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Review Article Questionable abutments: General considerations,

changing trends in treatment planning and
available options
D. Krishna Prasad, Chethan Hegde, Anshul Bardia, D. Anupama Prasad
Department of Prosthodontics and Crown and Bridge, A. B. Shetty Memorial Institute of Dental Sciences,
Nitte University, Deralakatte, Mangalore, Karnataka, India

Address for correspondence: Dr. D. Krishna Prasad, E‑mail: drkrishnaprasadd@yahoo.in

ABSTRACT
Abutment teeth are called upon to withstand the forces normally directed to the missing teeth, in addition to those usually applied
to the abutments. Whenever possible, an abutment should be a vital tooth. Normally, teeth with active periodontal problem should
not be used as abutment teeth. The use of multiple splinted abutment teeth, non‑rigid connectors or intermediate abutments makes
the procedure much more difficult and often the result compromises the long‑term prognosis. In cases where tooth preparation
cannot solve the problem, the use of various attachments and a telescopic retainer must be considered. Understanding the basic
concepts of how to retain various restorative components and how to protect the remaining tooth structure, will enable us to
answer the numerous questionable situations that arise during the restorative process will be facilitated. Thus, this will result
in final restorations that are based on sound design principles.

CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY

• Fixed prosthetic treatments are always dependent upon the support they receive from abutment teeth. Abutment teeth should
have sufficient coronal structure to provide retention to the prosthesis. It might sometimes be necessary to expose or increase the
clinical crown by periodontal surgery for support and esthetics. It is also seen that many a times the teeth are supra erupted as a
result of absence of opposing dentition which calls for the need of intentional endodontic treatment. By a combination of treatments
with interdisciplinary dentistry, we will succeed in providing a functional prosthesis which fulfils esthetic and restorative needs.

Key words: Abutments, fixed partial dentures, questionable abutments

INTRODUCTION faulty fabrication. Of particular concern to dentists is the

selection of teeth for abutments. They must recognize

T he goal of dental treatment is to provide the

optimal oral health, esthetics and function.
Therapeutic efforts should produce predictable
treatment results that are easily maintainable and
reliable over the long‑term. This objective applies to
each tooth in the dentition and to the dentition as a
whole. Partial dentures transmit forces through the
abutments to the periodontium.
Failures are due to poor engineering, the use of
improper materials, inadequate tooth preparation and
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DOI:
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the forces developed by the oral mechanism and the
resistance of the tooth and it’s supporting structures to
these forces. Successful selection of abutments for fixed
partial dentures requires sensitive diagnostic ability.
Considerable time and expense are spared and loss of
a patient’s confidence can be avoided, by thoroughly
investigating each abutment tooth before proceeding
with tooth preparation.
QUESTIONABLE ABUTMENT
SITUATIONS IN FIXED PARTIAL
DENTURE PROSTHESIS
• Extensively damaged teeth
• Periodontaly weakened teeth
• Pier abutments
• Tilted abutments
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Prasad, et al.: Questionable abutments
• Cantilever fixed partial dentures
• Short abutments.
Extensively damaged teeth
The criteria for the use of a cast metal, metal‑ceramic
or all‑ceramic restoration is when tooth has been
damaged to the extent that it must be reinforced and
protected. It should not be surprising that unmodified
classic preparation designs are used infrequently. The
amount of tooth structure destroyed is only one factor to
consider in selecting a restorative material and designing
a preparation. Equally important is the location of the
destruction and the amount of the tooth surface involved.
Location can be classified as peripheral, occurring on the
axial surfaces of the tooth; central, in the center of the
tooth; or combined, with destruction in both sites.[1]
Principle of substitution
When it is necessary to compensate for mutilated or
missing cusps, inadequate length and in extreme cases
even a missing clinical crown, the principle of substitution
is used.
Two rules should be observed to avoid excessive tooth
destruction while creating retention in an already
weakened tooth:
• The central “core”  (the pulp and the 1.0‑mm‑thick
surrounding layer of dentin) must not be invaded in
vital teeth. No retentive features should extend farther
into the tooth than 1.5 mm at the cervical line or down
1.5 mm from the central fossa. If caries removal results in
a deeper cavity, any part lying within the vital core should
be filled with glass ionomer cement. Any preparation
feature added for mechanical retention is kept in the
safe area of the tooth, peripheral to the vital core
• No wall of dentin should be reduced to a thickness
less than its height for the sake of retention. This may
preclude the use of a full veneer crown, or if one must
be used, it might first require the placement of a core
or foundation restoration.
Box forms
Small to moderate interproximal carious lesions or prior
restorations can be incorporated the preparation as a box
form. This substitute for grooves serves the dual purpose
of caries removal and retention form.
Grooves
Grooves placed in vertical walls of bulk tooth structure
must be well‑formed, at least 1.0 mm wide and deep and
as long as possible to improve retention and resistance.
Multiple grooves are as effective as box forms in providing
resistance and they can be placed in axial walls without
excessive destruction of tooth structure.[2]
Journal of Interdisciplinary Dentistry / Jan‑Apr 2013 / Vol‑3 / Issue‑1
Bases and cores
When the destruction of tooth structure is more extensive,
a decision must be made whether to augment the
retention and resistance by adding bases or to build up
the tooth preparation with a core.
Cement bases are used only to protect the pulp and
to eliminate undercuts in defects in tooth structure
produced by the removal of caries or old restorations.
Glass ionomer and zinc polycarboxylate cements are
excellent materials for this purpose. They are non‑irritant
to the pulp and have some adhesive properties that
make them less likely to become dislodged during
subsequent preparation of the tooth. Deep areas of the
preparation near the pulp may be covered with calcium
hydroxide.
Modifications for damaged vital teeth
• Evaluate pulpal health
• Assess the periodontal condition
• Make a preliminary preparation design
• Remove previous restorations and bases, all caries and
any unsupported enamel
• Evaluate the strength of the remaining walls: If the
thickness to height ratio of a wall lies between 1:1 and
1:2 it should be supported. Any wall with a thickness
to height ratio of less than 1:2 is subject to fracture and
should be shortened
• Finalize the preparation design.
Periodontaly weakened teeth
Periodontal health is a prerequisite of successful
comprehensive dentistry. To achieve the long‑term
therapeutic targets of comfort, good function, treatment
predictability, longevity and ease of restorative and
maintenance care, active periodontal infection must be
treated and controlled before the initiation of restorative
dentistry.
Rationale for therapy
• Periodontal treatment is undertaken to ensure the
establishment of stable gingival margins before tooth
preparation. Non‑inflamed, healthy tissues are less
likely to change as a result of subgingival restorative
treatment or post‑restoration periodontal care[3]
• Certain periodontal procedures are designed to provide
for adequate tooth length for retention, access for tooth
preparation, impression making, tooth preparation
and finishing of restorative margins in anticipation of
restorative dentistry[4]
• Periodontal therapy should follow restorative care
because the resolution of inflammation may result in
repositioning of teeth or in soft‑tissue and mucosal
changes[5]
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Prasad, et al.: Questionable abutments
• If traumatic forces applied to teeth with ongoing
periodontitis, it may result in increased tooth mobility,
discomfort and possibly the rate of attachment
loss [Figure 1].
Sequence of treatment
In general, preparation of the periodontium for the
restorative dentistry can be divided into two phases:
(1) Control of periodontal inflammation with non‑surgical
and surgical approaches and (2) pre‑prosthetic periodontal
surgery.
Situations in which a tooth has a short clinical crown
and is inadequate for the retention of a required cast
restoration, it is necessary to increase the size of the clinical
crown using periodontal surgical procedures. Surgical
crown lengthening procedures are performed to provide
retention form to allow for proper tooth preparation,
impression procedures and placement of restorative
margins and to adjust gingival levels for esthetics.
Pier abutments
A pier (inter mediate) abutment is a natural tooth
located between terminal abutments that serve to
support a fixed or removable dental prosthesis. Rigid
connectors (e.g., solder joints) between pontics and
retainers are the preferred way of fabricating most fixed
partial dentures. However, a completely rigid restoration is
not indicated for all situations requiring a fixed prosthesis.
Physiologic tooth movement, arch position of the
abutments and a disparity in the retentive capacity of the
retainers can make a rigid 5‑unit fixed partial denture a
less than ideal plan of treatment.
Studies in periodontometry have shown that the
faciolingual movement ranges from 56 to 108 µm and
intrusion is 28 µm. Teeth in different segments of the arch
move in different directions (because of the curvature
Figure 1: Traumatic occlusion with attachment loss
14
of the arch). The faciolingual movement of an anterior
tooth occurs at a considerable angle to the faciolingual
movement of a molar.
Use of the non‑rigid connector is restricted to a short span
fixed partial denture replacing one tooth. Prostheses with
non‑rigid connectors should not be used if prospective
abutment teeth exhibit significant mobility. Nearly 98%
of posterior teeth tilt mesialy when subjected to occlusal
forces. If the keyway of the connector is placed on the
distal side of the pier abutment, mesial movement seats
the key into the keyway more solidly. Placement of the
keyway on the mesial side, however, causes the key to
be unseated during its mesial movements.[6]
Tilted molar abutments
A common problem that occurs with some frequency is
the mandibular molar abutment that has tilted mesialy
into the space formerly occupied by the lost natural teeth
anterior to it [Figure 2]. It is impossible to prepare the
abutment teeth for a fixed partial denture along the long
axes of the respective teeth and achieve a common path
of insertion. There is a further complication if the third
molar is present.
• Uprighting of the tilted molar with orthodontic
treatment[7]
• Fixed partial denture using a proximal half‑crown as a
retainer on a tilted molar abutment
• Fixed partial denture using a telescopic crown and
coping as a retainer on a tilted molar abutment
• A non‑rigid connector on the distal aspect of the molar
retainer compensates for the inclination of the tilted
molar.
Cantilever fixed partial dentures
A cantilever fixed partial denture is one that has an
abutment or abutments at one end only, with the other end
of the pontic remaining unattached. This is a potentially
Figure 2: Tilted molar abutment
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Prasad, et al.: Questionable abutments
destructive design with the lever arm created by the pontic
and it is often misused.
A cantilever fixed partial dentures should replace only one
tooth and have at least two abutments. It can be used for
replacing a maxillary lateral incisor. There should be no
occlusal contact on the pontic in either centric or lateral
excursions.
A cantilever pontic can be used to replace a first premolar
if full veneer retainers are used on the second premolar
and first molar abutments. Cantilever fixed partial denture
replacing a mandibular first molar, using both premolars
as abutment teeth. To minimize stress on the abutments,
the pontic is the size of a premolar rather than a molar.[8]
QUESTIONABLE ABUTMENT
SITUATIONS IN REMOVABLE PARTIAL
DENTURE
• Damaged teeth
• Fixed partial dentures serving as abutments
• Isolated abutment
• Anteriors as abutment
• Missing anteriors
• Fabricating restorations to fit existing denture retainers.
Damaged teeth
Abutment contours should be altered during mouth
preparations in the following sequence:
• Proximal surface is prepared parallel to the path of
insertion to create guiding plane
• Height of contour on buccal (and lingual) is lowered
when necessary to permit clasp placement to be located
more favorably (i.e., middle‑gingival third)
• Labial reduction demonstrating favorable location of
height of contour and mesiobuccal undercut location.
Figure 3: Wax pattern modification on dental surveyor
Journal of Interdisciplinary Dentistry / Jan‑Apr 2013 / Vol‑3 / Issue‑1
Occlusal convergence of height of contour is also
evident
• Spoon‑shaped disto‑occlusal rest preparation that will
direct occlusal forces along long axis of tooth should
be the final step in mouth preparations.
Fixed partial dentures serving as abutments
One advantage of making cast restorations for abutment
teeth is that the mouth preparations conventionally done
in the mouth after cementation of the crown can be done
on the surveyor with far greater accuracy during the
fabrication stage itself [Figure 3]. It is difficult to make
several proximal surfaces parallel to one another while
preparing them intraorally.
The ideal crown restoration for a removable partial
denture abutment is the complete coverage crown,
which can be carved, cast and finished to ideally satisfy
all requirements for support, stabilization and retention
without compromise for cosmetic reasons [Figure 4].
Porcelain veneer crowns can be made equally satisfactory
only by the additional of contouring the veneered surface
on the surveyor before the final glaze.
Regardless of the type of crown used, the preparation
should be made to provide the appropriate depth for the
occlusal rest seat. This is best accomplished by altering the
axial contours of the tooth to the ideal before preparing
the tooth and creating a depression in the prepared tooth
at the occlusal rest area.
Isolated abutments
The average abutment tooth is subjected to some distal
tipping, rotation, torqueing and horizontal movement, all
which must be held to a minimum by the quality of tissue
support and the design of the removable partial denture.
The isolated abutment tooth, however, is subjected also to
mesial tipping because of lack of proximal contact. Despite
Figure 4: Cast partial denture abutments ‑ Rest seat fabrication on crowns
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Prasad, et al.: Questionable abutments
indirect retention, some lifting of the distal extension base
is inevitable, causing torque to the abutment.
In contrast, an isolated anterior abutment adjacent to a
distal extension base usually should be splinted to the
nearest tooth by means of a fixed partial denture. The
effect is two‑fold: (1) The anterior edentulous segment is
eliminated, thereby creating an intact dental arch anterior
to the edentulous space; and (2) the isolated tooth is
splinted to the other abutment of the fixed partial denture,
thereby providing multiple abutment support. Splinting
should be used here only to gain multiple abutment
support and not to support an otherwise weak abutment
tooth.
Missing anterior teeth
When a removable partial denture is to replace missing
posterior teeth, especially in the absence of distal
abutments, any additional missing anterior teeth are
best replaced by means of fixed restorations rather than
included in the removable partial denture. In any distal
extension situation, some anteroposterior rotational action
will result from the addition of an anterior segment to the
denture. The ideal treatment plan, which would consider
the anterior edentulous space separately, may result in
conflict with economic and esthetic realities. Each situation
must be treated according to its own merits.
Fabricating restorations to fit existing
denture retainers
Ideally, all abutment teeth would best be protected with
complete crowns before the removable partial denture is
fabricated [Figure 5]. Except in the scenario of recurrent
caries (due to defective crown margins or gingival
recession) abutment teeth so protected may be expected
to give many years of satisfactory service in the support,
stabilization and retention of the removable partial
denture. Economically a policy of insisting on complete
coverage for all abutment teeth may well be justified from
Figure 5: Complete coverage crowns with palatal milling
16
a long‑term viewpoint. It must be recognized, however
that in practice complete coverage of all abutment teeth
is not always possible at the time of treatment planning.[9]
QUESTIONABLE ABUTMENT
SITUATIONS IN OVERDENTURES
While selecting abutments for overdentures, the position
of the tooth in the arch and its position between the buccal
and lingual cortical plates should be evaluated carefully.
The crown‑root ratio is improved considerably by reducing
the clinical crown height when preparing the tooth for
its role as an abutment [Figure 6]. The angulation of the
tooth to be used for an abutment is also considered. For
effective distribution of the functional forces applied to
the remaining root, the root should be in an axial position
perpendicular to the direction of the occlusal forces.
When periodontal disease produces bone loss and
recession, the clinical crown may be of much greater
length than the anatomic crown. Therefore during
abutment selection care should be taken that there
is adequate supporting the present, because the
crown‑root ratio will be improved later. Mobile teeth or
teeth with sever osseous defects are poor candidates for
abutments.[10]
DISCUSSION
Any tooth can be considered as an abutment tooth. But
the abutment tooth have to withstand the forces from
a different direction than one crowned as an individual
tooth. Many clinicians avoid root filled tooth or teeth
including post and core crown because of the chances
of fracture of the roots. However, this risk depends upon
whether the tooth is used as an abutment or as a member
of the abutment teeth in a large bridge so that the forces
are shared by other abutments.
Figure 6: Overdenture abutments with primary coping
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Prasad, et al.: Questionable abutments

With the advent of newer materials and advancing
technologies, endodontically treated teeth can be
used successfully as abutment teeth. Teeth with
active periodontal disease are not used as abutments.
The tooth/teeth are first treated for the periodontal
problem and then considered as an abutment. Various
periodontal procedures can be employed to improve
the quality of the tooth/teeth before its use as an
abutment.
There is often a concern with selecting tilted tooth/
teeth as an abutment. These teeth can be modified using
the various prosthodontic approaches in combination
with orthodontic techniques. Thus, with the combined
approaches of endodontics‑periodontics‑prosthodontics,
we can preserve the natural tooth and utilize it as an
abutment.
CONCLUSION
From the above discussion, we understand that the
abutment teeth bear the forces developed by the
oral mechanism and transmit these to the underlying
periodontium. Thus, the proper selection of abutments
influences the prognosis of the treatment. Successful
selection abutments would require prompt diagnosis and
meticulous treatment planning. Whenever possible, an
abutment should be a vital tooth. However, a tooth that
has been endodontically treated and is asymptomatic,
with radiographic evidence of a good seal and complete
obturation of the canal, can also be used as an abutment.
While root canal therapy saves roots, sound post
endodontic restoration saves crowns. Combination of
these procedures (endodontic‑periodontic‑prosthodontic)
have been able to successfully salvaged more teeth and
restored its form and function in recent times.
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1. Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE.
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p. 181‑210.
2. Kishimoto M, Shillingburg HT Jr, Duncanson MG Jr. Influence
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3. Kois JC. The restorative‑periodontal interface: Biological parameters.
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4. Smukler H, Chaibi M. Periodontal and dental considerations in clinical
crown extension: A rational basis for treatment. Int J Periodontics
Restorative Dent 1997;17:464‑77.
5. Sato S, Ujiie H, Ito K. Spontaneous correction of pathologic tooth
migration and reduced infrabony pockets following nonsurgical
periodontal therapy: A case report. Int J Periodontics Restorative
Dent 2004;24:456‑61.
6. Standlee JP, Caputo AA. Load transfer by fixed partial dentures with
three abutments. Quintessence Int 1988;19:403‑10.
7. Khouw FE, Norton LA. The mechanism of fixed molar uprighting
appliances. J Prosthet Dent 1972;27:381‑9.
8. Ewing JE. Re‑evaluation of the cantilever principle. J Prosthet Dent
1957;7:78‑92.
9. Alan BC, David TB. Preparation of abutment teeth. McCracken’s
Removable Partial Prosthodontics. 11th ed. St. Louis: Mosby; 2011.
p. 205‑16.
10. Lord JL, Teel S. The overdenture: Patient selection, use of copings,
and follow‑up evaluation. J Prosthet Dent 1974;32:41‑51.

The past few decades have witnessed acceleration in
advancements in materials, techniques and concepts that
have been well‑researched and scientifically accepted.
How to cite this article: Prasad DK, Hegde C, Bardia A, Prasad DA.
Questionable abutments: General considerations, changing trends in
treatment planning and available options. J Interdiscip Dentistry 2013;3:12-7.
Source of Support: Nil, Conflict of Interest: None declared.

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