CLINICAL

RESEARCH
Implant Inclination and Cantilever Length
Are Not Associated with Bone Loss in
Fixed Complete Dentures: A Prospective Study
Bernardo A. Camargo, DDS, MSc, PhD
Integrated Regional University (URI), Erechim, Rio Grande do Sul, Brazil.

Luís G. R. Drummond, DDS, MSc

Montenegro, Rio Grande do Sul, Brazil.

Ahmet Ozkomur, DDS, MSc, PhD

Lutheran University of Brasil (ULBRA), Canoas, Rio Grande do Sul, Brazil.

Eduardo A. Villarinho, DDS, MSc, PhD

Maria Ivete B. Rockenbach, DDS, MSc, PhD
Eduardo R. Teixeira, DDS, PhD
Rosemary S. A. Shinkai, DDS, MSc, PhD
Pontifical Catholic University of Rio Grande do Sul (PUCRS), Porto Alegre, Rio Grande do Sul, Brazil.

Purpose: To investigate whether the inclination of the most distal implant and the cantilever length
influence marginal bone loss in implant-supported fixed complete dentures (ISFCDs). Materials and
Methods: A novel method using computed tomography images was developed to measure the mesiodistal
implant inclination. The cantilever length was measured during ISFCD fabrication. Radiographs were
obtained after ISFCD installation at 1 and 3 years after loading. Results: A total of 30 subjects with 62
implants were included. Accumulated marginal bone loss was 0.35 ± 0.49 mm. No significant association
was found between marginal bone loss and cantilever length or implant inclination. Conclusion: Implant
inclination and cantilever length do not seem to affect marginal bone loss. Int J Prosthodont 2019;32:17–19.
doi: 10.11607/ijp.6022

Implant-supported fixed complete dentures (ISFCDs) with tilted distal implants and
reduced cantilevers can increase support of the polygonal area, which would favor
prosthesis biomechanics.1–5
This prospective study investigated whether the mesiodistal inclination of the distal
implant and/or cantilever length affect marginal bone loss in ISFCDs after 1 to 3 years
of function. A novel method to measure the mesiodistal inclination of implants is also
described.

MATERIALS AND METHODS

This was an observational cohort study with a prospective correlational design. The
research protocol was approved by the institutional ethics committee and conducted
according to the Declaration of Helsinki. A consecutive sample was selected from
among the dental school patients treated with ISFCDs (for an edentulous maxilla and/
or mandible, with metallic framework, acrylic resin veneering, and artificial teeth) ac- Correspondence to:
cording to the eligibility criteria. Dr Rosemary S. A. Shinkai
Av. Ipiranga, 6681 – Prédio 6
90619-900, Porto Alegre/RS, Brazil
Definition of Implant Inclination in Relation to the Occlusal Plane Email: rshinkai@pucrs.br
The mesiodistal inclination of the most distal implant was measured in relation to the
actual occlusal plane after the ISFCD installation using cone beam computed tomog- Submitted June 19, 2018;
accepted June 24, 2018.
raphy (CBCT) images reconstructed in the KODAK Dental Imaging Software CS 3D ©2019 by Quintessence
version 3.2.9 (Kodak Dental Systems, Carestream Health). Publishing Co Inc.

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 Clinical Research

Table 1   Descriptive Data of the

Study Sample
Variable n Mean ± SD
Cantilever length (mm)
 Maxilla 17 17.00 ± 7.49
 Mandible 30 11.47 ± 4.22
 Total 47 9.91 ± 5.98
Implant inclination (degrees)
a b
 Mesial 19 8.68 ± 5.97
Fig 1  (a) Procedure to define the occlusal plane using sequential sagittal sections. The  Distal 26 6.46 ± 5.58
reference line was drawn tangent to the cuspids of the posterior denture teeth and the
Bone loss (mm) from 0 to 1 y
incisal edge of the central incisors (yellow arrow) to define the occlusal plane. (b) Procedure
to compute the implant inclination. With the use of the angle measurement tool, the angle of  Mesial 62 0.25 ± 0.38
the implant’s long axis was measured in relation to the occlusal plane, yielding the mesiodistal  Distal 62 0.21 ± 0.48
implant inclination (in degrees).  Mean 62 0.23 ± 0.38
Bone loss (mm) from 1 to 3 y
Table 2   Comparison of Marginal Bone Loss (mm) Between Mandible  Mesial 20 0.02 ± 0.14
and Maxilla  Distal 20 0.02 ± 0.18
 Mean 20 0.02 ± 0.15
Bone loss Mandible (mean ± SD) Maxilla (mean ± SD) Pa
Bone loss (mm), 3-y cumulative
0 to 1 y 0.17 ± 0.25 0.31 ± 0.47 .086
 Mesial 20 0.29 ± 0.49
1 to 3 y 0.01 ± 0.11 0.06 ± 0.17 .162  Distal 20 0.28 ± 0.43
3-y cumulative 0.15 ± 0.28 0.41 ± 0.46 .218  Mean 20 0.28 ± 0.40
aWilcoxon test for paired samples. SD = standard deviation.

A straight reference line was drawn in the center of the most distal im- RESULTS
plant to define its long axis. A second reference line was drawn tangent to
the cuspids of the posterior denture teeth and the incisal edge of the central Table 1 shows the descriptive re-
incisors using sequential sagittal CBCT sections. This second line was con- sults. The sample consisted of 30
sidered the actual occlusal plane as defined by the anterior and posterior subjects (21 women and 9 men)
teeth (Fig 1a). The angle between the two reference lines was computed with 62 implants (37 mandibular
as the mesiodistal inclination of the most distal implant in relation to the and 25 maxillary). Two distal im-
occlusal plane (Fig 1b). plants were excluded because the
region of interest was not visible in
Cantilever Length Measurement the radiographs.
The length of the distal prosthetic cantilever was measured during the reha- Bone loss did not differ between
bilitation treatment using a digital caliper and recorded as the distance from the mandible and maxilla (Table 2).
the most distal point of the implant abutment to the end of the metallic No significant correlation was found
framework. between bone loss and cantile-
ver length or implant inclination
Vertical Marginal Bone Level Measurement of the Distal Implants (Table 3).
Periapical digital radiographs were obtained using the parallel technique,
with film holders individualized with putty silicone to standardize the posi- DISCUSSION
tioning for each patient over time. Data were collected after ISFCD installa-
tion (baseline) and at the 1- and 3-year follow-up sessions (T1 and T3). This study showed no association
The implant length was used as reference for calibration of the linear between cantilever length and mar-
measurement in the ImageJ software (US National Institutes of Health). Two ginal bone loss. A recent systematic
reference points were adopted between the most coronal part of the bone- review reported that marginal bone
implant contact and the bottom of the implant platform. loss may not be influenced by can-
tilever length, but little scientific evi-
Statistical Analyses dence was available.3
The data were analyzed using descriptive and inferential statistics at a signif- Distal implant inclination was not
icance level of 5%. For marginal bone loss, the values between the maxilla associated with marginal bone loss
and mandible were tested with Wilcoxon test for paired samples. Spearman in the short term. There is no con-
correlation coefficients were used to test for bivariate associations of mar- sensus on the reference anatomical
ginal bone loss with cantilever length and implant inclination. points for measurement of implant

18 The International Journal of Prosthodontics

© 2019 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
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 Camargo et al

Table 3   Spearman Correlation Coefficients (ρ) Between the Study ACKNOWLEDGMENTS
Variables
Cantilever length Mesial inclination Distal inclination For their collaboration, the authors would
Cantilever length like to thank their colleagues Maria Paula
Coltro, Luciano Costa Petri, Roberta Ávila,
 ρ – –0.247 –0.180
and Marcos Naconecy and professors
 P .308 .378
Márcia Rejane Brucker, Helena Wilhelm
Bone loss, 0 to 1 y (mesial) de Oliveira, and Sérgio Kato. This research
–0.234 .336 0.313 project received financial support from the
 ρ
.113 .123 .120 Brazilian Ministry of Education/Coordination
 P
for the Improvement of Higher Education
Bone loss, 0 to 1 y (distal) Personnel (CAPES) and the Brazilian Ministry
 ρ –0.025 –0.189 0.222 of Science, Technology, and Innovation/
 P .868 .438 .276 National Counsel of Technological and
Scientific Development (CNPq). This study
Bone loss, 0 to 1 y (mean) was presented as a poster at the 26th an-
 ρ –0.155 0.170 0.338 nual scientific meeting of the European
 P .298 .488 .091 Association for Osseointegration (EAO), in
Madrid, Spain, on October 5–7, 2017.
Bone loss, 1 to 3 y (mesial)
 ρ –0.026 0.252 0.135
 P .864 .298 .511
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planes for measurement considered the theoretical axial occlusal force vector
and the true occlusal plane established by the oral rehabilitation with ISFCD.

CONCLUSIONS

Neither distal implant inclination nor cantilever length affected marginal

bone loss in ISFCDs. The method to measure implant inclination provides
an objective tool for studying the relation between numeric inclination and
clinical outcomes.

Volume 32, Number 1, 2019 19

© 2019 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.