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103]

Case Report

Different techniques for management of pier

abutment: Reports of three cases with review
of literature
Puja Hazari, Surabhi Somkuwar, Naveen S. Yadav, Sunil Kumar Mishra
Department of Maxillofacial Prosthodontics and Implantology, Peoples Dental Academy, Bhopal, Madhya Pradesh, India

ABSTRACT
For restoration of arches with pier abutments, if a rigid connector is used and occlusal load is applied on the abutment teeth at one
end of fixed partial denture (FPD), it results in the pier abutment acting as a fulcrum. It will tend to lift the other end like a Class
I lever causing stress on the terminal abutments and ultimately failure of the FPD and trauma to the periodontium. The purpose
of this article is to summarize various treatment approaches to minimize the effect of forces in long span bridges given in cases
of pier abutment.

Key Words: Nonrigid connector, pier abutment, precision attachment

Introduction abutments since under occlusal load maximum stresses

The occlusal forces applied to a fixed partial denture (FPD)
are transmitted to the supporting structures through the
pontic, connectors, and retainers.[1] An FPD with the pontic
rigidly fixed to the retainer provides adequate strength and
stability to the prosthesis and also minimizes the stresses
associated with the restoration. But if an edentulous space
occurs on both sides of a tooth, creating a pier abutment
then physiologic tooth movement, arch position of the
abutment, and a disparity in the retentive capacity of the
retainers can make a 5-unit FPD a less than ideal plan
of treatment.[2] Pontic are considered as heartthrob of
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are concentrated on them. Selection of the right type of
connector can make a real difference between success and
failure.[3] Researchers had given different opinions about
nonrigid connectors which are tabulated in Table 1.[4-12] The
purpose of this article is to summarize various treatment
approaches to minimize the effect of forces in long span
bridges given in cases of pier abutment. The treatment
options in case of pier abutment are implant in edentulous
spaces or FPD with nonrigid connectors, using precision
and semi-precision attachments.
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DOI: How to cite this article: Hazari P, Somkuwar S, Yadav NS, Mishra SK.
10.4103/2321-4848.183343 Different techniques for management of pier abutment: Reports of three cases
with review of literature. Arch Med Health Sci 2016;4:89-92.

Corresponding Author:
Dr. Sunil Kumar Mishra, Department of Maxillofacial Prosthodontics and Implantology, Peoples Dental Academy, Bhopal,
Madhya Pradesh, India. E-mail: drsunilmishra19@gmail.com

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Hazari, et al.: Management of pier abutment

Case Reports endodontically treated, it was also restored with a porcelain

Case 1
Restoration using independent implant-supported restorations
A 55-year-old patient presented with missing maxillary
first premolar (14) and first molar (16) on the right side.
The second premolar (15) was a pier abutment. After
complete radiological and medical examination, two implants
supported restorations for each missing tooth were planned.
Orthopantomograph was taken, bone mapping was done,
and implant sizes were determined. In 16 area and 14 area,
the first stage surgery was done and an implant fixture
measuring 3.75 mm × 8 mm and 2.8 mm × 10 mm (Adin,
Israel), respectively, were placed. A shorter implant was
placed in 16 area due to the proximity of the maxillary sinus.
A narrower implant was placed in 14 area due to prominent
canine fossa and thinner cortical plate in that area [Figure 1].
After a waiting period of 6 months for osseointegration, the
second stage surgery was done, and porcelain fused to metal
restorations were placed. As the pier abutment, 15 was also
Figure 1: Intraoral radiograph showing implants placed adjacent
to pier abutment
fused to metal restoration [Figure 2].
Case 2
Restoration using prefabricated precision attachments
A 52-year-old patient visited the Department of
Prosthodontics with a chief complaint of inability to masticate
and poor esthetics. Intraoral examination revealed missing
first molar (16) and second molar (17) of maxillary right
side and missing first premolar (24) and first molar (26)
of the maxillary left side with deep bite. After discussing
all the treatment options, it was decided to rehabilitate
the case with 5-unit FDP using nonrigid connectors on
the distal aspect of pier abutment and an FDP using rigid
connector on the right side. A precision attachment (Vario
Soft 3, Bredent, Germany) was selected for this case. It
had frictional retention, plastic pattern male and female,
with built in paralleling mandrels. Tooth preparations were
done with respect to canine (23), second premolar (25),
and second molar (27) on left side and impressions were
made. Wax pattern was fabricated with patrix/male as a part
Figure 2: Final implant retained prosthesis

Table 1: Review of literature

Author Summary of study
Broken (1951)[4] NRC should be placed at one of the terminal retainer
Gill (1952)[5] Suggested that NRC can be placed at one or both sides of pier abutment
Adams (1956)[6] Suggested placing NRC on the distal aspect of pier abutment and if required then add one more on the distal aspect of anterior retainer
Shillingburg and Fisher (1973)[7] Suggested that patrix part should be prepared within the contours of retainer and matrix is attached to the distal pontic
Standlee and Caputo (1988)[8] Suggested that tension between the terminal retainers and their respective abutments, rather than a pier fulcrum, is the mechanism of failure
Nishimura et al. (1999)[9] Studied the stress transfer patterns with variable implant support and simulated natural teeth through rigid and nonrigid connection under simulated functional
loads and concluded that rigid connector in particular situations caused only slightly higher stresses in the supporting structure and demonstrated more
widespread stress transfer
Misch (2005)[10] Suggested that in conventional FDP, the “male” portion of a nonrigid attachment usually is placed on the mesial aspect of the posterior pontic, whereas the
“female” portion is attached to the distal aspect of the natural pier abutment tooth. This prevents mesial drift from unseating of attachment. However, an implant
does not undergo mesial drifting, and the NRC location is more flexible. For a natural pier abutment between two implants, a stress breaker is not indicated
Savion et al. (2006)[11] Suggested that the possible etiology behind debonding is due to development of extrusive reactive forces at anterior abutment and flexural forces in posterior
abutment
Oruc et al. (2008)[12] Observed that the stress distribution and values of an FPD and pier abutment are affected by the presence and location of an NRC. Distal region of pier
abutment is considered the area of minimum stress concentration
NRC = Nonrigid connectors, FDP = Fixed dental prosthesis

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Hazari, et al.: Management of pier abutment

of pontic pattern and matrix/female as a part of a crown
pattern. Accurate alignment of female part is crucial. This
is accomplished with a dental surveyor. After casting, metal
try-in of the individual units was done to verify proper seating
and then finally restorations were finished [Figure 3]. Mesial
3-unit bridge with keyway was cemented first and then distal
2-unit bridge with key was cemented with glass ionomer
cement (GC, Fuji, America) [Figure 4].
Case 3
Restoration using customized semi-precision attachments
A 30-year-old patient presented with missing mandibular
first premolar (44) and first molar (46) on the right side for
FPD [Figure 5]. Due to financial factors, patient cannot afford
for dental implants and FPD with precision attachment.
FPD with a semi-precision attachment was fabricated
with a key-keyway or Tenon-Mortise connector. Mortise
(female) part prepared within the contours of the wax
pattern of the retainer. Casting was done and the first
segment was cemented [Figure 6]. For the second portion,
a second impression was made. Care was taken to make
the impression of the female portion with accuracy. Second
casting was done with a tenon (male) portion attached to
the pontic. Metal try-in of the second segment was done
and proper key-keyway fitting was verified. Ceramic build
up was done. The second segment was cemented [Figure 7].
Discussion
The existence of pier abutment which promotes a fulcrum-
like situation that can cause the weakest of the terminal
abutments to fail and may cause the intrusion of a pier
abutment.[13] There is a need for stress breakers on a pier
abutment which is supporting prosthesis on both ends as
nonrigid connector so that shear stresses can be transferred
to supporting bone rather than concentrating them in
connectors. A stress breaker minimizes mesiodistal torquing
of abutments and permits them to move independently.[14]
The bonhomie of rigid and nonrigid connectors can increase
the lifespan of an abutment in 5-unit FDPs as it transfers
less stress on the abutments. Furthermore, allowing

Figure 4: Postcementation occlusal view of 5-unit fixed movable

Figure 3: Two halves of long span bridge
prosthesis

Figure 5: Pretreatment view Figure 6: First segment with keyway cemented

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Hazari, et al.: Management of pier abutment
Figure 7: Second segment with key cemented
physiologic tooth movement, it eliminates any hindrance
as against a fixed restoration with all rigid connectors.[3] The
precision attachment is indicated in cases with compromised
periodontal conditions to reduce the stresses on the abutment
tooth. It is contraindicated in patients with abnormally
high caries rate and where there is inadequate space. The
semi-precision attachments were indicated in cases where
patient cannot afford costly precision attachments. In this
case series, restorations using prefabricated precision
attachments (case report 2) and customized semi-precision
attachments (case report 3) were used for the patient to
overcome the stresses generated in long span bridges in
cases of pier abutments. This treatment options are for
patient who cannot afford dental implants or patients with
poor bone support were implant cannot be placed.
FPDs have been considered the standard of care before
the advent of implant therapy. The long-term survival of
FPDs has been reported to be 87% at 10 years and 69%
at 15 years.[15] Factors that predisposed to failure included
nonvital anterior abutments and pier abutments.[16] Hence,
in such cases, dental implant can be a better alternative as
presented in case report 1 of this article for the patient with
good bone support and financially affordable.
Conclusion
One of the treatment options in case of pier abutment
is placing two implants one in each edentulous regions
followed by independent crowns. By doing so, we are
completely eliminating the load and fulcrum-like situation
associated with the pier abutment. However, implants can
only be placed after complete medical and radiological
evaluation. In cases where implants cannot be placed
92 Archives of Medicine and Health Sciences / Jan-Jun 2016 / Vol 4 | Issue 1
because of medical or financial conditions nonrigid
connectors are advocated. Precision and semi-precision
attachments provide room for slight movements which
prevents loading of the pier abutment created due to
the fulcrum-like situation and increases the lifespan of
5-unit FDP.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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