Key Implant Positions: Treatment Planning Using the Canine and First Molar Rules

Carl E. Misch, DDS, MDS, PhD(hc), and Jennifer T. Silc, BS, DDS, MS
 
Historically, treatment planning for implant dentistry was mainly driven by the existing bone
volume in the edentulous sites. As a result, distal cantilevers were extended from anterior
implants or shorter implants were placed in the posterior regions of the mouth. A second
historical phase of treatment planning has since developed based upon soft-tissue aesthetics. In
this scheme, in order to improve the interproximal papillae, implant positions in aesthetic regions
are limited and replaced by ovate pontics.
The primary causes of complications in implant dentistry are related to biomechanics. 1

For example, early loading failures outnumber surgical healing failures, especially in soft bone,
when forces are greater than usual and/or implant sizes are shorter than 10 mm. When higher
biomechanical stresses are applied to the implant “system,” one or more of the components
may have complications. The “system” includes the occlusal porcelain, the prosthesis, the
abutment screw, the implant components, the marginal bone (especially at the crestal region), the
bone-implant-interface, and the implant body. Complications include porcelain, component or
implant body fracture, unretained restorations, crestal bone loss, implant mobility and/or failure. 2

Misch developed a treatment plan sequence to decrease the risk of biomechanical overload
consisting of (1) prosthesis design, (2) key implant positions for the prosthesis, (3) patient force
factors, (4) bone density in the edentulous sites, (5) implant number beyond the key positions, (6)
implant size, (7) available bone in the edentulous sites, and (8) implant design (Table 1). This
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article will consider the canine and first molar sites as key implant positions for a prosthesis.

GUIDELINES FOR KEY IMPLANT POSITIONS

Table 1. Biomechanical Treatment Table 2. Key Implant Positions

Plan Sequence
No cantilevers in partially edentulous
1. Prosthesis patients or completely edentulous
2. Key implant positions maxillae
3. Patient force factors
4. Bone density in the edentulous No 3 adjacent pontics when multiple
sites adjacent teeth are missing
5. Implant number beyond the key The canine and first molar positions are
positions important abutment locations
6. Ideal implant size
7. Available bone in edentulous
sites
8. Implant design

With regard to biomechanical force reduction, some abutment positions are more critical than
others in a fixed prosthesis. There are 3 general guidelines to determine key implant abutment
positions: (Table 2)
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-Cantilevers on the prosthesis should be preferably eliminated. Hence, the terminal abutments in
the prosthesis are key abutment positions, especially in partially edentulous patients.
-Three adjacent pontics should not be designed in the prosthesis, especially in the posterior
regions of the mouth.
-The canine and first molar sites are key abutment positions, especially when additional adjacent
teeth are missing.

BIOMECHANICS MUST BE CONSIDERED

In the biomechanics of an arch, there are some specific locations that are more important than
others. In the premaxilla of the dental arch, these positions are represented by the canines. In
fact, the natural dentition in both arches respects this biomechanical position. The natural canine
has the greatest root surface area of any anterior teeth. A fixed restoration replacing a canine is at
greater risk than most any other restoration in the mouth. The maxillary and/or mandibular
adjacent incisor is one of the weakest teeth in the mouth and the first premolar is often one of the
weakest posterior teeth.
A traditional fixed prosthetic axiom indicates that it is contraindicated to replace a canine
and 2 or more adjacent teeth. Therefore, if a patient desires a fixed prosthesis, implants are
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required whenever the following adjacent teeth are missing in either arch: (1) the first premolar,
canine and lateral incisor; (2) the second premolar, first premolar, and canine; and (3) the canine,
lateral, and central incisors (Figure 1).

Figure 1. When the maxillary Figure 2. When the maxillary

right canine, lateral incisor,
and central incisor are
missing; the key implant
positions are the canine and
central incisor.
first premolar, canine, lateral
incisor, and central incisor are
missing; the key implant
positions are the first
premolar, canine and central
incisor.

Figure 3. A patient missing Figure 4. Blocks of bone from

the right maxillary first the mandibular symphysis are
premolar to the right central fixated to the edentulous site
incisor. There is inadequate to augment the key implant
bone in the key implant sites. regions.

Figure 5. After 5 months of Figure 6. A 4-unit fixed

healing for the bone graft, implant prosthesis is cemented
endosteal implants are inserted to the implants after 4 months
into the key implant positions: of healing.
the first premolar, the canine,
and the central.

Figure 7. When the first Figure 8. Implants are

premolar, second premolar,
first molar and second molar
are missing: the key implant
position are the first premolar,
first molar and second molar.
inserted into the posterior left
mandible, in a patients
missing 4 adjacent teeth. The
key implant positions are the
first premolar, first molar and
second molar.

Figure 9. A splinted 4-unit Figure 10. A panoramic

fixed prosthesis is cemented radiograph from Figures 8 and
onto the implant abutments 9.
after 5 months.
Whenever the canine and 2 adjacent teeth are missing, implants are required to restore the patient
because (1) the length of the span is 3 adjacent teeth, (2) the lateral direction of force during
mandibular excursions increases the stress against the implant support system, and (3) the
magnitude of the bite force is increased in the canine region compared to the anterior region.
Therefore, under these conditions, at least 2 key implant positions are required to replace these 3
adjacent teeth, including the canine (especially when one of the terminal abutments is the canine
position).
In most prostheses designs, 3 adjacent pontics are contraindicated on implants, just as
they are contraindicated on natural abutments. The adjacent abutments are subjected to
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considerable additional force when they must support 3 missing teeth, especially in the posterior
regions of the mouth. In addition, all pontic spans between abutments flex under load. The
greater the span between abutments, the greater is the flexibility of the metal in the prosthesis.
The greater the load, the greater the flexure will be. This metal flexure places shear and tensile
loads on the abutments. The greater the flexure, the greater will be the risk of porcelain fracture,
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uncemented prostheses, and abutment screw loosening.

A one pontic span exhibits little flexure under a load.6 A 2 pontic span flexes 8 times
more than a one pontic span, if all other variables are equal. A 3 pontic span flexes 27 times
more than a one pontic span. Hence, not only is the magnitude of the force increased to the
adjacent abutments when the prosthesis has 3 pontics (since they are supporting 2 abutments and
3 pontics), but the flexure of the metal increases to a point that the incidence of complications
make the treatment plan contraindicated, especially when forces are greater (as in the canine
region).
It should be noted the flexure of materials in a long span is more of a problem for
implants than natural teeth. Since natural roots have some mobility both apically and laterally,
the tooth acts as a stress absorber and the amount of material flexure may be reduced. Since an
implant is more rigid than a tooth (and also has a greater modulus of elasticity than a natural
tooth) the complications of increased load and material flexure are greater for an implant
prosthesis. Since it is contraindicated for 3 posterior pontics in a natural tooth fixed prosthesis, it
is even more important to limit pontics in an implant restoration to 2 missing teeth.

DIRECTION OF LOAD AND MAGNITUDE OF FORCE

Angled loads to implant bodies increase the force to the implant system. A 15≤ angled force
increases the amount of force by 25.9%, while a 30 ≤ angled force increases the force 50% more
compared to an axial force in the long axis of the implant. As a consequence, the risk of
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abutment screws loosening in the implant system is increased, an increased risk of crestal bone
exists, the implant body may fracture and/or the implant may become mobile.
This is especially noteworthy in the maxilla, since the force starts inside the arch and is
pushed outside of the arch. An arch is stronger when the force is applied from the outside to
inside (as in a mandibular situation). Since angled forces magnify the amount of the force to the
implant system and in the maxilla the forces are directed to the outside of the arch during
mandibular excursions. Most maxillary anterior prostheses should limit the number of pontics in
the restoration.
The maximum bite force which a patient applies to the central and lateral incisors is in
the range of 25 to 35 lbs. This force is increased to 90 to 100 lbs in the canine region. This is
because of Class III lever dynamics and the canine is closer to the temporomandibular joint than
the anterior teeth. In addition, more muscle mass in the temporalis and masseter muscles contract
when the canine is engaged in occlusion, compared to the central and lateral incisors.

KEY IMPLANT POSITIONS

When the second premolar, first premolar and canine are missing, the key implants positions are
the canine and the second premolar. When canine, lateral incisor, and central incisor are missing;
the key implant positions are the canine and central incisor. When the 3 adjacent teeth are the
first premolar, canine, and lateral incisor; the key dominant implant positions are the first
premolar and the canine. When the lateral incisor is wider than 6 mm, an implant is also placed
in this area to avoid a cantilever. However, when the lateral incisor is less then 6 mm the first
premolar and canine may replace the 3 teeth. These implant positions result in an anterior
cantilever to replace the lateral incisor. However, since the smaller than average lateral incisor is
in the anterior region with the least bite fore, the cantilever is of limited negative impact. In
addition, the occlusion is modified so no occlusal contact is present on the lateral incisor pontic
in centric occlusion or excursions of the mandible.
When there are multiple missing teeth, and the canine edentulous site is a pier abutment
position, the canine position is a key implant position to help disclude the posterior teeth in
mandibular excursions. Hence, when 4 or more adjacent teeth are missing, including a canine
and at least one adjacent posterior premolar tooth, the key implant positions are the terminal
abutments, the canine position, and additional pier abutments which limit the pontics spans to no
more than 2 teeth (Figures 2 to 6).
The first molar is also a key implant position. The bite force doubles in the molar position
compared to the premolar position in both maxilla and mandible. The natural dentition increases
the diameter of the molar as a consequence of the increased force and the first molar has twice
the surface area of a premolar tooth. In addition, the edentulous span of a missing first molar is
10 to 12 mm, compared to a 7-mm span for a premolar.
The maxillary sinus often invades the first molar site and a sinus graft is often necessary
to place an implant of adequate length. As a result, a cantilever is often prescribed to replace the
first molar. The worst case scenario for a biomechanical treatment plan is to place a cantilever in
the molar position, which further magnifies the highest force in the mouth. This is especially
important to consider in the maxilla, where the bone density is less. Remember, the natural
dentition uses 3 roots splinted together in the first molar region.
When a first molar is missing, the key implant positions include the terminal abutments
for the prosthesis and the first molar position. For example, in a patient missing the first
premolar, second premolar, first molar, and second molars, there are 3 key implant positions
needed to restore the full function of the missing teeth: the first premolar and second molar
terminal abutments, and the first molar pier abutment (Figures 7 to 10).

CONCLUSION
The most common complications in implant dentistry are related to biomechanical overload and
include implant failure, crestal bone loss, abutment screw loosening, uncemented or unretained
prosthesis and implant failure. As a consequence, a logical scenario is to reduce force factors in
the treatment plan.
There are key implant positions within a prosthesis that are more critical to reduce force.
Of these positions, the positions of the canine and first molar are 2 of the more important
locations. Both the magnitude of the force is increased and the direction of force is modified at
these arch locations. Hence, whenever these teeth are included in the implant restorations, an
implant should be positioned in these sites.

References

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