David R.

Burns, OMD
Assistant Professor

lohn E. Ward, ODS, MSO Associate Professor

A Review of Attachments for Removable Partial Denture Design: Part 1. Classification and Selection

Department of Removable Prosthodontics Virginia Commonwealth University School o Dentistry Box S66 MCV Station Richmond, Virginia 23298

An attachment is a mechanical device, other than a clasp assembly, that functions as a direct retainer. Attachments for removable partial denture treatment are reviewed and a method for classifying different types of attachments is provided. Attachments are categorized as precision or semiprecision, depending upon the method of manufacture; internal or external, according to their intracoronal or extracoronal location relative to the abutment tooth; and rigid or resilient, as determined by the amount of movement allowed between the component parts. They are also classified by design. The advantages and disadvantages of attachment use as well as indications and contraindications are considered. Additionally, the conventional clasp-type direct retainer is compared to attachments. Int J Prosthodont 1990:3:98-102.

A an aura of mystery, primarily because of a lack of knowledge and experience. Not all practitioners
may consider tbe use of attachments as essential, but a basic understanding is useful and important. Tbe purpose of this two-part paper is to present the fundamentals of attachments for removable partial dentures. Part 1 defines attachments and discusses their function and indication. Part 2 discusses treatment planning and attachment selection. Definition of Attachment By definition, an attachment is a mechanical device for the fixation, retention, and stabilization of a dental prosthesis.' For removable partial denture prosthodontics, it is a mechanical device, other than a clasp, that functions as a direct retainer.^ As the direct retainer, it must provide: (1) support resistance to movement of the prosthesis toward the tissue; (2) ree/ii/onresistance to movement of the prosthesis away from the tissue; (3) reciprocation counteraction of the forces exerted by the retentive component; (4) siafe;7/zaf/onresistance to horizontal movement of the prosthesis, and (5) fixation resistance to movement ofthe abutment tooth away

ttachments have always been surrounded by

from the prosthesis and movement of the prosthesis away from the tooth. Additionally, the direct retainer should be passive when the prosthesis is in its terminal position. An attachment derives its functions tiirough closely fitting, coupling parts. It incorporates one component into the removable partial denture and the connecting component is traditionally incorporated into a cast crown or fixed partial denture (Fig 1). Recent advances in resinretained prostheses have led to the introduction of the resin-bonded connecting component that is luted directly onto the enamel of the abutment tooth. Classification of Attachments Attachments may be classified in a number of ways.'" They may be classified as cither precision or semiprecision, depending on the method of fabrication and tolerance of fit. Precision attachments have prefabricated, machined components with precisely manufactured metal-to-metal parts with close tolerances. The fabrication methods for semiprecision attachments yield a less precise tolerance. These may be either manufactured patterns (made of plastic, nylon, or wax) or hand waxed.

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Anachments are classified according to their relationship to the abutment tooth. If the attachment is incorporated within (he body of the abutment tooth intracoronally, it is an internal attachment; when located extracoronal ly, it is an external attachment. Neither type of attachment is applicable to all circumstances. Selection of an internal or external attachment is based on design considerations for the prosthesis and the anatomic morphology, location, and position of the abutment tooth. Internal attachments have the advantages of maintaining forces more in line with the long axis of the tooth and having a more desirable resistance to vertical and lateral forces, while external attachments require less reduction of the abutment tooth. Attachments are also classified as either rigid or resilient. Rigid attachments are those that theoretically allow no movement of their component parts during function. However, even under the best of conditions, minute movement of the prosthesis will occur when occiusal forces are applied. The amount of movement will increase with wear of the components. Resilient attachments provide a defined amount and direction of movement of their component parts, permitting movement of the denture base toward the tissue under function, while theoretically minimizing the amount of force being transferred to the abutment teeth.'' Thus, the resilient attachment acts as a "stress director,"'* Resilient attachments may provide a hinged motion, allowing movement along one plane Fig 2), or a rotary motion, allowing movement along many planes (Fig 3), The precision intracoronal attachments ate usually designed to function as rigid attachments, while the extracoronal attachments are usually resilient. Rigid intracoronal attachments provide all of the necessary functions of a direct retainer." The resilient extracoronai attachments, in contrast, do not always supply suitable support and bracing because of their resilient nature. This represents a point of controversy, because for the resilient attachments to maintain their ability to move freely in all planes without binding or torquing the teeth, the connection between the components of the resilient attachments must be the only contact between the removable partial denture and the teeth. When this premise is followed, the removable partial denture derives little more than retention from the abutment teeth, while support, bracing, and stability are derived primarily from the residual ridge. Therefore, some believe that additional components must be incorporated into the removable partial denture design to provide the necessary functions of a direct retainer and follow sound principles of prosthodon-

Fig 1 An attachment derives its tunction through closely fitting, coupling parts. One component of the attachment is incorporated into the removable partial denture. The connecting component is incorporated into the abutment tooth.

^
Fig 2 Hinged resilient attachment allowing movement only along the sagittai piane, thus restricting lateral movement. (Dalbo attachmeht, APM-Sterngoid, San Mateo, California.)

T f ^^' ^ilowing movement along attachment, Preat Corp, San Wateo, Cail:

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Attachmeni! hu Removable Parlial Derilures, Part I

tics. Specially designed rests and guiding planes on surveyed crowns contacted by the major connector may be used to supply support and bracing for the prosthesis" (Fig 4), The rests and guiding planes also provide the positive relationship between the rigid framework and teeth necessary to evaluate the fit of the framework and the relationship of the denture base to the residual ridge. Unfortunately, when this feature is incorporated, the movement of the prosthesis is more restricted, but proponents feel that the benefits of such a design outweigh some loss of movement of the prosthesis. Finally, attachments are classified according to design, and there are many designs and combinations. The following are examples: The key and key-

way design is representative of the rigid type (Fig 5]. The ball and socket is a multidirectional resilient design incorporating a ball freely moving within a socket (Fig 6], The bar attachment design consists of a prefabricated metal bar of specific dimensions and shape that extends across an edentulous area just superior to the tissue of the residual ridge. It is permanently attached to cast crowns or resin bonded to the enamel of the abutment teeth (Fig 7). Retention is usually gained with a precisely fitted clip incorporated intotheacrylic resin of the denture (Fig 8). Deciding on Attachment Use Attachments have a number of desirable qualities that indicate tbeir use in place of conventional ciasps. The primary indication is esthetics.^ Conventional clasp assemblies and rests may be visible and unesthetic, whereas the attachment is concealed within the contours of the abutment tooth or within the body of the removable partial denture. Another appropriate indication for the use of attachments is for divergent abutment teeth with high survey lines. The use of conventional clasps would require the placement of clasp arms high on the tooth, or lowering of the height of contour through tooth modification or placement of surveyed crowns. Although attachment use may also require crowns, the preparations do not need to be made parallel to one another. This is because the path of placement of the removable partial denture is determined by parallel placement of the attach-

Fig 4 Rests and guiding planes incorporated in surveyed crowns are contacted by tne removable partiai denture major connector and provide increased support and bracing. This design also provides a method for evaiuation of the fit of the frarnework to the teeth.

Fig 5 (Left) Key and keyway (semiprecision) attachment design. Fig 6 (Right) Ball and socket design.

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ments within the surveyed crowns, independent of the parallelism of the crowns themselves.'" A major advantage of the use of attachments is that the point of force application to the tooth is more apical than for occlusal or incisai rests, thus shortening the lever arm and decreasing torquing forces. Attachments may also allow better crossarch force transmission and stabilization than clasps, but this is determined by the type of attachment used, the number of guiding surfaces, and the design and adaptation of the framework and attachment. There are a number of negative aspects to the use of attachments,' In general, whenever a conventional clasp can be used it is the retainer of choice. The use of attachments requires additional expense to the patient, for both the crowns or resinbonded retainers on the abutment teeth as well as the attachments themselves. Poor dental motivation and manual dexterity of the patient may result in earlier failure than with the use of conventional clasping. Repairs or alterations are difficult or impossible with some attachments. Short clinical crowns contraindicate the use of attachments. A minimum of 4 mm of vertical space is necessary for most attachments." Therefore, a minimum of 6 mm of clinical crown would be necessary to retain the attachment without overcontour. This occlusogingival length is required so that there is adequate space hetween the plane of occlusion and the gingiva for placement of both the attachment and the prosthetic teeth. Likewise, for attachments that rely on frictional resistance for retention, the occiusogingival length is important in providing enough length of parallel contact hetween the components of the attachment to enable adequate retention. It is possible, however, to provide supplemental means of retention, such as locks, retentive clasp arms, etc. Placement of attachments in the incisor and canine areas can also be difficult because of limited faciolingual tooth width (Fig 9). The anatomy of the abutment tooth and the ipace requirements for the attachment must be considered. Adequate space between the pulp and the normal contours of the tooth is necessary for the intracoronal component of an internal attachment. If the pulp of the abutment tooth is large, preparation of the tooth for a crown plus additional reduction for placement of an internal attachment may necessitate root canal therapy. This may not preclude the use of attachments, but may be an indication for the use of an extracoronal attachment. Biologic conditions that contraindicate a conventional removable partial denture also preclude the use of attachments.' These include poor periodon-

Fig 7 Bar attachment design.

Fig S Clip incorporated into the denture base iocks tightly over the bar. providing retention.

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Fig 9 Placement of attachments in the incisor and oanine areas can be difficult because cf limtted faciohnguai tooth width.

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tal health of abulmenl teeth, poor tissue quality or quantity, poor crown-to-root ratio, and enrlodontic and restorative considerations. The greatest deterrent to the use of attachments is their complexily. The close tolerances demand coordination between the denture base, partial denture framework, and supporting tissues. The treatment therefore becomes considerably more difficult to plan, accomplish, and maintain.'- The use of attachments requires a thorough knowledge of basic prosthodontic principles, appropriate traininj; and experience with the particular attachmenl used, technical skills, and clinical ability and judgment. Summary An introductory review of attachments, including classification, parameters for use, advantages, and disadvantages, has been presented. Pari 2 discusses treatment planning and attachment selection for removable partial denture treatment. References 1. Acidemy of Denture ProstbeMts: CImsiirv iit Prii<,thodont,c Terms, ed S SI Louis, CV Mosby Co, I %7.

2. Tregiiskei |N, Ward |E: Removable Partial Denture Ciinial Study Manual. Richmond. Virginia, Virginia CommiinWfallh University, Sthool (if Dentistry, I9H11, p 1. i. Becerra C, Mattniee M: A Llawiiication ot pff-ciiron ltchmenls. / Prasthet Dent i9li7,Sfl: i22 -127. 4. Preiskel HVW: Prctision .lilathments: Uws and abuses. I Prasl/ierDenf 197),10.491 492. 5. Henderson D, McCivney GP, Calleberry D|: McCraci<en's Removable Partial Prosthodiintics. ed 7. Si Louii, CV Mosby Cr>, 1985, p 79. 6. Preiikcl tlW: Precisian Attachments in Prosthotiontii.s\ Vol I. The Applications of Intr.tcoronai anri Extracoronai Attaciiments. Chicago, Quintessence Publ Co, 19it4, p UlS. 7. Blatierfein L: Tbe use of ihe semiprecision resi in removable parricii dentures. / Proslhet Dent I969;22:.{)7-112. 8. Singer 1: improvemonis in predsion-ailached removable partial dentures. / Prosthet Dent 1567;! 7:69-72. 9. Cunningham DM: inditalions and conlraindicalions for precision ailachmenls. Denl C/m Nor//) Am 1970;14:595fjlll. 10. Lorencki SF: Planning precision attachment restoration;. / Proslhet Dent 1969:21 :.';06-.';08. 11. Preiskei HW: Precision Attachments in Prosthodontics: Voi !. Tiie Applications of Intracoronal and Extracoronai Attachments. Chicago, Quintessence Publ Co, 1904, p 32. 12. Sthuyier CH: An analysis of Ihe use and relative value of Ihe precision atlachment and the clasp in partial denture picinning / Proslhet Dent 195:^:711-714

Literature

Abstract-

Stability in the Correction of Dentofacial Deformities: A Comprehensive Review Postoperative stability of skeletai segments repositioned during orthognattiic surgery was reviewed. Factors ttiat atfected the stabiiity of orthognathic surgery procedures inciuded the type and duration of masiilary-mandibular fixation, the number ot skeletal sections involved, condylar dispiacement following surgery, ttie use cf presurgicai orthodontics, ttie direction of movement of the bone, the posterior face height, and the tension of the suprahyoid muscuiature. The resuits showed that maxiilary superior repositioning tends to be a stable operation, but maxillary inferior repositioning has a tendency tc be unstabie. witti the upper lip generaliy lengttiening postoperatively. The greater the mandibular advancement, the greater the tendency for relapse. Ttie clinicai implications of various stabilization techniques are not fuiiy understood. Welch TB. J Oral Ma'illotac Surg 1989:471142-1149 References: 9S Repeints: Or Welch, Department ol Oral and Maiillotacial Sjrgery, Loma Linda Uriiversity, Loma Linda. California 9235O.-Srepien Wagner. DDS. Abstract and
Book Revietv Editor, Albuquerque, New ttiexico

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