Journal of Oral Rehabilitation
Journal of Oral Rehabilitation 2010 37; 525–531
Impact of implant number, distribution and prosthesis
material on loading on implants supporting fixed prostheses
T . O G A W A * †1 , S . D H A L I W A L ‡1 , I . N A E R T * , A . M I N E * , M . K R O N S T R O M §, K . S A S A K I †
& J . D U Y C K * *Department of Prosthetic Dentistry, BIOMAT Research Group, Catholic University of Leuven, K.U.Leuven, Belgium,
†
Division of Advanced Prosthetic Dentistry, Tohoku University Graduate School of Dentistry, Sendai, Japan, ‡Department of Dental Clinical
Sciences, Dalhousie University, Halifax, NS, Canada and §Department of Restorative Dentistry, University of Washington, Seattle, WA, USA
SUMMARY The purpose of this study is to evaluate axial
forces and bending moments (BMs) on implants
supporting a complete arch fixed implant supported
prosthesis with respect to number and distribution of
the implants and type of prosthesis material. Seven
oral Brånemark implants with a diameter of 3.75 mm
and a length of 13 and 7 mm (short distal implant)
were placed in an edentulous composite mandible
used as the experimental model. One all-acrylic, one
fibre-reinforced acrylic, and one milled titanium
framework prosthesis were made. A 50 N vertical
load was applied on the extension 10 mm distal from
the most posterior implant. Axial forces and BMs
were measured by calculating signals from three
strain gauges attached to each of the abutments.
The load was measured using three different models
with varying numbers of supporting implants (3, 4
and 5), three models with different implant distribu-
Introduction
Nowadays an implant supported fixed prosthesis is
considered to be a reliable treatment alternative for
edentulous patients. Long-term studies have demon-
strated that the edentulous jaw can be successfully
restored with implants supporting a fixed prosthesis (1–
4). Nevertheless, factors such as bone anatomy, quality
and quantity, as well as limited financial resources can
be an obstacle for patients to receive oral implant
therapy. Using fewer implants placed in strategic
positions to achieve a favourable force distribution
and the use of relatively inexpensive prosthetic mate-
1
First and second author equally contributed.
ª 2010 Blackwell Publishing Ltd
tion conditions (small, medium and large) and three
models with different prosthesis materials (titanium,
acrylic and fibre-reinforced acrylic). Maximum BMs
were highest when prostheses were supported by
three implants compared to four and five implants
(P < 0.001). The BMs were significantly influenced by
the implant distribution, in that the smallest distri-
bution induced the highest BMs (P < 0.001). Maxi-
mum BMs were lowest with the titanium prosthesis
(P < 0.01). The resultant forces on implants were
significantly associated with the implant number
and distribution and the prosthesis material.
KEYWORDS: distribution of implants, edentulous
mandible, fixed dental prosthesis, strain gauge, the
number of implants
Accepted for publication 30 January 2010
rials may help to overcome these problems (5, 6). It is of
utmost importance, however, to avoid biological
implant failure or technical complications. It is there-
fore crucial to understand the biomechanical impact of
implant number, distribution and prosthesis material.
In situations where the bone volume is not adequate
for installing an optimal number of implants that are
favourably distributed, bone augmentation procedures
or the use of fewer implants can be considered. Given
that the mechanical conditions play a role in the implant
prognosis (7–11), it is important to know from a biome-
chanical point of view what impact reduced number of
supporting implants and the distribution would have.
Strain gauge (12) and finite element analyses (13) of
implants supporting fixed prostheses indicate that the
doi: 10.1111/j.1365-2842.2010.02076.x
526 T . O G A W A et al.
highest stresses occur around the distal implants. A distal
cantilever seems to further jeopardize the mechanical
condition. In vivo strain gauge measurements (14)
indicate that loading of distal extensions causes a hinging
effect of the prosthesis, thereby inducing considerable
compressive forces on the implants closest to the place of
load application and lower compressive or tensile forces
on the other implants. This study also observed that
implant loading increased with a decreasing number of
supporting implants. Significant differences in bending
moments (BMs) were found between three versus four
or five, six supporting implants. Further, it’s likely that
not only the number but the distribution as well has an
impact on the forces on the implants.
Titanium or its alloys are today considered to be the
‘gold standard’ as the basis for implant supported fixed
prostheses because of its favourable mechanical proper-
ties in comparison with acrylic resin (1, 5, 15, 16).
However, metal frameworks supporting fixed prostheses
are expensive to fabricate and for this reason, cheaper
and clinically safe alternatives were considered. To grasp
the effect of material stiffness or rigidity on the implant
loading, three materials having relatively different stiff-
ness were therefore compared in this study. Conven-
tional and fibre-reinforced acrylic resin prostheses offer a
cheaper alternative for the patient and offers additional
advantages such as ease of production and repair (17).
This study aims to evaluate the effect of number and
distribution of implants supporting a complete arch
fixed prosthesis, the effect of prosthesis material, as well
as the interaction between these variables.
The hypotheses of this study are:
1 An increase in number of supporting implants leads
to a decrease in individual implant loading.
2 Maximum BMs on the supporting implants are lower
in case of a larger implant distribution.
3 There is a combined effect of implant number and
distribution on the load on implants.
4 Prosthesis material properties affect load distribution
among the implants supporting a fixed prosthesis.
Materials and methods
Mandible and implant
An edentulous composite mandible* with physical
properties similar to real bone (18) was used (Fig. 1a).
*Sawbones, Vashon, WA, USA.
The exterior portion of the mandible consisted of a hard
cortical shell (density: 1.7 g cm)3), while the interior
portion was cancelous (density: 0.25 g cm)3).
TiUnite regular platform oral implants (Brånemark
System†) with a diameter of 3.75 mm and a length of
13 or 7 mm (short distal implant) were used. Five 13-
mm implants were placed between the mental foram-
ina with an inter-implant distance of 10 mm and
parallel to each other. Distal to the mental foramina,
a 7-mm short implant was placed in the position of the
first molar, mimicking a superior position towards the
inferior alveolar nerve. Implants were labelled from 1 to
4, with n.1 being the most anterior and n.4 the most
distal (Fig. 1b). Upon implant placement, 5-mm Multi-
unit abutments (Brånemark System†) were attached
to the implants using a final torque of 35 N cm.
Three fixed prostheses with similar shapes and
dimensions, but with different materials were manu-
factured (titanium, all-acrylic and fibre-reinforced
acrylic). The titanium prosthesis consisted of a milled
titanium framework (Procera†), veneered with acrylic
resin teeth and a polymethylmethacrylate base. The
acrylic prosthesis was composed using polymethyl-
methacrylate base and veneered with acrylic resin
teeth, whereas the fibre-reinforced acrylic prosthesis
consisted of polymethylmethacrylate reinforced with
glass fibres (Stick‡), and veneered with acrylic teeth.
The material consisted of continuous unidirectional
glass fibres that were impregnated with polymethyl-
methacrylate monomer. Given the small inter-implant
distance, the fibre was weaved around the implants
once in an ‘S’ configuration. All the prostheses had a
passive fit verified microscopically.
Strain gauge measurement
Each of the seven abutments was prepared with three
strain gauges (FLG-02-11 of TML§: Resistance:
120  0.3 X). The strain gauges were bonded to the
lateral abutment surface 120 apart, according to the
manufacturer’s instructions and calibrated according to
the calibration procedure described in previous studies
(14, 19). The mandibular model was stabilized with a
stone base (type III dental stone) to ensure correct
orientation and correct loading. Fifty strain gauge
†
Nobel Biocare, Gothenburg, Sweden.
‡
StickTech Ltd, Turku, Finland.
§
Tokyo Sokki Kenkyujo Co., Ltd., Tokyo, Japan.
ª 2010 Blackwell Publishing Ltd
 IMPACT OF SEVERAL VARIABLES ON IMPLANTS LOADING
signals were generated per second. A computer pro-
gram under Windows was developed to process the
data and to transform these data into a numerical
representation of an axial force (AF) and two BMs
around perpendicular axes. By use of the BMs around
both perpendicular axes, the total BM on the abut-
ments could be calculated (19).
Test condition and data analysis
In this study, a total of 27 test conditions were
examined. The test conditions were categorized by
three different numbers of implants (3, 4, and 5), three
different distribution types (small, medium, and large)
(Fig. 2), and three different prosthesis materials (ac-
rylic, fibre-reinforce acrylic, and titanium).
A 50 N axial static load was applied 10 mm posterior
to the most distal implant of each test condition by
means of a custom made pneumatic loading device¶
(load range: 0–1000 N, error: 1 N). The same load was
applied three times on both sides. Because there were
no significant differences between left and right side
values for each implant, the six values, obtained from
three measurements from both sides, were used for
further analysis. Implant positions were defined as P1 to
(a)
Fig. 1. (a) View on the edentulous composite mandible*. (b) Schematic diagram of the implant locations. Implants are labelled with n.1
being the most anterior and n.4 the most distal implant.
Fig. 2. Overview of the different test conditions, with varying
number and distribution of the implants. The numbers in this
table correspond to the upper left figure.
¶
EAST-MICAS, K.U. Leuven, Belgium.
ª 2010 Blackwell Publishing Ltd
527
P5 according to the distance to the loading position.
Figure 3 illustrates the positions of the implants.
Statistical analysis
The resulting AFs and BMs were analysed by three-
factor analysis of variance (ANOVA) and followed by a
Scheffe test with the significance set at P < 0.05. All the
statistical analyses were performed using the SPSS
version 13.0 for Windows**.
Results
The mean AFs and BMs of all implants in the different
test conditions are shown in Fig. 4, together with the
statistical outcome. There is a clear tendency that the
highest AFs and BMs values occur at the implant closest
to where the load was applied. This was true for all but
two test conditions. Many negative AFs were observed
at the intermediate implants, especially when three or
four supporting implants were used. Except for the
model using three supporting implants, no significant
differences in AFs were found between the distribution
types and prosthesis materials. The BMs, however,
were significantly influenced by the distribution types.
(b)
Fig. 3. Load application area for the different numbers of
implants involved. A 50 N axial load was applied 10 mm posterior
to the most distal implant of each test condition.
**SPSS Inc., Chicago, IL, USA.
528 T . O G A W A et al.
Fig. 4. Mean (SD) axial forces and bending moments on all implants for the different test conditions. The table below the figure indicates
the results of the statistical analyses (ANOVA and Scheffe; *P < 0.05, **P < 0.01, ***P < 0.001, N.S.: not significant).
These significant differences were detected between
all distribution types in case of three supporting
implants (212–313, 212–414, 313–414; P < 0.001).
When four implants were used, significant differences
in BMs were observed between the models 3223 and
4334 and between 3223 and 4224 (P < 0.001). When
five implants were used to support the prosthesis,
significant differences were noted between the models
32123 and 43134 and between 32123 and 42124
(P < 0.001).
The BMs in the model with four supporting implants
were significantly higher for the titanium when com-
pared with the acrylic (P < 0.05) and the fibre-rein-
forced acrylic prosthesis (P < 0.001).
The highest AFs and BMs were found on the
implant closest to the point of load application in
almost all test conditions (92.6%), and were therefore
used as maximum values for each test condition
(Fig. 5). There were significant differences depending
on the number of implants and distribution types.
Bending moments in of the model with three sup-
porting implants were significantly higher than those
models with four and five supporting implants
(P < 0.001). Type of prosthesis material was not
significantly associated with the maximum AFs, but
the maximum BMs were significantly lower for the
titanium compared to the acrylic and the fibre-rein-
forced acrylic prosthesis (P < 0.01).
Discussion
This study evaluates and compares AFs and BMs in
different models with varying number and distribution
of implants and with different prosthesis materials by
means of in vitro strain gauge measurement under static
loading conditions.
ª 2010 Blackwell Publishing Ltd
 IMPACT OF SEVERAL VARIABLES ON IMPLANTS LOADING
Fig. 5. Maximum (SD) axial forces and bending moments (data of P1: most distal implant) for each test condition. The table below the
figure indicates the results of the statistical analyses (ANOVA and Scheffe; *P < 0.05, **P < 0.01, ***P < 0.001, N.S.: not significant).
The first hypothesis, stating that an increase in
number of supporting implants leads to a decrease in
load on the individual implant, was confirmed. Espe-
cially the BMs were significantly higher in the model
with only three supporting implants. This logical result
is in agreement with findings in a previous study where
implant loading increased with a lower number of
supporting implants (14). Nevertheless, no significant
difference in maximum BMs was found between the
models using four and five supporting implants. The
fact that the biomechanical situation significantly
altered when only three implants were used suggests
that not only the number but also the distribution of
the implants plays an important role. Reducing the
number of supporting implants from four to three
subjected the implants to significantly higher BMs.
The second hypothesis, stating that maximum BMs
on the supporting implants are lower in case of a larger
implant distribution, is also confirmed as significantly
higher BMs were found in case of a limited implant
distribution (P < 0.001). This finding confirms that a
favourable spread of the implants reduces peak BMs.
Implant number and distribution appeared to have
an interacting effect on implant loading. Whereas the
difference between medium and large implant distri-
bution was significant in the models with three
supporting implants, this significant difference was lost
in the models with four and five supporting implants.
When the area representing the implant support is
considered, it shows that this area is affected more by
ª 2010 Blackwell Publishing Ltd
529
the implant distribution in case of less implants. This
area, formed by the supporting implants when imagi-
nary lines are drawn connecting them in a horizontal
plane, is a parameter that is determined by both
implant number and distribution and is therefore a
useful tool to understand their combined effect. The
area formed by three supporting implants increases
considerably as the distance between them is extended.
On the other hand, when four or five supporting
implants are used, this area does not change to the
same extent. When models with large and medium
distribution types are compared to each other, this
imaginary area formed by the supporting implants
decreases 68.1% in of the model with three implants,
32.2% in of the model with four implants and only
8.6% in of the model with five implants. This supports
the observation that implant distribution becomes a
more important determinant for implant loading when
the implant number decreases. The results of this study
indicate that favourable implant distribution improves
load distribution among the implants, resulting in lower
peak BMs, and this effect becomes more pronounced
with a decreasing number of supporting implants.
Furthermore, this study underlines the relevance of
posterior implants, providing distal support to the
prostheses. Even in case of five supporting implants,
the importance of the distal implant was evident,
resulting in significant differences between the models
with (42124 and 43134) compared to the models
without posterior implants (32123). Distal implants
530 T . O G A W A et al.
cause a decrease in distance between distal occlusal
forces and the implant support, thereby limiting the
BMs. Distal prosthesis support is therefore recom-
mended, certainly in clinical situations with limited
load-bearing capacities (e.g. low quality or quantity of
bone) (20–23).
The highest forces were, in most cases, observed on
the implant closest to the point of load application,
which is in agreement with findings in several other
studies (12, 14, 24). This suggests that these distal
implants still have a greater risk for mechanical over-
loading, despite the biomechanical advantage of a distal
implant.
Also the fourth hypothesis can be supported as
significant differences in maximum BMs were observed
between the titanium framework prosthesis and the
acrylic as well as the fibre-reinforced acrylic prostheses.
The maximum observed BMs were significantly lower
for the titanium prosthesis when compared to the two
other types of prostheses. In the model with four
implants, however, the mean BMs appeared to be
higher for the titanium framework prosthesis than for
those fabricated of acrylic or fibre-reinforced acrylic. In
the models using three and five implants, again no
significant differences in mean BMs were found. These
results suggests that in general the prosthesis material
had only a limited effect on the mean loading of the
implants, but the maximum BMs were significantly
lower with the metal prosthesis. This can be explained
by the higher stiffness of the metal framework pros-
thesis, which leads to a smaller deformation of the
prosthesis at the site of load application, thereby
resulting in a better distribution of the forces among
all supporting implants. This tendency was already
observed in previous studies (15, 16, 25, 26), but never
explicitly demonstrated. The lower deformation for
stiffer materials may also reduce risk of fatigue and
eventual failures related to overloading of the compo-
nents (15, 16).
Although it is evident that excessive load on implants
can lead to marginal bone loss and eventually to implant
failure in animals (27, 28), mechanical loading as such
does not need to be detrimental per se. Mechanical
loading significantly affects bone behaviour and
provides stimuli resulting in mineralized bone forma-
tion adjacent to the implant (29–34). Bone loss because
of mechanical overload will only occur when the
mechanical loading exceeds the bone’s load bearing
capacity because of unfavourable conditions such as low
bone quality, limited bone quantity, adverse functional
habits, compromised medical health (e.g. diabetes), etc.
It is in such situations that the findings of this study can
be helpful to support the clinical decision making.
Conclusions
In summary, the resultant forces on implants are
significantly associated with number and distribution
of implants and prosthesis material. Significantly higher
maximum BMs were observed when the prosthesis was
supported by only three implants and in case a limited
implant distribution was simulated, and when (fibre-
reinforced) acrylic resin was used as prosthesis material.
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Correspondence: Joke Duyck, Department of Prosthetic Dentistry,
BIOMAT Research Group, School of Dentistry, Oral Pathology, and
Maxillofacial Surgery, Faculty of Medicine, Katholieke Universiteit
Leuven, Kapucijnenvoer 7, B-3000 Leuven, Belgium.
E-mail: Joke.Duyck@uz.kuleuven.be