lin Oral Impl Res 1995: 6: 40-48 Printed tn Dennark al rights reserved Copyright © Mankseacrd 1995 CLINICAL ORAL IMPLANTS RESEARCH ISSN 0805-716) Vertical load distribution on a three-unit prosthesis supported by a natural tooth and a single Branemark implant An in vivo study Rangert B, Gunne J, Glantz P-O, Svensson A. Vertical load distribution on a three-unit prosthesis supported by a natural tooth and a single Brénemark implant. An in vivo study. Clin Oral Impl Res 1995: 6: 40-46. © Munksgaard, 1995 in vivo bite forces, implant axial forces and bending moments were meas- ured on 5 patients with fixed posterior prostheses supported by a natural tooth and a single Branemark implant. The results demonstrate that the vertical loads applied to the prostheses are shared between the tooth and the implant. The maximum bending moment transferred to the im- plant (10-15 N-cm) was well below the acceptable load limits for the mech- anical components (50-60 N-cm), even at bite forces exceeding 100 N. ‘The main reason for this load sharing seems to be the inherent bending flexibility of the implant screw joint, which matches the axial flexibility of B. Rangert’, J. Gunne?, P.-O. Glantz’, A. Svensson* ‘Nobelpharma AB, Goteborg, 2Department of Prosthetic Dentistry University of Umea, “Department of Prosthetic Dentistry, University of Lund, Malmo, Sweden Key words: BRANEMARK SYSTEM* implant ~ connection ~ in vivo measurement ~ axial load - bending moment — tooth mobitty Bo Rangert, Nobelpharma AB, Box 5190, $-40226 Goteborg, Sweden the periodontal ligament of the tooth. Over the years since osseointegrated implants were introduced, there has been some controversy con- cerning the appropriateness of connecting im- plants to teeth in fixed prostheses. The osseointe- grated implant does not have any periodontal liga- ‘ment and is therefore more firmly anchored to the bone. This difference in bone attachment has raised the concern that an osseointegrated implant may be too rigidly fixed and too stiff to share the functional loads with connected teeth. The IMZ implant is designed with an intramobile element to overcome the stiffness (Kirsch & Ackermann 1989). The Branemark implant does not comprise such an element. However, it has been demon- strated (Sekine et al. 1986) that the Branemark im- plant has a clinically measurable lateral flexibility, which is due to a combination of elasticity of the supporting bone and the implant components. ‘One elementary case of connection is a pros- thesis supported ‘by one implant and one tooth. The feasibility of this therapy, using Brinemark 40 ‘Accepted for publication 6 June 1994 implants, has been demonstrated in case reports (Ericsson et al. 1986; Sullivan 1986: Naert 1991) and has been documented in a longitudinal in vivo study (Astrand et al. 1991; Gunne et al. 1992). An obvious advantage of connection in this situation is that it accommodates a fixed prosthesis where the anatomy only allows for the placement of one implant. This case has been investigated from the mechanical point of view in vitro (Rangert et al. 1991), showing that a single Brinemark implant has an inherent bending flexibility that matches the axial mobility of a connected tooth. The purpose of this study was to measure the in vivo vertical load distribution on a fixed bridge supported by one tooth and one Brinemark implant, rigidly connected to each other (Fig. 1). Jn vivo measure- ments of lateral loads on a single IMZ implant in the molar region, connected to a tooth in the pre- molar region, have earlier been performed on 10 patients; Richter et al. (1992) reported lateral bending moments up to the order of 25 N-cm dur-Fig. 1, One implant and one tooth rigidly connected by a pros- thesis Fig. 2. Prosthetic bridge with MaeCollum attachment and lock= ing serew Fig. 3. Strain-gauged abutment in situ ing occlusion and chewing, To our knowledge, no data has been presented of int vivo registered axial forces on a fixed bridge supported by one tooth and one implant rigidly connected to each other. Material and method Patient selection Of 23 consecutive patients treated with fixed pros- theses, each supported by one implant ad modum Vertical load distribution Brdnemark connected to a natural tooth, at the University of Umea, Sweden (Astrand et al. 1991; Gunne et al. 1992), 5 were selected for load meas- urements with strain-gauged implant abutments, ‘The selection criteria were 1) 5.5-mm or 7-mm abutment heights being used (the available sizes of abutments equipped with strain gauges) and 2) pa- tient willingness to participate in the experimental set-up. All patients were women with a mean age of 65 years, ranging from 59-71 years. Their partial ed- entulism was classified as Kennedy Applegate Class I. Each patient had a prosthesis in the lower jaw supported by one implant in the second pre- molarifirst molar position and one tooth in the cuspid/first pre-molar position. On the other side of the residual front teeth, the patients had a free- standing implant supported prosthesis in the corre- sponding positions. The prostheses had been worn for 5 years (4 patients) and 6 years and occluded to removable complete dentures. The connection was of a rigid type accomplished by a MacCollum attachment with a horizontal locking screw pre- venting axial mobility of the attachment (Fig. 2). The positions of implants and teeth supporting the prostheses are documented in Table 1 Strain gauge measurement ‘The technique for load registration on Brinemark implants, based on strain-gauged implant abut- ments, has been comprehensively described else- where (Glantz et al. 1993 comprises the following. A standard abutment (BRANEMARK — SYSTEM®. — Nobelpharma, Sweden) is equipped with a minimum of 3 strain gauges for registration of axial strain of the abut- ment surface. The implant abutment is subjected to a number of in vitro loading conditions (axial forces and bending moments) for calibration pur- poses. From this calibration, the coefficients can be calculated that correlate any in vivo measured strains to a specific combination of axial force and bending moment applied to the abutment. In this study, abutments with 3 strain gauges each were used. A strain-gauged abutment in situ is seen in Fig. 3. Table 1. Positions of prosthesis units Pam 91200 84S Implant = 45 GG Ponic = «4—= 455 BSH Tooth ao 4 4 8B aRangert et al. 140 Bie force Tine increment in secons Fig. 4. A load cycle for a bite on the fork demonstrating bite force, implant force and implant moment 160% aos | 120% | 00% 20% ee} Patient eT aon} 28 | a _ Tooth Patient #2 Imptont Postion of bite for Fig. 5. Relative implant forces vs position of the bite fork (pa- tients with mean biting force 12 N) Connection of the strain-gauged abutments The patients’ bridges were removed and the orig- inal abutments were replaced by previously strain- gauged and calibrated abutments. The orientation of the gauges was identified by the position of the wiring, and the patients were photographed to document these positions. The patients’ original bridges were then attached to the strain-gauged abutments by the prosthetic gold screws, and the locking screw of the bridge attachment was tightened. No deviation from the standard pro- cedure of bridge connection was made. in vivo loading conditions The patients were asked to apply maximum bite force on a specially designed bite fork, width 10 mm and height 5 mm (Glantz & Stafford 1985), The bite force was registered simultaneously as the load registration on the abutment. The bite fork was placed in 3 typical positions: 1) above the tooth, 2) on the pontic between tooth and implant and 3) above the implant. Presented load values ‘Two sequences of bite force registrations were per- formed on each patient. The values presented are 42 the mean values of these two load cycles. Each load cycle had a duration of 2-3 s. One typical load cycle is presented in Fig. 4. As the bite force varies over time, the ratio between the measured load on the abutment and the applied bite force (relative force) was calculated. The length of the period for calculating the relative force was limited {o ensure that the relation between bite force and implant force was sufficiently constant. The inte- gration time for this mean value calculation was typically 1 s. The mean value of the relative force times the mean value of the maximum bite forces (implant force) was calculated. The force on the tooth was presented as the difference between the bite force and the implant force (tooth force), The bending moments are presented as the maximum values of the vector sums. The inte- gration time was typically 0.1 s. The reason for not presenting each vector component separately is that the implant position and angulation relative to each individual prosthesis varied significantly from patient to patient and detailed analysis of the moment direction was not found to be essential for this investigation, Results Patient groups with reference to biting ‘The maximum bite forces applied by each patient during the test cycles are presented in Table 2. The patients were divided into two groups, according to the magnitude of these forces, 2 light-biting group (mean force 12 N) and a hard-biting group (mean force 95 N). Force distribution The relative forces on the implants, versus the posi- tion of the bite fork, are presented for each patient in Fig. 5 and 6. The implant forces and tooth forces, versus the position of the bite fork, are pre- sented in Fig. 7 and 8 respectively. For the light- biting group. the implant force was rather con- Table 2 Patiet Tooth Pontic Implant Mean (all units) ‘Mean maximum biting force (N) of lght-biting group at 6% 1915 18 2 en) 1 Total mean 12.N Mean maximum biting force (N) of hard-iting group 8 73 10595 93 4 3 MAT 90 Total mean 95 NY 6 75 2% 101