Effect of splinting on load distribution of extracoronal

attachment with distal extension prosthesis in vitro

Hussein G. El Charkawi, BDS, MSc, MS, PhD,a and Mohammed Tark El
Wakad, BSc, MS, PhDb
Cairo University and Helwan University, Cairo, Egypt

Previous reports have suggested that the restoration of distal extension edentulous
areas with an extracoronal precision attachment partial denture necessitates splinting
of abutments. However, the number of splinted teeth remains controversial. In this
study, strain gauge technology was used to monitor stresses induced around the
abutment and in the distal extension area under different loads as a function of the
number of splinted abutments. Three strain gauges were installed in the outer buccal,
lingual, and distal surfaces of the abutment to record stresses in the three planes of
motion, and another gauge was placed under the distal extension base. The reduction
of the number of splinted units from three to two resulted in an insignificant increase
of stresses recorded, whereas reduction of the number from two to one resulted in a
significant increase of stresses nine times greater than the three-unit splint values. On
the basis of this in vitro model, at least two teeth on each side should be splinted when
extracoronal distal extension attachment prostheses are used. (J Prosthet Dent
1996;76:315-20.)

E xtracoronal attachments may be useful in distal
extension cases compared with the conventional clasp
assemblies. Extracoronal attachments provide superior
retention and esthetics1 They may also distribute occlusal
forces better to the supporting structures if spaces or
springs are incorporated into their design2> 3 However,
the use of these attachments has certain limitations. One
of these limitations is the excessive torque applied to
the most distal abutment. This may necessitate splinting
of the abutments.4-6 Splinting may minimize the hazard-
ous effects of excessively loading the abutments. However,
the preferable number of splinted teeth is debatable. Pre-
iske17 reported the need for splinting all of the anterior
teeth when an extracoronal attachment is used, whereas
Kratochvil et al8 suggested that fewer teeth need splint-
ing. Splinting of abutments often necessitates reduction
of sound tooth structure. Fixed splints also compro-
mise periodontal health care because of the wide joints
between the units of the splint that can interfere with oral
hygiene measures7 Margins of fured splints may
cause gingival irritation if they encroach on the gingiva.g
Limiting the extent of a fixed splint may reduce such haz-
ards.
In this study, strain gauge technology was used to eval-
uate the effect of number of splinted abutments on the
pattern of load distribution in structures supporting an in
Submitted for the Judson C. Hickey Scientific
competition, September 1995.
aAssociate Professor of Prosthodontics, Faculty
tal Medicine, Cairo University.
bLecturer, Mechanical Engineering, Faculty
Technology, Helwan University.
vitro model of distal extension removable partial dentures
(RPDs) retained by extracoronal attachments.
MATERIAL AND METHODS
An acrylic resin partially edentulous mandibular model
(Kennedy class I) was constructed from anatomically cor-
rect models that had complete and anatomically correct
root forms (Kilgore Int. Inc., Coldwater, Mich.). The root
forms were coated with 0.3 mm thick elastomeric mem-
brane to simulate the periodontal ligament. Another layer
of elastomeric membrane, uniform thickness of 2 mm of the
same material (Deguflex monophase, Degussa AG, Frank-
fort, Germany), was used to fabricate a soft tissue replica
at the distal extension region. The second premolars were
the last remaining teeth. The canines and premolars on
each side were prepared to receive a three-unit full-cover-
age fured splint. Waxing was carried out on the model. A
ledge on the lingual aspect on each side of the second pre-
molars was trimmed and perfected by a surveyor (to
receive a bracing arm). Rest seats were prepared on the
mesial surface of the second premolars and the distal sur-
face of the first premolars. Guide planes were created on
the distal surface of the second premolars with the sur-
veyor.
The matrices (keyways) of extracoronal semiprecision
attachments (Elephant attachments, Beta 7R, Elephant,
Le Horn, The Netherlands) were attached to their paral-
leling mandrels, placed on the surveyor, and adhered to the
waxing. The matrices were placed in the most distal and
Writing Award gingival positions. The wax patterns were then sprued, in-
vested, cast to a nickel-based alloy (Durabond, Matech Inc.,
of Oral and Den-
Calif.), and divested. They were then finished and polished
of Engineering and in accordance with the manufacturer’s recommendations
(Fig. 1). The cast splint was checked for proper seating with

SEPTEMBER 1996 THE JOURNAL OF PROSTHETIC DENTISTRY 3 15

THE JOURNAL OF PROSTHETIC DENTISTRY ELCHARKAWIANDELWAKAD

Fig. 1. Finished cast splint. Fig. 3. Top view of model with simulated mucosa re-
moved shows buccal, lingual, and distal strain gauges
around abutment (arrows) and distal extension strain
gauge on steel beam (arrow).

surfaces of the right second premolar. The axial walls of the

alveolar ridge at the sites of the strain gauges were reduced
below the crest of the ridge, were parallel to the long axis
of the tooth, and were 1 mm thick. Another strain gauge
was installed on a steel beam that was placed under the
distal extension base (Fig. 3). This assembly magnified the
effect of load in this area. All strain gauges were bonded to
the acrylic resin surface according to the instructions pro-
vided by the manufacturer. After bonding, a protective and
insulating polyurethane coating (M Coat A, Measure-
ments Group Inc., Raleigh, N. C.) was applied to the sur-
Fig. 2. Finished metallic prosthesis in place. Arrows
face. All lead gauge wires were secured in place with an
point to anterior, middle, and posterior points of loading.
epoxy resin bonding agent (&minute epoxy, Devcon, Den-
ver, Cola.) and adhesive tapes to avoid any possible move-
disclosing wax (Kerr Mfg. Co., Romulus, Mich.) and then ments that may affect the accuracy of the system (Fig. 4).
cemented with a glass ionomer cement (Ketac-Cem, ESPE, The strain gauges were connected to a Wheatstone elec-
Seefeld-Oberbay, Germany). The ledges were perfected tronic bridge circuit (PR 9307 carrier frequency bridge,
with a milling machine. Philips, Holland). For each active strain gauge, a fluctua-
The model with the splint was then duplicated, accord- tion dummy gauge was connected to half of the Wheatstone
ing to manufacturer recommendations, to receive an RPD bridge to compensate for any ambient temperature fluctu-
metallic frame. A chromium-cobalt frame (Rexillium, Ren- ation.
fert, Hilzingen, Germany) was fabricated on the duplicate A modified surveyor (Key Surveyor, J. M. Ney Co.,
model (Fig. 2). The patrices (key portions) were soldered to Bloomfield, Conn.) was used to apply static loads within
the framework. Each attachment had a spacer 0.4 mm the reported physiologic limits of 20,30, and 40 newtonslo
thick that was placed between the keyway and key during at preselected points on the anterior, middle, and posterior
fabrication and then removed. Points of interference be- occlusal surfaces of the distal extension metallic base (Fig.
tween the RPD and cast splints were detected with 4).
disclosing wax and eliminated. Acrylic resin distal exten- Microstrains were recorded (1) with the three units
sion bases were constructed under the frame and were ad- splinted together (one canine and two premolar+ (2) after
hered to it by epoxy resin. separation of the canine from the two premolars and (3)
To monitor the effect of the applied forces in the three after separation of the premolars (without any splinting).
planes of motion, three strain gauges (FLA-&IL-II, TML Five measurements were recorded for each testing condi-
Tokyo Sokki Kenkyujo Co. Ltd., Tokyo, Japan) (specifica- tion, with enough time elapsed between each recording to
tions gauge (G) length 5 mm, G width 1.5 mm, base 10 x 3 allow complete rebound of the resilient structures. Positive
mm, nominal resistance 120 Ohm, and gauge factor 2.14) contacts without actual union to simulate natural tooth
were installed in the outer buccal, lingual, and distal axial contact were maintained after separation of the units.

316 VOLUME 76 NUMBER 3

EL CHARKAWl AND EL WAKAD THE JOURNAL OF PROSTHETIC DENTISTRY

RESULTS
Table I presents an increase for the microstrains re-
corded from the buccal strain gauge with a reduction of the
number of splinted units. This inversely proportional rela-
tion was nonlinear. Decreasing the number of splinted
teeth from two to one significantly influenced microstrains.
However, decreasing the number of splinted teeth from
three to two did not show significant increase in micros-
train recordings in most tested conditions. The same pat-
tern was recorded in the lingual, distal, and distal exten-
sion (saddle) strain gauges (Tables II through IV).
The percentage of increase between three and two units
with posterior loading of 40 N is 5% (mean 100.0 to 105.0
microstain units) and 52% between two and one (mean
Fig. 4. Loading device on model and carrier frequency
105.0 to 160.0) in the buccal strain gauge (Table I). The
bridge. Arrow points to fixation of gauge wires.
percentage increase was from 6.82% to 51.06% in the lin-
gual strain gauge (Table II); 7.2% to 59.3% in the distal
strain gauge (Table III); and 10.45% to 56.76% in the dis- distal extension strain gauge and the abutment strain
tal extension strain gauge (Table IV). gauges, because the distal strain gauge was mounted on a
There was a direct proportional and significant relation- steel beam to magnify its readings.
ship between applied load magnitudes and recorded mi- The greatest m.icrostrains recorded around the abut-
crostrains. This relation was highly linear, as calculated ment were, in decreasing order, at the distal strain gauge,
from Pearson’s coefficient of correlation.11 followed by the lingual and the buccal. The distal strain
Table V reveals that moving the point of loading poste- gauge was bonded1 on the surface that was nearly perpen-
riorly resulted in a significant increase of microstrains re- dicular to the plane of bending, thus deformation on this
corded. Table V also indicates that the distal strain gauge surface was attributed to both axial force and bending mo-
exhibited the highest microstrains recorded, followed by ment. The bending moment equals:
the lingual and then the buccal gauges (means 235.0, Bending force x lever arm
177.5, and 160.0, respectively). These results were consis-
where the lever arm is the distance between the point of
tent with anterior, middle, and posterior points of loading.
loading and the fulcrum around which the prosthesis tends
to rotate.
DISCUSSION On the other hand, the buccal and lingual strain gauges
The problem of disparity of support in distal extension were bonded to surfaces that were nearly parallel to the
prostheses has always been an intriguing challenge for plane of bending. The recorded microstrains at these sites
prosthodontists. Many treatment modalities were advo- were principally attributed to axial force and not to bend-
cated to distribute occlusal forces between natural teeth ing moment. I4 This explains their lower magnitudes when
and the residual ridge. Extracoronal attachments, which compared with the distal strain gauge. Another sequela of
splint natural teeth together, may distribute these forces. such a pattern of load distribution is that the rate of
However, the number of the teeth to be splinted remain a increase of microstrains when the point of loading was
controversial issue. Factors such as root form, periodontal moved posteriorly was not similar for all strain gauges. It
or bony support, resiliency or the mucosa, and applied force was greater for the distal extension and distal strain
are variable factors. Recent studies began questioning the gauges than it was for the buccal and lingual strain gauges.
need for cross-arch splinting with fixed types of splints be- The slightly greater microstrains recorded from the lin-
cause increasing the number of splinted teeth beyond a gual strain gauge may be explained by the slight lingual
certain limit may not result in a signifkant reduction of anatomic inclination of the splinted mandibular teeth.15
loads imposed on the supporting structures.i2~i3 In this The model used in this study represented ideal anatomic
study reduction of the splinted units from three to two in- and tooth alignment forms. It also included a simulated
creased the microstrains recorded around the abutment by periodontal ligament and gingival tissues. These proper-
only6.82%(asrecordedfromlingualstraingauge),whereas ties attempt to si:mulate the natural function of the denti-
reducing the number from two to one revealed a 51.06% tion and tissue and help to validates the testing method by
increase (almost 8 to 9 times) (Table II). The same occurred controlling the variables. In vitro studies could be valuable
in the distal extension area; microstrains recorded with when the experiments are concerned with measuring
two units splinted increased by 10.45% whereas the one- comparative values and/or behavioral pattern of the tested
unit microstrain recordings increased by 56.76% (Table models.16 What really matters is the proper interpretation
IV). However, no comparison was carried out between the of any technique using models, in terms of methodology,

SEPTEMBER 1996 317

THE JOURNAL OF PROSTHETIC DENTISTRY EL CHARKAWI AND EL WAKAD

Table I. Effects of splinting on microstrains recorded from the buccal strain gauge

Number of Anterior point Middle point Posterior point

Load supporting
(N) teeth zi SD CV (%) dl d2 il SD CV (%I dl d2 3 SD CV (%I dl d2

20 3 045.0 4.33 09.60 B b 047.5 0.00 0.00 B ab 052.5 4.33 8.29 B a

2 045.0 2.50 05.56 B b 052.5 0.00 0.00 B a 055.0 4.33 7.86 B a
1 067.5 4.33 06.41 A b 077.5 6.63 8.55 A ab 080.0 3.53 4.41 A a
30 3 062.5 4.33 06.92 B b 067.5 4.33 6.41 B ab 075.0 4.33 5.77 B a
2 070.0 7.50 10.71 B b 072.5 4.33 5.97 B ab 082.5 4.33 5.24 B a
1 105.0 6.63 06.31 A a 112.5 7.50 6.67 A a 122.5 6.63 5.41 A a
40 3 085.0 2.50 02.94 B b 092.5 6.63 7.16 B ab 100.0 5.00 5.00 B a
2 095.0 8.65 09.11 B a 100.0 6.63 6.63 B a 105.0 6.63 6.31 B a
1 137.5 6.63 04.82 A b 150.0 9.03 6.02 A ab 160.0 5.00 3.13 A a
ii, Arithmetic mean; SD, standard deviation; CV, coefficient of variance; N, newton, dl, Duncan multiple range test between number of supporting teeth; dZ,
Duncan’s multiple range test between points of loading. Means with the same letter are not significantly different at p < 0.05.

Table II. Effect of splinting on microstrains recorded from lingual strain gauge

Number of Anterior point Middle point Posterior point

Load supporting
W) teeth If SD CV (%) dl d2 ii SD CV (%) dl d2 E SD CV (%) dl d2

20 3 047.5 2.50 05.26 B b 055.0 4.33 7.86 B a 057.5 00.00 0.00 B a

2 047.5 0.00 00.00 B c 055.0 5.33 7.86 B b 062.5 04.33 6.92 B a
1 072.5 7.50 10.34 A b 082.5 4.33 5.24 A ab 092.5 02.50 2.70 A a
30 3 067.5 4.33 06.41 B b 075.0 6.63 8.83 B ab 085.0 04.33 5.09 B a
2 075.0 2.50 03.33 B b 085.0 6.63 7.79 B ab 090.0 06.63 7.36 B a
1 110.0 8.65 07.86 A b 125.0 4.33 3.46 A ab 135.0 11.45 8.48 A a
40 3 087.5 4.33 04.94 B b 097.5 4.33 4.44 B b 110.0 04.33 3.93 B a
2 097.5 9.03 09.26 B b 105.0 4.33 4.12 B ab 117.5 08.65 7.36 B a
1 147.5 6.63 04.49 A b 165.0 6.63 4.02 A a 177.5 04.33 2.44 A a
Key to abbreviations in footnote to Table I. Means with the same letter are not significantly different at p < 0.05.

Table III. Effect of splinting on microstrains recorded from distal strain gauge

Number of Anterior point Middle point Posterior point

Load supporting
(N) teeth x SD CV(%) dl d2 zi SD CV (%) dl d2 x SD CV (%) dl d2

20 3 055.0 00.00 00.00 B b 062.5 6.63 10.60 B ab 067.5 5.00 7.41 B a

2 057.5 04.33 07.52 B b 067.5 4.33 06.41 B a 075.0 5.00 6.67 B a
1 095.0 04.33 04.55 A b 105.0 6.66 06.31 A ab 117.5 4.33 3.68 A a
30 3 082.5 06.63 08.03 B b 090.0 4.33 04.80 B b 102.5 6.63 6.46 B a
2 087.5 09.00 10.29 B b 100.0 6.63 06.63 B ab 110.0 0.00 0.00 B a
1 140.0 04.33 03.09 A c 160.0 4.33 02.70 A b 175.0 4.33 2.47 A a
40 3 112.5 06.63 05.89 B b 120.0 4.33 03.60 C b 137.5 4.33 3.15 c a
2 115.0 10.90 09.48 B c 130.0 5.00 03.85 B b 147.5 4.33 2.93 B a
1 187.5 07.50 04.00 A c 215.0 5.00 02.33 A b 235.0 4.33 1.84 A a
Key in footnote to Table I. Means with the same letter are not significantly different at p < 0.05.

assumptions, and limitations. This study used static loads tional impression techniques, such as the altered-cast im-
to evaluate RPDs. Two main problems are associated with pression technique, to limit the displacement differential
the use of static loads in the evaluation of RPDs. (1) Static between the periodontal ligament and the mucosa covering
loads yield information that is valid only for the specific the residual ridge.18 Limiting the forces received by the
points of measurements; therefore, it becomes difficult to supporting structures is another way to decrease the effect
judge whether the selected points are the best ones for of a bending moment. This could be achieved by maximum
evaluating the RPD design tested. (2) It is difficult to mimic base coverage reductionlg ofthe area ofthe occlusal table,20
the chewing cycle.15a I7 use of minimal cusp height,21 and resilient materials.15
Bending moments may be minimized by using func- Stress directors have also been considered as a mean of

318 VOLUME 76 NUMBER 3

EL CHARRAWI AND EL WARAD THE JOURNAL OF PROSTHETIC DENTISTRY

Table IV. Effect of splinting on microstrains recorded from the distal extension strain gauge

Number of Anterior point Middle point Posterior point

Load supporting
(N teeth x SD CV (%) dl d2 2 SD CV (%) dl d2 z SD CV (%) dl d2

20 3 057.5 2.50 4.35 c c 072.5 4.33 5.97 B b 087.5 6.63 5.57 B a

2 065.0 0.00 0.00 B c 077.5 4.33 5.58 B b 095.0 0.00 0.00 B a
1 102.5 4.33 4.22 A c 120.0 4.33 3.60 A b 147.0 6.63 4.49 A a
30 3 085.0 7.50 8.82 B c 110.0 4.33 3.93 B b 127.5 4.33 3.39 C a
2 095.0 6.63 6.97 B c 117.5 5.00 4.26 B b 135.0 4.33 3.20 B a
1 155.0 5.00 3.32 A c 185.0 6.63 3.58 A b 217.0 0.00 0.00 A a
40 3 117.5 0.00 0.00 c c 145.0 6.63 4.57 C b 167.5 6.63 3.96 C a
2 130.0 4.33 3.33 B c 160.0 4.33 2.70 B b 185.0 8.65 4.68 B a
1 202.5 4.33 2.14 A c 245.0 9.03 3.68 A b 290.0 9.03 3.11 A a

Key in footnote to Table I. Means with the same letter are not significantly different at p < 0.05.

Table V. Effect of load magnitude with posterior point loading

Buccal strain gauge Lingual strain gauge Distal stain gauge Distal extension

Load cv CV
(N) ti SD dl d2 ?? SD (%) dl d2 x SD (%I dl d2 ii SD cv (%) dl

No. of supporting teeth = 3

20 052.5 4.33 8.29 C b 057.5 00.00 0.00 C b 067.5 5.00 7.41 C a 087.5 6.63 5.57 c
30 075.0 4.33 5.77 B b 085.0 04.33 5.09 B b 102.5 6.63 6.46 B a 127.5 4.33 3.39 B
40 180.0 5.00 5.00 A c 92.5 04.33 3.93 A b 117.5 4.33 3.15 A a 117.5 6.63 3.96 A
No. of supporting teeth = 2
20 055.0 4.33 7.86 C b 062.5 04.33 6.92 C b 075.0 5.00 6.67 C a 095.0 0.00 0.00 c
30 082.5 4.33 5.24 B b 090.0 06.63 7.36 B b 110.0 0.00 0.00 B a 135.0 4.33 3.20 B
40 105.0 6.63 6.31 A b 117.5 08.65 7.36 A b 147.5 4.33 2.93 A a 185.0 8.65 4.68 A
No. of supporting teeth = 1
20 080.0 3.53 4.41 c c 092.5 02.50 2.70 C b 117.5 4.33 3.68 C a 147.0 6.63 4.49 c
30 122.5 6.63 5.41 B b 135.0 11.45 8.48 B b 175.0 4.33 2.47 B a. 217.0 0.00 0.00 B
40 160.0 5.00 3.13 A c 177.5 04.33 2.44 A b 235.0 4.33 1.84 A a 290.0 9.03 3.11 A

Key in footnote to Table I. Means with the same letter are significantly different at 1, < 0.05.

reducing loads on the abutments, especially if used with unit splint) had an insignificant effect on the stresses re-
splinted teeth.s 16, 22, 23 corded.
2. Increasing thle magnitude of applied load signifi-
CLINICAL SIGNIFICANCE cantly increased the stresses transmitted to the support-
The results ofthis study suggest that in situations where ing structures.
extracoronal attachments are used with free-end saddles, 3. Moving the point of loading in a posterior direction
at least two splinted teeth on either side should be used. increased the stresses.
Preiskel” noted that the use of bracing arms may reduce 4. The greatest stresses recorded around the distal
the loads from falling on the attachment and may improve abutment were on the distal surface, followed by the
its bracing action. Equitable distribution of stresses could lingual and buccal surfaces.
be achieved by light retention elements to support rests
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