Precision and SemiPrecision Attachments Where? When? Why?

George E. Bambara, MS, DMD FACD, FICD

Objectives of the Program

Understanding how attachments preserve hard and soft tissue Selection of the appropriate attachments Understand the uses of attachments Familarization with different attachments Maintenance and hygiene

Properly Designed Clasps Work

?????? Concerns ??????

Uneven distribution of forces Possible orthodontic movement Periodontal compression

Removable Partial Dentures Periodontal Status

RPDs WERE ASSOCIATED WITH Increased periodontal pathology Increased plaque and tarter accumulation Increased gingival inflammation Increased probing depths Increased recession Increased abutment tooth mobility

Zlataric et.al., The Effect of Removable Partial Dentures on Periodontal Health of Abutment and Non-Abutment Teeth. JPeriodontology, 2002, 73: 137-144

Clasps vs. Attachments

CLASPS: Less expensive. 5 to 6 year life. 30% loss of retention. Poor chewing efficiency. 93% caries rate. 50% compliance. ATTACHMENTS: 15 year + life. More expensive. 99% retention. Excellent chewing efficiency. 8% caries rate. 100% compliance.

Rantanen, Wetherall and Smales, Feinberg et.al.

CLASS I LEVER

Class II Lever

CLASS III LEVER

Class III Lever

Indications for Attachments

Aesthetics Redistribution of forces Minimize trauma to soft tissue Control of loading and rotational forces Non parallel abutmentsSegmenting Future salvage efforts- Segmenting Retention

Functional Classifications
Class 1A- Solid, rigid, non-resilient Class 1B- Solid, rigid- lockable Class 2- Vertical resilient Class 3- Hinge resilient Class 4- Vertical and hinge resilient Class 5- Rotational and vertical resilient Class 6- Universal, omni-planer

Patient Dexterity and Attachment Wear

Insertion and removal cause wear Poor dexterity Avoid multiple attachments with complex a complex path of insertion Use lingual guiding arms

What is a Precision Attachment?

An attachment that is fabricated from milled alloys Tolerances are within .01mm

Precision Attachments They are Generally

Intracoronal Rigid = NonResilient

Benefits of Precision Attachments

Consistent quality Controlled wear Less wear Easier repair Standard parts are interchangeable

What is a Semi-Precision Attachment?

An attachment that is fabricated by the direct casting of plastic, wax, metal, or refractory patterns Their method of fabrication subjects them to inconsistencies

Benefits of Semi-Precision Attachments

Less costly Easy fabrication May be cast in alloy

Semi-Precision Attachments They Are Generally

Extracoronal Non-rigid = Resilient

Resilient Attachments
0.1mm 0.4 mm difference in the displacement of the tissue and the denture base, as opposed to the axial intrusion of the abutment teeth Directs forces to the supporting tissues and the abutment teeth

Selection of Attachments
Location Opposing arch Function Retention Available space ( 3-5mm ) Cost

Criteria Selection for Resilient and Non Resilient Attachments

Do not oppose two resilient attachments unless teeth are very weak Opposing distal extensions with strong abutments: upper - non resilient, lower - resilient Lower distal extension vs. Natural dentition - resilient Full denture - non resilient

Coronal Attachments
INTRACORONAL: Placed within the contours of the crown form Needs more tooth reduction Rigid connectors EXTRACORONAL Placed outside the contours of the crown form Needs less tooth reduction Stress redirectors and are considered resilient

Stud Attachments
A ball and socket type of attachment in which one component is attached to an abutment or implant, and the other element is retained in the prosthesis

Advantages Stud Attachments

Low profile Easy hygiene maintenance Enhanced crown/root ratio

Dalla Bona The Ball Attachment

A spherical, resilient, adjustable stud attachment with vertical and rotational movement for retaining partial and complete overdentures

Advantages
Low Profile - limited space Easy path of insertion Adjustable female All adjustments done in prostheses Can be rigid vertical movement only Can be resilient vertical and rotational Easy fabrication Hygienically maintainable

Accessory Attachments
Plunger Screw Type Frictional

Magnetic Attachments
Processing magnet- in denture Intraradicular keeper
All magnetic attachments should be processed chairside in the denture

Magnetic Indications
Overdentures Implant restorations

Magnetic Realities
Provide little lateral stability Used in limited applications Heat curing will weaken magnets Corrosion

Attachment Selection
Overdentures- Ridge evaluation and esthetics Fixed- Ridge evaluation, gingival esthetics Number of implants Anterior-Posterior spread Opposing arch ?? Function Fixed- Rigid, screw retained Overdenture- Load bearing or nonload bearing Retention Available space Cost

Patient Considerations
Parallel attachments for easier path of insertion Less attachments better Patient dexterity Hygiene Stannous Fluoride rinses 3 month recall

Anterior/Posterior Spread
A line from the center of the most anterior implant to a line joining the distal aspects of the two most distal implants Indicates the amount of cantilever that can be reasonably placed Usually, 2.5 times the A/P spread

A/P Spread
Actual Length of Cantilever Depends on: Stress factors Parafunctional Habits Crown heights Implant width Number of implants Opposing teeth or denture

Controlling Stress

Stress=Force/Area
Force

Stress
Area

Torque=
Force x Perpendicular distance from the line of force to the center of rotation

Cuspal Inclination

Cuspal Inclination

Treatment Plan Options

Fixed Removable

Implant Supported

Soft Tissue Supported Implant Retained

Treatment Plan Option 1 Lower Edentulous Fixed 5-6 Implants

Prosthetic Options-Lower 5-6 Implants

Hybrid Denture Fixed Crown and Bridge Cantilever 10-15mm

6 Implants-Fixed Implant Supported

24 23 22 X X

25 26 27 X X

5 Implants- Fixed Implant Supported

B A X X

D E X X

Treatment Plan Option 2 Lower Edentulous Removable 5 Implants

Prosthetic Options- Removable Overdenture-Implant Supported

Gold Bar w/ O Rings Distalized O Rings Cantilever 10-20mm Gold Bar with Hader Clips Distalized ERAS Cantilever 10-20mm

C B A D E A B

C D E

Treatment Plan Option 3 Lower Edentulous Removable 4 Implants

Prosthetic Options- Removable Implant and Tissue Supported

Gold Bar with O Rings Cantilever 5-10mm

Gold Bar with Hader Clips and ERAS Cantilever 5-10mm

b a

c d a

c d

Treatment Plan Option 4 Lower Edentulous Removable 3 Implants

Prosthetic Options- Removable Overdenture-Lower Implant and Tissue Supported

Gold Bar w/ 2- O RingsOverdenture No Cantilevers

3 Implants- Removable Overdenture Implant and Tissue Supported

C B D

Treatment Plan Option 5 Lower Edentulous Removable 2 Implants

Prosthetic Options Removable Overdenture-Lower Tissue Supported

Gold Bar w/ Hader Clip O Ring on each implant ERA attachment on each implant

2 Implants-Removable Tissue Supported

Treatment Plans Upper Edentulous Four Options

Treatment Plan Option 1 Upper Edentulous Fixed 8 Implants

Prosthetic Options Fixed- Upper Implant Supported

Fixed Crown and Bridge Hybrid Denture No Cantilevers Necessary

8 Implants- Fixed Implant Supported

X 7 6 X 4 3

X 10 11 X 13 14

Treatment Plan Option 2 Upper Edentulous Removable 8 Implants

Prosthetic Options- 8 Implants Removable- Upper Implant Supported

Gold Bar w/ O RingsOverdenture Gold Bar w/ 3 Hader Clips Overdenture- No Palate Cantilevers-Optional

8 Implants- Removable Implant Supported

Gold Bar Overdenture Gold Bar Overdenture w/ O Rings w/ Hader Bar / Clips

7 6 4 3

10 11 13 14 4 3 6

10 11 13 14

Palate

No Palate

Treatment Plan Option 3 Upper Edentulous Removable 6 Implants

Prosthetic Options Removable- Upper Implant Supported

Gold Bar w/ 4- O Rings and distal to #s 4 and 13 Gold Bar w/ Hader Clip- ERAS distal on #4 and 13Overdenture-No Palate Cantilever 5-10mm

6 Implants- Removable Implant Supported Gold Bar w/ O Rings 5-10mm Cantilever Gold Bar w/ Hader clips and ERAs 5-10mm Cantilever

7 5 4

10 12 13 4 5

10 12 13

Treatment Plan Option 4 Upper Edentulous Removable 4 Implants

Prosthetic Options Removable- Upper Tissue Supported

Gold Bar w/4 O RingsOverdenture w/ No Palate Gold Bar w/ Hader Clip and 2 distalized ERA attachments w/ Overdenture- No Palate No Cantilever

Arch Form 4 Implants-Tissue Supported

Square Arch Tapered Arch

6 4

11 13 5

11 12

Maximum contact with tissue No contact with Bar Attachments are for retention ONLY

Treatment Planning
Design sensibility and flexibility in the treatment plan Design and implant concepts will vary Plan ahead for success Have a disaster plan In most cases, less attachments are better

What Is an Overdenture

A complete denture that is supported and often retained by the underlying teeth or implants and tissue

Abutment teeth or implants may or may not be connected to the denture via attachments

Studs Load bearing

Bars Magnets

Copings Implants

Overdenture Attachments
Teeth Extraradicular Combinations Posts Non-Load-bearing Intraradicular

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Overdenture Attachments
Radicular:
Extraradicular
Studs, magnets, ERA

Bars:
Bar joints Bar units
Round Ovoid Square Rectangular

Intraradicular
Zaag, Zest, Sterns root anchor

Objectives of the Program

Understand how overdentures preserve hard and soft tissue Maintain proprioception Understand the function of overdenture attachments and simplify attachment selection Increasing crown/root ratios to preserve abutments Hygiene maintenance

Carlson and Persson, Odontologist Revy, Sweeden 1967

Anterior mandible
average bone loss first year after extractions was 4mm

Tallgren, JPD,1972 Bone loss continues for at least 25 years

Dentures vs Overdentures
Natural dentition Chewing 90% Efficiency 59% 79%

Complete dentures Overdentures

Rissin and House, JPD, 1978

Indications for Overdentures

Periodontal disease Few remaining teeth Insufficient crown/root ratios Vertical space Favorable path of insertion Retention

Advantages of Overdentures
Maintenance of bone height around teeth by preserving roots Attenuates resorption patterns of alveolar ridges Gentler to the tissues Increases crown/root ratios Psychological security Enhanced speaking ability Maintains Proprioception

Disadvantages of Overdentures
Esthetic Considerations Bulkiness Root canal therapy Increase space requirements: -interarch -interocclusal Increase costs

Crown / Root Ratios

Attachment Retained Overdentures

All the advantages of Overdentures

PLUS
Superior aesthetics Stability and comfort Mechanical retention Increases proprioception Rigidity or resiliency Support

Increased psychological security and patient acceptance

Overdentures
Attachment Considerations
Load Bearing Solid / Rigid
Transfers stress towards the retained roots or implants and away from the ridge No vertical resiliency, some hinge or rotational resiliency Shares the load of occlusion with the mucosal surface
Magnets, Flexi ball, Dalbo Rotex, Bars

Overdentures
Attachment Considerations
Non- Load Bearing Resilient Transfers stress away from the retained roots or implants and towards the tissue Vertical resiliency Selected frequently
Dalla Bona, Rotherman, Ceka, Uni Anchor, OSO, ORS, ERA, Bars

Overdenture Evaluation
Partial Denture Present
Tooth position Occlusion Mount casts to vertical dimension

No Partial Denture
Mount cast to vertical dimension Diagnostic denture wax up reestablish occlusion Silicone matrix for space evaluation

Direct Placement
Male or female premanufactured attachment is cemented into root Denture is made and inserted Corresponding male or female attachment is inserted in root Attachment is picked up directly in the overdenture with cold cure acrylic

Placed by Dentist

Indirect Placement
Male or female attachment is cemented into root or may need to be cast onto coping Corresponding male or female transfer analog is inserted into root attachment Transfer impression is taken and models are poured with transfer in place Laboratory processes denture with corresponding attachment in place

Placed by Laboratory

Proceedures To Follow
5 mm or more root remaining in bone Stable perio Mount study models evaluate space required Select OD attachment obtain reference manuals Begin denture proceedings Root canal therapy Decoronate roots, extractions, insert temporary denture reline allow time for healing Prep tooth for attachment and cement attachment Insert denture, make adjustments, post placement reline Pick up male attachment in denture

Hader Round

Spark Erosion Andrews

Dolder

Ovoid

Bar Designs
Double Bar Custom Milled Rectangular Square

Branson

Attachments and Bars

Intra Bar Extra Bar Circum Bar

Extra Bar
Attachment placed on the superior aspect of the bar
Increases strength of bar Requires more interarch space

Intra-Bar
Connection between the two components directs the forces of mastication closer to the crest of the ridge Decreases lever arm mechanics on the supporting teeth Bar strength may be compromised

Circum-Bar
Attachment wraps itself around the bar

Allows for rotation around bar

The Milled Bar

Main Advantage Final prosthesis is extremely stable because lateral forces are best managed by an intimately fitting primary and secondary bar This minimizes stress on the attachments

The Bar Overdenture Advantages

Increased stability and retention than an attachment retained overdenture Accomodates a wide variety of implant angulations Bar splints implants together Provides better resistance to lateral forces when in function Pose less of a chance of failure at bone-implant interface

The Bar Overdenture Disadvantages

More costly More technique sensitive