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Prosthesis‐Implant Arch Area Ratio (PIAAR) – A New Geometric Paradigm,

Replacing the Current ‘A‐P Spread’ of a Cantilever in Full‐Arch Implant
Prosthesis: A Proof‐of‐Concept Experi...

Article in Journal of Prosthodontics · May 2022

DOI: 10.1111/jopr.13523

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DOI: 10.1111/jopr.13523

ORIGINAL ARTICLE

Prosthesis-Implant Arch Area Ratio (PIAAR) – A New Geometric

Paradigm, Replacing the Current ‘A-P Spread’ of a Cantilever in
Full-Arch Implant Prosthesis: A Proof-of-Concept Experiment

Young K. Kim DMD, DMSc, FACP

Department of Prosthodontics, NYU College of Abstract

Dentistry, New York, NY
Purpose: The anterior-posterior spread concept is relied upon to understand the bio-
Correspondence
engineering aspects of cantilevers in fixed complete denture prostheses. This concept is
Dr. Young K. Kim, Department of Prosthodontics, not evidence-based. With no other category existing in contemporary implant dentistry,
NYU College of Dentistry, 345 East 24th Street this conventional anterior-posterior spread concept may have limited more precise and
New York, NY 10010.
E-mail: ykk2@nyu.edu
accurate biomechanical analysis. This paper aims to validate a scientific rationale for
utilizing this new prosthesis-implant arch area ratio instead of the preexisting anterior-
posterior spread concept.
Materials and methods: Utilizing the preexisting mathematical principle of “Heron’s
formula,” enabling the calculation of the area of a triangle with three known lengths and
no angular information, a new prosthesis-implant arch area ratio is introduced through
algebraic derivation. Geometrically, three different sections of prosthetic cantilevers
are defined as: (1) anterior cantilever; (2) lateral cantilever; (3) posterior cantilever. The
prosthesis-implant arch area ratio is defined as the prosthesis arch area (anterior, lateral,
or posterior cantilever) divided by the sum of the platform arch area and the selected
prosthesis arch area. As a proof-of-concept experiment, fifteen different laboratory cast
arches (n = 15) were chosen; theorized four implant platforms were referenced from
the conventional anterior-posterior spread ration of 1:1.5, followed by calculating plat-
form arch area and prosthesis arch area using Heron’s formula. Then, three different
horizontal arch width ratios (1:1, 1.25:1, and 1.5:1) under the constant linear height
ratio of anterior-posterior spread (1:1.5) were drawn to assign different experimental
groups of prosthesis arch area on each patient scenario, followed by cantilever com-
parison combining all ratio values (n = 45). One-way ANOVA and Tukey’s post hoc
multiple comparison tests were used for statistical analysis.
Results: One-way ANOVA revealed statistical differences of all prosthesis-implant
arch area ratios on each cantilever group; anterior cantilever, F(2, 42) = 8.326, p
= 0.0009; lateral cantilever F(2, 42) = 43.92, p < 0.0001; posterior cantilever, F(2,
42) = 26.66, p < 0.0001, as well as cantilever’s comparison, F(2, 132) = 240.8,
p < 0.0001. Tukey’s post hoc test showed a statistically significant ascending trend of
prosthesis-implant arch area ratio as the horizontal width ratio increases. Interestingly,
the posterior cantilever had the greatest prosthesis-implant arch area ratio.
Conclusions: Compared to the preexisting anterior-posterior spread concept, a new
prosthesis-implant arch area ratio seemed to be a more categorized, geometric, and per-
ceptive modality of assessing the prosthetic cantilever in a full-arch implant-supported
prosthesis, allowing a more systematic indexing of different full-arch implant clinical
scenarios with greater specificity and consistency.

KEYWORDS
Biomechanics, engineering, full-arch, geometric, implant

J. Prosthodont. 2022;1–7. wileyonlinelibrary.com/journal/jopr © 2022 by the American College of Prosthodontists. 1

2 KIM
FIGURE 1 (a) Conventional A-P spread concept with 1:1.5 ratio; (b) Mathematical equation of “Heron’s formula”
With a significant increase in full-arch implant rehabilitation
treatments, understanding the principles of engineering have
become even more pivotal. Until now, the anterior-posterior
(A-P) spread (Fig 1a) was the primary means to correlate
biomechanical relevance in the distal cantilever of the pros-
thesis on an implant-supported fixed full-arch prosthesis.1,2
However, this somewhat overly simplified linear interpreta-
tion might incur a significant inconsistency in a wide array
of different clinical scenarios, especially in full-arch splinted
implant-supported prosthesis, due to: different widths of var-
ious arch sizes; unequal distal prosthetic cantilever lengths;
uneven distal implant platform locations; and buccally or
lingually flared prosthesis designs. Although other factors
such as implant depths, occlusal forces/schemes, abutment
connections/directions, etc, might be potential etiologies of
biomechanical complications, this paper focused on introduc-
ing a new paradigm, modifying the preexisting A-P spread
rule, primarily on the coronal portion of prostheses for its
simplicity of application.
Despite several emerging concepts like a guideline for
anterior contours3 and zygomatic prosthesis4 for fixed com-
plete dentures, the preexisting biomechanical interpreta-
tion of distal cantilever guidelines5,6 were not sufficiently
grounded in evidence-based research. There is currently no
available biomechanical concept in correlating the size of
cantilever prosthesis contour to implant platform distribu-
tion or assessing different quadrants of prosthetic cantilevers
in full-arch splinted implant restorations. Since an increased
number of assessment parameters allows for a more accurate
perception of three-dimensional (3D) object analysis,7,8 the
arch area may be more appropriate than a simple linear ratio
in the realm of cantilever assessment. The null hypothesis
tested was that, in a preset 1:1.5 ratio of conventional A-P
spread on all groups, there would be no significant difference
of the prosthesis-implant arch area ratio (PIAAR) amongst
different horizontal arch widths of fixed complete dentures
on all cantilevers.
In mathematical principles, inferred from the Pythagorean
theorem, “Heron’s formula”9 was used to calculate a triangu-
lar area with known values of three sides without any angu-
lar information (Fig 1b). This algebraic principle9 was the
fundamental modality to derive a new geometric biomechan-
ical paradigm of calculating the arch area from both implants
and prosthesis on a full-arch implant-supported prosthesis, as
illustrated in this paper.
MATERIALS AND METHODS
Platform arch area (PLAT) was originated by utilizing seg-
mented triangles of Heron’s formula9 allowing a precise area
calculation from distributed implant platforms. The example
used in Figure 2(a) served as the basis for all theoretical cal-
culations relevant to this manuscript. The theoretical model
was based on four implants retained fixed complete denture
(Fig 2a), positioning most anterior implants in reference to a
horizontal line created by connecting palatal gingival margins
of central incisors, four lines connecting the central point of
each implant platforms exist (A, B, C, and D), along with one
cross-sectioning line (E), all of which resulted in two differ-
ent triangles (A1 and A2). The summation of these two tri-
angle areas derived PLAT—the area created by four implant
platforms. Explicit area calculation of different PLATs was
always possible regardless of implant numbers, positions, or
orientations because added cross-sectioning lines can formu-
late multiple aligned triangles, followed by consistent and
consequent area calculation using Heron’s formula (Fig 2b).
Similarly, prosthesis arch area (PROS) was derived through
multiple triangles of Heron’s formula. Along with four
implant platforms, there were two different axis lines as
viewed from the occlusal view—one crossing the cen-
ter of the two most anterior implants (X-axis); and, the
other crossing the center of the two most distal implants
(Z-axis) were drawn—similar to the line drawing process
from the original A-P spread concept.10 Then, primary refer-
ence points were designated as follows (Fig 3a); “a” points—
the most buccal point on each incisor; “b” points—the most
buccal point on each canine; “c” points—the most buccal
point on the disto-buccal cusp of the terminal tooth on each
side; “d” points—two points presenting on the prosthesis’
most outer layer along the X-axis; “e” points—two points
presenting on the prosthesis’ most outer layer along the
Z-axis.
Different prosthetic cantilevers could be calculated by con-
necting and segmenting through all these primary reference
points with sectioned multiple triangles as follows; anterior
PROSTHESIS-IMPLANT ARCH AREA RATIO (PIAAR) 3

FIGURE 2 (a) Schematic diagram of platform arch area (PLAT) and its derivation; (b) Variations of PLATs on different number of implant fixtures.

F I G U R E 3 (a) Schematic diagram of prosthesis arch area (PROS) and its derivation; (b) Variations of PROSs on different number of implant fixtures
and various prosthetic morphologies

cantilever (PROS-A), red color; lateral cantilever (PROS-
L), lime color; posterior cantilever (PROS-P), green color.
PROS-L could be derived via subtracting the PROS-M (blue
color) by PLAT (purple color) (Fig 3a).
With this conceptual visualization, each clinical scenario
with different implant orientations and diverse prosthetic
morphologies could repeatedly derive a predictable calcula-
tion of each prosthetic cantilever’s area, regardless of its vari-
ation (Fig 3b).
PLAT and PROS on each cantilever mentioned above
could derive the following PIAARs, numerically and equa-
tionally expressed as follow; PIAAR-A (anterior cantilever)
4 KIM

F I G U R E 4 Occlusal views of different arch gypsum casts with trajectory four implant fixtures with same vertical A-P spread of 1:1.5 ratio (n = 15) and
schematics of platform arch area (PLAT)

= PROS-A / (PROS-A + PLAT); PIAAR-L (lateral can-
tilever) = PROS-L / (PROS-L + PLAT); PIAAR-P (posterior
cantilever) = PROS-P / (PROS-P + PLAT).
Fifteen different laboratory cast arches (n = 15) were cho-
sen, followed by designating trajectory four implant plat-
forms referenced from the conventional A-P spread 1:1.5
ratio (Fig 4), applying to all experimental groups. Then,
three different horizontal arch width ratios (1:1, 1.25:1,
and 1.5:1) under the same linear ratio of A-P spread
(1:1.5) were created (Fig 5) to assign different experimen-
tal groups of PROSs on each patient scenario. After dis-
secting and connecting through primary reference points,
both PLAT and PROS were calculated using Heron’s for-
mula (Fig 6). After extracting each value of the PIAAR
through different horizontal width groups, each cantilever
group’s PIAAR was then ultimately compared (n = 45).
Data was presented as mean ± standard deviation. Statisti-
cal significance was examined by one-way analysis of vari-
ance (ANOVA) to compare PIAARs amongst different hor-
izontal arch width ratios (1:1, 1.25:1, and 1.5:1), as well as
average PIAARs in anterior, lateral, and posterior cantilevers.
One-way ANVOA test was followed by Tukey’s post hoc
multiple comparison tests and a p < 0.05 was considered
significant.
PROSTHESIS-IMPLANT ARCH AREA RATIO (PIAAR)
FIGURE 5 Experimental design of different arch width length ratios (1, 1.25, and 1.5), along with consistent platform arch area (PLAT)—pink color
F I G U R E 6 Dissection of platform arch area (PLAT) (upper left corner), prosthesis arch area (PROS) (upper right corner), and different arch width ratio
groups (lower) with multiple triangles of Heron’s formula
RESULTS
Unlike the consistent preset value of conventional linear A-P
spread (1:1.5) ratio throughout all samples, one-way ANOVA
revealed statistical significance on all PIAARs of different
cantilever groups; anterior cantilever, F(2, 42) = 8.326,
p = 0.0009 (Fig 7a); lateral cantilever, F(2, 42) = 43.92, p <
0.0001 (Fig 7b); posterior cantilever, F(2, 42) = 26.66, p <
0.0001 (Fig 7c). Tukey’s post hoc test showed a statistically
significant ascending trend amongst different arch width
groups as the width ratio increases. In the PIAAR of the ante-
rior cantilever, there was statistical significance between 1
versus 1.25 (p = 0.0442) and 1 versus 1.5 (p = 0.0006), while
there was no statistical significance between 1.25 versus 1.5
(p = 0.2729). In the PIAAR of the lateral cantilever, there
was statistical significance on all comparisons as 1 versus
1.25 (p < 0.0001), 1 versus 1.5 (p < 0.0001), and 1.25 versus
1.5 (p = 0.0022). In the PIAAR of the posterior cantilever,
there was statistical significance between 1 versus 1.25 (p <
0.0001) and 1 versus 1.5 (p < 0.0001), while there was no
statistical significance between 1.25 versus 1.5 (p = 0.0975).
5
The average PIAAR comparing each cantilever group,
combining all width groups (n = 45), was also analyzed
(Fig 8). One-way ANOVA revealed statistical significance,
F(2, 132) = 240.8, p < 0.0001. Tukey’s post hoc test showed
a statistically significance between anterior versus posterior
(p < 0.0001) and lateral versus posterior (p < 0.0001), while
there was no statistical significance between anterior versus
lateral (p = 0.5716).
DISCUSSION
A-P spread was defined as the distance between a linear
line connecting the most terminal aspects of implant plat-
form to the center of the most anteriorly distant implant
(Fig 1a).10 In the realm of the full-arch implant-supported
prosthesis, many scholars have attempted investigating the
A-P spread concept and distal cantilevers to correlate in
biomechanical engineering and clinical implications.10,11
Several empirical approaches to provide clinical guidelines
have been attempted, yet inconsistency of implant platform
6 KIM
F I G U R E 7 Prosthesis-implant arch area ratios (PIAARs) amongst different arch width ratio groups of (a) anterior cantilever; (b) lateral cantilever; and
(c) posterior cantilever
F I G U R E 8 Different cantilevers comparing the prosthesis-implant
arch area ratios (PIAARs)
distributions and prosthetic morphologies raised a significant
uncertainty of its predictability, along with a wide array of
other heterogenetic potentials such as (1) different widths
of various arch sizes; (2) unequal distal prosthetic cantilever
lengths; (3) uneven distal implant platform locations; and (4)
buccally or lingually flared prosthesis design.
In the modern trend of minimally invasive and computer-
guided surgery, various concepts in full-arch implant-
supported rehabilitation such as the all-on-four concept3 or
zygomatic implants4 have been successfully advanced. After
these surgical routes, to compensate narrower or wider arch
sizes for better esthetic and reconstructive outcomes, coronal
prosthetic morphology had to become more buccally or lin-
gually flared. In such cases, besides addressing the hygienic
issue of food impaction on the prosthetic undercuts, there
was no clear clinical guideline of how much contouring is
ideal in terms of structural integrity and biomechanical prin-
ciples. Clearly, qualified engineering investigation seemed to
be highly insufficient, primarily due to a lack of precise and
accurate categorization in experimental groups. In edentulous
maxillary implant-supported fixed rehabilitation, a more con-
structive categorization of orofacial anatomy in reference to
the esthetics and reconstructive prosthodontics emerged with
buccal contouring with pink gingiva prosthesis3 yet no avail-
able study existed to investigate any potential consequences
of having long-span anterior prosthetic cantilevers in refer-
ence to biomechanical and prosthetic complications due to
the lack of sophisticated categorization.
As architectural engineering emphasized the empirical rel-
evance of the area interpretation for its mechanical anal-
ysis of building construction,7,8 this new PIAAR concept
seemed rational enough for further observation and inves-
tigation in implant biomechanics of reconstructive dentistry
for cantilever prosthesis. Notably, this new arch area ratio
concept resonated with its novelty revisiting the preexist-
ing A-P spread concept where only linear lines used to
get interpreted in 3D perceptuality. Through this proof-
of-concept experiment, an empirical question of justify-
ing this new and more dimensional assessment modal-
ity, compared to the preexisting A-P spread concept, was
narrated, and validated with statistically significant data
results. The PIAAR of different arch width ratios was ana-
lyzed; the null-hypothesis was rejected on all cantilever
groups.
PROSTHESIS-IMPLANT ARCH AREA RATIO (PIAAR)
This paper has several limitations including the prede-
termined anterior implant positions, and not incorporating
other potential etiological engineering aspects. However,
throughout this paper, it is clearly demonstrated that, within
different cantilevers arch morphologies of the same conven-
tional linear ratio length of A-P spread, the PIAAR con-
cept enabled a more systematic categorization of cantilever
status in each clinical scenario. This discovery portrayed a
realization of possible oversimplification in the past conven-
tional A-P spread concept and the consequential necessity
of further investigating PIAAR through in vitro mechani-
cal experiments and/or retrospective clinical studies. Inter-
estingly, different cantilever groups showed a statistically
significant difference, particularly with posterior cantilever,
which justified categorizing PIAAR on each cantilever quad-
rant for clinical implication. Then, accordingly, specific clin-
ical guidelines for designing a prosthesis cantilever on a full-
arch implant-supported prosthesis would then be available.
Furthermore, incorporating advanced software and artificial
intelligence technologies, a possible web-based platform may
be created for guiding clinicians to get an automated visual
instruction of ideal implant distribution based on submitted
intraoral occlusal photographs or surface files of trajectory
prosthesis.
As if a discovery of mathematical formula in par-
allel parking agitated the auto-industry market, this
conceptual PIAAR could significantly impact modern
implant dentistry. As more concrete principles, guidelines,
and innovations via PIAAR emerge through academic
and clinical arenas, systematic perceptual preplanning in
computer-guided implant surgery become feasible—a new
era of prosthetically driven implant surgery in the realm of
digital dentistry.
CONCLUSIONS
Compared to the preexisting A-P spread concept, a new
prosthesis-implant arch area ratio (PIAAR) seems to be
a more categorized, geometric, and perceptive modality
of assessing the prosthetic cantilever in full-arch implant-
supported prosthesis. This new paradigm would enable more
constructive indexing of different full-arch implant clinical
scenarios with enhanced specificity and consistency, allow-
ing a more qualitative execution of surgical and reconstruc-
tive prosthodontics, and further enable prosthetically driven
implant placement.
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7
DISCLOSURE
U.S. Provisional Patent Application is filed, under Young
K. Kim (solo inventor), through New York University—
(attorney Docket No. 50124/09501 USPTO Customer No.
121587).
ORCID
Young K. Kim DMD, DMSc, FACP https://orcid.org/0000-
0002-1984-206X
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How to cite this article: Kim YK: Prosthesis-
implant arch area ratio (PIAAR) – a new geometric
paradigm, replacing the current ‘A-P spread’ of a
cantilever in full-arch implant prosthesis: A
proof-of-concept experiment. J Prosthodont 2022;1-7.
https://doi.org/10.1111/jopr.13523