Modern application of the Skinner

vertical movement stress director for

distal extension partial removable dental
prostheses: A clinical report
Kyle S. Schulz, DDS,a Donald Downs, DDS,b and David R.
Cagna, DMD, MSc
College of Dentistry, University of Tennessee Health Science
Center, Memphis, Tenn
This article describes the prosthetic rehabilitation of a partially edentulous patient with a partial removable dental
prosthesis (PRDP) designed to dissipate stress transmission to the denture foundation and abutment teeth. The Skinner stress director is considered an alternative design for managing partially edentulous patients. (J Prosthet Dent
2013;110:61-65)
Current demographic trends indicate a dramatic growth in the older
adult subgroup of the population, a
growth projected to continue through
2050.1 As a result, an increase in
partially edentulous patients is also
expected, 2 and it is reasonable to assume that dentists will be tasked with
managing an increasing number of
partially edentulous patients with a
variety of prosthodontic restorations.
A conventional Kennedy Class I
partial removable dental prosthesis
(PRDP) is characterized by natural
tooth abutments anterior to bilateral
posterior edentulous segments. The
disparity in support between natural
tooth abutments and residual edentulous ridges renders both at risk of
deterioration during high force functional and parafunctional loading.
Historically, PRDP design modifications were given much attention in an
attempt to direct stress transmission
differentially to the residual ridge and
supporting teeth. One of these design
modifications, the Skinner vertical
movement stress director,3 is intended
to permit more even distribution of
functional loads along the edentulous

ridges while simultaneously minimizing nonaxial stress on abutments.

When most or all mandibular posterior teeth are missing, prosthodontic restoration represents a substantial
biomechanical challenge. If edentulous areas are present posterior to residual natural tooth abutments (Kennedy Class I or II), biomechanically
optimal removable prosthesis design
becomes particularly problematic.4
When indicated, the effective use
of dental implants can facilitate the
support of planned prosthodontic
restorations.5 However, unfavorable
anatomic, biologic, or biomechanical conditions related to the posterior
mandibular dental arch frequently
contraindicate implant therapy. Additionally, specific health conditions,
a desire to avoid dental surgery, or insufficient financial resources may prohibit patients from pursuing implant
treatment options. The identification
of viable prosthodontic solutions that
permit improved function, acceptable
patient comfort, and optimal biomechanical management of anticipated
residual tissue loading is desirable.
Optimal design, execution, and

management of distal extension base

PRDPs must account for the disparity in available prosthesis support.
Kennedy Class I PRDPs derive support anteriorly from relatively stable
natural tooth abutments and healthy
periodontal tissues. Posteriorly, this
restoration must rely on the compressive loading of the relatively resilient
soft tissues of the residual edentulous
ridges.4,6 Disparity in the displacement
of available foundational support for
the Kennedy Class I PRDP7-13 necessitates careful design consideration to
avoid the mechanical and/or biologic
breakdown of the system.14 When the
posterior prosthetic teeth of the PRDP
are loaded during occlusal function,
the extension bases are driven into the
soft tissue foundation. Because natural abutments are generally not capable of similar vertical displacement,
the entire prosthesis will rotate about
a fulcrum located at the abutments.
This functional rotation of the PRDP
has the potential to contribute to the
deterioration of available support systems, namely posterior bone/soft tissue changes, anterior abutment mobility, and periodontal degradation.6

This manuscript was presented as a table clinic before the American Academy of Restorative Dentistry, Chicago, Ill, February 2011.
Private practice, Pueblo, Colo.
Private practice (retired), Colorado Springs, Colo.
c
Professor, Associate Dean of Postgraduate Affairs, and Director of Advanced Prosthodontics Program.
a

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Volume 110 Issue 1

Guiding prosthodontic principles
have historically included the preservation of remaining oral tissues.15
In designing an PRDP, consideration
must be given to the impact of functional stress on natural abutments.
According to Boucher, Stress exerted
against the teeth and their attachment
apparatuses by occlusal forces may
be within the adaptive capacities of
the tissues, or the tissues may not be
capable of compensation and adaption resulting in tissue destruction.16
The transfer of occlusally derived stress
from prosthesis to natural abutments
based on various clasp assembly design features has been reported.17-20
Equally important is functional stress
transfer through the PRDP to the residual edentulous ridge. Here, stress has
been described as force per unit area
with temporal (duration, intensity,
and frequency) and directional (shear,
torque, and moment) cofactors.14
Craig and Farah21 demonstrated
that the loading of distal extension
base PRDPs resulted in stress concentrations in the supporting bone
and periodontal ligaments of second
premolar abutments, as well as in
bending moments in the abutments.
Their conclusion suggested that the
thicker the mucosa overlying the residual edentulous ridges, the greater
the magnitude of abutment bending
moments and the greater the amount
of force transferred to abutments.
Mensor14 investigated the average
pressure curves on residual ridges of 5
different PRDP designs. He concluded
that loading a conventional Kennedy
Class I PRDP resulted in both shear
and moment forces; an PRDP incorporating a hinge-type stress director
imparted only shear forces, while an
PRDP containing a vertically resilient
stress director induced neither shear
nor moment forces in the system.
The Skinner vertical movement
stress director,3,22 when designed into
a distal extension base RPDP, is intended to permit even distribution of
functional loading along the edentulous ridges while simultaneously minimizing nonaxial stress transmission to

abutments. The goal is long term preservation of the remaining dentition.

The purpose of this clinical report
is to illustrate and describe key elements of design and clinical execution
for the Skinner vertical movement
stress director.

CLINICAL REPORT
A 60-year-old woman presented
to the authors private practice stating that she was no longer satisfied
with the esthetics of her maxillary
complete denture and that her mandibular Kennedy Class I PRDP no longer provided comfortable function.
Her medical history was unremarkable except for a 1 pack/day cigarette
smoking habit. She had been offered
several different dental treatment options over the past 10 years, including plans involving bone grafting and
dental implant placement. The patient considered all dental implant
options to be unacceptable and unaffordable. Her wish was to preserve the
remaining dentition (Fig. 1) and to
receive new maxillary and mandibular
removable dental prostheses.
After intraoral and extraoral examinations, maxillary and mandibular diagnostic casts were made. A
facebow record, an interarch centric
relation record, and an interarch protrusive record were made by using
carefully adjusted record bases and
wax rims. The casts were mounted in
a semi-adjustable articulator (Denar
Mark 330; Whip Mix Corp, Louisville,
Ky). Wax trial dentures were fabricated and placed to assess esthetics and
phonetics.
Mounted diagnostic casts and wax
trial dentures were then assessed for
available prosthodontic restorative
space. The mandibular diagnostic
cast was surveyed to identify the path
of prosthesis placement, to evaluate
available axial abutment contours,
and to consider design parameters for
the RPDP. Based on provider philosophy, available restorative space, and
survey findings, the treatment offered
to this patient included a mandibular

The Journal of Prosthetic Dentistry

PRDP incorporating a Skinner vertical

movement stress director and a maxillary complete denture.
Design considerations related to
the Skinner vertical movement stress
director include: a minimum of 7 mm
interarch space from the crest of the
partially edentulous ridge to the opposing functional cusps must be available (Fig. 2); the primary framework
should derive support and retention
from abutments through conventional clasp assemblies; a strut oriented
perpendicular to the occlusal plane
and extending along the crest of the
edentulous ridge should project from
the distal guide plate of the primary
framework; an overcasting to which
denture teeth and flanges are processed should be fabricated to fit over
the primary framework strut (Fig. 3);
the fit between the overcasting and
the strut should be designed to permit vertical movement of the prosthetic segment relative to the primary
framework; and a pin placed through
a hole in the strut should connect the
prosthetic segment to the primary
framework (Fig. 4).
A definitive impression for the
mandibular PRDP was made with
vacuum-mixed irreversible hydrocolloid (Jeltrate; Dentsply Caulk, Milford, Del). The impression was cast
in Type IV dental stone (Die Keen Die
Stone; Heraeus Kulzer, LLC, South
Bend, Ind). The PRDP primary framework was then fabricated, incorporating conventional clasp assemblies, a
lingual bar major connector, and distally extending struts.
The framework was placed intraorally and fit was optimized by using
standard clinical procedures.4 The
framework was returned to the definitive cast in preparation for an altered
cast impression. Wax relief was placed
over the edentulous ridges. Light-activated resin recording rims (Triad Denture Base Resin; Dentsply Intl, York,
Pa) were attached to the framework
struts. Intraorally, peripheral tray extensions were adapted with modeling
plastic impression compound (Kerr
USA, Romulus, Mich) and border

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July 2013

1 Patients residual mandibular dentition on inital

presentation before therapy.

2 Components and dimensions of primary framework. (A)

minimum of 1 mm between depth of occlusal anatomy and
superior edge of strut. (B) approximately 1 mm depth cuts
to accommodate physiologic movement of base. (C) 1 mm
metal from adjusted superior border of strut and pin hole.
(D) 1 mm for initial pin hole. (E) 1 mm for pin hole elongation to accommodate physiologic base movement; (F) approximately 2 mm from pin hole to inferior surface of strut.

molding was completed. The altered

cast impression was made with a light
body impression material (Imprint III;
ESPE 3M Dental Products, St Paul,
Minn). Leaf gauge (Huffman Leaf
Gauge; Huffman Dental Products
LLC, Springfield, Ohio) guided centric
relation records (Futar-D; Kettenbach
LP, Huntington Beach, Calif ) were
made. In the laboratory, the edentulous segments of the definitive cast
were removed, and the altered cast
was poured in Type IV dental stone
(Die Keen Die Stone; Heraeus Kulzer
LLC). The mandibular cast was then

Schulz et al

mounted against the maxillary complete denture.

Overcastings were made to fit
the struts (Fig. 4). A hole was drilled
through each strut and associated
overcasting. Pins made from 18 gauge
wire (Paliney No. 7; Dentsply Caulk)
were inserted through the holes to
connect the overcastings to the primary framework.
Denture teeth were selected (Portrait; Dentsply Intl). A mesial-todistal recess was created in the ridge
lap portion of the posterior denture
teeth to accommodate the overcast-

ings during tooth placement. Upon

completion, the wax trial denture was
placed to verify that the appropriate
occlusal vertical dimension had been
established coincident with centric relation mandibular posture.
With the pin in place and the
primary framework attached to the
waxed prosthetic segments, the PRDP
was processed 4 and finished 23 by using conventional methods. The completed prosthesis was placed and disclosed (PIP Paste; Mizzy, Myerstown,
Pa) to assess and adjust fit. Occlusal
adjustments were accomplished (AccuFilm; Parkell, Inc, Edgewood, NY)
before releasing the broken stress element of the RPDP.
In order to determine the degree
of expected vertical denture displacement during posterior functional
loading, tissue compressibility along
the residual edentulous ridges was
assessed at multiple sites by using a
ball burnisher hand instrument. An
observed maximum of 1 mm tissue
compressibility was noted. The PRDP
prosthetic segments were disassembled from the primary framework by
opening a window through the lingual
flange denture base resin and retrieving the pin (Fig. 5). Depth cuts of 1
mm were made in the superior surface
of both struts (Fig. 6). Superior strut
surfaces were then uniformly reduced
by 1 mm and line angles rounded,
and cut surfaces were finished and
polished. Pin holes in the struts were
elongated by 1 mm in an apical direction to provide for physiologically appropriate movement of the prosthetic
segments during functional loading.
The PRDP was reassembled and
freedom of movement verified between the prosthetic segments and
the primary framework (Fig. 7).
Chemically activated acrylic resin (Repair Resin; Dentsply Intl) was used to
seal denture base openings over the
pins and to re-establish smooth lingual flange contours. The completed
prosthesis was provided to the patient
(Figs. 8, 9). The patient returned for a
24-hour postinsertion evaluation and
required no adjustments.

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Volume 110 Issue 1

3 Overcasting fits accurately on framework strut, has

hole for pin, and provides retention for denture teeth and
denture base resin with flanges.

4 Pin in place connecting overcasting to primary framework.

5 Opening in denture base resin exposing pin for

retrieval.

6 Approximately 1 mm depth cuts guide reduction of superior strut surface, combined with elongation of pinhole by
same amount, to accommodate vertical movement of overcasting/prosthetic segment. Distal notch in strut engages
prosthetic segment to prohibit lifting with sticky foods.

7 Assembled PRDP including adjusted strut with elongated pin hole, overcasting processed into denture base,
and pin connecting base to framework. Blue arrow
indicates occlusal loading which leads to independent
movement of overcasting.

8 Intaglio surface depicting intimate fit of overcasting to

strut.

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July 2013

9 Definitive mandibular PRDP (Class I, Modification 1)

with Skinner vertical movement stress directors.

DISCUSSION
Careful consideration should be
given to PRDP designs that accommodate the disparity between natural
abutment and residual edentulous
ridge support. The dynamic functional relationship between these
prostheses and their support systems
is complicated. The prosthetic design
suggested by C.N. Skinner 3,22 was directed at a biomechanical solution
intended to spare abutments while
evenly distributing functional prosthesis loading to the residual edentulous foundation.
Conditions that prohibit the application of the Skinner vertical movement stress director design include
short abutments and insufficient vertical restorative space. When abutments are short, aspects of the framework may project above the required
occlusal plane, negating any possibility of vertical movement of the
prosthetic segments. Therefore, any
consideration of the Skinner design
must begin with a minimum of 7 mm
of vertical restorative space. The use
of metal occlusal surfaces23 or fabrication of overcastings and prosthetic
teeth in a single unit may permit the
use of this design in the presence of
reduced restorative space.

SUMMARY
This clinical report describes the
fabrication and placement of a distal extension PRDP that incorporates
a stress directing design intended to
preserve residual hard and soft tissues. By incorporating the capacity
for vertical movement of the prosthetic segments, forces encountered during functional loading will be more
evenly distributed along the edentulous ridges and nonaxial stress on the
abutments reduced. Contemporary
application of the Skinner vertical
movement stress director provides
comfortable and durable function to
a compromised and complex group
of patients requiring posterior tooth
replacement.

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Corresponding author:
Dr Kyle S. Schulz
3911 Outlook Blvd
Pueblo, CO 81008
Fax: 719-544-6777
E-mail: nodcdrschulz@msn.com
Copyright 2013 by the Editorial Council for
The Journal of Prosthetic Dentistry.

Schulz et al