Periodontology 2000, Vol.
4, 1994, 23-40
Printed in Denmark . All rights reserved
Biomechanical aspects of fixed
bridgework supported by natural
teeth and endosseous implants
DANLUNDGREN
& LARSLAURELL
Treatment that includes extensive fixed prosthodon-
tics is frequently chosen to restore mutilated den-
titions. A successful long-term outcome of such
prosthetic rehabilitation depends not only on con-
trol of disease-related factors but also requires care-
ful consideration and control of biomechanical fac-
tors, related to both the prosthetic construction per
se and the supporting units.
The occlusal force pattern, that is, the magni-
tude, duration, frequency, distribution and direc-
tion of the forces during function, decisively influ-
ences both the bridgework and the abutments. The
energy produced by the occlusal activities must not
exceed the strength of either the bridge com-
ponents or the abutments and their supporting
tissues to achieve a good long-range prognosis. It is
therefore important that the bridgework be given a
proper fit, dimension and occlusal design to match
the occlusal forces. Careful dimensioning and de-
sign of any included cantilever segment is of ut-
most importance.
The supporting abutment units (natural teeth or
endosseous implants) should have sufficient ca-
pacity to carry and retain the construction. This calls
for an adequate number and distribution of abut-
ments in relation to the bridge extension and
necessitates a reasonable biomechanical design of
the prepared or prefabricated abutments. An appro-
priate quantity and quality of the tissues supporting
and retaining the abutments are, in turn, fundamen-
tal for the entire construction.
The aim of this chapter is to discuss biomechan-
ical factors of importance for a successful, long-term
outcome of rehabilitation of dentitions with fixed
bridgework supported by either natural teeth or en-
dosseous implants exclusively or by a combination
Copyright 0 M u n k s g u a r d 1994
PERIODONTOLOGY 2000
ISSN 0906-6713
of teeth and implants. Both complete and partial
edentulism are considered.
Occlusal force pattern
Occlusal activity: frequency of occlusal contacts
The intensity of occlusal activities has considerable
individual variation. Examining teeth for occlusal
wear demonstrates that some dentitions, although
they have been in function for many years, seem to
have been subjected to a minimum of occlusal ac-
tivities apart from chewing and swallowing. Other
dentitions reveal by extensive occlusal wear that
much of the masticatory muscle energy has been
spent on parafunctional activities, such as clenching
and grinding. Although many factors may be associ-
ated with incisal and occlusal wear, bruxism is one
that correlates well with this type of dental break-
down (9). Trenouth (60) showed that the total oc-
clusal contact time per night of patients with brux-
ism was about 7 times longer than that of subjects
without such activities (38.7 min vs 5.4 min). In ad-
dition, it has been reported that the degree of oc-
clusal wear is positively correlated with the magni-
tude of occlusal forces during function (17). Taken
together, these data show that 1) the time spent on
chewing and biting is comparatively limited and 2)
clenching and grinding activities considerably in-
crease both the instantaneous amount of energy and
the energy per time-unit affecting the dentition.
Consequently, the presence, type and intensity of
parafunction should be considered carefully when
fixed prosthodontics is planned and carried out to
meet the individual demands on the construction
and its supporting units and to achieve acceptable
23
Lundgren & Laurell
durability of the treatment. These considerations are
especially highly applicable in planning and carrying
out treatment including implant-supported bridge-
work to avoid overload of both the implant-bone
units and their suprastructures. In fact, Quirynen et
al. (54) reported from a follow-up study of Brbnem-
ark@implants supporting fixed bridges that excess-
ive marginal bone loss (more than 1 mm of annual
bone loss also after the first year) andlor implant
loss correlated well with the presence of overload
due to the presence of parafunctional activity.
Occlusal forces
Usually, occlusal forces have been measured by
means of biting on a strain-gauge transducer (bite-
fork) placed locally between the tooth arches (7, 8,
23). Such an arrangement is limited by the fact that
the tooth arches have to be discluded to a great ex-
tent to give place for the transducer. Another limi-
tation is that only static, artificial force can be meas-
ured at one point or area at a time without
consideration to how the forces are distributed over
the entire dentition during natural function. There-
fore, occlusal forces measured by means of bite-fork
devices represent the voluntary muscular capacity
during artificial, conscious biting and are not repre-
sentative of local or total occlusal forces acting on a
dentition during natural function. Usually, these
force values are substantially larger than the local
forces occurring during natural function. Conse-
quently, such force data are less suitable for as-
sessing the loads affecting the supporting structures
or as reference values for dimensioning of fixed
bridgework, as they will lead to overestimation of the
need for both abutment support and bridge dimen-
sions.
To overcome the disadvantages of assessing bite
forces using bite-forks, a single transducer has been
built into a crown or a bridge-pontic to register local
forces (11, 21). However, only one area at a time can
be studied and there is no reported control of poss-
ible force leakage due to inadequate placement of
the transducer in relation to the occlusal surfaces.
Gibbs et al. (18) used a sound-transmission tech-
nique that does not require intraoral equipment to
measure the total occlusal forces (over the entire
tooth arch) exerted during chewing and swallowing.
However, this indirect method does not permit
measurement or calculation of local forces in various
parts of the dentition or the prosthetic construction.
In addition, the imprecision of the method is con-
siderable.
24
In a series of investigations of axially directed oc-
clusal forces (14, 311, a novel method was used by
which occlusal forces could be studied in various
parts of the dentition and over the entire dentition
simultaneously during natural functioning (40). This
method used several strain-gauge transducers di-
mensioned such that they could be mounted into
artificial crowns, bridge-pontics or removable den-
tures without interfering with the occlusion. At least
4 and sometimes as many as 8 transducers were
used, distributed in the prosthetic constructions
such that bilateral and simultaneous contacts were
created both anteriorly and posteriorly. Each trans-
ducer registers the local forces evoked in the part of
the dentition where the transducer is located. The
total force acting on the entire dentition is assessed
by adding the local forces. Thus, the force pattern,
that is, the magnitude of the force and the duration
and frequency of force application, can be evaluated
during chewing and swallowing and during jaw-clos-
ing without food both locally and totally at the
same time.
Total chewing and jaw-closing forces obtained in
dentitions with cross-arch bridges of different design
and with different abutment support (13, 38,42,43)
using the method described are presented in Table
1. It appears that the total amount of chewing force
loading the entire bridgework (when chewing roast-
beef and potato salad) varied between 55 and 166 N
on average. The total sum of forces loading the
bridge construction when the subjects were asked to
close their jaws with maximal strength without food
varied between 264 and 336 N on average.
Fig. 1 - 4 demonstrate the corresponding local (an-
terior and posterior) forces to the total forces in
Table 1 during chewing and jaw-closing. Fig. 1 shows
the distribution of local chewing and jaw-closing
forces on tooth-supported cross-arch bridges with
bilateral, posterior end abutments. Fig. 2 illustrates
the corresponding forces on tooth-supported cross-
arch bridges with unilateral, posterior 2-unit canti-
lever segments. Fig. 3 shows the same type of forces
distributed on tooth-supported cross-arch bridges
with bilateral, posterior 2-unit cantilever segments.
In all these figures the bridge constructions are oc-
cluding with natural teeth. Fig. 4 illustrates the same
type of forces distributed on implant-supported
cross-arch bridges with bilateral, posterior 2-unit
cantilever segments occluding with complete den-
tures.
These illustrations show that, in the presence of
bilateral end abutments (Fig. l), local chewing and
jaw-closing forces are larger in the posterior regions
 Biomechanical aspects of fixed bridgework

Table 1. Axially directed, naturally occurring, occlusal forces (newtons) in dentitions with tooth- or implant-sup-
ported fixed bridges. Mean values and standard deviations of total forces loading the entire prosthetic construction
during chewing (based on individual mean values) and during jaw-closing (based on individual maximal values);
n=number of subjects
Tooth support Tooth support Tooth support Implant support
Bilateral end abutment Unilateral cantilever Bilateral cantilever Bilateral cantilevera
(n=12) (n=12) (n=6) (n= 10)
Chewing 109264 5 5 5 19 121274 166?75
Jaw-closing 3202 117 264" 108 309 2 90 336297
a Complete denture in the antagonizing jaw.

I40 7 Bilateral end abutments Bilateral 2-unit cantilevers

Maximal closing
Meanchewing -C Mean chewing
120 1

z
40 -

V '
E4 i i EA
Preferred Non-preferred
Chewing side
Y

C2
.

c1
Preferred
A . Non-preferred
,i c 1
. I . ,

c2
.

Fig. 1. Local mean chewing forces and local maximal
forces (newtons) during jaw-closing without food. The
cross-arch bridges are tooth-supported and supplied with
posterior bilateral end abutments (EA). The anterior
transducers are mounted in the first premolar area (A)
and the posterior transducers close to the end abutments
(FA).The opposing jaw has natural teeth with or without
fixed bridgework.
Chewing side
Fig. 3. Local mean chewing forces and local maximal
forces (newtons) during jaw closing without food. The
cross-arch bridges are tooth-supported and supplied with
posterior bilateral 2-unit cantilever segments. The an-
terior transducers (A) are mounted to occlude with the
incisor area. The posterior transducers are mounted in
the first (Cl) and the second (C2) cantilever units. The
opposing jaw has natural teeth with or without fixed
bridgework.

-
Unilateral 2-unit cantilever

- Max closing
Meanchewing
Bilateral cantiteversiimplants

s
0 40
z

I I
EA A A c2
Preferred Non-preferred
Chewing side C2 C1 F3 F1 F1 F3 C1 C2
Preferred Non-preferred
Fig. 2. Local mean chewing forces and local maximal Chewing side
forces (newtons) during jaw-closing without food. The Fig. 4. Local mean chewing forces and local maximal
cross-arch bridges are tooth-supported and supplied with forces (newtons) during jaw closing without food. The
posterior unilateral end abutment (EX)on one side of the cross-arch bridges are implant-supported and supplied
jaw and a posterior &unit cantilever segment on the other with posterior, bilateral 2-unit cantilever segments. The
side. The anterior transducers are mounted in the first opposing jaw is supplied with a removable denture in
premolar area (A) and the posterior transducers close to which 4 anterior transducers are mounted to occlude with
the end abutment (EA) or in the distal unit (C2) of the the frontal implant-supported area (F3-F3) and 4 pos-
cantilever segment. The opposing jaw has natural teeth terior transducers with the first (Cl) and the second (C2)
with or without fixed bridgework. cantilever units.

25
Lundgren & Laurel1
than in the anterior (24, 42). On the other hand,
when end abutments are missing and the bridge
(occluding with natural teeth) is supplied with pos-
terior 2-unit cantilever segments uni- or bilaterally
(Fig 2, 3), the forces are considerably smaller over
the second (distal) than over the first (mesial) canti-
lever unit. This is valid irrespective of whether the
prosthetic construction is supported by implants or
by natural teeth (16, 38, 43). However, when pos-
teriorly cantilevered cross-arch bridges (whether
tooth- or implant-supported) are occluding with
complete maxillary dentures, the occlusal forces are
larger in the posterior regions despite a lack of end
abutments (13, 41, 46) (Fig. 4). In addition, these
studies have shown that the occlusal forces in such
dentitions are of the same magnitude as in den-
titions with tooth-supported bilateral end abutment
bridges.
This disagrees with the general belief, based on
bite force measurements using bite-forks, that a
complete denture implies reduced occlusal forces.
The observations made by Falk et al. (16) also con-
tradict the postulation made by Erhardsson (12) that
complete dentures in the opposite jaw demand
smaller dimensions of the bridge framework than do
natural teeth but corroborate the findings reported
by Ann (3, 4) and Glantz & Stafford (20). In fact, the
stress exerted on the posteriorly cantilevered bridges
and their supporting structures was about 40%
larger when occluding with a complete denture than
when occluding with natural teeth or fixed bridges
due to the larger moment (forcexlever) evoked by
the unfavorable distribution of forces on the canti-
lever segments opposing a complete denture (16).
Thus, cantilever segments constitute a greater threat
to the prosthetic construction when occluding with
a complete denture than when occluding with natu-
ral teeth. This difference in cantilever joint stress
probably explains the finding by Isikowitz (25) that
technical failures for free-end saddle bridges oc-
curred more frequently when the opposite jaw was
supplied with a complete denture than with natural
teeth.
These findings of the magnitude and distribution
of occlusal forces along cantilever segments are valid
provided that simultaneous occlusal contacts with
the antagonizing prosthetic construction or teeth are
present not only along the entire extension of the
supported part of the bridge but also along the en-
tire cantilever segment (43, 46).
By adjusting local occluding units in such a way
that they will be in lighter contact with each other
or to a variable extent inferiorly placed with no con-
26
~ ~~~
tact in habitual occlusion, it is possible to reduce the
magnitude of the local occlusal forces not only dur-
ing jaw-closing in habitual occlusion but also during
chewing and swallowing (46). If, on the other hand,
a premature contact, even as small as about 100 pm,
is introduced, the local chewing and closing forces
may increase substantially (15, 3 5 ) . If such a prema-
ture contact becomes located on, for instance, the
second unit of a posterior 2-unit cantilever segment,
the risk for technical failure is obvious.
Although the magnitude of occlusal forces de-
veloped during natural functioning varies consider-
ably between individuals (13, 43, 61), there are some
characteristics in common. Thus, chewing forces are
usually much smaller than maximal closing forces.
In addition, the force-withstanding capacity of the
supporting structures (the teeth and periodontium
and the implants and supporting bone) will not nor-
mally be fully utilized during chewing or during
maximal closing provided that there is no excessive
parafunction (13, 32, 33, 42, 61). Furthermore, most
individuals, although symmetrically supplied with
posterior end abutment support, seem to prefer one
side as their chewing side (24, 42, 46) on which not
only the chewing forces but also the closing and
biting forces are larger than on the non-chewing side
(Fig. 1-4).
The pattern of distally decreasing occlusal forces
along posterior cantilever segments of more than
one pontic included in an implant-supported (or
tooth-supported) bridgework and occluding with
natural teeth or implant-supported bridgework is
due to a larger apical deflection or bending of a
cantilever beam when loaded compared with an
end-supported beam. Thus, during closing in habit-
ual occlusion, the mechanical law of bending will
regulate the force distribution along the cantilever
segment. Also, during chewing of soft food, the force
pattern is basically the same as during jaw-closing,
as the bending of the cantilever beam surpasses the
force concentration caused by the bolus inter-
ference.
In all probability, neuromuscular feedback mech-
anisms are involved in the regulation of the force
pattern, as individuals with unilateral cantilever seg-
ments consistently prefer the contralateral end abut-
ment side as the chewing side (43), and individuals
with bilateral cantilever segments tend to place the
bolus in the anterior abutment-supported region
(38).
The reversed or distally increasing force distri-
bution pattern found with a posteriorly cantilevered
bridge occluding with a complete removable denture

(Fig. 4) is probably due to the fact that a complete
denture is supported by a mucosal soft tissue, the
resilience of which is smaller in the posterior region
than in the anterior. The magnitude of this differ-
ence in resilience exceeds the degree of deflection of
the end of the cantilever beam, thus converting the
expected decreasing force gradient to an increasing
one (16).
Stress and strain, deflection and
bending
All objects react with stress and strain when sub-
jected to force or load. The compression and tension
that arise within the object always cause deforma-
tions due to the movement and thereby altered posi-
tion of its smallest components, the atoms or mol-
ecules. If these deformations are minute and
temporary, as when stiff and stable materials are
loaded with small forces of short duration, they
might be difficult to discover clinically, but they be-
come quite evident when the material has a high
elasticity and the forces are large. The stress distri-
bution within a bridge-beam interposed between
two abutments depends on many factors such as the
point of attack and direction of the force, the vari-
ability in shape of the beam and the abutments, the
type of material, etc. Basically, however, the maximal
stress (the stress concentration) appears at the
middle portion of such a beam if the beam has a
uniform shape and is supported by comparable
abutments. However, the stress concentration in a
uniformly shaped cantilever bridge-beam is concen-
trated to the connector section between the beam
and the abutment when the beam is subjected to
force. Thus, the weakest point of a uniformly shaped
beam interposed between two abutments is at the
midportion of the beam, whereas a comparable
cantilever beam has its weakest point in the connec-
tor section at the abutment. This pattern may be
substantially modified by several factors, such as dif-
ferences in the elasticity of the attachment of each
abutment to the jaw bone, local neuromuscular
feedback mechanisms of the supporting tissues and
local variations in the elasticity of the supporting
jaw bone.
The distance between the point(s) of force appli-
cation and the connector cross-section of a canti-
lever beam is termed the lever. The product of the
magnitude of the force and the length of the lever is
termed the moment. The size of the moment is one
decisive factor that determines the stress and strain
Biomechanical aspects of fixed bridgework
evoked in a beam of a given dimension. Thus, a
comparatively small force that affects a connector
cross-section via a relatively long lever arm exerts
the same moment on this section as a force that is
twice as large but is acting via a lever arm half that
of the first arm (Fig. 5).
Other factors of decisive importance for the mag-
nitude and distribution of stress and strain are the
material and the dimension of the beam. Depending
on the type of material and the state in which the
material is used, it might be characterized as elastic
or stiff. However, all materials subjected to load react
initially with an elastic, reversible deformation. An
elastic material has a broad field of elasticity and a
stiff material has a narrow field. This means that, for
a given force, the elastic material reversibly deflects
a longer distance in the direction of the force than a
stiff material. A material deformed within its field of
elasticity always regains its original state after un-
loading, since the atoms and molecules move back
to their original positions of equilibrium. However,
an elastic material is not identical to a weak material
[certain types of rubber materials may be very elas-
tic and very strong), and a stiff material is not ident-
ical to a strong material (certain types of glass are
very hard but also very brittle).
If a material is deflected (yielded) beyond its field
of elasticity (passes its yield limit) into its field of
plasticity, it becomes permanently deformed, be-
cause it can no longer regain its former state of rest
because the atoms or the molecules have been
>..
Thus M1 = M2 when F2 = 2 F l
Fig. 5. The stress and strain exerted on the weakest point
of a cantilever beam, that is, the connector cross-section
(CCS) between the beam and the abutment, is the same
when a force F1 is applied on a distance L1 from CCS as
when a force F2, twice as large as F1, is applied on half
the distance, L2, from CCS.
27
Lundgren & Laurell
forced to take new positions in a new equilibrium.
Such a material has not lost strength but has
changed shape. If the same material is forced to be
deformed beyond its field of plasticity, it reaches its
ultimate stress limit; after passing that limit it will
fracture. The strength of a material, or the magni-
tude of force or load it can withstand until it will
fracture, depends on 1) its atomic or molecular
structure and how it is modified and handled during
fabrication (for example, gold alloys composed of
varying amounts of different types of metals and dif-
ferently hardened or unhardened) and 2) the dimen-
sioning of the material, especially in relation to the
force direction.
However, not only the structure and dimensioning
of the material but also the type of force determine
when the material will fracture. Thus, frequently ap-
plied forces will, with time, cause the material to
fracture due to fatigue if they continuously exceed
about two thirds of the ultimate stress limit value of
the material. Still another factor of basic importance
is the velocity by which a force hits an object, as the
impact energy produced by a high-velocity force is
more deleterious to the object than a low-velocity
force. It is, however, unlikely that the mandibular jaw
under any circumstances will achieve such velocities
that deleterious effects will arise because of excess-
ive impact energy.
Fig. 6. When a cantilever beam is loaded with a force F,
the resulting stress (0)will be concentrated to the connec-
tor section between the beam and the abutment (the
weakest point). The stress is directly proportional to the
magnitude of the force (F) and the length (L) and width
(w) of the beam, and the height (H) of the beam has a
squared influence on the stress magnitude. This means
that if a cantilever beam is doubled in length the stress
will double for the same force, and if the height of the
beam is halved the stress will be 4 times as high for the
same force.
28
The importance of the dimensioning of a bridge-
beam is illustrated in Fig. 6 and 7 by the formula for
stress applied to a cantilever beam (Fig. 6) and the
formula for deformation or deflection of an identical
beam due to bending (Fig. 7) when it is subjected to
a vertical (axial) force at the end of the beam. The
stress formula for a cantilever beam is:
G = F X LX 32/WXH‘
where (T is the evoked stress in N/mm’ of the cross-
section of the beam at the cantilever connection, F
is the magnitude of the force in newtons, L is the
length of the beam in mm, 32 is a constant for a
beam with an elliptic cross-section at the cantilever
connection, H is the height (the distance in the force
direction) and W is the width of that connection. The
evoked stress of the beam is directly proportional to
the magnitude of the force as well as to both the
length and the width of the beam: doubled force or
beam length will double the beam stress (due to
doubled moment), and a doubled beam width will
halve the beam stress. The height of the beam
(which is raised to the second power in the formula),
however, influences the stress more. Thus, a doubled
beam height reduces the beam stress by 75%, and a
halved beam height increases the beam stress 4
times.
The deformation or deflection (yielding, flexure or
bending) of an object depends on not only 1) the
properties of the material (the higher the elastic
modulus (E), the stiffer the material) but also on 2 )
Fig. 7.When a cantilever beam is loaded with a force F,
the resulting deflection (6) of the beam-end is directly
proportional to the magnitude of the force (F) and the
width (W) of the beam, while both the length (L) and the
height (H) of the beam have a cubed influence on this
deflection. This means that if a cantilever beam is doubled
in length or halved in height, the beam end will deflect 8
times as much as before for the same force.

the shape (circular, elliptic or square-shaped cross-
section) and 3 ) the dimension of the object in re-
lation to the direction of the forces. The deflection
formula for the cantilever beam is:
6= FX L3X 64/3 X n X E X WX H3
where 6 is the deflection of the beam end in mm, 64
and 3 are constants and n is related to the elliptic
cross-section of the connection of the beam. E is the
elastic modulus in N/mm2 of the material. An alter-
ation of both the length (L) and the height (H) of the
beam has a greater influence on the deflection or
bending than on the stress of the beam, as these two
factors are raised to the third power in the deflection
formula but only to the first and second power (re-
spectively) in the stress formula (Fig. 6). Thus, a
doubled beam length or a reduction of the beam
height to half the original height will increase the de-
flection of the beam end 8 times, and the correspond-
ing increase of the stress is 2 times and 4 times respec-
tively. It is therefore possible to substantially increase
the amplitude of deflection of, for instance, a canti-
lever beam end of a bridge by intentionally reducing
its height, without necessarily jeopardizing its
strength because of excessive stress. Ideally, the abut-
ment crowns of a bridge construction should be di-
mensioned to be as non-deformable (stiff)as possible
to ensure that the luting cementum (or the abutment
screw of an implant-supported bridge) does not
break. The bridge beams, especially of the cantilever
type, should preferably be more deflective to be able
to deflect away from the occlusal forces during chew-
ing and when closing in habitual occlusion, thereby
concentrating the forces to the abutment regions. An-
other clinical situation when a bridge beam is inten-
tionally dimensioned to achieve a critical deflection
of the beam-end to favorably distribute the forces is
when an implant-supported beam of cantilever type
is to be connected to a natural tooth.
Amount and distribution of
abutment support
The traditional opinion, going back to Ante’s law (5),
claims that there should be at least the same total
amount of remaining periodontal ligament tissue to
support a fixed bridge on natural teeth as the total
maximal amount of periodontal ligament tissue of
the teeth to be replaced. The validity of this state-
ment has been seriously questioned in several inves-
tigations undertaken during the last 2 decades. Thus,
it has repeatedly been shown that the amount of
Biomechanical aspects of fixed bridgework
periodontal tissue supporting a bridge of cross-arch
design can be very much reduced in relation to the
original amount of periodontium and still have the
capacity to successfully carry the bridge construc-
tion with good long-term prognosis (32, 34, 36, 37,
39, 48, 50-52). In fact, dentitions treated for ad-
vanced periodontal disease and restored with fixed
bridgework with a reasonable distribution of the
abutments in relation to the extension of the bridge
may function satisfactorily for several years with as
little as 10%of the original periodontal ligament area
remaining as support (37, 48).
This means that a small number of abutment teeth,
preferably not fewer than 4, can successfully support
a cross-arch bridge if they are reasonably distributed.
Thus, the length of the beams of the framework inter-
posed between the abutment crowns may be up to 30
mm without jeopardizing the prognosis of the bridge,
also in a long-term perspective, provided that the re-
quirements of proper retention, dimension and oc-
clusal design (see below) are met (37). It has also been
shown that the capacity of an extremely reduced but
healthy periodontium supporting such abutments
and constructions is large enough not to influence the
chewing and jaw-closing forces (32) or the chewing
pattern and chewing capacity during natural func-
tioning (33).
The horseshoe shape of a cross-arch bridge means
that it resists lateral occlusal forces more effectively
than a straight segment bridge in the maxillary jaw,
which is more prone to tilt in the buccal direction or
to become hypermobile due to lateral forces. This
is especially the case if the occlusal force activity is
intense and the periodontal support is very much
reduced. This tilting or hypermobility can be pre-
vented or reduced by designing low cuspal inclines
in relation to adjacent teeth and/or by connecting or
extending the bridge to include a larger number of
abutments, thereby lending the construction a more
favorable design.
The critical number, distribution and amount of
bony support of endosseous implants for carrying
fixed bridgework with good long-term prognosis
have not been as thoroughly documented as have
the number of teeth and the amount and distri-
bution of periodontal support needed for tooth-an-
chored bridges. Available data, however, indicate
that 4 reasonably distributed implants secure a long-
range maintenance of bony support for at least a 10-
unit cross-arch bridge, also including bilateral pos-
terior 2-unit cantilevers, provided that the bone
quality is reasonable (1, 2, 54). Usually, a minimum
length of 10 mm is advocated for each implant.
29
Lundgren & Laurel1
Retention and dimension of abutment crowns
The luting cementum is still the weakest biomech-
anical link in a tooth-supported bridge construction,
especially for abutments adjacent to cantilever seg-
ments (29, 56). Fracture of the cementum, leading to
loss of retention of the abutment crown, may result
in rapidly, irreparable caries destruction of the abut-
ment tooth. Proper preparations with long and par-
allel surfaces of both vital and nonvital abutment
teeth and with a cervical tooth embracement of at
least 3 mm in height are therefore mandatory for
preventing loss of retention, particularly in bridges
including cantilever segments (37, 38). To optimize
retention, pre-prosthetic crown-lengthening surgery
sometimes has to be performed.
Another important retention factor is the degree
of fit of the abutment crown to the prepared tooth.
Other decisive factors are the type and dimension
of the crown. Fixed bridges with long interabutment
spans or cantilevers should be supplied with full-
coverage abutment crowns. In addition, the crowns
should be dimensioned to ensure a stiffness that
prevents fracture of the luting cementum due to
crown deformation, even with intense occlusal activ-
ity and large occlusal forces.
The retention of cemented implant-supported
bridges should be subjected to the same type of con-
siderations as the tooth-supported bridges, although
the retentive capacity of the luting cementum is
higher when (rough) metal is attached to metal. In
implant systems that exclusively use screws to attach
the supraconstruction to the implant abutments, the
retentive capacity of the supraconstruction is related
to the friction forces attained when the attaching
screws are tightened. These forces in turn are related
to the shape and dimension of the screws (28).
Interabutment and cantilever
segments
Interabutment segments
Whenever reasonable, end abutments should be in-
corporated in fixed bridgework. This means that
there should be at least 2 abutment units to support
a segment bridge and preferably 4 units to support
a cross-arch bridge, with 2 of the abutments placed
posteriorly in the second premolar or molar region.
The dimensioning of the interabutment pontics and
their connections (solder joints) to the abutment
crowns usually should not cause any problems if
they are constructed in harmony with these crowns.
30
Few abutments supporting an extensive cross-arch
bridge means long interabutment beams, which re-
quires a relatively large cross-section area. Den-
titions treated for advanced periodontal disease
usually exhibit both long clinical crowns, which are
advantageous for proper retention, and a large inter-
occlusal space, which facilitates proper dimen-
sioning. Given these prerequisites, there should be a
negligible risk of fracturing a properly constructed
end abutment bridge, provided there are no excess-
ive parafunctional activities.
A bridge supported by endosseous implants dis-
tributed as for tooth-supported end abutment
bridges should be dimensioned in analogy with the
latter. Although they are less resiliently connected to
the supporting bone, there is no reason based on
published follow-up studies to recommend coarser
beams and connectors for implant-supported
bridges than for tooth-supported bridges.
Cantilever segments in natural teeth
It is well known that many clinical situations require
(both tooth- and implant-supported) fixed bridge-
work of cross-arch extension to restore function and
aesthetics and in which posterior end abutments are
not available. In such situations a satisfactory pros-
thetic reconstruction may still be attained by insert-
ing posterior endosseous implants as end abutment
support. However, it is not always possible to use
implants for this purpose due to inadequate bone
volume. The alternative is to include one or several
posterior cantilever units in the construction. The
incorporation of cantilever extensions in fixed,
tooth-supported prosthetic constructions is, how-
ever, controversial. Traditionally, the opinion is
either that the use of cantilevers is absolutely contra-
indicated or that a maximum of one cantilever unit
should be permitted to avoid jeopardizing the bridge
construction and its supporting teeth. Such state-
ments have usually been anecdotally based without
any support from clinically well-controlled studies.
However, some clinical investigations on the prog-
nosis of extensive bridge constructions supplied
with one or more cantilever units have been pub-
lished. Thus, Randow et al. (56) examined the results
of extensive fixed prosthodontics performed by gen-
eral practitioners in a retrospective questionnaire
study. Their investigation demonstrated a technical
failure rate for fixed bridges after 7 years in service of
8% for constructions including distal end abutment
teeth, 16% for fixed bridges with single cantilever ex-
tensions, 34%for bridges with unilateral double can-

tilever extensions and 44% for bilateral double can-
tilever extensions. The main cause of failure was loss
of retention of the anchor crowns adjacent to the
cantilever segments, followed by fracture of the re-
construction. The frequency of failures increased
substantially with time in service, especially for con-
structions with bilateral cantilever pontics. In these,
loss of retention was located at the abutment tooth
adjacent to the cantilever segment, and the fractures
occurred in the beams mesial or distal to the retainer
crown of the same abutment tooth.
The findings by Randow et al. (56) were confirmed
in a follow-up study by Karlsson (29). In a retrospec-
tive long-term clinical study, he examined the
bridges after 14 years in service. The prosthetic treat-
ment had been performed by private dental prac-
titioners. The average technical failure rate was 26%.
Fixed bridges with distal abutment support ex-
hibited a failure rate of 11%,and those with canti-
lever extensions showed a failure rate of 36%. The
number of failures increased with number of canti-
lever units and with time in service, and the main
cause was loss of retention of distal abutment
crowns.
It therefore appears that there is a markedly in-
creased risk of failure if a fixed cross-arch bridge is
provided with cantilever units. These studies, how-
ever, did not closely evaluate the biotechnical quality
and design of the construction, such as the prepara-
tion form of the abutments and dimensioning of the
bridgework. Nor was the design of the occlusal con-
tact pattern, especially of the cantilever segments,
described. In addition, it is not possible from the re-
ported findings to establish whether the patient ma-
terial included subjects with excessive parafunc-
tional activity and/or exhibited dentitions with short
clinical crowns.
Nyman & Lindhe (51) presented a technical failure
rate of less than 8%, including loss of retention
(3.3%),fracture of bridgework (2.1%) and fracture of
abutment teeth (2.4%) after 5-8 years in 159 peri-
odontally treated patients supplied with extensive
cantilever fixed bridges. During this period, no
further loss of attachment had occurred. These
bridges were all performed by or under the super-
vision of the senior staff of the Department of Peri-
odontology at the Faculty of Odontology of the Uni-
versity of Goteborg.
Laurel1 et al. (37) reported on the long-term prog-
nosis of extensive fixed bridges with uni- or bilater-
ally placed 2- or 3-unit cantilevers. These construc-
tions had all been performed by the authors or
under their supervision as part of the overall treat-
Biomechanical aspects of fixed bridgework
ment of advanced periodontal disease. The follow-
up period for 34 patients (with 36 cross-arch
bridges) varied between 5 and 12 years, with an aver-
age of 8 years. During this period, one bridge con-
struction was lost due to complete periodontal
breakdown caused by excessive occlusal trauma due
to parafunctional activities in conjunction with an
extreme psychosocially caused stress period for the
patient. In another patient, one (vital) abutment
tooth of a 12-unit bridge, supported by 2 abutments,
was fractured. In the remaining 32 patients, the
bridges exhibited continuously acceptable function.
No further periodontal breakdown occurred in any
of these patients and no technical failure of the
bridge constructions was observed.
However, special requirements were established
for the design of these constructions: 1) optimal re-
tention (long and parallel surfaces), especially of the
retainer crowns adjacent to the cantilever segments;
2) establishment of occlusal contacts anteriorly as
well as posteriorly along the entire prosthetic con-
struction in habitual occlusion; 3) an occlusal mor-
phology guiding the occlusal forces in an apical di-
rection, anteriorly as well as posteriorly; 4) anterior-
guided lateral movements with no latero- or medio-
trusive contacts on the cantilever segments; and 5)
metal framework heights of at least 5 mm and
widths of 4 mm preferably along the entire tooth
arch and definitely distal and mesial to the retainer
crowns adjacent to the cantilever segments.
The authors concluded that, although failures do
occur, they can be kept to a minimum provided that
special attention is paid to retention, dimensions
and occlusal design of the bridge construction and
that the periodontal tissues are properly treated. In-
dividually related follow-up recalls should include a
careful control of the occlusal contact pattern of the
cantilever segments. The often observed, gradually
developing, hard contacts on the cantilever units
due to less occlusal wear of the cantilevers than of
the abutment-supported crowns should be elimin-
ated to avoid development of supracontacts causing
occlusal force concentration to the cantilever seg-
ments.
As previously discussed, the occlusal force distri-
bution on the cantilever segments and thereby also
the stress concentrations in the framework and in
the supporting units can be comparatively well con-
trolled by occlusal adjustments. However, this can
also be done by intentional dimensioning of the can-
tilever segment. Thus, the height of the connector
can be moderately reduced, which substantially in-
creases the apical deflection of the beam end when
31
Lundgren & Laurell
loaded without necessarily causing fatigue stress in
the connector, as the deflection increases more than
the stress. The increased deflection means that the
cantilever forces become redistributed towards the
abutment-supported segment after such a connec-
tor reduction. It is also possible to increase substan-
tially the amplitude of apical deflection of a canti-
lever beam end (=25%) by a design characterized by
successively increasing the reduction of the beam
height towards the beam end. Such a modification
does not influence the stress of the beam, as the
connector area is left intact. Such a design also con-
sumes less framework material.
Cantilever segments in implants
Although the incorporation of cantilever extensions
in fixed, tooth-supported prosthetic constructions is
controversial, it is generally accepted to include 2 or
even 3 posterior cantilever units in implant-sup-
ported bridges of cross-arch design. A large number
of documented cases verify a high long-term success
rate of such cases, especially in the mandibular jaw
(2).
It is mandatory that individually related follow-up
recalls of implant-supported bridges also include a
careful control of the occlusal contact pattern, es-
pecially of the cantilever segments. Hard contacts on
the cantilever units due to less occlusal wear of the
cantilevers than of the implant-supported crowns
should be eliminated to avoid occlusal force concen-
tration to the cantilever segments.
Occlusal design in
tooth-supported bridges
The occlusal force pattern described is based on the
criteria for stable occlusion proposed by Beyron (6).
These criteria include 1) wide freedom in centric
(habitual) occlusion, 2) bilateral stability in centric
(habitual) occlusion, 3) no interference between the
retruded and centric (habitual/intercuspal) posi-
tions, 4) occlusal contacts, preferably along the en-
tire construction in centric (habitual) occlusion, 5)
an occlusal morphology guiding the occlusal forces
in an apical direction anteriorly as well as pos-
teriorly, 6) for the maxillary bridges a balcony shape
of the singulum palatae should be aimed at, 7) an-
terior-guided lateral movements with slight or no
latero- or mediotrusive contacts on posterior canti-
lever segments.
32
Occlusal design in
implant-supported bridges
As related to prosthetic rehabilitation by means of
implants, occlusion is somewhat empirical (61). It
seems, however, reasonable to apply the basic prin-
ciples for stable occlusion proposed by Beyron (6)
that are intended for extensive fixed bridgework sup-
ported by natural teeth, also on implant-supported
fixed bridgework.
Occlusal stability, characterized by bilateral and
anterio-posterior distribution of occlusal contacts,
should be ensured, since this will create stability in
the entire masticatory apparatus. This also results in
a proper force distribution without undue force con-
centrations on individual implants. The require-
ments for a perfect fit of an implant-supported
bridge are also very high, since this will promote
proper stress distribution. If undue static stresses are
concentrated on individual bridge components and
implants after screw-tighteningor cementation of an
inaccurately fitting bridge, there is a great risk of
damage both to these components and to the sup-
porting bone. The accentuation of the need for pre-
cise adaptation of an implant-supported bridge to
the implant abutments is therefore highly relevant in
a discussion of proper occlusal force distribution.
Criteria 5-7 proposed for tooth-supported bridges
are especially important if not mandatory to ensure
a stable occlusion with force distribution concen-
trated to the anterior abutment region, when the
bridgework includes posterior uni- or bilateral canti-
levers. Working-side contacts should be designed to
provide immediate disocclusion of the cantilevers
and may be either canine-guided or group function-
guided. There should be no balancing contacts. It is
preferable to place the working-side contacts as
anteriorly as possible to reduce the bending moment
achieved during lateral excursions. The report by
Quirynen et al. (54) that lack of anterior occlusal
contacts of implant-supported cross-arch bridges
with posterior cantilevers correlated well with ex-
cessive marginal bone loss around the implants
underlines the importance of a proper occlusal de-
sign of implant-supported bridgework.
Occlusal material in
implant-supported bridges
Most of the implant-supported bridges that have
been scientifically documented in terms of success

~~
and failure rates have been supplied with acrylic resin
teeth. It has been suggested that resin, considered a
shock-absorbing material, should be beneficial com-
pared with porcelain fused to metal in reducing
stresses in the implant-bone interface in impact force
conditions (10,59).These conclusions were based on
theoretical assessments and calculations using a fi-
nite element analytical technique. On the other hand,
Ismail et al. (26),also using the finite element analysis,
found that the use of resin teeth as a shock absorber
may not be valid. In addition, apart from being con-
tradictory, such theoretical calculations imply a num-
ber of extrapolations, making the conclusions less
valid when they are applied to in v i m conditions. In
reality, occlusal impact loads, or loads applied at a
high rate, are probably very uncommon in the clinical
situation. It may, in fact, be questioned whether the
comparatively low velocity achieved by closing the
mandible can cause any occlusal impact forces of any
deleterious significance.
In a recent clinical investigation, Hobkirk &
Psarros (24) studied the chewing pattern and the
chewing forces in patients with mandibular implant-
supported cross-arch bridges, alternately supplied
with acrylic resin teeth or porcelain teeth. They
could not find any differences in the peak masticat-
ory forces for subjects chewing different types of
food using acrylic resin or porcelain teeth. It there-
fore seems unlikely that the use of metal-ceramic
material would imply such a threat against the im-
plant-bone interface that some sort of shock-ab-
sorbing arrangement (59) would regularly be re-
quired. This doubt is supported by the findings
reported from a 2-year follow-up study by Naert et
al. (49). They found no adverse effects on the bone-
implant interface or the fixture components. In ad-
dition, there were no fractures of the occlusal por-
celain, whereas such fractures frequently were ob-
served when composite resin was used.
A somewhat different question might be whether
the more attrition-resistant porcelain teeth have
more deleterious effects on implant components
and supporting bone than acrylic resin teeth in pa-
tients with severe parafunction.
One well-known problem with the use of por-
celain-fused-to-metal restorations is related to the
high demands on close fit of implant-supported
framework to the implant abutments, because the
firing of metal-ceramic materials may warp a casting
that initially fit accurately. Such a bridge has to be
sectioned and postceramic soldered to avoid stress
concentrations that may jeopardize the osseointe-
gration of the implants.
Biomechanical aspects of fixed bridgework
Another problem in using metal-ceramic ma-
terials may be the deformation of the posterior can-
tilever segment of the cross-arch bridges, which can
easily cause ceramic fracture. One solution to this
problem might be to use acrylic resin teeth in this
segment; another is to dimension the segment so
that its deformation is negligible and instead reduce
the stress by inferior placement of the posterior oc-
clusal contacts. A third way to overcome this compli-
cation might be to separate the ceramic material of
each cantilever unit by avoiding ceramic proximal
contacts.
Implant-supportedbridges in the
partially edentulous jaw
Indications for free-standing bridges
When properly inserted, high-quality implants of
an endosseous type are osseointegrated. This
means that they are incorporated in the jawbone in
close contact with the surrounding bone tissue
with no intervening connective tissue. This means
that the implant is more stiffly connected to the
jawbone than is the natural tooth with its peri-
odontal ligament, which permits considerable de-
flection or yielding of the tooth when loaded.
Consequently, there should be a risk of undue force
transmission to the osseointegrated implants when
they are placed in the same jaw as natural teeth.
Theoretically, the force concentrations might either
result in overloading of the implants andlor their
surrounding bone tissue or create an unfavorable
force distribution in other structures of the stoma-
tognathic system.
A certain amount of restraint has therefore been
advocated in using implants to support fixed
bridgework in partially edentulous jaws. Recently
published case reports or series of consecutive
cases (27, 49, 54, 55, 60, 63) indicate, however, that
such apprehension might be somewhat exagger-
ated. It is also our clinical experience that endosse-
ous implants can carry free-standing bridge con-
structions in partially edentulous dentitions in both
the mandibular and the maxillary jaws with good
long-term prognosis provided that there is enough
bone volume, good bone quality and no extreme
parafunctional activity. At least 2 , but preferably 3
implants with a minimum length of 10 mm are ad-
visable to secure the long-term support of such
bridges.
33
Lundgren & Laurel1
Occlusal equilibration of natural teeth and
implants
Careful control of the overall occlusion is necessary,
as always. It is recommended to register and, if
necessary, adjust all occlusal contacts, also when the
patient bites hard together in habitual occlusion and
when performing powerful latero- and mediotrusive
movements. This helps to avoid supracontacts on
the implant-supported units, since such units are
more stiffly anchored than natural teeth. If there are
signs of parafunctional activities, it is advisable to
make an extra light contact or even place the oc-
clusal units supported by the implants in an inferior
position in relation to the overall occlusal plane,
even in the centric habitual position. This will sub-
stantially reduce or even eliminate the occlusal
forces over the implant-supported unit.
It is possible to arrange for light or no occlusal
contacts during latero- and mediotrusive move-
ments posterior to the cuspids by securing a low(er)
cuspal incline of the premolars and molars and to
still have a normal occlusal contact in centric habit-
ual occlusion.
A natural tooth is easily intruded (about 50 pm) to
the bottom of its socket by small forces (<20 N) (53).
Endosseous, osseointegrated, screw-shaped im-
plants, on the other hand, will intrude to a much
lesser degree (about 2 pm) for a 20-N force (58).This
means that if such separate, implant-supported
crowns are placed to alternate with natural teeth and
are adjusted so that their occlusal and incisal surfaces
are level with the corresponding surfaces of the natu-
ral teeth when these are located in their extruded rest
positions, the implants will take up the majority of the
force when the subject is lightly tapping the teeth to-
gether and, when the subject is biting hard in habitual
occlusion, the implants will absorb almost all force. If,
on the other hand, the occlusal (incisal) surfaces of
the separate implant-supported crowns are placed or
adjusted to be level with the corresponding surfaces
of the natural teeth when these are intruded into the
bottom of their sockets, there will be a fairly equal dis-
tribution of force on teeth and implants during biting
hard together. However, with this arrangement of oc-
clusal contacts, the natural teeth take up almost all
force during light tapping.
Thus, it is possible to determine the relative distri-
bution of force between the natural teeth and the
osseointegrated implants in a partially edentulous
jaw by simply performing the occlusal adjustments
either during light tapping or during hard biting. It has
repeatedly been shown that a very slight inferior posi-
34
tioning of a single occlusal unit reduces or even elim-
inates the local forces at that unit both during biting
and chewing (46). In principle, the same technique
can be used to distribute the occlusal forces, also dur-
ing lateral excursion movements. In other words, the
cuspal or incisal inclines of the implant-supported
crown units can be adjusted either during light tap-
ping or during hard biting in strategic lateral posi-
tions, depending on the desired distribution of load
between teeth and implants. The light tapping oc-
clusal equilibration distributes more force to the im-
plants during function, and the hard biting equili-
bration distributes the force more evenly over teeth
and implants. Neither of these techniques is likely to
result in tooth elongation. The relative distribution of
force also depends on variation in mobility between
the teeth and, during chewing, also on the type of
food.
The location of the implants and the teeth in re-
lation to the location of the jaw-closing muscles may
decisively influence the effect of the occlusal adjust-
ments due to the elasticity of the masticatory appar-
atus. Thus, if an implant-supported bridge is inserted
in, for instance, either the first or the fourth quadrant
and there are natural teeth in the rest of the dentition,
the discrepancy in apical deflection between the im-
plants and the contralateral teeth is compensated for
by the elasticity of the mandible, so that there appears
to be an even bilateral force distribution, maybe not
during light tapping, but during biting in habitual oc-
clusion. In fact, ifthe quadrant with natural teeth hap-
pens to be the patient’s preferred chewing side, the
forces are likely to be larger on that side, not only dur-
ing chewing (24,42) but also during biting in habitual
occlusion (42), even though the forces are larger on
the implant side during light tapping.
Thus, the technique chosen for occlusal equili-
bration in implant-restored partially edentulous den-
titions depends on whether the tooth or teeth or the
implant(s) or none of them have to be protected and
on whether functional supracontacts are introduced
that will disturb the masticatory apparatus, although
they do not interfere with the occlusion during light
tapping. To our knowledge, there are no experimental
data available on the latter issue.
The matter of protection has many aspects. There
are many situations in which a sufficient number of
adequately osseointegrated implants need no protec-
tion and would have been capable of functioning sat-
isfactorily also in the absence of the remaining teeth,
provided that the implants are reasonably well dis-
tributed. In such situations, it may be appropriate to
concentrate the occlusal forces on the implants to un-

load more or less hypermobile teeth and to use the
implants to raise a collapsed bite. However, some-
times proper protection is decisively important for a
good prognosis, such as when, often in the maxillary
jaw, a small bone volume is combined with large mar-
row spaces, a narrow apical base creating long levers
to the occlusal and incisal surfaces during both cen-
tric and eccentric biting and, in addition, the need for
extensive cantilever segments. If such a dentition also
shows signs of parafunctional activity, it is definitely
advisable to take advantage of the remaining stable
teeth and to distribute as much force as possible to
them and to place the cantilever segment in an oc-
clusally inferior position.
It is often argued that very light or no occlusal con-
tact on the most posterior cantilever unit of a cross-
arch bridge may negatively affect the stability of the
stomatognathic system, possibly resulting in prob-
lems with the temporomandibular junction. How-
ever, the absence of the second cantilever unit does
not reduce such a risk and is less satisfactory aesthet-
ically. In such situations, cantilever contacts to obtain
stability have to be balanced against the risk of undue
stress concentrations and aesthetic requirements. In
this context, a shortened dental arch often gives suf-
ficient stability to the masticatory system. There are
exceptions when extensive molar support is needed
for anatomic reasons or to cope with problems with
the temporomandibular junction. In such cases,
measures should be undertaken to solve these prob-
lems with removable prostheses or fixed, implant-
supported bridgework in the molar region.
When the dentition is edentulous in the anterior re-
gion only (for example from first premolar to first pre-
molar) and thus has intact molar occlusion, the prog-
nosis for an implant-supported anterior bridge is
even better than for a totally edentulous dentition
from an occlusion-biomechanical point of view, as
there usually is no need for cantilevers. The only
forces that impact such a bridge (in the absence of ex-
treme parafunctions) are the relatively small anterior
forces in habitual occlusion, during biting off food
pieces and during lateral and anterior mandibular ex-
cursions.
Connections between natural teeth
and implants
The assumption that osseointegrated implants are
virtually immobile under loading has led to the rec-
ommendation that stiff connections between im-
Biomechanical aspects of fixed bridgework
plants and teeth should be avoided because of the
risk of undue loading of the implants. Intra-mobile
elements, incorporated into the implants to elimin-
ate the mobility discrepancy, have therefore been
advocated when teeth and implants are to be con-
nected (30). However, no convincing, controlled ex-
perimental data demonstrating the inevitable need
for such elements have yet been presented.
Sekine et al. (58) tested the mobility of Brine-
mark@fixture-abutment units in the mandibular jaw
of humans. They demonstrated that it was possible
to laterally displace such free-standing units at an
angle when a laterally directed force of 20 N was ap-
plied to the abutment. This displacement is due to a
combination of the elasticity of the supporting bone
and the lateral angle of tilt of the threaded com-
ponents of the fixture-abutment unit. The lateral dis-
placement amplitude varied between 17 and 66 pm.
Theoretical calculations
The schematic illustrations in Fig. 8 show the load-
ing effect of a force applied on a natural tooth con-
nected to an osseointegrated endosseous implant via
a fixed bridge. Fig. 8a shows the situation before
loading. In Fig. 8b, a vertically (axially) directed force
of 10 N has been applied to the bridge at the tooth-
supported retainer crown. At the very moment of
load application, the bridge functions as a cantilever
construction, supported by the implant only. How-
ever, the moment of 240 N.mm (the force of 10 N
times the length of the beam of 24 mm) rapidly
angles the implant-abutment-crown unit (20 mm in
height) in the lateral direction with a certain ampli-
tude. If we assume that this lateral amplitude is
about 50 pm, the corresponding apical amplitude of
the bridge-beam is at least 50 ym at its tooth-sup-
ported end, since the beam is 24 mm long. This api-
cal deflection (yielding) is sufficient for a tooth with
normal apical mobility to reach the bottom of the
socket for very small forces, and when intruded
further, the apical yield of the root is close to zero,
even if large forces are applied (53). Thus, the ini-
tially cantilever-functioning bridge is very rapidly
converted to a bilaterally supported bridge by the
angular deflection of the implant-abutment-crown
unit. The initially attained and very short-lasting
moment of 240 N . mm creates stress concentrations
well below what is suggested to be the limit value for
1) the interface integrity of an implant, incorporated
into bone with normal density, 2) the yield strength
of a properly dimensioned connection between the
35
Lundgren & Laurel1
v2 4 m m I
Angling of
implant-beam
unit
b
Fig. 8. Outline of a stiff prosthetic connection between an
osseointegrated implant and a natural tooth. The height
of the implant-abutment-crown unit is supposed to be 20
mm and the distance between the tooth and the implant
24 mm. a. Starting position before loading. b. An axially
directed force of 10 N has been applied to the bridge at
the tooth-supported retainer crown. This is presumed to
angle the implant with an amplitude of 50 pm, which re-
beam (type I11 dental gold alloy) and the implant-
abutment-crown unit.
Another effect of the initial loading of the bridge
is the bending of the beam (Fig. 8c). According to
the formula for cantilever beam-bending, the apical
deflection of the tooth-supported end of the beam
is about 50 pm when a force of 10 N is applied at
that end, provided that the height of the beam is 4
mm and the width is 3 mm at the connector be-
tween the beam and the implant-supported retainer
crown. Thus, only 10 N of axial force is needed to
bend the beam so much that the root touches the
bottom of the socket, thereby converting a cantilever
construction into a bilaterally supported one.
If the effect of the angular deflection of the bridge
beam is also taken into consideration, only about
5-6 N is needed to convert the bridge from an im-
plant-supported cantilever construction to a bilat-
eral construction, supported by one tooth and one
implant. If, on the other hand, the tooth is hypermo-
bile with an apical yield of as much as 100 pm for
small axial forces, the root will still reach the bottom
of the socket and give rise to a counterforce after 10
N of initial loading.
These calculations show, for example, that a man-
dibular canine in one quadrant can be stiffly con-
nected with an osseointegrated implant located in
the region of the extracted contralateral canine via
a fixed bridge and dimensioned as discussed above
without the risk that undue axial forces will cause
undue stress to the bridge or the implant. This is
valid also when such a canine is hypermobile with
twice as large apical yield as normally observed.
Consequently, a tooth with hypomobility (for in-
stance, a firmly attached canine or molar with full
periodontal support) can be stiffly connected to an
10 N
sults in a potential apical deflection of the beam at the
supporting tooth of at least 50 pm. The tooth is supposed
to reach the bottom of the socket after 50 pm of apical
yielding. c. Another effect of the applied force is bending
of the beam, resulting in an apical deflection of the beam
at the supporting tooth of about 50 pm, if the height of
the beam is 4 mm and the width is 3 mm.
implant with a much shorter bridge beam than ex-
emplified above and still be expected to decisively
contribute to the uptake of force.
Fig. 9 shows the same type of bridgework as dis-
cussed above but with a distance between the sup-
porting tooth and implant unit of half that of the
previously described bridgework. Assuming that the
implant leans with the same amplitude as previously
discussed (about 50 ym) given a load of 20 N (which
creates a bending moment of 240 N.mm with a
beam length of 12 mm) at the tooth-supported end
of the bridge, the apical deflection of the beam end
is about 30 pm. This is not enough to convert an
initially cantilever-functioning bridge unit into a bi-
laterally supported one. The deflection of the beam
end due to bending of the beam after application of
the 20 N load is only about 12-13 ym. Adding the
angular deflection to that from the bending of the
%3
Angling I
a
Fig. 9. Outline of the same type of bridgework as in Fig.
8, but with a distance between the supporting tooth and
implant of half that in Fig. 8, that is, a beam length of 12
mm. If the same moment as in Fig. 8 is applied (20 N X 12
mm=240 N-mm), the apical deflection of the beam end
will be about 30 pm due to angling of the implant-abut-
ment unit and about 12 pm due to bending of the beam,
if dimensioned as in Fig. 8. This will probably not meet
the requirement of a reasonably equal distribution of
force on tooth and implant.

beam, gives a total of about 42-43 ym of deflection,
which is too little if the tooth yields 50 ym. However,
if the height of the beam is reduced from 4 to 3 mm
at the connector site, the deflection of the tooth-
supported beam end increases about 2.5 times due
to bending, from 12-13 pm to 30-32 pm. Together
with the angular deflection of 30 pm, we now slightly
exceed the apical deflection of a tooth with normal
mobility. The height reduction of the beam to permit
a larger deflection of the beam end does not result
in stress concentrations exceeding the yield strength
of the chosen material.
If the distance between the tooth and the implant
is further reduced in the same type of bridgework so
that they become located quite close to each other
with no intervening pontic, this approaches a situ-
ation with too little apical yielding of the natural
tooth due to angular deflection of the beam to be
useful for our purposes. Deflection due to bending
of the connector (bridging part) between the natural
tooth and the implant means that the dimensions of
the bridging part of the construction must be re-
duced to a level where there is an obvious risk of
fatigue fractures. However, in such a situation a hy-
pomobile tooth still may contribute to uptake of
force.
Generally, it may be assumed that, if an osseointe-
grated implant is stiffly connected to an immediately
adjacent tooth, the implant has to absorb more force
than the tooth to which it is connected. In the ex-
treme case (hypermobile tooth), the situation is the
same for the implant as if it had been supplied with
a cantilever unit. It may well be that the implant-
bone interface can also withstand the forces applied
on its natural tooth cantilever unit, especially if the
forces of the dentition happen to be small or if the
local forces over the cantilever unit intentionally are
reduced by infra-occluding that unit (46). Obvious
indications for this type of connections may be a de-
sire to reduce mobility or to prevent an expected mi-
gration of the tooth.
Clinical relevance
The clinical relevance of the discussed theoretical
calculations has been demonstrated in experiments
and follow-up studies in humans (44, 45, 47, 48).
These authors followed, for about 4 years, a small
number of subjects with stiffly connected tooth-im-
plant constructions with the teeth and implants
located at a critical minimum distance from each
other in relation to the angling and bending of the
framework beams. Using routine parameters for
Biomechanical aspects of fixed bridgework
clinical examination, the tooth-supporting and im-
plant-supporting tissues were evaluated without
finding adverse reactions. The force distribution on
some of the constructions was also measured before
they were connected. These data verify the calcu-
lations presented here.
Furthermore, Rangert et al. (57) presented data
from mechanical in uitro tests of the Brdnemark@
implant system showing that the screw joints, which
attach the prosthetic gold cylinder and the perimu-
cosal abutment to the fixture, form a flexible system.
The flexibility is of a magnitude that seems to match
the vertical mobility of a natural tooth, stiffly con-
nected to such a system by means of a fixed bridge
with at least one intervening pontic between the im-
plant and the tooth. Calculations of vertical load dis-
tribution, based on measured flexibility data ob-
tained through tests of the screw joints, show that
the axial forces are shared almost equally between
tooth and implant, without taking the flexibility of
the surrounding bone or the framework of the
bridgework into account. This implies that the
Brinemark@ implant system, which consists of a
screw in a screw in a screw, may have overall flexi-
bility (obtained not only from the screw joints, but
also from the deflection of the bridge-beam and the
elasticity of the bone) of a magnitude that permits
stiff connection to a natural tooth with normal mo-
bility located quite close to the implant, with the
forces still reasonably shared between the two units.
However, this hypothesis has to be scientifically
proven in clinical trials to evaluate indications and
treatment results. The results from a clinical study
by Gunne et al. (22) corroborate the experimental
data referred to. They presented an intraindividual
study in which free-standing or tooth-connected,
implant-supported bridges had been followed in 23
partially edentulous patients for 3 years. Each sub-
ject had been supplied with one free-standing bridge
supported by 2 Brdnemark implants in either the
third or the fourth quadrant. On the contralateral
side, the bridge was supported by one implant and
one tooth to which the retainer crown was ce-
mented. The distance between the implant and the
tooth corresponded to at least the width of 1, but
usually 2, premolar pontics. The implant and the
tooth were rigidly screwed together using a McCol-
lum T-attachment. This permitted unscrewing of the
implant-supported part of the bridge to check the
osseointegration of all implants. The survival rate in
terms of the number of persisting osseointegrated
implants after 3 years in service was 89% for free-
standing bridges and 91% for implant-tooth-con-
37
Lundgren & Laurel1
nected bridges. Another clinical study presented by
Naert et al. (49) confirms these data. Thus, fixed
bridgework connecting natural teeth with osseointe-
grated implants did not show more frequent im-
plant-interface, periodontal or mechanical problems
than free-standing bridges.
Lateral force, stress and deflection
It has been shown that the stress pattern of fixed
bridgework can be very complicated, particularly in
constructions including cantilever beams (19, 59).
However, most of the prosthetic constructions dis-
cussed here exhibit an occlusal morphology char-
acterized by wide freedom in centric and low cuspal
incline (6, 14, 31, 37, 38). This implies that, during
jaw closing in habitual occlusion and also during
chewing, virtually all occlusal force is directed axially
(perpendicular to the occlusal plane) in the region
posterior to the canines. The comparatively small,
laterally directed force components are mainly
found in the front or canine region during lateral ex-
cursions or during biting. For fixed bridgework, it is
therefore usually justified to confine stress calcu-
lation to vertical bending stress and deformation as-
sessment to vertical deflection, as lateral bending
and shear stress are rather small in the cantilever
connections. However, this does not mean that lat-
eral force, stress and deflection should be ignored in
conjunction with such prosthetic constructions. As
discussed previously, the magnitude, direction and
intensity of lateral forces are of utmost importance
for the prognosis of all types of prosthetic recon-
structions during extreme parafunction. In relation
to inserted implants, the long axis of which deviates
extremely from a plane perpendicular to the occlusal
plane, axially directed occlusal forces may give rise
to lateral force components of considerable magni-
tude. Whether such force components are more del-
eterious to the implant-bone interface than are
forces parallel to the long axis of the implants re-
mains to be determined.
Another situation in which lateral forces deserve
attention is when a natural tooth is stiffly connected
to an implant, since it may be more difficult to dis-
tribute lateral than axial forces reasonably equal be-
tween the implant and a tooth with normal trans-
verse mobility, particularly if the tooth is located
close to the implant. The same mechanical laws are
valid for lateral and vertical force and deflection. It is
therefore possible to calculate and to experimentally
determine the conditions for lateral force distri-
bution between an implant and a tooth connected
to each other.
Lateral forces on a natural tooth stiffly connected
to an implant with a force direction along the tooth-
arch should not harm the implant unit, as there is
no or negligible leverage to enlarge the effect of the
forces. Buccolingually directed forces on such a
tooth, on the other hand, cause both shear stress
and torsial tension at the implant-bone interface
due to leverage caused by the beam between the
tooth and the implant. The magnitude of this stress
and tension depends on the (buccolingual) mobility
of the tooth, the dimension (length, height and
width) and material composition of the bridge
beam. When screw joints are used to attach the
bridge to the connected implant unit, the torsial re-
sistance of these joints may be critical. It has there-
fore been suggested that the connected tooth should
have only a minor buccolingual mobility to avoid
loosening of the screw (57).
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