Prosthodontics

Harold W Preiskel Alon Preiskel

Precision Attachments for the 21st Century

Abstract: This paper outlines the evolution of precision attachment applications from partial denture retention to the implant-retained overdenture. Clinical Relevance: Understanding precision attachments in the osseointegration era is essential to obtain optimal treatment outcomes with the new therapeutic methods available. Dent Update 2009; 36: 221227

By the end of the 1970s, precision attachments were playing an increasing role in prosthodontics. These small elegant devices were able to connect removable prostheses to their abutments, unite components of fixed prostheses, or provide a variety of other applications. With a century of development behind them they bore testimony to the ingenuity of enterprising dedicated clinicians and technologists. Faced with an ageing, fit and active population expecting a greater quality of care, it appeared that the demand for attachment-retained sophisticated prosthodontics would be insatiable. The development of predictable osseointegration techniques produced a quantum leap in treatment possibilities and with it a change in prosthodontic direction. The osseointegration era heralded new

a treatment planning protocols. No longer was the removable prosthesis the only restoration for large edentulous spans, while distal extension spaces could be restored with fixed prostheses, at least in many instances, and were much preferred by patients. Furthermore, there was no need to involve abutment teeth and the total cost of the two approaches was not dissimilar. Even more importantly, the edentulous patient could now look forward to a significant b improvement in the quality of life with the attachment-retained overdenture playing a significant role and now with more than a quarter of a century of success. It is therefore the aim of this article to discuss contemporary uses of precision attachments.

Precision attachments
Precision attachments can be classified into five main groups:1 Intracoronal attachments This group has its main applications in connecting units of fixed prostheses, retaining restorations with distal extensions or bounded removable prostheses (Figure 1). A subdivision of this group, semiprecision attachments, are specially formed, deep occlusal rest seats which are useful in the stabilization of removable prostheses (Figure 2). In the early days of osseointegration, intracoronal attachments

Harold W Preiskel, MDS(Lond), MSc(Ohio), FDS RCS(Eng), Consultant Dental Surgeon, Specialist in Prosthodontics and Restorative Dentistry and Alon Preiskel, BDS(Lond), MClinDent(Lond), MFDS RCPS(Glasg), MRD RCS (Edin), Specialist in Prosthodontics and Implant Programme Coordinator at the Eastman Dental Institute, 25 Upper Wimpole Street, London, UK. May 2009

Figure 1. (a) An intracoronal attachment in a pontic used to support and retain a unilateral distal extension base. (b) A similar attachment duly aligned is employed in the distal abutment on the contralateral side.

were unsuccessfully used to join implants and tooth-supported restorations. The movement potential proved a drawback, not an advantage. Extracoronal attachments This group provides stability and retention for DentalUpdate 221

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Figure 2. An example of a semi-precision attachment-retained prosthesis after 30 years of use.

Figure 3. (a) Dalbo extracoronal attachments employed to support and retain a bilateral distal extension partial denture. Bracing arms are usually unnecessary in view of the profile of the actual attachment. (b) The Dalbo design incorporates a tilt preventing flange; other extracoronal units may require an indirect retainer.

removable distal extension prostheses (Figures 3 and 4 ). Stud attachments Usually in the form of ball and socket devices, the attachments serve primarily for overdenture stabilization and retention. Bar attachments. Originally used for splinting groups of teeth, they are now mainly employed for overdenture retention and stabilization, but have maxillofacial prosthodontic applications as well. An auxiliary group, including springloaded plungers and small screws. Interestingly, the technology involved in the production of small screws has been incorporated into several well known dental implant systems. In fact, the manufacturers of precision attachments are often heavily involved in implant component manufacture, albeit anonymously. Osseointegration development has led to the decline of intracoronal and extracoronal precision attachment usage but by no means its elimination, as there are some medical contra-indications for implant placement. There are other situations where extensive and possibly unpredictable grafting procedures would be required, making the well retained removable prosthesis the restoration of choice. However, it is with the overdenture that the greatest applications have emerged. The implant-supported overdenture had become the accepted method of treatment within five years of the 1982 Toronto conference. By 1989, a conference on implant-supported overdentures had been convened in Brussels2 and, within the following decade, research data established the method as a predictable and versatile

Figure 4. A rigid type of extracoronal attachment incorporating a bracing arm.

Figure 5. Stud attachments are relatively straightforward retention and supporting devices for overdentures on implants.

Figure 6. A significant mandibular defect following tumour removal. The overdenture approach obviates the requirement for extensive grafting procedures.

Figure 7. Impression surface of the overdenture. The design of this recent stud retainer allows the retention to be adjusted in small increments by means of a screwdriver.

treatment option.3-9 Nowadays, being edentulous in developed countries can be viewed as a pathological state. Indeed, the McGill Consensus Meeting in 2002 established two ball and socket stud type attachments on implants as the recommended approach for the edentulous milieu.10 While stud and bar attachments had been designed for root-supported overdentures, they were readily and speedily adapted for use with implants11-14 (Figures 5-9).

Retention systems
Once placed in the mouth, a removable prosthesis is subjected to a variety of forces applied in different directions. Retention can be considered as the force that resists withdrawal along the path of insertion. The ideal overdenture has inherent stability and a border seal that provides retention; the additional retaining devices simply serve an auxiliary role. Unfortunately, the ideal situation does not always apply. Anatomical considerations May 2009

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Figure 9. Designs with flattened studs minimize vertical space requirements. Figure 8. Diagram of the Dalbo Elliptical stud retention system.

Figure 10. The Locator retention system is a relative newcomer and proving popular. Retention is provided by a replaceable resin component within the female section.

may dictate reduction of a flange, or an open palate design may be felt appropriate with implant-supported restorations, all of which result in far higher loads upon the retaining devices. Glantz and Nilner15 famously described the overdenture as a load transfer device of an unpredictable nature. Owing to midline stress concentrations, they recommended a metal denture base for open palate designs. Retaining devices may also act to provide occlusal support and stabilization, irrespective of whether or not they were actually designed to withstand these forces. Retainers may be required to provide occlusal support and, during chewing, high loads may be applied briefly. The potential moments from loads well away from the retainers highlight the difficulty of preventing distortion of flexible retention tips unless some additional stabilizing component is incorporated. Naturally, the most important stabilizing component should be the removable prosthesis itself. A denture that consistently tips and rotates around its supporting and retentive structures is likely to apply excessive loads. Small wonder that adjustment of stud and bar retaining clips and associated breakages are very high on the list of complications that arise with overdenture treatment.16 If the retention apparatus is strong enough, these loads will simply be transmitted further along the chain. Any projection above the level of the mucosa requires a corresponding hole in the denture. The bulkier the retainer, the larger the hole, correspondingly weakening the denture base. As the height May 2009

a of the projection increases, the faciolingual space becomes more critical, the alignment of the retaining components with each other becomes more difficult, and the path of the insertion of the overdenture becomes more precise. It can now be understood why there has been a continued search for small retaining systems. Such units would be particularly useful in the treatment of b patients of Asian extraction, where vertical space is often restricted (Figures 10 and 11). A flat root covering, such as employed with a miniature magnet, would have advantages. The retention characteristics of the units require consideration because, under masticatory loads, the occlusal table will move until the displacing forces loads are matched by the denture-supporting Figure 11. Overdenture constructed mid 1980s. Note excessive length of distal cantilevers. structures. A combination of good design and wide support should reduce this movement potential to low levels, of the order of 300 microns or so, but some provided. It is interesting that some of movement must inevitably occur.17 the newer, smaller attachments fare just A clasp or attachment retention as well as their larger, older counterparts system should exert little or no retention in this respect. While older magnetic force when the removable prosthesis is retainers had relatively ineffective retention fully seated. The retention force exerted characteristics, recently developed yet develops as the prosthesis is displaced smaller corrosion resistant units perform along its path of withdrawal. Magnetic better in the mouth and hold promise. devices, on the other hand, exert maximum Some of the larger ball and retention forces when the prosthesis is fully socket designs, cumbersome as they might seated and these forces reduce sharply be, provide a wide range of retention, as the prosthesis is displaced. A retaining making them less technique sensitive. Space device that provides ample retention, with permitting, they can be employed with components separated by less than 100 implant and root-supported prostheses microns, but whose retention falls away and are straightforward to employ. Bar very rapidly so that it is ineffective at 200 retainers appear to have similar retention microns separation, would be virtually characteristics to the larger ball and socket useless in the mouth. A small retention systems, and are particularly useful for range of about 300 microns must be implant prosthodontics. DentalUpdate 223

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Figure 12. Despite distal extension solder joint failure, this prosthesis is still well retained and stable. Nowadays, distal cantilevered bar extensions are best avoided when possible or reduced not to exceed 4 mm if their use is essential.

Figure 13. Mandibular overdenture approach with Dolder Bar.

Bar attachments on implants

Jemt et al6 have shown that the bar supporting and retaining maxillary overdentures on implants plays a significant role in its efficiency. Increased occlusal force capacity with the bar and clip suggested that these components withstood an appreciable load. Indeed, when fixed prostheses were substituted, the maximum occlusal force hardly changed in the short term, although it did increase over a period of time. The study further indicated that the velocity of the opening phase of the mandibular movement was related to the stability of the restoration placed in the mouth, a factor that will influence masticatory efficiency. Although the principles of root and implant-supported bars are similar, there are important differences. The implant has no periodontal ligament to accommodate minor discrepancies of adaptation and the implant is unlikely to be placed in a site corresponding with the position of the root it replaces. Indeed, the pattern of resorption of the maxilla may result in the implant being 710 mm palatal to the root position. Complications that may arise include the distortion of the shape of the anterior palate, unless the bar is attached to the facial surfaces of the implant copings. Vertical space available for the copings may be less than expected if the implants are directly opposite the lower anterior teeth. One of the advantages of the bar assembly is the ability to place the retaining clips where there is the greatest space, and to provide short cantilevers

when sufficient abutments are available. The stabilizing effect of a short 4 mm maxillary cantilever and retainer is quite remarkable but should only be used in conjunction with four abutments. Even so, fractures of distal solder joints are by no means unknown and longer cantilevers are better avoided (Figures 12 and 13). Bar attachments are normally more straightforward to employ on implant-supported mandibular dentures than on root-supported prostheses. They are valuable in maxillofacial prosthodontics and with extra-oral applications such as auricular prostheses.

Figure 14. Dolder Bar FSI incorporates telescopic components obviating the need to solder the bar to the abutment. The manufacturers claim a stress free connection.

Bar retainers
The original concept of employing bars for implant overdenture support hinged upon the necessity to connect the implants. Bar retainers were simply soldered to the implant abutment assembly. While this is still an effective approach, the need to connect the implants remains unproven. Bar retainers allow some movement between the two components. They can be subdivided into two types: Single sleeve bar joints; Multiple sleeve bar joints.
Single sleeve bar joints

Figure 15. Retention clip of a multisleeve unit. These small retention devices are useful but vulnerable to overload.

The Dolder bar joint is an excellent example of this type of attachment. This well-tried bar is produced from wrought wire, pear-shaped in crosssection and running just in contact with the oral mucosa between the abutments. An open-sided sleeve is built into the impression surface of the denture and engages the bar when the denture is inserted. A new version of this attachment,

the Dolder Bar FS1, incorporates a telescopic sleeve and tube arrangement, obviating the need for solder joints at the abutment/bar interface (Figure 14). As a single sleeve bar has to run straight, it cannot follow the anteroposterior curvature of the ridge, nor can it be adapted to small vertical contours. This type of bar therefore lends itself to square arches where the remaining roots or implants can be joined by a straight line. If the roots or implants lie in a curved arch, the space for the denture base will be restricted lingual to the bar and the denture may break unless a metal lingual plate is employed. May 2009

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Where the arch is markedly curved, the bar may occupy too much tongue space, so that it is generally better to select a different attachment system. Nevertheless, there are situations where splitting the bar in the mid-line and soldering may work well with the retaining sleeve split into two segments. Unless all the surfaces of the bar are kept plaque-free, there will be resulting irritation. One of the more common mistakes associated with bar-joint prostheses is to push out the necks of the lower anterior teeth in an effort to make room for the bar. This gives the patient the appearance of a swollen lip and a mouth perpetually full of food. Appearance apart, the lip will exert a displacing action on the denture. A denture that moves perceptibly in the mouth requires attention. It may require rebasing, a relocating procedure, or remaking, but if a continuous movement is allowed to take place unchecked it will cause damage to denturesupporting structures. Apart from removal of sharp edges, it should be unnecessary to cut away significant amounts of the denture base covering the margins of the supporting roots or implants. The leverage potential when cantilevers are employed is surprisingly large, as the loads applied to the system are considerable. Nowadays, extensive distal extensions to any bar assembly are not recommended in view of the potential for fracture of soldered joints. More than 20 years ago, the principal authors patients suffered a 50% solder joint fracture ratio with 7 mm cantilevered bar extensions. If such an extension were deemed necessary, 4 mm is a sensible maximum length. It is normally considered wise practice to incorporate an occlusal stop in the design.
Multiple sleeve joints

The retaining sleeves, or clips as they are sometimes known, are relatively short. This allows the bar to follow the curvature of the ridge and to be adapted to its vertical contours. This approach has become popular with implant-supported overdentures. In the anterior maxilla, this method is often employed with a curved arch. However, the leverage potential should be appreciated. Sleeves can be placed at

sites with the greatest amount of space. In selecting the profile of the bar, the length of the span must be taken into account, as the connection between the abutments must be rigid. Failure to achieve this rigidity might lead to stress concentrations around the implants.18 Of the various cross-sections available, the circular section is the most versatile as it can be bent in all planes, whilst pear-shaped and oval cross-sections are also available. Both wax and plastic patterns are produced; these can be cut and adapted before casting, a procedure that requires a great deal of attention to detail. When more than one sleeve is incorporated in an antero-posterior curve, it is likely to prevent hinge rotation. This is normally of little clinical significance if the denture base is well adapted and correctly extended. Problems often arise with implant-supported maxillary dentures with an open palate design, where a stabilizing component has been omitted. Multiple sleeve systems lend themselves to distal cantilevered extensions, as the small sleeves allow for an extension of less than 4 mm providing retention. The use of cantilevered extensions normally requires at least four implants. Sleeves positioned on the extension will prevent any tendency for the distal part of a lower denture to rise when sticky foods are chewed. In the maxilla, this becomes even more important, ensuring that there is no tendency for the posterior border of the upper prosthesis to drop. The relatively small sleeves of these retaining systems could be subjected to considerable forces (Figure 15). Occlusal stops and stabilizing components should always be incorporated in the design if constant adjustments and occasional breakages are to be avoided. Metal sleeves are secured within the acrylic resin by retention tags. Nowadays, removable plastic sleeves can be incorporated that have good resistance to wear.

Technical considerations
Insufficient space for the attachment is a common problem. While hardly technical, it is a problem that may first become apparent in the laboratory. Measurement of the vertical and buccolingual space should have been

part of the preliminary treatment, but carelessness at this early stage may become obvious comparatively late in the therapy, when the attachment is set up on the master cast after the final trial insertion. The wax-up of the trial insertion is conventional and, when the position of the anterior artificial teeth has been decided, it is then recorded with a silicone mask. This mask allows the teeth to be removed and subsequently replaced in exactly the same position. If, at this late stage, insufficient room is available, a smaller attachment will have to be selected. Where the space problems do not allow this approach, the treatment plan may need to be reviewed, as raising the level of the occlusal plane, or pushing forward the necks of the anterior teeth as last minute attempts to position the attachment, seldom succeed. They result in prosthodontic problems of even greater magnitude that may require the remaking of the entire restoration. Adjustments for retention normally involve minute distortions of the free end of the sleeve, using a dental instrument for the purpose. While straightforward for small, single sleeve bars, the longer sleeve of the Dolder bar is more difficult to adjust in this manner. The manufacturers have therefore produced special instruments that may be used to deform the edge of the sleeve to increase retention. Particularly useful devices are also produced to reduce retention, should this have been inadvertently over tightened. Since the overdenture is acting as a force transfer system, it is apparent that loads applied from the removable prosthesis to the bar will, in turn, be transmitted to the solder joint. Failures of these joints under load are by no means uncommon and the process of soldering requires care and skill. The clinician should be aware of the problem involved. Multisleeve bars are usually easier to adapt to the master cast, although annealing will be required. Both single and multisleeve bars will need to be soldered to the abutments. The soldering of any bar prosthesis requires a great deal of expertise and care. No matter what alloy is used, some distortion can easily arise and the effect of a comparatively small distortion is greatly magnified when the span of the bar is long and may give rise to a pronounced rock May 2009

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on the master cast. All sections need to be annealed (usually 5 minutes at 70 C) before assembly for soldering. After soldering, full heat hardening treatment is necessary.

Magnetic retainers
Although magnetic retention systems have been used in prosthodontics for some 60 years, their application to overdentures only became possible with the introduction of rare earth alloys with high field strength and an intrinsic coercivity many times that of earlier alloys. This allowed the production of magnets that were not much larger than stud retainers. The pioneering work of Gillings, at the University of Sydney, developed a split pole magnet assembly using cobalt samarium alloys.19 When paired with a magnetizable alloy keeper, this produced closed field magnetic retention. Other clinical advantages became immediately apparent. The magnet was placed in the denture and the flat keeper on the abutment root, so that the path of the insertion of the denture was unaffected by the retainer. In fact, the prosthesis was effectively self-seating, a bonus for elderly or arthritic patients, while the denture construction was relatively straightforward. Adjustments for wear were unnecessary and maintenance should have been simpler than for mechanically-based retention systems. Initial concerns over the possible biological effects of magnetic fields were resolved, but the problem of corrosion proved more difficult to overcome. Only recently has the corrosion issue been solved with the production of iron neodymium boron magnets in a laser-welded capsule. Any protection for the magnet had to be extremely thin. Greater impetus to produce magnetic retainers arose from the development of overdentures supported by implants, as magnets required only a small modification of existing systems. These retainers lent themselves to awkwardly positioned or angled implants that would have been difficult or impossible to connect with bars. All that was required was a modified keeper to fit the transmucosal abutment that incorporated the keeper. Since magnetic retainers resist shear loads to a very small extent (10% of May 2009

the normal retention force), only a small amount of lateral load can be transmitted by the actual retainer. Studies of patient preferences demonstrated that magnets took third place to stud and bar retention systems, but development continues apace.

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Conclusions
Precision attachments have always been valuable tools in the armamentarium of the prosthodontist. The changing direction of the specialty impacts upon these valuable devices that seem set to continue their support role throughout the first half of the 21st century.

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References
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