K{vanç Akça Implant–tooth-supported fixed partial

Serdar Uysal
Murat Cavit Çehreli
prostheses: correlations between in vivo
occlusal bite forces and marginal bone
reactions

Authors’ affiliations: Key words: fixed prostheses, implant, natural tooth, occlusal force, periapical radiograph
K{vanç Akça, Murat Cavit Çehreli, Department of
Prosthodontics, Faculty of Dentistry, Hacettepe
University, Ankara, Turkey Abstract
Serdar Uysal, Department of Oral Diagnosis and Purpose: To evaluate maximal occlusal bite forces (MOF) and marginal bone level (MBL)
Radiology, Faculty of Dentistry, Hacettepe
University, Ankara, Turkey changes in patients with implant–tooth-supported fixed partial prostheses (FPP).
Material and methods: Twenty nine partially edentulous patients consecutively who
received 34 three-occlusal unit FPP with terminal implant and tooth support were subjected
Correspondence to:
K{vanç Akça DDS, PHD to quantification of MOFs using a sub-miniature load cell connected to a data acquisition
Çetin Emeç Blv, 6. cadde system and measurement of the MBL changes around implants in digitalized periapical
54/3 06450 Öveçler
Ankara radiographs obtained at prostheses delivery and 24-month follow-up.
Turkey Results: MOFs for implant support (mean: 353.61 N) significantly differed from tooth
Tel.: þ 90 312 4726898
Fax: þ 90 312 3113741
support (mean: 275.48 N) (Po0.05), while gender did not influence MOFs (P40.05). MBL
e-mail: akcak@hacettepe.edu.tr; changes at mesial and distal sites of the implants at 24 months of functional loading were
kivanc.akca@veezy.com 0.28 and 0.097 mm respectively.
Conclusion: Although MOFs under functional loading might indicate an increase in load
participation for supporting implant, the rigid connection between implant and natural
tooth via three-occlusal unit FPP does not jeopardize the time-dependent MBL stability of
the implant under functional loads.

Date:
Accepted 15 December 2004
To cite this article:
Akça K, Uysal S, Çehreli MC. Implant–tooth-supported
fixed partial prostheses: correlations between in vivo
occlusal bite forces and marginal bone reactions.
Clin. Oral Impl. Res. 17, 2006; 331–336
doi: 10.1111/j.1600-0501.2005.01169.x
Copyright r Blackwell Munksgaard 2006
In the last decade, dental implants have
been successfully used in the treatment of
partially edentulous patients (Buser et al.
1997; Lekholm et al. 1999; Naert et al.
2002). The philosophy of treatment con-
cepts, however, particularly regarding the
decision-making criteria for rehabilitation
of partially edentulous arches via tooth–
implant connection vs. free-standing im-
plant restorations is still a topic of argu-
ment, not only because of the differences in
the biomechanics of natural teeth vs. im-
plants but also because of different conclu-
sions derived from clinical studies (Hosny
et al. 2000; Naert et al. 2001). Indeed, the
differences in the nature of anchorage of
implant to bone could be considered as a
biomechanical challenge in tooth–implant-
supported fixed partial prostheses (FPP).
Owing to inharmonious mobility (Sullivan
1986; Naert 1993), overloading of implant
in such prostheses was alluded to as a
possible factor for implant failure by nu-
merical analyses (Van Oosterwyck et al.
1998). However, conclusive statements
have been driven for rigid design including
terminal implant and tooth to support for
short-span FPP (Gunne et al. 1992; Brägger
et al. 2001; Lindh et al. 2001a).
Related to a significant increase in sen-
sory perception thresholds of dental im-
plants in comparison with natural teeth
(Hämmerle et al. 1995), higher occlusal
forces might be expected on an implant
supporting an FPP. However, in vivo oc-
clusal force measurements revealed similar

331
Akça et al . Biomechanical outcome of implant–tooth-supported prostheses
data for natural dentition in comparison
with implant-supported FPP (Mericske-
Stern et al. 1995). Peri-implant tissues,
therefore, seem to acquire bone-originated
exteroception following osseointegration
(Van Loven et al. 2000). Although osseo-
perception is not comprehensively known,
research suggests that peri-implant nerve
fibers might have a crucial role in the
sensory perceptions of external mechanical
stimuli on endosseous titanium implants
that reach the level of consciousness (Wang
et al. 1998; Wada et al 2001; Çehreli et al.
2002).
The purpose of this prospective clinical
study was to appraise the assumption
(Naert et al. 2001) that rigid connection
of implants to teeth to support a -three-
occlusal unit FPP causes more marginal
bone loss around implants because of in-
creased bending load under functional
loading.
Material and methods
Patient selection and FPP
This clinical study comprised 29 partially
edentulous, systemically healthy, consecu-
tive patients with a mean age of 48.3 years
(range 31–73 years), who received three-
occlusal unit terminal implant and tooth-
supported FPP to restore maxillary and
mandibular Kennedy Classes I and II par-
tially edentulous arches, resulting in 34
porcelain fused to metal FPP. In all of the
FPP, the anterior terminal premolar abut-
ment tooth was rigidly connected to a
terminal implant (Ø 4.1 mm
10 mm
s Fig. 2. Interocclusal bite record with load-cell appro-
ITI SLA solid screw dental implant, In-
stitut Straumann, Waldenburg, Switzer-
land) that was placed one occlusal unit
distally leaving a pontic space (Schroeder
et al. 1996). One of the tooth abutments in
the maxilla and three in the mandible had
previously received root canal treatment.
All FPP were rigid in design and fabricated
according to defined principles (Belser
et al. 2000). A mean distance of 11.58
 1.36 mm between the mid-distal mar-
ginal finish -line of the tooth and the center
of the implant was measured on the models
using a digital caliper (FowlerSylvac, Syl-
vac SA, Crissier, Switzerland). Solid abut-
ments (Institut Straumann) were used for
all implants for cement retention. FPP
were permanently cemented (Akça et al.
332 | Clin. Oral Impl. Res. 17, 2006 / 331–336
2002) (Fig. 1a and b), and FPP delivery was
assigned as baseline for the radiographic
evaluation. All prostheses were in contact
with opposing natural dentition or FPP,
and occlusal concepts derived for conven-
tional teeth-supported FPP were carried out
(Shillinburg et al. 1997).
Occlusal force measurement
Maximal occlusal bite forces (MOFs) were
recorded using a strain-gauge-based sub-
miniature load cell (3.5 mm height and
6.35 mm active measuring diameter;
ELFS-B4, ELt Entran Sensors & Electro-
nics, Fairfield, NJ, USA) having a compres-
sive measurement range of 0–500 N. The
load cell was connected to a data acquisi-
tion system (ESAM Traveller 1, Vishay
Micromeasurements Group, Raleigh, NC,
USA) and corresponding software (ESAM;
ESA Messtechnik GmbH, Olching, Ger-
many). Measurements were carried while
the patients were seated in an alert feeding Fig. 1. ITI dental implant (Ø 4.1 mm
10 mm) in
position to simulate the natural chewing place of second molar tooth and solid abutment for
functional position (Okeson 1989). To pro- connection to second premolar tooth (a) and com-
pleted three-occlusal unit rigid fixed partial pros-
vide intermaxillary stability during the
theses (FPP) with tooth and terminal implant
tests, an interocclusal record at centric support (b).
occlusion was made with a polyether oc-
clusal registration material (Ramitec, Espe
Dental AG, Seefeld, Germany) (Carr &
Laney 1987). Seperate interocclusal bite
force measurement records were made for
each of the implant and the tooth support
of an FPP with the load cell placed over the
intended occlusal surface. Data were ob-
tained in five consecutive trials with the
interocclusal bite record in separate test
sessions for tooth and implant support
(Meriscke-Stern et al. 1993, 1995). Pa-
tients were asked to apply maximum mas- priately placed over the occlusal surface of tooth
ticatory forces to record MOFs (Fig. 2). support to measure maximal occlusal bite forces
(MOF) for tooth.
Radiographic evaluation
Marginal bone levels (MBLs) at the mesial (1.25 mm) (Brägger et al. 1996). Assess-
and distal side of implant support were ment of MBL change was based on the
measured linearly on the periapical radio- linear deviation of 24-month follow-up
graphs made by a paralleling device (Dents- measurements from the baseline counter-
ply Rinn, Rinn Cooperation, Elgin, IL, parts (Fig. 3).
USA), which were digitalized and analyzed
in a software for image analysis (ImageJ Statistical analyses
1.32j, NIH, Maryland, MD, USA) at After determination of normal distribution

400 magnification in a computer. The of data by the Kolmogorov–Simirnov test,
distance between the implant shoulder and MOFs within implant and tooth supports
first bone-to-implant contact (DIB) was and between female and male subjets were
measured by setting a scale in the software compared with general linear model test.
by referring to a known vertical distance of The mean MBL change at mesial and distal
two consecutive threads of the implant sites after 24 months was compared with
 Akça et al . Biomechanical outcome of implant–tooth-supported prostheses

Student’s t-test at the 95% confidence 24 months at the mesial site (mean:
level (Po0.05). 0.28  0.519 mm) was significantly
higher than at the distal site (mean:
0.097  0.518 mm) (Table 3).
Results

Following functional loading for a mini- Discussion

mum of 24 months, a 100% cumulative
success rate was established according to Although bone apposition on implant sur-
the success criteria proposed Buser et al. faces and maintenance of implant–bone
(1990, 1997). Table 1 presents the distribu- contact at the ultrastructural level are pre-
tion of implant- and tooth-supported FPP. requisites for successful long-term survival
MOFs on implant supports were higher of the implant, variability of movement
than tooth supports but not for three of range between a rigidly splinted dental
34 FPP. Statistical analyses revealed sig- implant and tooth leads to a biomechanical
nificant differences for MOFs between im- concern. The assumptions based on over-
plant and tooth support (F ¼ 59.02; P ¼ 0), loading of the dental implant had led to the
but not for gender (F ¼ 0.04; P ¼ 0.947). use of non-rigid connection systems to
The mean MOFs recorded for implant and compensate the differences in mobility
tooth supports were 353.61  14.71 and between implant and tooth (Kirsh & Ack-
275.48  13 N, respectively (Table 2). Ra- ermann 1986; Sullivan 1986; Ylantz &
diographic measurements revealed stable Nyman 1986). However, evidence-based
Fig. 3. Baseline (a) and 24 months after (b) periapical
MBLs around implant supports. The total data have revealed that a rigid FPP may
views of the fixed partial prostheses (FPP) presented
in Fig. 1. MBL improvement from baseline to be constructed to prevent intrusion of tooth
support when connected to a dental im-
plant (Åstrand et al. 1991; Quirynen et al.
Table 1. Distribution of implant- and tooth-supported FPP 1992; Olsson et al. 1995; Gunne et al.
n Mandible Maxilla 1999; Kindberg et al. 2001).
First PM to Second PM to First PM to Second PM to Numerous techniques and instruments
second M second M second M second M have been introduced to measure occlusal
Male 13 6 9 1 1 forces. Most of these instruments produce
Female 16 4 11 1 1 favorable outcomes and are based on an
Total 29 10 20 2 2 engineering calculation and conversion of
PM, premolar; M, molar; FPP, partial prostheses. deformation recorded by strain gauges
using either commercially available trans-
ducers or custom-made devices (Anderson
Table 2. MOFs (N) recorded in implant- and tooth-supported FPP 1953; Scott & Ash 1966; Lundquist et al.
n Mean Standard deviation Minimum Maximum Standard error 1986; Carr & Laney 1987). However, two
Female major factors that might lead to a variabil-
Tooth 17 273.58 68.78 151.95 386.82 18.39 ity in occlusal force measurements are the
Implant 17 353.75 74.28 191.61 467.13 20.8 differences in devices and methods (Richter
Male 1995), and the physical and the psycholo-
Tooth 17 277.37 82.32 105.28 416.86 18.39
gical state of the subject (Bates et al. 1975).
Implant 17 353.47 95.90 195.6 507.49 20.8
The validity of occlusal forces measured at
FPP, partial prostheses; MOF, maximal occlusal bite forces. incresead vertical occlusal dimension with
devices placed interocclusally was ques-
tioned, and a specially designed non-rigid
Table 3. MBL change at 24 months
appliance made for individual use was re-
Paired t df Significantly
differences two-tailed commended (Richter 1995). In the current
study, a sub-miniature load cell was used
Mean Standard Standard 95% confidence
deviation error interval of the because of the advantages of simplicity and
mean difference standardization in comparison with equili-
Lower Upper bration and fabrication requirement of spe-
cial measurement devices, as suggested by
Mesial–distal 0.183 0.520 0.089 0.002 0.364 2.06 33 0.048n
Richter (1995).
n
Represents statistically significant difference between mesial and distal (Student’s t-test) Po0.05. Meriscke-Stern et al. (1995) have re-
MBL, marginal bone level.
ported similar MOFs for implant-, teeth-,

333 | Clin. Oral Impl. Res. 17, 2006 / 331–336

Akça et al . Biomechanical outcome of implant–tooth-supported prostheses

and implant and tooth-supported FPP using
miniature force transducers. Measureme-
nts of the current study revealed compar-
able MOFs with Meriscke-Stern et al.
(1995). In the current study, however, the
measuring instrument was placed directly
on the occlusal surfaces of FPP supports to
record MOFs rather than defined test
locations (e.g., first premolar, first molar),
and statistically significant differences in
MOFs were recorded for tooth and implant
supports. The difference in MOFs between
the implant and tooth terminal supports
could be explained by (i) posterior location
of implants close to the temporomandibu-
lar joint rather than placement in the ante-
rior, leading to a decrease in the lever arm
and an eventual increase in occlusal force
and (ii) reduction of osseoperception of
implants compared with natural teeth (Ja-
cobs et al. 2001). Nevertheless, an approxi-
mately 20% increase in MOF over the
implant support could be expected to be-
cause of physiologic capacity. Therefore,
sensory perception of external mechanical
stimuli of the natural tooth through rigid
connection with the implant, and activa-
tion of protective sensory mechanism from
the mechanoreceptors in the periodontal
ligament around opposing natural teeth,
might be possible causes for comparable
MOFs for implant and tooth supports.
Further, commentary depending on scien-
tific data (Wada et al. 2001; Onur et al.
2003; Weiner et al. 2004) could be made as
the evolutionary development of peri-im-
plant proprioception via coupling of exist-
ing nerve fibers in bone to the implant
surface. Overall, it might be assumed that
the above-mentioned scenario leads to in-
creased load partitioning, but not to over-
loading of the implant support, when
connected to a natural tooth.
Longitudinal radiographic follow-ups of
MBL stability have been frequently con-
ferred as implant success criteria in
implant-supported prostheses. Although
Hosny et al. (2000) reported that the an-
nual change of the MBL around connected loss was reported for freestanding implant-
and freestanding implants did not differ supported fixed prostheses (Gunne et al.
significantly, the same researchers reported 1992; Lindh et al. 2001b). Within the
a three times greater bone loss in the case of limitations of the present study, the con-
a rigid tooth–implant connection as com- sequences of increased functional loading
pared with freestanding partial prostheses of implants, rather than overloading, when
or non-rigid tooth–implant connections rigidly connected to teeth might explain
(Naert et al. 2001). Depending on out- the existing biomechanical differences be-
comes from a novel biomechanical in vitro tween theoretical assumptions and clinical
testing approach (Wang et al. 1999) and evidences.
finite-element analyses (Van Oosterwyck
et al. 1998), Naert et al. (2001) stated that
marginal bone loss was related to increased Conclusion
stress and strain patterns. Thus, biomecha-
nical suggestions depending on empirical The following conclusions were derived
consequences of in vitro stress analysis, from outcomes of the current 2-year fol-
where certain assumptions are required to low-up clinical evaluation of terminal im-
simulate actual circumstances, revealed plants and teeth supporting a rigid three-
overloading of implants when rigidly con- occlusal unit FPP:
nected to teeth (Nishimura et al. 1996;
1. Higher MOFs are produced over pos-
Uysal et al. 1996). However, in the current
terior implants than the anterior tooth
study, an increase in bone height was
support.
observed at the mesial sites of the implants,
2. Connecting implants rigidly to teeth
which may reveal minimal bone gain or an
has promising MBL stability for im-
extremely stable situation. More realistic
plants.
modeling of the periodontal membrane
with non-linear visco-elastic spring ele-
ments in a tooth connected to an implant
scenario (Menicucci et al. 2002) could
explain the disagreement of the present
study regarding the MBL stability with
the above-mentioned assertions. Meni-
cucci et al. (2003) have reported that im-
plant support experienced lower stress
levels under transitional loading conditions
compared with static loading. Gunne et al.
(1997) carried out in vivo measurements of
vertical forces and bending moments for a
three-unit FPP supported by freestanding
implants and implants connected to teeth.
They did not find major differences in
functional load magnitudes related to
the support type. Similar outcomes,
 0.09  0.52 mm MBL change around
implants, have been reported after 24
months of function when connected to
teeth to support FPP (Lindh et al. 2001b).
Further, more pronounced marginal bone

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