YttieLmqfw, EHWQp aad Anselm Langer, DMDb

Tel Aviv University, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel
Aviv, Israel, and Hebrew University-Hadaaaah School of Dental Medicine, Jerusalem, Israel

De~&te recent devaIameats in dental implp&ology, the conservative approach to

roat prsservatioa is still valid. In view of increased root caries rate in the elderly
arid Eax oral hygiene habits of most overdenture wearers, placing protective
copings on root abutments, when economically feasible, is the preferred method of
treatment. Retention of overdentures is increased by including stud attachments in
the abutments. Incorporation of cast metal frameworks is recommended to prevent
base fractures. (J PROSTEET DENT 1991;66:784-9.)

USING ROOTS AS ABUTMENTS

T he principle in reconstructive prosthodontics
should always be to preserve natural teeth or their roots as
long as possible.
Despite recent developments in the field of dental
implantology, the conservative approach to root preserva-
tion in both jaws is still valid.
The inferior functional status of complete dentures is the
result of their dependence on a mucoperiosteal foundation.
The overdenture treatment derives supplementary sup-
port and retention from roots retained under the base af-
ter the terminal teeth have been intentionally reduced to
the gingival level. Using roots as abutments enhances den-
ture performance.
Overdentures should be considered a preferred alterna-
tive to complete dentures (Figs. 1 through 3), especially in
patients with insufficient alveolar bone support.‘, 2 Experi-
enced prosthodontists are wary of radical tooth extraction
in the mandible.
By contrast, there is less hesitancy in extracting all max-
illary terminal teeth and roots. Considering present knowl-
edge, this radical approach should be revised, even when
the conditions for a satisfactory conventional complete
denture are favorable (Figs. 4 through 6).
Overlaid roots not only transmit more detailed informa-
tion through the sensory nuclei to the motor centers and
muscles,3, 4 but also increase chewing power during
mastication.5T6 Overdentures also have a longer life ex-
pectancy since root presence renders the foundation less
k;usceptible to time- and stress-related resorption.
Instructor, Section of Oral Rehabilitation, Tel Aviv University,
The Maurice and Gabriela Goldschleger School of Dental Med-
ic.:ine.
’l-‘rofessor Emeritus, Department of Oral Rehabilitation, Hebrew
University-Hadassah School of Dental Medicine.
i 01 l/25937
Epidemiologic and clinical aspects
Modern endodontics and periodontics make it possible
to preserve the roots of teeth destroyed by caries or com-
promised by periodontal disease. Treating teeth endodon-
tically to serve as overdenture abutments by cutting them
down to root level, followed by obturation with silver
amalgam, glass ionomer, or composite resin, is now com-
mon practice.
In routine overdenture treatment, roots are rounded,
contoured, smoothed, and polished to prevent debris and
plaque accumulation and left bare underneath the denture
base.
Fixed denture bases preclude self-cleansing of roots and
their gingival tissues. In the absence of painstaking oral
hygiene, the resultant accumulation of food and plaque se-
verely threatens abutment health through exposure to car-
ies and periodontal pathosis.7-g Ettinger et al.1° found a
progressive increase in caries rate of up to 20.6% in bare
root abutments over a &year period. In a 2-year longitudi-
nal study, Toolson and SmithI’ found that 34.8% of the
unprotected roots were affected by caries after a year, and
a further 19% a year later.
In 254 overdenture patients recalled at 6-month inter-
vals for evaluation and maintenance treatment, Ettinger12
found that a strict recall regimen cut down the rate of
abutment loss to only 4.2% over a period of 12 years. Al-
most all the roots were bare (97%). Root loss was equally
attributable to periodontal disease and caries.
These clinical findings suggest that neglect of oral
hygiene and lack of maintenance treatments in overden-
ture patients owing to lax recall regimens, are the main
reasons for abutment failure.
Most overdenture patients are advanced in age. Xerosto-
mia, often affecting postmenopausal women and geriatric
patients, contributes to inadequate self-cleansing of root
surfaces and consequently to increased caries incidence.13
ROOT-RETAINED OVERDENTURES: PART I

F ig. 1. Four roots fitted with dowel coping-borne Rotherman attachments used as over-
denture abutments in mandible.
F ig. 2. Corresponding receptacle C-ring anchors are incorporated in denture base.
Chrome-cobalt framework is reinforced with solid bar lingual to abutments.
F ig. 3. W ith denture in place, attachment components interlock into retentive units,
mechanically linking superstructure to abutments.

In people 50 years of age and over, Massler found that the
increased rate of root caries was attributable to changes in
bacterial oral flora and the greater frequency of cariogenic
odontomyces viscosus.l4 In geriatric patients, Nyvad and
Fejerskov15 found that caries affected all root surfaces,
predominantly (75 % ) on buccal surfaces.
Depending on their caries resistance and ability to with-
stand occlusal loads, abutments are left bare, covered with
protective copings, or fitted with stud attachments (Fig. 7).
For treating elderly patients and individuals with a history
of high caries incidence, and in teeth where carious lesions
or other defects preclude attaining smooth and highly pol-
ished root surfaces, protective abutment coverage with
copings is recommended. Cast gold copings, or those of
other compatible metals, can be flat, dome-shaped, or con-
ical. They provide additional root support to the denture
base,and if they protrude 2 to 3 m m above the gingival line,
also enhance its positional fixation. However, their effect
on denture retention is marginal.
To increase retention, the option of incorporating preci-
sion attachments into selected root copings should be con-
sidered when economic and clinical considerations per-
mit.16 Because additional strain is thereby imposed on
root-coping assemblies, intraradicular dowel anchorage is
essential to prevent them from becoming dislodged.
Resilient versus rigid precision
attachments
A combination of periodontal root support with an oth-
erwise resilient mucoperiosteal environment characterizes
the overdenture foundation.
In oral situations, continual multidirectional and oblique
forces of varying intensity and frequency act between the
denture base and the abutments. Resilient attachments
with built-in stress-breaking action are specifically de-
signed to provide the appropriate compensatory coupling.
However, whether they are safety valves protecting the
abutments from damaging occlusal forces or anchors for
unretentive restorations remains to be determined, al-
though it is conceivable that they serve a dual purpose.

THE JOURNAL OF PROSTHETIC DENTISTRY 785

 LANCER AND LANCER

Fig. 4. Maxillary canine roots fitted with dowel coping-borne Micro-Fix attachments.
Fig. 5. Labial flanges excised apical to copings and base reinforced with cast chrome-co-
balt framework. Corresponding matrices housing elastic steel rings are embedded in base.
Fig. 6. Exposed labial regions of abutments contribute to more healthy, hygienic
environment.
Fig. 7. Firm, strategically positioned mandibular roots fitted with attachments in elderly
patient with xerostomia. Rests were covered with protective copings in view of high risk
of caries. Keeping copings as separate units facilitates self-cleansing and easy access for
brushing.

Alternatively, rigid or cylinder-type attachments may be
used in overdent.ure fabrication. In precision attachments
linking removable restorations to the rest of the dentition,
initial rigidity inevitably decreases in time with metal wear
and fatigue. Rigid attachments on firm roots, strongly an-
chored into the bone, become loose and ineffective. On the
other hand, mobile or less stress-resistant abutment. roots
may be lost before attachment rigidity starts to slacken.
In view of the present state of knowledge and the lack of
tangible criteria, stud attachments designed, a priori, as
resilient connectors seem to have a longer useful lifespan
and a broader safety margin in overdenture fabrication
than rigid ones.
Stud attachments
Stud attachments (resilient “snap fasteners”) are the
most popular, mainly in Europe, where many diverse types
are manufactured. They consist of two components fitting
together, the at,tachment incorporated in the coping (Fig.
1) and the receptacle embedded in the denture base (Fig.
2). W ith the denture in position, the components interlock
to form a retentive unit, mechanically attaching the super-
structure to the abutments (Fig. 3). Arbree and Galowic17
reported that the attachments were adequately retentive,
easy to keep clean, and displayed stress-breaking proper-
ties. Stewart and Edwardsls tested five commercially man-
ufactured stud-type attachments with similar multidirec-
tional stress-breaking properties. They simulated the forces
acting on them by testing with 44,000 locking-unlocking
cycles of the receptacle and attachment components,
equivalent, in their view, to approximately 40 years of use.
They concluded that each type was sufficiently durable to
withstand these forces and that forces of 10 to 20 newtons
exerted during separation of the components do not inflict
damage on the periodontium.
Clinical aspects of stud attachments
The stud-type attachment is selected in accordance with
the available vertical interarch space and the required ver-
tical, rotational, or multidirectional resilience.
Many types of prefabricated stud attachments suitable
for use in overdenture construction are available. It is good
ROOT-RETAINED OVERDENTURES: PART I

Fig. 8. Accumulation of food debris and plaque in space underneath denture base led to
gingival inflammation.
Fig. 9. Multiple attachments are sufficient to retain dentures constructed without labial
border seal.
Fig. 10. Receptacle components imbedded in reinforced denture base.
Fig. 11. Esthetic effect of eliminating bulging flanges is particularly favorable in people
with thin lips.

practice to choose only a few for routine use to become
thoroughly familiar with their properties, action, and the
clinical and laboratory procedures involved. MensoP
pointed out that there is no need for highly sophisticated
and expensive attachments and that the necessity for sim-
plification in selecting and using attachments for overden-
ture fixation cannot be overemphasized.
Application of the Rotherman and Micro-Fix (Cendres
and Metaux SA, Biel-Bienne, Switzerland) stud attach-
ments in these examples reflects the authors’ personal
preference based on clinical experience. The mechanical
snap effect between the coping-borne studs (Figs. 1 and 4)
and the overlaying denture is provided by the receptacle
counterparts: a highly elastic circumferential gold C-ring in
the Rotherman attachment (Fig. 2) and a plastic matrix
housing a steel ring (Fig. 5) in the Micro-Fix anchor.
These particular attachments with built-in multidirec-
tional stress-breaking action are simple in design, easy to
maintain, and durable. The stud attachments are wear-re-
sistant, but metal fatigue and breaking of the elastic
element- can occur. They can be readily reactivated or re-
placed ir: the base. It is advisable to stock spare receptacle
c:inpon:ms for emergency situations.
In spite of their stress-breaking action, stud attachments
must be applied selectively to the roots after their capacity
for bearing additional loads has been determined during
the preparatory stages of treatment.
Copings preferably should be applied as separate units
to facilitate self-cleansing and convenient access for me-
ticulous brushing around the entire marginal periphery
(Fig. 7). Although splinting the abutments by soldering the
copings together results in more favorable force distribu-
tion, it almost inevitably leads to gingival irritation and in-
flammation, becausebridging the proximal interroot spaces
renders them inaccessible to proper maintenance.
Hygienic and esthetic advantages of stud
retention
In keeping with the principles of complete denture con-
struction, maximal extension of the maxillary and man-
dibular overdenture bases is essential. Accordingly, vesti-
bular overdenture flanges should extend into the mucosal
fold along the entire denture border. However, during
placement the overdenture flanges may interfere with the
mucosal bulge surrounding retained roots and may need to
be relieved from within in order to pass over the bulbous
787
 LANGER AND LANGER

Fig. 12. Retained roots uniformly distributed along maxillary ridge in patient with gag
reflex.
Fig. 13. Roots used as overdenture abutments.
Fig. 14. Size of base stabilized by attachments was significantly reduced to forestall gag
reflex.
Fig. 15. Fracture in acrylic resin base is caused by fulcrum effect of attachment copings
and excision of vestibular flanges.

obstruction and prevent injury. In turn, this creates an
empty space underneath the base, which facilitates accu-
mulation of food debris and plaque and is conducive to
gingival irritation and inflammation around the abutments
(Fig. 8).
Kotwal’” pointed out that if extraction of roots and the
subsequent surgical correction are not carried out, labial
flanges must be removed, thereby compromising the bor-
der seal. However: with the use of stud attachments to
provide supplementary mechanical anchorage for den-
tures, it is possible to reduce the interfering vestibular
bnges apical to the coping, thereby exposing the bulge and
-resting a more hygienic environment (Figs. 4 through 6).
Where multiple anterior abutments are present the
e~rdenture can be made without a labial flange (Figs. 9
! 1xrough 11). Under normal conditions, adhesion and cohe-
.,!)‘;1 of a properly formed base, reinforced by stud attach-
scents, ensure good denture retention, even without a per-
I’c,ct labial border seal. Preventing protruding subnasal
l)~minence by eliminating bulging labial flanges is advan-
-i;geous in slender women with thin lips.
Stud attachments may be used in patients who cannot
tolerate palate coverage with the denture base. Provided
that abutments are uniformly distributed along the max-
illary alevolar ridge, extension of the base may be reduced
if necessaryto reduce the gag reflex (Fig. 12). Coping-borne
stud attachments fitted onto favorably distributed roots
produce sufficient mechanical retention (Figs. 13 and 14).
Base fracture prevention
As a result of ridge resorption, abutments may act as
fulcrum points allowing the denture to rock on the resilient
mucoperiosteal foundation. Ensuing fatigue of the base
material may give rise to base fracture under load (Fig. 15).
Cutting away labial flange sections overlying copings or
stud attachments renders the base even more prone to
fracture at these fulcrum points. A sturdy, stress-resistant
cast metal framework within the base is recommended as
a routine procedure.
Experience with overdentures overlying abutment cop-
ings without metal framework reinforcements has been
disappointing.20 Of 18 overdentures made by prosthodon-
ROOT-RETAINED OVERDENTURES: PART I
tists in a geriatric clinic, nine of 12 mandibular fractured
within 4 months to 2 years and three of six maxillary over-
dentures fractured within 11 months to 4 years. Fractures
in mandibular dentures occurred whether they occluded
with natural or artificial teeth. The three fractured maxil-
lary overdentures were all opposed by natural teeth. W ith-
out exception, the fractures occurred across one or more
abutments (Fig. 15). Repair with autopolymerizing acrylic
resin had short-lived success.In four of nine mandibular
dentures, the problem was solved by inserting cast chrome-
cobalt frameworks into the repaired bases. Five of the
mandibular prostheses and all of the maxillary dentures
had to be remade.
Routinely, cast chrome-cobalt frameworks are incorpo-
rated in all new overdentures. These frameworks consist of
a rigid net infrastructure embedded inside denture bases
(Figs. 5 and 12). In the most fracture-prone surfaces lingual
to the abutments, the mandibular frameworks are strength-
ened with a solid, stress-resistant bar (Fig. 2). In a 5-year
follow-up of 25 reinforced overdentures, there was not a
single fracture.
The chair time and laboratory costs involved in repair-
ing failures more than economically justify the use of rein-
forced overdentures, especially if cast copings containing
precision attachments are used.
SUMMARY
Most overdenture patients are advanced in age. In view
of the increased root caries rate in the elderly and the lax
oral hygiene habits in overdenture wearers, the use of pro-
tective copings on root abutments, when economically fea-
sible, is the preferred method of treatment.
The retention of overdentures is increased when preci-
sion attachments are included in the copings. In the
absence of tangible criteria, the attachments are selected
on the basis of clinical experience and personal preference
instead of scientific evidence. Resilient stud attachments
appear to be the most suitable for overdenture retention.
Application of retentive attachments allows partial elim-
ination of the labial flange. This procedure improves
cleanliness in the abutment region and may improve facial
esthetics.
Using cast copings with precision attachments requires
reinforcement of dentures with cast metal frameworks to
prevent base fracture.
THE JOURNAL OF PROSTHETIC DENTISTRY
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Reprint requests to:
DR. YAIR LANGER
10 RAV ASHI ST.
TEL AVN 69 395
ISRAEL
789