The effect of partial denture

connectors on gingival health

Sandra Orr\ Gerard J. Linden^ and

Hubert N. Newman'
^Department of Restorative Dentistry, Queen s
University ot Belfast, UK: ^insiitute of Dental
Surgery, University of London, UK

Orr S. Linden GJ and Newman HN: The effect of partial demure connectors on
gingival health. J Clin Periodontol 1992; 19: 589-594.
Abstract. The effect on the gingiva of a variety of relationships of a removable
partial denture connector to the gingival margin was investigated in 10 subjects.
Acrylic resin baseplates were designed incorporating a variety of relationships of
the connector to the gingival margin. The appliances were worn for a 12 hour
period daily, for 21 days. At baseline and at days 7, 21 and 49. plaque index,
gingival index and probing pocket depth measurements were recorded, and
subgingival plaque samples were examined using darkfield microscopy. No increase in plaque accumulation was detected in any area at any time interval.
There was a significant increase in gingival index at day 21 in areas where the
appliance covered the gingival margin. Small increases in probing pocket depth
were recorded at day 21. there being no difference between any of the test areas.
Baseline values were re-established by day 49, No significant differences were
detected in the percentage of motile organisms or spirochaetes counted in the
subgingival plaque samples collected from any area. It was concluded that deterioration in gingiva] health occurred rapidly following the insertion of a removable
appliance, and that coverage of the gingiva] margin, irrespective of the degree of
gingival relief, had a detrimental effect.

El Ghamrawy (1976), Addy and Bates

(1979) and Stipho et al. (1978) found
removable partial dentures were associated with increased plaque accumulation, not only on tooth surfaces in
direct contact with the denture but also
on teeth in the opposing arch, and in
some cases, even on buccal surfaces of
teeth. Several studies have shown increased or continuous periodontal
breakdown in patients fitted with partial dentures (Carlsson et ai, 1965, Derry & Bertram 1970. Rissin et al. 1979),
It is possible to reduce the effect of removable partial dentures on the periodontium. Bergman et al. (1982) and
Chandler & Brudvik (1984) demonstrated only minor periodontal effects
in patients recalled regularly for supportive treatment, including professional oral hygiene. Taken together
these studies suggest that the insertion
of a partial denture constitutes a risk
factor for periodontal health. One particular problem may be the relationship
of the denture connector to the gingival
margin, Bissada et al. (1974) concluded
that if tooth approximation was necessary, the gingiva! margin should be relieved, i.e. there should be a space
underneath the denture base, whereas
Hobkirk and Strahan (1979) concluded

that the appliance should be very closely

applied to the gingival margin.
The aim of this study was to investigate the effect on the gingiva of a variety
of relationships of a removable partial
denture connector to the gingival margin. In addition darkfield microscopy
was used to examine associated microbiological changes, in an attempt to
identify whether a disease-associated
flora became established in the period
shortly following the insertion of a removable partial denture.
Material and Methods
10 healthy adult volunteers were selected from Dental Surgery Assistants
working at the Eastman Dental Hospital. London. Each subject had an intact
maxillary arch, adequately restored
dentition and displayed no occlusal abnormalities. The purpose and design of
the study were explained clearly to each
subject and voluntary informed consent
obtained. None had previously worn a
removable appliance, nor had they any
medical condition which contra-indicated their inclusion in the study, Ali
subjects were right-handed.
The upper first premolars and first
molars were selected as test teeth, and in

Key words: partfal dentures: plaque: gingivat

infiammation.
Accepted for publication 6 August 1991

each subject the upper second premolars

were present so that the test teeth were
not contiguous. Two mandibular teeth
were chosen as controls. In each subject
the mean gingival index was <0.5 and
plaque index < 1. so that scaling was
not deemed necessary prior to basehne
recordings. Aiginate impressions were
made for each subject, and a heat-cured
acrylic resin baseplate was constructed
which covered the palatal gingivae from
the upper canine to the second molar
(Fig, 1). The appliances were retained
by embrasure hooks, 4 test areas. A-D,
were incorporated into the design of the
baseplate relating to the palatal surfaces
of teeth 14. 16. 24 and 26. as shown in
Table I.
Baseline recordings of plaque index
(Silness & Loe 1964) and gingival index
(Loe & Silness 1963) were made at the
mid-buccal, mid-palatal, mesio- and disto-palatal surfaces of each test and
control tooth. A thinned William's
periodontal probe, tip diameter 0.5 mm
(the unmodified probe had a tip diameter of 0.7 mm) was used to measure
probing pocket depth. All clinical data
were recorded by one examiner who was
an experienced periodontist (S.O.).
Samples of subgingival plaque were collected from the apical limit of the gin-

590

Orr el al
pairs signed ranks tests, while MannWhitney fZ-tests were performed for between area comparisons,
10 healthy female subjects aged 18-22
years completed the study.

Results
Plaque index (PlI)

There were no differences in the plaque

levels recorded at baseline for right or
left quadrant teeth, or between test and
control teeth (Fig, 2), Buccal surfaces
had low levels of clinically detectable
plaque throughout the study period.
The mesial, distal and palatal,'lingual
surfaces of the test and control teeth
were comparable at each time point.
There were only minor fluctuations
from baseline values between each of
the test areas during the period of study.
Fig. I. Heat-cured acrylic resin baseplate, covering the palatal gingivae from the upper canine
to the second molar, retained by embrasure hooks. The test areas incorporated into the design
of the baseplate are labelled.
Gingival index (Gl)

gival crevices on the mesio-palatal aspect of the test and control teeth, using
a Gracey pattern curette number 5/6,
The plaque samples were transferred to
bijou bottles containing 0,2 ml of 0,85%
saline, and the resulting plaque suspensions were dispersed by expulsion ten
times through a 25 gauge needle. One
drop was applied to a microscope slide
which was cover-slipped and sealed with
nail varnish to reduce evaporation and
streaming, A darkground system (Standard 14, Zeiss, Oberkochen, Germany)
was used to examine the slides at a magnification of X 1000 under oi! immersion. All slides were prepared and examined within one hour in an attempt to
reduce loss of bacterial motility
(Omar & Nevmian 1986), 200 bacteria
from randomly selected fields were
counted and classified into the four
morphological groups as described by
Mousques et al. (1980): coccoid cells.

motile organisms, spirochaetes and

other morphotypes.
The subjects were instructed in the
Bass method of brushmg. which was to
be performed twice daily, and supplied
with an Oral B 35 brush (Oral B Laboratories Ltd. Aylesbury, Bucks, England,) and Crest Toothpaste (Crest.
Procter & Gamble, Newcastle, England), The appliances were then inserted, adjusted to be in harmony with
the occlusion, and the subjects instructed to wear them 12 hours daily, during
waking hours, for a period of three
weeks. Clinical measurements and
plaque samples were obtained after 7
and 21 days, A fmal assessment was
carried out at day 49, four weeks after
discarding the appliance.
Statistical investigations

Changes which occurred within areas

were evaluated using Wilcoxon matched

Table I. Test areas incorporated into the design of the acrylic resin baseplate
Test area

Tooth

Relationship of framework

14

16

24

26

the appliance covered and was closely applied to the gingival margin
<i,e,. no gingival relieOthe appliance incorporated a relief chamber which extended 1 mm
horizontally and 1 mm vertically from the gingival margin,
the appliance incorporated a relief chamber which extended 2 mm
horizontally and 2 mm vertically from the gingival margin,
the appliance did not cover the gingival margin and was terminated 3
mm from it.

Gingival health was maintained at the

buccal surfaces at all time intervals (Fig,
3), 80% of test and 82% of control surfaces had GIO at baseline. At day 21,
only 28% of test surfaces had a GIO
compared with 73yo of control surfaces.
The difference between these groups
was significant at the 1% level. At day
21 bleeding was observed (GI 2) at 18%.
of the test surfaces as shown in Fig,
3, 7 of the 10 subjects had developed
bleeding in at least one site. By day 49
no bleeding was evident and 93% of the
test surfaces had GI 0, No bleeding was
recorded at buccal or control surfaces
at any time.
The effects of the varying degrees of
gingival relief are shown in Fig, 4, Between 77 and 84% of surfaces in the
different test areas had GI 0 at baseline.
At day 21, only 17-20% of the surfaces
in test areas A, B and C, where the
appliance covered the gingival margins,
had Gl 0, Tbe differences from baseline
within each of these areas were significant at the 1% level. In test area D
where the appliance terminated 3 mm
from the gingival margin, 50% of the
surfaces had GI 0 at day 21, and in this
test area, the changes from baseline
were not statistically significant. No significant differences in G] were detected
between test areas A. B and C at day
21; however, significant differences were
detected between each of these and test
area D ( / ' < 0.05).

Partial dentures and gingival health

BASELtNE

7 DAYS

40 -

20 -

21 DAYS

49 DAYS
KJ TOO
<

DO -1

II

SO m
60 -

SO-

40 -

40 -

20 -

20

BUCCAL

CONTROL

TEST

PI I
Q

Discussion

and D at any time. Baseline values were

re-established by day 49,

Probing pocket deptti

Probing pocket depth measurements recorded for buccal or control surfaces

remained essentially the same throughout the study, 75% of probing depths at
the test surfaces measured 0 or 1 mm at
baseline (Fig, 5). At day 21, this had
reduced to AV'A,. with 9"/, measuring 3
mm or more. This was not statistically
significant. No difference was detected
between surfaces in test areas A, B, C

BUCCAL

Microbiological data

At baseline, motile organisms were detected in the plaque samples from test
areas in three subjects. At day 21. this
had increased to 8 subjects (Table 2), In
the control areas. 1 subject presented
with motile organisms at baseline and 2
subjects at day 21. at which time the

GI

7 DAYS

BUCCAL

CONTROL

CONTROL

49 DAYS

21 DAYS

f1

00

80 -

GO

40-

20 -

BUCCAL

CONTROL

TEST

increase in mean number of motile organisms was greater for test than control sites; however, the increases were
small and the difference was not statistically significant, Spirochaetes were
more prevalent than motiles in both test
and control areas throughout the study,
but as with motiles, formed a small proportion of the monitored flora. Table 3
shows the small increase from baseline
in the mean percentage of spirochaetes
per 200 organisms counted, for both test
and control areas. No significant differences were detected in the mean percentage of motile organisms or spirochaetes
counted between test areas A. B. C and
D. At each time interval coccoid cells
remained predominant and baseline
values were re-established for all morphotypes by day 49.

BUCCAL

Fig. 2. Frequency distribution of plaque index with time.

BASELINE

591

BUCCAL

g. 3. Frequency distribution of gingival index with time.

The wearing of a prosthesis for three

weeks did not lead to any measurable
change in the level of plaque in the subjects. It is possible that plaque accumulation was increased by the presence of
the appliance, but that this was not observed clinically due to thorough plaque
removal by the subjects prior to examination. The subjects were instructed in
Bass brushing and asked to brush twice
daily, however, it became evident during
the study that the majority were brushing several times during the day. This
would explain the low level of plaque
accumulation observed in these subjects. These results conflict with those
of Rissin et al, (1979). who observed
significantly increased plaque accumulation in partial denture wearers; however, their subjects were selected from
a group of patients in whom greater
baseline values for plaque would be expected, and who would be unlikely to
perform the rigorous oral hygiene regimen demonstrated by the present study
group,
Gingival health was maintained in
buccal and mandibular control sites
throughout the study. Gingivitis did develop in areas covered by the appliance
after only three weeks, with bleeding
evident in 18% of test sites and in 7 of
the 10 subjects. This was despite the low
levels of clinically detectable plaque in
this group of healthy, highly motivated
subjects. By day 49, 4 weeks after discarding the appliance, baseline values
were re-established in all test areas. The
rapid resolution of the gingiva! inflam-

592

Orr et al.
BASELINE

Table 2. Prevalence of motile organisms in 10

subjects and mean dark-field counts in test
and control areas

7 DAYS
100.
60 .

Test

Control

60 .

n mean (sem)

n mean (sem)

3
6
8
4

1
4
2
2

baseline
7 days
21 days
49 davs

40.
20 .

A B C

A B C D
GI=1

GI-0

A a C D

G1=O

A B C D

GbO

49 DAYS

GI=1

A B C D

GI=2

GI=1

Fig. 4. Frequency distributton of gingival index with varying gingival relief. A - no relief: B
- 1 mm; C - 2 mm: D - 3 mm.

mation probably resulted from the high

level of oral hygiene praetised.
The individuals had a healthy periodontium at baseline, with minimal
probing depths, and attachment levels
corresponding to the enamel cement
junction. Only small increases occurred
in probing depth in response to the insertion of the appliance. At day 21, a
maximum of 4 mm was recorded at only
one site. The inereases in probing depth
were due to gingival swelling principally
associated with the onset of gingival in-

(0.1)
(0.3)
(I)
(0.2)

0.05
0.70
0.45
0.25

(0.05)
(0.3)
(0.4)
(0.2)

e c D
GI=1

A B C D

21 DAYS

0.23
0.68
2.68
0.43

flammation. Some gingival swelling

may also have been caused by direct
trauma from the appliance, as suggested
by Hobkirk & Strahan (1979). The
rapid development of gingivitis suggests
that emphasis should be placed on early
review of patients who receive removable partial dentures, so that gingival
health can be monitored and oral hygiene reinforced if necessary.
Minimal quantities of subgingival
plaque were obtained from the gingival
crevices during sampling. The scanty

subgingival plaque in addition to the

shallow probing depths recorded may
have accounted for the lack of significant microbiologic changes throughout
the study. Although there was an increase in crevice depth after appliance
insertion, the crevices did not deepen
sufficiently to allow disease-assoeiated
morphotypes to flourish. A marked increase in spirochaete and motile counts
would not have been anticipated as
these organisms are usually found in
deeper poekets (Omar et al. 1990). An
increase in the proportion of spiral organisms has been reported in denture
wearers (El Ghamrawy 1976); however,
this occurred during a period of no oral
hygiene. In the present study the excellent supragingival plaque control probably affected the proportional counts
subgingivally (Siegrist & Komman
1982).
Bissada et al. (1974) reported that
gingival health was adversely affected
by removable partial dentures, this
being most severe where the appliance
closely contacted the gingival margin.
They concluded that the optimum relationship occurred when the denture
base was placed as far from the gingival
margin as possible; however, if tooth
approximation was necessary the gingival margin should be relieved by incorporating a space between the denture
base and the gingiva. This is accomplished by grinding the fitting surface of
the denture in relation to the gingival
margin, or by blocking out the gingival

80

60 -

0/1 MM
2MM
3MM
4MM

Table 3. Prevalence of spirochaetes in 10 subjects and mean dark-field counts in test and
control areas
Control

Test
mean (sem)

20-

BASELINE

7 DAYS

21 DAYS

Fig. 5. Changes tn probing pocket depth at test sites.

49

DAYS

baseline
7 days
21 days
49 days

8
8
9
7

0.68 (0.2)
0.48(0.1)
1.38 (0.3)
0.58(0.!)

n mean (sem)
4
4
4
6

0.40 (0.2)
0.35 (0.1)
0.65 (0.2)
1.20(0.4)

Partial dentures and gingiva! health

margin area on the master cast prior to
processing the appliance. In the present
study, no significant differences in Gingival Index were detected between sites
with no gingival relief and those with 1
or 2 mm of relief. Hence, coverage of
the gingival margin by the appliance,
irrespective of the degree of gingival relief, had a detrimental effect on gingival
health. Unlike the results obtained by
Hobkirk and Strahan (1979), both relieved and unrelieved areas of the baseplate were equally detrimental to gingival health, since all test areas where
the gingival margins were covered by
the appliance showed an increase in
both Gingival Index and probing depth.
Terminating the appliance 3 mm from
the gingival margin had the least damaging effect. The baseline and subsequent readings indicated that the subjects' brushing technique was equally effective in all quadrants, and so regional
differences in plaque control were unlikely to have been responsible for the
variation in gingival health. From the
results obtained in this study, it would
appear that where possible, denture
connectors should terminate at least 3
mm from the gingival margin. The results highlight the need for further
studies to clarify the optimum relationship of partial denture connectors to the
gingiva, since all such connectors must
come into close approximation to the
gingival margin of one or more abutment teeth.

Conclusions
Deterioration in gingival health occurred rapidly following the insertion of
an appliance, even in the presence of a
high level of oral hygiene.
Coverage of the gingival margin, regardless of the degree of relief, had a
detrimental effect on gingival health.
Where possible, partial denture connectors should be located at least 3 mm
from the gingival margin.

Acknowredgements
We are grateful to the Dental Surgery
Assistants of the Eastman Dental Hospital, London, who enabled the study
to take place, and the staff of the Department of Prosthetic Dentistry for
their support, particularly Mr, C. Malton, who made the appliances.

Zusamtnenfassung

593

aucune des zones, les echantillons de plaque

sous-gingivale preleves n'ont presente de difference significative concemant la proportion
d'organismes motiles ou de spirochetes denombres. En conclusion, une deterioration de
la sante gingivale se produisait rapidement
apres la pose d'un appareii amovible. et le
recouvrement du rebord gingival avait un effet prejudiciable. independamment du degre
de protection de la gencive.

Die Wirkung der Verbindungselemente von

Teilprothesen aufdie Gesundheit der Gingiva
An 10 Probanden wurde die Wirkung aufdie
Gingiva bei einer Vieizah! von Relationen
der Teilprothesen-Verbindungselementen zur
marginalen Gingiva untersueht. Es wurden
Kunststoff-Basisplatten entworfen. die eine
Vielzahl von Relationen der Verbindungselemente zur marginalen Gingiva aufweisen. Die
Vorrichtungen wurden fiir 21 Tage 12 Stunden pro Tag getragen. Der Plaqueindex. Gingivaindex und die Sondierungstiefe wurden
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Address;
Gerard Linden
Department of Restorative Dentistry
School of Clinical Dentistry
Queen's University
Grosvenor Road, Belfast
Northern Ireland. BT12 6BP
UK