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Stress & force factors in implants

CONTENTS:
Introduction
Stress factors
Early crestal bone loss
Various hypotheses related to early crestal bone loss
Force factors
Para function
Masticatory dynamics
Position of the abutment in the arch
Direction of load forces
Nature of the opposing arch
Effect on treatment planning
Summary
References
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Stress & force factors in implants
Introduction:
An understanding of the etiology of early crestal bone loss unretained restorations
and fracture of components enables the practitioner to de!elop a treatment plan
capable to reduce force factors"
#hese factors are e!aluated in magnitude duration direction type and magnification
effects"
Various methods to reduce these factors are employed"
Implant complications from stress$
%" Implant failure
&" Early crestal bone loss
'" (cclusal o!erload bone loss
)" Scre* loosening +prosthesis or abutment,
-" Implant fracture +body or component,
." Prosthesis fracture +occlusal material or frame*or/,
Early crestal bone loss:
It !aries in amount and dramatically decreases after the first year" #his phenomenon is
described as sauceri0ation"
#he initial transosteal bone loss around an implant forms a !1 or a u1shaped
pattern*hich has been described as ditching or sauceri0ation around the implant"
The current hypotheses for the early crestal bone loss:
%" Periosteal Reflection 2ypothesis"
&" Implant (steotomy 2ypothesis"
'" Autoimmune Response of 2ost 2ypothesis"
)" 3iological 4idth 2ypothesis"
-" Stress Factors 2ypothesis"
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Stress & force factors in implants
Periosteal Reflection Hypothesis:
It causes a transitional change in the blood supply to the crestal cortical bone" 5utting
cones de!elop from monocytes in the blood and precede ne* blood !essels into the
crestal regions of bone"
#he greater the amount of trabecular bone under the crestal cortical bone the less
crestal bone loss is obser!ed"
#o place the implant in sufficient a!ailable bone an implant ridge is usually -mm or
*ider at the crest"
#his theory *ould lead to a generali0ed hori0ontal bone loss of the entire residual
ridge reflected not the locali0ed ditching pattern around the implant"
Implant Osteotomy Hypothesis:
#he implant osteotomy causes trauma to the bone in immediate contact *ith the
implant and a de!itali0ed bone 0one of about %mm is created around the implant"
#he crestal region is more susceptable to bone loss during initial repair because of its
limited blood supply and the greater heat generated in this denser bone"
If heat and trauma during implant osteotomy preparation *ere responsible for early
crestal bone loss the a!erage bone loss of %"-mm from the first thread is not obser!ed
at second1stage unco!ery surgery ) to 6 months after implant placement"
Autoimmune Response of Host Hypothesis:
#he primary cause of bone loss a round natural teeth is bacteria induced" 3acteria are
the causati!e element for !ertical defects around implants"
(cclusal trauma may accelerate the process but trauma alone is not a determining
factor"
If bacteria *ere causal agent for initial bone loss *hy does most bone loss occur the
first year +%"-mm, and less +7"%mm, each successi!e year8
#he bacteria theory does not e9plain ade:uately the early crestal bone loss phenomenon"
iolo!ical "idth Hypothesis:
A!erage biological *idth1&"7)mm
#he periimplant tissues e9hibit histologic sulcular and ;unctional epithelial 0ones
similar to a natural tooth"
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Stress & force factors in implants
#he primary difference is the lac/ of connecti!e tissue attachment and the presence of
primarily & fiber groups rather than %% *ith the natural tooth"
#ames and $eller e9plained biological seal phenomenon"
2emidesmosomes help from a basal lamina1li/e structure on the implant *hich can
act as a biological seal"
2emidesmosomal seal only has a circumferential band of gingi!al tissue to pro!ide
mechanical protection against tearing"
3iological seal around dental implants can pre!ent the migration of bacteria and
endoto9ins into the underlying bone but it is unable to constitute ;unctional epithelial
component of the biologic *idth similar to the natural tooth"
5omponents of the linear body cannot physiologically adhere to or become
embedded into the implant body"
Stress %actors Hypothesis:
3one modeling and remodeling are controlled by the mechanical en!ironment of
strain"
Remodeling also is called bone turno!er and allo*s the implant surface to adapt to its
biomechanical situation"
Dental implants are fabricated from titanium or its alloy"
Modulus of elasticity of titanium is - to %7 times greater than bone"
4hen t*o materials of different moduli are placed together *ith no inter!ening
material and one is loaded a stress contour increase *ill be obser!ed *here the t*o
materials first come into contact"
#he stress contours form a !1 or u1shaped pattern *ith greater magnitude near the
point of the first contact"
#he stresses found at the crest *hen beyond physiologic limits may cause
microfracture of bone or strain in the pathologic o!erload 0one and resorption"
(cclusal loads on an implant may act as a bending moment that increases stresses at
the crest"
Scre* loosening and crestal bone loss are repeated *ith increased fre:uency before
the fracture of the implant body"
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Stress & force factors in implants
#he bone is less dense and therefore *ea/er at implant unco!ery than it is after % year
of prosthetic loading"
3one is .7< minerali0ed at ) months and ta/es -& *ee/s to completely minerali0e"
Partially minerali0ed bone is *ea/er than completely minerali0ed bone"
4o!en bone first forms around an implant"
4o!en bone is unorgani0ed and *ea/er than lamellar bone *hich is organi0ed and
load bearing structure"
=amellar bone forms se!eral months after the *o!en bone has replaced the
de!itali0ed 0one around the implant at insertion"
#he bone changes from a fine trabecular pattern after initial healing to a coarse
trabecular pattern after loading especially in the crestal half of the implant interface"
Density of the bone is related directly to the strength and elastic modulus the crestal
bone strength may increase in relation to the functional loading"
Absence of radiographic bone loss is most often obser!ed *hen stress factors are
reduced"
#he stress is greatest at the crest compared *ith other regions of the implant body"
#he denser the bone the less crestal bone loss obser!ed"
#he ma9illary arch often e9hibits greater bone loss than the mandibular arch"
A !ery dense bone captures the stress closer to the crestal region" A!ery soft bone
allo*s the stress to be transmitted farther along the implant interface"
#he softer the bone the farther the stress pattern apical progression"
Implants that maintain crestal bone negate the hypotheses of periosteal reflection
osteotomy preparation and biological *idth"
STRESS %ACTORS:
#he etiology of early crestal bone loss and early implant failure after loading is
primarily from e9cess stress transmitted to the immature implant1bone interface"
(ne biomechanical approach to decrease stress is to increase surface area"
Another method to decrease stress is to decrease forces"
%orce may be decreased in
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Stress & force factors in implants
%" Magnitude
&" Duration
'" #ype
)" Direction
-" Multiplication factors"
%orce factors:
Stress is directly related to force"
As a result any force factor magnifies the stress"
(nce the prosthesis type is determined the potential force le!els that *ill be e9erted
on the prosthesis should be e!aluated and accounted for in the o!er all treatment plan"
#he initial implant sur!i!al early loading sur!i!al early crestal bone loss incidence
of abutment or prosthetic scre* loosening and unretained restorations porcelain
fracture and component fracture are influenced by the factors of force"
&ental factors that affect stress primarily include:
%"Parafunction
3ru9ism
5lenching
#ongue thrust
&" Masticatory dynamics
'" #he position of the abutment in the arch
)" #he nature of the opposing arch
-" Direction of load forces
." #he cro*n1implant ratio"
N(RMA= 3I#E F(R5E$
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Stress & force factors in implants
3ite Forces
Perpendicular to occlusal plane
short duration
3rief total period+>min?day,
Force on each tooth$&7 to '7 psi
Ma9imum bite force$-7 to -77 psi
Perioral Forces
More constant
=ighter
2ori0ontal
Ma9imum *hen s*allo*ing+' to - psi,
3rief total s*allo* time+&7 min?day,
PARAF@N5#I(N$
Parafunctional forces on teeth or implants are characteri0ed by repeated or sustained
occlusion and ha!e long been recogni0ed as harmful to the stomatognathic system"
#he most common cause of implant failure after successful surgical fi9ation or early
loss of rigid fi9ation during the first year of implant loading is the result of
parafunction"
5omplications occur *ith greater fre:uency in the ma9illa because of a decrease in
bone density and an increase in the moment of force"
Nadler has classified the causes of parafunction or non functional tooth contact into
the follo*ing si9 categories$
%" local"
&" systemic"
'" psychological"
)" occupational"
-" in!oluntary"
." !oluntary"
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Stress & force factors in implants
=ocal factors include$

#ooth form or occlusion and soft tissue changes such as ulcerations or
pericoronitis"
Systemic factors include$
5erebral palsy epilepsy and drug related dys/inesia"
Psychological causes include$
#he release of emotional tension or an9iety"
#hey occur *ith greatest fre:uency"
(ccupational factors$
5oncern professionals such as dentists athlets and precision *or/ers musician
*ho de!elops altered oral habits"
In!oluntary mo!ement$

#hat pro!o/es bracing of the ;a*s"
Voluntary causes$
5he*ing gum or pencilspipe smo/ing"
#he parafunction may be categori0ed as$
Absent"
Mild"
Moderate"
Se!ere"
ru'ism:
It is !ertical or hori0ontal non functional grinding of teeth"
3iting force *as greater +) to Atimes normal,"
&ia!nosis:
Symptoms include repeated headaches a history of fractured teeth or restorations
repeated uncemented restorations and ;a* discomfort on a*a/ening"
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Stress & force factors in implants
Si!ns include an increase in si0e of the temporal and masseter muscles de!iation of
the lo*er ;a* on opening limited occlusal opening increased mobility of teeth
cer!ical abfraction of teeth fracture of teeth or restorations and uncemented cro*ns
or fi9ed prosthesis"
#he best and easiest *ay to diagnose bru9ism is to e!aluate the *earing of teeth"
Se!ere bru9ism changes normal masticatory forces by magnitude +higher bite forces,
duration +hours rather than minutes, direction +lateral rather than !ertical, type
+shear rather than compression, and magnification +) to A times normal,"
Clenchin!:
It generates constant force e9erted from one occlusal surface to the other *ithout
any lateral mo!ement"
#he direction of load may be !ertical or hori0ontal"
&ia!nosis:
Signs include tooth mobility muscle tenderness and hypertrophy de!iation during
occlusal opening limited opening stress lines in enamel cer!ical abfraction and
material fatigue"
#he clenching patient has the Bsnea/y disease of forceC"
Fremitus a !ibration type of mobility of a tooth is often present in the clenching
patient"
(ther signs stress lines in enamel stress lines in alloy restorations"
A common clinical finding of clenching is a scalloped border of the tongue"
#he tongue is braced against the lingual surfaces of the teeth during clenching
e9erting lateral pressures and resulting in the scalloped border"
%ATI()E %RACT)RES:
Increase in force magnitude and duration"
5lenching patient suffer from a phenomenon called creep *hich also results in
fracture of components"
Ton!ue Thrust and Si*e:
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Stress & force factors in implants
Parafunctional tongue thrust is the unnatural force of the tongue against the teeth
during s*allo*ing"
A force of )% to A7>g?cm on the anterior and lateral areas of the palate has been
recorded"
#he force of tongue thrust is of lesser intensity than in other parafunctional forces it
is hori0ontal and can increase stress at the permucosal site of the implant"
#he placement of implants and prosthetic teeth in patients *ith large tongue results
in an increase in lateral force *hich may be continuous"
A prosthetic mista/e is to reduce the *idth of the lingual contour of the mandibular
teeth"
#he lingual cusp of the restored mandibular posterior teeth should follo* the cur!e
of 4ilson and include proper hori0ontal o!er;et to protect the tongue during
occlusion"
+ASTICATOR, &,NA+ICS:
#hey are responsible for the amount of force e9erted on the implant system"
#he force is related to the amount and duration of function"
#he si0e of the patient can influence the amount of bite force"
Forces recorded in *omen are &7lb less those in men"
#he se9 muscle mass e9ercise diet state of the dentition physical status and age
may influence muscle strength masticatory dynamics and therefore ma9imum
biteforce"
POSITION "ITH IN THE ARCH:
#he ma9imum biting force is greater in molar region and decreases as measurements
progress anteriorly"
Mansour et al" e!aluated occlusal forces and moments mathematically using a
5lassIII le!er arm the condyles being the fulcrum and the masseter and temporalis
muscles supplying the force"
#he anterior biting force is decreased in the absence of posterior tooth contact and
greater in the presence of posterior occlusion or eccentric contacts"
&IRECTION O% -OA&:
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Stress & force factors in implants
#he direction of occlusal load results in significant differences in the amount of
force e9erted on an implant"
Forces are tensile compressi!e or shear to the implant system"
3one is strongest to compressi!e forces '7< *ea/er to tensile loads and .-<
*ea/er to shear loads"
All the stresses occur in the coronal half of implant bone interface"
Much less stress occur *ith !ertical loads compared *ith an angled load on an
implant"
A lateral load on an implant cro*n ma/es the cro*n height act as a le!er and force
magnifier"
=ateral forces represent a -7< to &77< increase in stress compression compared
*ith !ertical loading and tensile streses may increase more than tenfold"
#he direction of forces may be one of the more critical factors to be e!aluated
during implant treatment planning"
#he a!erage occlusal load of natural dentition is at %& degrees to the tooth root"
Mandibular premolar implants are best positioned for a9ial loading"
Mandibular posterior implants are placed *ith a facial inclination of the implant
ape9 to a!oid perforation of the submandibular fossa"
If the forces of occlusion are not a9ial to the implant body additional implants
*ider implants stress relie!ers in the prosthesis or o!erdentures should be
considered"
OPPOSIN( ARCH:
Natural teeth transmit greater impact forces through occlusal contacts than do softer1
tissue borne complete dentures"
Implant o!erdentures impro!e the masticatory performance and permit a more
consistent return to centric relation occlusion during function"
#he ma9imum force is related to the amount of tooth or implant support"
CRO"N HEI(TH:
It affects the amount of forces distributed to the implant1prosthetic system in the
presence of lateral or cantile!ered forces"
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Stress & force factors in implants
#he greater the cro*n height the greater the moment of the force under the lateral
loads"
#he cro*n height acts as a le!er *ith any lateral force"
Since stresses are concentrated at the crest of the rigidly fi9ated implant the cro*n
height multiplier increases stress rapidly"
For e!ery % mm cro*n height increase a force increase may be &7<"
An indirect relationship is found bet*een the cro*n and implant height"
#he lesser the bone !olume the greater the cro*n height and the greater the number
of implants indicated"
AREA %ACTORS:
A)T+ENT N)+ER:
#he o!erall stress to the implant system may be reduced by increasing the surface
area o!er *hich the force is applied"
Most effecti!e method to increase the number of implants used to support the
prosthesis"
#he retention of prosthesis is impro!ed *ith greater no" of splinted abutments"
4ith this the amount of stress to the system is reduced and the marginal ridges on
the implant cro*ns are supported by the connectors of the splinted cro*ns *hich
applies compressi!e forces rather than shear loads on the porcelain"
(ne implant for each tooth missing may be indicated in the posterior regions of the
mouth for a large young male patient *ith se!ere parafunction"
A)T+ENT POSITION:
Implant positioning is related to implant number because more than t*o implants are
needed to form a biomechanical tripod"
5antile!ers are a force magnifier and represent a considerable ris/ factor in implant
support scre* loosening crestal bone loss fracture"
#herefore implant no" D position should aim at eliminating cantile!ers especially
*hen other force factors are increased"
#he best *ay to reduce ris/ factors is to increase implant no"
I+P-ANT SI.E:
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Stress & force factors in implants
#he surface area of implant support may also be increased by the si0e of the implant"
Each 'mm increase in height can impro!e surface area support by more than &7<"
#he significance in increased length is not found at the crestal bone interface but
rather in initial stability and the o!erall amount of bone implant interface"
#he increased length also pro!ides resistance to tor:ue or shear forces *hen
abutments are scre*ed into place"
#he surface area of implant support system is directly related to the *idth of the
implant"
Each 7"&-mm increase in implant diameter may increase the o!erall surface area
app" - to %7<"
3one augmentation in *idth may be indicated to increase implant diameter by %mm
or app" &-< increased surface area"

I+P-ANT &ESI(N:
Implant macrodesign may affect surface area e!en more than an increase in *idth"
A cylinder implant pro!ides '7< less surface area than a con!entional threaded
implant of same si0e"
A threaded implant *ith %7 threads for %7mm has more surface area than one *ith -
threads"
A thread depth of 7"&mm has less surface area than an implant *ith 7")mm"
SCRE" -OOSENIN(:
#he platform of the implant body is larger in the larger diameter implant" So less
force is transmitted through scre*s during occlusal loads"
Scre* loosening may be decreased by a preload *ith a tor:ue *rench on the scre*"
#he threads of the scre* form a '7 degree angle"
A rotational force on the scre* places a shear force on the incline of the thread"
Most systems use a '7 to '- Ncm rotational force on the abutment scre* to preload
or stretch the scre* *ithout ris/ of fracture"
A more effecti!e method to preload the scre* is to tighten the scre* to the
recommended amount and then untighten the scre* after a fe* minutes and
retighten it to the re:uired tor:ue force again"
Scre* loosening is affected by the no" of threads"
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Stress & force factors in implants
#he height of the antirotational component of the implant body also can affect the
amount of the force applied to the abutment scre*"
#he higher the he9agonal height the less stress applied to the scre*"
%ATI()E %RACT)RES:
Materials follo* a fatigue cur!e *hich is related to the number of cycles and the
intensity of force"
#he magnitude of the force increases o!er time because the muscles become
stronger and the number of cycles on the prosthetic components is greater as a result
of the parafunction"
ONE &ENSIT,:
#he density of bone is in direct relationship *ith the amount of implant1bone
contact"
#he less area of bone contacting the implant body the greater the o!erall stress"
Progressi!e bone loading changes the amount and density of the implant1bone
contact"
#he body is gi!en time to respond to a gradual increase in occlusal load"
#his increases the :uantity of bone at the implant interface impro!es the bone
density and impro!es the o!erall support system mechanism"
#he !ery dense bone of resorbed anterior mandible +D%, has the highest percentage
of lamellar bone in contact *ith an endosteal implant"
Amount of stress to the implant increases in D) bone because fe*er regions of bone
contact are present"
EFFE5#S (N #REA#MEN# P=ANNINE$
Solution is an increase in implant1bone surface area"
Additional implants are the solution of choice to decrease stress rather than only an
increase in implant *idth or height"
#he amount of bone in contact *ith the implant is also increased as a multiple of the
no" of implants"
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Stress & force factors in implants
#he greater the diameter of the implant the lesser the stress transmitted to the
surrounding crestal bone"
An increase of 7"-mm of the abutment post diameter may increase the fatigue
strength by '7<"
The implant treatment plan is modified primarily in t/o /ays /hen implants are
inserted in the posterior re!ion0
%" additional implants"
&" occlusal considerations"
#he elimination of posterior lateral occlusal contacts during e9cursi!e mo!ements is
recommended *hen opposing natural teeth or an implant or tooth supported fi9ed
prosthesis"
#his benefits in t*o aspects$
@se of a night guard is helpful for the bru9ism patient *ith a fi9ed prosthesis to
transfer the *ea/est lin/ of the system to the remo!able acrylic appliance"
Anterior guided disocclusion of the posterior teeth in e9cursions is strongly
suggested in the night guard *hich may be designed to fit the ma9illa or mandible"
A soft night guard *hich is slightly relie!ed o!er the implants is used in clenching
patient"
A night guard *ith a hard acrylic outer shell and soft resilient liner has
biomechanical ad!antage to reduce the impact of the force during parafunction"
@nli/e teeth implants do not e9trude *hen no occlusal force is present" As a result
the night guard can be relie!ed around an immediate implant so the teeth bear the
entire load"
Implant failure during healing is parafunction found *ith a patient *earing a soft
tissue supported prosthesis o!er a submerged implants"
#he time inter!als bet*een prosthodontic restoration appointments may be
increased through progressi!e bone loading techni:ues"
Anterior implants submitted to lateral parafunction forces re:uire further treatment
considerations"
Additional implants are indicated *ith greater diameter"
#he e9cursions are canine guided if natural healthy canines are present"
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Stress & force factors in implants
Mutually protected occlusion is de!eloped if the implants are in the canine position
or if this tooth is restored as a pontic"
#he forces must be disturbed along the long a9is of the implant narro* occlusal
tables to pre!ent inad!ertent lateral forces decrease the forces necessary for
mastication and lea!e greater space for the tongue"
Enameloplasty of the cusp tips of the opposing natural teeth is indicated to impro!e
the direction of !ertical forces *ithin the guidelines of the intended occlusion"
Submerged t*o1phase protocols are recommended in patients *ith hori0ontal force
factors such as lateral tongue thrust"
Myofunctional therapy and autogenous bone grafts to modify the bone di!ision for
endosteal1t*o stage implant placement cantile!ered bridges from the anterior teeth
or con!entional remo!able partial dentures are !alid treatment ob;ecti!es"
If the anatomical conditions do not permit the placement of implants a remo!able
o!erdenture +RP1) or RP1-, is indicated"
RP1) or RP1- may be remo!ed during periods of parafunction"
Stress distributors may be used in the attachment system"
CONC-)SION:
Additional implants are the solution of choice to decrease along *ith an increase in
implant *idth or height to decrease the no" of pontics and dissipate stresses more
effecti!ely to the bone structure especially at the crest"
REFEREN5ES$
%" Dental implant prosthetics F 5arl E" Misch
&" Principles and practice of implant dentistry F 5harles 4eiss Adam 4eiss"
'" #issue F integrated prosthesis" (sseointegration in clinical dentistry F
3ranemar/ 0arb Albre/tsson
)" (ral rehabilitation *ith implant supported prosthesis 1Vincente
-" I#I dental implants1 #homas E"4ilson
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