Prosthodontics

Biodynamics of attachments used in overdentures: Experimental analysis with photoelasticity

Carlos Labaig*/Rafael Marco**/Antonio Fons*/Eduardo J. Selva*

Abstract Treaiment with overdeniiires is an alternative to conventional complcie prostheses.

Different types ofattachments can be placed in natural teeth that act as retainers Jor overdentures. The photoefastic relationship between the design ofthe attachment and the distribution of occlusal forces among the abutment teelh and the distal alveolar ridges was examined. The results were used to develop a classification for clinical cases so that the correct attachment design can be selected. (Quintessence Int 1997;28:I83-19O.)

Clinical relevance

The use of stress-breaker attachments is indicated for periodontaliy compromised teeth to release the stress and direct it to the distal alveolar ridges. The use of rigid attachment is reserved for periodontally sound teeth, because they can support the greatest amount of stress.

Inlruduction

In recent years, overdentures have been widely used because they provide several different advantages: a reduction in bone loss,' the maintenance of a proprioceptive sensation, which has psychological advantages for the patient.' and better retention and stability''' Among the basic principles accepted by most prosthodontists is to use the patient's remaining teeth

or roots as long as possible.' Inven in implant dentistry, the preservation of remaining teeth is a therapeutic tendency, A great number of patients have teeth with severe destruction ofthe coronal portion, as a result of caries, and a poor long-term periodontal prognosis. These remaining teeth, whose restoration would be difficult and expensive, can be ideal for providing support and retention Ibr an overdenture. The six mandibular anterior teeth usually remain in the oral cavity longer than do the rest ofthe teeth. The incisors are frequently periodontaliy involved, so the mandibular canines have a survival index four times greater than that of any other tooth,*' The mandibular canines, therefore, are the teeth most often used to support overdentures. A great variety of retention systems are available in the market for use with overdentures. They are most easily classified by their biomechanical behavior: 1, Rigid attachments do not permit any movement among their components. The design is based on two cylindric systems of parallel walls that fit into each other like a thimble (eg. the Gerber system and telescopic crowns). 2, Stress-breaker attachments permit rotary movements ofthe prosthesis in one or several directions in space. The design is basically a sphere that rotates inside a hollow cap (eg, the Dalbo B system and the Dolder bar system).

* Associate Priifesiur, Depjnmcnt of Prostiiodontits iind Ocdiiiion, University or ValenfiLi, FCiillj of Medicine and Odnnlolugy, Valencia, Spain. " Assistant Professor, Dpannent of Proslhodnniics and Occlusion, Universily of Valenciu, Faculty of Medicine and Odontology, Valencia, Spain, Reprint rcquesis: Dr Ralael Marco, C/Casc Oliag, I, 460It) Valencia, Spam

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Fig I Model ot the mandibular arch, poured in PL-2 photoelastic resin. The canines, which have been prepared with the Gerber system, are in piace.

Fig 2 Gerber system soldered to the post core and cemented in the canine root canai The canines are poured in PL-1 photoelastic resin.

the supporting structures adjacent to the remaining roots and the distal free alveolar ridges when different retention systems were used.
Method and materials

Fig 3 Overdenture in place, covering the canines and the distai alveolar ridges.

3, Resilient attachments permit vertical movements. This type should not be used, if possibie, because they require more space and are mechanically complex. The verticai tnovement ofthe prosthesis increases bone rsorption; when, as a consequence, this movement ceases, the remaining teeth and the mucosa are compromised. Magnets, because of their peculiar characteristics, are difficult to classify among the types of attachments. In the oral cavity, multidirectional and oblique fores are continuously generated in varying frequencies and intensities. These fores act on the base ofthe prosthesis and the abutment teeth. An overdenture works with a combination of periodontal root abutment resilienee and mucopeiiosteal resihence,''^ The aim of this study was to compare Ihe forces aflecting

In stress analysis, a system is modeled in photoeiastic plastic, loaded, and then viewed through a circular polariscope. Stress patterns are photographed through the polarizing filters ofthe polariscope. In the present study, the experimental model tried to reproduce, with the maximal fidelity that pertnits use of the photoclastic method, a partially edentulous human mandible in which the mandibular canines were the only remaining teeth (Fig 1}. The teeth were reproduced with a photoelastic resin whose modulus of elasticity is close to that of dentin. Six mandibular left and six mandibular right eanines were fabricated. The telescopic crowns were prepared with parailel walls to obtain a rigid behavior. Two eanines were sectioned coronally, and a root canal was made along the longitudinal axis of each tooth so that a cast post could be cemented. A rigid Gerber-type retention system was soldered to the cast (Fig 2). Two canines were prepared similarly but with a Dalbo B system (Cendres Mtaux). Two catiines were prepared with a Dolder bar system (Cendres Mtaux). Two canines were prepared as the others were, but a magnet was used (Cemag, Cendres Mtaux), The last two canines were prepared for a rest-proximal plate-1-bar clasp (RPI) system, so a mesio-occlusai rest and a distal guidance piale were prepared. Six overdentures were fabricated. The female parts ofthe different retention systems were placed in the tissue area ofthe mandibular eanines (Fig 3).

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Two resilient elements were introduced to simulate the biodynamic conditions of the oral cavity: the periodontal ligament, which was reproduced with an elastomeric material, 0.1 mm thick: and the fibromucosa that covers the distal free alveolar ridges, which was reproduced with an elastomeric material, 1,5 to 2.0 mm thick. Once the model was prepared with the different overdentures. it was placed on a turning platform in the center of a loading arch that could rotate 360 degrees. A fixed light source, which consisted of a 45-degree mirror at which was aimed a fiberoptic light, was placed in the center ofthe model. The model could rotate around the light source so that all areas ofthe mandible could be observed without variations in the physical conditions ofthe study. Then the filters of the circular polariscope were installed, and photographs were taken at the level of both canines and the distal free alveolar ridges for each retention system and under four loading conditions: unloaded, and with 24-, 44-. and 64-kg occlusal loads, applied bilaterally. When a photoelascic material is loaded, it is possible, with a polariscope, to observe differently colored fringes. The colors and the extent ofthe fringes indicate the amount of stress that is being applied as well as tbe greatest concentration ofthat stress within the model. The photographs were studied with computer equipment for image analysis with a PIP-FZ 1024 Matrox card, which allows measurement ofthe color fringes that represent stress in the photoelastic model. The results for the different retention systems were compared.
Results

Fig 4 Telescopic crown system. When this system is used, the stress is concentrated on the right canine (RC) and left canine (LC) while tbe right alveolar ridge (RAR) and left alveolar ridge (LAR) are stress free.

The models were analyzed with each one of the retention systems installed and without any load to determine an initial condition in which the model was stress free.
Telescopic crown'.

incrementally with the load. Thus, when the forces were distributed, the canines supported most ofthe load, relieving the distal zones of stress. Only when the load applied was significantly higher did the distal free alveolar ridges begin to absorb stress, although the canines were always stressed to a greater magnitude. The photoelastic photographs revealed that distribution of the stress near the abutment teeth was concentrated around the apex ofthe canines (Figs 5 and 6). Only when the forces were ver>' high did the areas around the distal surface ofthe canines begin to show stress zones. These observations indicated that the telescopic crowns, as a rigid retention system, transmitted the greatest part of the load to the abutment teeth. In this way, the distal areas are relieved of most ofthe forces applied to the occlusal surfaces of the overdenture. Gerber system The concentration of stress around the roots of the mandibular canines had absolute values slightly smaller than the mandibular distal alveolar ridges had (Fig 7). This retention system behaved almost rigidly, because only when forces were very high was significant stress directed to distal zones. Nevertheless, when a load was applied, the distal area had a higher stress

The concentration of stress was greater near the mandibular canines than in the distal free alveolar ridges (Fig 4). The concentration of stress was always greater in the canine than in the distal alveolar ridge on the same side. The concentration of stress in the distal edentulous zones remained the same when forces of 24 and 44 kg were applied, while the stress in the canines increased

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Fig 5a Stress distribution around the canine when a stressbreaker attachmeni is used.

Fig 5b The black hole represents ihe canine root. A stress-breaker is being used, and a low-order fringe fS apparent surrounding the periodontal ligament

Fig 6a Stress distribution over the distai alveolar ndge when a stress-breaker attachment is used.

Fig 6b A high stress concentration is observed in the distai alveolar ndge, represented by a three-order photoelastic fringe. The darkest areas represent the highest ooncentrafion of stress

Load

[23 24 kg ^

44 kg d ] S-t kg

Fig 7 Gerber system. When this system is used, the concentration of stress is siightly lower around the canines (RC and LCI than m the distal alveolar ndges (RAR and LAR),

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concentration than did the abutment rotats. This was probably due to the small size ofthe alUtchment, which did not allow a greater absorption of load.
Bar system

The data in Fig 8 indicate the small amount of stress cDncentrated near the roots ofthe mandibtilar canine abutments. Overall, it is compared with the absolute values observed in the distal areas. This bar-type retention system behaved like a real stress-breaker, and all the load applied in the occlusal surface ofthe overdenture was distributed to the distal edenttilous zone. This is understandable, considering the rotating movement ofthe holder in the overdenture over the cylinder-form bar. The stress around the abutment root was initially concentrated at the apex. When the forces increased, the stress was situated in its apical distal third. This would mean that, if the occiusai loads were high, the overdenture would traction distally to the unit formed by the abutment roots and the bar that connects them {Rgs 9 and 10),
Dalbo system

Frg 8 Bar system. When thts system ts used, the stress is dislribuled to Ihe dislal alveolar ridges (RAR and LAR), relievtng the canines (RC and LC),

For the Dalbo system, distribution of forces was equal among the canines and their distal free alveolar ridges (Fig II), The stress around the root surface was mainly concentrated in its distal portion, confirming that, although this system behaved like a real stress-breaker, it had a torquing etfect over the abutment tooth to which it was attached. Magnet .tystem With the Cemag magnet system, the concentrations of stress near the canines were minimal, no matter what load was applied, although the stress gradually increased (Fig 12), It would be a compromise to classify this system as a stress-breaker, because this system does not work like a real load distributor. The stress in the abutment roots was caused exclusively by the stress in the reciprocal plane surfaces of ihe system that keep in contact. The distal free alveolar ridges bilaterally received the stress from the forces in the occlusal surfaces, liPI system Quantitatively, the absolute values registered were high near the canines and in the distal alveolar ridges (Fig 13), The stress in the distal areas was moderately higher than that registered in the abutment teeth.

Discussion Although this is an in vitro study, which may or may not reproduce the conditions in vivo, it is possible to make certain observations about the findings,"' Any technique that uses models musi be understood tinder the conditions t3f its own methodology, with its advantages and disadvantages, ' ' However, the model's limitations do not invalidate the comparative results found with diverse loads and restorative treatments.'' Among the existing techniques used for analysis of stress and deformation, the four-dimensional photoelasticity was selected because it is especially useful in the biodynamic analysis of structures that have a complicated form or complex loading conditions such as those found in removable partial prostheses and overdentures,'-' This study showed, as have previous reports,^ that the stress generated by the retention systems for overdentures tends to be divided between the abutment teeth and the alveolar ridge, depending on the retentive capacity of these systems. Those attachments with higher rigidity or retentive capacity induce a higher concentration of stress in the abutment tooth, relieving part ofthe stress in the distal free alveolar ridges. When the retention system behaves as a stress-breaker, the abutment teeth are reiieved of most

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Ftg 9a Stress distribution arounc Ihe canine when a rigid altachment s used

Fig 9b The black hole represents the canine root. A rigid system is betng used, and a three-order photoelasttc frtnge can be observed in the distal area o! Ihe canine surface, representing the highest concentration of stress

Ftg 10a Stress distribution over Ihe distal alveolar ridge when a ngid attachment is used.

Ftg 10b A low concentration of stress is observed tn the distal alveolar ridge, wtth low-order photoelastic fringes. The lightest area represents the lowest stress.

Fig 11 Dalbo system, This system shows an equal distribution of forces among the canines [RC and LC) and !he distal alveolar ridges (RAR and LAR),

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Fig 12 Magnet system. The concentration ot stress around the canines (RC and LC) is minimal, and the maximai stress is directed to the distal alveolar ridges (RAR and LAR).

Fig 13 RPI system. The stress in the distal alveolar ridges (RAR and LAR) is slightly higher than that on the canines (RC and LC).

of the stress, which is distributed to the alveolar ridges.''' When complete or partial removable prostheses are designed, the occlusal forces should be transmitted along the longitudinal axis of the abutment teeth to minimize the horizontal torque and protect the periodontal ligaments. The photoelastic model used in this study revealed that this goal was achieved to different degrees, depending on the design ofthe system used. The rigid design of the Gerber system directs a higher concentration of stress to the abutment teeth, relieving, to some degree, the alveolar ridges. This system could be indicated when the patient has more than two abutment teeth and the aim is to design a tooth-supported overdenture instead of an overdenture supponed by teeth and mucosa. If there are only two abutment teeth, they can be used if their periodontal condition is fair and the aim is to preserve distal free alveolar ridges that exhibit extensive rsorption. Overdentures with telescopic crowns and distal free alveolar ridges transmit less stress to the edentulous zones, and in the abutment teeth the forces are equilibrated. '^ At the same time, the stress in the distal zone is concentrated distally to the abutment teeth and not distally to the free alveolar ridge. This retention system better distributes the occlusal forces- The use of telescopic crowns could be especially indicated when there are three, four, or five abutment teeth with good

periodontal health and little mobility. In our clinical work, nevertheless, it has been established that the use of telescopic retention systems deereases the mobility of periodontally involved teeth. This eould be due to the axial distribution ofthe load with this system and to the apical distribution ofthe resulting stress secondary to the design of this friction retention system. The objective of a stress-breaker system is to decrease the torque over the abutment tooth in which the attachment is installed. The Dalbo system fulfills this objective. The forces are transmitted along the longitudinal axis ofthe root. The Dalbo system was, after the magnets, the one that behaved most favorably whh the abutment root. Only when the load applied was extremely high did stress-concentration zones start lo appear in the distal surface ofthe root, because it is then, when the prosthesis sinks in the mucosa, that the base ofthe prosthesis has a shear efiect over the abutment tooth. This situation simulates that of a patient who has resorbed alveolar ridges and does not have the prosthesis periodically relined. The excessive degree of mobility ofthe saddle may work against the stress-breaker effect ofthe retention system, and then the prosthesis tractions distaily to the abutment tooth: thus begins an iatrogenic periodontal effect that will dramatically shorten the survival ofthe toothThe present results corroborated the report by Thayer and Caputo"" that the Dolder bar applies less
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Stress to ihe remaining roots and more over the posterior edenttiious zones, distributing the occlusal forces in a better way in those situations in which the teeth are not periodontally involved and they receive the splinting effect ofthe bar. The use of magnets would be recommended in patients with conserved alveolar ridges that are capable of supporting the occlusal forces generated in the biodynamic of a removable complete prosthesis. This would otier these patients the possibility of a slight improvement in the retention and stability of their prosthesis and at the same time conserve the proprioceptive sensation near the canine area. The results indicated that, ofthe systems tested, the RPI system generated among the highest stress concentrations on the abutment teeth, sometimes even higher than those generated by the rigid systems. This could mean that ihe torquing effect that is believed to be due to the traction ofthe saddle over the abutment tooth is actually caused by the occlusal rest situated mesially in the canines. Therefore, an overdenture with an RPI retention system would not be indicated for any situation. Clinical experience by itself is not enough to determine if a prosthodontic design is acceptable. Laborator>' investigations are necessar>' to analyze ihe forces generated by removable prostheses. In addition, controlled clinical studies are essential to evaluate the effects ofthe prosthesis on the oral tissues. Conclusions Treatment with overdentures offers an alternative to conventional complete prostheses to increase the comfort of patients by providing a more stable reconstruction. After analysis ofthe results ofthis photoelastic study, we propose classifying clinical cases, to allow selection ofthe correct treatment, in one of four classes: Class I. Resistant abutment tooth and resistant alveolar ridge. In this clinical situation, any design could be used with a high rate of success. Class //. Weak abutment tooth and resistant alveolar ridge. The use of a stress-breaker could be indicated to release the stress from the abutment teeth. Mucostatic impressions with maximal compression ofthe mucosa should be used, so that in rest position the retention systems will be inactive if there is vertical resiliency.

Class III. Resistant abutment tooth and weak alveolar ridge. Rigid retention and mucofunctional impressions with wax or zinc oxide-eugenol paste, which slightly compress the mucosa, should be used. C7i/.v.s V. Weak abutment tooth and weak alveolar ridge. This clinical situation is one of the most compromising in prosthodonlics. Different techniques must be combined to minimize any mechanical damage to both weakened structures. In these circumstatices, any therapeutic solution would have a poor prognosis: alternative therapies should be considered.

References
1. Tallgrin A. The tiinlinuini rediiclion of Ihe residual alveljr ridges ill ciimplete denture wearers; A mised longiludinai sludy covering 25 years. 1 Prmtliel Dent ]'n2:ll: 120. 2. Crum RJ. Loiselle RJ. Orjl perception and proprioceplion. J Proslhet Denl l9 .'. Renner RP. Foerth D. Levey tj. Preventive prosttiodontksOverdenture service. NY Siaie Dent! 1977.4.1:17. 4. Craig RG. Farali JW, El-Taliawi HM. Three-dimenbiunal photoeljstit streis analysis of maxillary compiete dentures. J Proslhet Dent I974;3M2;-I29 5. LangerY. Langer A. Root-retained verdentures: Parti. Biumectianic.il and clinical aspects J Prosthet Dent 199;ei6:7g4-789. 6 Langer Y, Langer A Root-retained overdentjres- Partit. Managing trauma between edentulous rEdges and opposite dentition J Prosthet Dent I9y2:67:77-Ml. 7. Prieskel HW Precision Attachments in Prosthodontics: Applications of tntracoronal and Extracoronal =.\taclimems. Chicago: Quintessence, 1984. 8. Thayer HH. Caputo AA. Occlusal force transmission by overdenturo attachments J Prosthet Dent 1979:41 266-271. 9. SelvaOtaolaurruchi E. Experimental Models Analysis in Removabtt Partial Prosthesis With Photoelast ici ty Itiiesisl. 1992. 10. K.U SH. McDowell GC. Kotowicz WE. Pholoelastic stress analysis uf mandibular partial dentures with mesial and distal occlusal rests. J Prosthet Dent 19M6;56:4S4-46. 11. Dempsler WT, Adams WJ. DudJIes IA. Arrangement in the jaws of roots ofthe teelh. J Am Denl Assoc I963;67 779. 12. Hood JA, Farih JW, Craig RG. Slress and deflections of three difTerent ponlie designs. J Prosthet Dent 197S;J3;54-59.

1.1. Farah JW. MacGregor AR. Miller TP. Slress analysts of disjunct removable partial dentures. J Proslhet Denl 1979:42:271-276. 14. Thayer HH. Capulo AA. Photoelastic stress a na lys i s of o verde n tu rs attachments. J Prosthet Detil 19aO;4_1:6ll-6l7. 15. Pezzoli M,RossettoM. CalderalePM. Evaluation of load transmission by distal-extension removable partial dentures by using reliection photoelaslieUy. J Prosthet Denl 1986;56;J29-3.17. 16. Thayer HH, Caputo AA. Effects of overdentures iipoti remaining Ural structures. J Prosthel Dent [977:.n:.-!74-3m. D

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