Precision attachments

This seminar is of postgraduate level, which will be helpful for students. The presenter has added the information from various sources and the references are quoted in the last few slides of the seminar to gather more information about the seminar.

1. PRECISION ATTACHMENTS Presented by: Aakriti Maheshwari JR-3

2. CONTENT Introduction Definition Classification Indications / Applications of precision attachments Contraindication Advantages /Disadvantages Intracoronal attachment Extracoronal attachment Bar attachments How to choose an attachment Conclusion

3. HISTORY

4. WINDER PARR STAIR Svirsky D. Attachment-Retained RPD Simplified. Oral Health. 2004;94(3):19-28. 4

5. CHAYES MCCOLLUM Svirsky D. Attachment-Retained RPD Simplified. Oral Health. 2004;94(3):19-28. 5

6. An attachment is a connector consisting of two or more parts. One part is connected to a root, tooth or implant and the other part to prosthesis. - GPT-9 INTRODUCTION

7. PRECISION ATTACHMENTS SEMI- PRECISION ATTACHMENTS

8. First component or Matrix is a metal receptacle or keyway, which is positioned within the normal clinical contours of a cast restoration placed on the attachment. Second component or Patrix , is attached to the removable partial denture.

9. COMPONENTS OF PRECISION ATTACHMENT SYNONYMS: Internal attachments, frictional attachments, slotted attachments, parallel attachments, and key and keyway attachments.

10. CLASSIFICATION OF ATTACHMENTS Based on method of fabrication and the tolerance of fit Precision attachment (prefabricated types) Semiprecision attachment (custom made / laboratory made types) Dr Burns, 1990 Burns DR, Ward JE. A Review of Attachments for Removable Partial Denture Design: Part 1. Classification and Selection. International Journal of Prosthodontics. 1990 Jan 1;3(1). 10

11. Intracoronal attachment Resilient Non-resilient Extracoronal attachment Resilient Non-resilient Acc.Goodkind & Baker, 1976: Burns DR, Ward JE. A Review of Attachments for Removable Partial Denture Design: Part 1. Classification and Selection. International Journal of Prosthodontics. 1990 Jan 1;3(1). 11

12. Radicular/ Intra radicular stud type attachments Bar type attachments Burns DR, Ward JE. A Review of Attachments for Removable Partial Denture Design: Part 1. Classification and Selection. International Journal of Prosthodontics. 1990 Jan 1;3(1). 12

13. No movement of component parts during function BASED ON FUNCTION OF MOVEMENT RIGID RESILIENT Permit movement of denture base during functional loading Based on function or movement Burns DR, Ward JE. A Review of Attachments for Removable Partial Denture Design: Part 1. Classification and Selection. International Journal of Prosthodontics. 1990 Jan 1;3(1). 13

14. ACC.(GEORGE E RAY, 1978) Passive attachments: Are made in solid section so that patrix fits into the matrix in the fashion of interlocking parts retention between two parts depends on accuracy of the fit , shape of the joint, and area of contact. Ex-Passive Omega attachment Passive Beyler attachment Burns DR, Ward JE. A Review of Attachments for Removable Partial Denture Design: Part 1. Classification and Selection. International Journal of Prosthodontics. 1990 Jan 1;3(1). 14

15. Active attachments Differs from passive attachments that some form of spring is used to give additional retention. E.g. Omega attachments active friction grip, McCollum attachment active friction grip ACC.(GEORGE E RAY, 1978) Burns DR, Ward JE. A Review of Attachments for Removable Partial Denture Design: Part 1. Classification and Selection. International Journal of Prosthodontics. 1990 Jan 1;3(1). 15

16. Locked precision attachments Locked precision attachments are either bolted together by means of a sliding bolt or latch (latch grip) or May by pinned or screwed together . ACC.(GEORGE E RAY, 1978) Burns DR, Ward JE. A Review of Attachments for Removable Partial Denture Design: Part 1. Classification and Selection. International Journal of Prosthodontics. 1990 Jan 1;3(1). 16

17. 1.FRICTIONAL BASED ON MODE OF RETENTION 2.MECHANICAL 3. MAGNETIC 4. SUCTION Burns DR, Ward JE. A Review of Attachments for Removable Partial Denture Design: Part 1. Classification and Selection. International Journal of Prosthodontics. 1990 Jan 1;3(1). 17

18. When to use??????? 19

19. Patil R, Shetty O. Prosthetic rehabilitation using extra coronal attachments. International Journal of Dentistry Research. 2019;4(1):5-8. CASE REPORT

20. Long span replacements Periodontal involvement Fixed prosthesis with intra coronal attachments INDICATIONS Sectional dentures Preiskel HW, Preiskel A. Precision attachments for the 21st century. Dental update. 2009 May 2;36(4):221-7. 23

21. CONTRAINDICATIONS Poor periodontal support. Poor crown to root ratio Poor oral hygiene habits Abnormally high carious rate Inadequate space / room to employ the attachment Compromised endodontic and restorative conditions Preiskel HW, Preiskel A. Precision attachments for the 21st century. Dental update. 2009 May 2;36(4):221-7. 24

22. 25 ADVANTAGES : Improved esthetics Preiskel HW, Preiskel A. Precision attachments for the 21st century. Dental update. 2009 May 2;36(4):221-7.

23. Reduces Non axial loading Decreases Torquing forces Preiskel HW, Preiskel A. Precision attachments for the 21st century. Dental update. 2009 May 2;36(4):221-7. 26

24. Broken stress philosophy Preiskel HW, Preiskel A. Precision attachments for the 21st century. Dental update. 2009 May 2;36(4):221-7. 27

25. DISADVANTAGES Complexity of design, procedures for fabrication & clinical treatment Minimum occlusogingival abutment height (4-6mm) Expensive Preiskel HW, Preiskel A. Precision attachments for the 21st century. Dental update. 2009 May 2;36(4):221-7. 28

26. Requires aggressive tooth preparation Preiskel HW, Preiskel A. Precision attachments for the 21st century. Dental update. 2009 May 2;36(4):221-7. 29

27. SELECTION OF ATTACHMENTS 30

28. FACTORS 1 2 LOCATION OF ATTACHMENT ABUTMENT CONDITION SPACE AVAILABLE FUNCTION OF ATTACHMENT 3 4 31

29. Abutment condition Mc Cord and Smales (2012) TEETH structurally sound Good alignment and position Abutment tooth roots and supporting alveolar bone Alveolar bone- good quantity Soft tissue- good quantity and quality 32

30. 33

31. The vertical space is measured from the tissue to the marginal ridge BL or LL space should be measured accurately to avoid over contouring the restoration in this dimension. An additional 1mm should be added to the buccal-lingual measurement for metal precision attachments to allow for the casting alloy. Mesial-Distal measurements are critical for intracoronal attachments, since a box preparation is required. SPACE

32. 35

33. 36

34. Selecting an Attachment System for a Removable Partial Denture Intracoronal Extracoronal Non-Resilient Resilient Largest attachment can be used within the given space Requires more teeth preparation and tooth reduction than extracoronal attachment. If there is insufficient space, the abutment retainer will be over contoured on the proximal surface resulting in periodontal problems. Employed in areas of inadequate space, they create areas which may be difficult to clean leading to maintenance problems.

35. COLOR CODED MILLIMETER ATTACHMENT GAUGE Red designates 3 to 4 mm Yellow designates 5 to 6 mm Black designates 7 to 8 mm. Burns DR, Ward JE. A Review of Attachments for Removable Partial Denture Design: Part 1. Classification and Selection. International Journal of Prosthodontics. 1990 Jan 1;3(1). 38

36. 04 03 FACTORS TO BE CONSIDERED 01 02 BULK RETENTION MECHANISM ADJUSTMENT PLAQUE CONTROL Preiskel HW, Preiskel A. Precision attachments for the 21st century. Dental update. 2009 May 2;36(4):221-7.

37. INTRACORONAL ATTACHMENTS 40

38. INTRACORONAL ATTACHMENTS SLOT FLANGE Precision attachment (prefabricated type) Semiprecision attachments (custom made) Kanathila H, Doddamani M, Pangi A. An insight into various attachments used in prosthodontics: A review. Int J Appl Dent Sci. 2018;4(4):157-60. 41

39. INTRACORONAL ATTACHMENTS Friction fit without adjustment potential Friction fit with adjustment potential Ex- crismani Unsuitable for RPD Ex- Beyeler attachment 42

40. RECESS THE FEMALE PART OF ATTACHMENT FUNCTIONS 43

41. CROSS SECTION -T/H SHAPED 44

42. STERN G/A ATTACHMENT CRISMANI UNITS 45

43. Wider Crismani attachment : Incorporate wire clip to increase the retention Access to clip by removing the screw 46

44. Mccollum attachment Single adjustment slot Retention  expanding the adjustment slot 47

45. Schatzmann attachment Spring loaded plunger system Female –retraction groove to engage plunger with in male component 48

46. 49 QUERY

47. 50 Q1. Can Precision attachment be used in Periodontal involvement cases? Removable partial dentures with extra coronal clasps should not be used as a splinting vehicle as they create forces too great for periodontally involved teeth to withstand. The intra coronal retainers on the other hand, allow for better control of bucco lingual, mesio distal and vertical forces.

48. 51 Q2. Which precision attachment provides retention, stability and support? 1. Intracoronal attachments: are mainly used in connecting units of fixed partial prostheses, retaining restorations with distal extension or bounded removable prostheses. 2. Extracoronal attachments: provides stability and retention for removable distal extension prostheses. 3. Stud attachments: Usually in the form of ball & socket, this attachment serves primarily for overdenture stabilization and retention of the prosthesis. 4. Bar attachments: Used for splinting groups of teeth, currently used for overdenture retention and stabilization.

49. 52 Q3. Does attachment gives strength to prosthesis? In distal extension appliances, the abutment teeth are placed under strain and require special attention. In order to provide a sufficiently high safety in this area, it is always better to splint two or more teeth together. The splinting of teeth increases their strength in geometric proportion and permits over contouring for the purpose of receiving the attachment as an alternative to deeply recessing the attachment into the abutment tooth.

50. 53 Q4. Amount of tooth destruction?

51. 54 Q5. Opposing arch prognostic value?

52. S EMI PRECISION RESTS 55

53. STERN SEMI PRECISION ATTACHMENT 56

54. 1.Proximal form / side walls – lateral force control Depth and taper of rest seat Depth should not be less than 3mm Convergence of lateral walls should not exceed 5 degree 57

55. Occlusal form / outline form – controls amount of rotation Rectangle –basic occlusal outline R esist displacement of prosthesis away from the abutment tooth. 58

56. Gingival floor form : serves the function of reciprocation Flat Inclined Channeled Added reciprocation 59

57. EXTRACORONAL ATTACHMENTS HENRY . R. BOOS(1900) 60

58. Jain R, Aggarwal S. Precision attachments-An overview. Ann Prosthodont Restor Dent. 2017 Jan;3(1):6-9. 61

59. RIGID EXTRACORONAL ATTACHMENTS Roach attachment (ball and tube attachment) Oldest attachment Patrix – round ball Matrix - tube bilateral cantilever prostheses Jain R, Aggarwal S. Precision attachments-An overview. Ann Prosthodont Restor Dent. 2017 Jan;3(1):6-9. 62

60. PROJECTION UNITS SUBGROUPED RIGID PROJECTION UNITS PROJECTION ALLOWING PLAY BTW TWO SECTIONS Jain R, Aggarwal S. Precision attachments-An overview. Ann Prosthodont Restor Dent. 2017 Jan;3(1):6-9. 63

61. Two basic types were manufactured: Axial rotation joint Rotation joint CONNECTING UNITS Jain R, Aggarwal S. Precision attachments-An overview. Ann Prosthodont Restor Dent. 2017 Jan;3(1):6-9. 64

62. COMBINED ATTACHMENTS Consist of hinge connector joined to intracoronal attachment No projection remains when denture is removed Box preparation required Jain R, Aggarwal S. Precision attachments-An overview. Ann Prosthodont Restor Dent. 2017 Jan;3(1):6-9. 65

63. PATRIX AND MATRIX STABILEX ATTACHMENT Jain R, Aggarwal S. Precision attachments-An overview. Ann Prosthodont Restor Dent. 2017 Jan;3(1):6-9. 66

64. CONEX ATTACHMENT Jain R, Aggarwal S. Precision attachments-An overview. Ann Prosthodont Restor Dent. 2017 Jan;3(1):6-9. 67

65. EXTRACORONAL RESILIENT ATTACHMENT DALBO Jain R, Aggarwal S. Precision attachments-An overview. Ann Prosthodont Restor Dent. 2017 Jan;3(1):6-9. 68

66. Advantages E xcellent resistance to distal and lateral displacing forces Good contact is maintained. Available in two sizes-6mm and 4mm Jain R, Aggarwal S. Precision attachments-An overview. Ann Prosthodont Restor Dent. 2017 Jan;3(1):6-9. 69

67. CEKA ATTACHMENT Metal ring 1.4mm Attachment pins Spacer ring Waltz ME. Ceka extracoronal attachments. Journal of Prosthetic Dentistry. 1973 Feb 1;29(2):167-71. 70

68. Support Bracing Retention Insertion and removal Reduces frictional wear two diametrically opposed slits are placed in the ball portion of the pin and extend down into the shaft. 71

69. ADVANTAGES ESTHETIC EASE OF ASSEMBLY IN RPD REDUCES STRESS TO ABUTMENT TEETH INTER CHANGEABLE PARTS Jain R, Aggarwal S. Precision attachments-An overview. Ann Prosthodont Restor Dent. 2017 Jan;3(1):6-9.

70. Disadvantages (Wolf RE 1980) : Lack of occlusal stability. Bulky Rebasing problems Improper control of force distribution Encroachment on the gingival papilla Jain R, Aggarwal S. Precision attachments-An overview. Ann Prosthodont Restor Dent. 2017 Jan;3(1):6-9. 73

71. Reslan MR, Osman E, Segaan L, Rayyan M, Joukhadar C. Comparison between Integrated and Parallel Interlock Designs of an Extracoronal Attachment-retained Distal Extension Removable Partial Dentures: A Clinical Trial. Journal of International Society of Preventive & Community Dentistry. 2021 Jan;11(1):41. RPDs of both designs showed an increase in periodontal parameters. Integrated interlock design showed better scores. It is preferable to use the attachment-retained RPD with integrated interlock instead of parallel interlock design 74

72. BAR ATTACHMENTS 75

73. BAR ATTACHMENTS BAR UNITS BAR JOINTS SINGLE SLEEVE MULTIPLE SLEEVE 76

74. 77 Requires plaque removal skill on the part of the patient than other retainers Vertical and buccolingual space requirements will limit applications 1 3 2 Requires adequate retention for abutment retainers if cementation failures are to be avoided disadvantages 77

75. TYPES Dolder bar joint Hader bar ACKERMANN BAR AND CM CLIP BAKER CLIPS 78

76. DOLDER BAR 79

77. DOLDER BAR Teeth selected as abutments should have approx. one third supporting alveolar bone remaining Kennedy class 1, mod 1, either a canine or premolar remains on either side of arch Bar should be parallel to plane of occlusion and at right angle to the median axis. 80

78. SCHUBIGER SCREWS 81

79. ACKERMANN BAR AND CM CLIP 82

80. Available in different cross sections Short extension of bar must be carried 5 mm behind the most distal root. Sleeve- prevents the distal part of lower denture to rise when sticky foods are chewed Spacer is supplied so that the clip does not rest directly on the bar providing vertical & rotational movements 83

81. HADER BAR 84

82. 85

83. Bar/implant retained overdentures are associated with improved chewing efficiency compared to conventional dentures. Dolder bar used to retain mandibular implant overdentures showed significant increase in chewing efficiency compared to Hader bar Hammas MA. CHEWING EFFICIENCY WITH DIFFERENT TYPES OF BAR JOINT USED TO RETAIN MANDIBULAR IMPLANT OVERDENTURES. A CROSS OVER STUDY. Egyptian Dental Journal. 2018 Apr 1;64(2-April (Fixed Prosthodontics, Dental Materials, Conservative Dentistry & Endodontics)):1727-36. 86

84. STUD ATTACHMENTS 87

85. STUD ATTACHMENTS MALE- Dowel/Post retained restoration FEMALE- Denture base of prosthesis Classified as – Rigid stud units Resilient stud units Extraradicular units Intraradicular units AlmEldeen HI. CRESTAL BONE LOSS USING DIFFERENT STUD ATTACHMENTS IN DISTAL EXTENSION CASES. Egyptian Dental Journal. 2017 Jan 1;63(1-January (Fixed Prosthodontics, Dental Materials, Conservative Dentistry & Endodontics)):925-31. 88

86. Space requirement of these attachment is intermediate between dome shaped coping and thimble shaped coping. These should be placed parallel to the long axis of the tooth. 89

87. DALBO STUD UNITS Ball and socket joint Smallest of all units 4mm high Spherical shaped male section easy to clean Nylon ring- protects the lamellae Retention- altering the free ends of lamellae Vertical and rotational movement AlmEldeen HI. CRESTAL BONE LOSS USING DIFFERENT STUD ATTACHMENTS IN DISTAL EXTENSION CASES. Egyptian Dental Journal. 2017 Jan 1;63(1-January (Fixed Prosthodontics, Dental Materials, Conservative Dentistry & Endodontics)):925-31. 90

88. ROTHERMANN UNIT Button shaped attachment Requires little vertical space Height-1.1mm Male- groove of uneven depth Clip of female section slides over tapered upper edge. AlmEldeen HI. CRESTAL BONE LOSS USING DIFFERENT STUD ATTACHMENTS IN DISTAL EXTENSION CASES. Egyptian Dental Journal. 2017 Jan 1;63(1-January (Fixed Prosthodontics, Dental Materials, Conservative Dentistry & Endodontics)):925-31. 91

89. GERBER ATTACHMENT GERBER ATTACHMENT AlmEldeen HI. CRESTAL BONE LOSS USING DIFFERENT STUD ATTACHMENTS IN DISTAL EXTENSION CASES. Egyptian Dental Journal. 2017 Jan 1;63(1-January (Fixed Prosthodontics, Dental Materials, Conservative Dentistry & Endodontics)):925-31. 92

90. ZEST ANCHOR SYSTEM AlmEldeen HI. CRESTAL BONE LOSS USING DIFFERENT STUD ATTACHMENTS IN DISTAL EXTENSION CASES. Egyptian Dental Journal. 2017 Jan 1;63(1-January (Fixed Prosthodontics, Dental Materials, Conservative Dentistry & Endodontics)):925-31. 93

91. O-SO Ring Patrix system- post with the groove or undercut Matrix system- O ring gasket AlmEldeen HI. CRESTAL BONE LOSS USING DIFFERENT STUD ATTACHMENTS IN DISTAL EXTENSION CASES. Egyptian Dental Journal. 2017 Jan 1;63(1-January (Fixed Prosthodontics, Dental Materials, Conservative Dentistry & Endodontics)):925-31. 94

92. MAGNETIC ATTACHMENTS Somarium cobalt ( Sm -Co) Neodymium iron boron (Nd-Fe-B) – 20% stronger Somarium iron nitride – High magnetization Used for retention of mandibular overdentures (tooth and implant supported over dentures ) 95

93. CLOSED FIELD SYSTEMS 96

94. SELECTION OF KEEPER SELECTION OF KEEPER 97

95. 98

96. Ball attachments used to retain implant assisted distal extension partial dentures were associated with lower strains compared to locator and magnetic attachments ELsyad MA, Omran AO, Fouad MM. Strains around abutment teeth with different attachments used for implant‐assisted distal extension partial overdentures : an in vitro study. Journal of prosthodontics. 2017 Jan;26(1):42-7. 99

97. RECENT ADVANCES 100

98. PRECI VERTEX AT Dawson PE. A new attachment system for removable partial dentures. Signature. 2016 Spring:1-7. PMID: 9227145. 101

99. 102

100. 103

101. Yellow females have normal retention. White females have reduced retention. Red females have increased retention PRECI CLIX Dawson PE. A new attachment system for removable partial dentures. Signature. 2016 Spring:1-7. PMID: 9227145. 104

102. RHEIN 83 USA Dawson PE. A new attachment system for removable partial dentures. Signature. 2016 Spring:1-7. PMID: 9227145. 105

103. OT CAP Dawson PE. A new attachment system for removable partial dentures. Signature. 2016 Spring:1-7. PMID: 9227145. 106

104. OT TECHNO CAP Dawson PE. A new attachment system for removable partial dentures. Signature. 2016 Spring:1-7. PMID: 9227145. 109

105. Dawson PE. A new attachment system for removable partial dentures. Signature. 2016 Spring:1-7. PMID: 9227145. 110

106. 111

107. CONCLUSION Precision Attachment removable partial denture is the treatment of choice because of esthetics, abutments alignment or the need for greater cross arch bracing . It must be used with a thorough knowledge and understanding of prosthodontics principles

108. REFERENCES 113 Harold W. PREISKEL:PRICISION ATTACHEMNTS IN prosthodontics:overdentures and telescopic prosthesis vol2 Harold w. Preiskel:precision attachments in prosthodontics:the applications of intracoronal and extracoronal attachments vol 1 Staubli PE. Attachments & implants: reference manual. 6th edn . San mateo , CA: attachments international, 1996. Jaroslow b, gazis d. A multi-attachment approach to partial dentures. Trends & techniques in the contemporary dental laboratory. 1985 dec;2(10):39-44. Waltz me. Ceka extracoronal attachments. Journal of prosthetic dentistry. 1973 feb 1;29(2):167-71. Www.Sterngold.Com / sterngold /docs/666111_b.Pdf?Mscsprofile 78

109. REFERENCES 114 Wang HY, Zhang YM, Yao D, Chen JH. Effects of rigid and nonrigid extracoronal attachments on supporting tissues in extension base partial removable dental prostheses: a nonlinear finite element study. The Journal of prosthetic dentistry. 2011 May 1;105(5):338-46. 78 Schuh C, Skupien JA, Mesko ME, Valentini F, Pereira-Cenci T, Boscato N. Resilient Attachments as an Alternative to Conventional Cast Clasp Removable Partial Denture: 3-Year Follow-up. The Journal of Indian Prosthodontic Society. 2014 Dec 1;14(1):273-8 .