http://dx.doi.org/10.

17159/2519-0105/2019/v74no10a5
The SADJ is licensed under Creative Commons Licence CC-BY-NC-4.0. RESEARCH < 549

Outcomes of mandibular Kennedy

Class I and II prosthetic rehabilitation
- an observational study
SADJ November 2019, Vol. 74 No. 10 p549 - p555

J Chamoko1, S Khan2

SUMMARY ACRONYMS
Loss of teeth may have a negative impact on appear- FPDPs: Fixed Partial Denture Prosthesis
ance, nutrition and function. Removable prostheses RPDPs: Removable Partial Denture Prosthesis
for mandibular distal extension areas have been asso- RPI: I-Bar System
ciated with more negative outcomes than with tooth- SDA: Shortened Dental Arch
bounded saddles.

Aim Keywords
To describe the outcomes of rehabilitation with Ken- Clinical Outcomes, Mandibular distal extension dentures,
nedy Class I and II dentures five years after insertion. Abutment tooth loss, Denture replacement, Repair,
Patient opinion.
Methods
Dental laboratory and patient records were accessed
INTRODUCTION
to identify patients fitted with mandibular distal exten-
sion dentures between January 2011 and June 2017 Tooth loss due to caries, periodontal diseases and
by the Oral Health Centre of the University of the trauma is sometimes unavoidable.¹ The World Health
Western Cape. Information on the prosthesis, oral Organization (WHO) guidelines indicate that the highest
health status and study outcomes was recorded and prevalence of partial edentulism occurs between the
augmented by telephonically interviewing 30 patients, ages 35-44 years2 and that 12.6% of that sector of the
randomly selected from the initial sample. adult population was completely edentulous.2

Results However, according to the South Africa Demographic

Observed outcomes included ‘low frequency of use’ and Health Survey (SADHS), 23% of adults aged be-
and ‘high patient dissatisfaction.’ Most common were: tween 35-44 years were completely edentulous.3 Many
remakes (n=26), abutment tooth extractions (n=12) and South Africans must therefore be partially edentulous.
repairs (n=9). A large proportion (n=105) of the sample The patterns of tooth loss do vary amongst different
received no follow-up treatment. No statistically signifi- populations,4 and various studies have attempted to
cant associations existed between the outcomes and investigate the link between tooth loss and the different
the variables of age, gender, type of opposing dentition, socio-economic factors between communities.5-7
number of recalls and denture base material used.
Whilst not all lost teeth need to be replaced, rehabilitation
Conclusion of tooth loss is related to enhancing functions such as
Most commonly reported oral health problem asso- mastication and speech and aesthetics and may there-
ciated with wearing Kennedy Class I and II dentures fore be important.2
was abutment tooth loss. Remakes and repairs were
frequent outcomes. From the clinician’s point of view, prosthetic rehabili-
tation aims to improve the distribution of occlusal forces
Author affiliations: on the remaining teeth, maintain the stability of the
1. Joanna Chamoko: BChD; MSc (Dent), University of the Western dentition and increase masticatory performance. In con-
Cape, Tygerberg, South Africa.
ORCID Number: 0000-0003-2958-1606
trast, the perception of the patient of prosthetic reha-
2. Saadika Khan: BChD; PDD (Clin Dent); MSc (Dent); PhD (Com bilitation is centered on the improvement of aesthetics
Health), Senior Lecturer/ Principal Dentist, University of the Western and mastication with minimal discomfort and disrup-
Cape, Tygerberg, South Africa.
ORCID Number: 0000-0001- 6017-959X
tion to oral functions.1
Corresponding author: Saadika Khan
Senior Lecturer/ Principal Dentist, University of the Western Cape, Rehabilitation of shortened or posteriorly reduced dental
Tygerberg, South Africa. arches, though, is not always necessary as sufficient
Email: [email protected]
Author contributions: masticatory function can be achieved with 20 teeth,
1. Joanna Chamoko: Principal Researcher and thesis completion having 9-10 posterior occluding pairs of teeth.8 Indeed it
- 70% has shown that patients have scant knowledge of the
2. Saadika Khan: Supervisor of thesis and writing paper - 30%
consequences of missing teeth.9
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RESEARCH

Oral rehabilitation in partial edentulism, however, is not in probing depths.18 Their study does highlight the
just to correct problems such as impaired mastication, positive influence of recall visits on the success of
aesthetics and speech, but also addresses the decline newly placed RPDP’s.18
of patient-assessed quality of life that accompanies
tooth loss. The major determining factor for treatment 3. Patient factors: Ensuring patient satisfaction is as
is the location of the lost tooth or teeth. The literature important as treatment planning in defining success
has shown that partial edentulism is more common in with the use of a prosthesis.1,3 Patients who consider
the mandible than the maxilla. the discomfort of a dental prosthesis to outweigh
the perceived benefits will not wear it, with negative
Younger adults tend to present with Kennedy Class III consequences on success.
and IV partial edentulism. This is attributed to the early
loss of the first molars as these teeth erupt first (and Thus, a dentist considering prosthetic rehabilitation is
therefore become exposed to possible disease factors) wise to ensure he or she addresses all concerns
and to loss of anterior teeth due to the susceptibility of expressed by patients. It has been recorded, though,
children to trauma that affect these teeth.5 that dental practitioners may be limited by the pa-
tients’ poor oral hygiene, chronic illness (like diabetes)
As individuals get older and lose more teeth the adverse social habits (like smoking) and, by the
Kennedy Class III extends into a Class I and Class II. implications of financial cost.17
The Kennedy Class I and II partial edentulism is more
common in the mandible while Classes III and IV being 4. Biomechanical factors: Restoration of Kennedy
more common in the maxilla.5 Class I and II partially edentulous mandibles with
RPDPs has historically posed biomechanical challen-
Removable partial denture prosthesis (RPDPs) place- ges because they derive support from two different
ment is more common with Kennedy Classes I and II tissues.15 A mandibular distal extension denture is
while rehabilitation of Classes III and IV is usually with a supported by the periodontal ligament via the teeth,
fixed partial denture prosthesis (FPDPs) and implant- through the action of the rest seat, and by the
supported prostheses, depending on patient factors mucosal tissues of the residual ridges.
such as preference and finances, and on the condition
of remaining teeth, and supporting tissues.5 Variable degrees of displaceability occur between
these two tissues.11,12,19,20 These will definitely impact
Clinicians are more often faced with challenges in pro- negatively on the comfort of patients and their ability
viding adequate support, retention and stability when to wear these prostheses and eventually on treat-
restoring the mandibular distal extension spaces using ment outcomes.
RPDPs. Individuals may present with severely resorbed
ridges due to disuse, migration and mal-positioning In an effort to counteract these challenges, certain
of posterior teeth, lost inter-arch space due to over- measures in RPDP treatment have been developed
eruption of opposing natural teeth; and teeth that are and applied, with varying degrees of success, including:
unable to serve as abutments due to their poor perio- special impression techniques, alternate RPDP designs
dontal condition or unfavorable position after drifting.1,4-5 such as the mesial rest combined with a proximal
plate and I-bar (RPI) system, shortened dental arch
These sequelae also occur with other classes of partial (SDA), use of precision-attachments and implant-sup-
edentulism. The impact is often magnified when mandi- ported dentures.11,12,19,21-23
bular posterior teeth have been lost early and distal
partial edentulism is of long-standing duration.10 The aim of this study was to assess outcomes of
treatment with mandibular Kennedy Class I and II pros-
The most important factors that influence the success thetic rehabilitation during a period of 5-6 years after
of prosthetic rehabilitation of Kennedy Class I and II insertion, by inspecting the file records of patients and
mandibular arches maybe categorized as follows:1,11-18 through telephonic interviews. The following objectives
were addressed:
1. Mechanical factors: Fractures of the major and
minor connectors, 17 requiring retreatment of the 1. To determine a demographic analysis of the patients
free-end RPDPs. and the types of dentures constructed, and to track the
clinical history of the dentures.
2. Biological factors: The wearing of RPDPs may be
associated with an increased risk of caries and 2. To assess the opinions of patients of their prosthetic
periodontal disease.16 Retention of a RPD is through rehabilitation through telephonic interviews.
tooth and ridge coverage, predisposing the teeth to
plaque accumulation and bacterial overgrowth, pos- METHODS
sibly but not always leading to caries and perio-
dontal disease.16 This was a retrospective observational study involving
qualitative data collection methods including a telepho-
Isidor and Budtz-Jorgensen (1990) recalled patients nic interview section including open-ended questions
biannually for the first two years then annually for to allowing some of the sample of patients to share
three years and recorded high plaque scores and their opinions. From the records of the Oral Health
gingivitis but, remarkably, with no significant changes Centre at the University of the Western Cape (UWC), a
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RESEARCH < 551

convenience sample was selected of patients who had RESULTS

been fitted with posterior mandibular prostheses during
the period January 2011- June 2017. A smaller sample Ethical clearance was obtained from the UWC Bio-
of 30 patients, a subset of this initial sample, was tele- medical Ethics Committee (Registration Number: BM
phonically interviewed using a questionnaire with open- 16/7/25). All participants had at the outset of treat-
and closed-ended questions. Records accessed were: ment signed a consent form meeting the requirements
of the Declaration of Helsinki.24
a). Dental laboratory records: On these records were
clearly documented the personal details of patients, According to the technical laboratory records, 335 lower
the type of the prosthesis, which dental arch, whether RPDPs had been made during the period January 2011
it was an acrylic or cobalt-chrome RPDP and when it to June 2017. Of these, 160 were lower partial acrylic
was delivered to the patient. and 175 were lower partial metal (cobalt-chrome) RPDPs.

b). Patients’ dental records: Data recorded included Access was gained to 269 patient clinical files (66
the patient’s age and contact details, the design of patient records were not found, 19.7%). These recorded
the prosthesis (Hospital instructions are to include a total of 217 mandibular partial dentures, and the
a design within the patient folder), any repairs and occurrence and percentage prevalence of the different
remakes of the prosthesis, the loss of abutment dentures are shown in Table 1. From amongst the total
teeth, and any recorded patient opinions concern- patient records accessed, 152 complete patient records
ing the prosthesis. were found for patients who had been supplied with
either a Kennedy Class I or Class II mandibular RPDP.
c). Telephonic interviews with patients: The informa- Kennedy Class I (n=95) was the most common, whilst
tion obtained from the Hospital records pertaining only 57 Kennedy Class II dentures had been delivered
to the outcomes of the prosthetic rehabilitation was during the study period.
complemented by conducting 15-minute telephonic
interviews with a small sample of patients, a subset of Table 1. Distribution of dentures delivered, according to Kennedy
the initial sample. classification.
Kennedy Class Number Percentage %
These individuals verbally answered 12 questions Class I 95 44
related to the treatment received. Follow-up ques- Class II 57 26
tions were asked where necessary to clarify answers Class III 58 27
to open-ended questions. The interviews were re- Class IV 7 3
corded to ensure an accurate account of the Total 217 100
patients’ responses, which were then entered into
the personal files. From the compiled data the observed outcomes record-
ed were:
Patient participation was voluntary and informed
consent was obtained before administering the a). Recall: At the time of the study, most patients (69%)
questionnaire, following the principles of the Decla- had not returned to the Oral Health Centre for any
ration of Helsinki.24 follow-up treatment.

The following patients were excluded from the sample: b). Remakes: Twenty-six remakes had been required
if they: were fully edentulous; had incomplete dental (17%), usually due to poor fit, to reports of pain and
records, wore prostheses rehabilitating Kennedy Classes discomfort, or mechanical failures and loss of abut-
III and IV, rehabilitation of Kennedy Class I and Class II ment teeth.
using FPDPs, overdentures (ODs) or implant-retained
prostheses and patients with any prostheses fabricated c). Extraction of abutment teeth: Recorded were 12 in-
and fitted in other public or private clinics. stances (8%). The reasons for extractions, whether
due to periodontal disease or caries, were not clear.
Data collection involved the completion of Excel spread-
sheets with the information gleaned from accessed d). Repairs were not commonly required (n=9, 6%), but
records, and from the summaries of the recording of were due to loss of an abutment tooth and subse-
the responses to the questionnaires used for the tele- quent tooth addition, and also to midline fractures
phonic interviews. Data analysis included computation or fractured clasps.
of standard descriptive and comparative statistics.
These outcomes were all considered an indication of
Frequency calculations of demographic details, patient treatment failures. Most remakes or repairs had oc-
records and questionnaire responses were completed curred within the first two years of denture delivery.
and one sample or two sample t-tests of significance Relines and restored abutments could not be analyzed
were calculated to determine the outcome of any asso- as outcomes because of the minimum occurrence.
ciations; the information was grouped to ascertain the
distribution of variables amongst specified intervals and Only one prosthesis of the 152 RPDP Kennedy Class
in order to make meaningful deductions. Data collec- I and Class II sample included in this study had been
tion and analysis were completed using Excel and relined and only one individual had an abutment tooth
SPSS software. restored following denture delivery.
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RESEARCH

a). Age distribution and outcomes Age category and type of failure
14
The most common outcome recorded for this cohort is
12
the number of ‘remakes’ of RPDPs, especially for those
patients in the age category 65-74 and 75 years and 10
above. No remakes were reported for individuals aged
25-34 years (Figure 1). 8

6
It was found that all expected cell frequencies were not
greater than five, resulting in a chi squared test being 4
unsuitable. A Fisher’s Exact Test for association was
2
therefore conducted between age categories and re-
ported failures or study outcomes. Only a rather mode- 0
rate weak negative association was found between age 25-34 35-44 45-54 55-64 65-74 75+

categories and study outcomes ( φ =-0.298; p = 0.119). Age category

Remake Repair Extracted abutment

b). Gender distribution and mandibular distal Figure 1. Graph indicating age distribution and study outcomes.
extension RPDPs
Females constituted the greater proportion (72%) of
individuals who had been rehabilitated with either Age category and type of failure
mandibular Kennedy Class I (72%) or Class II (58%) 16
RPDPs. A moderately weak association was shown
between gender and Kennedy Classification (φ = 0.1403; 14

p = 0.082). 12

More denture failures were recorded for the female 10

participants than their male counterparts. The most

8
common negative outcome in both gender groups
was ‘remakes’ of dentures. 6

4
Figure 2 is an illustration of the distribution of study
outcomes in relation to differing conditions in the 2
opposing maxillary arch and shows that the most
common outcome for patients with mandibular distal 0
Edentulous Partially edentulous Partially edentulous
extension RPDP treatment is ‘remakes’. with RPDP without RPDP

Remake Repair Abutment tooth extraction

However, Fisher’s exact test did not reveal a statistical-
ly significant association and therefore the nature of Figure 2. Frequency distribution of outcomes related to opposing dentition.

the opposing arch did not significantly affect the out-

come of the prosthetic treatment.

14
Type of denture material and outcomes
12
Having the denture remade was the most common
outcome for both types of denture materials used as 10

denture bases as shown in Figure 3. The graph also

8
shows that the majority of denture failures occurred with
those made with cobalt-chrome denture base material. 6

4
In determining whether an association exists between
denture material and Kennedy Classification a chi square 2
test was carried out, for the expected cell frequencies
were greater than five. 0
Acrylic CrCo
Type of denture material
The result showed there was no significant associa-
tion between denture material and Kennedy Classifi- Remake Repair Abutment tooth extraction Total failures
cation (χ2 = 0.0502; p = 0.823). The type of denture Figure 3. Graph indicating the two types of denture materials and
material, therefore, did not significantly influence the study outcomes.
resulting outcome.

From the quantitative analysis the most common ob- abutment tooth. About 27% of the remakes were
servations were that a large majority of the patients prompted by the loss of an abutment tooth. Half of
did not return for follow-up treatment, the prosthesis the repairs were tooth additions after the loss of an
was either remade or repaired or the patient lost an abutment tooth.
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RESEARCH < 553

There was, however, no statistical relationship between patient education, the initial step in management and
any of the outcomes including the loss of abutment which continues throughout the treatment and mainte-
teeth and the other measured variables. Since the nance stages.
remakes or repairs occurred within a short period of
time (all occurred within two years of denture delivery) Communication between the clinician and patients is
they are considered to be treatment failures as is the key to successful treatment outcomes. The patient
loss of abutment teeth. must understand the benefits and limitations of the
treatment so that unattainable expectations are lowered
The combined total number of these failures was 47 and misuse of the prosthesis is prevented.
from amongst the sample of 152 (31%). The remainder
of the cases should not be considered as successes The patient also has a role to play in maintaining the
because when the sample of 30 individuals were oral tissues and the denture prosthesis through consis-
interviewed, their responses made it clear that that was tent hygiene practices.25 The literature has shown that
not always the case. RPDP wearers are prone to tooth loss as a result of
periodontal breakdown and caries and the action of the
After consulting the literature, the following criteria were denture as a Class I lever.11,13-16,19
selected for further investigation through the telephonic
interviews: the frequency and impact of wear, replace- The delivery of the denture does not signify the end
ment and satisfaction with RPDPs. of treatment but the patient is expected to attend
follow-up visits to mitigate, at an early stage, any ad-
Patient comments recorded with regards to the fre- verse effects of wearing the denture.14,16,26-27 The nega-
quency and impact of wear indicated that most of tive influence of RPDPs on oral health status can be
them seldomly wore or did not wear the denture at all. minimized when a system of periodic recalls is imple-
mented, studies showing a low incidence of caries,
The reasons given were ‘discomfort’, ‘painful’, ‘didn’t fit abutment tooth loss and periodontal disease.3,14,16,26-27
properly’ and ‘can’t eat or chew with it.’ Their comments
also centered on the position and poor aesthetics of A significant proportion of the patients did not return
the clasps necessary for retention, yet these were to the treatment centre for monitoring. The outcome of
included according to the design and as per standard loss of abutment teeth in this study could be attributed
Oral Health Centre protocol. to multiple factors: poor oral hygiene practices by the
patient, incorrect diagnosis, inadequate patient educa-
The responses of patients regarding the replacement tion about maintenance, poor selection of treatment
of dentures were hardly answered, and those who options and improper denture design.
responded said ‘they did not go back for another
denture’ or ‘they were on a w aiting list’. Patients showing poor adaptability to previous RPDPs
may have benefited from fixed alternatives instead of
Patients were requested to score their rate of satis- multiple remakes.28 Certain individuals in the study
faction with dentures on a scale of 1 to 10. The low population had their distal extension RPDPs remade
scores (mostly below 4) which 67% of individuals three or four times in the period under observation.
gave confirmed their dissatisfaction with their RPDPs.
The use of the RPI system (n=6) was limited in the
They recounted their experience of a negative impact study sample population and may indeed be regarded
on wearing of RPDP such as ‘nothing improved with as outdated. The treatment choice based on the
their dentures’. The contrary was obviously true for diagnosis and as it related to the problems observed
those minority of patients who reported wearing their was, therefore, poor. Satisfied patients, who scored the
‘denture all the time’ or ‘most of the time’, as they prosthetic treatment as 6 or higher, were pleased
were totally satisfied (with scores of 6 or more) and with how the denture improved their mastication.29
did not require replacement dentures. These individuals However, sixty seven percent of patients reported
reported a positive impact on chewing and functioning. seldomly wearing the denture or not wearing it at all if
discomfort or pain was experienced.
All the RPDP patients wanted their appliances to
ensure an improvement in their aesthetics and function- Some patients were functioning well with a complete
ing, but many were clearly disappointed. They seemed maxillary prosthesis and the remaining anterior mandi-
unaware of the option of returning to the treatment bular teeth. thus, a misdiagnosis of treatment could
center to have these denture problems corrected, have been made as these patients may have been
which could have improved the denture experience better suited for management with SDAs.22
(Many did return but for other reasons such as
scaling and restorations). Carr and Brown (2011) included the use of the altered
cast technique as part of the six phases to providing
DISCUSSION a distal extension denture with the best support.25,27
The technique was not used at all to make the 152
The success of prosthetic rehabilitation is the shared prostheses observed during this study.
responsibility between the clinician and the patient.25
This implies correct diagnosis, correct treatment plan- The outcome of loss of abutment teeth in this study
ning and careful execution of the work together with could be attributed to multiple factors: poor oral hygiene
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RESEARCH

practices by the patient, incorrect diagnosis, inadequate a limited number of patients. Had clinical examina-
patient education about maintenance, poor selection of tions been conducted more precise information may
treatment options and improper denture design. have been gathered. Comparison of outcomes with
patients wearing dentures other than those rehabili-
Status of the prosthesis tating Kennedy Class I and II edentulous spaces would
be instructive.
The study indicates that remakes and repairs are not
only a parameter for measuring the status of the Account was not taken of the duration of time since
prosthesis but also of oral health and patient satisfac- fitting the denture, although it was noted that most
tion, for remakes were prompted by three reasons: repairs and remakes occurred within two years of
complaints about the fit of the denture, lost abutment denture delivery. More detailed investigation into the
teeth and fractures.26 influence of different materials and of the opposing arch
may have been warranted.
Patient opinion

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