TOPICS OF INTEREST

Cantilever and Implant Biomechanics:

A Review of the Literature, Part 1
Arthur M. Rodriguez, DMD, MS, * Steven A. Aquilino, DDS, MS, f
and Peter S. Lund, DDS, MS$

In Part 1 of this two-part literature review, the biomechanics of cantilever fixed partial dentures
are reviewed. Theoretical constructs of implant biomechanics with special emphasis on implant-
supported cantilevers are also discussed. Finally, an overview of the literature regarding occlusal
forces generated by patients with implant-supported prostheses is presented.
J Prosthod 1994;3:47-46. Copyright o 1994by the American College of Prosthodontists.

INDEX WORDS: implant cantilevers, cantilever loading, implant occlusal force

AS I h f P I A i PROSTHODOANTICS grows in
popularity, the findings of long-term prospective
clinical research conducted by the Brsnemark group
ing. At a central plane of molecules dividing the
beam in half along a horizontal plane, there is
neither compression or tension. This is defined as the
remains unparallelled.1-4It has provided the basis for neutral axis. Above this axis, the beam is subjected to
our current confidence in implant prosthodontics. compression, and below, to tension."." Also, the bend-
This research was based on the restoration of the ing moment of the beam, or deflection, varied in-
fully edentulous arch in which four to six implant versely with the cube of the depth and directly with
fixtures were placed between the medial walls of the the cube of the length? Therefore, if a beam was
maxillary sinuses or the mental foramina for construc- doubled in length, or its depth cut in half, its
tion of a fixed implant prosthesis. Prosthesis success flexibilitywould be eight times as great.jJ
rates of 99% in the mandible and 92% in the maxilla The shape assumed by the neutral axis of a beam
have been reported when strict criteria for success supported on each end during deflection or elastic
were followed.2However, prosthodontic design con- bending is referred to as the deflection curve. The
cepts have been based primarily on theoretical con- shape of this curve is a function of the bending
structs or extrapolation of classic prosthodontic moment (M) of the beam, the modulus of elasticity
theory. The biomechanical aspect of implant prosth- of the material (E) and the moment of inertia of the
odontics requires further investigation. entire cross-sectional area (I). This deflection curve
relationship is defined by M/EI. This product, EI, is
Beam and Cantilever Theory referred to as the flexural rigidity or bending modu-
lus of the
In 1952, Smyd5 first analyzed fixed partial dentures In engineering terms, all resultant forces acting
based on accepted engineering principles of a beam. on the fixed partial denture or the beam and its
He explained that a beam supported at both ends is support must equal zero for a state of equilibrium to
subject to both compression and tension upon load- exist.9 The reactions from added restraints or mul-
tiple abutments (greater than two), however, cannot
be determined from simple equilibrium equations
*StaffProsthodontirt, VeteraniAdminzstralion Medlical Center, High- alone.6Variations of irregular beam shape and non-
land h u e , Pittsbuqh, Pil; Arrutant ProJiimr, Drjmtmenl ofReJtoralive
linear supports make the applicability of engineering
fintishy, L'nioersity ofPittsburgh School of Dental Medicine, Pittshurgh,
PA. equations to the clinical situation even more compli-
tProji,rsor and Graduale Prozram Dzrectw, Department ofProrthodon- cated.
tics, linioenity oJiIoorfia College oJiDentisly,IozNa City, L4. A cantilever fixed partial denture (F'PD) is one
$Assistant Prnjxror,Department ofprohdontics, linicersiy ofIowa that has an abutment or abutments at one end only.
Cullege ofDntistv>Ames.
The other end of the pontic remains unattached.j
Corresfindencr to: Arthur M. Rodripz, DMD, MS, L'eterun s' Admin-
irtration medical Cpnlur,HighlandDn'ce,Pittsburgh, PA 15206. This creates a class I lever system, which dramatically
C o p ~ g h0t 1994 @ the Amm'can College ojPmsthodonti.rts alters the direction and magnitude of forces on the
I05!&94IX/94/ 0301-0008$.5.00/ 0 abutment teeth. Authors warn against the use of

JournaI ofProsthodontics, Vol3,N o I liMarch), 1994::pp41-46 41

42 Cantilever and finplant Biomechanics Rodriguez,Aquilino, and Lund

cantilevers in FPD d e s i g ~ i . ~Ewing'

J ~ I enumerated design in vivo. They studied one patient with a
factors that he considered critical when comidering six-unit conventional FPII involving two mesial abut-
the use of a cantilevered FPD and clinical situations ments, one distal abutment, and a bar representing
in which its use could be beneficial. In situations the pontic span. Strain gauges were placed on the
invohing natural dentitions, the periodontal attach- underside or cenical surface of the pontic bar.
ment, alveolar support, root morpholog of abut- During occlusal loading of the conventional FTD,
ments, and favorable arch-to-arch relationships were strain was mainly positive (+) showing tension or
critical factors to be considered when planning the elongation as prcdicted by Smyd.j After sectioning
u5e of a cantilever FPD. the distal abutment, most strain was recordcd as
Crabb,12 S~hweikert,'~ and Wright'* listed guide- compression (-). With an unsupported end, the
lines and recommendations for the use of cantile- pontic span was then being compressed on the
vered tooth-supported FPDs. Recommendations in- underside by the occlusally directed force. As cantile-
cluded careful force considerations and extreme ver loading progressed distally (ie, effectivc cantile-
caution along with good periodontal support and ver length increased), strain immediately distal to
maintenance. They also expressed limited optimism the terminal abutment increased and strain between
for posterior cantilever FPD success. Schweikert" the two mesial abutments dccreascd.
recommended full coverage for all abutments and a Heringlake and Goodkind'* studied the mobility
metal of high melting temperature, good strength, of three supporting abutments (canine, first and
and good hardness. A gold-palladium alloy was sug- second premolars) for a single pontic cantilevcr
gested to resist thermal distortion during porcelain (premolar pontic) in vivo. Mobilities were recorded
application and bending stresses during function. over a period of timc for all abutmcnts while varying
Schweitzer et all5 expressed many of these same the number of abutments supporting the cantilever
concerns. They also theorized that the farther away pontic. Because only mobility was recorded, it could
from the fulcrum (distal abutment) or the longer the not be shown that the abutment adjaccnt to the
cantilever, the more efficient the force transfer and pontic received more than 50% of the load as was
the lower the force necessary to produce the same shown by Henderson et However, it was shown
stress at the abutments. Therefore, the longer the that the distal abutment (second premolar) had the
lever arm, the greater the number and support o f greatest mobility throughout the study. As fewer
abutments necessary. Schweitzer et al also hypoth- teeth supported the cantilevered pontic, the mobility
esized that upon loading a distd cantilevered pontic, of these abutments increased. After sectioning the
the most distal abutment would be depressed and canine and first premolar from the cantilever prosthe-
the more anterior abutment would be elevated. sis, and allowing them to function as single units,
Henderson et all6 examined stress transfers to their mobility dccreased.
abutments in a cantilever FPD. They showed that as
the number of abutments decreased, the resultant
force imparted to the abutments during cantilever
Theoretical Implant
loading increased. This resultant force was often
Biomechanics
greater than the actual force applied to the cantile- The use of osseointegrated implants for prosthesis
ver. In addition, the most distal abutment consis- support complicates prosthetic biomechanics be-
tently received the greatest percentage of force. The cause of the rigid nature o f the implant fixture^.'^^^"
direction of force imparted to the abutment farthest The most frequently quoted literature regarding
from the cantilevered pontic in a multiple abutment implant biomechanics has been thcoretical in na-
FPD was vcrtically upward during axial or 4.5" load- ture.'""
ing. Their in vitro study used a four-unit FPD with BrunskP defined biomechanics as the application
mandibular canine and first and second premolar of engineering mechanics to the solution of biological
abutments with a distal premolar pontic. Strain problems. Brunski8 also emphasized the importance
gauges were used to convert pontic movement to of the effects of biomechanical principles on the
magnitude of force. Although no statistical analyses overall goals of implant design: (1) to support loads
were performed, the previously stated trends were without fracturing, and (2) to transmit these forces
evident. and moments to interfacial tissues in ways that avoid
Glantz et all7investigated magnitude and direc- damage to these tissues.
tion of strain in a supported FPL) and a cantilever SkalakIq theorized that the stiffness, k, of an
 March 1994, T70lume 3. Number I 43

implant in bone was the proportionality constant forces might increase the maximum load per screw
relating axial force (F) to axial intrusion (x) of the froin one and one-half to two times the applied load.
implant (k = F/x). As compared with a natural The principles theorized by Skalakwere expanded
tooth, this k value was large and was analagous to a upon by Rangert et aL2' They described two types of
spring constant. Richter,20using a spring resistance bending moments in a Brinemark implant-sup-
analogy similar to Skalak, estimated that the resil- ported fixed prosthesis that would not be as well
ience of the implant/bone system was 10 to 100 times tolerated as axial forces. The first involved forces
higher than that of a natural tooth in bone. There- exerted on anlerior implant fixtures during loading
fore, under similar loads, an osseointegrated implant of a posterior cantilever with the implants arranged
would absorb a greater amount of stress (ie, Force/ in an arch-form configuration. The posterior cantile-
Area) as compared with a natural tooth. ver loading point and the two adjacent implant
Brunski et a1,22 in a study of five-unit tooth/ fixturcs would function like a seesaw with the termi-
implant-supported FPDs in dogs, showed that the naJ implant fixture as the fulcrum (Fig 1). The
more rigid osseointegrated interface absorbed a anterior implant fixture would be subjected to a
tensile force proportional to the lever arm ratio
greater amount of force than the slightly resilient
( a h ) . The posterior implant fixture would be sub-
fibro-integrated interface.
jected to a comprcssive force that would be the sum
Rangert et alZ3described the cantilever forces at a
of the applied cantilever load and the compensating
Brsnemark implant fixture when it was attached to a
tensile force. The tensile force would be of greater
natural tooth. In their in vitro test, the resilience of
concern because of its tendency to separate compo-
the periodontal ligament accounted for a cantilever-
nents.
type force exerted at both the gold screw and the
However, according to Rangert et a1': when more
abutment screw. The abutment/gold cylinder screw than two implant fixtures shared the load from a
joint of the Brinemark implant acted as a flexible cantilever, this secsaw analo<gywould not be strictly
element in this situation. Moments generatcd by applicable. Also, the amount of load transferred to
loading a cantilever extension of a fixed implant the unloaded side of the prosthesis would depend on
prosthesis could be considerably larger. Rangert the amount of bone and prosthesis flexibility and
pointed out that although screw breakage or fatigu- could not be predicted from the seesaw analogy.
ing may not result from this type of motion, scrcw Rangert et a1 concluded that the crucial factor in all
loosening could easily occur. cases was that the anterior-posterior implant fixture
An analysis of the forces acting on the implant distribution compensate for a loaded cantilever. They
prosthesis was presented by Skalaklg in 1983. He also stated that an increase in the number ofimplant
stated that the implant-supported fixed prosthesis fixtures within a given distance would increase the
was a curved elastic beam and that the stiffness of safety margin.
the implant fixtures and of their connection to the
prosthesis influenced its defortnation under load.
The implant fixture was expected to react elastically
because of its close apposition to bone, that is, its
deflection would be proportional to the load. Skalak
theorized that the screws, because of their smaller
cross section, were considerably less rigid than the
framework. Given a stiff prosthesis, Skalak esti-
mated the force on the individual implant fixture to
be a function of the applied load, its position relative
to the center of rotation of the prosthesis, and the
total number of implant fixtures present. Skalak
went on to hypothesize that although an incrcased
number of implant fixtures would decrease the force
at each implant site, the optimum number of im-
plants could safely be predicted if the maximum load
Figure 1. Seesaw analogy of implant cantilever loading.
(Reprinted nith permission from Kangcrt B, .Jemt T,
capability of each implant fixture were known. He Joriieus L: Forces and moments on Brhemark implants.
warned, however, that the introduction of cantilever Int J Oral Maxillofac Jmplants 1989;4:241-247.)
44 Cantzkuer andlmplant Biomechanics Rodnguet Aquilinn, and Lund

The second type of bending moment involved a English2*theorized a seesaw analogy somewhat
force remote to a straight line connecting the im- different from that of Rangert et d2' He stated that
plant fixtures in a prosthesis (ie, remote site loading posterior cantilever loading of a fixed implant pros-
of linearly arranged fixtures). This would occur thesis produced tensile forces in the most anterior
during cantilever loading when the implants were fixtures that could be compensated for by extending
arranged linearly as opposed to in an arch-form prosthetic anterior teeth fommd of the most ante-
curvature. The lever arm system in this situation rior fixtures to produce a counterbalancing bending
would be within the fixture itself, with the posterior moment. However, the notion that a second anterior
edge of the abutment acting as the fulcrum. This cantilever could be beneficial in decreasing posterior
same type of bending moment would occur when an cantilever stress seems questionable.
individual fixture received a lateral force (Fig 2). In Mendelson et alZ5tested quantitatively the theo-
the above situations, Rangert et al" believed that the retical predictions of implant fixture loading for a
implant fixture absorbed more of the bending mo- fixcd prosthesis described by Skalak.'9 This study
ment with an increase in force transmission to the used Brznemark fixtures threaded into a 1-in thick
bone as opposed to a more favorable distribution of aluminum plate with specially designed load-scnsing
forces among multiple implant fixtures. These bend- Brdnemark abutments. They concluded that for
ing moments could lead to abutment screw or gold vertical loads at distal and midline locations on the
screw loosening and subsequent breakage. prosthesis, the Skalak model underprcdictcd implant
In conclusion, Rangert et a12' pointed out that an forces nearest the loading point. They attributed this
optimal preload or tightening of the gold screw was to a lower-than-predicted rigidity of the metal/
essential because once the gold cylinder/abutment acrylic prosthesis.
joint opened, all force would be taken by the gold Brdnemark et a126approximated deflection of the
screw. Rangert et a1 also recommended a passive fit cantilevered prosthesis by the following equation:
of all gold cylinders and a sufficiently rigid franie-
KFL
work. They stated that a less rigid framework would Deflection = -
impart more stress to the implant fixtures closest to EWH
the loading point, with poorer overall stress distribu- where K equaled a constant, F was the applied load,
tion. E was the modulus of elasticity of the material used
in the prosthesis, and L, Mi, and H (length, width and
height) were the dimensions of the cantilevered part
of the prosthesis.

Occlusal Forces and Implant

Prostheses
Forces gcnerated during normal function (chewing,
biting, and swallowing) as well as potentially heavy
parafunctional forces can vary greatly among indi-
viduals. Irivesligatvrs over the years using bite fork
strain gauges or strain gauges incorporated into
prosthetic replacements have measured maximal
biting forces ranging from 64 N to 90 N for complete
denture wearers2' to 720 N for dentate subjects.28.2q
CraigjUcited axial force loads as ranging from 200 N
to 2440 N for dentate human adults. Variation in the
results of these studies can be partially attributed to
Figure 2. Bending moments on implants. (A) bending various techniques of generating and recording these
moment due to cantilever loading; (B) remote site loading bite forces.
of linearly arranged fixtures; (C) bending mornrnt due to The increased magnitude of lexer effects created
nonaxial occlusd loading. (Reprinted with permission
from Rangert B, Jemt T, Jorneus L: Forces and munients
by a cantilevered segment complicates theories of
on Brinemark implants. Int J Oral hfaxillofac Implants force transmission during biting as mentioned previ-
1989;4:241-247.) ously. Also, relationships of force distribution may
vary greatly between implant- and tooth-supported cantilever segments. They found 70% of the total
cantilever design^.^'-^^ The complete denture patient biting force taken by the cantilever segments when
has been assumed to generate less occlusal force the maxillary denture was supraoccluded in eight
than the dentate i n d i v i d ~ a l . ~Therefore,
~,~' it has points, as opposed to 55% when only four contacts
been assumed that cantilever forces would be de- existed.
creased when occluding with a complete denture as Conversely, Lundgren et a1j5 showed that placing
opposed to a natural dentition.15 the most distal segments of the cantilever prosthesis
However, Lundgren et a P showed that with a in infraocclusion resulted in a significant decrease in
mandibular irnplant-supported cantilever prosthesis total force along the entire prosthesis when opposing
opposing a complete maxillary denture, mean chew- a complete denture. This benefit is decreased, how-
ing and swallowing forces were greater than with ever, by the severity of the denture tipping. An
tooth-supported cantilevers opposing natural teeth occlusal interference in the cantilevered segment
and equal to forces involving conventional P D s resulted in an increase in vertical bending stress at
opposing natural teeth. For the implant prosthesis, the distal cantilever joint during closing forces.33
these posterior cantilever forces exceeded the forces In comparing gentle biting, normal chewing force,
of the implant-fixture-supported area against the and maximal biting force, Haraldson et aP7 showed
anterior part of the maxillary denture. Also, the that patients restored with osseointegrated implants
patients wearing the complete dentures used a according to E n e m a r k protocol showed biting forces
greater percentage of their maximal biting force equal to patients restored with FPDs on periodon-
during normal function, probably because of a de- tally involved teeth but slightly less than patients
crease in mandibular mucosal proprioception. Canti- with a full complement of natural teeth. Mean
lever forces were reported to be greater with the maximal biting force was found to be 144.4 N.
implant-supported prosthesis opposing a complete Carr and studied 14 denlure patients who
denture than with tooth-supported cantilevers oppos- received osseointegrated implant-supported prosthe-
ing natural dentitions, probably for two reasons: a ses. Maximum occlusal force (MOF) in the molar
decreased flexure of the implant cantilevers because region was measured before and 3 months after
of their rigid nature, and the tipping action down- placement of the implant prosthesis. MOF ranged
ward and posteriorly of the maxillary denture. from 22N to 11 1N before treatment and 44N to 253N
Falk et aI3l measured occlusal forces in implant- after treatment. Interestingly, patients in this study
supported prostheses using strain gauges placed on who were edentulous less than 15 years showed a
supraoccluded contact areas in the opposing maxil- four times greater increase in MOF from baseline
lary denture. Mean maximal closing force for the compared with those patients edentulous longer
implant-supported prosthesis opposing a complete than 15 years.
denture was found to be 336 98 N. These forces
+_ Based on chewing efficiency increase following
represented the total force exerted on all portions of placement of an implant prosthesis,Jemt and Carls-
the prostheses. They also showed that vertical bend- son38showed a correlation between high posttreat-
ing stress measured at the distal cantilever,joint was ment chewing efficienq increase and low pretreat-
greater when an implant-supported cantilever pros- ment levels of bite force and mandibular velocity.
thesis occluded against a completc denture as op- However, regardless of pretreatment levels of bite
posed to natural teeth. Vertical bending stress was force, all subjects showed comparable mean bite
expressed as M/Wb, where M equalcd the vertical forces after rehabilitation. Also, there was a poor
bending moment that was equal to force multiplied correlation between self-assessed chewing efficiency
by the distance. Wb represented the bending resis- and objective testing of chewing efficiency.
tance of the cantilever beam, which was equal to Lindquist and C a r l ~ s o nshowed
~~ a doubling of
width x height X ~ r / 3 2Forces
. along the cantilever maximal biting force of previous denture wearers
itself decreased distally against the natural dentition after placement of an osseointegrated mandibular
while progressively increasing when opposed by a fixed prosthesis. This doubling was noticed 2 months
complete denture. Again, tipping of the denture was after prosthesis placement. However, 3 years after
theorized to cause this phenomena. placement of the prosthesis, a three-fold increase in
Also, Falk et a13' showed that increasing the maximal biting force was observed. Chewing effi-
number of occlusal contacts could actually increase ciency also increased, although not as dramatically.
the percentage of total occlusal load borne by the They hypothesized that there was a period of adjust-
46 C a n t z k r andIm@ant Biomechanics Rodriguez. Aquzlano, and Lund

mcnt and adaptation after prosthesis placement in 21. Rangert B, Jemt T, Jorneus L: Forccs and moments- on
which chcwing efficiency and maximal biting force Brdnemark Implants: Int J Oral Maxillofac Implants 1989;4:
21 1-247
increased.
22. Brunski ,JB, Hipp ~JA,El-M'akad M: Dental implant design:
Biomechanics and interfacial tissues.J Oral Implantol 1984;12:
365-377
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