Precision Attachment

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Prosthesis, Dental Caries, Removable Partial Denture, Prosthetics, Salicylic Acid,

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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.

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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.

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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.

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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.

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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.

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