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Five-year clinical follow-up of prefabricated precision attachments: A comparison of uniand bilateral removable dental prostheses
Johannes Schmitt, DMD1/Manfred Wichmann, PhD, DMD2/ Stephan Eitner, PhD, DMD3/Jrg Hamel, DMD4/ Stefan Holst, PhD, DMD3
Objectives: To evaluate the clinical long-term success of prefabricated precision attachments in retaining uni- or bilateral removable dental prostheses. Method and Materials: Twenty-three patients with uni- or bilateral shortened dental arches received removable dental prostheses attached to the residual dentition with two types of precision attachments. Results: After 5 years, 70% of bilateral and 25% of unilateral removable dental prostheses remained clinically functional. The most frequent cause of clinical failure was fracture of the abutment teeth for bilateral partial dentures and irreversible wear of the precision attachment for unilateral prostheses. Oral hygiene status significantly improved, and the mean pocket depth of the abutment teeth did not increase after 5 years. Conclusion: Removablepartialdentureprostheses,retainedbilaterallywithprecisionattachments, are a reliable treatment modality without negative long-term effects on periodontal health, whereas unilateral removable dental prostheses cannot be recommended because of high clinical failure rates. (Quintessence Int 2011;42:413418)

Key words: distal free end, precision attachment, removable dental prosthesis, unilateral

A shortened dental arch or distal free-end situation is defined as a dentition with intact anterior teeth and a reduction of occluding pairs of posterior teeth that affect the premolars and molars.1 Restorative solutions include fixed tooth- or implantretained restorations and removable dental prostheses. A removable dental prosthesis can be retained by clasps or extracoronal attachments or be designed as an overdenture retained by telescopic copings. When evaluating the long-term survival of

teeth adjacent to treated or untreated posterior-bounded edentulous spaces, teeth restored with fixed dental prostheses had a 10-year survival estimate of 92% compared with spaces that remained untreated (81% survival of adjacent teeth). However, the application of removable dental prostheses resulted in only a 56% survival rate.2 The advantages of using attachmentretained removable dental prostheses are improved esthetics, readjustable retention force, and a reduced incidence of secondary caries that is often observed with claspretained dentures.3 While some clinical

Assistant

Professor,

Dental

Clinic

2,

Department

of

studies of precision attachmentretained removable dental prostheses report good results with 80% of the prostheses functioning properly after a 3-year period,4 other studies observed failure rates of 35% to 40% after 5 years and only a 30.1% clinical survival rate after 8 years.5 In longitudinal studies, the lack of success of extracoronal attachments was attributed primarily to biologic and secondly to technical factors.6,7

Prosthodontics, University Clinic Erlangen, Erlangen, Germany.

2

Dean and Clinical Director, Dental Clinic 2, Department of Prosthodontics, University Clinic Erlangen, Erlangen, Germany.

Associate

Professor,

Dental

Clinic

2,

Department

of

Prosthodontics, University Clinic Erlangen, Erlangen, Germany.

4

Private Practice, Karlsruhe, Germany.

Correspondence: Dr Johannes Schmitt, Dental Clinic 2, Department of Prosthodontics, schmitt@uk-erlangen.de University Clinic Erlangen, Glueckstr 11, 91054 Erlangen, Germany. Email: johannes.

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MethOd and MateRialS

Patients presenting with uni- or bilateral shortened dental arches were informed of the study and gave their written consent. The study protocol was approved by the local ethical committee (IRB no. 2783). A total of 23 patients participated in the study in 2000 and 2001 and received a total of 20 bilaterally retained removable dental prostheses and eight unilaterally retained removable dental prostheses retained by precision attachments (Swiss Mini-SG System, Cendres & Meteaux). The Mini-SG system is a prefabricated precision attachment system based on one universal male and several different female components. For all Kennedy Class II situations, splinting of abutment teeth was performed. In addition, bracing arm constructions were planned (Fig 1). In Kennedy Class I cases, splinting of abutment teeth was carried out for all but three dentures (Fig 2). For Kennedy Class I bilateral situations, extracoronal attachments with interchangeable plastic inserts that are adjustable with To achieve long-term clinical success with precision attachments, at least two abutment teeth should be splinted,8 and a number of technical improvements have been developed in recent years. These include adjustable retentive forces with set screws and interchangeable plastic inserts that allow for easy recovery of retention and eliminate problems associated with wear of components. Despite the number of studies of precision attachments available, no data are available comparing the clinical performance and success of precision attachments in uni- or bilateral edentulous situations. The rationale of the present prospective clinical investigation was to assess the long-term outcome of unilaterally retained removable dental prostheses or bilaterally retained removable dental prostheses with regard to their technical and biologic complications. It was hypothesized removable that bilaterally prostheses Prostheses survival rates after 3 and 5 years of clinical function are shown in Table 1. For bilaterally retained removable dental prostheses, the most common complication and cause for prosthesis failure was fracture of abutment teeth, whereas for unilaterally retained removable dental prostheses, irreretained dental an activation screw or by replacing the insert itself were used, whereas the unilateral removable dental prostheses were anchored with spring bolt attachments. The first examination was conducted 2 weeks after the prosthesis was inserted (baseline). Follow-up examinations were performed annually for 3 years and after 5 years of clinical function. To evaluate oral hygiene status and gingival inflammation, Plaque Index (PI) and Gingival Index (GI) scores were assessed.9,10 Periodontal probing depths were measured at six locations near each abutment tooth. Data analysis consisted of descriptive statistics and the Wilcoxon test for paired data (P .05).

Fig 1 Removable dental prostheses for Kennedy Class II occlusion. Unilateral prosthesis for Kennedy Class II with splinted teeth (mandibular central and lateral incisors and right canine and first premolar). The inset image shows the female part of the Mini-SG attachment with spring bolt and activation screw.

ReSultS

would positively affect long-term stability and longevity of the prosthesis, whereas unilaterally retained removable dental prosthesis retention would be more susceptible to technical complications.

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Fig 2 Removable dental prostheses for Kennedy Class I occlusion. Bilateral prosthesis for Kennedey Class I, and the unsplinted single abutment teeth (maxillary right first premolar and left canine). The inset image shows the female part of the Mini-SG attachment with the plastic insert and activation screw.

Fig 3 Irreversible mechanical wear on the male attachment part. The inset image shows a new male attachment part.

table 1

Prostheses survival rates Class i: Bilateral distal extensions (baseline, n = 20) 80.0% 70.0% Class ii: unilateral distal extensions (baseline, n = 8) 62.5% 25.0%

Year 3 5

table 2

Reasons for prosthesis failure Class i: Bilateral distal extensions (total no. of attachments = 43) Class ii: unilateral distal extensions (total no. of attachments = 8) 4 1 1

Irreversible mechanical wear of attachment Fracture of abutment splinting Fracture of abutment tooth Caries

4 2

versible mechanical wear of the male part of the attachment occurred (Table 2 and Fig 3). Four nonsplinted abutment teeth (two vital, one endodontically treated) fractured in the bilateral group.

For bilaterally retained removable dental prostheses, the attachment retention force could usually be restored with screw activation, but exchange of the plastic insert was necessary in one-third of all attachments

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table 3

technical complications occurring during the 5-year observation period Class i: Bilateral distal extensions (total no. of attachments = 43) Class ii: unilateral distal extensions (total no. of attachments = 8) 3 4 3 1

Attachment screw activation Change of plastic insert Irreversible mechanical wear of attachment Fracture of ceramic veneering Decementation

20 17 1

during the 5-year observation period. In four clinical cases, the male part of the spring bolt attachment for the Kennedy Class II situations showed irreversible mechanical wear after 4 years of clinical function, and the restoration had to be replaced (Table 3). The mean probing depth values ranged from 2.1 to 3.1 mm for the abutment teeth after 5 years and did not increase compared with baseline values (.023 P .850). DataforPIandsulcusbleedingindex(SBI) showed a statistically significant decrease (P < .001) and dropped to 52.1% and 50.2%, respectively, in both groups after 5 years.

removable dental prosthesis design without reciprocation elements in patients with a reduced vertical dimension may put this type of restoration at risk for failures. In vitro investigations showed that these attachments tend to introduce significantly more stress at the terminal abutment tooth compared with clasp-retained dentures.14 With the use of the extracoronal attachment systems, fracture of unsplinted abutment teeth or caries on splinted abutments can lead to irreversible prosthesis failure. Therefore, use of the extracoronal attachment system requires at least two splinted, vital, and periodontally healthy abutment teeth.8,13 The survival rate for the unilaterally retained removable dental prostheses was 25.0% after 5 years; using the miniaturized attachment system for this indication is highly questionable. An in vitro investigation demonstrated that movement of the abutment tooth and denture base of unilaterally stabilized dentures is significantly greater than with the bilateral design.15 Jin et al recommended positioning occlusal contacts exactly on top of the crest of the alveolar ridge and not extending the restorations distally to the first molar.15 The observed destructive and irreversible wear of the miniaturized male attachment part and the fracture of a vital and splinted abutment tooth in the present investigation is a strong indicator of prosthesis movement during clinical function. It can be assumed that the design of a unilaterally retained removable dental prosthesis without crossarch stabilization and extended cantilever lengths creates significant stress on the fixed dental

diSCuSSiOn
The observed survival rate of precision attachmentretained bilateral removable dental prostheses was comparable to the reported survival rates of clasp-retained removable dental prosthesis after 5 years, but inferior to the 95.1% survival rate reported for telescopic crownretained dentures.11,12 Despite the vitality of the teeth, three of the observed abutment tooth fractures, all of which led to failure of bilateral dentures, occurred on nonsplinted attachments and are in accordance with data reported in the literature.13 Thus, the low survival rate of 70% after 5 years refers partially to nonsplinted abutment teeth, which created a lack of uniformity in the bilaterally retained removable dental prosthesis group. Nonsplinted abutment teeth with a

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prosthesis. The additional lack of control on the lateral and vertical forces on both the removable and fixed dental prosthesis may be the primary reason for the observed technical failures. As suggested by other authors, bilateral stabilization should be recommended for Kennedy Class II situations if removable dental prostheses are used.1517 A remarkable finding of this study was the need to change the plastic insert in the female part of the bilaterally retained removable dental prosthesis attachments, confirming previous in vitro findings that showed only negligible amounts of wear on plastic female inserts in comparison with metal-alloy matrix and patrix components.18 Improvement in periodontal parameters is a positive result of this study, contrasting with reports of clasp-retained removable dental prostheses
19

aCKnOwledgMentS
The authors express their gratitude to dental technician Erwin Schtz for his outstanding collaboration and excellent technical expertise during years of clinical teamwork. The study was supported by Cendres & Meteaux.

RefeRenCeS
1. Kyser AF. Shortened dental arches and oral function. J Oral Rehabil 1981;8:457462. 2. Aquilino SA, Shugars DA, Bader JD, White BA. Tenyear survival rates of teeth adjacent to treated and untreated posterior bounded edentulous spaces. J Prosthet Dent 2001;85:455460. 3. Wagner B, Kern M. Clinical evaluation of removable partial dentures 10 years after insertion: Success rates, hygienic problems, and technical failures. Clin Oral Investig 2000;4:7480. 4. Zajc D, Wichmann M, Reich S, Eitner S. A prefabricated precision attachment: 3 years of experience with the Swiss Mini-SG system. A prospective clinical study. Int J Prosthodont 2007;20:432434. 5. Studer SP, Mder C, Stahel W, Schrer P. A retrospective study of combined fixed-removable reconstructions with their analysis of failures. J Oral Rehabil 1998;25:513526. 6. Owall B. Precision attachment-retained partial dentures. 1: Technical long-term study. Int J Prosthodont 1991;4:249257. 7. Owall B. Precision attachment-retained removable partial dentures. Part 2: Long-term study of ball attachments. Int J Prosthodont 1995;8:2128. 8. Altay OT, Tsolka P, Preiskel HW. Abutment teeth with extracoronal attachments: The effects of splinting on tooth movement. Int J Prosthdont 1990;3:441448. 9. Quigley GA, Hein JW. Comparative cleansing efficiency of manual and power brushing. J Am Dent Assoc 1962;65:2629. 10. Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963; 21:533551. 11. Vermeulen AH, Keltjens HM, vant Hof MA, Kayser AF. Ten-year evaluation of removable partial dentures: Survival rates based on retreatment, not wearing and replacement. J Prosthet Dent 1996; 76:267272. 12. Wstmann B, Balkenhol M, Weber A, Ferger P, Rehmann P. Long-term analysis of telescopic crown retained removable partial dentures: Survival and need for maintenance. J Dent 2007;35:939945. 13. Owall B, Jnsson L. Precision attachment-retained removable partial dentures. Part 3. General practitioner results up to 2 years. Int J Prosthodont 1998; 11:574579.

that

described

increased plaque accumulation and periodontal inflammation. Our results showing that inflammatory signs improved and periodontal probing depths generally appeared quite stable over time led to the conclusion that precision attachmentretained removable dental prostheses contribute less to formation of dental plaque compared with clasp-retained removable dental prostheses. Furthermore, a precise attachment between the prosthesis and abutment teeth with adjustable retentive forces seems to be useful in maintaining periodontal health. It can be argued that the reduced number of patients in the unilaterally retained removable dental prosthesis group is inadequate to draw definitive conclusions about the attachments performance. However, the observed failure parameters (destructible wear) were identical in all patients and presented a general reason for failure that can also be expected in larger samples sizes. Therefore, it can be concluded that the Mini-SG attachment is suitable for anchoring bilaterally retained removable dental prostheses, whereas in unilateral distal free-end situations, the design of removable dental prostheses should include crossarch stabilization if alternative fixed restorations are not feasible. Unilaterally retained removable dental prostheses cannot be recommended because of high clinical failure rates.

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14. Saito M, Miura Y, Notani K, Kawasaki T. Stress distribution of abutments and base displacement with precision attachment- and telescopic crownretained removable partial dentures. J Oral Rehabil 2003;30:482487. 15. Jin X, Sato M, Nishiyama A, Ohyama T. Influence of loading positions of mandibular unilateral distal extension removable partial dentures on movements of abutment tooth and denture base. J Med Dent Sci 2004;51:155163. 16. Zarb GA, Bergmann B, Clayton JA. Prosthodontic Treatment for Partially Edentulous Patients. St Louis: Mosby, 1978:449462.

17. Carr AB, Mc Givney GP, Brown DT. MCCrackens Removable Partial Prosthodontics, ed 9. St Louis: Mosby, 1994:157158. 18. Wichmann MG, Kuntze W. Wear behavior of precision attachments. Int J Prosthodont 1999;12:409414. 19. Yeung AL, Lo EC, Chow TW, Clark RK. Oral health status of patients 56 years after placement of cobalt-chromium removable partial dentures. J Oral Rehabil 2000;27:183189.

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