review of prosthetic restoration in patients with shortened dental archs

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Japanese Dental Science Review (2011) 47, 167174

a va i l a ble at ww w. sc ie nce di r ect . com

jo u rn al ho m epag e: ww w.eKenji Fueki *, Eiko Yoshida, Yoshimasa Igarashi

Section of Removable Partial Denture Prosthodontics, Graduate School of Medical and Dental Sciences, Tokyo Medical and DentalUniversity, Japan

Received 26 November 2010; received in revised form 18 March 2011; accepted 22 March 2011

Introduction

Replacement of missing teeth and maintenance of 28 teethhas been the traditional treatment goal. Removable partial

dentures (RPDs), cantilever fixed partial dentures (CFPDs) andimplant-supported fixed partial dentures (IFPDs) can be uti-lized to restore distal extension edentulous space in posteriorarea. Treatment with RPDs is the most common of theseoptions, because it is noninvasive and inexpensive. However,patients who have missing posterior teeth frequently stopwearing RPDs [13]. Furthermore, treatment with RPDs hasa high biological cost with high caries incidence and period-ontal breakdown of abutment teeth [46]. Thus, fixed restora-tions using CFPDs or IFPDs are recommended as alternativeoptions for replacement of distal extension edentulous spaceespecially in patients who have high risk for caries occurrenceand periodontal disease [710].

KEYWORDSProsthetic restoration;Shortened dental arch;Removable partialdenture;Cantilever fixed partialdenture;Implant-supported fixedpartial denture

Summary The literature regarding the effect of prosthetic restoration in patients having distalextension edentulous space in posterior area (shortened dental arch: SDA) is reviewed in thefollowing article. Information retrieval followed a systematic approach using PubMed. Articles inEnglish published between 1966 and March 2011 describing the outcome of treatment withvarious prostheses were evaluated. From the search results of 98 articles, 21 articles met theinclusion criteria. Treatment with removable partial dentures (RPDs) improved masticatoryfunction, patient satisfaction and oral health-related quality of life (OHRQoL). However, nosignificant difference was found in the outcomes between patients with RPDs and with cantileverfixed partial dentures (CFPDs). Caries developed more frequently after treatment with RPDs thanCFPDs. The time to survival for CFPDs was not longer than that for RPDs, while more visits tomaintain RPDs were required than for CFPDs. No significant difference was found in masticatoryfunction, OHRQoL, and occlusal stability between patients with RPDs and those without restora-tion of missing molars. Consequently, treatment with RPDs for SDA seems to be less advantageousthan CFPDs or no restoration for missing molars. Further research is required to validatetreatment with implant-supported fixed partial dentures for SDA.# 2011 Japanese Association for Dental Science. Published by Elsevier Ltd. All rights reserved.

* Corresponding author at: Section of Removable Partial DentureProsthodontics, Department of Masticatory Function Rehabilitation,Division of Oral Health Sciences, Graduate School of Medical andDental Sciences, Tokyo Medical and Dental University, 5-45 Yushima1-chome, Bunkyo-ku, Tokyo 113-8549, Japan. Tel.: +81 3 5803 5514;fax: +81 3 5803 5514.

E-mail address: [email protected] (K. Fueki).

1882-7616/$ see front matter # 2011 Japanese Association for Dental Science. Published by Elsevier Ltd. All rights reserved.doi:10.1016/j.jdsr.2011.03.003A systematic review of propatients with shortened dethetic restoration intal arches

l s evier . c om / lo cat e/ jds r

CFPD has two or more abutments at one end and is leftunsupported at the other end. Treatment with CFPDs hasbeen utilized as an alternative treatment option for reduceddentition in patients who refuse treatment with RPDs [1113]. Restoration for distal extension edentulous space usingCFPDs is usually limited up to the second premolar, thusmissing molars remain unrestored (premolar occlusion). Kay-ser named partial edentulism of distal extension edentulousspace in posterior area as shortened dental arch (SDA) (Fig. 1)[14]. He proposed that patients with at least 4 occlusal units(premolar occlusion) have sufficient adaptive capacity tomaintain oral function [14], and prosthetic rehabilitationshould be considered from a problem-oriented approach[1518]. The Kayser/Nijmegen group then conductedcross-sectional studies and longitudinal studies, and reportedthat the oral function, occlusal stability and periodontalsupport of SDA patients were well maintained, and therewas no marked effect of lacking molar support on signs andsymptoms of temporomandibular disorders (TMDs) [19]. TheSDA concept in which missing molars are not restored iswidely accepted among dentists in European countries[2022].

Although some researchers have reviewed literaturewith respect to validation of the SDA concept proposedby Kayser [19,23], it has not been reviewed systematicallywhether prosthetic restorations improve oral function of

168 K. Fueki et al.SDA patients. The aim of this article was to systematicallyreview literature regarding the effect of prostheticrestoration in SDA patients. The specific research questionsevaluated are (1) whether treatment with RPDs for distalextension edentulous space improves oral function, patientsatisfaction and oral health-related quality of life (OHR-QoL) compared to treatment with CFPDs (premolar occlu-sion) or no restoration and (2) what are the advantages/disadvantages of treatment with RPDs over IFPDs, CFPDs orno restoration for SDA.

Figure 1 A shortened dental arch in which missing molars arenot restored with dentures.Materials and methods

Search strategy

An electronic database (Medline) was accessed using PubMedto search for all relevant articles published between 1966 andMarch 2011. Key elements for the search strategy wereshortened dental arch or SDA. Articles retrieved were limitedto human research published in English dental journals. Thearticles returned by the databases were then filtered forspecific inclusion criteria: (1) articles in which patients hadunilateral or bilateral distal extension edentulous space(s) inthe posterior region (Kennedy Class I or Class II condition) ofmaxilla and/or mandible; (2) articles in which the distalextension edentulous space(s) were restored with RPDs,IFPDs or CFPDs; and (3) articles in which statistical compar-isons of outcome measures were made within subjects beforeand after prosthetic treatments, between patients withRPDs, CFPDs, IFPDs or no restoration. Review articles withoutmeta-analysis were excluded. In addition to the databasesearch, relevant articles meeting the inclusion criteria wereacquired from references of the retrieved articles by amanual search.

Article analysis

Characteristics of studies such as the authors, publicationyear, dentition, number of patients, follow-up period, out-come measures and results were extracted from originalarticles. In this review, treatment with CFPDs that replacedmissing posterior teeth up to second premolars (premolarocclusion) and no restoration for missing molars wereregarded as the SDA concept, while treatment with RPDsor IFPDs that replace missing posterior teeth to molars wereregarded as the traditional concept. Study design wasassessed using a clinical epidemiology-based classification.Level of evidence was rated by two authors following theUnited States Agency for Healthcare Research and Quality(AHRQ, http://www.ahrq.gov/) recommendations (I, meta-analysis of multiple studies; II, experimental studies; III,well-designed, quasi-experimental studies; IV, well-designed, non-experimental studies; and V, case reportsand clinical examples).

Results

Ninety articles were identified by PubMed (Last search date;March 17, 2011). Of the 90 articles, 13 articles met theinclusion criteria. In addition, 8 articles which satisfied theinclusion criteria were identified by the manual search(Fig. 2). There were no level I meta-analyses, 10 articles(4 studies) were rated as level II, 2 articles (2 studies) wererated as level III, and 9 articles (6 studies) were rated as levelIV, according to AHRQ recommendations (Table 1).

Oral function and nutrient intake

Prospective studies found that the masticatory performanceand jaw movement during chewing in patients with mandib-ular bilateral SDA and maxillary complete denture improvedafter treatment with mandibular RPDs and new maxillary

f th

Restoration for shortened dental arch 169complete dentures [24,25]. A case-control study reportedthat the masticatory performance in patients with mandib-ular bilateral SDA was similar to patients with RPDs, whilemaximum bite force and tooth contact area in patients withRPDs were significantly greater than that in the SDA patients(no restoration) [26]. Cross-sectional studies found that theperceived chewing ability of patients with RPDs was similar toSDA patients (no restoration) [2730]. A randomized con-trolled trial (RCT) found that perceived chewing ability inpatients with CFPDs (premolar occlusion) was greater than inpatients with RPDs [31]. A prospective study [25] and RCT[32] found that treatment with RPDs did not improve nutri-tion intake in SDA patients. Cross-sectional studies [2729],an RCT [33] and a longitudinal study [34] reported that bothtreatments with RPDs and with CFPDs did not increase clinicalsigns of TMD, while an RCT found that TMD was more fre-quently identified in patients with RPDs compared to patientswith CFPDs [31,35] (Tables 2 and 3).

Patients satisfaction and QoL

An RCT reported that treatment with RPDs improved patient

Identified articl es MEDLINE search (n=90 )

Hand search (n=8)

Articles in clu ded in the paper

(n=21 )

Article s full-text screening

(n=40)

Figure 2 Outline osatisfaction in terms of chewing ability and oral comfort [36].However, there was no statistically significant difference inthe patient satisfaction between patients with RPDs andthose with CFPDs [36]. An RCT found that OHRQoL improvedafter treatment with RPDs, while no statistically significantdifference was found between patients with RPDs and thosewith CFPDs due to small sample size [33]. A cross-sectionalstudy [37] and a case-control study [38] found that OHRQoLand generic QoL in patients with RPDs were of similar level tothe SDA patients (no restoration) (Tables 2 and 3). OHRQoL inpatients with IFPDs was higher than those with RPDs, whilethe generic QoL in patients with RPDs was similar to thosewith IFPDs [38].

Abutment teeth and periodontal tissue

Two RCTs found that caries developed more frequently aftertreatment with RPDs compared to CFPD treatment [35,39].Gingival inflammation and plaque accumulation on abutmentteeth of RPDs were higher than those of CFPDs 2 and 5 yearsafter treatment, while probing pocket depth, tooth mobilityand alveolar bone height were almost identical for bothtreatments [40,41]. There was no significant difference intooth mobility, alveolar bone height, occlusal contact, over-bite and interdental spaces of remaining teeth betweenpatients with RPDs and SDA patients (no restoration) [30],and identical results were found at a 6-year follow up [42](Table 3).

Survival time and follow-up treatment

An RCT found that time to survival for RPDs was shorter thanfor CFPDs, but not statistically significant [43]. A recent RCTfound no statistically significant difference in tooth loss aftertreatment with RPDs or with CFPDs 3 years after treatment[44]. Two RCTs reported that treatment with RPDs requiredmore maintenance visits after treatments compared toCFPDs [31,35,43] (Table 3).

Discussion

Article s exclude d after ti tle

and ab strac t screening

(n=58)

Articles exclu ded after

full-text screening

(n=19)

e literature search.Studies comparing treatment outcomes within subjectsbefore and after treatment indicated that RPD improvedmasticatory function, patient satisfaction and OHRQoL. How-ever, studies that compared the outcomes between subjectsfound that patients with RPDs did not show significantlygreater masticatory performance, patient satisfaction andOHRQoL than for those with CFPDs (premolar occlusion) or norestoration for missing molars. Furthermore, treatment withRPDs showed higher risk for caries incidence, gingival inflam-mation and poor oral hygiene than treatment with CFPDs.Survival rate and tooth loss in patients with CFPDs were notsignificantly less than in patients with RPDs, but more visitsfor maintenance after treatment were required in patientswith RPDs. These suggest that treatment with RPDs does nothave significant advantage over treatment with CFPDs. Risksfor TMD and occlusal instability without restoration of miss-ing molars were not higher than for treatment with RPDs.Therefore, the SDA concept seems to be a more favourableoption than treatment with RPDs when considering a mini-

Table 1 Characteristics of articles included in this review.

Authors Publicationyear

Evidencelevel a

Studydesignb

Meanage

Dentition of SDApatients

Study group(sample size) c

Control(samplesize)d

Follow-upperiod

Outcomemeasures

Budtz-Jrgensen et al.

1987 II RCT 69 Mandibular SDA andmaxillary completedenture

CFPD(27)/RPD(26) 2 years Chewing ability, TMD,caries incidence,maintenance

Isidor et al. 1987 II RCT 69 Mandibular SDA andmaxillary completedenture

CFPD(27)/RPD(25) 2 years Periodontal condition,oral hygiene

Budtz-Jrgensen et al.

1990 II RCT 69 Mandibular SDA andmaxillary completedenture

CFPD(27)/RPD(26) 5 years Clinical outcome

Isidor et al. 1990 II RCT 69 Mandibular SDA andmaxillary completedenture

CFPD(27)/RPD(25) 5 years Periodontal condition

Moynihan et al. 2000 II RCT 65 Mandibular SDA Resin-bondedCFPD(30)/RPD(30)

1 year Nutrition intake

Jepson et al. 2001 II RCT 67 Mandibular SDA Resin-bondedCFPD(30)/RPD(30)

2 years Caries incidence

Jepson et al. 2003 II RCT 67 Mandibular SDA Resin-bondedCFPD(30)/RPD(30)

1 year Patient satisfaction

Thomason et al. 2007 II RCT 67 Mandibular SDA Resin-bondedCFPD(30)/RPD(30)

5 years Survival time,maintenance

Walter et al. 2010 II RCT 59 Maxillary and/ormandibular SDA

CFPD or NR(106)/RPD(109)

3 years Survival rate

Wolfart et al. 2005 II RCT 62 Maxillary and/ormandibular SDA

CFPD(13)/RPD(17) 1 year OHRQoL, TMD

Jemt et al. 1983 III Pros 61 Mandibular bilateralSDA and maxillarycomplete denture

RPD(6) 58 weeks Masticatorymovements

Gunne et al. 1985 III Pros 61 Mandibular bilateralSDA and maxillarycomplete denture

RPD(19) 2 months Dietary intake,masticatoryperformance, chewingability

Witter et al. 1989 IV Cross Maxillary and/ormandibular SDA

NR(55)/NR with pastexperience ofRPD(19)/RPD(25)

Chewing ability,esthetics, occlusalstability, TMD



CD(72) Subjective chewingfunction, esthetics,TMD, functional habit

170

K.

Fueki

et

al.



CD(72) Tooth mobility,Alveolar bone height

Witter et al. 1994 IV Long Maxillary and/ormandibular SDA

NR(55)/RPD(19) CD(52) 6 years Occlusal contact, overbite, tooth mobility,alveolar bone height

Witter et al. 1994 IV Long Maxillary and/ormandibular SDA

NR(55)/RPD(19) CD(52) 6 years TMD, chewing ability,esthetics

Leak et al. 1994 IV Cross 60 Maxillary and/ormandibular SDA

NR(195)/RPD(77) CD(69) Chewing ability,mandibular function,socio-psychologicalimpact

Kuboki et al. 1997 IV Cross 59 Mandibular unilateralSDA and maxillarycomplete dentition

NR(12)/RPD(12)/IFPD(12)

Generic QoL, OHRQoL

Armellini et al. 2008 IV Cross 54 Maxillary and/ormandibular SDA with/without anteriorunrestored missingteeth

NR(65)/RPD(57) CD(38) Generic QoL, OHRQoL

Aras et al. 2009 IV Case 56 Maxillary completedentition andmandibular bilateralSDA

NR(10)/RPD(10) CD(10) 1 year Masticatoryperformance,maximum bite force,occlusal contact area

a II: experimental studies, III: well-designed, quasi-experimental studies, IV: well-designed, non-experimental studies.b RCT: randomized controlled trial, Pros: prospective study, Cross: cross-sectional study, Long: longitudinal study, Case: case-control study.c RPD: conventional removable partial denture, CFPD: cantilever fixed partial denture, IFPD: implant-supported fixed partial denture, NR: no-restoration for SDA.d CD: complete dentate subjects.

Resto

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mum intervention approach. However, it should be notedthat the SDA concept may be contraindicated in patientsunder 50 years of age and with malocclusion such as AnglesClass III or a sever Class II relationship, evidence for paraf-unction, pre-existing TMD and a marked reduction in alveolarbone support for remaining teeth [45].

On the other hand, evidence for advantage of treatmentwith IFPDs over RPDs or no restoration is limited [37]. A casecontrol study suggested that treatment with IFPDs has advan-tage with respect to OHRQoL over treatment with RPDs or norestoration. In the early 1980s, when Kayser proposed the

SDA concept, treatment with IFPDs had not been well estab-lished in SDA patients. Since then, application of implant-supported dentures has increasingly expanded to treatmentfor partial edentulism. It is necessary to carry out moreclinical studies to validate treatment with IFPDs for SDA asalternatives of RPDs and CFPDs with respect to not onlyOHRQoL but also patient satisfaction and oral function.

Kayser claimed that treatment with RPDs for SDA is overtreatment because of their high biological cost, and thus norestoration for missing molars (SDA concept) is recommendedas a limited treatment goal in an aged population with highrisk of caries incidence and periodontal disease [7,1518].Overall, studies retrieved in this systematic review supporthis opinion. However, recent studies reported that treatmentwith RPDs for SDA is a more preferred option than no restora-tion from the patients perspective [46,47]. In addition, arecent study showed that SDA patients who complained ofchewing inability tended to choose treatment with RPDs [48].Therefore, treatment with RPDs seems to be a necessaryoption for SDA from the patients perspective regardless ofthe high biological cost, and the SDA concept seems to beapplicable in a limited population. Indeed, the SDA concept iswidely accepted by dentists in European countries, Tanzaniaand Japan, but is not widely practised [20,22,49,50]. Thisdiscrepancy between the attitude of dentists to the SDAconcept and patients preference for treatment optionsshould be evaluated further.

In Japan, the treatment cost of acrylic resin-based RPD iscovered by the national health insurance system, thereforepatients can receive treatment with acrylic resin-based RPDat a reduced fee. On the other hand, treatments with metal-

Table 2 Effect of treatment with RPD on masticatory func-tion, nutrition intake, TMD, patient satisfaction and OHRQoL(comparisons before and after treatment).

Outcomes Results

Objective masticatory functionMasticatory performance Improvement [25]Jaw movement Improvement [24]

Nutrient intake No improvement [25,32]TMD No change [33]

Patient satisfactionSummary score Improvement [36]General satisfaction Appearance Chewing Improvement [36]Comfort Improvement [36]

OHRQoL Improvement [33]

PD

re

26][26[2627

27

172 K. Fueki et al.Table 3 Comparison of outcomes between SDA patients with Ror IFPDs.

Outcomes RPD vs. no

Objective masticatory functionMasticatory performance RPD = NR [Maximum bite force RPD > NR Tooth contact area RPD > NR

Perceived chewing ability RPD = NR [Nutrient intake TMD RPD = NR [Patient satisfactionSummary score

OHRQoL RPD = NR [37,Generic QOL RPD = NR [37,Caries incidence

Periodontal conditionGingival inflammation Probing pocket depth Tooth mobility RPD = NR [30]Alveolar bone height RPD = NR [30,Occlusal contact PRD = NR [42]Overbite PRD = NR [42]Interdental space PRD = NR [42]

Oral hygiene Time to survival Tooth loss Maintenance visits and without restoration, between patients with RPDs and CFPDs

storation (NR) RPD vs. CFPD

] ] 30] RPD < CFPD [31]

RPD = CFPD [32]29,34] RPD > CFPD [31,35]

RPD = CFPD [36]38] RPD = CFPD [33]38]

RPD > CFPD [35,39]

RPD > CFPD [40,41]RPD = CFPD [40,41]

RPD = CFPD [40,41]42] RPD = CFPD [40,41]

RPD < CFPD [40,41]RPD = CFPD [43]RPD = CFPD or NR [44]RPD > CFPD [30,35,43]

Restoration for shortened dental arch 173based RPDs, CFPDs and IFPDs are not covered by the nationalhealth insurance system. The large difference in costs amongtreatment options is likely to have a significant influence ondecision making. Cost-benefit comparisons among the treat-ment options for SDA should be investigated in future studies.Socio-economic status of patients, such as gender, income,occupation and educational level, is likely associated withthe issue of treatment cost and thus it may confound decisionmaking. Further research is required to investigate how thesefactors affect the choice of a prosthetic restoration in SDApatients.

Although treatment with RPDs for SDA improved patientsperception of chewing ability, it had no impact on nutrientintake [25,32]. Eating behaviour and food preferencesdevelop over an extended period and they are influencedby a variety of socio-economic, ethnic, and psycho-physio-logic factors [51]. Thus, restoration of missing posterior teethmay not be enough to alter dietary habits in terms of nutrientintake.

The majority of studies retrieved in this review werecarried out in European countries. Application and limita-tions of the SDA concept are still being debated in Japan[52,53], because the health care system and socio-economicfactors in Japanese SDA patients differ from those in Eur-opean countries. More evidence based on clinical studies inJapanese SDA patients are required to validate application ofthe SDA concept in Japan.

Conflict of interest

There are no potential conflicts of interest.

Acknowledgment

This study was supported in part by a Grant-in-Aid for Scien-tific Research (A) (No. 19592228) from the Ministry of Educa-tion, Culture, Sports, Science and Technology of Japan.

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A systematic review of prosthetic restoration in patients with shortened dental archesIntroductionMaterials and methodsSearch strategyArticle analysis

ResultsOral function and nutrient intakePatients satisfaction and QoLAbutment teeth and periodontal tissueSurvival time and follow-up treatment

DiscussionConflict of interestAcknowledgmentReferences

review of prosthetic restoration in patients with shortened dental archs

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