CASE REPORT

Attachment Retained Removable Partial Denture: A Case

Report
Sumit Makkar,1 Anuj Chhabra,2 Amit Khare3

ABOUT THE AUTHORS

1) Dr. Sumit Makkar MDS.
Senior Lecturer,
Department of
Prosthodontics, ITS-Centre
for Dental Research &
Studies, Muradnagar
Ghaziabad.
Abstract
Attachment-retained Removable Partial Denture (RPD) is not an outdated treatment modality.
It is even more contemporary in today's appearance-oriented society than when it was first
introduced. There is significant number of patients who could benefit from this treatment
option, both short and long term. However, lack of proper knowledge, overwhelming number
of attachments available in the market, multiple adjustments and repairs are making dentist
reluctant to offer and provide attachment-retained RPD to their patients. The purpose of this
article is to provide an overview and a simplified approach to this treatment modality by a
clinical case report.
KEYWORDS: Attachment , Removable Partial Denture

2) Dr. Anuj Chhabra MDS.

Reader,
Department of
Prosthodontics, ITS-Centre
for Dental Research &
Studies, Greater Noida.
3) Dr. Amit Khare MDS.
Reader, Department of
Prosthodontics, Peoples
college of Dental Sciences
and research centre,
Bhopal.
Corresponding Author:
Dr. Sumit Makkar
Department of Prosthodontics
ITS-Centre for Dental
Research & studies,
Muradnagar Ghaziabad.
E- mail:
sumitmakkad@gmail.com
Contact no: 91-9268138938.
39
IJCDS • MAY,
Introduction
Our ever-increasing knowledge of the oral environment, together with technological
improvements and good armamentarium, has taken us to give a restoration which is
esthetically pleasing and comfortable. This makes it all the more important to
reconcile what is actually feasible with the patient's own expectations.
Rehabilitation of partially edentulous situations can be challenging when it is distal
extension situations where a fixed prostheses cannot be fabricated. Implant retained
restoration are an option but this is sometimes not possible due to insufficient amount
of bone or economic reasons. In these cases acrylic or cast partial denture was largely
preferred, with barely satisfactory esthetical results.
Precision attachment has long been considered the highest form of partial denture
therapy. Attachment retained RPD is the treatment modality that can facilitate both
esthetic and a functional replacement of missing teeth and oral structures. The few
retrospective studies available show a survival rate of 83.3% for 5 years, of 67.3% up to
[1,2]
15 years and of 50% when extrapolated to 20 years.
This article outlines some of the essential considerations in planning of a precision
attachment retained partial denture with a clinical report.
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.
[3]
Precision attachments can be classified in to four main groups .
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. This type of attachment 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. Swiss
logic, ZAAG, Zest anchor is example of stud attachments. One of the
advantages
of©stud
2011 • 2(2) is Journal
2011 Int. thatofthey
Clinical promote
Dental Science better oral hygiene and crown root
ratio is improved with low profile stud attachments.
logic, ZAAG, Zest anchor is example of stud attachments.
One of the advantages of stud is that they promote
better oral hygiene and crown root ratio is improved
with low profile stud attachments.
4. Bar attachments. Originally used for splinting
groups of teeth, currently used for overdenture retention
and stabilization.
Indications and contraindications for precision
retained partial denture
The variability in the circumstances for use of
attachments and the variety of attachments available
preclude the establishment of a standard model.
Selection of precision attachment should be based on
the functional and physiologic requirements of the
prosthesis. Consideration of the laboratory expertise
in using particular attachments must be
contemplated.
The overwhelming indication for the attachment RPD is
aesthetics. Numerous skilfully designed conventional
RPDs are not worn simply because the patient does not
like the appearance. Elimination of the buccal or labial
direct retainer or clasp arm is a key factor in establishing
an esthetically acceptable design.
The contraindications to the use of attachments in RPDs
are numerous. Short clinical crowns prove to be the
foremost contraindication to the use of attachments in
the construction of RPDs. The tooth must have adequate
crown height to house the attachment components and
effectively offset the leverage forces exerted on the
crown. In addition, adequate height must be present for
the corresponding attachment components to be
housed within the RPD framework or supportive acrylic
resin while allowing an optimal artificial tooth placement
[1,2,3 4,5,6]
. attachments are nonresilient and may require double
Biomechanics and support for attachment retained
RPD
Once a decision has been made to restore a region
with attachment prosthesis, the manner in which the
vertical and horizontal forces are to be supported
requires consideration. A partial prosthesis may be
tooth borne or tooth-tissue borne. Attachments for
Kennedy Class III and Class IV tooth-supported
prostheses should be considered solid, whereas large
Class IV and distal extension I or II prostheses which
are increasingly tissue supported and it should be
considered resilient. Rigid attachment allows virtually
no movement between the prosthesis and the
abutment tooth. Resilient attachments allow for a
spectrum of movement ranging from limited
[6]
uniplanar to universal. Staubli has categorized rigid
and resilient attachments into six classifications, from
rigid to universal resiliency. The higher classification
number correlates with a greater degree of resiliency
and suggests less torque transfer to the root or
implant abutment.
IJCDS • MAY, 2011 • 2(2) © 2011 Int. Journal of Clinical Dental Science
Table :1
:1 Classification
Classificationofofattachments
attachments
Class 1a Solid, rigid, non-resilient
Class 1b Solid , rigid, lockable with U- pin.
Class 2 Vertical Resilient
Class 3 Hinge Resilient
Class 4 Vertical and Hinge Resilient
Class 5 Rotational and vertical resilient
Class 6 Universal , Omniplanar
In general, the more precise or rigid the attachment
design is, the greater is the degree of indirect retention
inherent in the design. Additionally, the more widely
spaced the retainers are, the greater the support and
stability are when compared with a design with retainers
placed closely together.
With the aid of a surveyor, the anticipated path of
insertion must be evaluated to develop appropriate
guiding planes and attachment placement within the
confines of the natural dentition. A less resilient
attachment will generally dictate a smaller degree of
tolerance or more parallelism relative to the path of
insertion.
Selection of attachment
Proper attachment selection requires evaluation of 3
factors: location, retention and available space.
Location: Intracoronal attachments are incorporated
entirely within the contours of the cast crown for the
tooth. The advantage of the intracoronal attachment is
that the forces exerted by the prosthesis are applied
more closely to the long axis of the tooth. Intracoronal
abutting or splinting of the adjacent teeth. This form of
attachment offers indirect retention and a more precise
path of placement.
The three-dimensional size of the tooth will predict the
functional or biomechanical success with this
attachment. A clinical crown of greater than 4 mm is
[7]
generally required with a similar faciolingual width. In
situations with diminished attachment length as a result
of reduced interocclusal height, milled lingual bracing
arms should be considered.
Extracoronal attachments are situated external to the
developed contours of the crown. The majority of
extracoronal attachments have resilient attributes.
Attachment alignment is not as critical in highly resilient
extracoronal attachments due to the omniplanar motion
possible. This creates the advantage of multiple paths of
placement for the prosthesis. Patients with
biomechanical limitations not withstanding a rigid
attachment apparatus or anatomic limitations precluding
a finite path of placement are strong candidates for
resilient attachments.
40
Retention: Retention of the attachment components may
be based on frictional, mechanical, frictional-mechanical,
magnetic, and suction characteristics. Frictional retention
is developed by the resistance to the relative motion of
two or more surfaces in contact. Greater surface contact
will usually correlate with an increase in the amount of
retention. Mechanical retention implies the resistance to
relative motion by means of a physical undercut. The
degree of undercut and the ability to adjust the physical
component will predict retention. Magnetic retention is
created by attraction of certain materials to a
surrounding field of force produced by the motion of
[8]
electrons and atomic alignment. They were not effective
until a small but strong closed field cobalt-samarium (co-su)
magnet was developed that would fit on to the surface of a
tooth. A metal keeper is attached to the tooth surface,
usually into the root canal and the magnet is contained
within the resin of the denture base. The alloy in the magnet
produces a magnetic force that is both constant and
extraordinary strong. Suction is created by a negative
pressure similar to the intaglio surface of a denture to
the supportive residual ridge.
Space: Space is a principal consideration for the selection
of an attachment. Vertical space is measured from free
gingival margin to the marginal ridge of the abutment.
Cautious placement of the superior aspect of the
attachment will circumvent occlusal interferences. The
length of attachments that rely on frictional retention
should be maximized to maintain resistance to
dislodgment. Placement of the attachment should be as
low on the tooth as possible to reduce the tipping or
leverage forces applied. Buccolingual space is equally
important to avoid over contouring the crown.
Additional bulk will be required buccal and lingual to the
attachment for the casting alloy. Proper analysis of
mesiodistal measurement ensures proper proximal
contour and will provide an indication of a need for
boxes in the development of the preparation. The largest
attachment possible should be selected. This requires
careful preparation analysis that includes the
arrangement of denture teeth in a diagnostic wax-up.
This will help ensure the highest functional and esthetic
value to the reconstruction.
Case report
A 55-year old female reported to private dental practice
with chief complain of missing teeth in lower posterior
region and inability to eat food. She was wearing a distal
extension removable partial denture and the presence of
mandibular extra coronal clasp retainers was negatively
affecting the aesthetics. On clinical examination
nd st
mandibular 2 premolar, 1 & 2nd molar were absent
st
and mandibular canine & 1 premolar was of adequate
height with sound periodontal support.
In lieu of compromised aesthetics, impaired function with
existing partial denture it was planned to construct
mandibular removable partial denture with extracoronal
attachment. The patient rejected the options of implants
41 IJCDS • MAY, 2011 • 2(2) © 2011 Int. Journal of Clinical Dental Science
because of the need for additional surgery and the
unacceptable duration of treatment phase.
[9]
TECHNIQUE
1. Diagnostic impressions were made and mounted on
semi adjustable articulator using a face bow.
Following which diagnostic wax-up was done on the
mounted casts.
2. A putty matrix (Express STD Putty; 3M ESPE, St. Paul,
Minn.) was made over the completed diagnostic wax-up
for evaluation of the existing space for the extracoronal
resilient attachment.
3. The attachment system was selected on the basis of
available space. (OT CAP, Rhein 83 Inc, USA)
4. Tooth preparation was done on mandibular canine
st
and 1 premolar to receive PFM crowns ( Fig :1).
Impression was made and poured in die stone. Following
which crowns have been waxed to full contour and
milled in wax for maximum guiding plane surface. The
patrices was added to the axial surfaces of the abutment
using a dental surveyor, lingual to the centre of proximal
contour. This ensures that the bulk of matrice does not
interfere with esthetic of buccal cusp of replacing
denture tooth. (Fig :2)
5. Following which casting, finishing, and veneering of
the fixed component was done.(Fig: 3)
6. The fixed component including veneered metal-
ceramic crowns & the patrices were tried in the patient
mouth ( Fig: 4) and a pick-up impression was made
(Imprint II; 3M ESPE).
7. The matrices of the attachments was placed in the
receptacles ( patrice of the attachments) which were in
the crowns on the refractory cast .
8. The wax up of framework of the removable partial
denture was done, invested and casted.
9. The framework was evaluated in the patient mouth
and jaw relation was done using occlusal rims.
10. Try-in was done and acrylisation of removable partial
denture was performed.
Fig : 1 Tooth Preparation done on 43,44

Fig: 2 Wax Pattern with Patrice attached.
Fig: 3 PFM Crowns with Patrice attached
Discussion
[10]
Dr. Herman Chayes first reported the invention of
th th
attachment in early 20 century. To the late 20 century,
with growing technology the attachment has been
applied to the superstructure of implant. Precision
attachment has exceptional feature of being a removable
prosthesis with improved aesthetics, less post-operative
[7]
adjustments and better patient comfort. They are
mostly indicated in long edentulous spans, distal
extension bases and non parallel abutments.
Understanding the difference in nature and behaviour of
the tissues supporting RPD is critical for long term
10
success of the prosthesis . These differences multiplied
by the function create major stresses on the tooth-tissue
prosthesis. The stress-control on abutment is an essential
factor for the success of distal extension cast partial
denture which is achieved through dual impression
technique, broad coverage and stable denture base, rigid
design, physiologic shimming, splinting of abutments,
[11-12]
proper selection of attachment and clasp design.
In this case report abutments were of adequate clinical
crown height to receive attachment; multiple abutments
were splinted anterior to edentulous span to aid in
[13]
better distribution of stresses. Kapur et al has
st nd
suggested that splinted 1 and 2 premolar by full
coverage crown , has provided good support and
improved the prognosis of cast partial denture.
[14]
Moreover Extra coronal OT CAP are castable
attachments with elastic retention. With its elasticity it is
possible to control the flexure and construct a resilient
and shock absorbing prostheses.

Summary & Conclusion

Removable partial dentures fabricated with precision

attachments are the viable options for patients in whom
fixed prosthesis, implants are contraindicated. Adherence
to precision techniques, proper diagnosis and periodic
recall preventative therapy will result in successful
treatment and preservation of the patient's existing
dentition.
Fig: 4 PFM Crowns trial in the mouth
References

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Treatment planning and attachment selection.
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3. Preiskel HW. Precision attachment in

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Fig: 5 Final Prosthesis in Occlusion.
Publishing Co Ltd,1995

42
IJCDS • MAY, 2011 • 2(2) © 2011 Int. Journal of Clinical Dental Science
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43 IJCDS • MAY, 2011 • 2(2) © 2011 Int. Journal of Clinical Dental Science