BMJ Case Rep: first published as 10.1136/bcr-2019-233744 on 25 August 2020. Downloaded from http://casereports.bmj.
com/ on August 31, 2020 at University of Rochester Medical Center.
Department of Prosthodontics,
Faculty of Dental Science,
Banaras Hindu University
Institute of Medical Sciences,
Varanasi, Uttar Pradesh, India
Correspondence to
Dr Pavan Dubey;
​drpavan26@​gmail.c​ om
Accepted 29 June 2020
© BMJ Publishing Group
Limited 2020. No commercial
re-­use. See rights and
permissions. Published by BMJ.
To cite: Saneja R,
Bhatnagar A, Raj N, et al. BMJ
Case Rep 2020;13:e233744.
doi:10.1136/bcr-2019-
233744
Learning from errors
Case report
Semiprecision attachment: a connecting link between
the removable and fixed prosthesis
Ritu Saneja, Atul Bhatnagar, Nancy Raj, Pavan Dubey  ‍ ‍
SUMMARY and mode of retention as intracoronal and extra-
coronal.4 In an intracoronal attachment the matrix
Oral rehabilitation of partially edentulous arches requires
careful treatment planning before any prosthodontic is fitted within the contour of crown whereas, in
intervention. The connection of the metal framework extracoronal attachment, the matrix is outside the
of fixed (fixed dental prosthesis (FPD)) and removablecontoured crown.
partial denture using adhesive attachments is a good Few advantages of intracoronal attachments are
appearance, unaffected retention by crown contour
alternative prosthetic option when solely fixed prosthesis
(FPD or implant) cannot be used due to anatomical and minimum stresses on abutment teeth but intra-
coronal attachment requires extensive abutment
limitation. Attachments are the tiny interlocking devices
preparation and therefore becomes the reason for
that act as a hybrid link to join removable prosthesis to
the abutment and direct the masticatory forces along early and easy wear off.
the long axis of the abutment. This joint acts as a non-­Extracoronal attachments have few advantages
rigid stress breaker, which helps in distributing the over intracoronal as they can be universally used
occlusal load. Precision and semiprecision attachment (no restriction in size), have greater freedom in
have always been bordered by an aura of mystery due design and can be fashioned to give greater reten-
tion.2 4
to technique sensitive procedure and lack of knowledge.
The following case describes a combined contemporary Unlike removable restoration, fixed-­ removable
Protected by copyright.
and conventional approach and treatment sequence with prosthesis (RPD with attachment) offers consid-
erable advantages of preventing lateral movement
the use of attachments for the rehabilitation of partially
edentulous arches. and selective movement of prosthesis on occlusal
loading. Therefore, minimise the transfer of stress
over abutment tooth and provide a biomechanical
advantage in long-­ span partial edentulism.4 The
BACKGROUND attachment retained RPD significantly improves the
Prosthetic rehabilitation of partially edentulous retention, functional efficiency corresponding to a
arch aims at restoration of function, preservation fixed prosthesis and aesthetics and hygiene main-
of periodontium and aesthetics.1 Various treatment tenance of a removable prosthesis. However, the
modalities are available for partially edentulous biomechanical factor must be taken into account
patients, such as clasp retained removable partial during treatment planning for therapeutic results.5
denture (RPD), RPDs with adhesive attachments, From the patient's perspective, a removable pros-
a fixed dental prosthesis (FPD) and an implant-­ thesis with attachment offers more retention, masti-
retained prosthesis. catory efficiency and aesthetics due to decreased
Conventional fixed partial denture is not recom- mobility of prosthesis than the one fabricated
mended in a long-­edentulous span with compro- without attachment.5
mised bone support from a residual ridge. The The use of precision attachments among dental
dental implant as a treatment of choice is also professionals has been very limited since its intro-
limited due to need of ridge augmentation. There- duction because of the limited curriculum in under
fore, combining fixed prosthesis with removable graduation and technique sensitive laboratory
denture using precision attachments always remains needed for precise placement of attachment. A
an alternative treatment modality to conventional reliable laboratories support for incorporating the
clasp-­retained removable prosthesis. To counteract appropriate attachment and insight of proper treat-
the damaging effect of lateral forces, attachments ment planning in a particular clinical situation is
along with clasp may also be used to retain and must.
stabilise the prosthesis.2
As per glossary of prosthodontics term (GPT) an
attachment can be defined as ‘a retainer consisting CASE REPORT
of a metal receptacle (matrix) and a closely fitting A 41-­year-­old woman reported to the Prosthodontic
part (patrix), the matrix is usually contained within Postgraduate Section, Faculty of Dental Sciences,
the normal expanded contour of the crown on Banaras Hindu University with the chief complaint
abutment teeth and patrix is attached the remov- of inability to chew food from right back tooth
able partial denture framework’.3 Further, an region associated with a dull pain on biting hard
attachment can be classified according to the food. On clinical examination, the patient revealed
method of fabrication as precision or semiprecision the dental history of the fixed partial denture in all
Saneja R, et al. BMJ Case Rep 2020;13:e233744. doi:10.1136/bcr-2019-233744 1

Learning from errors
Figure 1  Preoperative orthopantomagram X-­ray.
four quadrants for last 9 months. In the maxillary arch, there was
dislodged metal-­ceramic bridge prosthesis bilaterally and in the
mandibular arch, it was clearly evident that the porcelain facing
was fractured with exposed metal coping on 35 and 38 abutment
teeth. Both maxillary and mandibular arch had bilateral saddle
areas surrounded by prepared teeth anteriorly and posteriorly.
On examination of the maxillary arch, on the right side a total
of 5 teeth were present that is, 18, 14, 13, 12, 11 and among
these, the teeth used as abutment were 14 and 18 for the metal-­
ceramic prosthesis, similarly on the left side a total of 5 teeth
present were 21, 22, 23, 27, 28 while tooth number 23 and 27
were serving as an abutment for the previous prosthesis.
In the mandibular arch, on the left side a total of 6 teeth were
present, that is, 38, 35, 34, 33, 32, 31, while 2 teeth 36 and 37
were missing. Similarly, on the right side, a total of 6 teeth were
present, that is, 41, 42, 43, 44, 45, 48 while teeth missing were
46 and 47. Therefore, as per Applegate's rule, both maxillary
and mandibular arches had Kennedy Class III modification 1
edentulous spaces.
INVESTIGATIONS
To make a definitive treatment plan, we should always analyse
the three most important components of diagnostic procedure
especially in prosthetic dentistry which are6
1. Thorough clinical examination.
2. Radiographical examination.
3. Diagnostic mounting.
Figure 2  (A,B) Diagnostic models; (C) diagnostic mounting with wax-­
up.
2 Saneja R, et al. BMJ Case Rep 2020;13:e233744. doi:10.1136/bcr-2019-233744
BMJ Case Rep: first published as 10.1136/bcr-2019-233744 on 25 August 2020. Downloaded from http://casereports.bmj.com/ on August 31, 2020 at University of Rochester Medical Center.
To achieve all the three objectives, a comprehensive clinical
examination was done for evaluating the condition of abutment
teeth after removing the old prosthesis. Radiographic evaluation
and its correlation with the clinical condition were done with
orthopantomagram X-­ray as an aid in diagnostic tool (figure 1).
Diagnostic impressions of the maxillary and mandibular arches
were made using irreversible hydrocolloid (Zelgen, Dentsply,
Germany). The impressions were poured with type 3 gypsum
product, that is dental stone (Kalstone, Kalabhai, Karson, India).
The facebow transfer was done and the bite registration record
was made using bite registration paste (O-­bite, DMG). Diag-
nostic mounting was done using maxillary and mandibular cast
in the centric bite record (figure 2A,B).
TREATMENT
Before starting the treatment, all the modalities of treatment
options were explained to the patient but the patient agreed to
treatment protocols of the present case report.
In case of the maxillary arch, it was decided to fabricate cast
partial denture (CPD) along with individual porcelain fused
metal (PFM) jacket crown for 13, 14, and 18 (right side) and 23
and 27 (left side).
In case of the mandibular arch, contemporary technique with
fixed-­removable dental prosthesis was planned. It was decided
to attach extracoronal attachment on the proximal surface of
the second premolar bilaterally. First premolars (34, 44) were
also used along with second premolar (35, 45) as a abutment
Protected by copyright.
and splinted together with metal porcelain jacket crown to aid
in the retention of the fixed component of the above-­mentioned
combination.
For another important component of the prosthesis that is,
removable component, a CPD fabrication was planned after
evaluating available existing space.
Entire procedure along with appointment schedule was elab-
orated to the patients, and bilingual informed consent was
obtained.
To estimate the existing space for extracoronal resilient attach-
ment, a diagnostic wax pattern was fabricated and a putty index was
made from addition to silicone putty material (Aquasil, Dentsply,
Germany) (figure 2C). The abutment teeth 34, 35, 38, 44, 45 and
48 were prepared to receive PFM restoration. A two-­stage putty-­
wash impression was made and poured in type 4 gypsum stone
(Kalstone, Kalabhai, Karson). The provisional polymethyl meth-
acrylate prosthesis was fabricated with the help of putty index and
cementation was done using temporary luting agent (Temp-­Bond;
Kerr Corporation, Romulus) (figure 3). Wax patterns were fabri-
cated for all the prepared teeth and matrix portion of the extra-
oral attachment was attached on the distal wall of 35 and 45 wax
pattern using a dental surveyor. The selection criteria for choosing
a particular size was based on available space aiming at providing
2 mm of clearance from the gingival margin to preserve the peri-
odontium of abutment teeth. Wax copings with Precision attach-
ments were cast using the lost wax technique of casting. Special
attention was given during finishing and sandblasting procedure of
casted prosthesis to avoid wear of extracoronal attachment
Metal Try-­in of the splinted crown with patrix component
was done to check for margin and occlusal clearance (figure 4).
Pick-­up impression was made using putty consistency of addi-
tional silicon and poured to fabricate CPD framework (figure 5).
Attachment positioning plastic burn out caps (matrix compo-
nent) were positioned on the cast and a new refractory was made
to cast a lingual bar CPD. A retentive cap was inserted in CPD
after try-­in in the patient mouth.

Figure 3  Provisional restorations.
In the maxillary arch, finish line margins of all the prepared
abutments were refined, Surveying of the wax pattern was
accomplished and thereafter PFM crown. Cast partial frame-
work was also designed and fabricated (figure 6).
A second facebow transfer was done after final cementation of
crowns in maxillary arch and jaw relation was recorded with bite
registration paste followed by articulation and teeth arrange-
ment. Waxed denture trial was done followed by acrylisation
with heat-­polymerised acrylic resin (figure 7). Lab remounting,
along with clinical remounting procedures, were performed in
both centric and eccentric positions. To evaluate any kind of
Figure 4  Splinted metal-­ceramic crown on 34, 35, 44,45 with
attachment component.
Saneja R, et al. BMJ Case Rep 2020;13:e233744. doi:10.1136/bcr-2019-233744
BMJ Case Rep: first published as 10.1136/bcr-2019-233744 on 25 August 2020. Downloaded from http://casereports.bmj.com/ on August 31, 2020 at University of Rochester Medical Center.
Learning from errors
Figure 5  Pick-­up impression with putty for the fabrication of
removable prosthesis.
high points and premature contacts, marks were obtained using
40 micron articulating paper (BAUSH articulating paper).
After occlusal correction, Cementation of PFM crowns in the
mandibular arch was done using luting (type 1) glass ionomer
cement (GC Gold Label 1, Japan) and CPD was also inserted
simultaneously. The patient was asked to close in centric occlu-
Protected by copyright.
sion. After completion of cementation, occlusal contacts were
again marked to check for any high point.
OUTCOME AND FOLLOW-UP
At recall visits at 1 week, 1 month and 3 months for follow-­up,
the prosthesis was found to satisfactory in terms of function and
aesthetics (figure 8).
DISCUSSION
There are the various treatment modalities present for the reha-
bilitation of partially edentulous state, such as clasp-­retained
RPD, FDP and an implant-­ retained prosthesis. The dental
implant was not taken as treatment of choice due to anatom-
ical and financial barrier. Tooth supported FDP was not a viable
option because of compromised biomechanics of the prosthesis
in the long-­edentulous span. Removable prosthesis with the
attachment was planned as treatment of choice due to the benefit
Figure 6  Cast partial prosthesis trial.
3

Learning from errors
Figure 7  Final mandibular prosthesis.
of aesthetic, retention and improved functional efficiency over
conventional clasp retained RPD. Moreover, this particular case
presented as unconventional Kennedy’s class III as tooth poste-
rior to the edentulous span does not display suitable contour
for retention on surveying. These unconventional class III act as
Kennedy’s class II on application of unseating force and class III
with seating force.7 On posterior abutment non-­retentive clasp
is given to enhance stability and attachment is given on anterior
abutment to improve retention. However, a conventional treat-
ment modality of CPD was planned for the maxillary arch.
A fixed-­removable prosthesis is an efficient and cost-­effective
treatment option for long span partially edentulous ridge. There
are multiple advantages of such prosthesis, namely, retention
and stabilising qualities of a fixed prosthesis along with freedom
in teeth arrangement, hygiene maintenance and aesthetics of
removable prosthesis. Besides these advantages, the attachment
allows the prosthesis to be inserted and removed several times
without losing retention. On the same time, it also splints the
teeth and provides favourable biomechanics.8 9
However, the biomechanical factor must be taken into consid-
erations when using attachment-­RPD design. Repeated removal
and placement of prosthesis result in wear of the retention
clip, requiring periodic replacement of the clip. Other possible
disadvantages include extensive tooth preparation, splinting of
teeth together, minimum abutment height of 5–6 mm required
for attachment functionality and laboratory techniques need an
expert dexterity in fabricating this prosthesis. Daily oral hygiene
maintenance and care of the prosthesis are required on the part
Figure 8  Final maxillary and mandibular prosthesis.
4 Saneja R, et al. BMJ Case Rep 2020;13:e233744. doi:10.1136/bcr-2019-233744
BMJ Case Rep: first published as 10.1136/bcr-2019-233744 on 25 August 2020. Downloaded from http://casereports.bmj.com/ on August 31, 2020 at University of Rochester Medical Center.
of the patient. The long-­term success of the prosthesis requires
knowledge of important laboratory techniques, clinical skills,
and proper execution of all the clinical and laboratory proce-
dures. In terms of clinical success, the fixed-­removable bridge
meets all the demands of function and aesthetic appearance with
the added benefit of facilitating the careful postoperative evalu-
ation of oral soft tissue.
Dr Herman ES Chayes introduced Chayes' attachment in
1912, which forms the basis of modern friction grip attachment.
These two joints are so arranged that they articulate to a precise
but separable joint, where the matrix envelops the patrix.10
Both intracoronal and extracoronal attachments are biome-
chanically favourable for the abutment. All the biomechanics of
extracoronal attachments lie outside the crown structure and are
attached to the proximal surface of the crown. They are mainly
indicated in those areas where the loss of tooth tissue renders it
incapable of intracoronal attachments.11
Selection of attachment is based on many factors11 12 -
1. Crown root ratio desired.
2. Type of coping.
3. Vertical space available.
4. Available teeth support.
5. Available bone support.
6. Location of abutments.
Cohn states that ‘The precision attachments prevent lateral
stresses to periodontium of abutment teeth when inserting or
removing the denture. It distributes stress vertically to the tooth
during function and stabilises the abutment teeth during lateral
Protected by copyright.
stresses’.13 Precision attachments provide better vertical support
and stimulation to the underlying tissue through intermittent
vertical massage.14
CONCLUSION
Although FPD is better tolerated by the patients in comparison
to RPD, the latter is still prevalent in partially dentate people.
The acceptance of RPDs has increased when used along with
precision attachments. FPD/RPD with attachments are a great
therapeutic treatment option in this case with limiting anatom-
ical consideration of bone factor and unretentive abutment.
Adherence to precision techniques, a proper diagnosis will result
in successful treatment and preservation of the patient's existing
dentition.
Learning points
►► Before planning for extracoronal attachment, crown height of
teeth adjacent to the edentulous span should be sufficient to
allow room for placement of the attachment.
►► Careful positioning of attachment will increase the longevity
of the prosthesis by avoiding unnecessary wear of attachment
on lateral loading.
►► Abutment use for attachment placement should have sound
periodontal health and if needed should be splinted to
provide better support.
Contributors  The case was done by RS and NR. Supervised by AB Co-­
supervised,edited and communicated by PD.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Obtained.
Provenance and peer review  Not commissioned; externally peer reviewed.

ORCID iD
Pavan Dubey http://​orcid.​org/​0000-​0003-​3720-​4640
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Learning from errors
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