Surveying removable partial dentures: the importance of guiding planes and

path of insertion for stability

O. L. Bezzon, DDS, PhD, a M. G. C. Mattos, DDS, a and R. F. Ribero, DDS b
Department of Dental Materials and Prosthodontics, School of Dentistry of
Ribeir~o Preto, University of S~o Paulo, Silo Paulo, Brazil

Statement of problem. Although removable partial dentures are a favored option for the restoration of
many situations that involve partial tooth loss, some patients are not satisfied with a removable partial
denture, especially when it is not stable during mastication. A dental surveyor can be used to prevent
countless problems related to the production of removable partial dentures. Many professionals working
with oral rehabilitation fail to take advantage of the many uses of a surveyor in planning and designing
chromium alloy and other metal removable partial denture frameworks.
Purpose. This article uses an academic approach to describe the criteria used to determine the path and
removal of a removable partial denture. A fundamental requirement for understanding the correct use of
the dental surveyor is to prevent indiscriminate use of a path of insertion perpendicular to the occlusal
plane, and extreme inclinations of the cast in the attempt to create undercuts on some teeth. (J Prosthet
Dent 1997;78:412-18.)

When performing oral rehabilitation with rc-
movable partial dentures (RPDs), the objective o f the
dentist should be to make a prosthesis that the patient
can easily seat and remove from the mouth and yet, when
seated, the prosthesis will resist the dislodgment poten-
tial caused by masticatory function, especially mastica-
tion o f sticky foods. The problem involves an interac-
tion o f engineering and biologic elements, so a biome-
chanical approach should be used for its solution. On
this basis, it is imperative that diagnostic casts for all
RPDs be analyzed with a dental parallelometer (sur-
veyor), the instrument that permits accurate planning
o f each structural detail o f the prosthesis.1
A diagnostic cast should be surveyed for three major
reasons: (1) determination o f the path o f insertion to
obtain efficient and esthetically pleasing retentive clasps;
(2) tracing the survey line to enable positioning o f the
rigid parts o f the prosthesis, so they will seat without
interference; this procedure provides information about
the need to recontour the abutments and other teeth
and to improve the functioning o f rigid parts and the
esthetic aspects related to it; and (3) analysis o f the con-
tour o f soft tissues to prevent the occurrence o f lesions
that result from seating the prosthesis. 2 The use o f a
dental surveyor permits the dentist to plan, study, and
design an RPD that will provide adequate retention, sup-
port, stability, and esthetic appearance. 3,4
In 1954, Applegatc s commented that the intelligent
use o f the dental surveyor is the best way to prevent the
occurrence o f countless problems frequently related to
oral rehabilitation with RPDs. However, daily contact
with professionals in our vicinity shows that there are
many dentists who have no dental surveyor and are un-
aware o f the importance o f its use when they are mak-
ing RPDs, because they believe the technician may be
more experienced and they choose to delegate the re-
sponsibility to the technician. 6
The objective o f this study was to use an academic
approach to remind dental practitioners o f the under-
standing of the dynamics involved in determining the
path of insertion, a fundamental condition for the in-
clusion o f the dental surveyor as a tool o f routine use in
planning and designing RPDs.
PATH OF INSERTION AND REMOVAL

~Associate Professor. The RPD path o f insertion and withdrawal is the di-
bAssistant Professor. rection in which the prosthesis moves in relation to the

412 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 78 NUMBER 4

BEZZON, MATTOS, AND RIBERO
Fig. 1. Parallelometer (surveyor).
support system when it is seated in or removed from the
mouth, guided by the contact of its rigid parts with the
a b u t m e n t s / T h u s the contours of the teeth that contact
the component parts of the RPD have a decisive influ-
ence on the determination of the ideal path of insertion
and withdrawal. Because the paths of insertion and with-
drawn involve equal movements but in opposite directions,
they may be referred to only as the path of insertion.
To determine the path of insertion for any RPD, the
diagnostic cast should be positioned on the cast holder
and analyzed in relation to the vertical rod (surveying
stylus) of the parallelometer (surveyor) (Fig. 1). The
vertical movement of the surveying stylus represents the
path of insertion itself, which changes with each new
inclination given to the diagnostic cast on the adjust-
able cast holder. The object of this process of analysis is
to determine the ideal path of insertion. Because sur-
veying is an individual process for each RPD, specific
influencing factors must be analyzed and conditions
developed by mouth preparation to accommodate the
desired path of insertion. These factors include: (1) guid-
ing planes, (2) tooth contours, in general, and more
specifically undercuts on the teeth and soft tissues, (3)
esthetic appearance, and (4) interferences. 1,3
GUIDING PLANES
The flat axial surfaces in an occlusal-gingival direc-
tion on abutments are referred to as guiding planes. They
should be prepared to be parallel to one another and to
the path of insertion as determined by the surveying
stylus. These surfaces very seldom occur naturally and
need to be prepared directly on enamel or on cast or
composite restorations. 8 During insertion, the rigid parts
of the prosthesis contact with these surfaces, which di-
rect the movement of the RPD until it is seated securely
in the predetermined terminal position in the mouth.
OCTOBER 1997
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 2. When functioning, RPD is pulled by sticky food in di-
rection perpendicular to occlusal plane. This direction, de-
fined as potential path of dislodgment (PPD), indicated by
arrows in this schematic drawing, does not depend on direc-
tion of insertion selected by dentist.
UNDERCUT SURFACES
The inclination given to the cast in relation to the
surveying stylus (path of insertion determined for the
prosthesis) should result in undercuts on the abutments
measured gingivally from the survey line. The under-
cuts should be proportionally equal in depth and con-
vergence angle on all abutments and should permit the
retentive clasp tips to engage the undercut in the gingi-
val third of the tooth. Abutment contours should also
permit contact of the rigid components of the clasp arms
in the opposite side of the middle third of the tooth to
accommodate. 9
ESTHETIC APPEARANCE
Esthetic appearance can be considerably improved,
especially with anterior abutments, by trying different
paths of insertion. Small changes in the inclination of
the cast can be made to seat the components of the pros-
thesis in less exposed regions that do not impair the
patient's appearance, without jeopardizing the remain-
ing determining factors. The objective should always be
to obtain an appearance as natural as possible. 1°
INTERFERENCES
In the determination of the path of insertion, it is im-
portant to detect and resolve the presence of interference
from structures other than teeth that will interfere with
the placement of the prosthesis, such as exostoses, soft
tissue, and undercut ridges. It is often possible to find a
path of insertion that will prevent contact of the prosthe-
sis with these anomalies when, for some reason, they can-
not be removed surgically or corrected by other means.
DETERMINATION OF THE PATH OF
INSERTION
To determine the path of insertion, the diagnostic cast
should first be positioned on the cast-holding table,
413
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 3. Path of insertion (PI) perpendicular to occlusal plane
(dotted line) that coincides with potential PPD can be used
for RPD if it provides satisfactory undercut surfaces (arrows)
on abutments. These undercuts must be well-defined and of
maximum depth required for type of clasp arm used.
which in turn should be inclined in such a way that the
occlusal plane of the cast will be parallel to the table of
the surveyor. 4
The principle that governs the function of a dental sur-
veyor (Fig. 1) requires that the surveying rod (stylus) be
at a 90 degree angle (perpendicular) to the platform of
the surveyor. A line or plane perpendicular to one plane is
also perpendicular to any other plane(s) parallel to the
first plane. Therefore positioning the cast with the oc-
dusal plane parallel to the platform of the surveyor estab-
lishes a perpendicular relation between the surveying rod
and the occlusal plane, which would accommodate a path
of insertion perpendicular to the occlusal plane.
The selection of a path perpendicular to the occlusal
plane is considered to be favorable because, against the
advice of their dentist, many patients insert their RPDs
with a biting force and because this orientation of the
cast facilitates the mouth preparation necessary to make
the prosthesis function as it is intended, once it is fabri-
cated. 3
It is important to understand that a path of insertion
perpendicular to the occlusal plane, also referred to as
path of insertion of zero inclination, is an orientation
given to the cast to start the survey analyses. The survey
will be conducted in sequence by the analysis of the four
factors that influence the path of insertion mentioned
earlier. Obviously, the path of insertion that provides
the greatest advantage with respect to the influencing
factors will be considered the ideal path of insertion for
the situations in question.
414
BEZZON, MATTOS, A N D RIBERO
Pi Pi Pi Pi
Fig. 4. Cross-section of retentive clasp arms shown on facial
surfaces of abutments and cross-section of reciprocal clasp
arms shown on lingual surfaces of abutments. Horizontal
marks on distal of abutments indicate position of neutral zone
(survey line).
Understanding the biomechanics associated with the
insertion and withdrawal of the RPD is fundamentally
important. Regardless of the path of insertion deter-
mined for any RPD, there is always a potential path of
dislodgment (PPD) resulting from masticatory function
that pulls the prosthesis in a direction perpendicular to
the occhisal plane time when the patient completes each
chewing stroke and begins the next one, after closing
his mouth, opens it again in the continuation of the
masticatory cycle (Fig. 2). Thus the path of insertion
(PI) is of fundamental clinical importance because it
predetermines the placement of clasp arms in retentive
undercuts, which provides the retention and helps in
stabilizing the prosthesis during function (Fig. 3).
Figure 4 represents a clasp design situation that will
provide adequate retention and stability because the rela-
tively long guide planes at this PI are parallel to each
other and the facial undercuts for clasp retention are
approximately equal to each other and are equidistant
below the survey line. Understanding the potential paths
of dislodgment is fundamental for the professional to
design RPDs in which the PI may be slightly off of the
zero inclination of the occlusal plane. This may allow a
slight reduction in the amount of retentive undercuts
required to prevent dislodgment of the RPD during
normal mastication because properly designed rigid com-
ponents (minor connectors) on the framework will bind
slightly when they contact the prepared guiding planes
on the abutments and prevent easy dislodgment. The
inclination of the diagnostic cast grossly away from the
VOLUME 78 NUMBER 4
BEZZON, MATTOS, A N D RIBERO THE JOURNAL OF PROSTHETIC DENTISTRY

Pi Pi Pi "PI _ Pi Pi Pi

Fig. 5. Path of insertion (PI) perpendicular to occlusal plane
reveals discrepant undercut surfaces (large undercut on left
and none on right). Survey line on left abutment is about equi-
distant between occlusal surface and gingiva. Survey line on
right abutment is near gingiva.
Fig. 6. When cast table is inclined to right in attempt to dis-
tribute undercuts evenly, apparent undercut can be established
on right abutment of cast shown in Figure 5. This requires
extreme tilt and guiding planes have been ignored.

zero inclination to produce apparent undercuts will not

be satisfactory.
Analysis o f Figure 5 shows there is a considerable un- Pi Pi Pi

P
dercut on the facial surface of the abutment on the left
side and total absence o f an undercut on the abutment on
the fight side. A framework designed at this zero inclina-
tion would not have adequate retention. Inclining the
cast shown in Figure 5 to the right side (Figs. 6 and 7)
should result in a better distribution o f the undercut sur-
faces between the two abutments, creating a medium
undercut surface on the facial surface o f each abutment.
Thus the retentive facial clasp arms could be placed in
adequate retentive undercuts; however, it would com-
pletely eliminate the guiding plane on the lingual surface
o f the abutment on the fight side and would place the
guiding plane so near the occlusal surface o f the abut-
ment on the left side that it would be ineffective.
In the patient's mouth, the occlusal plane would again
be in a horizontal position, and the dislodging force or
sticky food could act in the direction indicated by the Fig. 7. Cross-section position of retentive clasp arms on facial
PPD illustrated in Figure 8. During function, the dis- surfaces of abutments and reciprocal clasp arms on lingual
lodging force could cause the RPD to rotate out o f place, surfaces. Same cast illustrated in Figures 5 and 6.
starting with the clasp on the right abutment, because
there would be no real undercut on that abutment to Clinically, the situation should be resolved by chang-
resist displacement. This condition is frequently identi- ing the facial contour o f the tooth on the right side to
fied as a problem for many RPD wearers. In this in- create an undercut necessary to facilitate proper posi-
stance, the error was the determination for the PI to be tioning o f the clasp arms and the correct functioning o f
based solely on the retention factor, which, although the prosthesis. The surface could be changed by making
important, should not be considered in an isolated man- a surveyed crown; reshaping the enamel, provided it is
ner because the guiding planes must also be considered. thick enough; or placing a suitable restoration.

OCTOBER 1997 415

THE JOURNAL OF PROSTHETIC DENTISTRY
Pi Pi Pi [Pi
/ /
Fig. 8. When RPD illustrated in Figure 7 is acted on by dis-
lodging force, PPD pull illustrated will be perpendicular to
original position of occlusal plane not in direction of PI; there-
fore, there will be no retentive effect by clasp on right side
and partial will be easily rolled off abutments. RPD will loosen
with every masticatory stroke.
Pi / Pi Pi Pi
/
Fig. 9. Different cast than in Figures 5 through 8 with facial
surfaces same as those abutments and different inclinations
of lingual surfaces.
Figure 9 depicts another situation in which the initial
analysis o f the cast in the zero inclination position had
undercuts on the facial surfaces o f the abutments that
were similar to the cast in Figure 5. However, the lin-
gual walls did not have the desired relation to the oc-
clusal plane. If this cast were tilted to the right side (Fig.
416
BEZZON, MATTOS, AND RIBERO
~
Pi
Fig. 10. Inclination of cast holder for distribution of undercut
surfaces of the abutments on cast shown in Figure 9 and de-
tection of guide planes on lingual surfaces of right and left
abutments (arrows).
Fig. 11. Drawing of cast shown in Figure 10 shows position of
cross-sections of retentive (facial surface) and reciprocal (lin-
gual surface) clasp arms.
10) to parallel the guiding planes with the PI, these guid-
ing planes would direct the movement o f insertion and
removal o f the prosthesis more favorably. The positions
o f the retentive and reciprocating clasp arms are shown
in Figure 11. Thus, if dislodgment occurs along the PPD
during function (Fig. 12), the lingual guide plane on
VOLUME 78 NUMBER4
BEZZON, MATTOS, AND RIBERO
the right side, aided by the one on the left side, should
bind against the abutment to resist the dislodgment o f
the prosthesis from the support system if the direction
o f the dislodgment is perpendicular to the occlusal plane.
This should provide the stability necessary for efficient
function.
Obviously, the inclined PI described for the theoreti-
cal case in question would still depend on the analysis o f
esthetic factors such as the occlusal positioning o f the
retention clasp on the right side and on the detection o f
possible anatomic interferences with the correct place-
ment o f the prosthesis. In any situation, it is necessary
to understand that the distribution o f the degree o f re-
tention is not the only definitive condition for the deter-
mination o f the PI.
DISCUSSION
Despite the significant evolution o f materials and pro-
cedures for oral rehabilitation, cobalt-chromium alloys
continue to be the alloy o f choice for RPDs. The option
to restore with an RPD permits the resolution o f com-
plex clinical problems, including extensive modification
spaces, distal extensions, and so forth, and to do so in a
relatively rapid manner and at an operational cost sub-
stantially lower than that o f other treatment modalities.
However, failures are observed with a number o f pa-
tients who are dissatisfied with this type o f dental pros-
thesis.
A critical analysis has revealed that dissatisfaction could
be avoided in many instances if the prostheses were made
in such a way as to satisfy the basic requirement o f mini-
mal dislodgment during mastication or speech, with dis-
satisfaction about esthetic appearance being relegated
to a second plane.
Many RPDs are made without essential elements for
correct functioning, with the excuse o f producing a bet-
ter esthetic appearance. Often these prostheses are es-
thetic but lack stability. Furthermore, unstable prosthe-
ses may significantly impair the prognosis o f treatment
because o f the irritation they provoke in the support
system.
The fabrication o f an RPD as a viable treatment mo-
dality for oral rehabilitation must be based on master-
ing the use o f the dental surveyor, starting with the un-
derstanding o f the aspects involved in the dynamics o f
insertion and withdrawal o f the prosthesis. A correct
analysis o f the factors that influence the PI prevents the
occurrence o f two frequent errors in the construction o f
these prostheses: (1) the indiscriminate use o f the PI with
zero inclination, and (2) excessive inclinations o f the cast
on the assumption that undercut surfaces can be "cre-
ated" by tilting the cast.
As a general rule, the PI with zero inclination should
be the starting point for the surveying process. This path,
which coincides with or slightly deviates from the PPD,
may be ideal when it provides a favorable approach to
OCTOBER 1997
THE JOURNAL OF PROSTHETIC DENTISTRY
Pi IPi Pi Pi
/
Fig. 12. When prosthesis illustrated in Figure 11 undergoes
action of PPD in direction perpendicular to occlusal plane,
guide planes that guide seating of RPD along PI prevent its
dislodgment during function by providing necessary retention
and stability.
the four factors that influence the PI. The PI inclined in
relation to the occlusal plane must necessarily be deter-
mined as a function o f guiding planes that will impose
such inclination on the prosthesis, thus reducing the
PPD.
When the ideal PI is determined for a particular cast,
the rational use o f the surveyor emphasizes the pecu-
liarities o f the contours o f the abutments and o f the re-
maining support regions, suggesting the necessary al-
terations to be made in the contours o f the abutments
for the fabrication o f the prosthesis.
In sequence, fully mastering the activities o f survey-
ing and designing the framework, as well as the plan-
ning and execution o f the alterations in the support sys-
tem, results in a rapid and easy, but also sophisticated,
construction o f RPDs. This will result in malting estheti-
cally pleasing and stable RPDs that will significantly
contribute to the health o f the stomatognathic system.
SUMMARY
1. A PI perpendicular to the occlusal plane (path with
zero inclination) should be the starting point for the
analyzing process.
2. A PI with zero inclination coincides with a PPD.
3. The ideal PI should provide a favorable approach
to the four influencing factors o f the PI.
4. A PI inclined in relation to the occlusal plane must be
directed toward guiding planes that will reduce the PPD.
417
THE JOURNAL OF PROSTHETIC DENTISTRY BEZZON, MATTOS, AND RIBERO

REFERENCES 9. Stern WJ. Guiding planes in clasp reciprocations and retention. J Prosthet
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Williams & Wilkins; 1981. p. 103-17. 10. Applegate OC. Use of the paralleling surveyor in modern partial denture
2. Weinberg LA. Atlas of removable partial denture prosthodontics. St Louis:
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CV Mosby; 1969. p. 81-4.
3. Lavere AM, Freda AL. A simplified procedure for survey and design of
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partial dentures. J Prosthet Dent 1974;32:103-6.
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5. Applegate OC. Essentials of removable partial denture prosthesis. Phila-
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delphia: WB Saunders; 1954. p. 17-35.
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Factors influencing perceived treatment need and the

dental attendance patterns o f older adults
Tickle M, Worthington HV. Br DentJ 1997,'182:96-100.

Purpose. As more older individuals maintain their dentition longer, the maintenance of these
dentitions will make up a larger part of dental practice in the future. The aim of this study was to
identify the variables that influence perceived treatment needs of these older individuals and pre-
dictive variables for reported dental attendance.
Subjects and Materials. A cross-sectional study that used a self-reporting, posted questionnaire
was used to sample two cohorts o f older individuals living in two economically different electoral
wards (one deprived and one affluent) of Liverpool, England. A random sample of 250 individuals
aged 60 to 65 years were drawn from each electoral ward and used for the posted sample question-
naire; 500 questionnaires were distributed. The instrument used was a Subjective Oral Health
Status Indicators (SOHSI). This instrument measured the impact of oral conditions in three broad
areas: (A) impaired function; (B) experiential effects of oral conditions, and (C) social and psycho-
logic effects of oral conditions. In addition, individuals were asked when they last saw a dental
practitioner as well as "Do you think that you need dental treatment now?" Data were collected
and statistically analyzed with a two-tailed test of significance.
Results. O f the 500 questionnaires mailed 342 were returned (68.4%). There was a highly signifi-
cant correlation between living in a deprived area and reported poor dental health. Recent pain
experiences and concern for oral health and appearance were significant predictors for perceived
treatment need. The main factor that predicted a subjective need for treatment was a reported
history of regular, asymptomatic recall dental visits. These individuals were six times more likely to
have a perceived treatment nccd than a poor dental attendee. The edentulous patients in both
groups were less likely to be regular and asymptomatic attendees and they are less likely to perceive
the need for regular treatment. 22 references. - - R P Renner

418 V O L U M E 78 NUMBER4