J Indian Prosthodont Soc

CLINICAL REPORT

Resilient Attachments as an Alternative to Conventional Cast

Clasp Removable Partial Denture: 3-Year Follow-up
Cristian Schuh • Jovito Adiel Skupien •
Mauro Elias Mesko • Fernanda Valentini •
Tatiana Pereira-Cenci • Noéli Boscato

Received: 19 September 2018 / Accepted: 25 November 2018

© Indian Prosthodontic Society 2018

Abstract The present clinical report describes the Introduction

prosthodontic management for a patient with uncontrolled
bleeding and diabetes mellitus treated with a maxillary Dental implants associated with removable partial dentures
complete denture and a mandibular partial fixed dental have been used with satisfactory results in the dental treat-
prosthesis designed to interface with a removable cast ment of patients with extensive tooth loss [1]. However, the
framework partial denture retained by 2 ERA attach- use of implants is not always affordable for many patients [2,
ments. This approach was undertaken to improve both 3]. In these situations, removable partial dentures (RPDs)
retention and stability of the distal extension Kennedy constitute a feasible option. RPDs are recommended for
Class I removable partial denture. The rehabilitation public health service clinics where costs must be considered,
provided better anterior esthetics than if treated with a mainly in those situations in which implants are not indicated
conventional clasp retained removable partial denture, by [4, 5], such as in individuals with poor general health status
employing a simple, practical design and offering a sig- that contraindicates the use of implants or any type of surgery
nificant biomechanical advantages, restoring both oral [2, 3]. In such situations, patients often would prefer not
health and function. Thus, this treatment modality, showing the anterior buccal clasps of RPDs.
involving an ERA system and transfixation in fixed RPDs can be retained and stabilized with a variety of
crowns, is an effective treatment and can be indicated as a attachments instead of RPD clasps. Extracoronal resilient
clinical alternative for edentulous and partially edentulous attachments (ERAs) have demonstrated appropriate mechani-
patients with systemic disorders or for patients in eco- cal resilience, retention and stability [6]. The main advantage of
nomic situations that might preclude implant-based ERA attachments, when compared with conventional clasp
rehabilitation. retained removable prostheses, are their esthetics, by eliminat-
ing the use of buccal/facial clasps of the RPDs thereby making
Keywords Removable prosthetics · Health status · the retentive design of the prosthesis invisible. In addition, when
Dental abutments · Dental benefits · Dental clasps compared to implant-supported prostheses, removable partial
dentures retained by ERAs have lower costs and a shorter time
span for fabrication [7]. Thus, the present clinical case report
describes the fabrication technique for a cast framework RPD
retained by ERA attachments, interfaced with a partial fixed
dental prosthesis, to provide for stability, retention and
C. Schuh
Department of Prosthodontics, CEOM, Passo Fundo, RS, Brazil
improved esthetics for a patient with compromised health.

· E. Mesko F. Valentini
J. Adiel Skupien M. ·
· Boscato (&) ·
T. Pereira-Cenci N. Outline of the Case
Graduate Program in Dentistry, Federal University of Pelotas,
Rua Gonçalves Chaves, 457, 2nd Floor, Pelotas, RS 96015-560,
Brazil A 55-year-old male with poor general health status pre-
e-mail: [email protected] sented to the Meridional Study Center in Uningá, Brazil,

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Fig. 1 Intraoral view of the

patient with (a) and without the
prosthesis (b), mandibular
occlusal view (c), maxillary
occlusal view (d)

Several treatment options were offered to the patient,

and the difficulty of obtaining adequate retention, stability,
and esthetics with an anterior buccal clasps for a mandib-
ular RPD was also considered. For this reason, a new
complete maxillary denture and a mandibular RPD with an
ERA attachment partial fixed dental prosthesis was the
chosen as the treatment of choice.
The mandibular anterior incisors were prepared with
round end diamond burs (KG Sorensen, Cotia, Brazil) to
prepare them to receive metal ceramic crowns. The left
canine and lateral incisor and right lateral and central
incisors were selected to be splinted and serve as abutment
Fig. 2 Initial radiograph
teeth for the RPD. Provisional acrylic resin crowns were
with the primary complaint of a lack of esthetics and poor fabricated for the mandibular anterior teeth, and a provi-
masticatory function. The clinical examination revealed a sional removable partial denture was created for the interim
need for both maxillary and mandibular arch rehabilitation replacement of the missing posterior teeth. Preliminary
(Fig. 1). maxillary and mandibular impressions were obtained with
The medical and dental histories were reviewed and irreversible hydrocolloid (Hydrogum; Zermach, Italy) and
discussed with the patient. The patient had a history of a definited cast of the tooth preparations was fabricated in
bleeding because of type II diabetes mellitus; therefore, type III gypsum (Microstone; Whip Mix Corp, Louisville,
implant therapy was excluded due to the risk of post-sur- KY). The wax-up of the metallic structure for the fixed
gical complications. prostheses was prepared. The matrix for each ERA
The intraoral examination revealed that the mandibular attachment (SternGold Implamed; SP, Brazil) was appro-
right molar presented with a clinically acceptable amalgam priately positioned allowing for adequate tissue clearance
restoration, while the remaining mandibular anterior inci- and vertical space for the patrix/housing, framework and
sors all presented with carious lesions. Radiographic overlying replacement tooth (Fig. 3). The crowns were
examination (Fig. 2) of these mandibular remaining ante- splinted for better distribution of the occlusal loading of the
rior teeth demonstrated periapical radiolucencies, necessi- posterior teeth on the removable partial denture that was
tating endodontic treatment, then posts and cores and full transmitted to the natural endodontically treated anterior
coverage indirect restorations. The residual root of the tooth abutments via the ERA attachments.
mandibular right premolar was recommended for Next, the try-in of the metallic structure was evaluated,
extraction. and the ERA attachment presented 4 mm of vertical height

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of the (full contour wax trial set up of the) partial fixed

dental prosthesis and maxillary complete denture were
conducted. Cementation was not performed at this time [8].
The next step was to clinically evaluate the partial fixed
dental prosthesis and the metallic framework of the RPD
(Remanium GM 380; Dentaurum, Pforzhein, Germany) at
the same time. The proper fitting of the removable
framework was evaluated in the milled areas of the partial
fixed dental prosthesis (Fig. 5). Cementation of a partial
fixed dental prosthesis is an important critical step because
slightly incorrect positioning of the crowns can result in
improper fitting of the removable partial denture to the
ERA attachments, causing premature loss of retention or
possible need to re-index the patrix housing to be aligned
properly with the ultimate position of the post cementation
orientation of the matrix on the fixed restorations; there-
fore, both the crowns and the removable framework had to
Fig. 3 Wax-up of the metallic structure: female ERA attachment on be inserted and cemented simultaneously. A self-adhesive
the left and right sides. Crowns positioned in the remaining resin cement (RelyX U100; 3M ESPE, St. Paul, MN) was
mandibular anterior teeth, already milled and with transfixation in
the lingual surface. Thin black arrows the transfixation; thick black used, and the crowns were kept in position with gentle
arrows female ERA attachment; white arrows the milling digital pressure until cement overflow. The excess cement
was carefully removed, and a recommendation was given
observed between the ridge crest and occlusal plane. In to the patient not to remove the partial denture during the
addition, it was placed at an appropriate distance from the first 24 h following cementation, to prevent crown
supporting tissues to allow for hygiene and for appropriate dislodgement.
interocclusal distance to involve the ERA attachment/metal The laboratory inserted a black (an ERA laboratory
housing, the artificial teeth and the acrylic resin of the processing) component (SternGold Implamed; SP, Brazil)
denture base. The milling and the transfixation (channels) to maintain the space necessary for the mpatrix ERA
on the lingual surface of the fixed metal crowns were also attachment during polymerization. The black component
evaluated (Fig. 4). was then replaced with a white least retentive ERA patrix,
After applying the ceramic, hygiene space was again after 1 week of clinical service to guarantee perfect inter-
evaluated, and esthetic, phonetic and functional evaluations face of the prosthesis to the teeth and soft tissues. Next,

Fig. 4 Bucco-lingual position

of the ERA attachment in the
center of the teeth. The metallic
structure was tried-in and
adjusted. The ERA attachment
components were positioned
with 4 mm of vertical height

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Fig. 5 Occlusal view of the

metal framework. The
mandibular incisor crowns were
milled to allow a proper fitting
of the removable framework

Fig. 6 Fixed prostheses

including the female ERA
attachment (a) and male ERA
attachment with white nylon
retentive component (b)

general health status, local risk factors, total treatment cost

and time, status of remaining teeth as well as their peri-
odontal support and bone health [2–5, 9].
The present clinical report described a treatment option
for which surgical management was deemed contraindi-
cated. Rehabilitation with an RPD, without clasps instead
using ERA attachments, and with splinted crowns on all
but one the remaining mandibular anterior teeth, milled and
transfixed in metal on the lingual surface, could be an
option for patients with blood disorders or poor bone
condition, for whom the surgical placement of implants is
contraindicated. This technique is innovative since the
distribution of load between abutment teeth and resiliency
of the tissue overlying the residual edentulous ridge is
balanced because the transfixation on the lingual surface of
the fixed metal is not rigid. The removable partial denture
only fits into of the fixed partial denture without over-
loading the system. Moreover, the resilience of this system
Fig. 7 Final facial view provides stress release because significant rotation of the
attachment is allowed, thus reducing the load concentrated
clinical evaluation of the fixed prostheses, including the on the RDP and teeth and making it suitable for patients
matrix and matrix for the ERA attachments, with the white with inadequate periodontal status [6, 10, 11].
retentive component was conducted at this time, as well as The ERA system includes retention elements in 4 colors
obtaining the patient’s opinion regarding the rehabilitation representing levels of resiliency. The white component
(Figs. 6, 7). provides the least retention; however, it is the most widely
used component because its retention is sufficient to retain
the RPD [11, 12], and for this reason, this component was
Discussion selected for the case presented. If after a period of time, the
prosthesis requires increased retention, the component
Different treatment options should be offered to patients, could be changed using a less resilient replacement patrix.
considering local and systemic factors such as the patient’s Fortunately, in this case, 1 year after the first evaluation, no

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adjacent teeth to the alveolar ridge [11]. In addition, milled

crowns direct forces in a more axial direction, and the
transfixation of the fixed crowns provides considerable sta-
bility and durability, not requiring adjustments [6].
This system presents a low failure rate, but it is
important to note that when there is a loss of retention, it is
necessary to replace the resilient matrix. An oral self-care
program that includes the use of fluoridated toothpaste,
effective biofilm removal and regular check-ups is man-
datory [19].

Fig. 8 Removable partial denture and complete maxillary denture in

position after 3-year follow-up Conclusion

Thus, this treatment modality, involving an ERA system

and transfixation in fixed crowns, is an effective treatment
and can be indicated as a clinical alternative for edentulous
and partially edentulous patients with systemic disorders or
for patients in economic situations that might preclude
implant-based rehabilitation.

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