Seminar 6 Precision Attachments

Direct retainers Part II
Precision attachments

Dr. Akshi Gvalani

P.G. Dept of Prosthodontics
Terna Dental College, Nerul, Navi Mumbai


The renaissance of attachment usage came about in the late 1950s with the work of
Steiger and Boitell followed by the first compilations of representative attachment
systems.

Precision/Semiprecision RPD is the treatment modality that can facilitate both an
aesthetic and a functional replacement of missing teeth and oral structures
DEFINITION
Precision quality or state of being precise
Attachment Mechanical device for the fixation, retention and stabilization of dental
prosthesis. PRECISION ATTACHMENT ( GPT-8)
A retainer consisting of a metal receptacle (matrix) and a closely fitting part
(patrix); the matrix is usually contained within the normal or expanded contours of the
crown on the abutment tooth/dental implant and the patrix is attached to a pontic or the
removable dental prosthesis framework.


SYNONYMS OF ATTACHMENTS
INTERNAL ATTACHMENTS
FRICTIONAL ATTACHMENTS
PARALLEL ATTACHMENTS
SLOTTED ATTACHMENTS
KEY AND KEY WAY ATTACHMENTS

Patrix Matrix
Flange Slot
Insert Crypt
Key Keyway
Fitting part Receptacle


HISTORICAL BACKGROUND
Winder
Winders design
Screw joint retention
First unilateral fixed detachable type of RPD

Parr (1886)
Extracoronal socket attachment

Stair (1886)
Telescopic abutment restoration


Ash (1912)
Split bar attachment system

Late 19th century :
Dr. Herman ES Chayes
T shaped Precision Attachment (1906)
H shaped Chayes Attachment (1912)

First attachment to be available in the market

CLASSIFICATION OF ATTACHMENTS
Based on method of fabrication and the tolerance of fit
Precision attachment (prefabricated types)
Semiprecision attachment (custom made / laboratory made types) Prefabricated wax /
plastic / nylon patterns
JOEL M ZAHLER ( 1980 )
The term SEMI PRECISION is misnomer as when properly made, the laboratory
fabricated attachment is just as precise as the prefabricated version.

According to their relationship to the abutment teeth

I. Intracoronal (Internal attachment) : attachment resides within the body/normal
contours of the abutment teeth

II. Extracoronal (External attachment) : attachment resides outside the normal
contours of the abutment crown/teeth

Based on stiffness of the resulting joint
Rigid attachments

Resilient attachments (Non rigid)


RIGID ATTACHMENT Metal to metal contact of the patrix and matrix restrict the
relative movement between the abutment and prosthesis during the functional
loading. Theoretically allow no movement of their component parts during
function. Usually used in bounded saddle situations where the abutment teeth
fully support the restoration and attachment, soft tissue does not give any
support.
RESILIENT ATTACHMENTS Attachments are designed to permit movement of the
denture base during functional loading Functional movement of the prosthesis may be
restricted to defined vertical, horizontal and or rotational path Theoretically minimizing
the amount of force being transferred to the abutment teeth.
Hinged motion Allowing movement along one plane.
Rotary motion Allowing movement along many planes.
Based on geometric configuration and design of the attachment

Key and Keyway
Interlocks
Ball and socket
Bar and clip / sleeve
Hinge
Telescopic

M.C. Mensor (1973)
Classification according to shape, design and primary area of utilization of attachment.
Intracoronal Telescope Auxiliary
Extracoronal (Pressure buttons) Screw units

Bar attachment Bar connectors

(Bar joints and bar
units)
Bolts

Stabilizers

Balances

Interlocks


Bacerra and Macantee(1987)

ADVANTAGES
Improved esthetics and elevated psychological acceptance
Mechanical Advantage ( in intracoronal attachment)

Direct the forces along the long axis of the teeth more apically
Force application closer to the fulcrum of the tooth
In Distal extension base cases Broken stress philosophy
Reduced stress to the abutment
Stress free rotational/vertical movements


Cross arch load transfer / force transmission and prosthesis stabilization may
also be improved - particularly with rigid precision attachments
Lateral forces on the abutment during the insertion and removal are eliminated
and more axial force during functions are achieved.
Compared to conventional clasp retained partial denture
Less liable to fracture than clasp
Less bulky and more esthetics
Better retention and stability
Less food stagnation

DISADVANTAGES
Complexity of design, complex principles and procedures for fabrication and
clinical treatment.
Abutment must be crowned

Precise and structurally demanding tooth preparation
Encroachment on the root canal space in attempt to prepare abutment to receive
attachments.
Minimum abutment occlusogingival height ( 4-6 mm )

In order to facilitate acceptable emergence profile.
To incorporate attachment components without over contour.

Shorted abutment may yield over contoured coronal restorations and reduced
frictional / binding retention of the attachment.
Expensive
Complexity of laboratory and clinical procedure
Attachment maintenance (repair or periodic replacement)
Wearing of attachment components - because of friction between metal parts
overtime and may require repair or replacement
Requires high technical expertise for successful fabrication experience and
knowledge on the part of dentist and laboratory technician are essential.
Cooperation and manual dexterity on the part of the patient
Difficult to insert and remove
Increase demand on oral hygiene performance

INDICATION / APPLICATIONS
Removable Prosthodontics
As a retainer in a removable tooth supported partial denture
For large well rounded abutments are available
For esthetic concern in the anterior part of the mouth
Stress Breakers Free end saddles/Distal Extension Base cases (DEB)
When cantilevered pontic is to be used as abutment
For movable joints in sectional dentures
Divergent abutment teeth with high survey lines difficult to get parallel path of
placement
As a retainers in tooth supported over denture


Fixed Prosthodontics
As a connector in fixed partial denture construction (long span bridges)

To overcome alignment problems where abutments have differing path of withdrawal
The existence of pier abutment : which promote a fulcrum like situation that can cause
the weakest of the terminal abutment to fail.

Implant prosthodontics
Implant supported over denture
They are used for connection between the tooth and the implant


CONTRAINDICATIONS
Poor periodontal support
Poor crown to root ratio
Poor oral hygiene habits
Abnormally high carious rate
Inadequate space / room to employ the attachment
Compromised endodontic and restorative conditions
Distal extension conditions
Senescent / handicapped individuals

Studies have also demonstrated that precision-attachment partials
last longer,
wear less,
need less adjustments,
look better,
work better,
less destructive,
protect abutment teeth, and
are easier to clean

Rates of unsuccessful treatment for clasp retained cast RPDs range from 3% to 40%
with mean being 26% (Frank et al, 1998).
Patients seek treatment with cast RPDs for the purpose of improving appearance and
masticatory function. It has been suggested that compliance improves when the
prosthesis meets the aesthetic requirements of the patient (Mazurat & Mazurat, 2003).
Treatment planning
Six important questions
1. Is the patient healthy ?
2. Is the prosthesis necessary ?
3. Is the patient suitable for the prosthesis?

4. How large is the span ?
5. What structures support the prosthesis ?
6. How is the prosthesis made ?

SELECTION OF THE ABUTMENT TEETH
Factors :
Sound abutment teeth
Number of the abutment teeth
Periodontal condition
Crown root ratio
Periodontal support
Pulpal status
Vitality of the pulp
Size of the pulp chamber
Requirements for the abutment teeth
Occlusogingival length minimum of 4 mm vertical space is required so that there
is adequate space.

Maximum Minimum Inadequate

Buccolingual space requirement
Placement of attachments in the incisors can be difficult because or limited
faciolingual width.
Adequate space between pulp and normal tooth contour is necessary for the
intracoronal component of an internal attachment.

1. Selection of the type of retainer
2. Selection of the attachment :

Selection is based on some factors:
Crown root ratio.
Clinical crown length/height the length of the attachment is the main criteria in
choosing the attachment, rather than the width.

Vertical space available.
Number of abutments used for support.
Location of the abutment / strongest abutment.
Quality of the bone of the residual ridge.
Cost.
Maintenance factors.

Selection of the attachment :

Intracoronal Vs Extracoronal

Size and shape of the abutment teeth
Intracoronal attachment - more teeth preparation and tooth reduction
If intracoronal attachments are used where there is insufficient space, the
abutment retainer will be over contoured on the proximal surface resulting in
restoration that can create periodontal problems.
In case the space is adequate intracoronal attachment is preferred as they direct
the forces along the long axis of abutment teeth.
Though extracoronal attachments are employed in areas of inadequate space
they can create areas which may be difficult to clean leading to maintenance
problems.
The lever arm associated with extracoronal attachment may not direct all force
along the long axis of teeth.

Resilient Vs Non resilient
Major differences of philosophy regarding the use of resilient or non resilient
attachment system occurs when dealing with distal extension edentulous
situation.
Theoretically, resilient attachment allows the functional forces to be directed to
the tissues and alveolar ridge and the non-resilient attachment primarily directs
the vertical functional forces to the abutment teeth.
Realistically, there is some sharing of functional loads in both systems.
ATTACHMENT SELECTION
In 1971, 126 attachments were listed and classified by Dr. Merrill Mensor; this is called
as E. M. attachment selector.

It has 5 charts giving specification as to the type of attachment.
It utilizes a colour coded millimeter attachment gauge to define the vertical clearance
available in the edentulous regions of occluded casts for attachment selection.
Red designates 3 to 4 mm, yellow designates 5 to 6 mm and black designates 7 to 8
mm.

INTRACORONAL ATTACHMENTS
Intracoronal attachment were introduced in the late nineteenth century with substantial
contribution from Dr. Herman ES Chayes.
Precision attachment (prefabricated type)
Semiprecision attachments (custom made)


Intracoronal precision attachment
Two component a matrix and patrix
Matrix (female) is waxed into the crown or bonded into a preparation in the tooth.
Patrix (male) is attached to the framework usually by soldering
Machined to close tolerance (0.001 inch average).
Axial space requirement
Average dimension of the intracoronal attachment is just over 1.5mm and
allowing for a minimum of 0.5mm of metal in the crown internal to the matrix.
Minimum of 2mm of reduction in the area of attachment is essential to keep the
final unit within normal contours.
The tooth must have sufficient clinical crown length to accept a matrix with a
minimum vertical height of 3mm.
Greater the vertical length of the attachment complex, the greater the potential
retention and stability that can be expected.
The width of the matrix in buccolingual direction will be in the range of 3mm.
Prefabricated intracoronal attachment
Modern attachment utilize an H shaped flange which is stronger and has nearly
double the frictional surface area of the earlier T-shaped flanges.
Atleast two but sometimes three or four of the attachments are included in the
denture and they have to be aligned so that the all the roots (and hence the
flanges) are parallel to each other to ensure insertion and removal.

Types of intracoronal attachment :
Depending on articular retention retention types between the matrix and patrix.
Passive attachment
Active attachment Active friction grip attachment
- Active snap grip attachment
Locked precision attachment

PASSIVE ATTACHMENT :
Matrix : Simple channels closed at one end to provide stop
Patrix : Solid slide
Channels of passive attachment may be round/elliptical slides

ACTIVE ATTACHMENT
Active friction grip attachment
Incorporate the adjustable spring mechanism for added retention.
Simplest form is split patrix, so that part of it forms a leaf spring which can be opened to
compensate for wear to give retention.
Function by forcing the part of the patrix against the matrix thus increasing the area of
contact and the effort required to separate them.
Friction grip attachments are often little larger than the bigger passive attachments and
are therefore suitable for use in the anterior and premolar regions of the mouth.

Active snap grip attachments
In snap grip attachments, the active element consists of a spring loaded plunger, a split
ring or a U spring which engages in a prepared pit or groove.
Active snap grip attachments are among the largest attachments and hence can usually
only be accommodated in molar retainers.


LOCKED PRECISION ATTACHMENT
They are either bolted by means of a sliding bolt or latch, or may be pinned or screwed
together when fully articulated.

SEMIPRECISION ATTACHMENTS

Definition: Laboratory fabricated rigid metalic extension (patrix) of a fixed or
removable dental prosthesis that fits into a slot type key way (matrix) in a cast
restoration allowing some movement between the component. - GPT 8
First semi precision attachment was constructed by Gillete in 1923. It had buccal and
lingual wrought clasps arms with a rectangular deep rest.
These semi precision attachment, almost always created in the dental laboratory either
in the wax or by milling the completed casting.
Deep rest seats can be fabricated in various out line forms to control the amount of
rotation around the horizontal axis and direction of movement of the resultant partial
denture.
Outline form controls the rotation
Side walls lateral force transmission
Flat gingival floor occlusal force transmission and
Retention provided by the frictional resistance between the rest and the rest seat.
According to Louis Blatterfein (1969): In designing of a semiprecision attachment 4
aspects of rest seat preparation may be taken into consideration
Occlusal form
Proximal form
Gingival floor form
Proximal surface placement


Occlusal form
Four type of deep rest occlusal outline forms- Controls the amount of rotation of
attachment

Circular Dovetail Rectangular Mortise
Proximal form :
Lateral force controlled
Controls the rotation around longitudinal axis in distal extension RPD .
According to Blatterfrin the angle the proximal / lateral wall makes with gingival
floor determines the rigidity of the retainer.

Parallel Tapering
Gingival floor form
The gingival floor form controls and serves the function of reciprocation.
Flat gingival floor provides reciprocation.

Inclined gingival floor is indicated for added reciprocation, usually indicated in
mortise occlusal form.

Channeled gingival floor : Used with rectangular occlusal outline form
(nonlocking occlusal outline).


In 1979 Ira D Wisner discussed about two basic types of semiprecision attachment
Locking
Non locking
Locking type :
Locking type of attachment do not allow for rotation and hence can be
considered as rigid
Locking type of internal attachment are not used with distal extension removable
partial denture because of inherent excessive leverages most often associated
with them
Non locking type :
Non locking type allows some movement and is useful in distal extension
conditions.
Non locking type of internal attachments in conjunction with sound prosthodontic
principles can be advantageously used in many instances in Class I and Class II
partially edentulous situation.
Neurohr Willian No. 2 mandrel with channeled gingival floor rectangular
occlusal outline (1930)
Thompson Dowel rest (1949) Thompson Morris J

Advantages of custom made attachment (semi precision attachment) :
Offers far greater adaptability to a wide variety of clinical situations . By
employing rest seats of various outline forms amount of rotation and direction
of movement can be controlled.
Variation in tooth size and shapes are most easily accommodated.
It allows the technician to achieve a far better crown contour in the critical
gingival area than is possible with the prefabricated precision attachment
Disadvantages :
Long term wear is more compared to prefabricated because of softness of alloy
used in their fabrication. Prefabricated attachments are made of alloys which are

harder and more resistant to wear than the alloys which are available to the lab
technician
No standardization of sizing : Lack of interchangiability of male and female
attachment
Repair and replacement of custom attachments are more difficult as composed
to prefabricated parts.
Greater degree of laboratory skill and attention in detail is required

EXTRACORONAL ATTACHMENTS
Introduced by Henry R. Boos (1900)
Modified by F .Ewing Roach (1908)
Application
Kennedys class I and class II

Boitel (1978)
Rigid attachments
Resilient attachments
Bar attachments
o Rigid attachment : do not allow any rotation of the partial denture in function
o Hinged attachment : Offers a stress breaking action to the distal extension bases
o Resilient attachment ERA : Permit limited amount of movement of the denture
base
Advantages :
No alteration of contour of the abutment crown
Can be used in short abutment teeth
Greater freedom in the design
Ease of insertion and removal

Disadvantages (Wolf RE 1980) :
Lack of occlusal stability

Rebasing problems
Improper control of force distribution
Encroachment on the gingival papilla ( use of mini attachment )

RIGID EXTRACORONAL ATTACHMENTS
Roach attachment (ball and tube attachment)
Oldest attachment
Patrix round ball
Matrix - tube

Pin and tube attachment
The simplest
Patrix - pin
Matrix tube


Stabilex attachment
Two retention pins
Disadvantage is increased length

Extracoronal resilient attachment

Colour coded caps
Most flexible White > Orange > Blue > Gray Most rigid

Two types of ERA
Standard
Reduce vertical (ERA RV) male part is 0.5mm shorter
Vertical resiliency of 0.4mm
Universal joint hinge action

O Ring attachment

Patrix - post with the groove or undercut.
Matrix O-ring synthetic polymer gaskets + encapsulator
O-ring are made up of
Silicone
Nitrile
Fluorocarbon
Ethylene propylene
Advantages of O-ring
Different degrees of retention
Ease in changing the attachment
Wide range of movement
Low cost

HINGED EXTRA CORONAL ATTACHMENT
Dalbo / Dallabona attachment
Patrix

Matrix


Dalbo stress breaker
Rotational and Vertical movement

Ceka attachment
Developed by Karl Cluytens (1951)
Two types - Ceka NV attachment
- Ceka revax

P (split metal post)


Functional aspect : Mark E, Waltz 1973
Support
Bracing
Retention

Insertion and removal
Reduces frictional wear

ROLE OF ATTACHMENTS AS STRESS BREAKER
Broken stress philosophy

Mensor (1972)
Stress director

tissue
Disadvantages of stress director :
Increased bone resorption and trauma
Occlusal contacts difficult to maintain
Loss of cross arch stabilisation

More complex, costly to make difficult to repair
AUXILLARY ATTACHMENTS
Screw and tube attachment
Key and keyway / interlocks
Presso Matic or Ipsco clip
Bar connectors
Attachments for sectional dentures / bolts
Screw and tube attachment
Indications :
To overcome alignment problems

Connecting one restoration of fixed partial denture to another
Allowing the removal of long span fixed partial denture for repair and examination
of abutment.
ATTACHMENT USED FOR SECTIONAL DENTURES
Two part dentures : One part - chrome cobalt base


Second part - removable acrylic flange with teeth
Advantage of superior esthetics and improved retention
Method of union :
Physical interference : Bolt retained prosthesis
Frictional resistance : Split post retained prosthesis
SECTIONAL DESIGNS
Individual sections / separate sections : uses mesial and distal surface of the
abutment teeth as guiding planes.

Hinged sections : Buccal and lingual path of insertion


Direct clasp retention in the construction of a removable restoration is indicated
(1) when the general hygiene promises to be good ;
(2) when the remaining teeth have no periodontal involvement and are properly
distributed for clasping;
(3) when the abutment teeth have the necessary convexity and lend themselves to
proper clasping ;
(4) when the denture can be expected to render many years of service.

Internal precision attachments are indicated:
(1) when few remaining teeth are present;
(2) when the hygiene promises to be poor;
(3) when the abutment teeth are overfilled or broken down, yet are serviceable if
they are restored by full coverage ;
(4) when splinting of teeth is indicated to aid in their preservation
(5) when the economic status of the patient is such as to permit their use.

Conclusion
Restoring and maintaining function and health of the partially edentulous mouth is one
of the most complex and exacting services the dentist is required to perform.
It requires a knowledge of
biomechanical factors,
vision,
judgment,
originality,
resourcefulness and, above all,
a will to do what the conscience dictates to be in the best interest of the patient


References
Precision attachments Gareth Jenkins.
Stewart KL, Rudd KD, Kuebkar WA. Clinical Removable Partial Prosthodontics. 2nd
ed.St. Louis, Missouri: CV Mosby; 1986
Miller EL, Grasso JE. Removable Partial Prosthodontics. Baltimore, U.S.A: Williams
and Wilkins; 1979
Preiskel HW. Precision Attachments in Dentistry. 3rd ed. London: Henry Kimpton; 1979

Seminar 6 Precision Attachments

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