Periodontology 2000, Vol.

17, 1998, 119-124 Copyright 6 M u n k s g a a r d 1998

Printed in Denmark. All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713

Biomechanical aspects
of prosthetic implant-borne
reconstructions
PER-OLOFJ. GLANTZ& KRISTERNILNER

All structures and combination of structures that are
exposed to functional loading can be exposed to
overload and thus to mechanical complications and/
or failures. In implant dentistry a range of epidemio-
logical studies have reported on the occurrence of
such failures in the prosthetic superstructures and
the implants as well as in the interfacial zone be-
tween the implants and the supporting bone (14, 16,
18, 20, 26, 30). Nevertheless, implant-supported
prosthodontics seem to be subjected to a somewhat
lower general mechanical complication and failure
rates than conventional ones (9, 17, 27).
The mechanical properties of dental implant sys-
natural tooth that is surrounded by a normal peri-
odontium (4, 28, 31, 36). The initial deflection of a
loaded implant is thus linear and elastic, whereas a
natural tooth has an initial phase of periodontal
compliance followed by a more rigid appearance at
the engagement of the alveolar bone (23). Thus, the
axial and horizontal mobility of a natural tooth has
been estimated to be larger than that of an osseo-
integrated implant by a factor of 10 to 100 (38). The
500

tems have been analyzed very frequently both with in

vitro and in vivo methods including finite element
analyses (2, 15,33-351, photoelasticity (41) and in vi-
tro (22) and in vivoload measurements (10, 19,21,29, 400

32). In general terms all applied measuring tech-

niques and methods for theoretical calculations have I

been hampered by the virtual impossibility of quanti- z

- 300
fying and controlling the great variation in force direc- U
0
A
tions and force magnitudes present in vivo. For this
reason the validity of the theoretical models pre-
sented for dental implant systems is questionable as 200

they all suffer from the same need for standardization

and simplification. Most approaches for calculation
of clinical loading situations consequently have I00
limited clinical value in implant dentistry, and as in
conventional prosthodontics, the significance of indi-
vidual parameters can only be estimated (7). In gen-
eral terms, because of the mentioned problems, in
vivo measurements are of particular significance.
Fig. 1. Strain (true) recorded by nine linear strain-gauges
(Gl-Gg) at different intercuspal in uitro loading levels (0-
500 N) of a fixed mandibular bridge (same as in Fig. 2)
Implant versus tooth mobility supported by an all-stone model, Note that the rigid and
solid nature of the bridge support gives an almost linear
The biomechanical situation for an osseointegrated strain increase in all studied parts of the bridge at in-
implant is fundamentally different from that of a creased loading. Source: Glantz et al. (12).

119
Glantz & Nilner
500
400
<- 300
D
0 pattern is recorded in the studied
2
200
100
--.
300 100 too 300 500
+ _ ~ m ~ " . c S~ T rR *~I C I *~ong*tm +
fundamental differences between functional strain
in tooth and implant-supported prosthetic super-
structures are illustrated in Fig. 1 and 2 (12).
The existence of fundamental biomechanical dif-
ferences between natural teeth and osseointegrated
implants have generated recommendations not to
use rigid prosthetic connections between teeth and
implants, and, if possible, to avoid combinations of
teeth and implants as abutments for individual pros-
thetic appliances. Recently presented data, however,
point to lower mechanical complication rates for
such combinations than estimated in calculations
from the known biomechanical differences (13).
Similarly, recently presented results from in viuo ex-
periments on the biomechanical significance of con-
trolled superstructure misfit have indicated higher
compliance for vital alveolar bone than originally
anticipated (24).
Neurophysiological control mechanisms may also
be responsible for the observed lack of in viuo versus
in uitro correspondence. It has, for example, been
demonstrated that osseointegrated implants are able
to transfer small rheological differences between
foodstuffs under chewing from the occlusal surface
of the superstructure through the implants to the vi-
tal, neurophysiologically competent supporting
tissues. This action achieves precise monitoring of
the chewing force generated (10).
A particular situation in which fundamental bio-
mechanical differences in bone support may be of
120
Fig. 2. Strain (true) recorded by
eight linear strain-gauges (Gl-G3
and G5-G9) at different intercuspal
in vitro loading levels (0-500 N) of
a fixed mandibular bridge (same as
in Fig. 1) supported by a cut and
composite (stone and silicone)
model. Note that, due to a higher
degree of structural and material
complexity of this bridge support,
a no-linear and complex straining
parts of the bridge at increased
loading. Source: Glantz et al. (12).
--- - - ----- 1,". 111
700 900 1100 1300
clinical significance is related to partially dentate pa-
tients with markedly reduced alveolar bone support.
In this group of patients there is a need for pros-
thetic treatment not only to replace lost or missing
teeth but also to stabilize the remaining dentition.
Even after proper healing of the periodontal tissues,
optimized stabilization of the remaining teeth is
often not obtained until a connection with the im-
plants has been obtained through a rigid superstruc-
ture. In this type of patient, incorporation of attach-
ments between tooth- and implant-supported parts
of the prosthetic superstructure should be con-
sidered to prevent development of uncontrolled
strain in the superstructure and implants and to
allow for necessary adjustments to be made in the
occlusal contact pattern of the appliance (6).
Force generation
Even though patients treated with dental implants
can also be exposed to a range of trauma situations,
the prosthetic and surgical planning of implant
treatments is generally only considering the loading
of implants and implant superstructures that takes
place during normal oral activity. A wide range of
intra- and interindividual loading variation must,
however, still be taken into account in that planning.
Bruxism must, for example, be considered as a
condition that requires special attention. It is associ-
 Biomechanical aspects of prosthetic implant-borne reconstructions
ated not only with increased loading levels but also
with prolonged loading times and an increased
number of loading cycles. Higher risks for fatigue
failures must therefore be expected for patients who
are bruxists.
There also seem to be genuine differences in the
oral functional loading levels among groups of non-
bruxist patients. It has, for example, been reported
that dissatisfied complete denture wearers had sig-
nificantly higher oral loading levels than satisfied
ones and that these differences were present also
after successful implant treatment of the originally
dissatisfied group (11).
The above-mentioned differences should be re-
garded as permanent from a clinical point of view.
They should therefore be included in the treatment
planning and influence decisions such as implant
selection] implant location and design of the pros-
thetic superstructure.
Force transfer in implant dentistry
When dental implants are subjected to physiological
loading, the absolute majority of the generated
forces are applied at the occlusal surfaces of pos-
terior reconstructions and the lingual surfaces of an-
terior ones. A range of local stress situations will de-
velop as these forces travel, first through the pros-
thetic superstructure and its possible implant
connections, then through the implants themselves,
finally to cross the implant-bone interface and be
dispersed in the supporting bone.
When forces are directed along the long axis of a
superstructure component or an implant, the de-
veloped stress is evenly distributed over the support-
ing structures and the surrounding bone. When the
force acts in transverse directions to the long axis of
the component and the implant, however, compon-
ent-implant bending occurs. Then only a reduced
portion of the supporting bone is involved in
counteracting the load, leading to increased stress
levels in particular sections of the implant-bone in-
terface. One of the key elements in the design of im-
plant dentistry is therefore to avoid the appearance
of high functional bending moments. This is
achieved by the placement of a sufficient number of
implants in optimal positions in the edentulous area
under treatment, followed by prosthetic treatment
with an appliance that maximizes even stress distri-
bution across the implant-bone interfaces.
A bending moment is the result of the applied
force multiplied by the lever arm. In mechanical en-
gineering there are a wide range of well-defined
equations for precise calculation of individual bend-
ing moments (5, 39). In implant dentistry, however,
such precise calculations cannot be made due to the
great variation in and unknown magnitudes of the
important mechanical background factors for the
bone and chewing mechanics of the individual pa-
tients. Based on the results from epidemiological re-
ports and experimental studies of standardized situ-
ations] certain basic recommendations can, how-
ever, still be made for implant treatment. In implant
dentistry, the mandible is especially subjected to
functional elastic deformations originating from
forces generated by attached muscles (38).When ri-
gid implants and implant superstructures are posi-
tioned in areas of high natural elasticity, high im-
plant bending moments also develop under con-
trolled oral axial loading conditions (10).
The number of the supporting implants is an im-
portant factor in implant biomechanics, and in gen-
eral terms, the functional rigidity of the reconstruc-
tion increases with the number of implants (28). It
should, however, be remembered that, for practical
purposes, particularly in the treatment of partially
dentate subjects, the greatest effect is obtained when
the number of supporting implants .is increased from
two to three.
For patients with extensive edentulous areas, the
shape of the edentulous alveolar ridge is of consider-
able importance for the biomechanics of the re-
stored situation. Here the length of the implant is of
both direct and indirect importance. The resistance
to bending is higher for longer implants. In patients
with resorbed alveolar ridges, however, in addition
to the fact that only short implants can be installed,
the superstructure crowns must be given increased
height to maintain the vertical dimension. This in-
creases the risk for functional overload by transverse
bending. To maximize the resistance to overload in
resorbed alveolar ridges, bicortical anchorage should
be aimed towards for the mandible, whereas for the
maxilla, bone transplants or utilization of additional
bone support should be considered, for example, in
the zygomatic bone (3).
If the occlusal shape of the edentulous ridge is
that of an arch, more favorable functional conditions
can generally be expected than for straight-line situ-
ations. In the arch-shaped situation, installation of
three or more implants at the top of the alveolar
ridge thus creates a situation with a relatively high
resistance to the functional bending moments that
may develop (Fig. 3, 4) (28, 38). If only two implants
are installed or if all implants are positioned in a
121
Glantz & Nilner
Fig. 3. Three implants positioned in a straight line (as
shown). This situation gives low resistance at functional
bending.
Fig. 4. Additional cross-arch implants give higher resist-
ance to functional bending (blue=clinical support area).
straight-line situation the biomechanical situation is
much less favorable. To increase resistance to bend-
ing, it has been suggested that, when three implants
are installed in straight-line alveolar ridges, the
middle implant should be given a deliberate offset
buccal or lingual position by 2 to 3 mm. Such an
action has been suggested to reduce the stress level
by approximately 50% (28).
Because of existing anatomical variation and the
need to position the implants in such a way that they
are surrounded by bone, their inclination may vary
somewhat. Such minor variation in implant incli-
nation does not seem to have any major negative
influence on the biomechanical situation (28). Prob-
lems with increased bending can occur, however, if
the buccolingual inclination is increased to such an
extent as to position the oral top of the implant out-
side the axial support of the superstructure.
Certain minor levels of misfit will always be pres-
122
ent between a prosthetic superstructure and its sup-
porting abutments: implants or natural teeth. In
conventional fixed prosthodontics, the presence of a
viscoelastic support will provide a certain compen-
sation for minor misfit (probably less than 30 pm).
In implant dentistry, however, there is clearly a need
for improved fit in order to prevent development of
uncontrolled local situations at the superstructure
connection (25, 40). This clinical problem is of great
importance and must be addressed with concern, at
the same time that it should be understood that the
supporting bone allows for a certain compliance
(37).
Implant selection
During the period of 2 decades that implant den-
tistry has been a generally accepted and integral part
of restorative dentistry, a very wide range of implant
materials and implant designs has been presented.
As many reported mechanical failures in implant
dentistry seem to be caused by time-dependent
phenomena such as creep and fatigue, from a bio-
mechanical point of view it is essential that:
brittle materials should be avoided or restricted in
their use in high stress situations; and
all implant systems should provide reports from
controlled testing over a period of at least 3 years
before market acceptance.
Superstructure selection
For partially dentate patients undergoing implant
treatment, the most suitable type of superstructure
Fig. 5. A fracture (encircled and marked with a white ar-
row) in the metal framework of an implant-supported
fked bridge. Courtesy of K. Randow.
 Biomechanical aspects of prosthetic implant-borne reconstructions
is a fixed partial denture. Removable appliances may
be used but are generally not recommended as they
have a somewhat less precise force transfer pattern,
with a risk for the development of long lever arms
(8).
Superstructure design
In partially dentate patients the design of prosthetic
superstructures should be focused on biological as
well as mechanical factors (4, 15). Among the bio-
logical factors, the properties of both the cortical and
the cancellous bone should be considered together
with the possibilities for bicortical fixation of the fix-
tures. The numbers, location and angulation of the
implants in combination with their rigidity and that
of the connections between different components
are technical factors that influence the design of the
suprastructure.
Because of the fundamental biomechanical differ-
ences given above, in implant prosthetics the risks
are lower for mechanical failures with cantilevered
reconstructions than in comparable conventional
fixed situations (1, 18, 27). They do exist, however, as
is illustrated in Fig. 5.
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