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Research Article
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A new look toward crown-to-implant ratio

PEDRAM PAKZAD, DDS & ALIREZA MOSAVAR, MSC

ABSTRACT: Purpose: To clarify how crown-to-implant ratio (C-I ratio) influences the bone biomechanically with its
two components: crown height and implant length. Methods: This three-dimensional finite element study was
performed in two phases. The first phase aimed to show the influence of the C-I ratio on the stresses in the peri-implant
bone and the second phase to reveal the impact of each of the two components of the C-I ratio: crown height and
implant length. During analyses, all models were subject to three different loading conditions – axial, buccolingual, and
oblique. Results: The crown-to-implant ratio was significantly influential on stress distribution in the peri-implant bone.
However, the crown’s height was significantly more prominent than the length of the implant. The most substantial
amount of stress was seen when long crowns were combined with off-axial loads. Being mostly dominated by the height
of the crown and far less by the implant’s length, the C-I ratio is not balanced and seems not to be a predictive
parameter in implant dentistry. (Am J Dent 2022;35:43-48).

CLINICAL SIGNIFICANCE: Crown-to-implant ratio is recommended to be assessed by its two components: crown height
and implant length because the former impacts stresses significantly more than the latter.

: Dr. Pedram Pakzad, Department of Prosthodontics, Dental Faculty, Isfahan (Khorasgan) Branch, Islamic Azad
University, Isfahan, Iran. E- : pakzadpedram@yahoo.com

Introduction considering the relevance of C-I ratio and peri-implant bone

With dental implants, treatment of tooth loss has success-
fully been accomplished for years.1 Nevertheless, factors that
could result in implant complications cannot be disregarded.
Biomechanical factors are of paramount importance.2 One of
these factors is the crown-to-implant ratio. Accordingly,
‘clinical crown-to-implant ratio’ and ‘anatomical crown-to-
implant ratio’ have been discussed;3,4 among which clinical
crown-to-implant ratio is more reliable when implant complica-
tions are to be assessed.3,4 Therefore, measurements in this
study were accomplished in accordance with the clinical
crown-to-implant ratio (C-I ratio) definition.5,6 C-I ratio could
be visualized by tracing a line at the level of the most coronal
bone-implant contact to divide the implant into two portions:
coronal and apical; then, calculating the quotient of the former
to the latter. In other words, crown height (known as crown
height space in some references) and implant length are the two
influential parameters in calculating C-I ratio. Higher C-I ratios
are anticipated following physiologic bone resorption. In-
creased bone resorption often leads to a treatment with
decreased implant lengths and raised crown heights7 if more
complex treatments with vertical bone augmentation are not to
be considered. The above-mentioned bone resorption may
result from tooth loss prior to implant surgery or may develop
after implant placement, lowering peri-implant marginal bone
level.8 A long crown in the presence of off-axial load acts as a
lever arm which magnifies applied forces.9 Care must be exer-
cised when working with cantilevers to avoid complications.
According to a published systematic review, the lowest and
highest documented values for C-I ratio are 0.5 and 4.95.10
Additionally, the mean values in all included articles in sys-
tematic reviews are greater than 1.00.10 It accentuates the fact
that C-I ratios of greater than 1.00 are a common occurrence in
implant dentistry. Alternatively, most clinical trial studies on C-
I ratio are heterogeneous;4,10 not only in comparison with each
other, but also regarding their own included data. Therefore,
systematic reviews have not so far revealed a certain outcome
resorption.3,10 Further precisely planned and designed studies
are needed to be conducted to reach a definite conclusion. It
would be beneficial to separately evaluate the two components
of the C-I ratio (crown height and implant length) to find out
where this ambiguity is lying.
In light of the above-mentioned issues, an effort to assess
stresses in the peri-implant bone under a controlled condition in
which the C-I ratio was the single variable was made. Addi-
tionally, the study was designed to re-evaluate the results in a
second phase. In the second phase, an attempt was made to
clarify the significance of each of the two components of the C-
I ratio (crown height and implant length) in altering stresses in
the bone. Application of finite element method makes pro-
viding such conditions possible. Finite element method is an
acceptable and efficient approach for studying the crown height
and implant length.11,12 In addition, this method leads to a better
understanding of biomechanical details and provides insight
into stress distribution.
Materials and Methods
Study design - This study examined the C-I ratio to see whether
it is valuable in predicting treatment outcome. The first phase
of the work aimed to assess the impact of the C-I ratio on the
stresses in the implant-surrounding bone, while the second
phase shed light on the two components of the C-I ratio, crown
height and implant length. This reveals the prominence of each
component of the equation.
In this finite element study, different C-I ratios were created
by shifting the level of the bone, which appropriately led to
different lengths of the implants and corresponding crowns. In
this way, total lengths of the implant-restoration complexes
(fixture plus crown) were constant, whereas the implant-
abutment junction positions were variable, resembling what
often happens in the clinical situation (Fig. 1). After under-
standing the C-I ratio’s influence, the study in its second phase
attempted to show how C-I ratio’s two components differed
from one another in impacting the stresses.

44 Pakzad & Mosavar
Fig. 1. Schematic illustration of modeled implants. The height of the crowns
and length of the implants in millimeters as well as C-I ratio are indicated
above each model. Models with a lighter background are related to the first
phase of the study and darker to the second.
Table. Mechanical properties of the materials.
____________________________________________________________________________________________________
Young’s
modulus
Model Material (GPa)
____________________________________________________________________________________________________
Occlusal covering of the crown Porcelain13 68.90
Coping of the crown Ni-Cr alloy14 220.00
Implant, abutment Titanium13 110.00
Crust of the bone block Cortical Bone14 14.70
Core of the bone block Cancellous Bone14 1.47
____________________________________________________________________________________________________
Phase I: C-I ratio - In this phase, like many previous studies,
only the C-I ratio was examined. Six three-dimensional implant
models with varied C-I ratios were used to examine the stress
distribution in the bone around regular-diameter implants under
three different loading conditions.
Models of bone blocks, implants, abutments, and crowns
were prepared in CATIAa software (version 5.20). Corres-
pondingly, the shape of the bone was simplified to that of a
block. Taking this into account, six different blocks, similar in
mesiodistal (MD) and buccolingual (BL) dimensions and
varying in vertical height (H), were modeled (MD=30 mm,
BL=20 mm, H=10, 12, 14, 16, 18, and 20 mm). These bone
blocks were composed of a core, serving as cancellous bone
and a 1.38 mm-thick crust, serving as cortical bone, which
covered all surfaces except mesial and distal sides. Afterward,
implants, abutments, and crowns were modeled. The total
length of all modeled implants was constant and equal to 24
mm for each model. In other words, the combined length of
bone enclosed and unenclosed portions of each model was 24
mm (16+8, 14+10, 12+12, 10+14, 8+16, 6+18). The implants’
design was adapted from six Straumannb standard implants
according to the following criteria: Regular Neck, endosteal
portion diameter: 4.1 mm, lengths: 6, 8, 10, 12, 14, 16 mm.
Abutments were designed with 12° tapering and added to the
implant models. Crowns were then added to the implant-
abutment complex. The crowns were simplified to a cylinder
with 2 mm occlusal thickness (0.8 mm metal, 1.2 mm
porcelain) (Fig. 1a).
Having obtained the geometry of each component, we
meshed the models by quadratic 10-node tetrahedron solid
elements using Abacusa FEA software (ABAQUS/CAE, Ver-
American Journal of Dentistry, Vol. 35, No. 1, February, 2022
Fig. 2. Top view of the models, showing patterns of stress distribution: A.
under axial load: circular pattern; B. under buccolingual load: oval pattern; C.
under oblique load: pear-shaped pattern.
sion 6.12-1) to attribute the mechanical properties of the desired
material to the models13,14 (Table). In this stage, all materials
were considered to be isotropic and linearly elastic.15 Having
the above procedures accomplished, we compiled each of the
six models by tying the components together.
Afterwards, loading conditions were simulated; accord-
ingly, each model was analyzed under three static loadings. First,
100 N load was applied axially (axial load). Second, 50 N load
was applied buccolingually, perpendicular to the implant’s long
Poisson’s axis (buccolingual load). Third, both aforementioned loads were
ratio applied simultaneously, which was estimated to be equal to a 112
0.28 N load applied obliquely with 27 degrees inclination from the
0.30 implant’s long axis (oblique load). Eventually, an aggregate of 18
0.35 analyses were performed, and the results reported.
0.30
0.30
Phase II: Crown height and implant length - In this phase, two
extra models were added to the previous ones for statistical
analysis to reveal the effect of the crown height and implant
length on the created stresses.
This phase of the study was designed to demonstrate how the
crown height and implant length affected the equation. In this
part, all the simulation procedures were exactly the same as
Phase I except the number of models. Two extra models were
incorporated into the previous ones. In these two models,
contrary to the last ones, the ‘implant + crown’ total lengths were
not equal to 24 mm, making individual statistical analysis on
crown height and implant length possible. The measurements for
one model were: 6 mm long implant and 8 mm long crown, and
for the other: 16 mm long implant and 18 mm long crown.
Statistical analysis - SPSSc software (released 2011, version
20.0) was used for statistical calculations. In this regard, one-
way and two-way ANOVAs and Pearson correlation calcula-
WLRQVZHUHFRQGXFWHG Į 0.05).
Results
Phase I: first six models - The pattern of stress distribution and
magnitude of stresses gained from the finite element analyses is
reported below. These are the reports on the first six models,
with the first step of the statistical analysis.
Stress distribution in the peri-implant bone under axial load -
In each model, maximum von Mises stress was noticed in the
cortical bone around the implant neck.12,15 Moreover, the stress
distribution pattern in all models was symmetrical. From a top
view, a circular pattern in cortical bone was apparent (Fig. 2a).
On the other hand, maximum stress in cancellous bone was
concentrated in the apical portion. On the whole, a better and
more even pattern of stress distribution was noticed with lower
C-I ratios.
American Journal of Dentistry, Vol. 35, No. 1, February, 2022
Fig. 3. Diagram of stresses in the cortical bone. The first phase of the study is
indicated with a lighter background and the second with a darker background.
Considering the numerical results, by an increase in C-I
ratio from 0.5 (8:16) to 3.0 (18:6), an increase from 12.1 to 18.8
MPa (55% increase) in cortical bone (Fig. 3) and 2.6 to 3.4
MPa (30% increase) in cancellous bone (Fig. 4) was observed,
which was statistically significant for both cortical and cancel-
lous bones (P< 0.05).
Stress distribution in the peri-implant bone under buccolingual
load - In this case, the greatest amount of stress was again
recorded in the bone around the implant neck. However, the
pattern of stress distribution was not symmetrical anymore.
Viewing the cortical bone from above, an oval pattern, with the
longer diameter laid buccolingually, was apparent (Fig. 2b).
This pattern was distinguishable in all six analyses. In contrast,
a variable pattern of stress distribution was distinct in
cancellous bone. In addition, migration of higher stresses from
cervical to apical was evident as the C-I ratio was increased. In
other words, no considerable stresses were found around the
apex of the implant with a C-I ratio of 0.5 (8:16), while in the
ratio of 3.0 (18:6), the apex of the implant was subject to the
primary stress values.
The numerical results predicted that maximum stress
increased from 68.9 to 158 MPa (129% increase) and 2.8 to
11.5 MPa (310% increase) in cortical (Fig. 3) and cancellous
(Fig. 4) bones, respectively. Statistical analyses revealed a
significant influence of the C-I ratio on stress distribution in
cortical and cancellous bones (P< 0.05).
Stress distribution in the peri-implant bone under oblique load
- Analyses under oblique load showed a non-symmetrical stress
distribution pattern in the cortical bone in all models. From a
top view, a pear-shaped pattern was noticed (Fig. 2c). In the
cancellous bone, the highest amount of stress existed around the
implant neck, implant threads, and implant apex. To be precise,
in the C-I ratio of 0.5 (8:16), it was the bone around the implant
neck that withstood the highest amount of stress; however,
growth in the amount of stress in the apical portion was evident
as C-I ratio was increased.
Looking through quantitative results, for the lowest to the
highest C-I ratios, stress values were variable from 78.9 to 170.5
MPa (116% increase) for cortical bone (Fig. 3) and 3.2 to 12.7
MPa (296% increase) for cancellous bone (Fig. 4). Eventually,
this amount of variation in stress values was statistically signifi-
cant for both cortical and cancellous bone (P< 0.05).
Crown-to-implant ratio 45
Fig. 4. Diagram of stresses in the cancellous bone. The first phase of the
study is indicated with a lighter background and the second with a darker
background.
Phase II: Adding two further models - The pattern of stress
distribution in the two added models was the same as their
corresponding loading situation in Phase I. The amount of
stress however differed, the report of which is described below.
A newly performed statistical analysis on all eight models
reported on the most valuable findings at the end.
Stresses in the peri-implant bone under axial load - In the short
model (the model with short crown and implant), recorded
values for von Mises stresses were 18.9 MPa in the cortical and
3.4 MPa in the cancellous bone. In the other model, which had
a long crown and implant (long model), the registered values
were 12.3 MPa in the cortical and 2.1 in the cancellous bone.
Stress distribution in the peri-implant bone under buccolingual
load - Under buccolingual load, greater values were registered:
77.5 MPa in the cortical and 5.3 MPa in the cancellous bone for
the short model and 143.3 MPa in the cortical bone and 5.9
MPa in the cancellous bone for the long model.
Stress distribution in the peri-implant bone under oblique load
- The greatest stress was recorded in the models under oblique
load. The cortical bone withstood 93 MPa and the cancellous
bone 7.7 MPa in the short model and 150.6 MPa and 5.6 MPa
respectively in the long model.
Valuable findings - The area of highest stress concentration was
always evident in the cervical cortical bone, with no exceptions.
In all models, the amount of stress in the cancellous bone was
very low. Apart from that, the axial load did not generate
critical values of stress, even in the cortical bone. Thus, we
restricted reporting details of the statistical analysis to the stress
in the cortical bone under buccolingual and oblique loads.
These off-axial loads created high amounts of stress in the
cortical bone. Similar to the first phase, Pearson correlation
showed a positive relationship between C-I ratio and stresses in
the bone [r (buccolingual)= 0.78, r (oblique)= 0.81]. This being
said, the phase II of statistical analysis revealed the fact that the
influence of the height of the crown (r (buccolingual)= 0.98, r
(oblique)= 0.97) was more prominent than the influence of the
length of the implant (r (buccolingual)= -0.29, r (oblique)= -
0.26). That means the rise in the crown’s height can intensify
stress much more than fall in the implant’s length.
Statistical analyses - To examine the effect of implant length
and crown height on the stresses we used two-way ANOVA.

46 Pakzad & Mosavar
According to the analyses on the results of the Phase II models
and two of the Phase I models with the C-I ratios of 0.5 and 3.0,
in axial loading the implant length is the influential factor (P<
0.05), while in buccolingual and oblique loadings the height of
the crown is the influential factor (P< 0.05).
Discussion
This finite element study, like the previous finite element and
photoelastic investigations,16,17 revealed a positive correlation
between C-I ratio and stresses in the peripheral bone, while
clinical studies tend not to consider this parameter as a crucial
factor in implant dentistry. In clinical studies,3,4,10 bias due to
many undesired factors, which may influence the results, is
anticipated. The examples of coincidentally occurring variables
which are difficult to control for achieving a homogeneous
sample population in clinical studies are as follows: (a) the
quality and quantity of the bone, which varies from person to
person and from a region of the jaw to another,18,19 (b) applied
forces, which are related to muscle strength and the presence or
absence of parafunctional habits (e.g., clenching and bruxism),18
which are again dissimilar in different cases, and (c) implant
macro- and micro-structure designs.20 Another challenge
regarding the clinical evaluation of the C-I ratio is the fact that
not only is a large population needed, but also the homogeneity
of samples should be maintained. With reference to systematic
reviews, many studies3,4,10 have failed to control the above
factors. In contrast, the finite element method gives us the
capability to have variables in control and to efficiently study one
single parameter individually.12
To date, although some studies10,21-23 reported the influence
of the C-I ratio on hardware and biological complications, the
matter still requires further investigation. An animal study24
performed under proper plaque control conditions, did not find
the C-I ratio as a risk factor for implant failure. Likewise,
Schulte et al25 reported the C-I ratios of failed implants to be the
same as successful ones. Systematic reviews concerning the
same matter reported varied conclusions. For example, Blanes3
found C-I ratio to be of no influence on marginal bone loss. In
addition, the author did not find any relationship between C-I
ratio and implant survival rate due to the lack of data. Along the
same line of research, Quaranta et al10 concluded that C-I ratio
is not a risk factor for biological complications and implant
failure. Similarly, Meijer et al26 concluded that the investigated
C-I ratios in included studies (0.9 - 2.2) did not show high rates
of biological or technical complications. Even more, Garaicoa-
Pazmiño et al4 noted the protective effect of higher C-I ratios on
marginal bone level.
Systematic reviews27-30 have shown short implants as a
successful treatment option. Not many of these papers have
reported on C-I ratio, but as an example, one study31 reported
short implants successful regardless of their C-I ratios.
Furthermore, other studies8,23,32 on short implants did not find a
significant relationship between C-I ratio and marginal bone
loss. More interestingly, the few available clinical studies on
crown height, have emphasized the negative impacts of this
parameter. Anitua et al22 found a significant positive correlation
between crown height space (CHS) and marginal bone loss.
Likewise, Galindo-Moreno et al33 claimed abutment height as a
key factor in marginal bone loss. These findings signal the fact
American Journal of Dentistry, Vol. 35, No. 1, February, 2022
that crown height may be a more important factor than implant
length.
In this study, if we reported based on the first phase of the
project, the C-I ratio itself could be claimed to be a determining
factor in the amount of stress. The second phase of the work,
though, reshaped our understanding of the C-I ratio and drew
more of our attention to the crown’s height.
Assuming that the C-I ratio’s destructive effects mostly
come from crown height, the authors reviewed finite element
and clinical studies which had assessed either of the two
components of the C-I ratio (e.g., crown height and implant
length). By this, respecting crown height, there was a general
agreement among finite element and photoelastic studies16,17,34
on the fact that greater crown heights were associated with
greater stresses in the bone. Moreover, in a clinical study,
Nissan et al17 pinpointed the fact that the influence of CHS is
more prominent than the C-I ratio from a biomechanical point
of view. With respect to implant length, finite element
studies16,35,36,37 expressed minor influence of this parameter on
peri-implant stresses. In clinical studies,27-30 systematic reviews
tend to approve the success of short implants. That is, implant
length might be a minor factor when implant complications are
to be discussed. Thus, when it comes to the C-I ratio, crown
height would be more influential on the treatment outcomes
than implant length.
Bone behavior differs in different mechanical conditions38
and it responds to applied strains;39 but with existing limi-
tations, it is too complicated a condition to be simulated using
the finite element method. Appropriately, like other finite
element studies,15,34 conditions were simplified. That is why in
interpreting the finite element results, it is essential to review
clinical studies in addition to previous finite element and
photoelastic investigations. By pooling all that information, a
conclusion can be reported based on both theoretical and
experimental studies.
Relying on the possibilities of finite element method, the
C-I ratio with its two components is the single isolated
variable that is evaluated under three different loading
conditions. Although the results of the first phase of this study
showed that C-I ratio is in direct relation to stresses in the
bone, in the second phase it was revealed that it is the crown
height that plays the most remarkable role. With implant
length approved as a minor factor, C-I ratio can be visualized
as an unbalanced ratio.
The direction of the load should not be overlooked as off-
axial load is associated with a much higher amount of stress
compared to axial load. This fact is also confirmed by other
finite element and photoelastic studies.17,35,40,41 Likewise, the
common acceptance, which is the presence of the highest
amount of stress in the cortical bone around implant neck,17,36,37
was also confirmed by this study. That is, regardless of C-I
ratio, crown height, implant length, and applied load, the bone
around the neck of the implant withstands the largest portion of
stresses. In other words, stresses in the cancellous bone are
negligible compared to the values in the cortical bone.
To summarize, by comparing the present finite element
study with existing clinical studies, it could be claimed that the
height of the crown is much more impressive than the length of
the implant biomechanically. Thus, C-I ratio seems not to be a
American Journal of Dentistry, Vol. 35, No. 1, February, 2022
relevant factor to refer to in implant dentistry. Having said that,
if the authors still want to add a line of conclusion about the C-I
ratio, that would be: clinically occurring C-I ratios seem to be
in a range that results in stresses which are tolerable by the
bone. Based on this study’s findings, the authors would advise
clinicians to minimize the non-axial component of the load
during occlusal adjustment procedures, especially when facing
long crowns. Furthermore, from a biomechanical point of view,
vertical bone augmentation procedures are preferred to other
surgical techniques such as nerve repositioning, which do not
alter the CHS. Finally, for further studies, it is suggested that
clinical samples be homogenous for assessment. This
homogenization should include both implant-related and
patient-related factors. In addition to that, it is important to
report the two components of the C-I ratio independently as
well as the C-I ratio itself. This can be realized by writing three
digits as ‘A (C:I)’, in which ‘A’ represents the C-I ratio, ‘C’
represents the crown height space, and ‘I’ actual length of the
imbedded implant in millimeters.
a. Dassault Systèmes SE, Vélizy-Villacoublay, France.
b. Institut Straumann AG, Basel, Switzerland.
c. IBM Corp., Armonk, New York, USA.
Acknowledgements: To Gholamreza Tabakhian, Prof. Mahmoud Kadkhodaei,
and Dr. Vahid Esfahanian for their unwavering support and invaluable
contributions to this project.
Disclosure: The authors declared no conflict of interest.
Dr. Pakzad is Research Assistant, Department of Prosthodontics, Dental School,
Islamic Azad University Isfahan (Khorasgan) Branch, Isfahan, Iran. Mr. Mosavar
is PhD candidate, Biomedical Engineering - Biomechanics, School of Mechanical
Engineering, College of Engineering, University of Tehran, Tehran, Iran.
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