Precision Attachment

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Complex multiple fixed and combined

fixed and removable prosthodontics
David Bartlett, David Ricketts, in Advanced Operative Dentistry, 2011

Patient 2
Precision attachments can be used in conjunction with other conventional
means of retention for removable prostheses. Consider the patient seen in
Figure 16.10; gold crowns have been placed on the molar teeth incorporating rest
seats, guide planes and undercuts to achieve support, stability and
conventional retention; however, retention is not so easily achieved anteriorly
without the presence of unsightly metal clasps. One way to overcome this is to
use a precision attachment on the upper left lateral incisor root. This tooth has
been root treated and prepared for a cast post and diaphragm onto which is
soldered the male component of a Rothermann type precision attachment; the
female ‘clip’ attachment is embedded into the fit surface of the denture (Figure
16.11). The male component consists of a disc with a concavity around its
periphery; the female clip seats into this concavity on insertion of the denture,
giving good retention.
Figure 16.10. Patient for which an upper cobalt chromium prosthesis is
planned. Gold crowns have been placed on the two molar teeth incorporating
rest seats, guide planes and appropriate undercuts. Additional retention is
gained anteriorly with a Rothermann-type precision attachment incorporated into
a cast post and diaphragm on the left lateral incisor.

Figure 16.11. Female component of Rothermann-type attachment embedded in the

denture base (left), the male component attached to the cast post and
diaphragm (bottom right) and diagrammatic representation of how the female
component clips into the recess on the sides of the male component (top
right).

> Read full chapter

The principles of tooth replacement

In Restorative Dentistry (Second Edition), 2007
Attachments
Precision attachments can be used to aid retention from the root. However,
they are expensive items and their maintenance is difficult. If required, they
should
only be placed in the more motivated patient. The increased retention brings
about higher loading of the teeth, particularly in the lateral direction, and such
forces are potentially damaging to teeth. If precision attachments are not
maintained properly, failure due to caries around the attachment or periodontal
breakdown is a potential hazard.

There are generally three different types of precision attachments available: studs,
bars and magnets. Studs are generally placed in the root face and the
attachment, in the form of a press clip, is retained in the denture (Fig.
12.55a). Bars have the advantage of spreading the loading between the
abutment teeth. However, they impart high loading to those teeth, are difficult
to clean and relining is complicated. The bar is attached to the root face via a
post system and the clip or sleeve is held in the denture (Fig.12.55b). Magnets
used in dentistry are made from either cobalt— samarium or iron—neodymium—
boron. They have the advantage that they are less likely to cause lateral
stresses to the abutment tooth and are clinically easy to use. Their
disadvantage is that they are liable to corrode in oral fluids over time. Special
base metal is supplied for use with magnets, which is cast into copings and
cemented into the root face. The magnets are positioned in the mouth and
retained in the denture using a self-cure acrylic (Fig. 12.56).

Fig. 12.55. Examples of (a) studs and (b) bars used to retain dentures.
Fig. 12.56. Dental magnets placed on abutment keepers ready to be cured
to the denture.

When planning treatment for overdentures, the clinician should consider

whether the support will come from the teeth, the mucosa or a combination
of the two.
Increasing the support provided by the tooth root may lead to increased
lateral stresses which may be detrimental in the long term. A mucosal-
supported denture receives increased retention and support from the greater
amount of alveolar bone that is present.

> Read full chapter

Dental Prostheses
Jing Zhao, Xinzhi Wang, in Advanced Ceramics for Dentistry, 2014

3.3.4 Precise Attachment Dentures

A precision attachment denture is a kind of RPD that contains precision attach-
ment(s) to lock the denture onto the natural teeth. Precision attachment dentures
are made up of two components. The ‘male’ part is fixed to the natural teeth
and the cor- responding ‘female’ section is incorporated into the denture. The
female and male pieces lock together to yield a very stable prosthesis that gives
the patient maximum comfort and ease of use. These locking effects hold the
denture securely in place and give the patient confidence to socialize and
smile.25 Commonly used precise attachments include keyway attachments, bar
attachments, stud-snap attachments, ball-socket attachments, and magnetic
attachments. In the magnetic attachment, for example (Figure 3.19), the
magnets are placed in the denture. When paired with a magnetizable alloy
keeper on the abutment roots, a closed field magnetic retention
is generated.26 The amount of retention can be adjusted to suit the patient’s
needs, and this magnetic attachment denture can be inserted and removed by
the patient.

Figure 3.19. A Kennedy class II defect dentine was restored by a magnetic

attach- ment- supported RPD.

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Precision and Semi-Precision Attach-

ments
George E. Bambara, in Contemporary Esthetic Dentistry, 2012

Material Options
Precision attachments are milled from high noble metals and must be cast
to high noble metal frameworks. They are obtained as finished products
ready for the laboratory to use. Their tolerances are so precise that errors
in the casting
process may prevent the final prosthesis from fitting well. Because of the
preciseness of fit, they are considered to be rigid attachments. Laboratory
technicians should have a good working knowledge of attachments and
attachment retained prosthetic fabrication techniques.

Semi-precision attachments can be cast in semi-precious or base metal.

Because they are cast, their tolerances are not as precise as those of their
precision counter- parts. One element is generally made of plastic and cast
along with the framework. The other element can be made of metal or has
a metal housing with a nylon or polymer insert. Because of the nature of the
material, the use of spacers in the curing
process which create vertical resiliency, and other design factors, semi-precision
attachments are very versatile in their function and are considered resilient.

Current Best Approach

Treatment planning consists of cast mounted models, radiographs, periodontal
charting, mobility assessments, thorough evaluation of the remaining teeth
and condition of the residual ridges, arch form, esthetics, and patient desires.
These are all used to determine the prosthetic design and the use of specific
attachments.
Cases are planned on an individual basis and determinations are made as to
whether the prosthesis will be implant or root supported and retained, implant
or root and tissue supported and retained, or soft tissue supported and
implant or root retained. Attachments allow dentists to vary treatment
planning. There is no one attachment prosthetic plan that fits all. The goal is to
have a salvageable plan should prosthetic failure occur in the future.

> Read full chapter

Removable Implant Complications

Randolph R. Resnik, in Misch's Avoiding Complications in Oral Implantology, 2018

Prosthesis Movement
Many precision attachments with varying ranges of motion are used in IODs.
The motion may occur in zero (rigid) to six directions or planes: occlusal,
gingival, facial, lingual, mesial, and distal.41 For example, a type 2 attachment
moves in two planes and a type 4 attachment in four planes. Attachment and
the prosthesis movement are independent from each other and should be
evaluated as such. An important item for the IOD treatment plan is to
consider how much prosthesis movement the patient can adapt to or
tolerate with the final restoration. It was to address this need that Misch has
formulated the concept of prosthesis movement instead of the classification of
the individual attachment. The PM classification encompasses movement
from PM-0 to PM-6 (Fig. 15.9).
FIG 15.9. Prosthesis movement. Hinging action of the prosthesis resulting from
anterior implants and lack of posterior soft tissue support (i.e., primary stress
bearing area – buccal shelf ).

(From Misch CE: Dental implant prosthetics, ed 2, St Louis, 2015, Mosby.)

PM-0.
A PM-0 attachment exhibits no movement in any direction. For example, if
the prosthesis is rigid (i.e., movement in no direction) when in place but can
be removed, the PM is labeled PM-0 regardless of the attachments used. If
an O-ring is used individually, they may provide motion in six different
directions. However, if four O-rings are placed along a complete arch bar, the
prosthesis rests directly on the bar and result in a PM-0 restoration. Because
of the design of the attachments and prosthesis, the end result would be a
fixed prosthesis (Fig. 15.10).

FIG 15.10. Prosthesis movement PM-0.

PM-2.
A hingelike PM permits movement in two planes (PM-2) and most often
uses attachments that have the capability to hinge. The most common
examples of PM-2 attachments are the Dolder bar and clip without a spacer
or Hader bar and clip.
A Dolder bar is egg shaped in cross section, and a Hader bar is round. A
clip attachment may rotate directly on the Dolder bar. A Hader bar is
more flexible because round bars flex (x4) related to the distance between the
abutments and other bar shapes flex (x3). As a result, an apron often is added to
the tissue side of the Hader bar to limit metal flexure, which might contribute
to unretained abutments or bar fracture.42 A cross section of the Hader bar
and clip system reveals that the apron, by which the system gains strength
compared with a round bar design, also limits the amplitude of rotation of the
clip (and prosthesis) around the fulcrum to 20 degrees, transforming the
prosthesis and bar into a more rigid assembly. The Hader bar and clip system
may be used for a PM-2 when posterior ridge shapes are favorable and soft
tissue is stable enough to limit prosthesis rotation (Fig. 15.11).

FIG 15.11. Prosthesis movement PM-2, 3, or 4 depending on the number and

types of attachments placed.

It should be noted that for these systems to function as designed, the hinge
attach- ment needs to be perpendicular to the axis of prosthesis rotation so
the PM also will be in two planes (i.e., PM-2). If the Hader or Dolder bar is at
an angle or parallel
to the direction of desired rotation, the prosthesis is more rigid and may
resemble a PM-0 system. As a consequence, the implant system may be
overloaded and cause complications such as prosthetic screw loosening or
fracture, implant crestal bone loss, and even implant failure. A Hader bar-clip
system is an ideal low-profile attachment for a RP-4 prosthesis with PM-0.
Usually, these clips are placed on the bar in different planes of rotation
around the arch.

PM-3.
A prosthesis with an apical and hinge motion is defined as a PM-3. An
example is a Dolder bar with a space provided over the bar. As a result, the
prosthesis moves toward the tissue and then rotates.

PM-4.
PM-4 allows movement in four directions.

PM-6.
PM-6 has a range of PM in all six directions. The most common
overdenture attachments for a PM-6 are independent O-rings or Locator
attachments (Fig. 15.12).

FIG 15.12. Prosthesis movement PM-6. O-Ring with a single implant may move
in all six directions.

> Read full chapter

Sleep and Snoring

Wayne Halstrom, in Contemporary Esthetic Dentistry, 2012

Other Considerations
Clinicians all develop biases based on knowledge and experience. The author's
bias is toward the use of implant-grade titanium precision attachments to
deliver the best results both in durability and function. The Silencer appliance
(Figure 31-1) uses precision attachments to enable adjustments in both the
anteroposterior positioning and the vertical positioning of the mandible.
FIGURE 31-1. Silencer appliance.

(Courtesy Silencer Products International Ltd., VancouVER, British Columbia.)

The author believes that the use of the vertical adjustments in treatment of
OSA patients is important. Bite change is a common companion to mandibular
advance- ment therapy. There is a lack of consensus as to the reasons for this
phenomenon. Experience involving a case load in excess of 3000 patients over
a period of 20 years has convinced the author that in patients with a steep
condylar pathway the increase of vertical dimension not only enhances the comfort
of the wearer but also avoids stretching of the mandibular ligaments, which
can invite a posterior open bite. Iden- tifying the slope of the condylar pathway
is possible using computed tomography (CT) scanning technology; however,
further complicating the costs of therapy may be unwelcome. Very careful
titration of the appliance in both dimensions will offer the best protection
against unwelcome occlusal changes.

> Read full chapter

The Maintenance Phase of Care

Samuel Paul Nesbit, in Treatment Planning in Dentistry (Second Edition), 2007

Special Considerations for Removable Prostheses

Abutment teeth for a removable partial denture or an overdenture are subject to the
same problems as abutments with fixed partial dentures. Overdenture
abutments are particularly susceptible to caries. Dentures are prone to occlusal
wear, midline fractures, flange fractures, and loss of teeth (Figure 9-11). Any
removable prosthesis may become stained or accumulate calculus. Removable
partial dentures in time will suffer from loosening, fatigue, or fracture of the
clasps or acrylic saddles or the frame components. A removable partial
denture with precision attachments is also prone to fatigue and wear of the
attachments with the eventual loss of retention. If the precision attachment
fractures, it is often difficult to repair, and in many cases it is best to replace
the prosthesis.
Figure 9-11. A, Removable partial denture (RPD) showing significant
wear. B, Patient with RPD in place. In this case the prosthesis survived longer
than most of the abutment teeth.

(Courtesy Dr. D.R. McArthur, Chapel Hill, NC.)

With any removable prosthesis, the dentist may find it helpful to segment
the evaluation into three components: clinical factors, patient factors, and
combination factors.

1. Clinical factors include an evaluation of the occlusion, stability,

adaptation, integrity, and retention of the prosthesis; the tissue
response; and the effec- tiveness of the patient's oral hygiene.
2. Patient factors include whether the patient has any symptoms or
reports problems with the fit or function of the prosthesis.
3. Combination factors include those issues that are important to both
patient and practitioner, and for which each may have a different
perspective. Esthetics provides a useful example. When opinions differ
regarding an esthetic issue, the patient's perspective should usually prevail.
However, the dentist must pro- vide appropriate information so that the
patient is able to make an informed decision. For example, if the patient
thinks the partial denture teeth are “too short,” the dentist's role is to
explain why the teeth were selected, positioned, and shaped as they are
(consistency with the form of adjacent teeth, available interarch space,
occlusal wear, and so on), what alternatives are available, how the
alternatives may affect esthetics and function, and at what cost. In this
situation, the ultimate decision to modify or remake the prosthesis is left
up to the patient assuming the request is reasonable and the patient has
realistic expectations of the outcome.
> Read full chapter

Root Form Implants

CHARLES M. WEISS, ... CRAIG COOPER, in Principles and Practice of
Implant Dentistry, 2001

Case as Presented

Patient’s Story.
A typical mainstream case presents with posterior edentulism, either in the
maxilla or mandible. The patient may have a removable, bilateral, free-end
saddle partial denture, in which case one may hear complaints of
complications associated with the natural abutments that have been
clasped or fitted with semi-precision or precision attachments. The patient
sometimes complains of odor, inability to chew food properly, poor esthetics,
or gingival tissue complications. When no removable prosthesis exists, typical
complaints are of a more significant inability to function; interference with
speech patterns; sunken, hollow cheeks; and loss of facial height.

Clinical Appearance.
Examination reveals a loose, unesthetic denture; poor hygiene; some loss of
gin- gival height; and perhaps the initial stages of bone loss around abutment
tooth roots. Facial contours may be com-promised, and interocclusal height
reduced. In mainstream cases, the edentulous portion of the alveolar ridge
shows adequate bucco-lingual width and attached gingiva.

Radiographic Interpretation.
The periapical radiograph reveals adequate osseous support around adjacent teeth,
and sufficient length and depth of available bone to accommodate the insertion
of enough implant abutment support to withstand anticipated functional loads
long-term within physiologic limits of health. The landmarks and osseous
borders are clearly identified on a periapical radiograph (Fig. 11-6).

Figure 11-6. Example of marked borders of available bone.

> Read full chapter

Plate/Blade Form Implants

Charles M. Weiss DDS, ADAM WEISS BA, in Principles and Practice of
Implant Dentistry, 2001

Case as Presented

Patient’s Story.
A typical mainstream case presents with posterior partial edentulism in either the
maxilla or mandible. The patient may have a removable bilateral free-end saddle
par- tial denture, in which case one may hear complaints of complications
associated with the natural abutments that have either been clasped or fitted
with semi-precision or precision attachments, or complaints of odor,
compromised function, esthetics, and gingival tissue complications. When no
removable prosthesis exists, or one cannot be tolerated, added concerns are a
more significant inability to function; interference with speech patterns;
sunken, hollow cheeks; and loss of facial height.

Clinical Appearance.
Examination reveals a loose, unesthetic denture; poor hygiene; some loss of
gingival height; and perhaps the initial stages of bone loss around abutment
tooth roots.
Often, accelerated wear of the occlusal and incisal surfaces of the remaining
teeth is observed. Facial contours may be compromised, and interocclusal
clearance reduced. The edentulous portion of the alveolar ridge is full, with
adequate buc- co-lingual width and a good band of attached gingiva.

Radiographic Interpretation.
The radiograph reveals adequate osseous support around potential natural co-abut-
ments, and sufficient length and depth of available bone to accommodate
the insertion of adequate implant abutment support to withstand anticipated
functional loads long-term within physiologic limits of health. The landmarks
and osseous borders are clearly identified (Fig. 13-7).

Figure 13-7. Panoramic preoperative radiograph showing bilateral posterior

eden- tulism in mandible.
 > Read full chapter

Soldering and Welding

B.W. Darvell DSc CChem CSci FRSC FIM FSS FADM, in Materials
Science for Dentistry (Tenth Edition), 2018

Although casting provides a means of making complicated shapes in metals

and other materials, there remain types of device where this is insufficient. For
example, if alloys with differing properties, such as due to differing amounts of
annealing or work hardening, are required to function in different parts of a
device then because casting cannot give that variation, some joining method
is essential. This is clearly so when alloys with differing compositions are
involved. Examples of this include the assembly of orthodontic appliances
from stainless steel wires and bands, assembly of bridges, and the fixing of
precision attachments to cast devices. In addition, on occasions it may be
necessary to repair a fractured device, although this is usually not a
satisfactory permanent solution. Although the use of rivets or nuts and bolts
may be appropriate fabrication techniques in many circumstances, for intra-oral
use there will be severe disadvantages or impracticalities. Thus, there is
usually little metal present in which to drill a hole, and this would cause a
weakening of the object, even if there were space and soft tissue trauma
could be avoided, which is unlikely. The risk of corrosion is also increased with
the numerous crevices which are thereby created. The use of adhesives,
epoxy resin and the like, is precluded because of relatively low strength, small
interfacial area, and poor fatigue-resistance under wet, oral conditions. What are
left, then, are soldering and welding as the only generally viable techniques.

> Read full chapter

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