Journal of Dentistry 30 (2002) 271–282

www.elsevier.com/locate/jdent

Review

The influence of functional forces on the biomechanics

of implant-supported prostheses—a review
Saime Şahin, Murat C. Çehreli*, Emine Yalçın
Department of Prosthodontics, Faculty of Dentistry, Hacettepe University, Ankara, Turkey
Revised 3 October 2002; accepted 16 October 2002

Abstract
Objectives: To evaluate published evidence related to the influence of functional forces on the biomechanics of implant-supported
prostheses.
Data and sources. The literature was searched for original research articles relating control of loads on dental implants, effects of early and
late occlusal loads, the influence of bone quality, prosthesis type, prosthesis material, number of supporting implants, and engineering
techniques employed for evaluating mechanical and biomechanical behavior of implants using MEDLINEw and manual tracing of references
cited in key papers otherwise not elicited.
Study selection. Current literature on implant biomechanics as main focus and pertinent to key aspects of the review.
Conclusions. The outcome of implant treatment is often maximized when implants are placed in dense bone, number of supporting implants are
increased, implant placement configuration reduces the effects of bending moments, and when a fixed prosthesis is delivered to the patient.
q 2002 Elsevier Science Ltd. All rights reserved.
Keywords: Biomechanics; Dental implants; Occlusal force; Fixed prosthesis; Overdentures

Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271
2. Biological effects of location and magnitude of applied force. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272
3. Occlusal forces following implant treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
4. Effects of prosthesis type, prosthesis material and implant support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274
5. The influence of bone quality and properties of bone-implant interface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
6. Immediate or early implant loading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
7. Comparison of engineering methods used to evaluate the biomechanics of implants . . . . . . . . . . . . . . . . . . . . . . . . 277
8. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278

1. Introduction observed after prosthesis delivery and are mainly related to

Since the preliminary studies on osseointegration, dental
implants have been extensively used for the rehabilitation of
completely and partially edentulous patients over the last
three decades [1 –6]. Despite the high success rates reported
by a vast number of clinical studies, early or late implant
failures are still unavoidable [7]. Late implant failures are
* Corresponding author. Tel.: þ 90-312-229-9669; fax: þ 90-312-
3113741.
E-mail address: mcehreli@hotmail.com (M.C. Çehreli).
0300-5712/02/$ - see front matter q 2002 Elsevier Science Ltd. All rights reserved.
PII: S 0 3 0 0 - 5 7 1 2 ( 0 2 ) 0 0 0 6 5 - 9
biomechanical complications. Yet, the mechanisms respon-
sible for biomechanical implant failures are not fully
understood and the literature concerning the influences of
several biomechanical factors are inconclusive [8].
There is a consensus that, the location and magnitude of
occlusal forces affect the quality and quantity of induced
strains and stresses in all components of the bone-implant-
prosthesis complex [9 – 18]. When evaluating the biological
effects of an applied load, it is essential to determine its
source. An implant-supported prosthesis may be under the
influence of external (functional or parafunctional forces)
272 S. Şahin et al. / Journal of Dentistry 30 (2002) 271–282

and/or internal (internal or external preload) forces [11,19, Table 1

20]. Qualification and quantification of these forces on
implants and in bone is required to understand the in vivo
behavior of these devices. So far, in vivo forces on implants
have been measured only at the abutment level [9]. Since
intraosseous strains in the vicinity of implants have not been
measured by means of biosensors, strain gradients that guide
bone modeling and remodeling processes around implants
are unknown. Currently, strain measurements in bone around
implants are undertaken by theoretical models implemented
with in vivo data or experimental in vitro models [16,20].
Yet, it is not truly known whether the results of many studies
really mirror the in vivo biomechanical characterization of
implants. Because correct evaluation of forces is often a
perplexing problem and a challenge to resolve due to several
accompanying parameters involved in experiments, correct
in vivo isolation of forces in the vicinity of implants are
always avoided. As a result, obtaining an undisputed
scientific proof becomes virtually impossible.
In all incidences of clinical loading, occlusal forces are
first introduced to the prosthesis and then reach the bone-
implant interface via the implant. So far, many researchers
have, therefore, focused on each of these steps of force
transfer to gain insight into the biomechanical effect of
several factors such as
Factors influencing load distribution on implants
Geometry, number, length, diameter and angulation of implants
Location of implant(s) in the arch
Type and geometry of the prosthesis
Prosthesis material
Superstructure fit
Location, direction and magnitude of applied occlusal forces on the
prosthesis
Condition of the opposing arch (prosthesis versus natural dentition)
Mandibular deformation
Bone density
Age and sex of the patient
Stiffness of food
bone which are theoretically the same in magnitude, but
in opposite directions. During clinical loading of an
implant, the direction of forces almost never coincides
along its central long axis, providing an absolute axial
loading. On the contrary, the occlusal force is applied at
different locations and frequently, in a direction that
creates a lever-arm, which causes reacting forces and
bending moments in the bone [19,23] (Fig 1). This

† force directions,
† force magnitudes,
† prosthesis type,
† prosthesis material,
† implant design,
† number and distribution of supporting implants,
† bone density, and
† the mechanical properties of the bone-implant
interface.

The aim of the review is to take these key elements and

review the current knowledge about the influences of
functional forces on the biomechanics of dental implants.
Areas where further research is needed will be highlighted.

2. Biological effects of location and magnitude

of applied force

There are several factors that affect force magnitudes in

peri-implant bone (Table 1). The application of functional
forces induces stresses and strains within the implant-
prosthesis complex and affect the bone remodeling process
around implants [21,22]. Yet, the physiologic tolerance
thresholds of human jawbones are not known and some
reported implant failures may be related to unfavorable
stress magnitudes.
Fig. 1. Absolute axial loading (AL) provides even loading of implants.
The application of an external load on an implant- Laterally positioned axial loading (LL) and oblique loading (OL), however,
supported prosthesis induces stresses within the entire create bending moments that cause unfavorable stresses in the gold screw
load-bearing system and stress reactions in the supporting (g), the abutment screw (a), and in and around the implant (i).
 S. Şahin et al. / Journal of Dentistry 30 (2002) 271–282
bending moment is the force times the orthogonal
distance between the force direction line and the
counter-acting support. The longer the distance, the
greater will be the bending moment [24]. Accordingly,
the fraction of force transmitted to implants and the
induced stresses are dependent particularly on where the
load is applied on the prosthesis [14,17]. For instance,
considering that two vertically placed implants supporting
a fixed prosthesis is axially loaded from the middle,
equal load partitioning is expected between implants. If
the load is applied only on one implant, it will bear the
entire load with a potential apical movement. Cantilever
loading will result in a dramatic increase in load
transferred to the implant neighbouring the cantilever
[14,16,18,24 –27]. Hence, it is imperative to establish an
equilibrium between acting and counter-acting forces.
During functional loading, however, implants may not
always reach this vital requirement and may fail.
Studies on bone biology suggest that implant over-
loading may lead to implant failure. When overloaded,
high deformations (above 2000 –3000 microstrain) occur in
bone surrounding implants [28]. When pathologic over-
loading occurs (over 4000 microstrain), stress and strain
gradients exceed the physiologic tolerance threshold of
bone and cause micro-fractures at the bone-implant
interface [25,29]. While overloading may be manifested
by the application of repeated single loads, which causes
micro-fractures within the bone tissue, continuous appli-
cation of low loads may also lead to failure, namely,
fatigue fracture. Excessive dynamic loading may also
decrease bone density around the neck of implants and lead
to crater-like defects [30]. Accordingly, overload-associ-
ated implant failures have been reported following the first
year of prosthodontic treatment [31]. In experimental
animal studies, similar findings have been reported. For
instance, Hoshaw and co-workers [32] reported that
overloading of implants resulted in an increased bone
resorbtion around the implant collar, and a decreased
percentage of mineralized bone tissue in the cortex within
350 mm of the implant was evident after 12 weeks of load
application. In other studies, early signs (1 – 4 weeks) of
implant overload in Macaca fascicularis monkeys resulted
as an absence of gross bone loss [33], but loss of
osseointegration was observed 4.5 – 15.5 months after
occlusal overload was commenced [34].
Marginal bone resorption may also be related to the lack
of mechanical coupling between the machined coronal
region of the implant and the bone, which avoids effective
transfer of occlusal forces from the implant to the cortical
bone. The extremely low intraosseous strains ( ø below
100 microstrain) thus cause bone resorption due to disuse
atrophy [35 – 39]. In this context, implant surface has a
crucial role; increased surface roughness balances bone
apposition and remodeling at the bone-implant interface.
Indeed, implant surface topography controls stress and
strain magnitudes at the interface [37,39]. If the surface is
273
rough, the total area used to transfer occlusal forces to
the bone increases. Eventually, lower stresses and strains
can be achieved in the vicinity of the implant. Rough-
surface implants also provide better mechanical interlock
with the bone in comparison with machined-surface
implants [40,41]. Hence, implants with smooth surfaces
have an inherent potential of experiencing debonding with
bone, which leads to bone resorption due to stress-shielding
[39]. Since greater amount of bone loss around total hip
prostheses were observed within the first 2 years [37], stress-
shielding may be an important factor leading to marginal
bone loss around implants, particularly within the first year
of oral function. Overall, it is evident that force magnitudes
around implants affect bone reactions. Although there have
been some attempts to explore bone differentiation around
implants so far, one can only understand the influence of
load factors on bone when its reactions are examined with
regard to tissue strains induced in the vicinity of load-
carrying implants.
Prostheses supported by one or two implants replacing
missing posterior teeth are subjected to an increased risk of
bending overload [42]. There are a number of safety
measures that may be employed during treatment such as
increasing implant support [43] or using staggered implant
placement. The philosophy of so-called tripodization (or
staggered implant placement) was based on the aim of
reducing bending moments when utilization of more than
two implants is provided within a prosthesis [44,45].
Indeed, the rationale for staggered implant placement
appears to be beneficial over in-line placement and has
garnered wide-acceptance. However, staggered implant
placement does not always compensate for the tensile
forces at the fixation (prosthetic) screw [46]. Yet, this
subject is also not understood in detail and needs further
evaluation. Perhaps, strain-gauge analysis and finite
element stress analysis may be helpful to enlighten the
effects of these clinically relevant parameters. However, we
should consider that this treatment option was initially
created for Brånemarkw implants, which have a butt-joint
implant-abutment connection (Fig. 1). In this design, the
abutment screw is the only element that keeps the implant
and the abutment assembled. This property makes the
design inherently weak to bending moments. In internal-
cone implants, i.e. ITIw and Astra Techw implants,
however, friction plays a crucial role in the maintenance
of screw-joint integrity in addition to the torque (preload)
applied during abutment tightening. These fundamental
differences in design affect the mechanical behaviors of
implants. Tripodization has never been considered as a
treatment option for rehabilitation of missing teeth with
ITIw implants. Two ITIw implants can carry a three-unit
fixed partial denture for several years without any
significant episodes of biomechanical complications. There-
fore, before accepting tripodization as a ‘must’ for the
treatment of partially edentulous archs, one should explore
whether it is really essential for all implant systems.
274 S. Şahin et al. / Journal of Dentistry 30 (2002) 271–282
3. Occlusal forces following implant treatment
For dentate humans, the maximum biting force varies
between individuals and different regions of the dental arch
[47,48]. Maximum bite forces depend on the capacity of
supporting tissues to tolerate force and the mental condition
of the patient during force measurements [49]. The greatest
maximum biting force reported to date is 443 kg N [50].
Dentate patients have 5 –6 times higher bite force than
complete denture wearers [51]. Present evidence based
principally on static force measurements indicates that, the
average biting force is 100 –150 N in adult males, and males
have higher biting force than females [47]. Raadsheer [52]
reported maximal voluntary bite forces as 545.7 N in men
(n ¼ 58) and 383.6 N in women (n ¼ 61), and the
maximum biting force measured was 888 N in men and
576 N in women.
Patients with implant-supported fixed prosthesis have a
masticatory muscle function equal to or approaching to that
of patients with natural teeth, or with tooth-supported fixed
partial dentures [53]. Placement of a mandibular fixed
implant-supported prosthesis in complete denture wearers
improves masticatory function and the magnitude of bite
force [54 – 56]. Haraldson and Carlsson [56] measured
15.7 N for gentle biting, 50.1 N for biting as when chewing,
and 144.4 N for maximal biting for 19 patients who had
been treated with implants for 3.5 years. In another study,
Carr and Laney [57] reported maximum bite forces between
4.5 and 25.3 N before and 10.2 – 57.5 N after three months
of treatment with implant-supported prosthesis, and empha-
sized that, the amount of increase was dependent on the
duration of being edentulous.
Forces on implants are also dependent on the location of
the implant in the dental arch. Mericske-Stern and Zarb [58]
investigated occlusal forces in a group of partially
edentulous patients restored with ITIw implants supporting
fixed partial prostheses and measured an average value of
maximum occlusal force lower than 200 N for first
premolars and molars and 300 N in second premolars.
These data suggest that implants placed in the posterior
region of the mouth are at greater risk for overloading.
Therefore, the use of wider and longer implants may be
recommended for implant treatment in the posterior region
[59 –62]. Nevertheless, in most situations, occlusal forces
are somewhat decreased due to age-related deterioration of
the dentition [47]. However, marginal bone resorption
occurs regardless of the force magnitudes applied on
implants, location of implants in the dental arch, and
implant design [63 –65]. Because the biological effects of
maximum bite forces on implants is unknown, current data
dealing with bite forces do not help to understand factors
leading to marginal bone loss. The loading history of
implants and the time required for accommodation of bone
cells to implants may be the influencing factors [66,67].
These parameters need to be studied by quantifying
time-dependent bone reactions around implants subjected
to controlled loads.
4. Effects of prosthesis type, prosthesis material and
implant support
The type of prosthesis affects the mode of implant
loading. In cement-retained implant restorations, the
occlusal surface is devoid of screw holes and the occlusion
can be developed that responds to the need for axial loading.
Screw-retained fixed prosthesis or overdentures, however,
are subjected to off-set loads that cause a substantial
increase in bending moments [68 – 70]. Only a few studies
appear on related literature and there are controversies. A
comparative in vivo study on axial and bending moments on
maxillary implants supporting a screw-retained fixed
prosthesis or an overdenture revealed that, force application
on an overdenture resulted in lower compressive force, but
higher bending moments on abutments during function
when compared to a fixed prosthesis [68]. Mericske-Stern
and collaborators [13] also registered forces on implants
supporting one-piece full-arch fixed prosthesis and bar-
retained overdentures in the maxilla. They concluded that,
the type of prosthesis did not have a determining effect on
force pattern. However, in overdenture treatment, the
resorption pattern of the maxilla affects positioning of the
implants and the denture teeth. Since the positioning of
denture teeth frequently creates an anterior or labial
cantilever, which acts as a long lever-arm, high bending
moments are created on maxillary implants. This situation
may explain why implant survival rates are significantly
lower in the maxilla, particularly with overdenture treat-
ment [71 – 75]. Hence, from a biomechanical aspect,
rehabilitation of the edentulous maxilla with implant-
supported overdentures is probably one of the most
challenging endeavors that faces the restorative dentist.
In overdenture treatment, since a wide range of
attachments are utilized, the detection of forces may also
depend on the number of attachments that affect the number
of rotational axis of the prosthesis. Factors that affect
loading patterns also include incorporation of an internal
metal frame (acrylic resin denture base versus chromium
cobalt substructure), rheological properties of the foodstuff
and framework fit [76,77].
Regardless of its design, an implant-prosthesis complex
transmits occlusal forces to the peri-implant bone [78 –80].
The force absorption quotient of the prosthesis material has,
therefore, been a topic of research interest. Skalak,
envisaged that, the use of acrylic resin teeth would be
useful for shock protection on implants [78] and Brånemark
and co-workers [79] have also recommended the use of
acrylic resin as the material of choice for the occlusal
surfaces of implant-retained prostheses. The resiliency of
this material was suggested as a safeguard against the
negative effects of impact forces and microfracture of
 S. Şahin et al. / Journal of Dentistry 30 (2002) 271–282
the bone-implant interface. The literature, however, is
inconclusive on its effect on shock absorption [81 – 86]. In
fact, acrylic resins are burdened with technical and
subjective disadvantages. For example, due to their low
wear resistances, premature contacts often occur after
several months of prosthesis delivery. On the other hand,
gold and porcelain surfaces are believed not to provide force
absorption, but they are also frequently used. Although the
choice of prosthesis material still remains as a topic of
controversy and argument, there is a consensus that it does
not have any influence on implant survival [87].
The number, length, diameter and positioning of
implants also have an influence on force transfer and
subsequent stress distribution around implants. The increase
in number, length and diameter of implants improve the
biomechanical behavior of implants, especially when
subjected to bending forces [15,43,88 –90]. Duyck and co-
workers [91] explored the distribution and magnitude of
occlusal forces on implants carrying fixed prostheses when
supported by 5 –6 and 3– 4 implants. Higher forces were
observed with a decreasing number of implants. Bending
moments were highest when three implants were used.
Loading of the extension parts of the prostheses caused a
hinging effect, which induced considerable compressive
forces on the implants closest to the location of load
application and lower compressive or tensile forces on other
implants. The result of this in vivo study is not surprising,
because the fraction of force that implants bear in similar
situations was already calculated 10 years ago by Osier [27].
Nevertheless, its clinical relevance towards treatment
outcome is questionable and requires further research.
Since 10-year survival rates of fixed prosthesis supported by
4 or 6 implants [92], or three wide-diameter implants as
introduced with the Brånemark Novum Systemw (Nobel
Biocare, Göteborg, Sweden), are quite high [93], the
number of implant support may not have a remarkable
effect on treatment outcome. However, we should also take
into account that, a recent prospective clinical trial and in
vivo force measurements on Novum Systemw implants
revealed that, the amount of crestal bone loss around distal
implants was not promising [94]. Overall, these clinical data
suggest that the more the supporting implants, the safer the
treatment may be.
For three unit fixed partial dentures, the use of three
implants in in-line configuration is believed to decrease
stress concentrations in comparison to two terminal implant
support [89]. On the other hand, it may not affect treatment
outcome in the rehabilitation of partially edentulous jaws.
The efficacy of staggered placement of three implants on
reducing bending moments has also not been substantiated
by clinical research and there is only a small pool of
knowledge on this issue. Rangert et al. [42] reported the
incidence of fractured Brånemarkw implants as low. Of
these, 90% occurred in the posterior region, the prostheses
were supported by two implants, all patients with fractured
implants were diagnosed to have parafunctional activities,
275
and all implants were 3.75 mm in diameter. However, there
is no report on ITIw standard 4.1 mm diameter solid screw
implant fracture in literature. Therefore, the use of two
wider implants for the treatment of three missing occlusal
units may be an alternative to tripod design. Since fixed
partial prosthesis in partially edentulous cases does not
benefit from cross-arch stabilization, more bending
moments are expected. However, conditions of opposing
arch may also affect the magnitude and direction of bending
forces such as a fixed partial denture opposing a complete
denture [95]. The results of these studies suggest that, the
mechanical characterization of implants have a great impact
on treatment outcome. Comparative clinical trials are thus
indicated to explore the effects of supporting implants,
giving particular emphasis on the effects of implant design.
5. The influence of bone quality and properties
of bone-implant interface
Bone is the structural foundation for a load-carrying
implant. Bone surrounding implants may be composed of
woven, lamellar, bundle or composite bone, which depends
on the age, functional status and systemic factors of the
patient. When a commercially-pure titanium implant is
installed in bone, a bridging callus which has minimal load-
carrying capability originates from the bone surrounding the
implant, and a lattice of woven bone reaches the implant
surface approximately in 6 weeks [96]. The woven bone is
often not completely replaced by mature and load-bearing
lamellar bone at 3 –6 months following implant surgery [97,
98]. A fibrous tissue interface exists at 1 month following
implantation, an average of 50% bone-implant contact at 3
months, a 65% bone implant-surface at 6 months and an
average of 85% bone-implant contact after 1 year following
placement of a machined-surface implant [99]. Healing
response subsequent to implant placement is characterized
by an increase in interfacial bond strength and bone-implant
contact, which improves the mechanical behavior of the
interface [100]. The interface stiffness, which is accepted as
a ruling factor for implant survival, has more than a
doublefold increase in 3 months in dogs that correspond to a
4 –6 month healing period in human mandibles [101].
One of the most significant factors that affect the
outcome of the implant treatment is the quality of the
bone around implants. The increase in bone density
improves the mechanical properties of the interface.
Implants are demonstrated to have less micromovement,
increased initial stability, and reduced stress concentrations
in high density bone [102,103]. In addition, knowing the
distribution of bone quality in various jaw regions assists the
clinician in dental implant treatment planning. Bone quality
types 1 and 4 are found much less frequently than types 2
and 3 [104]. Although variations in density exist in each
region, quality 2 bone dominates the mandible, and quality 3
bone is more prevalent in the maxilla. Both anterior and
276 S. Şahin et al. / Journal of Dentistry 30 (2002) 271–282
posterior jaw regions are often characterized by types 2 and
3 bone. The anterior mandible has the densest bone,
followed by the posterior mandible, anterior maxilla, and
posterior maxilla [105]. From a biomechanical point of
view, although 70% bone appears to withstand functional
forces [87], it is believed that implant survival rate is
directly proportional to the bone density [106]. However,
Truhlar and co-workers [107] reported that among 2,131
implants, quality 1 bone experienced the greatest failure
rate, whereas quality 2 and 3 bone had the lowest incidences
of implant failure. According to Bahat [108], the quality and
quantity of bone do not have a significant effect on implant
survival, but the surgical techniques are more important.
Many clinical studies have focused on the success of
endosseous implants with a variety of surface characteristics
and to clarify the osseointegration process. In early 90’s,
hydroxylapatite (HA) coated implants have been widely
used to improve initial stabilization of implants and to
increase bone-implant contact for treatments in low-density
bone. Following immediate placement, HA implants have
better bone-implant contact than titanium plasma-sprayed
(TPS) implants after 2 months of healing [109], but their
cumulative survival rates are relatively low when used for
overdenture support [110 – 112]. This may depend on local
and systemic factors. Although the HA coating does not
need to stay for longer than 1 year [113], dissolution or
mechanical failure of the HA coating has been reported,
which was attributed to the crystallinity and thickness of the
coating [114 – 116]. HA-coated implants may have better
long-term prognosis in low-density bone and when place-
ment of shorter implants are required [117,118].
Alterations in biomaterial surface morphology and
roughness have been used to improve tissue response and
the mechanical properties of the bone-implant interface.
Although the results are encouraging, there is a large
inconclusive literature on their clinical effects. In a recent
study conducted by Carr and co-workers [119], commer-
cially pure titanium, titanium alloy, and TPS implants
placed in baboons after 6 months of healing demonstrated
that bone-implant contact and percent bone area in maxilla
(50.8, 43.6%) was lower than the mandibula (60.8, 52.6%).
The biomaterial analyses, however, revealed no significant
differences. In a comparative histometric analysis of bone-
implant interface between a rough titanium surface and
smooth implants in low-density human jawbone after 3, 6,
and 12 months of submerged, undisturbed healing, the
rough implant had significantly higher bone contact in
comparison to the smooth implant [120]. Like-wise,
sandblasted large grid acid-etched (SLA) titanium implants
have also demonstrated greater bone-implant contact than
TPS implants [121,122]. Overall, the earlier-mentioned
studies suggest that implants with rough surfaces have more
bone-implant contact, which increases interface stiffness.
Indeed, this may improve implant survival. Nevertheless,
the clinical relevance of these studies is also questionable.
As mentioned previously in this paper, comparative clinical
studies between machined- and rough-surface implants
reported similar marginal bone levels [63 – 65]. Hence, the
very nature of implants does not appear to have any
influence on marginal bone loss as well as the implant
survival rate. The loading history [66,67] and the type of
force (static versus dynamic) applied on implants [30,123]
are probably more important. Despite a number of animal
studies on the effects of non-passive superstructures on bone
response [124,125], it is a well-known fact that static forces
have little or no effect on bone tissue [123]. On the contrary,
dynamic forces affect the form, mass and the internal
structure of bone [35,36]. The biological effects of dynamic
forces on bone reactions around oral implants have not been
well-documented. Fundamental research is thus needed on
biomechanics of peri-implant bone in well-controlled
mechanical environments.
6. Immediate or early implant loading
Osseointegration was based on a two-stage surgical
protocol and it was considered crucial to avoid loading of
the submerged implants during the healing period. However,
the coincidental success of the first application of immediate
(or early) loading [126] and consecutive research [127 –130]
on fixed prosthesis have revealed that two-stage implants
could be loaded in a relatively short period of time following
placement only in the inter-foramina of the edentulous
mandible to support a rigid permanent fixed cross-arch
supraconstruction. Randow et al. [130] reported 100%
success for immediately loaded implants after 18-month
function and Horiuchi et al. [131] reported 97.2% success
after a 8 –24-month follow-up period. Ten year survival rate
decreases to 84.7% for immediately loaded implants [128].
This treatment option emphasized the fact that, the anterior
mandible which is often composed of a highly dense bone
had the inherent potential to provide adequate support and
initial stability for early loading of implants. Accordingly,
the ‘same-day treatment protocol’ followed for the Bråne-
mark Novum Systemw (Nobel Biocare, Göteborg, Sweden)
comprised placement of majority of the implants (123 of 150)
in bone quality 2 and provided immediate loading of implants
in approximately 7.5 h [93]. The philosophy of this treatment
was probably based on preventing micromotion of implants
and distribution of functional loads with a rigid suprastruc-
ture. However, this treatment option does not offer many
advantages. Recent experience with the Brånemark Novum
Systemw is not promising (personal communication of MC
with Prof. Ignace Naert, Catholic University of Leuven,
2002). Failure of Novumw implants may be related to the
timing of superstructure connection. In conventional
immediate- or early-loading, the superstructure is usually
connected within 3 weeks following implant placement. In
the Novum Systemw, however, the prosthesis is delivered
in the same day. Since the load-carrying ability and
the micromotion resistance of the bone-implant interface
 S. Şahin et al. / Journal of Dentistry 30 (2002) 271–282
depends only on the initial mechanical interlock between the
implant and the bone, it is likely to have high micromotion
[132] and stress gradients around the neck of implants. This
may exceed the physiological tolerance threshold of bone
particularly around distal implants. Indeed, excessive
micromotion is directly implicated in the formation of
fibrous encapsulation. The literature suggests that there is a
critical threshold of micromotion above which fibrous
encapsulation prevails over osseointegration. This critical
level, however, is not zero micromotion as generally
interpreted. Instead, the tolerated micromotion threshold
was found to lie somewhere between 50 and 150 mm [132].
Lefkove and Beals [133] have applied early loads on four
ITIw implants to support mandibular overdentures with bars
and stated that a high level of predictability would be
achieved when the technique was followed. Ledermann et al.
[134] reported 60– 70% bone implant contact for 12-year
functioning implants immediately loaded with bar-retained
overdentures. This technique has over 95% success after 6.5
years of loading [135,136]. Recently, immediate loading of
single-tooth implants has been reported [137]. Actually, it
can be estimated that survival of single-tooth implants may
also be high. Piatelli et al. [138] found 86.69% bone-implant
contact in an immediately loaded single implant in man after
7 years of function and 60 – 70% for a TPS implant after 8 – 9
months of loading [139]. In an animal study, the bone-
implant contact for early-loaded implants in the maxilla and
mandible were 67.2% and 80.71%, respectively, [140]. As a
sequel of immediate loading, a large part of the implant
surface is covered by compact, mature lamellar bone with the
presence of many Haversian systems and osteons. The bone
at the interface with the implant is highly mineralized and
connective tissue or inflammatory cells are not found [141].
These histological observations along with the results of
clinical studies suggest that immediate loading of implants
supporting full-arch one-piece fixed prosthesis, overden-
tures, and single-tooth restorations can be performed.
There is an unavoidable evolution and rush for immediate
loading of implants, which has an important impact on the
psycho-social well-being of edentulous patients. To obtain
high successes with immediately-loaded implants, it is
essential to increase our knowledge on bone response around
immediately loaded implants. Fundamental studies are,
therefore, needed to elucidate mechanisms responsible for
functional adaptation of bone to implants subjected to
various loading regimens in order to control or avoid bone
loss around conventionally loaded implants, and to provide
predictable results for immediately loaded implants in man.
7. Comparison of engineering methods used to evaluate
the biomechanics of implants
When dealing with a complex stress analysis problem in
which a complete theoretical solution may prove imprac-
tical with respect to time, cost or degree of difficulty,
277
experimental techniques are often used. Current techniques
employed to evaluate the biomechanical loads on implants
comprises the use of mathematical calculations [46,142],
photoelastic stress analysis [143], two- or three-dimensional
finite element stress analysis [88,89] and strain-gauge
analysis (SGA) [10,11]. Since an almost actual represen-
tation of stress behaviors can precisely be provided, three-
dimensional finite element stress analysis (3D FEA) has
been introduced as a superior theoretical tool over two-
dimensional finite element stress analysis.
3D FEA and SGA have been extensively used to evaluate
the biomechanical loads on implants for accurate clinical
prediction. Generally, one of the major purposes of 3D FEA
technique is to solve physical problems or to determine the
effectiveness or behavior of an existing structure or
structural component subjected to certain loads. The
idealization of the physical problem to a mathematical
model requires certain assumptions that lead to differential
equations governing the mathematical model and, since the
procedure is numerical, it is imperative to assess the solution
accuracy. Additonally, the production of an appropriate and
effective mathematical model is crucial to elucidate the
physical phenomena, which requires the inclusion of
comprehensive structural simulation [144 – 146] of dental
implants, particularly for accurate quantification of induced
stress or strain.
The application of SGA on dental implants is based on
the use of electrical resistance strain-gauges and its
associated equipment, and provides both in vivo and in
vitro measurement of strains under static or dynamic loads.
Under an applied force, a strain gauge measures the mean
dimensional change where it is bonded [9,10,14,147,148] or
embedded [149]. The configurations of strain-gauges often
used for implant biomechanics are uniaxial and/or rosette,
and are usually bonded to implants, abutments and/or to
rigid connectors of a prosthesis. [9,10,14].
Comparative studies have revealed that there are
contradictions between data obtained from photoelastic
stress analysis and in vitro SGA on the quantification of
strains [143,149,150]. The application of 3D FEA and in
vitro and in vivo SGA has provided mutual compatibility and
agreement of obtained results [151,152]. However, in these
studies, strain-gauges were bonded on the surfaces of solid-
like structures and comprehensive finite element modeling
was not included. Thus, it may be estimated that comparison
of strains by both techniques may provide agreement on solid
or undetailed structures, i.e. the surface of rigid prosthetic
connectors, prosthetic retainers, cantilever extensions, and in
or around bone surrounding implants [153]. However, the
compatibility of these techniques are unknown when
analyzing structures such as the internal hex or morse-taper
of an implant body [153]. It is an undisputed fact that, one-
piece finite element modeling is not the actual scenario for
most commercially-available dental implants. Hence, for
loading conditions i.e. lateral or oblique loading, specific
parts of the implant – abutment interface will separate, or new
278 S. Şahin et al. / Journal of Dentistry 30 (2002) 271–282
parts which were initially not in contact will come in contact.
Consequently, more deformation may be expected,
especially at the neck of implants. In this regard, the pattern
and magnitude of deformation will be influenced by the
implant design [145,146].
In a three-dimensional finite element model (theoreti-
cal model), precise loading over predetermined points on
the occlusal surface of a prosthesis can be accomplished.
For in vivo or in vitro strain-gauge experimentation,
however, this may not be provided due to several factors
included in force transmission during load application by
opposing teeth or by an apparatus. Placement of the
gauges may have slight inaccuracies or the angulation of
implants may not be as precise as in a theoretical model.
Overall, the very nature of the physical experimental
technique makes it inherently subject to random error.
Currently, although SGA is the only technique that
allows in vivo measurements during clinical loading, the
results of in vivo and in vitro SGA do not agree on the
quantification of bending moments [9,19]. Additionally, to
determine the ‘actual’ amount of load on an implant
complex in vivo, isolation of the strains on each implant
abutment and/or component of the prosthesis prior and/or
after the cementation or screw tightening and following
clinical loading must be provided through several measure-
ments. However, even with this approach, strains can only
be recorded where gauges are bonded; measurements on
abutment and gold screws cannot be provided. This can be
measured only by 3D FEA which necessitates a compre-
hensive structural finite element simulation and non-linear
contact analysis. Such finite element models offer the
advantage of evaluating vital parameters like the effects of
clamping force of the screws or the effect of the internal
design of an implant collar [144 – 146], but since contact can
also be defined between the bone and the implant, this
technique offers several advantages for future biomechani-
cal studies. For instance, dynamic time-dependent bone
response to dental implants subjected to various loading
conditions can be studied.
As mentioned in the very beginning of this review,
correct qualification and quantification of forces on implants
are extremely crucial to understand the biomechanics of
implants. Biomechanical studies should, therefore, be
designed not only for descriptive purposes but also to
offer reliable and accurate data that has clinical relevance.
Contradictions between the results of many studies suggest
that validation studies are indicated.
8. Conclusion
A growing field of research is implant biomechanics due
to the fact that many aspects of implant treatment are based
on biomechanical principles. Some evidence exists on basic
tenets of bone reactions to loaded implants, but information
on the issue still remains scarse. Accordingly, the lack
fundamental studies on implant biomechanics coupled with
bone biology has, in many ways, led to insufficient
interpretation of the large pool of clinical data collected in
the last three decades.
Nevertheless, in the light of the current knowledge, it
seems that treatment outcome is improved when implants do
not bear excessive occlusal forces, implants are placed in
dense bone, the number or diameter of supporting implants
are increased, implant placement reduces bending moments,
and when implants support fixed prostheses.
References
[1] Branemark P-I, Breine U, Adell R, Hansson BO, Lindstrom J,
Ohlsson A. Intra-osseous anchorage of dental prostheses.
I. Experimental studies. Scandinavian Journal of Plastic and
Reconstructive Surgery 1969;3:81–100.
[2] Branemark P-I, Hansson BO, Adell R, Breine U, Lindstrom J, Hallen
O, et al. Osseointegrated implants in the treatment of the edentulous
jaw: experience from a ten years period. Scandinavian Journal of
Plastic and Reconstructive Surgery 1977;16:1–132.
[3] Adell R, Erikkson B, Lekholm U, Branemark P-I, Jemt T. A long-
term follow up study of osseointegrated implants in the treatment of
totally edentulous jaws. International Journal of Oral and Max-
illofacial Implants 1990;5:347–59.
[4] Van Steenberghe D, Lekholm U, Bolender C, Folmer T, Henry P,
Herrmann I, et al. The applicability of osseointegrated oral implants
in the rehabilitation of partially edentulism: a prospective multi-
center study on 558 fixtures. International Journal of Oral and
Maxillofacial Implants 1990;5:272–81.
[5] Jemt T, Lekholm U. Oral implant treatment in posterior partially
edentulous jaws: a 5-year follow-up report. International Journal of
Oral and Maxillofacial Implants 1993;8:635–40.
[6] Lekholm U, Van Steenberghe D, Hermann I, Bolender C, Folmer T,
Gunne J, et al. Osseointegrated implants in the treatment of partially
edentulous jaws: a prospective 5-year multicenter study. Inter-
national Journal of Oral and Maxillofacial Implants 1994;9:627 –35.
[7] Esposito M, Hirsch J-M, Lekholm U, Thomsen P. Biological factors
contributing to failures of osseointegrated oral implants (II)
Etiopathogenesis. European Journal of Oral Sciences 1998;106:
721 –64.
[8] Taylor TD, Agar JR, Vogiatzi T. Implant prosthodontics: current
perspective and future directions. International Journal of Oral and
Maxillofacial Implants 2000;15:66–75.
[9] Glantz P-O, Rangert B, Svensson A, Stafford GD, Arnvidarson B,
Randow K. et al. On clinical loading of osseointegrated implants. A
methodological and clinical study. Clinical Oral Implants Research
1993;4:99–105.
[10] Glantz P-O, Strandman E, Svensson SA, Randow K. On functional
strain in fixed mandibular reconstructions. I. An in vitro study. Acta
Odontologica Scandinavia 1984;42:241–9.
[11] Merickse-Stern R, Assal P, Buegerin W. Simultaneous force
measurements in 3 dimensions on oral endosseous implants in
vitro and in vivo. Clinical Oral Implants Research 1996;7:378–86.
[12] Merickse-Stern R. Force distribution on implants supporting over-
dentures: the effect of distal bar extensions. A 3-D in vivo study.
Clinical Oral Implants Research 1997;8:142–51.
[13] Merickse-Stern R, Venetz E, Fahrlander F, Burgin W. In vivo force
measurements on maxillary implants supporting a fixed prosthesis or
an overdenture: a pilot study. Journal of Prosthetic Dentistry 2000;
84:535–47.
[14] Assif D, Marshak B, Horowitz A. Analysis of load transfer and stress
 S. Şahin et al. / Journal of Dentistry 30 (2002) 271–282
distribution by an implant-supported fixed partial denture. Journal of
Prosthetic Dentistry 1996;75:285–91.
[15] Hobkirk JA, Havthoulas TK. The influence of mandibular defor-
mation, implant numbers, and loading position on detected forces in
abutments supporting implant superstructures. Journal of Prosthetic
Dentistry 1998;80:169– 74.
[16] Tashkandi EA, Lang BR, Edge MJ. Analysis of strain at selected
bone sites of a cantilevered implant-supported prosthesis. Journal of
Prosthetic Dentistry 1996;76:158–64.
[17] Brunski JB, Hipp JA. In vivo forces on endosteal implants: a
measurement system and biomechanical considerations. Journal of
Prosthetic Dentistry 1984;54:82–90.
[18] Richter E-J. Basic biomechanics of dental implants in prosthetic
dentistry. Journal of Prosthetic Dentistry 1989;61:602 –9.
[19] Smedberg JI, Nilner K, Rangert B, Svensson SA, Glantz SA. On the
influence of superstructure connection on implant preload: a
methodological and clinical study. Clinical Oral Implants Research
1996;7:55–63.
[20] Duyck J. Biomechanical characterisation of in vivo load on oral
implants. Thesis. Katholieke Universiteit Leuven; 2000. p. 8 –49.
[21] Bidez MW, Misch CE. Force transfer in implant dentistry: basic
concepts and principles. Journal of Oral Implantology 1992;23:
264–74.
[22] Branemark P-I, Zarb GA, Albrektsson T. Tissue-integrated prosthe-
sis. Osseointegration in clinical dentistry. Chicago: Quintessence;
1987. p. 129.
[23] Richter E-J. In vivo horizontal bending moments on implants.
International Journal of Oral and Maxillofacial Implants 1998;13:
232–44.
[24] White SN, Caputo AA, Anderkvist TA. Effect of cantilever length on
stress transfer by implant-supported prostheses. Journal of Prosthetic
Dentistry 1994;71:493– 9.
[25] Rangert B, Sullivan R. Biomechanical principles. Preventing
overload induced by bending. Nobelpharma News 1993;7:4–5.
[26] Shackleton JL, Carr L, Slabbert JCG, Becker PJ. Survival of fixed
implant-supported prostheses related to cantilever lengths. Journal of
Prosthetic Dentistry 1994;71:23–6.
[27] Osier JF. Biomechanical load analysis of cantilevered implant
systems. Journal of Oral Implantology 1991;17:40–7.
[28] Stanford CM, Brand RA. Toward an understanding of implant
occlusion and strain adaptive bone modelling and remodelling.
Journal of Prosthetic Dentistry 1999;81:553–61.
[29] Roberts WE. Fundamental principles of bone physiology, metab-
olism and loading. In: Naert I, van Steenberghe D, Worthington P,
editors. Osseointegration in oral rehabilitation. An introductory
textbook. London: Quintessence; 1993. p. 163–4.
[30] Duyck J, Naert I, Van Oosterwyck H, Ronold HJ, Naert I, Vander
Sloten J, Ellingsen JE. The influence of static and dynamic loading
on marginal bone reactions around osseointegrated implants: an
animal experimental study. Clinical Oral Implants Research 2001;
12:207–18.
[31] Quirynen M, Naert I, van Steenberghe D. Fixture design and
overload influence marginal bone loss and fixture success in the
Branemark system. Clinical Oral Implants Research 1992;3:104–11.
[32] Hoshaw SJ, Brunski JB, Cochran GVB. Mechanical loading of
Branemark implants affects interfacial bone modelling and remodel-
ling. International Journal of Oral and Maxillofacial Implants 1994;
9:345–60.
[33] Miyata T, Kobayashi Y, Araki H, Motomura Y, Shin K. The
influence of controlled occlusal overload on peri-implant tissue: a
histologic study in monkeys. International Journal of Oral and
Maxillofacial Implants 1998;13:677–83.
[34] Isidor F. Loss of osseointegration caused by occlusal load of oral
implants. A clinical and radiographic study in monkeys. Clinical
Oral Implants Research 1996;7:143–52.
[35] Frost HM. Skeletal structural adaptations to mechanical usage
279
(SATMU): 1. Redefining Wolff-s law: The bone modelling problem.
Anatomical Records 1990;226:403–13.
[36] Frost HM. Wolff’s law and bone’s structural adaptations to
mechanical usage: an overview for clinicians. Angle Orthodontist
1994;64:175–88.
[37] Bobyn JD, Mortimer ES, Glassman AH, Engh CA, Miller JE, Brooks
CE. Producing and avioding stress shielding. Clinical Orthopaedics
and Related Research 1992;274:79 –96.
[38] Huiskes R, Weinans H, Van Rietbergen B. The relationship between
stress shielding and bone resorption around total hip stems and the
effects of flexible materials. Clinical Orthopaedics and Related
Research 1992;274:124 –34.
[39] Pilliar RM, Deporter DA, Watson PA, Valiquette N. Dental implant
design-effect on bone remodelling. Journal of Biomedical Materials
Research 1991;25:467– 83.
[40] Buser D, Schenk RK, Steinemann S, Fiorellini JP, Fox CH, Stich H.
Influence of surface characteristics on bone integration of titanium
implants. A histomorphometric study in miniature pigs. Journal of
Biomedical Materials Research 1991;25:889–902.
[41] Buser D, Nydegger T, Hirt HP, Cochran DL, Nolte LP. Removal
torque values of titanium implants in the maxilla of miniature pigs.
International Journal of Oral and Maxillofacial Implants 1998;13:
611– 9.
[42] Rangert B, Krogh PH, Langer B, Van Roekel N. Bending overload
and implant fracture: a retrospective clinical analysis. International
Journal of Oral and Maxillofacial Implants 1995;10:326–34.
[43] Korioth TM, Chew CBW, Chung DH. Effect of implant number on
transverse bending moments during simulated unilateral loading of
mandibular fixed-detachable prostheses. Journal of Oral Implantol-
ogy 1998;24:93–6.
[44] Weinberg L, Kruger B. An evaluation of torque (moment) on
implant/prosthesis with staggered buccal and lingual offset.
International Journal of Periodontics and Restorative Dentistry
1996;16:252–65.
[45] Daellenbach K, Hurley E, Brunski JB, Rangert B. Biomechanics of
in-line vs. offset implants supporting a partial prosthesis. Journal of
Dental Research 1996;75:183. abstract.
[46] Sato Y, Shindoi N, Hosokawa K, Tsuga K, Akagawa Y. A
biomechanical effect of wide implant placement and offset
placement of three implants in the posterior partially edentulous
region. Journal of Oral Rehabilitation 2000;27:15–21.
[47] Helkimo E, Carlsson GE, Helkimo M. Bite force and state of
dentition. Acta Odontologica Scandinavia 1977;35:297–303.
[48] van Eijden TMGJ. Three-dimensional analyses of human bite-
force magnitude and moment. Archives of Oral Biology 1991;36:
535– 9.
[49] Carlsson GE. Bite force and chewing efficiency. Frontiers of Oral
Physiology 1974;1:265–92.
[50] Gibbs CH, Mahan PE, Mauderli A, Lundeen HC, Walsh EK. Limits
of human bite strength. Journal of Prosthetic Dentistry 1986;56:
226– 9.
[51] Haraldson T, Karlsson U, Carlsson GE. Bite force and oral function
in complete denture wearers. Journal of Oral Rehabilitation 1979;6:
41–8.
[52] Raadsheer MC, van Eijden TMGJ, van Ginkel FC, Prahl-Andersen
B. Contribution of jaw muscle size and craniofacial morphology to
human bite magnitude. Journal of Dental Research 1999;78:31– 42.
[53] Haraldson T, Carlsson GE, Ingervall B. Functional state, bite force
and postural muscle activity in patients with osseointegrated oral
implant bridges. Acta Odontologica Scandinavia 1979;37:195–206.
[54] Carlsson GE, Lindquist LW. Ten-year longitudinal study of
masticatory function in edentulous patients treated with fixed
complete dentures on osseointegrated implants. International Journal
of Prosthodontics 1994;7:448–53.
[55] Jemt T, Carlsson GE. Aspects of mastication with bridges on
osseointegrated implants. Scandinavian Journal of Dental Research
1986;94:66–71.
280 S. Şahin et al. / Journal of Dentistry 30 (2002) 271–282
[56] Haraldson T, Carlsson GE. Bite force and oral function in patients
with osseointegrated oral implants. Scandinavian Journal of Dental
Research 1977;85:200– 8.
[57] Carr AB, Laney WR. Maximum occlusal force levels in patients with
osseointegrated oral implant prosthesis and patients with complete
dentures. International Journal of Oral and Maxillofacial Implants
1987;2:101–8.
[58] Mericske-Stern R, Zarb GA. In vivo measurements of some
functional aspects with mandibular fixed prostheses supported by
implants. Clinical Oral Implants Research 1996;7:153–61.
[59] O’Mahony A, Bowles Q, Woolsey G, Robinson SJ, Spencer P. Stress
distribution in the single-unit ossointegrated dental implant: finite
element analyses of axial and off-axial loading. Implant Dentistry
2000;9:207–18.
[60] Linderholm H, Wennstrom A. Isometric bite force and its relation to
general muscle force and body build. Acta Odontologica Scandina-
via 1997;28:679–89.
[61] Misch CE, Bidez MW. Implant protected occlusion. Practical
Periodontics and Aesthetic Dentistry 1995;7:25–9.
[62] Bahat O. Treatment planning and placement of implants in the
posterior maxillae: report of 732 consecutive Nobelpharma implants.
International Journal of Oral and Maxillofacial Implants 1993;8:
151–61.
[63] van Steenberghe D, De Mars G, Quirynen M, Jacobs R, Naert I. A
prospective split-mouth comparative study of two screw-shaped self-
tapping pure titanium implant systems. Clinical Oral Implants
Research 2000;11:202– 9.
[64] Moberg LE, Kondell PA, Sagulin GB, Bolin A, Heimdahl A,
Gynther GW, et al. Brånemark system and ITI dental implant system
for treatment of mandibular edentulism. A comparative randomized
study: 3-year follow-up. Clinical Oral Implants Research 2001;12:
450–61.
[65] Engquist B, Åstrand P, Dahlgren S, Engquist E, Feldmann H,
Grondahl K, Marginal bone reaction to oral implants: a prospective
comparative study of Astra Tech and Brånemark system implants.
Clinical Oral Implants Research 2002;13:30– 7.
[66] Carter DR. Mechanical history and skeletal biology. Journal of
Biomechanics 1987;20:1095–109.
[67] Carter DR, Orr TE, Fyhrie DP, Schurman DJ. Influences of
mechanical stress on prenatal and postnatal skeletal development.
Clinical Orthopaedics and Related Research 1987;238:237 –50.
[68] Jemt T, Carlsson L, Boss A, Jorneus L. In vivo load measurements
on osseointegrated implants supporting fixed or removable pros-
theses: a comparative pilot study. International Journal of Oral and
Maxillofacial Implants 1991;6:413– 7.
[69] Barbier L, Vander Sloten J, Krzesinski G, Schepers E, Van der Perre
G. Finite element analysis of non-axial versus axial loading of oral
implants in the mandible of the dog. Journal of Oral Rehabilitation
1998;25:847–58.
[70] Hebel KS, Gajjar RS. Cement-retained versus screw-retained
implant restorations: achieving optimal occlusion and esthetics in
implant dentistry. Journal of Prosthetic Dentistry 1997;77:28–35.
[71] Bergendal T, Engquist B. Implant-supported overdentures: a
longitudinal prospective study. International Journal of Oral and
Maxillofacial Implants 1998;13:253–62.
[72] Lekholm U, Gunne J, Henry P, Higuchi K, Linden U, Bergstrom C,
et al. Survival of the Branemark implant in partially edentulous jaws:
a 10-year prospective multicenter study. International Journal of
Oral and Maxillofacial Implants 1999;14:639 –45.
[73] Eckert SE, Wollan PC. Retrospective review of 1170 endosseous
implants placed in partially edentulous jaws. Journal of Prosthetic
Dentistry 1998;79:415 –21.
[74] Bergendal T, Engquist B. Implant-supported overdentures: a
longitudinal prospective study. International Journal of Oral and
Maxillofacial Implants 1998;13:253–62.
[75] Jemt T, Chai J, Harnett J, Heath MR, Hutton JE, Johns RB, et al. A 5-
year prospective multicenter follow-up report on overdentures
supported by osseointegrated implants. International Journal of
Oral and Maxillofacial Implants 1996;11:291–8.
[76] Smedberg JI. Studies of maxillary overdentures on osseointegrated
implants. Swedish Dental Journal 1995;102(Suppl):1–49.
[77] Glantz P-O, Nilner K. Biomechanical aspects on overdenture
treatment. Journal of Dentistry 1997;25:21–4.
[78] Skalak R. Biomechanical considerations in osseointegrated pros-
theses. Journal of Prosthetic Dentistry 1983;49:843–8.
[79] Branemark P-I, Zarb G, Albrektsson T. Tissue integrated postheses.
Chicago: Quintessence; 1985. p. 11– 19, 117–28, 156–62.
[80] Branemark P-I. Osseointegration and its experimental background.
Journal of Prosthetic Dentistry 1983;50:399 –410.
[81] Davis DM, Rimrott R, Zarb GA. Studies on frameworks for
osseointegrated prostheses: Part 2. The effect of adding acrylic resin
or porcelain to form the occlusal superstructure. International
Journal of Oral and Maxillofacial Implants 1988;3:275–80.
[82] Gracis SE, Nicholls JI, Chalupnik, Yuodelis RA. Shock-absorbing
behavior of five materials for materials used on implants.
International Journal of Prosthodontics 1991;4:282–91.
[83] Cibirka RM, Razzoog ME, Lang BR, Stohler CS. Determining the
force absorption quotient for restorative materials used in implant
occlusal surfaces. Journal of Prosthetic Dentistry 1992;67:361– 4.
[84] Hobkirk JA, Psarros KJ. The influence of occlusal surface material
on peak masticatory forces using osseointegrated implantsupported
prostheses. International Journal of Oral and Maxillofacial Implants
1992;7:345–52.
[85] Sertgöz A. Finite element analysis study of the effect of super-
structure material on stress distribution in an implant-supported
prosthesis. International Journal of Prosthodontics 1997;10:19–27.
[86] Stegaroiu R, Kusakari H, Nishiyama S, Miyakawa O. Influence of
prosthesis material on stress distribution in bone and implant: a 3-
dimensional finite element analysis. International Journal of Oral and
Maxillofacial Implants 1998;13:781–90.
[87] Brunski JB, Puleo DA, Nanci A. Biomaterials and biomechanics of
oral and maxillofacial implants: current status and future develop-
ments. International Journal of Oral and Maxillofacial Implants
2000;15:15–46.
[88] Holmgren EP, Seckinger RJ, Kilgren LM, Mante F. Evaluating
parameters of osseointegrated dental implants using finite element
analysis–a two dimensional comparative study examining the effects
of implant diameter, implant shape, and load direction. Journal of
Oral Implantology 1998;24:80–8.
[89] Stegaroiu R, Sato T, Kusakari H, Miyakawa O. Influence of
restoration type on stress distribution in bone around implants: a
three-dimensional finite element analysis. International Journal of
Oral and Maxillofacial Implants 1998;13:82–90.
[90] Krekmanov L, Kahn M, Rangert B, Lindstrom H. Tilting of posterior
mandibular or maxillary implants for improved prosthesis support.
International Journal of Oral and Maxillofacial Implants 2000;15:
405 –14.
[91] Duyck J, Van Oosterwyck H, Vander Sloten J, De Cooman M, Puers
R, Naert I. Magnitude and distribution of occlusal forces on oral
implants supporting fixed prostheses: an in vivo study. Clinical Oral
Implants Research 2000;11:465–75.
[92] Branemark P-I, Svensson B, van Steenberghe D. Ten-year survival
rates of fixed prostheses on four or six implants ad modum
Branemark in full edentulism. Clinical Oral Implants Research
1995;6:227–31.
[93] Branemark P-I, Engstrand P, Ohrnell L-O, Grondahl K, Nilsson P,
Hagberg K, et al. Brånemark Novum: a new treatment concept for
rehabilitation of the edentulous mandible. Preliminary results from a
prospective clinical follow-up study. Clinical Implant Dentistry and
Related Research 1999;1:2–16.
[94] De Smet E, Jacobs R, van Steenberghe D, Naert I. In vivo forces and
peri-implant (re)modelling around immediately loaded implants. A
prospective clinical trial. Clinical Oral Implants Research 2002;13:
xxii. abstract.
 S. Şahin et al. / Journal of Dentistry 30 (2002) 271–282
[95] Gunne J, Rangert B, Glantz P-O, Svensson A. Functional loads on
freestanding and connected implants in three-unit mandibular
prostheses opposing complete dentures: an in vivo study. Inter-
national Journal of Oral and Maxillofacial Implants 1997;12:
335–41.
[96] Roberts WE, Turley PK, Brezniak N, Fielder PJ. Bone physiology
and metabolism. Journal of Californian Dental Association 1987;54:
32–9.
[97] Roberts WE. Bone tissue interface. Journal of Dental Education
1988;(52):804–9.
[98] Binderman I. Bone and biologically compatible materials in
dentistry. Current Opinions in Dentistry 1991;1:836–40.
[99] Johansson C, Albrektsson T. The integration of screw implants in the
rabbit: a 1-year follow-up of removal torque of titanium implants.
International Journal of Oral and Maxillofacial Surgery 1987;2:
69–75.
[100] Huja SS, Qian H, Roberts WE, Katona TR. Effects of callus and
bonding on strains in bone surrounding an implant under bending.
International Journal of Oral and Maxillofacial Implants 1998;13:
630–8.
[101] Brosh T, Persovski Z, Binderman I. Mechanical properties of bone-
implant interface: an in vivo comparison of the parameters at
placement and at 3 months. International Journal of Oral and
Maxillofacial Implants 1995;10:729–35.
[102] Holmes DC, Loftus JT. Influence of bone quality on stress
disribution for endosseous implants. Journal of Oral Implantology
1997;23:104–11.
[103] Kido H, Schulz EE, Kumar A, Lozada J, Saha S. Implant diameter
and bone density: Effect on initial stability and pull-out resistance.
Journal of Oral Implantology 1997;23:163–9.
[104] Lekholm U, Zarb GA. Patient selection and preparation. In:
Brånemak P-I, Zarb GA, Albrektsson T, editors. Tissue integrated
prostheses: osseointegration in clinical dentistry. Chicago: Quintes-
sence; 1985. p. 199 –210.
[105] Truhlar RS, Orenstein IH, Morris HF, Ochi S. Distribution of bone
quality in patients receiving endosseous dental implants. Journal of
Oral and Maxillofacial Surgery 1997;55:38–45.
[106] Jaffin RA, Berman CL. The excessive loss of Branemark fixtures in
type IV bone: a 5-year analysis. Journal of Periodontology 1991;62:
2–4.
[107] Truhlar RS, Morris HF, Ochi S, Winkler S. Second-stage failures
related to bone quality in patients receiving endosseous dental
implants: DICRG interim report No. 7. Dental implant clinical
research group. Implant Dentistry 1994;3:252–5.
[108] Bahat O. Branemark system implants in the posterior maxilla:
clinical study of 660 implants followed for 5 to 12 years.
International Journal of Oral and Maxillofacial Implants 2000;15:
646–53.
[109] Karabuda C, Sandalli P, Yalcin S, Steflik DE, Parr GR. Histologic
and histomorphometric comparison of immediately placed hydro-
xyapatite-coated and titanium plasma-sprayed implants: a pilot study
in dogs. International Journal of Oral and Maxillofacial Implants
1999;14:510 –5.
[110] Jones JD, Lupori J, Van Sickels JE, Gardner W. A 5-year comparison
of hydroxyapatite-coated titanium plasma-sprayed and titanium
plasma-sprayed cylinder dental implants. Oral Surgery Oral
Medicine Oral Pathology Oral Radiology and Endodontics 1999;
87:649–52.
[111] Lozada JL, James RA, Boskovic M. HA-coated implants: warranted
or not? Compendium Continuous Education in Dentistry 1993;15:
539–43.
[112] Watson CJ, Ogden AR, Tinsley D, Russell JL, Davison EM. A 3 –6-
year study of overdentures supported by hydroxyapatite-coated
endosseous dental implants. International Journal of Prosthodontics
1998;11:610 –9.
[113] de Groot K, Wolke JGC, Jansen JA. State of the art: hydroxylapatite
281
coatings for dental implants. Journal of Oral Implantology 1994;20:
232– 4.
[114] Denissen HW, Kalk W, de Nieuport HM, Maltha JC, van de Hooff A.
Mandibular response to plasma-sprayed coatings of hydroxyapatite.
International Journal of Prosthodontics 1990;3:53–8.
[115] Listgarten MA. Soft and hard tissue response to endosseous dental
implants. Anat Rec 1996;245:410–25.
[116] Lacefield WR. Characterization of hydroxylapatite coatings. Journal
of Oral Implantology 1994;20:214 –20.
[117] Meffert RM. Maxilla vs. mandible: why use HA? Compendium
Continuous Education in Dentistry 1993;15:533 –43.
[118] Teixeira ER, Wadomoto M, Akagawa Y, Kimoto T. Clinical
application of short hydroxylapatite-coated dental implants to the
posterior mandible: a five-year survival study. Journal of Prosthetic
Dentistry 1997;78:166 –71.
[119] Carr AB, Gerard DA, Larsen PE. Histomorphometric analysis of
implant anchorage for 3 types of dental implants following 6 months
of healing in baboon jaws. International Journal of Oral and
Maxillofacial Implants 2000;15:785 –91.
[120] Trisi P, Rao W, Rebaudi A. A histometric comparison of smooth and
rough titanium implants in human low-density jawbone. Inter-
national Journal of Oral and Maxillofacial Implants 1999;14:
689– 98.
[121] Cochran DL, Nummikoski PV, Higginbottom FL, Hermann JS,
Makins SR, Buser D. Evaluation of an endosseous titanium implant
with a sandblasted and acid-etched surface in the canine mandible:
radiographic results. Clinical Oral Implants Research 1996;7:
240– 52.
[122] Cochran DL, Schenk RK, Lussi A, Higginbottom FL, Buser D. Bone
response to unloaded and loaded titanium implants with a
sandblasted and acid-etched surface: a histometric study in the
canine mandible. Journal of Biomedical Materials Research 1998;
40:1–11.
[123] Turner CH. Three rules for bone adaptation to mechanical stimuli.
Bone 1998;23:399– 407.
[124] Jemt T, Lekholm U, Johansson CB. Bone response to implant-
supported frameworks with differing degrees of misfit preload: in
vivo study in rabbits. Clinical Implant Dentistry and Related
Research 2000;2:129–37.
[125] Jemt T, Lekholm U. Measurements of bone and framework
deformations induced by misfit of implant superstructures. A pilot
study in rabbits. Clinical Oral Implants Research 1998;9:272–80.
[126] Schnitman PA, Wohrle PS, Rubenstein JE. Immediate fixed interim
prostheses supported by two-stage threaded implants: methodology
and results. Journal of Oral Implantology 1990;16:96–105.
[127] Schnitman PA. Branemark implants loaded with fixed provisional
prostheses at fixture placement: nine-year follow-up. Journal of Oral
Implantology 1995;21:235.
[128] Schnitman PA, Wöhrle PS, Rubenstein JE, DaSilva JD, Wang NH.
Ten year results for Branemark implants immediately loaded with
fixed prostheses at implant placement. International Journal of Oral
and Maxillofacial Implants 1997;12:495 –503.
[129] Tarnow DP, Emtiaz S, Classi A. Immediate loading of threaded
implants at stage 1 surgery in edentulous arches: ten consecutive
case reports with 1 to 5-year data. International Journal of Oral and
Maxillofacial Implants 1997;12:319 –24.
[130] Randow K, Ericsson I, Nilner K, Petersson A, Glantz PO. Immediate
functional loading of Branemark implants. An 18-month clinical
follow-up study. Clinical Oral Implants Research 1999;10:8–15.
[131] Horiuchi K, Uchida H, Yamamoto K, Sugimura M. Immediate
loading of Branemark system implants following placement in
edentulous patients: a clinical report. International Journal of Oral
and Maxillofacial Implants 2000;15:824 –30.
[132] Szmukler-Moncler S, Salama H, Reingewirtz Y, Dubruille JH.
Timing of loading and effect of micromotion on bone-dental implant
interface: review of experimental literature. Journal of Biomedical
Materials Research 1998;43:192–203.
282 S. Şahin et al. / Journal of Dentistry 30 (2002) 271–282
[133] Lefkove MD, Beals RP. Immediate loading of cylinder implants with
overdentures in the mandibular symphysis: the titanium plasma-
sprayed screw technique. Journal of Oral Implantology 1990;16:
265–71.
[134] Ledermann PD, Schenk RK, Buser D. Long-lasting osseointegration
of immediately loaded, bar-connected TPS screws after 12 years of
function: a histologic case report of a 95-year-old patient.
International Journal of Periodontics and Restorative Dentistry
1998;18:552–63.
[135] Chiapasco M, Gatti C, Rossi E, Haefliger W, Markwalder TH.
Implant-retained mandibular overdentures with immediate loading.
A retrospective multicenter study on 226 consecutive cases. Clinical
Oral Implants Research 1997;8:48–57.
[136] Gatti C, Haefliger W, Chiapasco M. Implant-retained mandibular
overdentures with immediate loading: a prospective study of ITI
implants. International Journal of Oral and Maxillofacial Implants
2000;15:383–8.
[137] Gomes A, Lozada JL, Caplanis N, Kleinman A. Immediate loading
of a single hydroxyapatite-coated threaded root form implant: a
clinical report. Journal of Oral Implantology 1998;24:159– 66.
[138] Piattelli A, Trisi P, Romasco N, Emanuelli M. Histologic analysis of
a screw implant retrieved from man: influence of early loading and
primary stability. Journal of Oral Implantology 1993;19:303–6.
[139] Piattelli A, Paolantonio M, Corigliano M, Scarano A. Immediate
loading of titanium plasma-sprayed screw-shaped implants in man: a
clinical and histological report of two cases. Journal of Period-
ontology 1997;68:591–7.
[140] Piattelli A, Corigliano M, Scarano A, Quaranta M. Bone reactions to
early occlusal loading of two-stage titanium plasma-sprayed
implants: a pilot study in monkeys. International Journal of
Periodontics and Restorative Dentistry 1997;17:162 –9.
[141] Piattelli A, Corigliano M, Scarano A. Microscopical observations of
the osseous responses in early loaded human titanium implants: a
report of two cases. Biomaterials 1996;17:1333–7.
[142] Weinberg LA, Kruger B. A comparison of implant/prosthesis
loading with four clinical variables. International Journal of
Prosthodontics 1995;8:421–33.
[143] Clelland NL, Gilat A, McGlumphy EA, Brantley WA. A photoelastic
and strain gauge analysis of angled abutments for an implant system.
International Journal of Oral and Maxillofacial Implants 1993;8:
541 –8.
[144] Sakaguchi RL, Borgersen SE. Nonlinear contact analysis of preload
in dental implant screws. International Journal of Oral and
Maxillofacial Implants 1995;10:295–302.
[145] Merz BR, Hunenbart S, Belser UC. Mechanics of the implant-
abutment connection: an 8-degree taper compared to a butt joint
connection. International Journal of Oral and Maxillofacial Implants
2000;15:519–26.
[146] Akca K, Cehreli MC, Iplikcioglu H. Evaluation of the mechanical
characteristics of a reduced-diameter morse taper implant: a non-
linear finite element stress analysis. Clinical Oral Implants Research
2003; in press.
[147] Glantz P-O, Nilner K, Randow K, et al. On the biomechanics of
implant retained overdentures. In: Schepers E, Naert I, Theuniers,
et al., editors. Overdentures on oral implants. Leuven: University
Press; 1991. p. 153–65.
[148] Cehreli MC, Iplikcioglu H, Bilir OG. The influence of the location of
load transfer on strains around implants supporting four unit cement
retained prosthesis. Journal of Oral Rehabilitation 2002;29:
394 –400.
[149] Clelland NL, Papazolgou E, Carr AB, Gilat A. Comparisons of
strains transferred to a bone simulant among implant overdenture
bars with various levels of misfit. Journal of Prosthodontics 1995;5:
243 –50.
[150] Brosh T, Pilo R, Sudai D. The influence of abutment angulation on
strains and stresses along the implant/bone interface: comparison
between two experimental techniques. Journal of Prosthetic
Dentistry 1998;79:328–34.
[151] Baiamonte T, Abbate MF, Pizzarello F, Lozada J, James R. The
experimental verification of the efficacy of finite element modelling
to dental implant systems. Journal of Oral Implantology 1996;22:
104 –6.
[152] Keyak JH, Fourkas MG, Meagher JM, Skinner HB. Validation of an
automated method of three-dimensional finite element modelling of
bone. Journal of Biomedical Engineering 1993;15:505 –9.
[153] Akca K, Cehreli MC, Iplikcioglu H. Comparison of three-
dimensional finite element stress analysis with in vitro strain
gauge measurements on dental implants. International Journal of
Prosthodontics 2002;15:115– 21.