less for the ISRPD than for the
CRPD, regardless of the supporting area of the denture base.
There was an approximately 40 mm difference in denture
displacement between the ISRPD and CRPD.
As the supporting area of the denture base decreased, the
pressure (#36 and #46) and the denture displacement of the
CRPD were significantly increased ( p < 0.05).
In contrast, there were no differences in the pressure (#36
and middle area) and the denture displacement of the ISRPD,
regardless of the supporting area of the denture base.
4. Discussion
The purpose of this study was to analyze the relationship
between implant support and the denture supporting area on the
[(Fig._4)TD$IG] Research 57 (2013) 109–112
111
Fig. 4. Denture displacement.
stability of mandibular distal extension RPDs. The loading was
applied only vertically. Thus, the retention of the denture base,
bracing effectiveness of the implant and lateral movements of the
extension base could not be definitively confirmed in this study.
The thickness of the tissues covering the ridge will
undoubtedly affect the amount of denture movement and will
be an important factor in the direction of forces transmitted to
the supporting structure. The thickness of the residual ridge
mucosa in this study was selected as simulated thick soft tissues
based on the results of the previous studies [18–21].
The denture-supporting area of the CRPD should be
designed to be as large as possible within the non-movable
mucosa so that there is less occlusal force distributed on the
alveolar ridge. However, partially edentulous patients with
RPDs have often complained of discomfort from denture bases
covering the alveolar mucosa. Therefore, these patients may
prefer the smaller denture bases of distal extension RPDs. The
role of a partial denture base is to support the occlusal force and
prevent denture movement such as yawing, rolling, and
drifting. So as to prevent denture displacement, precise
attachment or Konus-telescope crowns have been used to
brace the RPD against the remaining tooth [5,22]. Previous
studies investigated the denture-sharing load and denture-
supporting area [23,24]. Kitamura et al. reported that the
connecting rigidity of direct retainers is a major factor in
controlling the movements of distal extension RPDs. As the
connecting rigidity increased, the denture base-sharing load
decreased even when the denture-supporting area changed [24].
The results of this study indicated that implant placement at
the distal edentulous ridge can prevent denture displacement of
the distal extension RPD, regardless of the supporting area of
the denture base. The denture-supporting area of the ISRPD can
be designed to be smaller compared with the CRPD because the
implant support helps prevent the displacement of the distal
extension RPDs and decreases the pressure on soft tissues.
Furthermore, it has been reported that the pressure to the
retromolar pad is smaller than buccal shelf and lingual border in
112 M. Sato et al. / Journal of Prosthodontic Research 57 (2013) 109–112
fundamental studies on functional pressure [24,25]. There was
no significant difference between before and after cutting of the
denture base of the retromolar pad area by implants placed
bilaterally at the distal extension region in this study, and it
seems that the pressure of the retromolar pad has no effect on
implant. In general, a shorter denture periphery makes the
patient comfortable [26]. The ISRPD design, in which the
implant is covered by the denture base as well as the CRPD,
may cause bacterial plaque to accumulate on and around the
implant. However, the ISRPD design includes the option of not
covering the periimplant gingival margins by the denture base.
The limitation of this study was that only vertical loading,
2 mm thickness of alveolar mucosa, and bilateral distal
extension missing model were tested, and the experimental
denture were formed like occlusal rim without the denture
teeth. However, horizontal forces and rotational moments are
also applied to the implant. Further study is needed to protect
the implant in the ISRPD from these excessive forces.
5. Conclusions
This study indicated that implant placement at the distal
edentulous ridge can prevent denture displacement of the distal
extension bases, regardless of the supporting area of the denture
base.
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