attachment dentistry slides handout
TRANSCRIPT
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Precision and Semi-
PrecisionAttachments
Where? When? Why?
George E. Bambara, MS, DMD
FACD, FICD
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Objectives of the Program Understanding how attachments
preserve hard and soft tissue
Selection of the appropriateattachments
Understand the uses of attachments
Familarization with different
attachments
Maintenance and hygiene
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Properly Designed Clasps
Work??????Concerns??????
Uneven distribution offorces
Possible orthodontic
movement
Periodontal compression
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Removable Partial Dentures
Periodontal Status
RPDs WERE ASSOCIATED WITH
Increased periodontal pathology
Increased plaque and tarteraccumulation
Increased gingival inflammation
Increased probing depths Increased recession
Increased abutment tooth mobilityZlataric et.al., The Effect of Removable Partial Dentures on Periodontal Health
of Abutment and Non-Abutment Teeth. JPeriodontology, 2002, 73: 137-144
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Clasps vs. Attachments
CLASPS:
Less expensive.
5 to 6 year life.
30% loss of retention.
Poor chewing
efficiency.
93% caries rate. 50% compliance.
ATTACHMENTS:
15 year + life.
More expensive.
99% retention.
Excellent chewing
efficiency.
8% caries rate. 100% compliance.
Rantanen, Wetherall and Smales, Feinberg et.al.
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CLASSI LEVER
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Class II Lever
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CLASS III LEVER
Class III Lever
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Indications for Attachments
Aesthetics
Redistribution of forces
Minimize trauma to soft tissue Control of loading and rotationalforces
Non parallel abutments-Segmenting
Future salvage efforts- Segmenting
Retention
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Functional Classifications
Class 1A-Solid, rigid, non-resilient
Class 1B-Solid, rigid- lockable
Class 2-Vertical resilient
Class 3-Hinge resilient
Class 4- Vertical and hinge resilient Class 5-Rotational and vertical
resilient
Class 6-Universal, omni-planer
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Patient Dexterity and
Attachment Wear
Insertion and removal cause wear
Poor dexterity Avoid multiple attachments with
complex a complex path of insertion
Use lingual guiding arms
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What is a Precision
Attachment?
An attachment that is fabricated from
milled alloys Tolerances are within .01mm
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Precision Attachments
They are Generally
Intracoronal
Rigid = NonResilient
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Benefits of Precision
Attachments
Consistent quality
Controlled wear Less wear
Easier repair
Standard parts are interchangeable
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What is a Semi-Precision
Attachment?
An attachment that is fabricated by
the direct casting of plastic, wax,metal, or refractory patterns
Their method of fabrication subjects
them to inconsistencies
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Benefits of Semi-Precision
Attachments
Less costly Easy fabrication
May be cast in alloy
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Semi-Precision Attachments
They Are Generally
Extracoronal Non-rigid = Resilient
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Resilient Attachments
0.1mm 0.4 mm difference in the
displacement of the tissue and the
denture base, as opposed to the axialintrusion of the abutment teeth
Directs forces to the supporting tissuesand the abutment teeth
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Selection of Attachments
Location
Opposing arch
Function
Retention
Available space ( 3-5mm ) Cost
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Criteria Selection for Resilient
and Non Resilient
Attachments Do not oppose two resilient attachments
unless teeth are very weak
Opposing distal extensions with strong
abutments: upper - non resilient, lower
- resilient
Lower distal extension vs.
Natural dentition - resilient
Full denture - non resilient
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Coronal Attachments
INTRACORONAL:
Placed within the
contours of the crownform
Needs more tooth
reduction Rigid connectors
EXTRACORONAL
Placed outside the
contours of the crownform
Needs less tooth
reduction Stress redirectors and
are considered
resilient
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Stud Attachments
A balland sockettype of attachment inwhich one component is attached to an
abutment or implant, and the other
element is retained in the prosthesis
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Advantages
Stud Attachments
Low profile
Easy hygiene maintenance Enhanced crown/root ratio
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Dalla Bona
The Ball Attachment
A spherical, resilient, adjustable studattachment with vertical and rotational
movement for retaining partial and complete
overdentures
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Advantages
Low Profile - limited space
Easy path of insertion
Adjustable female
All adjustments done in prostheses Can be rigid vertical movement only
Can be resilient vertical and rotational
Easy fabrication Hygienically maintainable
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Accessory Attachments
Plunger
Screw Type
Frictional
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Magnetic Attachments
Processing magnet- in denture
Intraradicular keeper
All magnetic attachments should be
processed chairside in the denture
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Magnetic Indications
Overdentures
Implant restorations
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Magnetic Realities
Provide little lateral stability
Used in limited applications Heat curing will weaken magnets
Corrosion
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Attachment Selection Overdentures- Ridge evaluation and esthetics
Fixed- Ridge evaluation, gingival esthetics
Number of implants
Anterior-Posterior spread Opposing arch ??
Function
Fixed- Rigid, screw retained
Overdenture- Load bearing or non- load bearing
Retention
Available space
Cost
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Patient Considerations
Parallel attachments for easier path ofinsertion
Less attachments better
Patient dexterity
Hygiene Stannous Fluoride rinses
3 month recall
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Anterior/Posterior Spread
A line from the center of the most anteriorimplant to a line joining the distal aspects
of the two most distal implants
Indicates the amount of cantilever that canbe reasonably placed
Usually, 2.5 times the A/P spread
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A/P Spread
Actual Length of Cantilever Depends on:
Stress factors Parafunctional Habits
Crown heights
Implant width Number of implants
Opposing teeth or denture
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Controlling Stress
Stress=Force/Area
Stress
Area
Force
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Torque=
Force x Perpendicular distancefrom the line of force to the
center of rotation
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Cuspal Inclination
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Cuspal Inclination
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Treatment Plan
Options
Implant Supported Soft Tissue Supported
Implant Retained
Fixed Removable
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Treatment Plan
Option 1
Lower Edentulous
Fixed
5-6 Implants
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Prosthetic Options-Lower
5-6 Implants
Hybrid Denture
Fixed Crown and Bridge Cantilever 10-15mm
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2223
24 25
26 27
6 Implants-Fixed
Implant Supported
X
X X
X
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B
A
C D
E
5 Implants- Fixed
Implant Supported
X
X
X
X
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Treatment Plan
Option 2
Lower Edentulous
Removable
5 Implants
P th ti O ti R bl
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Prosthetic Options- Removable
Overdenture-Implant Supported
Gold Bar w/ O Rings
Distalized O Rings
Cantilever 10-20mm
Gold Bar with Hader Clips
Distalized ERAS
Cantilever 10-20mm
A
BC
D
E E
DC
B
A
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Treatment Plan
Option 3
Lower Edentulous
Removable
4 Implants
P th ti O ti R bl
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Prosthetic Options- Removable
Implant and Tissue Supported
Gold Bar with O Rings
Cantilever 5-10mm
Gold Bar with Hader
Clips and ERAS
Cantilever 5-10mm
a
b c
d d
cb
a
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Treatment Plan
Option 4
Lower Edentulous
Removable
3 Implants
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Prosthetic Options- Removable
Overdenture-Lower
Implant and Tissue Supported
Gold Bar w/ 2- O Rings-Overdenture
No Cantilevers
3 I l t R bl O d t
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B
CD
3 Implants- Removable Overdenture
Implant and Tissue Supported
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Treatment Plan
Option 5
Lower Edentulous
Removable
2 Implants
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Prosthetic Options
Removable Overdenture-Lower
Tissue Supported
Gold Bar w/ Hader Clip
O Ring on each implant ERA attachment on each
implant
2 I l t R bl
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B D
2 Implants-Removable
Tissue Supported
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Treatment Plans
UpperEdentulous
Four
Options
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Treatment Plan
Option 1
Upper Edentulous
Fixed
8 Implants
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Prosthetic Options
Fixed- Upper
Implant Supported
Fixed Crown and Bridge
Hybrid Denture No Cantilevers Necessary
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8 Implants- Fixed
Implant Supported
3
107
6
4
11
13
14
XX
XX
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Treatment Plan
Option 2
Upper Edentulous
Removable
8 Implants
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Prosthetic Options- 8 Implants
Removable- UpperImplant Supported
Gold Bar w/ O Rings-Overdenture
Gold Bar w/ 3 Hader Clips
Overdenture- No Palate
Cantilevers-Optional
8 I l t R bl
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Gold Bar Overdenture
w/ O Rings
Gold Bar Overdenture
w/ Hader Bar / Clips
3
11
13
314
4
67
4
67
13
14
1110 10
Palate No Palate
8 Implants- Removable
Implant Supported
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Treatment Plan
Option 3
Upper Edentulous
Removable
6 Implants
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Prosthetic Options
Removable- Upper
Implant Supported
Gold Bar w/ 4- O Rings and distal
to #s 4 and 13 Gold Bar w/ Hader Clip- ERAS
distal on #4 and 13-
Overdenture-No Palate Cantilever 5-10mm
6 Implants Removable
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6 Implants- Removable
Implant Supported
Gold Bar w/ O Rings 5-10mm Cantilever
Gold Bar w/ Haderclips and ERAs
5-10mm Cantilever
4
5 12
13
107
125
107
134
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Treatment Plan
Option 4
Upper Edentulous
Removable
4 Implants
P th ti O ti
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Prosthetic Options
Removable- Upper
Tissue Supported
Gold Bar w/4 O Rings-
Overdenture w/ No Palate Gold Bar w/ Hader Clip and 2
distalized ERA attachments w/
Overdenture- No Palate
No Cantilever
Arch Form
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Arch Form
4 Implants-Tissue Supported
Square Arch Tapered Arch
4
6 11
13125
116
Maximum contact with tissue No contact with Bar
Attachments are for retention ONLY
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Treatment Planning
Design sensibility and flexibility in the
treatment plan
Design and implant concepts will vary Plan ahead for success
Have a disaster plan
In most cases, less attachments are better
Wh t I O d t
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What Is an Overdenture
A complete denture
that is supported and often
retained by the underlyingteeth or implants and tissue
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Abutment teeth or implants
may or may notbe connected to the denture
via attachments
Bars Copings
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Overdenture Attachments
StudsBars
Teeth
ImplantsMagnets
Copings
Posts
CombinationsIntraradicular
Extraradicular
?????????????????????????????????
Load bearing
Non-Load-bearing
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Overdenture Attachments
Bar joints
Bar units
Round
Ovoid
Square
Rectangular
Radicular:
ExtraradicularStuds, magnets,ERA
Intraradicular
Zaag, Zest,Sterns root
anchor
Bars:
Obj i f h P
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Objectives of the Program
Understand how overdentures preserve
hard and soft tissue
Maintain proprioception
Understand the function of overdentureattachments and simplify attachment
selection
Increasing crown/root ratios to preserveabutments
Hygiene maintenance
Carlson and Persson, Odontologist Revy, Sweeden 1967
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Anterior mandible
average bone loss first year after extractions was 4mm
Tallgren, JPD,1972
Bone loss continues for at least 25 years
Dentures vs Overdentures
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Dentures vs Overdentures
Chewing Efficiency Natural dentition
Complete dentures
Overdentures
90%
59%
79%
Rissin and House, JPD, 1978
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Indications for Overdentures
Periodontal disease
Few remaining teeth
Insufficient crown/root ratios Vertical space
Favorable path of insertion
Retention
Advantages of
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Advantages of
Overdentures
Maintenance of bone height around teeth bypreserving roots
Attenuates resorption patterns of alveolar
ridges Gentler to the tissues
Increases crown/root ratios
Psychological security
Enhanced speaking ability
Maintains Proprioception
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Disadvantages of Overdentures
Esthetic Considerations Bulkiness
Root canal therapy Increase space requirements:
-interarch
-interocclusal Increase costs
C / R t R ti
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Crown / Root Ratios
Attachment Retained
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Attachment Retained
Overdentures
All the advantages of Overdentures
PLUS
Superior aesthetics
Stability and comfort
Mechanical retention
Increased psychological security
and patient acceptance
Increases proprioception
Rigidity or resiliency
Support
ver en uresAtt h t C id ti
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Attachment Considerations
Transfers stress towardsthe retained
roots or implants and away from the ridge No vertical resiliency, some hinge or
rotational resiliency
Shares the load of occlusion with the
mucosal surface
Magnets, Flexi ball, Dalbo Rotex, Bars
Load Bearing
Solid / Rigid
ver enturesA h C id i
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Attachment Considerations
Transfers stress awayfrom theretained roots or implants and towards
the tissue
Vertical resiliency Selected frequently
Dalla Bona, Rotherman, Ceka, Uni Anchor, OSO,
ORS, ERA, Bars
Non- Load Bearing
Resilient
O d t E l ti
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Overdenture Evaluation
Partial DenturePresent
Tooth position
Occlusion Mount casts to vertical
dimension
No Partial Denture Mount cast to vertical
dimension
Diagnostic denture waxup reestablishocclusion
Silicone matrix forspace evaluation
Di t Pl t
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Direct Placement
Male or female premanufactured attachmentis cemented into root
Denture is made and inserted
Corresponding male or female attachment isinserted in root
Attachment is picked up directly in theoverdenture with cold cure acrylic
Placed by Dentist
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Indirect Placement
Male or female attachment is cemented
into root or may need to be cast onto
coping
Corresponding male or female transferanalog is inserted into root attachment
Transfer impression is taken and models
are poured with transfer in place Laboratory processes denture with
corresponding attachment in place
Placed by Laboratory
Proceedures To Follow
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Proceedures To Follow
5 mm or more root remaining in bone
Stable perio
Mount study models evaluate space required
Select OD attachment obtain reference manuals
Begin denture proceedings Root canal therapy
Decoronate roots, extractions, insert temporary
denture reline allow time for healing
Prep tooth for attachment and cement attachment Insert denture, make adjustments, post placement
reline
Pick up male attachment in denture
S k E iHader
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Bar Designs
Round
Ovoid
Square
Rectangular
Double BarCustom Milled
Spark ErosionHader
DolderAndrews
Branson
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Attachments and Bars
Intra Bar
Extra Bar
Circum Bar
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Extra Bar
Attachment placed on the superior aspect of
the bar
Increases strength of bar
Requires more interarch space
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Intra-Bar
Connection between the two components
directs the forces of mastication closer to
the crest of the ridge
Decreases lever arm mechanics
on the supporting teeth
Bar strength may be
compromised
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Circum-Bar
Attachment wraps itself around the bar
Allows for rotation around bar
The Milled Bar
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The Milled Bar
Main Advantage
Final prosthesis is extremely stable because
lateral forces are best managed by an
intimately fitting primary and secondarybar
This minimizes stress on the attachments
The Bar Overdenture
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Advantages
Increased stability and retention than anattachment retained overdenture
Accomodates a wide variety of implantangulations
Bar splints implants together
Provides better resistance to lateral forces whenin function
Pose less of a chance of failure atbone-implant interface
The Bar Overdenture
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Disadvantages
More costly
More technique sensitive