REMOVABLE

LOUIS

PROSTHODONTICS

BLATTERFEIN,

ROBERT

Attachment

fixation

Merrill
C. Mensor,
San Mateo, Calif.

M. MORROW,

S. HOWARD

for owrdamtures.

PAYNE,

Section editors

Part I

Jr., D.D.S.

1 he ultimate
objective of prosthodontic
service is to return the patient to as nearly
normal function
as possible. The basic overdenture
concept requires preservation
of
residual soft and hard tissues. Use of attachments
and adherence
to basic principles
of complete denture design can improve both retention andstability
of overdentures.
REVIEW

OF LITERATURE

The concept of attachment

fixation for the overdenture
originated
in Switzerland
around
1898, and Gilmore
popularized
it approximately
60 years ago.* Until publication of the studies by Gerber and Fenner, Gerber, and Miihlemann,
the literature on tooth mobility
and effects of attachments
on tooth viability contained
little
more than empirical
results. In some of the more significant
research on tooth movement, Korber
showed that a tooth becomes distorted under loading and produces
destructive
changes in the periodontium.
Fenner, Gerber, and Miihlemann2
found
almost no tipping of the tooth with rigid or cylindrical
attachments
and four times
more tipping with ball-type attachments.
Preliminary
to clinical research, Gerber
used models to evaluate both systems
under horizontal
loads and eccentric vertical loads. The results with eccentric vertical loads were similar mechanically
to the clinical findings of Fenner and associates.
In further studies, Gerber showed that when two attachments
were close together or
on a mandibular
prosthesis, the distal attachment
had a resiliency potential.
Fulcrum
dislodgment
of the prosthesis is prevented
by bending the mandible
or flexing the
prosthesis itself.
Dolder,4T 5 at the University
of Ziirich,
documented
more than 20 years experience with over 800 patients who successfully wore bar-fixation
dentures. His book on
bar joints and bar units presented
additional
clinical evidence of the success of an
attachment-stabilized
overdenture.
Read

before

*Korber,
April,
1962.

366

K.

the Academy
H.:

Personal

of Denture
Communication,

Prosthetics,

Washington,

University

D. C.

of Freiberg,

Freiherg

Im

Breisgau,

2%: 4

Attachment

fixation

for

overdentures.

Part

367

BASIC PROSTHETIC DESIGN

Use of attachments
introduces another factor in prosthetic design, i.e., need for a
critical attachment-prosthesis
relationship.
The requirements
for each type of attachment differ with the availability
or desirability
of resiliency and the adaptation
of the
denture base over denture-supporting
tissues. A displacement
wash in the final impression minimizes the differential
of displaceability
between abutments and denturesupporting
tissues.
Use of attachment
fixation does not overcome failures related to complete dentures; adherence
to basic principles
remains essential. Failure of overdentures
with
attachment
fixation does not result from use of attachments.
The true causes are improper selection of attachments,
failure to develop proper denture base extension and
border seal, and, for mandibular
bases, failure to cover the retromolar
pad. Improper
occlusal records can produce the same damaging
results to the few remaining
teeth
when making an overdenture
as they can when making conventional
removable partial dentures.
Availability
of proprioceptive
elements in an attachment-retained
overdenture
permits the use of gnathologic
procedures.
In some instances, this approach makes it
possible to use anterior
teeth along with relevant instrumentation
to dischrde the
posterior teeth.

MANAGEMENT

OF ABUTMENTS

Except for the telescope crown overdenture,

the teeth are treated endodontically
to permit maximum
crown reduction
and improved
crown-root
ratios. Nonattachment overdenture
abutments are usually 3 to 8 mm. high depending
upon root length
and form, bone support, and presence of multiple abutments.
In planning
an attachment, the crown is reduced to the level of the residual ridge to improve the crownroot ratio and, thereby, allow space for both attachment
and overlying tooth.
Periodontal
therapy should be completed
prior to final preparation
of the teeth.
Surgical intervention
in advance of preparation
of copings increases the mechanical
advantage of the improved crown-root
ratio and reduces the soft-hard tissue displaceability differential.
Excess soft tissue can be surgically removed or repositioned
over
the residual ridge and bone defects filled with a matrix of osseous coagulum
to improve stabilization.
The need for this procedure
can be established by digital examination of the mucosa for displaceability,
periodontal
probing for pocket depth, and
radiographic
study for cratering or angular defects.

TOOTH PREPARATION
Tooth preparation
varies with the type of retention
and support. If no attachments are planned,
the teeth can be minimally
restored with an occlusal amalgam or
a composite resin. The teeth and restorations are finished and polished;
they may be
prepared
later to receive a telescope crown or coping. It is essential to parallel the
preparations
and make a definite finish line at the gingiva when using telescope
crowns. Because of its length and parallelism,
the telescope crown gives more retention for the overdenture
than the polished clinical crown. Selection of a telescope
crown or a coping depends upon the mechanical
factors, caries index, oral hygiene,
and ability of the patient to pay for this treatment
plan.

368

J. Prosthet.
Dent.
April,
1977

Mensor

Fig. 1. Lack of bulk at attachment/dowel

coping
interphase
can cause fracture
or opening
of
the coping
(right).
A proper
inlay seat helps position
the coping,
prevents
rotation,
and proA. A.: Retentions
Zylinder,
Retentions
Puffer,
Biel.
vides necessary
bulk (left).
(F rom Gerber,
Switzerland,
1964, Cendres
& Metaux,
S.A.)

Tooth preparation
for a dowel coping to carry an attachment
requires more than
reshaping
of the root to the alveolar crest. The preparation
must provide both retention
and seal for the coping by using a parallel
chamfer preparation.
A tentshaped preparation
(two thirds to the facial and one third to the lingual side) prevents rotation
of the coping (Fig. 1) . Additional
orientation
of the coping is accomplished by developing
an inlay seat that also provides additional
bulk to join the
coping with the dowel and attachment.
The length of the dowel varies with the type
used. Most dowels should be no less than 8 mm. below the coping, with the exception of parallel-wall
dowels which can be as short as 4 mm. when they support an attachment-retained
overdenture.
IMPRESSION

TECHNIQUE

Impression
methods and materials vary according
to personal preference. Rubber
and silicone elastic materials or individual
modeling
compound
impressions
permit
the use of silver-plated
or artificial stone dies. However, hydrocolloid
impressions provide only artificial
stone dies. Impressions
of dowel preparations
can be complicated.
for lack of parallelism
can result in tearing or distortion
upon separation.
Several
impressions
should be made with the dowels in place for transfer. Then the dowel
copings are fabricated,
and these castings are related with a second master impression. An alternate
method requires individual
or full impressions
of preparations.
joining dowels to copings with resin, transferring
and soldering dowels to copings, and
preparing
casts and dowel copings for subsequent positioning
of the attachment
and
fabrication
of the overdenture.

yw&,r 4

Attachment

fixation

for overdentures.

Part

369

LABORATORY PROCEDURES
The coping is waxed to an occlusal thickness of at least 1 mm. The coping should
have a marginal
bulge to protect the gingival tissues. The occlusal surface is modified
to accept the attachment,
which is soldered to the coping after casting and rough
finishing.
Orientation
of most attachments
is established
with a parallelometer.
The Zest
anchor* and Gintat and Rothermann
* attachments do not require precise parallelism.
Other exceptions are plastic pattern types of attachments,
such as the QuinlivanS
Snapper and the Hader bar, which are incorporated
directly in the wax-up. Generally, attachment-coping
orientation
is determined
by the position of the denture
tooth and the availability
of space.

DOWEL SELECTION
Customized
cast dowels. Waxed dowels, which require bulk for adaptation,
usually are too short to give adequate retention.
Close tolerance and difficulties in controlling
expansion
of alloys are important
considerations
when waxing both dowel
and coping and when casting them as a unit. The discrepancies
are similar when an
inlay and a crown are made in the same casting. If expansion for the coping is adequate, the dowel is oversized and the coping cannot seat. The oversized dowel can
fracture
the root during
try-in or cementation
because of the wedge effect of the
dowel and the hydraulic
pressure of the cement. This problem
can be minimized
by
preparing
a cement release groove along the long axis of the dowel. An undersized
dowel permits the coping to seat properly;
however, the dowel retention
is compromised.
The diameter
of a cast dowel must be larger than that of a prefabricated
metal
dowel for equivalent
strength. Cast dowels usually are shorter and more tapered.
When fabricated
to a length of less than 8 mm., they do not retain attachment
bearing copings. When the attachment
functions, the coping separates from the tooth.
Prefabricated
resin patterns.
Prefabricated
dowel patterns have a matched set
of burs for preparing
the dowel space. Plastic dowel patterns minimize
technical
problems associated with customized
dowel copings because of differences in expansion of the wax pattern and the dowel and need for only one casting. The cross-sectional strength of a pattern dowel is considerably
less than that of a prefabricated,
high-fusing
alloy dowel of the same size. Cast dowels are also subject to porosity and
resultant fracture. Of the many dowel patterns available, those requiring
impression
pins with copper band impressions give the best results.
A promising
new system is the cylindrical
tapered dowel system.* It consists of a
series of color-coded
cylindrical
tapered burs and a matched set of burnable
dowels,
impression
dowels, and stainless steel/precious
metal dowels. This system satisfies the
mechanical
requirements
for a retention
dowel system using precision-fitted
resin
and prefabricated
metal dowels.
*APM-Sterngold,
twhaledent
$Quinlivan,
,$Ultratek

San Mateo,
International,
J.:

Personal

Attachments

New

Calif.
York,

Communication,
and Technology,

N. Y.
Buffalo,
Inc.,

N. Y., Oct.,

Concord,

Calif.

1973.

370

J. Prosthet.
Dent.
April,
1977i

Mensor

Fig.

2. Schenker
step
other for large canals.
retention
in the canal.

Fig.

3. V.
tapping.

K.

pivot dowels
come in two configurations,
The step compensates
for root taper, and

screw cap affords

Fig. 4.

the most

V.K.
double
screw (UTTOW)
base for fixation
of superstructures.

can

rigid

be used

mechanical
for

fixed

one for small

parallel

fixation.
removable

walls

canals and the

afford

of the coping
partial

dentures

maximum
and

is self-

and

as a

Prefabricated
metal dowels. Prefabricated
metal dowels have several advantages.
Their
precise fit and excellent
strength require
only minimal
canal enlargement,
thereby strengthening
rather than weakening
the tooth. As with resin pattern dowels,
matched
sets of burs are included.
The dowels are machined
from high-fusing
wrought
metal that is alloyed especially for the purpose. Most dowels have cement release grooves which reduce the risk of incomplete
seating or root fracture during
cementation.
Parallel-walled
dowels, such as the Schenker step pivot (Fig. 2), effectively resist
dislodgment
for their full length. Dowels of this type, 4 mm. in length, have been
used successfully to retain attachment
bearing copings,
The normal dowel coping preparation
previously
described is ideal for the prefabricated
metal dowel. A champfer
margin and an occlusal inlay seat prevent rotation of the coping and give bulk for the metallurgic
bond between dowel and coping.
Prefabricated
metal dowels can be transferred
in the initial impression
and incorporated in the laboratory
wax-up.
They also can be luted with wax or resin to the
coping during
the try-in and soldered after transfer from the mouth. Dowels are
notched in the coping area to serve as a mechanical
lock during casting or soldering.
Threaded
dowels. Threaded
dowels provide mechanical
fixation in addition
to
cementation.
The threading
of the V.K.* and Kurert
systems affords excellent retention. The V.K. system uses a simple positional
method with bar attachments
when
teeth are markedly
divergent
(Figs. 3 and 4). ;\nother
advantage
of the threaded
APM-Sterngold,
TUnion

Broach

San Mateo,
Company,

Long

Calif.
Island,

N. Y.

Volume 37
Number 4

Attachment

fixation

for

overdentures.

Purt I

371

dowel is that it facilitates cementation

of the coping in the absence of opposing teeth
to serve this purpose. A disadvantage
of threaded dowels is that use of a screw too
large for the cross section of the tooth can cause a fracture during final cementation.
During the past 18 years, I have experienced
failures with various dowel systems
for supporting
attachments.
I have seen no mechanical
failures in the 10 years that
I have used the Schenker step pivot. + Therefore
I recommend
this dowel system for
coping bearing attachments
and a threaded dowel system for copings carrying bars on
divergent
teeth.
COMPARING

BAR TO STUD

FIXATION

Splinting
of two or more teeth with a bar gives stability similar to that obtained
with a rigid stud-type attachment
when the overdenture
is in place. The only difference between the results in these two methods of splinting
is that the stud prosthesis allows independent
movement.
If one tooth is especially weak, the strong
tooth can serve as the fulcrum
point for movement
of the weaker tooth in the
prosthesis.
The bar often splints in more than one plane. Instead of the bar prosthesis moving one tooth, all or none of the teeth moves under a functional
load. A stronger and
a weaker tooth can be splinted with the result that the stronger tooth strengthens the
weaker tooth and the weaker tooth weakens the stronger tooth.
SUMMARY
Scientific evidence of both constructive
and destructive
movements of teeth has
influenced
the design and selection of attachments
for overdentures.
Dowel designs
that would be acceptable
for normal copings must be reconsidered
in view of the
mechanical
effectiveness of parallel-walled
dowels and screws. Coping designs for
attachment
overdentures
must provide retention,
resistance to rotation,
and bulk
when joined with the dowel and attachment,
without
negating
the advantage
of
the reduced crown-root
ratio. Splinting
with a bar-type attachment
( 1) has advantages over splinting
with a stud-type attachment
that outweigh
the disadvantages
of bulk and (2) provides ease of replacement
when one of several remaining
teeth is
excessively mobile.
Part II will consider the various types of bar, stud, and auxiliary attachments
for
the overdenture.
*APM-Sterngold,

San Mateo,

Calif.

References
1.

Gerber,

A. A.:

Retentions

Zylinder

Retentions

Metaux, S. A., pp. 7, 8, 19.

2. Fenner, W., Gerber, A. A., and Miihlemann,
3.
4.

Puffer,

Biel,

Switzerland,

1964,

Cendres

&

H. R.: Tooth Mobility

Changes
During
Treatment With Partial
Denture
Prosthesis,
J. PROSTHET.
DENT. 6: 520-525,
1956.
Mensor,
M. C.:
The Rationale
of Resilient
Hinge-Action
Stressbreakers,
J. PROSTHET.
DENT. 20: 204-215,
1968.
Dolder,
E. J.: The Bar Joint Mandibular
Denture,
J. PROSTHET.
DENT. 11: 689-707,
1961.

372

.I. lrostttet.
Drnt.
April,
1977

Mensor

.5. Dolder,
E. J.: Steg-Prothetik,
6. Robinson,
R. E.: Osseous
100.
SAN

S. ELLSWORTH,
MATEO,
CALIF.

Heidelberg,
Coagulum
for

STE.
94401

DISCUSSION
Henry E. Ebel, D&S.,

No.

1966, Alfred
Hiithig.
Boric Induction,
.J. Periodontal.

40: 50%5111,

1969.

509

MS.*

The continuous
pattern
of alveolar
bone loss, once the teeth have been removed,
has been
and Atwood.:,
.t Bone resorption
well documented
by such researchers
as Olsen,t
Tallgren,z
is so predictable
in most patients
that every
effort
should
be made
to preserve
root and
alveolar
bone. It is a sad state of affairs when so much time is spent constructing
dentures
to
flat edentulous
ridges
when
it is possible
to prevent
such conditions
of minimum
denture
support.
The article
by Dr. Mensor
demonstrates
several ways to preserve
the roots of periodontally
weakened
dentitions.
The reduced
crown-root
ratio
has heen an important
adjunct
for the
treatment
of weakened
or hopeless
dentitions.
Tooth-supported
overdentures
are far superior
in many ways to the conventional
denture
as they enhance
denture
base stability,
provide
positive retention
of alveolar
bone, aid in proprioception
and mastication,
and strongly
strengthen
the psychologic
factors of the patient.
Some overdenture
retention
attachments
have been designed
to function
within
the enlarged
root canal. Others
are designed
with various
retention
studs that are placed in retained
roots above the crest of the ridge. Dr. Mensor
has concentrated
on the latter.
I felt this was a
wise selection,
as there are several inherent
dangers
in trying
to embed such attachments
as the
CEKAt
within
the limited
and weakened
root canal areas.
From
the material
presented,
one can observe
the injured
periodontal
structures
even after
thorough
overdenture
construction.
Protecting
the collar
of the gingival
crevice
from injury
must
be a prime concern
for root preservation.
Inflammation
and proliferation
are frequently
observed
in the periodontal
tissues that approximate
the retained
roots, even though
the root
casting is well contoured
and oral hygiene
is acceptable.
Retained
roots frequently
have minimum
root length in the alveolar
bone. They are on the
ropes, so to speak, and present
a doubtful
prognosis.
I question
the widespread
use of overdenture
stud attachment
devices
because
of the horizontal
and dislodging
stress loads that
would
be imparted
to the roots I)y the overdenture.
A careful
assessment
of the denture
support areas and the number
and quality
of the retained
roots must he undertaken
before subjecting
these weakened
roots to the added loads of mechanical
retention.
I recommend
that the root not he reduced
to the depth of the gum crevice
whenever
poasible. Reduction
of the crown
root to a minimum
of 1 mm. above the gingival
crevice
inflicts
no mechanical
injury
to the periodontal
fibers, preserves
the integrity
of the anatomic
root, and
simplifies
periodontal
care and maintenance.
Of course,
where
esthetics
demand,
further
extension into the gingival
crevice cannot be avoided.
Studies by Lord and Tee15 show promising
results for the treatment
of roots that are used
for the support
of overdentures.
No casting
or attachments
are placed on the reduced
roots.
The endodontically
treated
canals are sealed with amalgam
or composites
and highly
polished.
Patients
are instructed
in good oral hygiene.
Added
protection
is provided
by the daily application
of minimum
amounts
of flouride
jel to the internal
root recesses of the overdenture.
Their
success
rate for this procedure
used in patients
treated
since 1965 has been unusually
high. Reline
procedures
of these all-acrylic
resin overdentures
are simplified,
because no castings or attachments
are embedded
or cemented
to the dentures
or roots.
*Chief

of Dentistry,

tCEKA,

p.v.b.a.,

Fairlane
North

Wales,

Center,
Pa.

Satellite

of Henry

Ford

Hospital,

Dearborn,

Mich.

Volume
Number

37
4

Attachment

fixation

for

overdentures.

Part I

373

One of the most frustrating

and time-consuming
procedures
has been the servicing
of attachments
in the mouth.
Although
seemingly
ideal in principle
and design,
maintenance
and
repairs
may prove
costly.
I strongly
advocate
that simplicity
of design as described
by Lord
and Tee1.s
When a root has been retained
for overdenture
treatment,
a facial-lingual
bony undercut
may exist. Some clinicians
have recommended
resilient
denture
material
in these sites. The use
of this type of retention
system would
seem to minimize
the need for attachment
locking
devices and, thereby,
to simplify
the overdenture
procedure.
Dr. Mensor
mentioned
that he experienced
no failures
with the Schenker
step pivot*
in
IO years. This dowel system appears
to be most promising
and far superior
to those that I have
used in the past, and I shall add it to my armamentarium.
Crack
lines induced
by mechanical
stress will probably
occur when using screw pins or
screw-type
posts in roots. Studies have been reported
on the microscopic
stress lines that result
even when using the small T.M.S.
pins.t
In my hands,
the bar-type
attachments
have been most sucressful.
They are usually
used
to provide
cross-arch
stabilization,
and yet they allow vertical
movement
and hinging
of the
denture
base.
The various
attachment
systems have been organized
in a compendium
by Dr. Mensor
known
as the E. M. Selector.$
It represents
30 points of information
about each attachment
and can be found in Kornfelds
book, Mouth
Rehabilitation.~
Dr. Mensors
studies
and personal
contacts
with
Prieskel,
Gerber,
Dolder,
Steiger,
and
Boitel add support
to his authoritative
references.
Dr. Mensor,
we thank
you for your contributions
to this meeting.
*APM-Sterngold,
San Mateo,
Calif.
twhaledent
International,
New York,

N. Y.

$Bell

Calif.

International

Inc.,

Burlingame,

References
1.
2.

Olsen, E. S.: Vertical

Dimension
of the Face, Dent. Clin. North
Am. 13: 611-622,
1964.
Tallgren,
A.: Changes
in Adult
Face Height
Due to Aging,
Wear and Loss of Teeth and
Prosthetic
Treatment,
Acta Odontol.
Stand.
15: l-122,
1957.
3. Atwood,
D. A.: Some Clinical
Factors
Related
to Rate of Resorption
of Residual
Ridges,
J. PROSTHET.
DENT.
12: 441-450,
1962.
4. Atwood,
D. A.: Reduction
of Residual
Ridges:
A Major
Oral Disease Entity,
J. PROSTHET.
DENT.
26: 266-279,
1971.
5. Lord, J. L., and Teel, S.: The Overdenture:
Patient
Selection,
Use of Copings,
and FollowUp Evaluation,
J. PROSTHET.
DENT.
32: 41-51,
1974.
6. Moffa,
J. P., and Razzano,
M. R.: In Courtade,
G. L., and Timmermans,
J. J., editors:
Pins in Restorative
Dentistry,
St. Louis,
1971, The C. V. Mosby
Company,
pp. 10-11.
7. Kornfeld,
M.: Mouth
Rehabilitation,
St. Louis,
1974, The C. V. Mosby
Company,
pp.
802-808.
FAIRLANE

19401

CENTER
HUBBARD

DEARBORN,

MICH.

DR.

48126