PA Case Article JOI Sept 2011pdf
PA Case Article JOI Sept 2011pdf
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  1. Precision Attachment Case RestorationWith Implant Abutments: A Review WithCase ReportsEdward Feinberg, DMDPassively retained precision attachment partial dentures have been used successfully onnatural tooth abutments since the 1920s. However, the dental profession has not advocatedtheir use with implant abutments. When used in the passive manner that has provensuccessful on natural tooth abutments, precision attachment cases on implant abutmentscan be an excellent treatment option. This type of case has been used successfully for morethan 17 years and offers tremendous advantages over the conventional overdentureapproach to removal restorations on implant abutments.Key Words: precision attachments, double tilt, implantsINTRODUCTIONDr Per-Ingvar Branemark, theoriginator of the osseointe-grated implant, has long rec-ognized the need for findingnew alternatives to restorethe dental arches with implants. ‘‘For thosepatients who have difficulties in acceptingand functioning with a mechanically unsta-ble prosthetic replacement for lost structureand function,’’ he noted, ‘‘solutions certainlystill remain to be found. The decisiveprerequisite is how to identify for eachindividual patient, an adequate, reliable andaffordable therapeutic alternative that canbe realistically provided in his or her entirelife—present and future.’’1When fixed bridgework cannot be madeon implants, most practitioners generallymake overdentures on the implant abut-ments. In fact, the entire approach to makingimplant restorations has been adapted fromdenture procedures, rather than from crownand bridge procedures. Dentures on im-plants have shortcomings that can becircumvented with a solution adapted fromcrown and bridgework: the precision attach-ment case.Precision attachment partial dentures canbe combined with implants to ideally restorethe upper and lower arches. The precisionattachment case is also an excellent solutionfor difficult restorative problems that cannotbe restored with fixed bridgework.MATERIALS ANDMETHODSBackground: precision attachment caseson natural teethThe precision attachment partial denturecase has enjoyed a long track record ofsuccess on natural tooth abutments. Exam-ination and follow-up of more than 1500cases during a 50-year period by Drs ElliotWestchester Academy of Restorative Dentistry, Scarsdale,NY.Corresponding author,e-mail: edfberg@earthlink.netDOI: 10.1563/AAID-JOI-D-10-00009.1CASEREPORTJournal of Oral Implantology489
  2. and Edward Feinberg overwhelmingly dem-onstrate that precision attachment casesoffer one of the most successful approachesto removable partial denture therapy.2Thesecases were all created according to the samebasic principles, even though the materialsdiffered. The basic principles include fullshoulder preparation of the abutment teeth,a 3-dimensional approach relating the prep-arations to the gingiva and the underlyingbone, and a step-by-step protocol for thepassive design and fabrication of the full-coverage restorations and the precisionattachment partial denture.3Cross-arch splinting of the anterior teeththat includes 2 strategic attachments bestdistributes the load of the precision attach-ment partial denture. The preferred arrange-ment is splinting the anterior segment fromcanine to canine, since the canines are thecornerstones of the arch and usually havethe longest roots.2Auxiliary attachmentsmay be added on posterior teeth foradditional support and retention.The importance of accurate impressionsand models cannot be overemphasized.Precision attachments must be used in aprecise manner. Great care must be taken toensure precision at every step, as the entirechain can only be as strong as the weakestlink. As George Klein remarked in 1951,4‘‘Noamount of skill in one step of the work willovercome an error in a previous step.’’Precision attachment cases must fit withprecision—the abutments must be stableand the frameworks must fit properly againstthe tissue without rock.Advantages of the precisionattachment caseIn addition to cosmetic appearance, main-tainable periodontal health, longevity ofabutment teeth, and patient comfort, preci-sion attachments cases offer an advantagenot possible with fixed bridgework: theability to salvage questionable teeth withouthaving these teeth jeopardize the success ofthe overall case. Practitioners have long beenindoctrinated that fixed bridgework is alwaysbetter for the patient. The prescription forfixed bridgework is often the rule—even forabutments with a questionable prognosis oflongevity. ‘‘Precision attachment partial den-tures should be theprimarytreatment planrather than long spans of fixed restorations,’’says Dr Elliot Feinberg.5‘‘After 30 years ofclinical evaluation of over 1000 precisionattachment cases,’’ Dr Feinberg concluded ina 1982 article, ‘‘my records indicate that theaverage age of an attachment-retained partialdenture is between 15 and 20 years’’6(Figures 1 and 2). One reason for this extraor-dinary success is—unlike fixed bridgework—questionable teeth can be included in aprecision attachment case, without servingas primary abutments. This design provides abuilt-in contingency plan in the event thatsomething happens to the weak abutment.When these teeth are lost, they are easilyadded to the partial denture without makinganything over. Interestingly, weak abutmentsrestored in this manner often last far longerthan anticipated.The free-moving attachmentThere are numerous attachments available forpartial denture therapy. These attachments areusually classified according to structural type(ie, intracoronal, extracoronal, anchor, ball andsocket, etc). However, the Feinberg Classifica-tion for Precision Attachments6categorizesattachments on the basis of function ratherthan structure. According to this classification,attachments fall into 2 categories:1. Rigid (mechanical locking action thatincludes clasps, lingual arms, springs, balland sockets, clip-bars, etc)2. Passive (free moving, stress-breakingaction)Despite the tremendous variation indesign and application, almost all of the490 Vol. XXXVII/No. Four/2011Precision Attachment Case Restoration With Implant Abutments
  3. precision attachments currently used indentistry are of the rigid variety. They aredesigned to mechanically engage the abut-ment teeth so as to prevent muscular andgravitational forces from dislodging thedenture during function. Unfortunately, rigidconnectors apply lateral forces to the abut-ment teeth that are ultimately destructivethrough their torquing action. These attach-ments may be no less harmful to theabutment teeth than conventional clasps.Clasps exert forces on the abutments evenwhen the partial is at rest.7A clasp partialdenture is generally transitory to a fulldenture, as it usually necessitates movingthe clasp to adjacent teeth as abutments arelost. The deleterious effects of rigid connec-tors are not confined to the abutment teeth.As Elliot Feinberg explains, ‘‘the tissue maybe subjected to constant pressure, resultingin ischemia, inflammation and resorption ofthe alveolar process.’’ In addition, wear of thecomponents of the attachment or erosionand caries of the enamel on the abutmentteeth are common consequences of rigidpartial denture connectors.8By contrast, the passive, free-movingattachment dissipates destructive lateralforces, preventing their infliction on theabutment teeth. The forces in a free-movingattachment are vertically directed and easilytolerated by the abutment teeth. ThomasForde, inThe Principles and Practice of OralDynamics,9theorizes that vertically directedforces drive the hydraulic system of denti-tional blood supply to the periodontalstructures, whereas rocking or rotationalforces disrupt the dentitional blood supply,causing ‘‘force-induced mouth degenera-tion’’ and loss of teeth. The tissue under apassive, free-moving attachment case isgenerally pink and healthy as a result ofthe vertically-directed physiologic stimula-tion during function. Passive, free-movingattachments also do not wear at a rapid rate.These attributes make it possible for free-moving precision attachment cases to suc-ceed for decades, even on the weakest teethimaginable.The precision attachment of choiceAttachment designs exist that offer stress-breaking action, but they are generally proneto breakage. Wetherell and Smalles foundthat 82% of partial dentures with attach-ments of stress-breaking design failed within6 years.10To compensate for this tendencytoward breakage, some attachments, such asFIGURES1–2.In his 1982 article inThe New York State Dental Journal, ‘‘Diagnosing and PrescribingTherapeutic Attachment-Retained Partial Dentures,’’ Dr Elliot Feinberg presents this case withquestionable teeth that was originally made in 1975. This patient is still wearing this case after 35years, and the questionable posterior abutments are still there! It is not likely that the upper left molarwould have survived 35 years with fixed bridgework. Full-mouth X rays taken (Figure 8 shows 28-yearX rays taken in 2003) over 3 decades reveal very little change in the periodontal bone. The precisionattachment components have not been altered or replaced in 28 years.FeinbergJournal of Oral Implantology491
  4. the ERA, include plastic or vinyl snap-onsleeves. Unfortunately, these componentsusually require frequent replacement.Most free-moving, precision attachmentcases during the past 50 years were fabri-cated with the Sterngold #7 attachment (nolonger on the market). The #7 attachmentwas patented in 1921 by Isadore Stern.Experience with thousands of Sterngold #7cases over a 50-year period has shown that itis rare to replace the male component of theattachment, even after decades of continu-ous function.8However, precision attachment partialdenture cases have been just as successfulwith the Whaledent International P3.4 at-tachment and with the Sterngold LatchAttachment. These attachments are similarin design to the Sterngold #7. They are allessentially keys (males) that fit with ma-chined precision into receptacles (females).Any male out of the box will perfectly fit anygiven female. Success with these attach-ments is a function not just of the attach-ment but also how the attachment is used.The Sterngold Latch attachment is similarin design to the #7 attachment, except that itis 1 mm shorter and contains a depression inthe male component of the attachment thatengages a ball in the internal face of thefemale component of the attachment (thelatch). This ball can be quickly (and carefully)wiped away from the female componentwith a one-fourth inverted cone bur in ahigh-speed handpiece so that it cannotengage the male. However, removal of thisball is usually not necessary since in actualpractice it ceases to function as a retentivemechanism almost immediately.The path of insertion mechanismof retentionThe path of insertion can be used as a retentivemechanism—one that functions as a truestress breaker, reduces wear of the attach-ments, and eliminates the need for retentionadjustment and eventual replacement of theattachment apparatus. The retention of thepartial denture results from creating anunconventional path of insertion that isdifferent from the pull of the muscles, theaction of the tongue, and gravity. ‘‘The path ofinsertion is unlike virtually any oral movementsuch as the patient’s tongue habits,’’ says DrElliot Feinberg, ‘‘so it is unlikely that normalflexing of the musculature will dislodge theprosthesis.’’8When a stress is applied to thepartial denture during function, it can moveslightly to release the stress, but it cannot bedislodged. The result is physiologic stimulationof the abutment teeth and the edentulousridges. Because the path of insertion techniquedoes not rely on the flexing of metalcomponents for retention, there is very littlewear on the attachment components. Manypatients wear these precision attachmentpartials for decades without replacing themale or female components of the attach-ment. When the partial gets loose, all that isrequired to make it tight is a reline. Nothing isever done to male or female components ofthe attachment to improve the fit.The path of insertion technique wasrefined by Dr I. Franklin Miller but has notachieved mainstream popularity becausefew practitioners are making precision at-tachment partial dentures. Precision tech-niques are required for their fabrication, andthere is a perception that the prosthesis istoo complex for patients with limited man-ual dexterity.8‘‘Original concern over the difficulty ofinsertion appears to be unsupported byclinical experience,’’ explains Dr Elliot Fein-berg. ‘‘In teaching patients how to insertmore than 1000 double-tilt cases ... just onepatient ... could not master the path ofinsertion with 15 minutes of practice.’’8Precision attachment partial dentures havebeen successfully used by patients witharthritis, Parkinson disease, and other diseas-es that affect manual dexterity.492 Vol. XXXVII/No. Four/2011Precision Attachment Case Restoration With Implant Abutments
  5. The double-tilt path of insertionTraditionally, intracoronal attachments areparalleled on the surveyor perpendicular tothe occlusal plane—the same line of inser-tion as the vector of gravity and line ofocclusion.8This method of surveying con-tributes to dislodging the partial denture,thereby necessitating locking mechanismssuch as lingual arms to retain the partialdenture.The double-tilt method of surveying issimple to accomplish the following:1. The master model is secured to thesurveyor table of the parallelometer. Themodel is placed with the occlusal planeapproximately parallel to the table withthe anterior teeth facing forward.2. The heel of the model (posterior) is raisedbetween 10uand 15uto provide ananterior-posterior tilt.3. The left or right side of the model issubsequently raised approximately 10uto15uto provide a mesio-distal tilt. Whetherthe left or right side is chosen depends onanatomy. The idea is to create a tilt thatwill allow the use of the fullest length ofthe attachments possible. The femaleattachments should be placed as closeto the shoulder as possible and as close tothe axial walls of the preparation aspossible (Figure 3).It is advisable to survey the double tiltwhen creating the wax-ups so that the boxesfor the attachments will be correct after thecastings have been soldered.CASEREPORTSThree cases demonstrate how precisionattachment partial dentures can be usedeffectively with implant abutments. Thecases were fabricated in exactly the samemanner than has proven successful withnatural tooth abutments:Lower implant precision attachment caseIn 1996, 3 implants were placed in the anteriorregion of the mandible. During this era,abutment connectors were screwed into theimplants in the manner originally advocatedby Dr Branemark. The fixed bridgework waxsubsequently screwed into place with 3-mmscrews. Generally, it is much better to createrestorations that are screwed retained directlyinto the implant rather than into an abutment.The 3-mm screws have a tendency to loosencompared with the longer and wider screwsused to retain bridgework at the level of theimplant. However, in this case, the fixedbridge was removed only once in 13 years.The precision attachment partial denturewas custom designed so that it is difficult totell where the fixed bridgework ends and thepontic teeth begin. The patient wears thepartial 24 hours a day and removes the partialonly for hygiene. One of the best featuresabout the precision attachment case is that thepartial can be altered to compensate for anychanges that occur in the tissue or theocclusion. In 2006, the partial was relined andthe teeth were replaced (chairside) andcustomized with Biolon-processed acryliccured in a pressure pot at 190uF and 30 psi.When a precision attachment partial denturegets loose, all that is necessary to tighten it is areline. Nothing was ever done to the male orfemale attachments (Figures 4–6).Upper precision attachment caseThis patient had upper and lower attach-ment cases on weak teeth prone to perio-dontal problems (Figures 7–11). The caseslasted more than 30 years. The original lowerattachment case is nearing its 40th year inthe mouth on teeth that have short conicalroots with periodontal bone loss.About 10 years ago, some upper teethfractured and the upper attachment casewas lost. The original attachment case wasconverted chairside to a denture with acrylicand Triad composite. This approach is farFeinbergJournal of Oral Implantology493
  6. superior to making an immediate denturebecause it is an easier transition and ensuresthat the patient maintains the same estheticsand vertical dimension. Although the transi-tional denture fit well, the patient did notlike wearing it and wanted to have implants.A guide stent was made by duplicating herdenture with the Lang Denture Duplicator,alginate, and clear orthodontic acrylic.Despite the guide stent, the surgeonplaced the implants too far labially. Angledabutments were screwed into the implantsto change the path of screwhole access.The patient is extremely comfortable andquite happy. She is thrilled to have herattachment case back! Nine-year X rays showwell-placed, long implants and precision fit ofthe bridgework. There has been no discern-FIGURE3.The double tilt. Dual path. Anteroposterior tilt 10u–15u. Lateral tilt 10u–15u. Elimination of alllocking mechanisms. Free movement of the attachment.FIGURES4–6.Case I: lower implant attachment case.FIGURE4.Three implants with screw-retainedabutments were placed in the anterior region of the mandible in 1995. The wax-ups are surveyed tocreate the double-tilt path of insertion for the boxes that will house the female attachments.FIGURE5.The finished case, 1996.FIGURE6.Thirteen-year X rays (2009).494 Vol. XXXVII/No. Four/2011Precision Attachment Case Restoration With Implant Abutments
  7. able change in the X rays since the case wasfabricated.Salvaging a fixed bridgework case withprecision attachments; connecting naturalteeth and implants withprecision attachmentsImplants are wonderful restorations wherethey can be done properly, but they arecertainly no panacea. This patient had a long-span fixed bridge on her lower left that failedafter many years of service, as well asperiodontally involved lower anterior teeth.She did not want to wear removable bridge-work and opted to have implants. Implantswere placed several times by a highlycompetent surgeon on the lower left quad-rant, but the patient ended up in the hospitalwith a massive infections. The lower left firstand second molar implants that survived areshort in length and may not have beenadequate to support fixed bridgework.Precision attachments provide the bestoption for salvaging this restorative night-mare. The precision partial ties all theremaining teeth and implants together. It isFIGURES7–11.Case II: upper precision attachment case.FIGURE7.The denture was duplicated using theLang Denture Duplicator and alginate to create a stent out of clear acrylic to guide implant placement.FIGURE8.Three implants were placed and fitted with angled abutments.FIGURES9–10.The finished case.The teeth appear longer than the original attachment case because of resorption and remodeling ofthe bone after the extractions. The vertical dimension has not been altered, and the patient shows thesame length of the anterior teeth when she smiles as she did with her denture.FIGURE11.Nine-year Xrays (2009).FeinbergJournal of Oral Implantology495
  8. acceptable to tie natural teeth abutmentsand implant abutments because the preci-sion attachment partial denture is not rigidlyconnected to them. A special housing with 2female attachments was made for theanterior implant. On the lower left, a 2-unitbridge was made with a female attachment.On the lower right, the existing fixedbridgework was modified to support theprecision attachment partial denture. Theporcelain was removed from the lower rightfirst bicuspid, and a porcelain-to-metal over-lay with a female attachment was perma-nently cemented to the bridge with acrylic.The precision attachment partial denturecontains 4 male attachments that fit into the4 female attachments. The major advantageof 4 attachments is that the partial denture isentirely supported by abutments, impartingtremendous stability. The precision attach-ment partial denture is as close to fixedbridgework as possible for this patient. Shecan bite into anything and eat anything.The main drawback of using 4 attachmentsin a precision attachment case is the extremeattention to accuracy and detail that is required.The importance of accurate impressions andmodels cannot be overemphasized. All of theattachments must be exactly parallel, as alter-ation of the males to compensate for an error inparallelism will compromise the end result.The partial denture also extends around thenatural tooth bridgework on the lower right.The extension is not retentive and serves onlyas a contingency plan in the event that thelower right bridgework is lost. If the bridge-work is lost, the extension will serve as ahousing for the bridgework, which will beadded to the partial denture with acrylic orcomposite to form a free-end saddle (Fig-ures 12–14).DISCUSSIONUnlike natural teeth, which are connectedto the bone by the periodontal ligament,implants are fused to the bone. These featsof engineering are quite strong—far stron-ger than the weak natural tooth abutmentsthat have supported precision attachmentdentures successfully for decades. Precisionattachment cases easily succeed on strongimplant abutments.There is no question that osseointegratedimplants have enjoyed a high degree ofsuccess with fixed bridgework. However, thissuccess is far from 100%. All engineeringfeats can be successful only if they aredesigned to withstand the forces to whichthey will be subjected. Colossal failures ofengineering feats like the 1948 TacomaNarrows Bridge disaster bear witness to thisfact. ‘‘If a designer overlooks just one way hisstructure may fail,’’ notes engineering expertHenri Petroski, ‘‘all may be for naught.’’11Asengineering feats, osseointegrated implantsare no exception. ‘‘Together with infections,the most common reasons for the loss ofimplant retention in bone are believed to beof a biomechanical nature,’’ say John Brunski,Per-Olaf, J. Glantz, Jill Helms, and AntonioNanci in Per-Ingvar Branemark’sOsseiointe-gration Book.1‘‘Surveys of the literature alsoreveal numerous reports on mechanicalfailures in the prosthetic superstructuressupported by titanium implants.’’It is therefore important to recognize thelimitations of fixed bridgework on osseointe-grated fixtures. Anatomical deficiencies may beimpossible to correct with bone grafts so thatimplants of adequate length can be placed.The patient may not even be a good candidatefor extensive implant surgery—for systemicreasons, financial reasons, or lack of patiencefor prolonged treatment. Branemark’s studieshave demonstrated that poor anatomy in theposterior region can be circumvented with 4 or5 anterior implants and fixed bridgework withposterior bicuspid cantilevers.1,12However, acantilevered fixed bridge may be the wrongchoice if anatomical deficiencies prevent theplacement of adequate-length implants; if496 Vol. XXXVII/No. Four/2011Precision Attachment Case Restoration With Implant Abutments
  9. bicuspid occlusion is inadequate for neuro-muscular comfort, esthetics, or function; or ifthe patient wore a precision attachment casesuccessfully in the past.When implants cannot support fixedbridgework, the traditional restorative solu-tion has been an implant-supported over-denture. A denture that rests on tissue canexert only 10% to 15% of the force of naturalteeth.13Although the placement of implantsmay improve the retention of a denture,patients who choose to go through thesurgery, time, and expense of implantswould really like to be rid of the denture.The patient who has worn a precisionattachment case prior to wearing a denture(as in case 2) knows the difference betweenthe two and is thrilled that a new precisionattachment case can be made with theplacement of only 3 implants.An implant-supported precision attach-ment partial denture is superior to animplant-supported overdenture for the fol-lowing reasons (Figure 15):1. Superior comfort and self-esteem. Theideal precision attachment case is madewith an anterior fixed bridge that doesFIGURES12–15.Case III: salvaging a fixed bridgework case with precision attachments; connecting naturalteeth and implants with precision attachments.FIGURES12–13.This case was made with 4 male-femaleattachments that connect natural teeth with implants. When the partial is in place, no one can tell shehas removable bridgework.FIGURE14.Five-year X rays (2009).FIGURE15.The implant overdenture vs theimplant precision attachment case. (a) Implants were used to retain a full denture. (b) Implants wereused to create fixed bridgework in the front and a precision attachment partial denture in the back.FeinbergJournal of Oral Implantology497
  10. not come out—unlike the overdenture.The patient does not feel old or freakishlooking in the mirror when the partialdenture is removed for hygiene.2. Superior function. Unlike a denture, pre-cision attachment cases do not haveanterior-posterior tipping forces. Patientswith implant-supported precision attach-ment cases can bite into anything. Anupper precision attachment case alsodoes not cover the entire palate as domost overdentures. A thin, posterior bardoes not interfere with tongue move-ments and speech, and it allows tastebuds on the anterior palate to function.3. Less surgery is required. As few as 3implants can restore an entire arch ofteeth. The implants are placed in theanterior region of the mouth, avoidingmuch of the poor-quality bone, thesinuses, and the mandibular nerve.4. Increased longevity. A precision attach-ment case does not place lateral forces onimplants, which can be destructive toimplants as well as natural teeth.5. Implant abutments can be combined withnatural tooth abutments. It is not a goodidea to make fixed bridgework on bothnatural tooth and implant abutments. Thisarrangement stresses the periodontal liga-ment of the natural tooth abutments, sincethe implant abutments are not resilient. W.Chee and S. Jivraj surveyed the literatureon this topic and concluded that ‘‘there isno doubt that the free standing optionwhere teeth are not connected to implantsis the preferred method of restoringmissing teeth.’’14The precision attachmentcase can link natural tooth and implantabutments (as in case 3) because theseabutments are not rigidly connected.SUMMARYThe passive precision attachment case hasbeen used successfully on natural toothabutments for more than 70 years. Thisrecord of success can be applied to implantabutments as long as there is adherence tobasic principles of engineering. The implant-precision attachment case offers the advan-tage of minimal implant surgery and avoid-ance of areas (usually posterior) in whichthere is poor bone quality or interferinganatomical structures. The precision attach-ment case also offers several advantagesover the conventional implant overdenture,such as no anteroposterior tipping forces,the ability to bite into any food, increasedself-esteem, and less tissue coverage forgreater comfort. To realize these advantages,attention to step-by-step detail is essential.REFERENCES1. Branemark P-I.The Osseointegration Book: FromCalvarium to Calcaneus. Berlin, Germany: QuintessenzVerlags-GmbH; 2005.2. Feinberg E, Feinberg E. Attachment retainedpartial dentures.N Y State Dent J. 1984;50:161–164.3. Feinberg E.Full Mouth Restoration in DailyPractice. Philadelphia, Pa: J.B. Lippincott; 1971.4. Klein G. Modern laboratory techniques forconstruction of movable-removable precision attach-ment cases.Dental Laboratory Review. 1951;48:27–29.5. Feinberg E. Diagnosing and prescribing thera-peutic attachment-retained partial dentures: a casestudy.N Y Sate Dent J. 1982;48:20–23.6. Feinberg E, Feinberg E. Successful precisionattachment removable partial dentures.Sedeltan: 90thAnniversary Convention Journal of the Sigma EpsilonDelta Fraternity. 1991;4:345–349.7. Solomon M. Precision attachments in partialdentures: gentler on abutments—more esthetic thanclasps.Quintessence Dent Technol. 1981;4:14–17.8. Feinberg E. Using the path of insertion to retaina partial denture.Trends Tech Contemp Dent Lab.1984;1(6):14–17.9. Forde T.The Principles and Practice of OralDynamics. London: Exposition Press; 1964.10. Wetherell JD, Smalles RJ. Partial denture failure:a: long-term clinical survey.J Dent. 1980;8:333–340.11. Petroki H.To Engineer Is Human: The Role ofFailure in Successful Design. New York, NY: VintageBooks; 1992.12. Branemark P-I, Zarb G, Albrektsson T.Tissue-Integrated Prostheses: Osseointegration in Clinical Den-tistry. Hanover Park, Ill: Quintescence; 1985.13. Winkler S.Essentials of Complete DentureProsthodontics. Philadelphia, Pa: WB Saunders; 1979.14. Chee W, Jivraj S. Connecting implants to teeth.Br Dent J. 2006;201:629–632.498 Vol. XXXVII/No. Four/2011Precision Attachment Case Restoration With Implant Abutments
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