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
remains unparallelled.1-4It has provided the basis for
our current confidence in implant prosthodontics.
This research was based on the restoration of the
fully edentulous arch in which four to six implant
fixtures were placed between the medial walls of the
maxillary sinuses or the mental foramina for construc-
tion of a fixed implant prosthesis. Prosthesis success
rates of 99% in the mandible and 92% in the maxilla
have been reported when strict criteria for success
were followed.2However, prosthodontic design con-
cepts have been based primarily on theoretical con-
structs or extrapolation of classic prosthodontic
theory. The biomechanical aspect of implant prosth-
odontics requires further investigation.
Beam and Cantilever Theory
In 1952, Smyd5 first analyzed fixed partial dentures
based on accepted engineering principles of a beam.
He explained that a beam supported at both ends is
subject to both compression and tension upon load-
*StaffProsthodontirt, VeteraniAdminzstralion Medlical Center, High-
land h u e , Pittsbuqh, Pil; Arrutant ProJiimr, Drjmtmenl ofReJtoralive
fintishy, L'nioersity ofPittsburgh School of Dental Medicine, Pittshurgh,
PA.
tProji,rsor and Graduale Prozram Dzrectw, Department ofProrthodon-
tics, linioenity oJiIoorfia College oJiDentisly,IozNa City, L4.
$Assistant Prnjxror,Department ofprohdontics, linicersiy ofIowa
Cullege ofDntistv>Ames.
Corresfindencr to: Arthur M. Rodripz, DMD, MS, L'eterun s' Admin-
irtration medical Cpnlur,HighlandDn'ce,Pittsburgh, PA 15206.
C o p ~ g h0t 1994 @ the Amm'can College ojPmsthodonti.rts
I05!&94IX/94/ 0301-0008$.5.00/ 0
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
neutral axis. Above this axis, the beam is subjected to
compression, and below, to tension."." Also, the bend-
ing moment of the beam, or deflection, varied in-
versely with the cube of the depth and directly with
the cube of the length? Therefore, if a beam was
doubled in length, or its depth cut in half, its
flexibilitywould be eight times as great.jJ
The shape assumed by the neutral axis of a beam
supported on each end during deflection or elastic
bending is referred to as the deflection curve. The
shape of this curve is a function of the bending
moment (M) of the beam, the modulus of elasticity
of the material (E) and the moment of inertia of the
entire cross-sectional area (I). This deflection curve
relationship is defined by M/EI. This product, EI, is
referred to as the flexural rigidity or bending modu-
lus of the
In engineering terms, all resultant forces acting
on the fixed partial denture or the beam and its
support must equal zero for a state of equilibrium to
exist.9 The reactions from added restraints or mul-
tiple abutments (greater than two), however, cannot
be determined from simple equilibrium equations
alone.6Variations of irregular beam shape and non-
linear supports make the applicability of engineering
equations to the clinical situation even more compli-
cated.
A cantilever fixed partial denture (F'PD) is one
that has an abutment or abutments at one end only.
The other end of the pontic remains unattached.j
This creates a class I lever system, which dramatically
alters the direction and magnitude of forces on the
abutment teeth. Authors warn against the use of

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

42 Cantilever and finplant Biomechanics
cantilevers in FPD d e s i g ~ i . ~Ewing'
J ~ I enumerated
factors that he considered critical when comidering
the use of a cantilevered FPD and clinical situations
in which its use could be beneficial. In situations
invohing natural dentitions, the periodontal attach-
ment, alveolar support, root morpholog of abut-
ments, and favorable arch-to-arch relationships were
critical factors to be considered when planning the
u5e of a cantilever FPD.
Crabb,12 S~hweikert,'~ and Wright'* listed guide-
lines and recommendations for the use of cantile-
vered tooth-supported FPDs. Recommendations in-
cluded careful force considerations and extreme
caution along with good periodontal support and
maintenance. They also expressed limited optimism
for posterior cantilever FPD success. Schweikert"
recommended full coverage for all abutments and a
metal of high melting temperature, good strength,
and good hardness. A gold-palladium alloy was sug-
gested to resist thermal distortion during porcelain
application and bending stresses during function.
Schweitzer et all5 expressed many of these same
concerns. They also theorized that the farther away
from the fulcrum (distal abutment) or the longer the
cantilever, the more efficient the force transfer and
the lower the force necessary to produce the same
stress at the abutments. Therefore, the longer the
lever arm, the greater the number and support o f
abutments necessary. Schweitzer et al also hypoth-
esized that upon loading a distd cantilevered pontic,
the most distal abutment would be depressed and
the more anterior abutment would be elevated.
Henderson et all6 examined stress transfers to
abutments in a cantilever FPD. They showed that as
the number of abutments decreased, the resultant
force imparted to the abutments during cantilever
loading increased. This resultant force was often
greater than the actual force applied to the cantile-
ver. In addition, the most distal abutment consis-
tently received the greatest percentage of force. The
direction of force imparted to the abutment farthest
from the cantilevered pontic in a multiple abutment
FPD was vcrtically upward during axial or 4.5" load-
ing. Their in vitro study used a four-unit FPD with
mandibular canine and first and second premolar
abutments with a distal premolar pontic. Strain
gauges were used to convert pontic movement to
magnitude of force. Although no statistical analyses
were performed, the previously stated trends were
evident.
Glantz et all7investigated magnitude and direc-
tion of strain in a supported FPL) and a cantilever
Rodriguez,Aquilino, and Lund
design in vivo. They studied one patient with a
six-unit conventional FPII involving two mesial abut-
ments, one distal abutment, and a bar representing
the pontic span. Strain gauges were placed on the
underside or cenical surface of the pontic bar.
During occlusal loading of the conventional FTD,
strain was mainly positive (+) showing tension or
elongation as prcdicted by Smyd.j After sectioning
the distal abutment, most strain was recordcd as
compression (-). With an unsupported end, the
pontic span was then being compressed on the
underside by the occlusally directed force. As cantile-
ver loading progressed distally (ie, effectivc cantile-
ver length increased), strain immediately distal to
the terminal abutment increased and strain between
the two mesial abutments dccreascd.
Heringlake and Goodkind'* studied the mobility
of three supporting abutments (canine, first and
second premolars) for a single pontic cantilevcr
(premolar pontic) in vivo. Mobilities were recorded
over a period of timc for all abutmcnts while varying
the number of abutments supporting the cantilever
pontic. Because only mobility was recorded, it could
not be shown that the abutment adjaccnt to the
pontic received more than 50% of the load as was
shown by Henderson et However, it was shown
that the distal abutment (second premolar) had the
greatest mobility throughout the study. As fewer
teeth supported the cantilevered pontic, the mobility
of these abutments increased. After sectioning the
canine and first premolar from the cantilever prosthe-
sis, and allowing them to function as single units,
their mobility dccreased.
Theoretical Implant
Biomechanics
The use of osseointegrated implants for prosthesis
support complicates prosthetic biomechanics be-
cause of the rigid nature o f the implant fixture^.'^^^"
The most frequently quoted literature regarding
implant biomechanics has been thcoretical in na-
ture.'""
BrunskP defined biomechanics as the application
of engineering mechanics to the solution of biological
problems. Brunski8 also emphasized the importance
of the effects of biomechanical principles on the
overall goals of implant design: (1) to support loads
without fracturing, and (2) to transmit these forces
and moments to interfacial tissues in ways that avoid
damage to these tissues.
SkalakIq theorized that the stiffness, k, of an
 March 1994, T70lume 3. Number I
implant in bone was the proportionality constant
relating axial force (F) to axial intrusion (x) of the
implant (k = F/x). As compared with a natural
tooth, this k value was large and was analagous to a
spring constant. Richter,20using a spring resistance
analogy similar to Skalak, estimated that the resil-
ience of the implant/bone system was 10 to 100 times
higher than that of a natural tooth in bone. There-
fore, under similar loads, an osseointegrated implant
would absorb a greater amount of stress (ie, Force/
Area) as compared with a natural tooth.
Brunski et a1,22 in a study of five-unit tooth/
implant-supported FPDs in dogs, showed that the
more rigid osseointegrated interface absorbed a
greater amount of force than the slightly resilient
fibro-integrated interface.
Rangert et alZ3described the cantilever forces at a
Brsnemark implant fixture when it was attached to a
natural tooth. In their in vitro test, the resilience of
the periodontal ligament accounted for a cantilever-
type force exerted at both the gold screw and the
abutment screw. The abutment/gold cylinder screw
joint of the Brinemark implant acted as a flexible
element in this situation. Moments generatcd by
loading a cantilever extension of a fixed implant
prosthesis could be considerably larger. Rangert
pointed out that although screw breakage or fatigu-
ing may not result from this type of motion, scrcw
loosening could easily occur.
An analysis of the forces acting on the implant
prosthesis was presented by Skalaklg in 1983. He
stated that the implant-supported fixed prosthesis
was a curved elastic beam and that the stiffness of
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
capability of each implant fixture were known. He
warned, however, that the introduction of cantilever
43
forces might increase the maximum load per screw
froin one and one-half to two times the applied load.
The principles theorized by Skalakwere expanded
upon by Rangert et aL2' They described two types of
bending moments in a Brinemark implant-sup-
ported fixed prosthesis that would not be as well
tolerated as axial forces. The first involved forces
exerted on anlerior implant fixtures during loading
of a posterior cantilever with the implants arranged
in an arch-form configuration. The posterior cantile-
ver loading point and the two adjacent implant
fixturcs would function like a seesaw with the termi-
naJ implant fixture as the fulcrum (Fig 1). The
anterior implant fixture would be subjected to a
tensile force proportional to the lever arm ratio
( a h ) . The posterior implant fixture would be sub-
jected to a comprcssive force that would be the sum
of the applied cantilever load and the compensating
tensile force. The tensile force would be of greater
concern because of its tendency to separate compo-
nents.
However, according to Rangert et a1': when more
than two implant fixtures shared the load from a
cantilever, this secsaw analo<gywould not be strictly
applicable. Also, the amount of load transferred to
the unloaded side of the prosthesis would depend on
the amount of bone and prosthesis flexibility and
could not be predicted from the seesaw analogy.
Rangert et a1 concluded that the crucial factor in all
cases was that the anterior-posterior implant fixture
distribution compensate for a loaded cantilever. They
also stated that an increase in the number ofimplant
fixtures within a given distance would increase the
safety margin.
Figure 1. Seesaw analogy of implant cantilever loading.
(Reprinted nith permission from Kangcrt B, .Jemt T,
Joriieus L: Forces and moments on Brhemark implants.
Int J Oral Maxillofac Jmplants 1989;4:241-247.)
44 Cantzkuer andlmplant Biomechanics
The second type of bending moment involved a
force remote to a straight line connecting the im-
plant fixtures in a prosthesis (ie, remote site loading
of linearly arranged fixtures). This would occur
during cantilever loading when the implants were
arranged linearly as opposed to in an arch-form
curvature. The lever arm system in this situation
would be within the fixture itself, with the posterior
edge of the abutment acting as the fulcrum. This
same type of bending moment would occur when an
individual fixture received a lateral force (Fig 2). In
the above situations, Rangert et al" believed that the
implant fixture absorbed more of the bending mo-
ment with an increase in force transmission to the
bone as opposed to a more favorable distribution of
forces among multiple implant fixtures. These bend-
ing moments could lead to abutment screw or gold
screw loosening and subsequent breakage.
In conclusion, Rangert et a12' pointed out that an
optimal preload or tightening of the gold screw was
essential because once the gold cylinder/abutment
joint opened, all force would be taken by the gold
screw. Rangert et a1 also recommended a passive fit
of all gold cylinders and a sufficiently rigid franie-
work. They stated that a less rigid framework would
impart more stress to the implant fixtures closest to
the loading point, with poorer overall stress distribu-
tion.
Figure 2. Bending moments on implants. (A) bending
moment due to cantilever loading; (B) remote site loading
of linearly arranged fixtures; (C) bending mornrnt due to
nonaxial occlusd loading. (Reprinted with permission
from Rangert B, Jemt T, Jorneus L: Forces and munients
on Brinemark implants. Int J Oral hfaxillofac Implants
1989;4:241-247.)
Rodnguet Aquilinn, and Lund
English2*theorized a seesaw analogy somewhat
different from that of Rangert et d2' He stated that
posterior cantilever loading of a fixed implant pros-
thesis produced tensile forces in the most anterior
fixtures that could be compensated for by extending
prosthetic anterior teeth fommd of the most ante-
rior fixtures to produce a counterbalancing bending
moment. However, the notion that a second anterior
cantilever could be beneficial in decreasing posterior
cantilever stress seems questionable.
Mendelson et alZ5tested quantitatively the theo-
retical predictions of implant fixture loading for a
fixcd prosthesis described by Skalak.'9 This study
used Brznemark fixtures threaded into a 1-in thick
aluminum plate with specially designed load-scnsing
Brdnemark abutments. They concluded that for
vertical loads at distal and midline locations on the
prosthesis, the Skalak model underprcdictcd implant
forces nearest the loading point. They attributed this
to a lower-than-predicted rigidity of the metal/
acrylic prosthesis.
Brdnemark et a126approximated deflection of the
cantilevered prosthesis by the following equation:
KFL
Deflection = -
EWH
where K equaled a constant, F was the applied load,
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
various techniques of generating and recording these
bite forces.
The increased magnitude of lexer effects created
by a cantilevered segment complicates theories of
force transmission during biting as mentioned previ-
ously. Also, relationships of force distribution may
vary greatly between implant- and tooth-supported
cantilever design^.^'-^^ The complete denture patient
has been assumed to generate less occlusal force
than the dentate i n d i v i d ~ a l . ~Therefore,
~,~' it has
been assumed that cantilever forces would be de-
creased when occluding with a complete denture as
opposed to a natural dentition.15
However, Lundgren et a P showed that with a
mandibular irnplant-supported cantilever prosthesis
opposing a complete maxillary denture, mean chew-
ing and swallowing forces were greater than with
tooth-supported cantilevers opposing natural teeth
and equal to forces involving conventional P D s
opposing natural teeth. For the implant prosthesis,
these posterior cantilever forces exceeded the forces
of the implant-fixture-supported area against the
anterior part of the maxillary denture. Also, the
patients wearing the complete dentures used a
greater percentage of their maximal biting force
during normal function, probably because of a de-
crease in mandibular mucosal proprioception. Canti-
lever forces were reported to be greater with the
implant-supported prosthesis opposing a complete
denture than with tooth-supported cantilevers oppos-
ing natural dentitions, probably for two reasons: a
decreased flexure of the implant cantilevers because
of their rigid nature, and the tipping action down-
ward and posteriorly of the maxillary denture.
Falk et aI3l measured occlusal forces in implant-
supported prostheses using strain gauges placed on
supraoccluded contact areas in the opposing maxil-
lary denture. Mean maximal closing force for the
implant-supported prosthesis opposing a complete
denture was found to be 336 98 N. These forces
+_
represented the total force exerted on all portions of
the prostheses. They also showed that vertical bend-
ing stress measured at the distal cantilever,joint was
greater when an implant-supported cantilever pros-
thesis occluded against a completc denture as op-
posed to natural teeth. Vertical bending stress was
expressed as M/Wb, where M equalcd the vertical
bending moment that was equal to force multiplied
by the distance. Wb represented the bending resis-
tance of the cantilever beam, which was equal to
width x height X ~ r / 3 2Forces
. along the cantilever
itself decreased distally against the natural dentition
while progressively increasing when opposed by a
complete denture. Again, tipping of the denture was
theorized to cause this phenomena.
Also, Falk et a13' showed that increasing the
number of occlusal contacts could actually increase
the percentage of total occlusal load borne by the
cantilever segments. They found 70% of the total
biting force taken by the cantilever segments when
the maxillary denture was supraoccluded in eight
points, as opposed to 55% when only four contacts
existed.
Conversely, Lundgren et a1j5 showed that placing
the most distal segments of the cantilever prosthesis
in infraocclusion resulted in a significant decrease in
total force along the entire prosthesis when opposing
a complete denture. This benefit is decreased, how-
ever, by the severity of the denture tipping. An
occlusal interference in the cantilevered segment
resulted in an increase in vertical bending stress at
the distal cantilever joint during closing forces.33
In comparing gentle biting, normal chewing force,
and maximal biting force, Haraldson et aP7 showed
that patients restored with osseointegrated implants
according to E n e m a r k protocol showed biting forces
equal to patients restored with FPDs on periodon-
tally involved teeth but slightly less than patients
with a full complement of natural teeth. Mean
maximal biting force was found to be 144.4 N.
Carr and studied 14 denlure patients who
received osseointegrated implant-supported prosthe-
ses. Maximum occlusal force (MOF) in the molar
region was measured before and 3 months after
placement of the implant prosthesis. MOF ranged
from 22N to 11 1N before treatment and 44N to 253N
after treatment. Interestingly, patients in this study
who were edentulous less than 15 years showed a
four times greater increase in MOF from baseline
compared with those patients edentulous longer
than 15 years.
Based on chewing efficiency increase following
placement of an implant prosthesis,Jemt and Carls-
son38showed a correlation between high posttreat-
ment chewing efficienq increase and low pretreat-
ment levels of bite force and mandibular velocity.
However, regardless of pretreatment levels of bite
force, all subjects showed comparable mean bite
forces after rehabilitation. Also, there was a poor
correlation between self-assessed chewing efficiency
and objective testing of chewing efficiency.
Lindquist and C a r l ~ s o nshowed
~~ a doubling of
maximal biting force of previous denture wearers
after placement of an osseointegrated mandibular
fixed prosthesis. This doubling was noticed 2 months
after prosthesis placement. However, 3 years after
placement of the prosthesis, a three-fold increase in
maximal biting force was observed. Chewing effi-
ciency also increased, although not as dramatically.
They hypothesized that there was a period of adjust-
46 C a n t z k r andIm@ant Biomechanics
mcnt and adaptation after prosthesis placement in
which chcwing efficiency and maximal biting force
increased.
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