Attachment Dentistry Slides Handout

8/12/2019 Attachment Dentistry Slides Handout

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Precision and Semi-

PrecisionAttachments

Where? When? Why?

George E. Bambara, MS, DMD

FACD, FICD


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Objectives of the Program Understanding how attachments

preserve hard and soft tissue

Selection of the appropriateattachments

Understand the uses of attachments

Familarization with different

attachments

Maintenance and hygiene


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Properly Designed Clasps

Work??????Concerns??????

Uneven distribution offorces

Possible orthodontic

movement

Periodontal compression


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Removable Partial Dentures

Periodontal Status

RPDs WERE ASSOCIATED WITH

Increased periodontal pathology

Increased plaque and tarteraccumulation

Increased gingival inflammation

Increased probing depths Increased recession

Increased abutment tooth mobilityZlataric et.al., The Effect of Removable Partial Dentures on Periodontal Health

of Abutment and Non-Abutment Teeth. JPeriodontology, 2002, 73: 137-144


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Clasps vs. Attachments

CLASPS:

Less expensive.

5 to 6 year life.

30% loss of retention.

Poor chewing

efficiency.

93% caries rate. 50% compliance.

ATTACHMENTS:

15 year + life.

More expensive.

99% retention.

Excellent chewing

efficiency.

8% caries rate. 100% compliance.

Rantanen, Wetherall and Smales, Feinberg et.al.


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CLASSI LEVER


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Class II Lever


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CLASS III LEVER

Class III Lever


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Indications for Attachments

Aesthetics

Redistribution of forces

Minimize trauma to soft tissue Control of loading and rotationalforces

Non parallel abutments-Segmenting

Future salvage efforts- Segmenting

Retention


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Functional Classifications

Class 1A-Solid, rigid, non-resilient

Class 1B-Solid, rigid- lockable

Class 2-Vertical resilient

Class 3-Hinge resilient

Class 4- Vertical and hinge resilient Class 5-Rotational and vertical

resilient

Class 6-Universal, omni-planer


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Patient Dexterity and

Attachment Wear

Insertion and removal cause wear

Poor dexterity Avoid multiple attachments with

complex a complex path of insertion

Use lingual guiding arms


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What is a Precision

Attachment?

An attachment that is fabricated from

milled alloys Tolerances are within .01mm


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Precision Attachments

They are Generally

Intracoronal

Rigid = NonResilient


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Benefits of Precision

Attachments

Consistent quality

Controlled wear Less wear

Easier repair

Standard parts are interchangeable


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What is a Semi-Precision

Attachment?

An attachment that is fabricated by

the direct casting of plastic, wax,metal, or refractory patterns

Their method of fabrication subjects

them to inconsistencies


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Benefits of Semi-Precision

Attachments

Less costly Easy fabrication

May be cast in alloy


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Semi-Precision Attachments

They Are Generally

Extracoronal Non-rigid = Resilient


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Resilient Attachments

0.1mm 0.4 mm difference in the

displacement of the tissue and the

denture base, as opposed to the axialintrusion of the abutment teeth

Directs forces to the supporting tissuesand the abutment teeth


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Selection of Attachments

Location

Opposing arch

Function

Retention

Available space ( 3-5mm ) Cost


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Criteria Selection for Resilient

and Non Resilient

Attachments Do not oppose two resilient attachments

unless teeth are very weak

Opposing distal extensions with strong

abutments: upper - non resilient, lower

- resilient

Lower distal extension vs.

Natural dentition - resilient

Full denture - non resilient


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Coronal Attachments

INTRACORONAL:

Placed within the

contours of the crownform

Needs more tooth

reduction Rigid connectors

EXTRACORONAL

Placed outside the

contours of the crownform

Needs less tooth

reduction Stress redirectors and

are considered

resilient


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Stud Attachments

A balland sockettype of attachment inwhich one component is attached to an

abutment or implant, and the other

element is retained in the prosthesis


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Advantages

Stud Attachments

Low profile

Easy hygiene maintenance Enhanced crown/root ratio


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Dalla Bona

The Ball Attachment

A spherical, resilient, adjustable studattachment with vertical and rotational

movement for retaining partial and complete

overdentures


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Advantages

Low Profile - limited space

Easy path of insertion

Adjustable female

All adjustments done in prostheses Can be rigid vertical movement only

Can be resilient vertical and rotational

Easy fabrication Hygienically maintainable


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Accessory Attachments

Plunger

Screw Type

Frictional


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Magnetic Attachments

Processing magnet- in denture

Intraradicular keeper

All magnetic attachments should be

processed chairside in the denture


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Magnetic Indications

Overdentures

Implant restorations


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Magnetic Realities

Provide little lateral stability

Used in limited applications Heat curing will weaken magnets

Corrosion


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Attachment Selection Overdentures- Ridge evaluation and esthetics

Fixed- Ridge evaluation, gingival esthetics

Number of implants

Anterior-Posterior spread Opposing arch ??

Function

Fixed- Rigid, screw retained

Overdenture- Load bearing or non- load bearing

Retention

Available space

Cost


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Patient Considerations

Parallel attachments for easier path ofinsertion

Less attachments better

Patient dexterity

Hygiene Stannous Fluoride rinses

3 month recall


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Anterior/Posterior Spread

A line from the center of the most anteriorimplant to a line joining the distal aspects

of the two most distal implants

Indicates the amount of cantilever that canbe reasonably placed

Usually, 2.5 times the A/P spread


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A/P Spread

Actual Length of Cantilever Depends on:

Stress factors Parafunctional Habits

Crown heights

Implant width Number of implants

Opposing teeth or denture


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Controlling Stress

Stress=Force/Area

Stress

Area

Force


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Torque=

Force x Perpendicular distancefrom the line of force to the

center of rotation


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Cuspal Inclination


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Cuspal Inclination


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Treatment Plan

Options

Implant Supported Soft Tissue Supported

Implant Retained

Fixed Removable


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Treatment Plan

Option 1

Lower Edentulous

Fixed

5-6 Implants


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Prosthetic Options-Lower

5-6 Implants

Hybrid Denture

Fixed Crown and Bridge Cantilever 10-15mm


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2223

24 25

26 27

6 Implants-Fixed

Implant Supported

X

X X

X


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B

A

C D

E

5 Implants- Fixed

Implant Supported

X

X

X

X


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Treatment Plan

Option 2

Lower Edentulous

Removable

5 Implants

P th ti O ti R bl


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Prosthetic Options- Removable

Overdenture-Implant Supported

Gold Bar w/ O Rings

Distalized O Rings

Cantilever 10-20mm

Gold Bar with Hader Clips

Distalized ERAS

Cantilever 10-20mm

A

BC

D

E E

DC

B

A


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Treatment Plan

Option 3

Lower Edentulous

Removable

4 Implants

P th ti O ti R bl


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Implant and Tissue Supported

Gold Bar with O Rings

Cantilever 5-10mm

Gold Bar with Hader

Clips and ERAS

Cantilever 5-10mm

a

b c

d d

cb

a


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Treatment Plan

Option 4

Lower Edentulous

Removable

3 Implants


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Overdenture-Lower


Gold Bar w/ 2- O Rings-Overdenture

No Cantilevers

3 I l t R bl O d t


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B

CD

3 Implants- Removable Overdenture



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Treatment Plan

Option 5

Lower Edentulous

Removable

2 Implants


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Prosthetic Options

Removable Overdenture-Lower

Tissue Supported

Gold Bar w/ Hader Clip

O Ring on each implant ERA attachment on each

implant

2 I l t R bl


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B D

2 Implants-Removable

Tissue Supported


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Treatment Plans

UpperEdentulous

Four

Options


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Treatment Plan

Option 1

Upper Edentulous

Fixed

8 Implants


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Prosthetic Options

Fixed- Upper

Implant Supported

Fixed Crown and Bridge

Hybrid Denture No Cantilevers Necessary


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8 Implants- Fixed

Implant Supported

3

107

6

4

11

13

14

XX

XX


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Treatment Plan

Option 2

Upper Edentulous

Removable

8 Implants


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Prosthetic Options- 8 Implants

Removable- UpperImplant Supported

Gold Bar w/ O Rings-Overdenture

Gold Bar w/ 3 Hader Clips

Overdenture- No Palate

Cantilevers-Optional

8 I l t R bl


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Gold Bar Overdenture

w/ O Rings

Gold Bar Overdenture

w/ Hader Bar / Clips

3

11

13

314

4

67

4

67

13

14

1110 10

Palate No Palate

8 Implants- Removable

Implant Supported


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Treatment Plan

Option 3

Upper Edentulous

Removable

6 Implants


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Prosthetic Options

Removable- Upper

Implant Supported

Gold Bar w/ 4- O Rings and distal

to #s 4 and 13 Gold Bar w/ Hader Clip- ERAS

distal on #4 and 13-

Overdenture-No Palate Cantilever 5-10mm

6 Implants Removable


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6 Implants- Removable

Implant Supported

Gold Bar w/ O Rings 5-10mm Cantilever

Gold Bar w/ Haderclips and ERAs

5-10mm Cantilever

4

5 12

13

107

125

107

134


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Treatment Plan

Option 4

Upper Edentulous

Removable

4 Implants

P th ti O ti


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Prosthetic Options

Removable- Upper

Tissue Supported

Gold Bar w/4 O Rings-

Overdenture w/ No Palate Gold Bar w/ Hader Clip and 2

distalized ERA attachments w/

Overdenture- No Palate

No Cantilever

Arch Form


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Arch Form

4 Implants-Tissue Supported

Square Arch Tapered Arch

4

6 11

13125

116

Maximum contact with tissue No contact with Bar

Attachments are for retention ONLY


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Treatment Planning

Design sensibility and flexibility in the

treatment plan

Design and implant concepts will vary Plan ahead for success

Have a disaster plan

In most cases, less attachments are better

Wh t I O d t


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What Is an Overdenture

A complete denture

that is supported and often

retained by the underlyingteeth or implants and tissue


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Abutment teeth or implants

may or may notbe connected to the denture

via attachments

Bars Copings


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Overdenture Attachments

StudsBars

Teeth

ImplantsMagnets

Copings

Posts

CombinationsIntraradicular

Extraradicular

?????????????????????????????????

Load bearing

Non-Load-bearing


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Overdenture Attachments

Bar joints

Bar units

Round

Ovoid

Square

Rectangular

Radicular:

ExtraradicularStuds, magnets,ERA

Intraradicular

Zaag, Zest,Sterns root

anchor

Bars:

Obj i f h P


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Objectives of the Program

Understand how overdentures preserve

hard and soft tissue

Maintain proprioception

Understand the function of overdentureattachments and simplify attachment

selection

Increasing crown/root ratios to preserveabutments

Hygiene maintenance

Carlson and Persson, Odontologist Revy, Sweeden 1967


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Anterior mandible

average bone loss first year after extractions was 4mm

Tallgren, JPD,1972

Bone loss continues for at least 25 years

Dentures vs Overdentures


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Dentures vs Overdentures

Chewing Efficiency Natural dentition

Complete dentures

Overdentures

90%

59%

79%

Rissin and House, JPD, 1978


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Indications for Overdentures

Periodontal disease

Few remaining teeth

Insufficient crown/root ratios Vertical space

Favorable path of insertion

Retention

Advantages of


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Advantages of

Overdentures

Maintenance of bone height around teeth bypreserving roots

Attenuates resorption patterns of alveolar

ridges Gentler to the tissues

Increases crown/root ratios

Psychological security

Enhanced speaking ability

Maintains Proprioception


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Disadvantages of Overdentures

Esthetic Considerations Bulkiness

Root canal therapy Increase space requirements:

-interarch

-interocclusal Increase costs

C / R t R ti


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Crown / Root Ratios

Attachment Retained


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Attachment Retained

Overdentures

All the advantages of Overdentures

PLUS

Superior aesthetics

Stability and comfort

Mechanical retention

Increased psychological security

and patient acceptance

Increases proprioception

Rigidity or resiliency

Support

ver en uresAtt h t C id ti


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Attachment Considerations

Transfers stress towardsthe retained

roots or implants and away from the ridge No vertical resiliency, some hinge or

rotational resiliency

Shares the load of occlusion with the

mucosal surface

Magnets, Flexi ball, Dalbo Rotex, Bars

Load Bearing

Solid / Rigid

ver enturesA h C id i


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Attachment Considerations

Transfers stress awayfrom theretained roots or implants and towards

the tissue

Vertical resiliency Selected frequently

Dalla Bona, Rotherman, Ceka, Uni Anchor, OSO,

ORS, ERA, Bars

Non- Load Bearing

Resilient

O d t E l ti


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Overdenture Evaluation

Partial DenturePresent

Tooth position

Occlusion Mount casts to vertical

dimension

No Partial Denture Mount cast to vertical

dimension

Diagnostic denture waxup reestablishocclusion

Silicone matrix forspace evaluation

Di t Pl t


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Direct Placement

Male or female premanufactured attachmentis cemented into root

Denture is made and inserted

Corresponding male or female attachment isinserted in root

Attachment is picked up directly in theoverdenture with cold cure acrylic

Placed by Dentist


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Indirect Placement

Male or female attachment is cemented

into root or may need to be cast onto

coping

Corresponding male or female transferanalog is inserted into root attachment

Transfer impression is taken and models

are poured with transfer in place Laboratory processes denture with

corresponding attachment in place

Placed by Laboratory

Proceedures To Follow


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Proceedures To Follow

5 mm or more root remaining in bone

Stable perio

Mount study models evaluate space required

Select OD attachment obtain reference manuals

Begin denture proceedings Root canal therapy

Decoronate roots, extractions, insert temporary

denture reline allow time for healing

Prep tooth for attachment and cement attachment Insert denture, make adjustments, post placement

reline

Pick up male attachment in denture

S k E iHader


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Bar Designs

Round

Ovoid

Square

Rectangular

Double BarCustom Milled

Spark ErosionHader

DolderAndrews

Branson


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Attachments and Bars

Intra Bar

Extra Bar

Circum Bar


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Extra Bar

Attachment placed on the superior aspect of

the bar

Increases strength of bar

Requires more interarch space


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Intra-Bar

Connection between the two components

directs the forces of mastication closer to

the crest of the ridge

Decreases lever arm mechanics

on the supporting teeth

Bar strength may be

compromised


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Circum-Bar

Attachment wraps itself around the bar

Allows for rotation around bar

The Milled Bar


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The Milled Bar

Main Advantage

Final prosthesis is extremely stable because

lateral forces are best managed by an

intimately fitting primary and secondarybar

This minimizes stress on the attachments

The Bar Overdenture


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Advantages

Increased stability and retention than anattachment retained overdenture

Accomodates a wide variety of implantangulations

Bar splints implants together

Provides better resistance to lateral forces whenin function

Pose less of a chance of failure atbone-implant interface

The Bar Overdenture


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Disadvantages

More costly

More technique sensitive

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