David K.

Burns, DM0 Assistant Professor

A Review of Attachments for Removable Partial Denture Design: Part 2. Treatment Planning and Attachment Selection

ohn E, Ward, ODS, MSD Associate Professor Department of Removable Prosthodontics Virginia Commonwealth University School of Dentistry Box 566 MCV Station Richmond, Virginia 23298

Part 2 follows the initial review of attachment partial dentures presented in Part 1 and considers the analysis of specific treatment requirements to provide a rationale for appropriate attachment selection. The tooth/tissue-supported removable partial denture is carefully reviewed and several treatment philosophies for attachment use in this situation are
discussed. Int i Prostbodont 1990;3:169-174.

the definition, classification, P art 1 addressedindications of attachments for functions, and removable partial dentures.' The development of good clinical judgment in using attachments for removahle partiai dentures is not an easy task. The complexity of attachments dictates that a thorough understanding of their selection, treatment planning, and use be a prerequisite to any clinical experience. This paper analyzes a number of different ciinicai situations in which attachments may be used and presents a method of determining an appropriate removable partial denture design. Application of Prosthodontic Principles Although there are few scientific data to aid in attachment selection, there are some prosthodontic principles that should be used. One principle to be followed, whether the prosthesis uses clasps or an attachment, is that forces should be widely distributed to all available tissues. The denture base of tooth/tissue-supported removable partial dentures should be extended to cover all of the residual ridge within the limitation of functional muscle movements. The teeth and denture-supporting area should both be used to provide support, bracing, retention, direct-indirect retention, and stability. If one of these tissues is incapable of providing these functions, other restorations (eg, complete dentures or a restoration using dental implants) should be considered. It is important that the removable partial denture framework can be properly related to the teeth and the denture base to the framework. This principle is satisfied if the entire framework is rigid and the

framework contacis three or more teeth, preferably widely separated and with rest seat preparations. Contact of the framework with only two abutment teeth is inadequate if there is no other way to positively relate the framework to the teeth. If a resilient attachment is used, there must be additional contact between the framework and the abutment teeth other than the attachments themselves, or there must be a way to deactivate the attachment, making the prosthesis rigid and thus allowing evaluation of the relationship between the base and the residual ridge. Treatment Analysis It is most important to select the appropriate attachment for a specific clinical situation. There is an enormous variety of attachments available to the dental profession,- but the average dental practitioner does not need to become proficient in the use of a large number of attachments. Many of the available attachments cannot be used universally and are only suited for a specific clinical situation. Likewise, some involve complex mechanisms, which may result in early failure or an inability to repair them. Therefore, practitioners need to identify a few attachments that can be used in the clinical situations they treat and should develop an expertise in their routine use. Clinical success using attachments requires an awareness of the potential forces a prosthesis can transfer to the teeth and residual ridges, as well as the methods available to reduce or distribute these forces. Analysis begins by classifying the edentulous spaces using a system such as the Kennedy Cias-

3, Number 2, 1990

169

The Inlernational amr\a\ of Frostliodontii

Attachments for Removaliie Partial Denfure, Pari I

a urn s/Ward

\
DETEHM N E SUPPORT FOP T

E R MOVABLE PARTIAL DENTURE

J
TOOTH SUPPORTE

\
TOOTH-TISSUE SUPIK>RT

REMOVABLE PARTIAL D

AU- ABUT^
f^'jnNCEPJCY PLAN L

oss

CK-

^O^TS^IOR

ABUTf^f-i

r AS TOOTH-TJSSUt if^VASLe PARTIAL

TS A %C Stf- 'PORTEO

ZT
OUALITV ANO QUAhTfTY OF SUPPOBT FROM

TEETH AMD TISSUE

/
KENNEDY CLA9S III USE RIQI ATTACHMENTS
SEBA^.TTACHM

+ i
i

ILO SOPHY

iOT:

f^OST mOJO A ^

ATTAO*^NJ KtST f>S!l-IENT

S Af^ NTftACCf^ONAl^
A rTACtt^/JTS AfIE

US

PHILO S O P H r

PHILOSOPHY

1
USE RllO ATTACHMENT

RESIUENI

X77IACCflOr4V.. PU.PAL Tissi

BE CCNSJCG^O S IN

CUL Q.7A,

CfiiMMS flAP
KJST

A T TACHMENT

JSE niGID ATTACHMENT

Size

iip> POS! nON

fliW/W/ft^

JF SPACE

iVieOJAT^ FCfl P

LACS^NT OF A
A 7TACHff^7.
DETEHMIH

PAPJSCliAfl

E ST BILiZINO

UCRUM UNE

/
TART ATTACH UEHT f F J C U LL H M S HOT PERPENChCULAR THE

\
USE niKGE ATTACHMENT IF FULCBUM 13 PEHPEUDICUL TO THE RESIDUAL RIDGES
8IL

TQ

RESIDUAL RIDQE3

ATEfAL HIND

ifESILIE^JT
TO h

T BE R.ACEr> PARALLEL

AT TAO-f^NTS ~ ANtHH

Fig 1

Flow chart for selection ot an attachment.

sification Systertn.' This will iidentify the type, location, anid number of eidentulous spaces (Fig 1). If the partially edentulous arch is a Kenneidy Class I or II situation tooth/tissue-supported), then the stabilizing fulcrijm line is also identified. This imaginary line connects the points of contact between the framework and the most distal abutment tooth on both sides of the arch around which the denture theoretically rotates when occlusal forces are applied on the denture base.'' Attachment Selection Kennedy Class II Partially Edentulous Arch For a totally tooth-supported prosthesis restoring a posterior edentulous space, there is no tissueward movement of the denture and therefore no stabilizing fulcrum line. In such a situation there is little controversy regarding the best treatment-a rigid internal attachment. This attachment not only pro-

vides good retention, but also excellent support and bracing because of its rigid interlocking components. However, if the long-term prognosis for one or both of the posterior abutment teeth is questionable, then a stress-director type of attachment can be used with the anterior abutments in contingency planning for the future loss of ihcse teeth. Kennedy Class I and II Partially Bdentuhus Arch Philosophies of Attachment Use for the Distal Extension Removable Partial Denture. The most difficult type of treatment plan is the one involving the distal extension removable partial denture, which relies on support from both hard and soft tissues. The distal extension removable partial denture must be considered differently and in more detail than the totally tooth-supported situation when selecting attachments. Such a situation is controversial and there are a number of treatment philosophies described in the literature.

Tfie Inlernational lournal of Proslhodoniics

1 7 Vc

. 3, Number 2. 1990

irns/Ward :,.

Attachments for Removable Partial Dentures, Pan 2

Fig 2 Advocates of tine stress-director philosophy believe that when the components of an attachment are rigidly connected, the loading of the distal extension can cause rotation and torquing of the abutment tooth around an axis within the root and potentially cause periodontal damage.

Some practitioners believe that the distal extension removable partial denture should use a nonrigid or stress-directing attachment. The theory is that some basal movement is inevitable during the function of a distal extension base that rests on soft tissue. Advocates of the stress-director philosophy helieve that the loading of the distal extension will result in rotation and torquing of the abutment tooth when the components of an attachment are rigidly connected.^'* fhis may result in damage to the periodontium (Fig 2)."^ Opponents of this philosophy believe that stress-director attachments allow the application of excessive force to the residual ridge, causing premature rsorption of the denture-bearing area. Also, stress-director attachments are thought to be mechanically more complex than rigid attachments and may be subject to increased wear and breakage. Another concept advocates the routine use of the rigid attachment in constructing the distal extension removable partial denture.'" Advocates indicate that the edentulous ridge, with a precisely fitting denture

base, can provide as much support as the ahutment teeth.'^ A removable partial denture with a cast metal hase developed from a mucostatic impression technique is desired. Opponents of this philosophy believe that the edentulous ridge cannot provide as much support for the prosthesis as the abutment teeth, stating that when tissueward loading of the prosthesis occurs, forces are transferred to the rigid attachment and abutment teeth. Tfiis applies potentiaily damaging torquing forces to Ihe ahutment teeth. Another philosophy is known as tbe stable base precision attachment removable partial denture concept'^ or the floating denture base concept." Tbis concept incorporates rigid internal attachments and a cast metal base made from a mucostatic impression of the residual ridge. The male portion of the attachment is connected to the denture base, allowing complete seating within the abutment tooth component only when the prosthesis is loaded with tissueward force. Therefore, at rest, the tissues of the denture-bearing area are in their ana-

", Number 3, (990

The International lournal of Prosthodontics

Atlachmenls for Rer.ioval)ie Parli,.! Dentures, Pari 2

Burns/Ward

Fig 3 At rest, the tissues of the denture-bearing area are in their anatomic torm and the attachment is not completely seated.

Fig 4 In tunction, ttie tissues of the denture-Dearing area are displaced and the vertical stops of the attachment come into contact, aliowing the attachment to resist turther occlusai forces.

tomic form and the attachment is not completely seated (Fig 3), The denture at this stage is totally tissue supported. In function, the tissues of the denture-bearing area are displaced into their functional form and the vertical stops of the attachment contact, allowing the attachment to resist further occlusai forces. Only at this stage is the denture supported by the teeth as well as the edentulous ridge (Fig 4), Proponents of this concept claim that the stimulation of the tissues under such a denture base prevents or retards residual ridge rsorption,' Opponents suggest that the rigid internal attachment allows only vertical movement of the denture base. This does not adequately allow for any rotational movement of the base that might otherwise occur in function. Therefore, the attachment may bind, producing adverse forces on the abutment teeth.
Force Distribution in the Distal Extension Remov-

able Partial Denture. An important factor to consider in selecting a philosophy for treating patients requiring distal extension removable partial dentures with attachments is balance between the forces applied to the residual ridge and abutment teeth. Philosophies vary greatly regarding the amount of support provided to the prosthesis by the individual structures. If the periodontium of the abutment teeth is healthy, providing good support for the teelh, and the residual ridge is composed of adequate, well-rounded, dense bone, then the ridge and teeth should be considered equally capable of providing support and the distribution of support should be equally balanced, 1 his is particularly true in the mandibular arch, where palatal support is not a factor. If the teeth are weak periodontally and the

residual ridge is composed of knife-edged bone of poor quality, then the ridge and teeth are both weak and the distribution of support should still be equally balanced. However, if the teeth are weak and the residual ridge is strong, the ridge should provide more support than the teeth. Conversely, if the leeth are strong and the ridge weak, then greater support should be supplied by the teeth. Other factors also influence attachment selection. These include interarch relationships, existing and proposed occlusal designs, interarch space, space available for attachment selection, treatment prognosis, and prosthesis design. Further consideration of these factors is necessary for a thorough understanding, but they cannot be addressed in this overview presentation. Unfortunately, analysis of the action of attachments used for distal extension removable partial dentures under function is difficult. Regardless of the many theoretical considerations and philosophies that influence the designs, adequate research analyzing the forces developed in all of the different supporting structures is sparse, Kratochvil et al'^ used photoelastic analysis to investigate the forces developed in the bone supporting the abutment teeth by distal extension removable partial dentures using attachment retainers of different designs. They found that the use of stress-director-type attachments resulted in low-intensity forces on abutment teeth, in contrast lo rigid attachments, which had a pronounced tendency to torque the primary abutment tooth distally. They also reported that the splinting together of abutment teeth resulted in better force distribution and reduced tortjuing of the teeth involved. In a similar study, Shohet^" found

Tlie internatiorial lournai of Prosliiodontii

172

Burn/Ward

Attachments for Removable Paitial Dentures, Pan 2

that the greatest torquing force was produced with a rigid attachment and a nonsplinted, single abutment tooth. These studies do support the use o the nonrigid or stress-director attachment with the distal extension removable partial denture, but they are based on analysis of forces within the abutment teeth and only infer indirectly the type of forces being applied to the residual ridge. When stress-director types of attachments are incorporated in removable partial dentures deriving part of their support from the teeth and part from the residual ridge, analysis of the edentulous space and the axis of rotation will aid in determining the type of stress-directing attachment to select. The hinged or directionally oriented attachment, such as the Dalbo attachment (APM-Sterngold, San Mateo, California), should be used, when possible, to provide additional bracing or resistance to lateral movement. This becomes especially necessary when the residual ridge is of poor quality and size, and it has insufficient vertical height to provide adequate resistance to lateral forces from the prosthesis.-^ The hinged attachment is best suited when it can be placed parallel to the edentulous ridge and perpendicular to the stabilizing fulcrum line. If used bilaterally, these attachments must be placed parallel to one another to prevent hinding. Therefore, hinged attachments are best suited for symmetric Kennedy Class I removable partial denture designs. However, they can be used successfully in other situations, such as asymmetric Kennedy Class I and Class II, if parallel placement is maintained. The rotary or multidirectional attachment, such as the Ceka attachment (Preat Corp, San Mateo, California), does not restrict movement in a particular plane. The attachment can be successfully used where ridges are not parallel to one another and where asymmetry exists. The hinged and rotary type of attachments are usually extracoronal. They should be used in conjunction with a properly designed major connector and a ledge or rest within a surveyed crown upon which the removable partial denture framework rests, providing support, bracing, and stability. The attachment itself provides resiliency, retention, and some additional stability.^^^^ This contact between the prosthesis and the teeth in an area other than the attachment will also provide a way to deactivate the attachment, accurately relate the framework to the teeth, and provide an evaluation of the fit of the denture base to the edentulous ridge. The hinged or rotary attachments are generally those of choice for most Kennedy Class I or Class II situations. The use of the stress-director attachment in this manner should result in a suitable distribution

of forces being shared by both hard and soft supporting tissues."" Some practitioners prefer to use the stable base precision attachment concept in the treatment of Kennedy Class I and II situations. Adequate research comparing the stress-director concept and the stable base concept does not exist. This is a controversial area and practitioners must decide on tlieir preference based on training and experience. As a rule, bowever, tbe use of rigid attachments with distal extension removable partial dentures is not recommended.^"*
Kennedy Class IV Partially Edentulous Arch

Missing teeth in the anterior of the arch are the final consideration. This includes teeth missing only in the anterior (Kennedy Class IV), but may also involve patients with missing anterior teeth in conjunction with missing posterior teeth (Kennedy Class I and II with an anterior modification space). These clinical situations are best treated with a fixed partial denture in the anterior edentulous space whenever possible. However, on occasion, attachment-type removable partial denture designs should be considered. This is particularly true when the edentulous ridge has a noncorrectable defect compromising esthetics and contraindicating the use of a fixed partial denture. The removable partial denture will incorporate a tissue-colored base that will substitute for the missing lissues and provide acceptable estbetic results. The ideal removable partial denture design for such situations involves the use of a tissue bar placed close to the edentulous ridge and connected as a fixed unit to the abutment lecth on either side of the space, using crowns or resin retainers. If the situation involves no missing posterior teeth or a unilateral posterior edentulous space, then the bar is used in con]unction with posterior teeth to provide support. Retention is provided by using a retentive clip or stud that is incorporated into the denture base and either snaps over or into the bar. Tbe retentive mechanism for the bar can be placed so that some movement of the framework in function can occur before retentive resistance is met. This avoids binding of the components in situations such as the movement of a unilateral distal extension denture base during functional loading. This can be accomplished by placing a temporary spacer between the har and the retentive mechanism when the mechanism (clip or stud) is being connected to the prosthesis. The spacer is subsequently removed and the resulting space provides freedom for movement of the prosthesis. The

- i, Number 2, 1950

173

The International Journal of Prostliodonlics

Altacliments fur Removable Pailisl iJenlum, l'rl 2

urns/Ward

amount of freedom is determined by the thickness of the spacer. If the situation involves a biiateral distal extension design, the tissue bar must be straight and flat, and it should be placed parallel to the stabilizing fulcrum line and perpendicular to the sagittal plane. The removable partial denture framework rests solely on the bar to gain support and retention. Under function, the prosthesis will rotate around the bar. The retention is provided by a clip that snaps over the bar and allows rotational movement at the bar/clip interface. The stud attachment will not allow this type of movement and should not be used. The guiding planes must be designed to provide bracing and fixation without interfering with movement. When this design is used, the proximal plate of the framework must be trimmed flush with the adjacent marginal ridge on the most posterior abutment to serve as a third point of reference and allow a method to relate the framework to the teeth for evaluation.

. Zahler |M: Intracoronal precision attachcuont^. i.'L-nt CIm North Am 1980;24:1 31-141. . Henderson D, McCivney GP, Ca Hfiberry DJ: McCracken'i Removable Partial Prosthodontics, ed 7. Si L0U5, CV Mosby Co, t985, p 17, Academy of Denture Proslhetlcs: Glossaiy of Frosthodontic Terms, ed 5. St Louis, CV Mosby Cu, 1987. Goodman J], Goodman HW. Balance of force in precision free-end restoration. / Prosthet Dent 1963;13.302-308. Henderson D, Blevins WR, Wesley RC, Seward T: The cantilever type of posterior fi^ied partiai dentures: A laboratory study. / Prosthet Dent 1970;24:47-67. Cohn LA: The physiologic basis for looth fixation in precision-attached partial dentures, / Prosthet Dent t9S6;6:220-244. Mensor MC: The rationale of resilienl hinge-action stressbreakers. / Prosthet Dent 1968,20:204-215. Andersen JA, Lammie CA: A clinical survey of partiai dentures. BrDent ! 1952;92:59-67, Carlsson CE, Hedegard B, Koivumaa KK: Studies in partial denture prosthesis. Ill: A longitudinal study of mandibular partial denlures with double extension saddles. Acta Odontol Scand 19&2;20.95-119, Fenner W, Gerber A, Muhlemann HR: Tooth mobility changes during treatment with partial denture prosthesis. ; Prosthet DeiiM 956:6:520-525. Seeman S: A study of the relationship between periodortal disease and Ihe wearing of partial dentures. Aust Dent ! 1963,8:206-208, Lammie CA, Osborne |: The bilateral free-end saddle lower denture. / Prosthet Dent 1954;4:640-652. Grosser D. The dynamics of internaf precision attaciimen!s. / Prosthet Dent 1953,3:393-401. Leff A: Precision attachment dentures. ; Prusthet Dent 1952;2:84-91. Clayton |A: A stable base precision attachment removable partial denture (PARPD): Theories and principles. Dent Ciin North Am 1980;24:3-29. Monteith 6D: Management of loading forces on mandibular distal-extension prosthesis. Part I: Evaluation of concepts for design, / Prosthet Dent 984;52:673-681. Long |H: Unpublished dara. Kratochvil F|, Thompson WO, Caputo AA: Photoelastic anaiysis of stress patterns on teeth and bone wirh attachment retainers for removable partial dentures. / Prosthet Dent 1981:46:21-28. Shohet H: Relative magnitudes of stress on abutment teeth with different retainers. J Prosthet Dent t969;21:267-282. Weinberg LA: Lateral force in relation lo the denture base and clasp design. / Prosthet Dent I956;6:785-800. Singer F: Improvements in precision-attached removable partiai dentures. / Prosthet Dent 1967;I7:69-72. Frechette A: Infiuerrce of partial denture design on distribution of force on abutment teeth. / Prosthet Dent 1956;6,-I95-212. Henderson D, McGivney GP, Caslleberry D|: McCracken's Removable Partial Prosthodontics ed 7 St Louis, CV Mosby Co, 1985 p 79.

Conclusion
The decision lo use attachments in removable partial denture design should be carefully considered. Clasp-type removable partial dentures should be used whenever practical because of their lower cost, ease of fabrication and maintenance, and the predictability of results. However, if an attachment removable partial denture is the treatment of choice because of esthetics, abutment alignment, or the need for greater cross-arch bracing, it must be used with a thorough knowledge and understanding of prosthodontic principles and attachment use, as well as an awareness of the intricacies and special problems associated with attachments. In treatment using the attachment-retained distal extension removable partial denture, the development of a stress-directing attachment design as weil as the proper distribution of forces between the residual ridge and abutment teeth should be goals for successful treatment.

References 1. Burns DR, Ward|: A review of attachments for removable partial denture design: Part 1. Classification and Selection, Intj Prosthodont 1990;3;9e-102.

Tiie International Journal of ProsthodonlJcs

174

VQlJitie 3, Number 2, 1990