2001 Lara G. Bakaeen
2001 Lara G. Bakaeen
2001 Lara G. Bakaeen
INTRODUCTION 1989.19 The conventional implant ver- tooth implants, unless the load is di-
tical stack is composed of the implant, rectly centered and parallel to the im-
everal clinical studies have
S
abutment, abutment screw, gold cylin- plant, a bending moment will always
evaluated implant-retained
der, and retaining screw. When assem- be present, even with a short lever
and supported prostheses in
bled, these components form 6 joints arm.22
complete and partially eden-
(interfaces).20 Several authors recommended re-
tulous patients. Although
As the screws are tightened past the ducing the width of the occlusal table
most of these investigations
finger-tight stage, a preload is applied to favor axial load on the implant in
had a high success rate, abutment and
to the screw and introduces a com- nonaesthetic regions.12,26–29 Reducing
prosthetic screw loosening was the
pressive stress as the components are the buccolingual width of a restoration
most frequently encountered compli-
being clamped together.3 Forces at- is not a new concept in dentistry. In
cation.1–8 Few studies have been pub-
tempting to disengage the parts are 1935, Schuyler30 advocated reducing
lished evaluating the outcome of sin-
called joint-separating forces. These the contacting surfaces as a means of
gle-tooth implant replacements, partic- forces must remain below the thresh- adjusting occlusal dysharmony, which
ularly molars.8 old of the established clamping force could result in occlusal trauma. Dyke-
Clinical documentation of single- and depend on many factors.20 Screw ma31 advocated narrowing the bucco-
molar, implant-supported restorations loosening occurs as a result of a lingual dimensions of pontics up to
is limited9 with an unknown long-term change in deformation among the 40% as a means of reducing load on
outcome.10 Several clinical studies have screw and connected members in re- the abutments. Weinberg29,32 suggested
reported a higher complication rate for sponse to an external load applied to a narrowing the occlusal table and/or
implant-supported restorations in the preloaded joint.21 moving the occlusal contact area more
premolar and molar regions.11–13 The Settling effect plays a critical role in in line with the implant location as one
greatest amount of force is generated screw stability. Settling occurs as the means to reduce the shearing stress on
in the first molar region during masti- rough spots (no surface is completely the retaining screws.
cation, with the chewing occurring pre- smooth) flatten under load, since they Since a molar is not equally wide as
dominantly in the first molar and sec- will be the only contacting surfaces it is long, it is difficult to provide op-
ond premolar regions.14,15 when the initial tightening torque is timal root-form support with 1 cylin-
Becker et al16 presented the results of applied.22 It is assumed that 2% to 10% drical implant. The placement of a
a retrospective analysis, which repre- of the initial preload is lost as a result crown that extends beyond the diam-
sented the first report of replacing sin- of settling,21 and as a result, the torque eter of the implant both mesiodistally
gle molars with implant-supported necessary to remove a screw is less and buccolingually are potential bio-
prostheses. Loosening of the gold re- than the torque used initially to place mechanical problems, which can lead
taining screws was the main compli- the screw.20 Thread friction is higher to screw loosening, fracture, and im-
cation. Balshi17 described the use of 2 for the first tightening and loosening of plant fatigue. The use of 2 implants
implants for the replacement of a sin- the screw. It then decreases after re- may help reduce these forces.
gle molar and reported success at a 1- peated tightening and loosening cy- The purpose of this study was to (1)
year follow up. The rationale was a bet- cles.23 It has been suggested that joints determine the effect of narrowing the
ter distribution of forces to the alveolar be tightened after the initial screw in- buccolingual width of the occlusal ta-
bone and greater stability of the pros- sertion and periodically thereafter.24 ble on the untightening torque re-
thesis. In retrospective comparative Screw loosening may be an early quired to loosen the gold screws after
analyses by Balshi et al,9,18 single mo- warning sign of biomechanical design subjecting implants and implant-sup-
lars were replaced by either 1 or 2 im- problems or occlusal overload.25 Ran- ported structures to occlusal loads,
plant-supported prostheses. During a gert et al19 described the implant as a and (2) to compare the incidence of
3-year evaluation period, screw loos- system with compensating forces and screw loosening and values of untigh-
ening was the most frequent compli- a lever arm, with the axial forces and tening torque of screws between
cation and was predominant in the bending moments being the main crowns supported by 1 wide-diameter
group with 1 implant. In a clinical re- types of loads acting on the implant- as opposed to 2 standard implants af-
port on wide and double implants in supported prosthesis. Axial forces are ter loading.
the posterior jaw, Bahat et al10 reported more favorable. A bending moment
higher failure rates for single implants MATERIALS AND METHODS
tends to produce rotation of a rigid
as compared with double implants. body. Bending moments could be the Two abutment-implant combinations
The theoretical concept of ‘‘preload- result of axial forces remote to a (2-implant assembly and wide-body
ing’’ implant components was intro- straight line combining 2 or more im- assembly) were tested with 9.8-mm
duced to the dental profession in plants or transverse forces. In single- (wide) and 8.4-mm (narrow) buccolin-
FIGURE 3. The gold cylinder is lowered into the mold 1.5 mm from the replica of the occlusal surface. A sprue within a sleeve is used to
maintain the 1.5-mm distance for all of the wax patterns.
FIGURE 4. The custom-designed chewing machine.
FIGURE 5. Computer-generated schematic line drawing of the custom-designed chewing machine. (A) Top view: (1) base plate, (2) loading
handle, (3) loading screw, (4) spring housing, (5) spring, (6) strain gauge, (7) fixed crown, (8) aluminum cam, (9) tested crown, (10) crown
fixture holder, and (11) rotating table. (B) Side view: (12) counting cam, (13) limit switch, (14) DC motor, and (15) spring housing holder.
the central fossa. This position was poration, Louisville, Ky) using a lined were then fixed to the corresponding
then indexed to ensure reproducibility. casting ring. The investment was al- implants with flat-headed gold screws
The 2-implant assembly was placed so lowed to bench set for 30 minutes ac- and tightened to 10 N-cm. The access
that the gold screws were over the ap- cording to the manufacturer’s instruc- holes were filled with cotton pellets
proximate area of the mesial and distal tions, and then burned out at 9008F at and sealed with composite resin.
triangular fossae. To reduce the possi- a rate of 188 per minute. Type III gold A custom-designed chewing ma-
bility of distortion of the wax pattern alloy (Majority; Ney Dental Interna- chine was constructed (Figures 4 and
over the 2 gold cylinders, pattern resin tional, Bloomfield, Conn) was used to 5A and B) to evaluate the untightening
was used to connect the gold cylinders cast the full crown restorations. The torque of the gold screws after func-
prior to dipping them in wax. The po- crowns were devested and cleaned ul- tion.
sition was then indexed. The remaining trasonically for 20 minutes. The crowns A gold crown representing the op-
part of the crown was waxed free hand were then placed in a pickling solution posing tooth was fixed by the crown
to the gold cylinder. The screw holes for 10 minutes and finished and pol- axle. The crown axle was molded with
were defined and the crowns un- ished by conventional methods. the crown on one end and touched a
screwed. The torque gauge was used to en- spring form on the other end by means
The wax patterns were sprued and sure that each abutment screw was of a disc. The other end of the spring
invested (Beauty Cast; Whip Mix Cor- torqued to 20 N-cm. The gold crowns was in contact with a disc that is con-
FIGURE 8. (A) The relationship of the crowns FIGURE 9. (A) The relationship of the crowns FIGURE 10. (A) The relationship of the
as they assume an intercuspal position. as the motion progresses. Contact is be- crowns further during the testing cycle.
Contact is between the palatal inclines of tween the corresponding buccal and lingual Contact is between the buccal inclines of the
the fixed crown (upper) and the buccal in- cusps. (B) Schematic representation of tooth buccal cusps of the fixed crown (upper)
clines of the test crown (lower), and be- contact. against the lingual inclines of the buccal
tween the palatal inclines of the palatal cusps of the test crown (lower). (B) Sche-
cusps of the fixed crown (upper) and the matic representation of tooth contact.
lingual inclines of the lingual cusps of the
test crown (lower). (B) Schematic represen- The crown samples were rotated back
tation of tooth contact.
and forth within the rotating table us- plants were numbered from 1 to 6
ing the switch button designed for cal- (group 1 5 implant 1; group 2 5 im-
cal screws at the bottom of each hold- ibration, which produced both clock- plants 2 and 3, where 2 represents the
ing cylinder until the disc attached to wise and counter clockwise motion as mesial side and 3 the distal side of the
the fixed crown assumed the refer- desired. Rouge and chloroform were test crown; group 3 5 implant 4; and
enced position. Once this position was used to check the consistency of the group 4 5 implants 5 and 6, where 5
obtained, the acrylic blocks holding the gliding motion on the inclines of all represents the mesial side and 6 the
samples were secured in place by crowns. The cams were then tightened distal side of the test crown). The un-
tightening the horizontal holding and their positions were indexed. The tightening torque was measured for
screws of the holding cylinders. crowns were subjected to 16 660 cycles the gold screws in the different groups
The aluminum cams on both sides of over 5.5 hours under 6 kg of load. before and after loading at 4 different
each crown were calibrated to ensure To account for the presence of 2 locations for 8 cycles on the simulated
that the desired motion was achieved. screws within groups 2 and 4, the im- chewing machine.
TABLE 1
Mean change scores and SD
Implant Mean* (N-cm) SD
Narrow crown/5-mm wide implant 0.2068 0.2853
Narrow crown/mesial, 3.75-mm implant 0.1000 0.1069
Narrow crown/distal, 3.75-mm implant 0.0750 0.0802
Wide crown/5-mm–wide implant 0.7000 0.1463
Wide crown/mesial, 3.75-mm implant 0.1063 0.0863
Wide crown/distal, 3.75-mm implant 0.1313 0.0593
*Mean of the difference between the untightening torque before and after loading.
TABLE 2
One-way analysis of variance using the Delta Test
Sum of
Source df Squares Mean Square F Pr . F*
Model 5 2.307 0.461 21.03 0.0001
Error 42 0.922 0.022
Corrected total 47 3.229
*A significant difference exists at P , .001.
TABLE 3
Scheffe test
Scheffe
Grouping Mean* (N-cm) Implant
A 0.7000 Wide crown/5-mm–wide implant
B 0.2689 Narrow crown/5-mm–wide implant
B 0.1313 Wide crown/mesial, 3.75-mm implant
B 0.1063 Wide crown/distal, 3.75-mm implant
B 0.1000 Narrow crown/mesial, 3.75-mm implant
B 0.0751 Narrow crown/distal, 3.75-mm implant
*Means with the same letter are not significantly different. Implant combination 4 was
significantly different from other groups.
FIGURE 11. (A) The relationship of the with a 5 .05 (Table 3). Implant 4 utes following the protocol suggested
crowns at the end stage of the testing cycle. (group 3) was significantly different by Dixon et al33 and Breeding et al.34
Contact is between the palatal cusps of the
fixed gold crown (upper) and the buccal in- from the other groups, which were not Although the untightening torque after
clines of the lingual cusps of the test crown significantly different from each other. subjecting the crowns to simulated
(lower). (B) Schematic representation of function was less than the untighten-
tooth contact. DISCUSSION
ing torque before loading for most of
All of the prosthetic gold screws tested the screws, the difference was insignif-
were tightened to 10 N-cm according icant when using 1-way analysis of
RESULTS
to the manufacturers’ instructions. The variance to describe the remaining
Using ‘‘change scores’’ (Table 1), a 3- untightening torque of the screws in groups (1, 2, 3, 5, and 6).
way analysis of variance (implant, lo- the different groups tested was about A study by Murphy35 showed that
cation, and cycle) indicated that there 2 N to 3 N less than the tightening the teeth contact only 5.9% of the time
was no significant difference between torque. These observations correspond during a mastication cycle. Outwaite et
cycle or location. Data from location to the findings of Shigely and Mis- al36 estimated that 1 million cycles of
and cycles were pooled. A 1-way anal- chke22 of a 2% to 10% reduction in pre- loading was equivalent to 5 years of
ysis of variance indicated a significant load within the first few seconds or heavy wear in the mouth. Using this
difference (Table 2; P , .001) among minutes after tightening as a result of estimate, Breeding et al34 estimated
implants. Pairwise multiple compari- the settling effect (embedment relaxa- that a month of intraoral loading re-
son tests using the Scheffe test were tion). To reduce the settling effect, the sulting from mastication would equal
carried out on mean change scores, screws were retightened after 10 min- 16 667 cycles.
Untightening torque after Prostheses mobility and screw loosen- distal space, and quality and quantity
simulated function ing were the most frequent complica- of bone are some of these factors. Ac-
tions associated with 1-implant molar cording to the results of this study, giv-
The finding that a wide-diameter im- restorations. The findings are also in en the same conditions, crowns sup-
plant with a wide occlusal table result- agreement with the study of Bahat et ported by 2 implants showed more fa-
ed in a loose screw on all of the post- al10 in which restorations supported vorable results and suggest the use of
load measurements is of significance. with 1 implant had a higher failure rate 2 implants to restore missing molars
When removing the wide-diameter as compared with restorations sup- whenever possible. If a single implant
sample (group 3) from the remaining ported by 2 implants. is to be used, special consideration
samples, there was no significant dif- should be given to the occlusion and
ference in the untightening torque Buccolingual width
the width of the occlusal table, partic-
among the test specimens. As the results of this study demon- ularly when dealing with patients with
The use of 2 implants to restore a strated that the buccolingual width is heavy masticatory forces and/or para-
molar tooth more closely mimics the not as critical when dealing with 2 functional habits.
anatomy of the roots being replaced standard implants as compared with 1 Although the problem of screw loos-
and doubles the surface anchorage wide-diameter implant, narrowing the ening and fracture might seem a nui-
area. This applies to the implant-sup- occlusal table should be considered for sance, it could be a warning sign to a
ported narrow occlusal table restora- wide-body implants. Reducing the more serious problem, such as over-
tion design and the 2-implant–sup- buccolingual width may require select- load. If the problem is not addressed,
ported wide occlusal table restoration ing a different occlusal scheme, such as more serious and nonretrievable com-
design. a cross-bite relationship or lingualized plications might arise. In addition, re-
The finding that the crowns sup- occlusion, to reduce the bending mo- pair and maintenance visits can be
ported by 2 implants exhibited untigh- ments on the implant and associated time consuming and frustrating to
tening torque of prosthetic screws structures. both the patient and the dentist.
comparable with the untightening During mastication, the entire occlu- Since the consistency and hardness
torque before loading supports the as- sal surface of the tooth is involved both of food decreases during the mastica-
sumption that doubling the implants directly and indirectly.37,38 In this tory process and is difficult to repro-
reduces the chances of rotational forces study, the inner inclines of the lower duce for testing purposes, the chewing
developing, which consequently reduc- molar samples, as well as the outer in- machine was fabricated to provide a
es the likelihood of gold screw loos- clines of the buccal cusps, were in- constant profile. The relatively small
ening.10 volved. Although the outer inclines of anteroposterior movement of the jaw
It has been suggested that 2 im- the buccal inclines are not directly in- during chewing is eliminated, thus
plants offer the advantage of eliminat- volved in the process of mastication, converting the 3-dimensional motion
ing mesiodistal bending and is stron- they are the functional inclines in lat- of the jaw into a 2-dimensional motion.
gest, yet not as efficient, in eliminating eral excursions when a posterior In a prospective study by Walton et
lateral bending forces. Lateral bending scheme of occlusion is adopted (ie, al39 on the maintenance of implant res-
forces are often due to excursive con- group function). If a canine-protected torations in private practice, screw
tacts.18 The results of this study, how- scheme of occlusion is adopted, or the loosening and fractures constituted
ever, demonstrated that the 2-implant tooth is free in excursions, gliding 24% of the complications.
design favorably withstood both me- against these inclines is a concern in
siodistal and buccolingual bending. Limitations of the study
patients with parafunctional habits.
Although the untightening torque for Being an in vitro study, reproducing
crowns with narrow occlusal tables Clinical implications and significance
actual mandibular movements in 3 di-
supported by single implants com- The prosthetic designs and materials mensions is not possible. The dental lit-
pared favorably with the untightening used to restore missing molars in this erature is equivocal when considering
torque before loading, 2 loose screws study might not be the treatment of tooth contact during mastication.15 It is
were observed during the testing cy- choice in every restorative situation. estimated that the teeth contact 60% of
cles. The screws in the wide-body im- The implications of the study, however, the time during the grinding phase.39
plants were loose on all occasions. do apply to most treatment options. The forces of mastication are not con-
These findings agree with the compar- There are many factors, other than the stant during masticatory cycles, but
ative study by Balshi et al9 in which restorative preference of the dentist, tend to vary depending on the man-
molars supported by 2 implants exhib- that play a critical role in determining dibular position and food consistency.
ited fewer complications as compared the location and number of implants Although it is recognized that a hy-
with molars supported by 1 implant. used. Anatomy, availability of mesio- draulic machine with a feedback ser-
vocontroller would be the best option,40 plant 6). Using this parametric analy- This paper was awarded first place in
due to cost considerations a simulated sis, group 3 (a wide crown supported the John J. Sharry Research Competi-
chewing machine was designed to gen- by one 5-mm–diameter implant), tion, American College of Prosthodon-
erate loads through deformation of a group 1 (a narrow crown supported by tists Annual Session, September 18,
coil spring of known stiffness by one 5-mm–diameter implant), and 1998, in San Diego, Calif. It was pre-
means of a rotating cam. There are group 4 (a wide crown supported by 2 sented before the American Academy
many studies in the dental literature standard 3.75-mm–diameter implants) of Implant Prosthodontics on Septem-
that have used machines of different were not significantly different from ber 22, 2000, in Lake Buena Vista, Fla.
designs to simulate masticatory func- each other. Within the parameters of This paper was based on a thesis sub-
tion. The chewing machine, custom de- this study and when using both para- mitted in partial fulfillment of the re-
signed for and used in this study, test- metric and nonparametric analyses, quirements for Dr Bakaeen’s degree of
ed the motion of 2 antagonistic teeth the single wide-diameter implant did Master of Science in the Graduate
against each other, which resembles a not compare favorably with the 2-im- School of Temple University, Philadel-
natural situation. plant restorative design. Using the phia, Pa, 1998.
It would have been preferable to nonparametric test, the width of the
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