Removable partial

dentures

Stanley F. Lorencki, D.D.S., WA.*

University of Califomiu,
College of Dentistry,

San Francisco,

Calif.

1 he prefabricated
precision
attachment
restoration
offers intracoronal
retention
and a means of fixation or splinting
of teeth, and it has the added singular feature
of being a removable
prosthesis,
Precision
attachment
restorations,
rather
than
fixed partial dentures, are the restorations
of choice in unusual conditions that might
include
nonparallel
abutments,
long edentulous
spans, distal extension
bases, or
residual ridges of peculiar shapes.
When a precision
attachment
prosthesis is indicated,
essential principles
must
be precisely followed.
Each phase must be analyzed thoroughly
before proceeding
to the next phase.
DIAGNOSIS
By means of accurate radiographs,
diagnostic casts, a thorough
mouth examination, and a health history, a professional
and critical evaluation
is made of the
support available for the partial denture in relation to the stresses that the restoration will transmit to the supporting
structures .I The ability of the abutment teeth to
resist occlusal stresses without
damage to the periodontal
membrane
is directly proportional
to the amount and quality of the investing tissues. These factors, in turn,
are determined
by the crown:root
ratio and by the number, shape, and size of the
roots. The use of a denture base of maximum
size to help transmit stresses to the tissues helps reduce the load on abutment teeth.
Quite often selective grinding
of teeth may be required
to obtain a correct relationship
between
opposing
teeth which will minimize
traumatic.
effects of an inharmonious
occlusion.
Occasionally,
judicious
splinting
is required
to offset shear
forces on abutments
and to provide stability. Bilateral
support will always provide
additional
stability. Not to be overlooked
is simplicity
of design and precise fit of
component
parts.
With the biomechanical
aspects established, the plan for the design of the restoration may be formulated.
The dental laboratory
technician
should be informed
of
clinical
aspects of the treatment
plan which might conceivably
affect laboratory
procedures.
*Associate

506

Clinical

Professor,

Division

of Fixrd

Prosthodontics.

Precision

attachment

restorations

507

ESTABLISHING THE PATH OF INSERTION

A duplicate
diagnostic
cast is mounted
on a surveyor table, and the tilt which
will determine
the proper path of insertion of the restoration
is selected. This angulation will permit placement
of the female part of each attachment
within the normal
contours of the abutment
teeth.
The smallest attachment
available always seems too large for the abutment
tooth.
Therefore,
the selected path of insertion
should be one which provides the greatest
conservation
of tooth structure and health of the pulp.
Fine lines that are parallel to the long axes of the abutment
teeth are drawn on
the sides of the base of the diagnostic
cast. A surveyor analyzer rod is placed against
the proximal
wall of an abutment
to project its long axis. The angle formed by the
intersection
of the extensions of these fine lines is bisected, and a mean line is drawn
on the cast. The table of the surveying instrument
is adjusted so that the mean line
on the side of the cast is parallel to the analyzer rod of the surveyor, thus providing
the correct anteroposterior
tilt. This angle of the cast is an average of the angles
formed by the proximal
surfaces of the abutments
and the base, and at this tilt,
the average amount
of preparation
of the involved
teeth is required
to accommodate the attachments.
Any other angle would require the removal of an excess
amount of tooth structure from one or the other of the abutments.
The determined
anteroposterior
tilt is maintained
in all succeeding steps.
A visual examination
is necessary to verify that the attachments
can be placed
over the center of the ridge and still be positioned
buccolingually
within the contours
of the teeth. This buccolingual
tilt of the cast is determined
by placing the female
attachment
on the mandrel
in the surveyor and by placing the attachment
against
the proximal
surface of one abutment.
The lateral tilt of the table is adjusted until
the attachment
can be accommodated
within the confines of the tooth and still can be
placed over the center of the ridge. Undercuts
in the ridge are noted. A fine line is
drawn on the tooth parallel
to the female attachment.
The same procedure
is followed with the other abutment,
and the lateral tilt is adjusted
to a harmonious
angle. This angle is usually parallel to the mean of the angle formed by the projection of lines parallel to the female attachments.
Occasionally
the tilt of one or both
abutments is such that recontouring
by means of a full veneer crown or repositioning by orthodontic
means will be required.
The long axes of the abutments
may parallel each other, and there would be no
mean line. If this occurs, an upper cast is slightly tilted either anteriorly
or posteriorly, and a lower cast is tilted posteriorly.
This slight tilt will preclude the possibility
of the path of insertion being perpendicular
to the occlusal plane and the subsequent
risk of the restoration
being displaced easily by gravity, the pull of sticky foods, or
the uplifting
push of the tongue.

POSITIONING THE ATTACHMENT

When the proper tilt is selected, the surveyor table is locked in position. A mandrel designed to fit the attachment
is mounted
in the surveyor holder, and a female
part of the attachment
is placed on the mandrel.
The flat side of the attachment
is
positioned
against the side of the abutment
adjacent
to the edentulous
space. The
center of the mandrel should be directly over the center of the ridge. The outline of

508

J. Pros. Dent.
May, 1969

Lorencki

the attachment
is scribed on the abutment
and will represent the buccolingual
width
of the box form on the preparation
necessary to house the female part of the attachment .
The box forms are cut in the abutments
on the cast to a size that will accommodate the female part of each attachment.
The attachments
must be of maximum
length and should be placed within the natural confines of the teeth.
The preparation
of the box forms on the cast helps in formulating
a blueprint
for
the work to be carried out in the mouth. An acrylic resin, compound,
or guttapercha matrix of each box is made. The matrix extends onto the occlusal surface
of the tooth and serves as an index to determine
the minima1 size of the box when
the preparation
is cut in the mouth.
Another
type of template is made of gold and covers a great deal of the uncut
stone tooth but does not cover any part of the box form. This gold index casting extends to the periphery
of the box form and merely outlines the box. When placed
on the uncut natural tooth, it will provide an outline of the extent of the structure
to be removed from the tooth to provide the necessary space for the attachment.

ADDITIONAL IMPORTANT CONSIDERATIONS

The following
additional
factors are important
considerations
in planning
precision attachment
restorations.
1. It is not necessary for the abutments to be parallel to one another. Parallelism
is achieved by paralleling
the attachments.
2. Space must be allowed for a thin layer of gold between the female part of the
attachment
and the walls of the prepared box.
3. The female part of the attachment
should be located within
the natural
contour of the coronal portion of the tooth to minimize
stresses and to form proper
patterns for flow of foods.
84. All the attachments
should be approximately
the same length to prevent
tipping and possible unseating of the restoration.

SUMMARY
The important
aspects for planning
precision attachment
restorations
have been
described. Thorough
diagnosis, establishment
of the path of insertion,
and proper
positioning
of attachments
are critical to the success of the restoration
and must be
carefully planned prior to initiation
of cutting procedures.

References
1.
2.
3.
4.

Kabcenell,
Lucia,
V.

J. L.: Stress
0.: Modern

Breaking
for
Gnathological

Partial
Dentures,
J. A. D. A. 63: 593-602,
1961.
Concepts,
St. Louis,
1961, The C. V. Mosby
Com-

paw.
Wilson,
W. H., and Lang, K. L.: Practical
Crown
and Bridge
1962, McGraw-Hill
Book Company,
Inc., pp. 209-211.
Cohn,
L. A.: The Physiologic
Basis for Tooth
Fixation
in
Dentures,
J. PROS. DEXT. 6: 220-244,
1956.
~JNIVERSITY

OF CALIPORNIA

SAN

FRANCISCO

MEDICAL

SAN

FRANCISCO,

CALIF.

CENTER

94122

Prosthodontics,
Precision-Attached

New

York,
Partial