Removable partial dentures

The root rest and the removable partial denture:

Marvin I. Wailer, D.D.S.*

lh e root rest is an endodontically treated root, covered by a low, dome-shaped

THE PROBLEM
We need the removable partial denture when posterior teeth are missing and
there is no distal abutment. We need it when the distribution of abutment teeth pre-
vents the use of a fixed prosthesis.
Treatment planning for periodontal prostheses favors rejection of the removable
partial denture, because horizontal and torqueing forces affect the abutment teeth.
The distal-extension partial denture intensifies this problem. Many solutions have
been suggested for the problem of a removable periodontal prosthesis. One approach
is the use of copings.‘-S
Coping retainers often provide too much resistance for the periodontal support
of abutment teeth. If the resistance form of the coping retainer is reduced, retention
for the prosthesis is severely compromised. These copings can be reduced to almost
the height of the gingiva and introduced as a root rest under the denture base of a
removable partial denture. Retention for the prosthesis can be obtained from direct
retainers on other abutment teeth. Horizontal resistance is gained from the border
extension of the denture base covering the root rest.

METHOD
Root rests and copings used in the treatment of five patients were evaluated. Pa-
tients who had root rests with a distinct loss of periodontal support were selected for
study. Each patient required the construction of a removable partial denture. The
prostheses were constructed with different combinations of direct retainers.
The clinical investigation was designed to determine: (1) if the root rest with
severe bone loss survives under a removable partial denture, (2) if the root rest has

*Attendha Staff, Section of Endodontics.

16
Fig. 1. The radiograph shows caries and fracture in lower second molar.
Fig. 2. The distal root rest coping on a diagnostic cast for a distal-extension partial denture.

strategic value, and (3) if there are reciprocal benefits between the root rest and
other abutment teeth.
Selecting teeth for root rests. We base our diagnosis for the teeth involved in a
periodontal prosthesis on at least four factors. These are (1) the crown-to-root ratio,
(2) the occlusal or functional forces the tooth will support, (3) the strategic value of
the tooth to the success of the treatment plan, and (4) the risk involved to the total
plan by retaining the tooth. We enter these factors into the “computer” of clinical ex-
perience and arrive at a decision to extract a tooth or to use it as a natural tooth or
as a modified tooth (coping) _
Only those teeth that cannot serve as normal abutments should be considered
for use as root rests. These include the teeth mutilated by caries or fracture that
cannot be restored by a normal post, coping, or crown.
Endodontic considerations for the root rest. Teeth treated as root rests can take
advantage of endodontic principles. The anatomic crown of the tooth has no signifi-
rance to the root rest. .2s a result, the access opening can be achieved by cutting off
the crown of the tooth horizontally. If the pulp tissue is vital and asymptomatic, a
one-sitting root canal filling can often be accomplished.
Preparing the root rest. After endodontic treatment is completed, the root is re-
duced to a crown preparation that exends slightly above the crest of the gingiva. A
post preparation is prepared into the root to achieve additional retention needed for
the coping. The tissues are retracted for an impression of the prepared root and post.
It is helpful to inrlude the rest of the dental arch in the impression so that the shape
of the coping can be relatrd to the other abutment teeth and alveolar ridges. The
low, dome-shaped coping is cast, highly polished, and cemented to place.
The root rest provides a vertical rest for the removable partial denture. If the
periodontal support is considered favorable, additional retention for the prosthesis
is achieved by increasing the vertical height of the coping and decreasing the degree
of taper. Retention can be reduced to satisfy the clinical situation by opening the
gingival diameter of the secondary resin crown of the denture base. The clinical situa-
tions are infinite, and the decision becomes one of clinical jud<gment and observation.
Adapting the secondary acrylic resin crown of the denture base. The removable
partial denture is designed for other rests, clasps, and copings and is rompleted with
18 Wailer J. Prosthet. Dent.
July, 1975

Fig. 3. The radiograph of the distal root rest after three years of service under the denture
base.

Fig. 4. Radiographs taken when the patient presented for treatment in 1969.

an acylic resin denture base that extends fully beyond the root rest. Tissue undercuts
need to be considered in the over-all design. The acrylic resin denture base is pro-
cessed against the impression of the root rest coping.
When the removable partial denture is complete and ready for insertion, the in-
ternal surface of the secondary resin crown is relieved in all its dimensions. Then
the partial denture is inserted and adjusted for seating of the direct retainers, border
extension, and occlusion. The secondary coping area is cleaned and dried, and self-
curing acrylic resin is added to the concavity. The partial denture is seated. The pa-
tient is asked to close and hold his teeth in occlusion. At intervals, the prosthesis is
released from the teeth to free any excess acrylic resin gripping to the gingival area.
After the acrylic resin has polymerized, the partial denture is removed, and the
secondary resin coping is ground so that there is no impingement in the gingival
sulcus.
The secondary resin crown is related to the root rest in function by this method.
When the partial denture is relined, the same procedure is used to relate the second-
ary resin crown to the root rest.

PATIENT REPORTS
No. I. The endodontically treated lower second molar was fractured horizontally,
and the result was hemisection of the roots (Fig. 1). After extracting the mesial root,
Fig. 5. The cuspid copings in place after four years. The ceramic-metal bicuspid crowns are
splinted and clasped by the prosthesis. The clasped right second molar is not seen. The man-
dibular restoration is a fixed prosthesis.
Fig. 6. The maxillary sleeve-coping retainers with supplementary clasps for retention. The
right cuspid coping was used as a rest for the first bicuspid clasp.

Fig. 7. The radiographs in 1974 of the five teeth retained in the maxillary arch. The upper
left cuspid is the only tooth retained in the left half of the arch.

a low, dome-shaped coping was made to cover the distal root (Fig. 2). This coping
was used as a root rest under the denture base to support the distal-extension partial
denture.
In spite of the severe loss of periodontal tissues on the mesial and lingual aspects
of the root rest, it has survived uneventfully for three years (Fig. 3). The loss of this
root rest would not necessitate a remake of the prosthesis.
The lamina dura on the distal part of the clasped second premolar is intact and
appears healthy.
No. 2. The patient presented with severe periodontal disease and occlusal dis-
organization (Fig. 4). The history of this 60-year-old woman revealed a diagnosis of
Weber-Rendu-Osler syndrome which resulted in daily hemorrhages and acute ane-
mia. Dental surgery was restricted by her physician to that reserved for hemophiliacs.
The removal of the adjoining hopeless teeth resulted in improving the peri-
odontal response of the upper left cuspid, right cuspid, and right first and second pre-
molars. The upper right second molar, though severely extruded, was retained.
Crown-and-sleeve coping retainers were prepared for the cuspids (Fig. 5). Retention
was reduced on the right cuspid coping, because deep caries present within the root
canal resulted in a shell-like root. Ceramic-metal crowns splinted the premolars.
These were clasped along with the extruded second molar. Broad palatal coverage
was used with the removable prosthesis (Fig. 6).
 J. Prosthet. Dent.
20 Wailer July, 1975

Fig. 8. Radiographs of the lower right cuspid before (left) and one year after treatment.
Fig. 9. The internal view of the mandibular prosthesis, showing the secondary resin coping in
the denture base.

Fig. 10. The maxillary cuspid is horizontally sectioned, endodontically treated, and prepared
to a dome shape.
Fig. 11. The maxillary prosthesis showing the addition of the secondary resin crown for the
cuspid and the labial flange.

The radiographic examination after four years shows the lamina dura intact on
the maxillary teeth (Fig. 7). The strategic left cuspid shows no apparent bone loss
although the periodontal pocket is still present. Retention of the prosthesis over this
tooth is now reduced. The use of a gold-veneer secondary crown makes the readapta-
tion difficult. Extending a labial flange over this root has aided retention.
The retained mandibular teeth were splinted with a fixed prosthesis without the
benefit of periodontal surgery or therapy. It is failing periodontally.
No. .?. Dental neglect of this 58-year-old man was attributed to a medical history
of diabetes and a four-year history of blood clots, apparently controlled with Couma-
din.
Mandibular treatment was keyed around the conversion of the lower right cuspid
to a root rest. The extreme loss of bone support of this tooth prevented the use of a
periodontal flap. Curettage was done. An immediate root canal filling was placed
(Fig. 8).
After a crown and a fixed prosthesis at the left were completed, the removable
prosthesis was designed. Clasp retainers were used on the right second molar and the
left fixed prosthesis (Fig. 9).
Maxillary treatment involved a crown and a fixed prosthesis and then a remov-
v$lll~e’, :;4 Root rest and removable partial denture 21

Fig. 12. The severe periodontal lesion of the upper left cuspid and left lateral incisor (above).
The postoperative radiographs (below) show the result of infrabony surgery after one year. The
height of the cuspid coping indicates a more desirable crown-root ratio.
Fig. 13. The cuspid root rest coping is in place.

able partial denture. The upper right second molar, right cuspid, left fixed prosthesis,
and third molar were clasped.
There have been no complications with the mandibular restoration. However,
the maxillary prosthesis and teeth were never stabilized. Two periodontal infections
precipitated the conversion of the upper right cuspid to a root rest (Fig. 10). A
labial flange was added to the denture base to gain stabilization of the removable
partial denture (Fig. 11) . A gold coping will be constructed when stabilization of
the prosthesis has been time tested.
No. 4. A 60-year-old man presented for treatment, stating specifically that
he must always “face the public” with his dentition intact. He rejected an overden-
ture. A poorly fitting removable prosthesis, traumatic occlusion, and a rigid clasp
were contributing to the periodontal destruction of a critical upper left cuspid.
Root canal treatment was completed for the cuspid. The upper left lateral incisor
was extracted to aid in the correction of the gross periodontal defect of the cuspid (Fig.
12). The veneer crown of the cuspid was severed horizontally from the root and luted
with acrylic resin to the clasp and denture base of his old partial denture. The root
of the cuspid was ground to a dome shape as a root rest (Fig. 13). The internal area
of the luted crown was adapted with acrylic resin to seat with his denture over the
cuspid root stump. Then periodontal surgery was performed for the infrabony pocket
of this tooth.
During the healing stage, the remaining lateral and central incisors were splinted
with acrylic resin veneered gold crowns. Internal attachments were placed. The root
rest coping, internal retainers with lingual arms, and broad palatal coverage provided
retention and stability (Fig. 14).
No. 5. A 72-year-old woman presented with failures of a crown and fixed pros-
thesis. Economics was a deciding factor in retaining the existing dental arrangement
where possible.
The upper left lateral incisor, 9 mm. to the apex, was endodontically treated and
converted to a root rest. The vital upper left cuspid was covered with a coping, as was
 J. Prosthet. Dent.
22 Wailer July, 1975

Fig. 14. The internal rest prosthesis shows the secondary resin crown in the denture base.
Fig. 15. The copings for the nonvital lateral incisor, vital cuspid, and vital second molar.
Fig. 16. The unilateral prosthesis shows three secondary resin crowns and the clasp retainer.
A rest was used mesial to the right central incisor.

the vital upper left second molar (Fig. 15) . A ceramic-metal crown was placed on
the upper left second premolar and designed to receive a clasp retainer.
The removable partial denture has excellent retention and stabilization. Cross-
arch stabilization was not used (Fig. 16).

CONCLUSIONS
(1) Teeth with limited periodontal support can be retained as root rests and used
strategically.
(2) The root rest has strategic value under the denture base of removable partial
dentures, combining clasp, internal rest, and crown-sleeve direct retainers. The bene-
fits to these teeth and the root rests are mutual.
(3) The denture base can be linked to natural abutment teeth in a compatible,
biomechanical arrangement while using the root rest for vertical support and even
retention.
(4) The extension of the denture base over the labial plate of the alveolar process
of the root rests is desirable. Its significance to periodontal therapy needs additional
study.
(5) Endodontic therapy is often simplified because of gross occlusal reduction of
the crown of the tooth.
(6) Patient and laboratory procedures fall into routine categories of fabrication.

PRACTICAL SIGNIFICANCE
In selected patients, the retention of endodontically treated roots, covered by low,
dome-shaped copings, can prolong the health of the remaining dental structures by
providing a vertical rest under a removable partial denture.
Volume 34 Root rest and removable partial denture 23
Number 1

Root rests can offer extended service if used for stabilization with the denture
base. The border extension of the denture base in the area of the retained root is a
factor in the strategic success of the root rest.
The findings suggest that we re-evaluate the approach to periodontal prosthesis.

References
1. Miller, P. A.: Complete Dentures Supported by Natural Teeth, J. PROSTHET. DENT. 8:
924-928, 1958.
2. Pound, E.: Gross Arch Splinting Versus Premature Extractions, J. PROSTHET. DENT. 16:
1058-1068, 1966.
3. Yalisove, I. L.: Crown and Sleeve Coping Retainers for Removable Partial Prostheses, J.
PROSTHET. DENT. 16: 1069-1085, 1966.
4. Schweitzer, J. M.: Discussion of Crown and Sleeve Retainers for Removable Partial Pros-
theses, J. PROSTHET. DENT. 16: 1086-1089, 1966.
5. Morrow, R. M., Feldman, E. E., Rudd, K. D., and Trovillion, H. M.: Tooth-Supported
Complete Dentures: An Approach to Preventive Prosthodontics, J. PROSTHET. DENT. 21:
513-522, 1969.
6. Schweitzer, J. M., Schweitzer, R. D., and Schweitzer, J.: The Telescoped Complete Den-
ture, J. PROSTHET. DENT. 26: 357-372, 1971.
7. Dodge, C. A.: Prevention of Complete Denture Problems by Use of “Overdentures,” J.
PROSTHET. DENT. 30: 403-411, 1973.
8. Maurer, C. R.: Complete Denture Construction on an Alveolar Process Containing En-
dodontically Treated Roots, J. PROSTHET. DENT. 30: 756-758, 1973.

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