Precision and Semi-

Precision
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
Clasps can be plaque traps

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 abutments-
Segmenting
Future salvage efforts- Segmenting
Retention
Stbiliti
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 non-
load 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
Stress
Area
Force
Torque=

Force x Perpendicular distance
from the line of force to the
center of rotation
Cuspal Inclination
Cuspal Inclination
Treatment Plan
Options
Implant Supported
Soft Tissue Supported
Implant Retained
Fixed Removable
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
22
23
24 25
26
27
6 Implants-Fixed
Implant Supported
X
X X
X
B
A
C
D
E
5 Implants- Fixed
Implant Supported
X
X
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
A
B
C
D
E E
D
C
B
A
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
a
b c
d
d
c b
a
Treatment Plan
Option 4
Lower Edentulous
Removable
3 Implants
Prosthetic Options- Removable
Overdenture-Lower
Implant and Tissue Supported
Gold Bar w/ 2- O Rings-
Overdenture
No Cantilevers

B
C
D
3 Implants- Removable Overdenture
Implant and Tissue Supported
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
B D
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
3
10 7
6
4
11
13
14
X X
X X
Treatment Plan
Option 2
Upper Edentulous
Removable
8 Implants
Prosthetic Options- 8 Implants
Removable- Upper
Implant Supported
Gold Bar w/ O Rings-
Overdenture
Gold Bar w/ 3 Hader Clips
Overdenture- No Palate
Cantilevers-Optional




Gold Bar Overdenture
w/ O Rings
Gold Bar Overdenture
w/ Hader Bar / Clips
3
11
13
3 14
4
6
7
4
6
7
13
14
11
10 10
Palate No Palate
8 Implants- Removable
Implant Supported

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 13-
Overdenture-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
4
5 12
13
10 7
12
5
10 7
13
4
Treatment Plan
Option 4
Upper Edentulous
Removable
4 Implants
Prosthetic Options
Removable- Upper
Tissue Supported
Gold Bar w/4 O Rings-
Overdenture 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
4
6 11
13
12 5
11 6
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
Overdenture Attachments
Studs
Bars
Teeth
Implants
Magnets
Copings
Posts
Combinations
Intraradicular
Extraradicular
?????????????????????????????????
Load bearing
Non-Load-bearing
Overdenture Attachments
Bar joints
Bar units
Round
Ovoid
Square
Rectangular
Radicular:
Extraradicular
Studs, magnets,
ERA
Intraradicular
Zaag, Zest,
Sterns root
anchor





Bars:

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, J PD,1972
Bone loss continues for at least 25 years
Dentures vs Overdentures

Chewing Efficiency
Natural dentition

Complete dentures

Overdentures
90%

59%

79%
Rissin and House, J PD, 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

Increased psychological security
and patient acceptance
Increases proprioception
Rigidity or resiliency
Support
Overdentures
Attachment Considerations



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


Load Bearing
Solid / Rigid
Overdentures
Attachment Considerations


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
Non- Load Bearing
Resilient
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

Bar Designs
Round
Ovoid
Square
Rectangular
Double Bar
Custom Milled
Spark Erosion
Hader
Dolder
Andrews
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