J Dent Sci 2010;5(1):1−7

O R IGINAL ART IC L E

The effects of splinting periodontally

compromised removable partial
denture abutments on bone stresses:
a three-dimensional finite element study
Allahyar Geramy,1* Mehdi Adibrad,2 Mahasti Sahabi3
1
Department of Orthodontics, Dental School, Tehran University of Medical Science and
Dental Research Center, Tehran University of Medical Sciences, Tehran, Iran
2
Department of Periodontics, Dental School, Isfahan University of Medical Science, Isfahan, Iran
3
Department of Prosthodontics, Dental School, Shahid Beheshti University of Medical Science,
Tehran, Iran

Received: Oct 18, 2009 Background/purpose: Periodontally compromised abutments complicate the treat-
Accepted: Jan 21, 2010 ment plan of distal extension removable partial dentures. The objectives of this
study were: (1) to determine if splinting a tooth with reduced bone height to a
KEY WORDS: healthy one is beneficial to the weak one; (2) to investigate fixed splinting of two
abutment; teeth (the first and second premolars) with various alveolar support levels on bone
biomechanics;
stress around the periodontal construction according to different crown to root
ratios of the periodontally compromised abutment; and (3) to assess the efficiency
finite element analysis;
of splinting in the presence of non-axial loads.
fixed splinting;
Materials and methods: Thirteen three-dimensional finite element models were
periodontal support; designed that included the mandibular first and second premolars and the surround-
removable partial denture ing bone. Ten models were similar except for the alveolar bone height around the
second premolar that had different amounts of bone resorption of 0−9 mm with splinted
teeth. The last three were the same except for the teeth which were not splinted.
A vertical force of 25 N was applied to each occlusal surface of the premolars. Finally,
von Mises stress was evaluated at three points for all models. In the first stage, the
efficiency of splinting was assessed. In the last stage, the effects of non-axial loads
were evaluated in the splinted teeth models.
Results: In stage 1, it was shown that splinting could redirect the stresses to apical
areas and prevented crestal bone from increased stress. In stage 2, the findings of von
Mises stress in the apical area of the first premolar were almost the same in all models.
In the apical area of the second premolar and the alveolar crest area, the bone stress
increased when the height of the alveolar bone of the second premolar decreased.
Stage 3 revealed that splinted teeth are efficient in carrying non-axial loads.
Conclusion: Splinting a very weak abutment to an adjacent healthy tooth might not
be beneficial. The acceptable crown to root ratio for fixed splinting a weak abutment
to an adjacent normal tooth was around 1.65−2.

*Corresponding author. Department of Orthodontics, Dental School, Tehran University of Medical Science and Dental Research
Center, Tehran University of Medical Science, Tehran, Iran.
E-mail: [email protected]

©2010 Association for Dental Sciences of the Republic of China

2 A. Geramy et al

Introduction In other studies,3,9 distal abutments had mesial and

distal osseous craters that were 4 mm deep. In a
The usual treatment choices for patients with pos- study by Wang et al.,12 severely compromised peri-
terior edentulous ridges are cantilever fixed partial odontal involvement of the terminal abutment was
dentures (FPDs), removable partial dentures (RPDs), defined as only one-third of the normal bone height
and implant-supported prostheses. However, anato- remaining. Finally, Aydin and Tekkaya17 assumed a
mic considerations or financial constraints may re- C/R ratio of 1 for periodontally weak abutments.
sult in considering the FPD or RPD options. Although Therefore, it seems that the literature lacks criteria
both of these treatment modalities can provide the for periodontal involvement.
patient with chewing function, patients often pre- The finite element method (FEM), which was in-
fer a fixed prosthesis because of perceived comfort troduced to solve structural mechanical problems,
and ease of maintenance. However, an FPD might not has long been applied in dentistry to determine
provide a suitable biomechanical solution because stresses and strains in dental structures caused by
of its limited capacity to transfer occlusal forces to occlusal forces.18 Three-dimensional (3D) FEM is a
distant portions of the arch. This limitation is espe- powerful tool for examining complex mechanical
cially prominent in situations of teeth with reduced behaviors of prostheses and surrounding structures.
periodontal support.1−5 Their usefulness in designing and analyzing dental
The mobility of natural teeth may increase when restorations is well established.19−24
the supporting periodontium is lost. It is, therefore, The objectives of this study were: (1) to assess the
important to reduce the deteriorating effects of the usefulness of splinting a tooth with reduced alveolar
poor supporting tissues under physiologic loads in bone height to a healthy one from a stress point of
rehabilitating periodontally compromised dentition.6 view; (2) to evaluate the effects of gradual alveolar
Tooth mobility in natural dentition may be eliminated bone loss of one tooth (the second premolar) in a
or controlled by proper diagnosis and management, splinted segment of two teeth (premolars); (3) to find
such as occlusal adjustments and tooth splinting in the greatest C/R ratio to splint a weakened tooth to
an inflammation-free environment.6,7 For conven- a healthy one beyond which the splinting is useless;
tional FPDs, joining teeth together in a splint system and (4) to evaluate splinted teeth when non-axial
is an important method used to decrease mobility loads are applied from a stress point of view.
in cases of reduced periodontal support.8 Several
biomechanical studies investigated the influence
of bone levels and splinting on teeth with reduced Material and methods
periodontal support height.9−12 The reduced bone
support and unfavorable crown to root (C/R) ratio of Thirteen 3D FEM models were created with a poste-
an abutment not only reduce the area of the peri- rior mandibular segment, first and second premolars
odontal ligament (PDL), but also increase the lever- based on the average dimensions,25 spongy, cortical
age when a non-axial load is applied. Biomechanical bone, and PDL (Fig. 1). The normal alveolar bone
factors, such as overload, leverage, torque and flex- model was the control, and bone loss was measured
ing, induce abnormal stress concentrations in the vertically from the crest of the second premolar
prosthesis and periodontium. Those studies dem- bone level in millimeters. Each model consisted of
onstrated that teeth splinting can decrease both a cancellous core surrounded by a 0.75-mm thick
the displacement and stress concentrations. cortical layer. A 0.25-mm thick simplified PDL layer
Berg and Caputo13 studied some aspects of stress was modeled based on the root-form geometry of
distributions of RPDs in bilateral maxillary distal the premolar. Ten models were similar except for
extension situations with progressive diminution of the alveolar bone height of the second premolar.
periodontal support. Itoh et al.3 investigated the In the first model, the alveolar bone height was nor-
effects of periodontal support and fixed splinting mal around the second premolar (C/R ratio, 0.55).
on load transfer by RPDs in mandibular bilateral dis- Gradual loss of alveolar bone in the second premo-
tal extension situations. They concluded that fixed lar increased to 9 mm in the last model (C/R ratio,
splinting of simulated periodontally compromised 3.09). In all models, the alveolar bone height around
abutments effectively redistributes forces to sup- the first premolar was kept normal. Two teeth were
porting structures. splinted in the crown so that they could be consid-
Considering Ante’s law 14 for FPDs, which was ered as one part with no deformation in the splint
questioned in several studies15,16, specific clinical area. In the last three models, the splint was deleted
guidelines for splinting are lacking. In all of those from the model with 1 mm, 4 mm, and 8 mm of alve-
studies, the definition of a weak abutment varied olar bone loss.
among clinicians. Yang et al.11 considered a C/R ratio SolidWorks 2006 (Solidworks Corp., Concord, MA,
of 1:0.7 for periodontally compromised abutments. USA) was selected to create the solid models. The
Splinting periodontally compromised abutments 3

A B

C D

Fig. 1 Finite element models: (A) with 1 mm of bone loss in the second premolar; (B) with 3 mm of bone loss in the
second premolar; (C) with 7 mm of bone loss in the second premolar; and (D) with 9 mm of bone loss in the second
premolar.

models were designed in a top-to-bottom manner

Table 1. Material properties used in the finite element
starting with a definition of volumes. The next step models
was to import the solid models into ANSYS Workbench
version 11.0 (ANSYS Inc., Canonsburg, PA, USA) to Young’s modulus Poisson’s
Material
construct the FEMs. All vital tissues were presumed (kg/cm2) ratio
to be elastic, homogeneous, and isotropic. The cor-
Enamel 8.26 × 105 0.33
responding elastic properties such as Young’s mod- Dentin 2.14 × 105 0.31
ulus and Poisson’s ratio were determined according to Periodontal ligament 70.3 0.49
recent research (Table 1).19−24 Models were meshed Spongy bone 2.15 × 103 0.38
with between 21,407 and 29,568 nodes, between Cortical bone 1.45 × 105 0.26
11,206 and 15,658 10-node-quadratic tetrahedron
body elements, and between 5129 and 7371 contact
elements in the model with the highest and the
lowest amounts of bone loss, respectively (Fig. 2).
As to boundary conditions, all nodes at the bottom
of the model were restrained so that rigid body
motion was prevented.
The study was divided into three parts. In part 1,
three models without splinted crowns (with normal,
and 4 mm and 8 mm of bone loss) were loaded with
a 25-N force vector on each premolar to assess the
stress situation of the alveolar crest compared to
apical stress to show that the crestal stress was
greater than apical ones in loading separate (non-
splint) crowns.
In part 2, 10 models with splinted crowns and Fig. 2 Meshed model with 1 mm of alveolar bone loss in
gradual bone loss were loaded with a vertical force the second premolar.
4 A. Geramy et al

A B

C D

Fig. 3 von Mises stress distributions in splinted models: (A) with 1 mm of alveolar bone loss, (B) with 3 mm of alveolar
bone loss, (C) with 7 mm of alveolar bone loss, and (D) with 9 mm of alveolar bone loss.

vector of 25 N onto each premolar crown. This stage

Table 2. von Mises stress findings in non-splint models
was intended to determine the desired C/R ratio
beyond which splinting was of little use. Stress (MPa)
In part 3, three splinted crown models with 1 mm,
4 mm, and 8 mm of bone loss were loaded with a non- AP5 Crest AP4
axial load of 25 N directed 15º towards the mesial Normal 1.477 0.141 1.990
to evaluate the effects of non-axial loads. With 4 mm of bone loss 1.559 2.129 1.405
Application of a vertical force of 25 N at each With 8 mm of bone loss 2.099 3.405 2.253
occlusal surface of the premolars was based on pre-
AP5 = apical area of the second premolar; Crest = intercrestal
vious studies.10,11 von Mises stresses were evalu-
area between the premolars; AP4 = apical area of the first
ated in three locations in the bone for all models: premolar.
the apical area of the first premolar, the apical area
of the second premolar, and the alveolar crest be-
tween premolars midway buccolingually reached
trough slicing the models. second premolar, the findings in this area were
1.477 MPa for the healthy model, which increased
to 2.099 MPa in the model with 8 mm of bone loss. In
Results the alveolar crest area, the findings began at
0.141 MPa for the healthy model and increased to
Results are divided according to the stages of this 3.405 MPa in the model with 8 mm of bone loss.
study. Loading non-splinted crowns revealed a higher These findings showed a predictable increase with
stress in the alveolar crest area than in the apical the progression of bone loss.
area of the premolar (Table 2). In the apical area In the loaded splinted crown models with gradual
of the first premolar, the von Mises stresses in this bone loss, some stress modifications at the three
area were in a range of 1.4−2.2 MPa in different points of assessment were revealed (Fig. 3), and
alveolar bone loss models with no predictable pat- numeric data of von Mises stresses in the different
tern in gradual bone loss. In the apical area of the models are given in Table 3. In the apical area of
Splinting periodontally compromised abutments 5

without showing a clear pattern of changes in the

Table 3. von Mises stress in each model assessed in
the bone socket of the teeth in three different loca- different bone loss models. In the apical area of the
tions midway mediolaterally second premolar, the findings were 1.364 MPa for
the model with 1 mm of bone loss, which increased
Stress (MPa) to 2.865 MPa in the model with 8 mm of bone loss.
C/R ratio The pattern was clearly an increase in this stress
AP5 Crest AP4
with gradual loss of alveolar bone. In the alveolar
0.67 1.495 0.144 2.063 crest area, findings began at 0.297 MPa for the 1-mm
0.80 1.296 0.271 1.955 bone loss model and increased to 0.922 MPa in the
0.95 1.607 0.443 2.008 last phase of the study in the model with 4 mm of
1.14 1.531 0.854 2.059 bone loss.
1.37 1.789 0.861 1.685
1.65 1.832 1.602 2.049
2.00 1.830 1.583 2.163
2.46 1.974 2.010 1.775
Discussion
3.09 3.170 2.083 1.883
Favorable masticatory forces within a healthy peri-
C/R = crown to root; AP5 = apical area of the second premolar; odontium, which thereby avoid occlusal trauma, are
Crest = intercrestal area between the premolars; AP4 = apical a primary concern in partially edentulous restora-
area of the first premolar.
tions. Ante’s law,14 Ewing’s requirements,9 and cross-
arch stabilization26,27 are all clinical guidelines used
to address this fundamental problem. Teeth may
Table 4. Stress findings in non-axial loading (15º shift have a less-than-ideal prognosis as abutments for an
in the vertical) RPD when there is slight mobility or an unfavorable
C/R ratio, perhaps combined with a conical root.1
Stress (MPa) The present study, as well as previous investi-
AP5 Crest AP4 gation,9 demonstrated the preferential develop-
ment of stresses within osseous defects and their
With 1 mm of bone loss 1.364 0.297 2.888 variations with the amount of periodontal support.
With 4 mm of bone loss 1.848 0.922 2.813 These stress concentrations suggest that occlusal
With 8 mm of bone loss 2.865 0.613 2.907 forces can exacerbate the situation in the defect
AP5 = apical area of the second premolar; Crest = intercrestal region and possibly cause further bone resorption,
area between the premolars; AP4 = apical area of the first depending on their magnitude and frequency. Loss
premolar. of bone support increases the maximum stresses
generated in the supporting structures, especially in
the alveolar bone crest. After horizontal bone loss
the first premolar, the findings of the von Mises from periodontal disease, the PDL-supported root
stresses in this area were around 2 MPa in all phases surface area can be dramatically reduced. In addi-
of alveolar bone loss. These findings did not show tion, bending moments affecting the supporting bone
a clear pattern of changes in different bone loss may be magnified because of the greater leverage
models. It could be considered to be the same in associated with a lengthened clinical crown. That
the various models. In the apical area of the second may explain the increased deflection and stress gen-
premolar, the findings were 1.495 MPa for the model erated in models with low bone support.28
with 1 mm of bone loss, which increased to 3.170 MPa A splint, according to the Glossary of Periodontic
in the model with a C/R ratio of 3.09. The pattern Terms is “an appliance designed to stabilize mobile
clearly showed an increase in stress with a gradual teeth”.3 There is general agreement to splint bilat-
loss of alveolar bone. The increase in stress reached eral distal extension cases to their healthy adjacent
twofold. In the alveolar crest area, the findings began teeth when the terminal abutments have reduced
at 0.144 MPa for the 1-mm bone loss model and in- support or unfavorable root forms.
creased to 2.083 MPa in the last phase of the study The improvement in stress distribution to the sup-
in the model with a C/R ratio of 3.09, which was porting structures with fixed splinting was demon-
about a 14.5-fold increase. strated for both mandibular and maxillary RPDs with
With application of non-axial loads in the three various attachment retainers.3,13,29 The results of
splinted crown models with 1 mm, 4 mm, and 8 mm our study with respect to the effect of fixed splinting
of bone loss, the efficiency of splinting with non- are in agreement with previous articles3,13,29 How-
axial loads was revealed (Table 4). In the apical area ever, there were some differences in the maximum
of the first premolar, the von Mises stresses were stresses and their distributions observed within the
2.81−2.90 MPa in all phases of alveolar bone loss periodontal structures after fixed splinting.
6 A. Geramy et al

The findings of the present investigation indicated 4.0 AP5

that fixed splinting of periodontally compromised 3.5 Crest
teeth can reduce the stress in the interdental crest

von Mises stress

3.0 AP4
area compared to the loading of non-splinted crown 2.5
models, which can protect this weak area against 2.0
destructive stresses. Indeed, fixed splinting improves
1.5
the stress distribution in the surrounding bone and
1.0
transfers stress from the interdental crest to the
0.5
apical area of teeth where there is better resistance.
Another point worth mentioning in this part of the 0.0

67

80

95

14

37

65

00

46

09

00
study was the von Mises stress findings of the cre-

0.

0.

0.

1.

1.

1.

2.

2.

3.

4.
stal bone in the healthy tooth structure model. This Crown to root ratio
stress was lower than the apical stress of both premo-
lars. This prevents us from splinting healthy teeth Fig. 4 von Mises stresses in apical areas and crestal bone.
AP5 = apical area of the second premolar; Crest = intercre-
for retention after orthodontic treatment.
stal area between the premolars; AP4 = apical area of the
The efficiency of splinting in non-axial loading first premolar.
was also shown in this study (Table 4). Although
fixed splinting is a time-honored method of improv-
regions (Fig. 4). But with higher C/R ratios, stresses
ing the status of weak abutments, there are certain
in the supporting structures significantly increase,
precautions that should not be overlooked. It is sel-
and this periodontally questionable tooth should
dom beneficial to splint an extremely weak abutting
be condemned in favor of using an adjacent healthy
tooth to a strong one. The result is generally to
tooth as the abutment, even though the span is
weaken the strong abutment rather than strength-
increased by one tooth by doing so.
ening the weak abutment.28,30 Phoenix et al.1 be-
To construct a finite element model, it is usually
lieved that sometimes it is advantageous to sacrifice
necessary to simplify the system by making some
a periodontally compromised tooth if an adjacent
assumptions. The final model represents an average
tooth can serve as a better abutment.
clinical situation, and generalization of its results
Previous studies reported that the lifespan of RPD
should be done with care.40,41 Therefore, because
abutments greatly depends on the quality of peri-
the finite element models used in this study do not
odontal support rather than its quantity.31,32 It was
identically reproduce all clinical situations, the appli-
demonstrated that teeth with bone loss may success-
cation of the results should be tempered with sound
fully be used as RPD abutments if splinted properly,
clinical judgment. However, this study suggests that
and their long-term maintenance is ensured.33,34
when an abutment displays decreased periodontal
Kratochvil and Caputo35 showed that physiologic
support, fixed splinting may provide adequate sup-
adjustment has a great influence on the direction
port and stabilization for an RPD, but it is not a me-
of force exerted on the abutments, PDL, and bone
thod of salvaging a tooth with an otherwise hopeless
supporting a distal-extension RPD. An unadjusted
prognosis.
casting exerts a tipping and torque action on the
Within the limitations of this 3D finite element
teeth and periodontium. Previous photoelastic and
stress analysis study, the following conclusions were
finite element stress analyses showed that an ad-
drawn: (1) splinting a tooth with reduced bone height
justed RPD has a favorably altered stress distribution
to an adjacent healthy tooth redirects stress from
in the periodontium with severe supporting bone
the bone crest to the apical areas of both teeth; (2)
loss.2,5,36−39
even after fixed splinting of two abutments, grad-
Nyman and Lindhe16 showed that under normal
ual loss of bone support increases the stress in the
circumstances, a C/R ratio of 1:1 is considered the
alveolar crest area; (3) fixed splinting of a very weak
minimum ratio that is acceptable for a FPD abut-
abutment to an adjacent healthy tooth might not
ment. Itoh et al.3 believed that positive effects
be beneficial (the maximum acceptable C/R ratio
of fixed splinting of RPD abutments are more pro-
for fixed splinting of a weak abutment to adjacent
nounced as the severity of the periodontal defect
normal tooth was shown to be 1.65−2); and (4)
increases. A review of RPD therapy by Phoenix et al.1
splinted teeth can tolerate non-axial loads.
pointed out that a tooth that has lost more than
50% of its bone support is a poor candidate for fixed
splinting. In contrast, the findings of our study sug-
gest that by fixed splinting of a weak abutment even
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