406 PERIIMPLANT STRESS OF SPLINTED IMPLANT-SUPPORTED CROWNS
Effect of Crown to Implant Ratio and
Implant Dimensions on Periimplant Stress
of Splinted Implant-Supported Crowns: A
Finite Element Analysis
Mehmet Bayraktar, DDS, PhD,* B. Alper Gultekin, DDS, PhD, Serdar Yalcin, DDS, PhD, and Eitan Mijiritsky, DMD
ince Brnemarks discovery,
S many studies have shown high
long-term success rates with the
use of standard-length osseointegrated
implants in the treatment of complete
or partial edentulism.15 However,
when evaluating patients for tooth
replacement therapy, especially in the
posterior maxilla and mandible, clini-
cians may encounter limited available
bone because of resorption and prox-
imity to structures such as the mandib-
ular canal and pneumatized maxillary
sinus. Many different approaches have
been used in implant-supported resto-
rations to resolve the problem of
advanced alveolar ridge resorption.68
Despite the good predictability and
success of bone grafting procedures,
patients are often reluctant to undergo
aggressive surgery because of the
inherent risks, associated morbidities,
procedural cost, elevated stress during
chairside treatment, and long healing
time.914 Therefore, the use of short
implants (length less than 10 mm) with
reduced bone height may provide sev-
*Private Practice in Implant Dentistry, Istanbul, Turkey.
Research Assistant, Department of Oral Implantology, Istanbul
University, Istanbul, Turkey.
Professor, Department of Oral Implantology, Istanbul
University, Istanbul, Turkey.
Private Practice in Implant Dentistry, Tel-Aviv, Israel.
Reprint requests and correspondence to: B. Alper
Gultekin DDS, PhD, Department of Oral Implantology,
Faculty of Dentistry, Istanbul University, Fatih, Istanbul
34390, Turkey, Phone: +90 5326757236, Fax: +90
2125323254, E-mail: alpergultekin@hotmail.com
ISSN 1056-6163/13/02204-406
Implant Dentistry
Volume 22  Number 4
Copyright 2013 by Lippincott Williams & Wilkins
DOI: 10.1097/ID.0b013e31829c224d
 BAYRAKTAR
Purpose: To assess the inuence
of different crown-implant (C/I)
ratios and implant dimensions on
periimplant stress in the partially
edentulous posterior mandible by 3-
dimensional nite element analysis
(FEA).
Materials and Methods: Two
implants were placed in the second
premolar and rst molar regions of
the mandibular model. The implants
were then splinted with a 2-unit xed
bridge. The inuence of 3 parame-
ters (C/I ratio, implant length, and
implant diameter) on periimplant
bone stress was then analyzed by
using FEA.
Results: C/I ratios showed
a direct relationship with periim-
plant bone stress, but the absolute
eral clinical advantages, such as pro-
tection of vital anatomic structures,
lower risks in bone augmentation,
and better patient acceptance of the
treatment.1518
Numerous studies published in the
early 1990s showed low success rates of
short machined-surface implants in the
mandible and maxilla.19,20 In the last
decade, implant macro- and microdesigns
have been greatly improved.2123 Recent
reports on short implants have demon-
strated success rates comparable to those
obtained with standard-length im-
plants.2426 Therefore, several researchers
ET AL
height of the clinical crown had
a much more signicant inuence.
The implant length had less inuence
on the periimplant bone stress than
the implant diameter. Lower stress
values were detected in wide-diameter
implants, even in scenarios involving
long crowns.
Conclusions: Crown height is
a more important factor affecting the
periimplant bone stress than the C/I
ratio for splinted implant-supported
crowns. Two-unit xed restorations
with high C/I ratios may be success-
fully used with wide-diameter im-
plants in the posterior mandible.
(Implant Dent 2013;22:406413)
Key Words: nite element analysis,
crown to implant ratio, implant
dimension, posterior mandible
have focused on short implants. Gener-
ally, all types of dental implants show
the same osseointegration phenomenon
initially. Many studies have revealed
that most failures of implant-supported
restorations occur after prosthetic load-
ing that accentuates the prosthetic con-
ditions and occlusal forces.27,28 Thus, for
long-term success, clinicians should
know the advantages and limitations of
not only the surgical but also the restor-
ative procedures involved in implant-
based treatment.
The limited surface area of short
implants with high crown to implant (C/I)
 IMPLANT DENTISTRY / VOLUME 22, NUMBER 4 2013 407

ratios could be a biomechanical disad-

vantage in the long-term because such
implants may be less resistant to detri-
mental nonaxial occlusal forces.2931
Such stress can cause crestal bone
loss, decrease the lifetime of osseointe-
grated implants, or increase the risk of
prosthetic complications such as recur-
rent screw loosening of abutments,
porcelain chipping, and decementation
or fracture of the components.3235
Fig. 1. Edentulous mandible scanning and sections being digitized. Splinting crowns on adjacent im-
plants are thought to distribute func-
tional forces applied to implants more
uniformly. This reduces potential over-
loading of crestal bone, which may lead
to fewer prosthetic and implant compli-
cations such as prosthesis loosening,
implant fracture, and implant
failure.30,36,37
The aim of this study was to assess
the inuence of different C/I ratios and
implant dimensions on the periimplant
stress in the partially edentulous poste-
rior mandible by 3-dimensional nite
element analysis (FEA).
Fig. 2. The second premolar and rst molar of the mandibular model extraction by using MATERIALS AND METHODS
a Boolean process.
In this study, the model of the
human mandible was based on a cadav-
eric mandible obtained from the Depart-
ment of Anatomy at the Faculty of
Dentistry, Istanbul University. The man-
dibular height and width were at least 10
and 5 mm, respectively. The edentulous
mandible obtained from the cadaver was
scanned by using a dental volumetric
tomography device (ILUMA, Orthocad,
CBCT scanner; 3M-Imtec, Ardmore,
Fig. 3. Modeling of implants, bone, and prostheses. OK) (Fig. 1). Volumetric data were re-
constructed in 0.2-mm-thick sections.
These sections were digitized and input-
ted in DICOM 3.0 format and visualized
by using 3D Doctor software (Able Soft-
ware Corp, Lexington, MA). Cortical
bone of 2 mm uniform thickness and
cancellous bone were modeled.
The second premolar and rst
molar of the mandibular model were
extracted by using a Boolean process
(Fig. 2). Straumann Standard Implant
(surgical soft tissue level, Straumann
Dental Implant System; Institut Strau-
mann AG, Basel, Switzerland) designs
were adopted for this study. Implant
Fig. 4. Static forces of 100 N application at 30 degrees obliquely to the lingual inclination of
and standard abutment models were
the buccal cusps. digitized by using a Next Engine 3D
scanner (NextEngine, Inc, Santa
408 PERIIMPLANT STRESS OF SPLINTED IMPLANT-SUPPORTED CROWNS  BAYRAKTAR ET AL

Table 1. Selected Material Properties (Young Modulus and Poisson Ratio) of Bone, RESULTS
Titanium, and Prosthetic Structures Used in the Study for Analysis The stress values for each model
Material Young Modulus (Gpa) Poisson Ratio are depicted in Figure 6. According to
Trabecular bone 1370 0.3
the amount of stresses on the periim-
Cortical bone 13,400 0.3
plant region, gures of different colors
Titanium 110 0.35 were used (Fig. 7). Stresses on each
Cobalt-chromium alloy 218 0.33 model were evaluated according to the
Feldspathic porcelain 82.8 0.35 stress values. In other words, the most
favorable models had the lowest stress
values, and the most deleterious models
had the highest stress values. The low-
est stress value around the cervical bone
was detected for a model with a diameter
of 5.0 mm, implant length of 8 mm, and
C/I ratio of 1:1. The highest stress value
was detected for a model with a diameter
of 3.5 mm, implant length of 10 mm,
and C/I ratio of 2:1 (Fig. 6).

Fig. 5. Elements and nodes of models.
Monica, CA) in macro resolution. The
foramen mentale was considered the
reference point for the anatomic model,
and implant localizations were planned
according to this reference point. The
mesial limit of the edentulous segment
was modeled by drawing perpendicu-
lars from the foramen mentale to the
alveolar ridge in line with the mesial
surface of the second premolar crown.
Two implants were placed in the second
premolar and rst molar regions in this
model. The implants were then splinted
with a 2-unit xed bridge (Fig. 3).
To calculate the mesiodistal width
of the second premolar and rst molar,
Wheelers Atlas of Anatomical Natural
Tooth Morphology was used as the ref-
erence.38 Accordingly, the mesiodistal
width of the second premolar and rst
molar was set to 7 and 11 mm, respec-
tively. The prosthetic superstructure was
simulated as a porcelain-fused-to-metal
restoration (ie, cobalt-chromium alloy
and feldspathic porcelain). The metal
thickness was 0.8 mm, and the porcelain
thickness was at least 2.0 mm. The Atlas
was used again for digitally preparing the
crown models. Cement thickness
between the framework and the abut-
ment was neglected. The interface of
the materials was assumed to be 100%
bonded or osseointegrated. Furthermore,
the materials were considered homoge-
nous, isotropic, and linearly elastic. The
corresponding elastic properties such as
Young modulus and Poisson ratio were
determined from the values cited in the
literature.8,29,31 Table 1 presents the
selected material properties.
In each model, static forces of 100 N
were applied at 30 degrees obliquely and
separately to the lingual inclination of
the buccal cusps (Fig. 4). Under the ob-
lique load, the minimum principal stress
values were calculated as the periimplant
bone stress, which are most commonly
reported in FEA-based studies to deter-
mine the overall stress at a point.
Simulation software (Autodesk,
Inc, San Rafael, CA) was used to design
the mathematical models consisting
basically of the mandible, implants,
and 2-unit xed prosthesis (Fig. 5).
Three implant-related variables
were considered in this study:
1. Length (6, 8, and 10 mm);
2. Diameter (3.5, 4, and 5 mm); and
3. C/I ratio (1, 1.5, and 2).
The inuence of these parameters
on the periimplant bone stress was
then analyzed.
DISCUSSION
Proper selection of implant dimen-
sions is generally based on the amount of
available bone. From the biomechanical
viewpoint, long- and wide-diameter im-
plants with low C/I ratios provide better
periimplant tissue stability in the long-
term because of favorable distribution of
occlusal forces.26,39,40 However, clini-
cians may choose different treatment
methods because of vertical and hori-
zontal resorption of the alveolar ridge.
These anatomic restrictions are more
common in the posterior region of the
jaw. In these situations, 2 treatment
modalities can be applied. One is surgi-
cal modication of the patients anatomy
by using advanced techniques such as
bone grafting with or without growth
factors, alveolar distraction, or bone
splitting to allow placement of long-
and wide-diameter implants.912 These
procedures are technique sensitive and
time consuming, associated with high
risk of morbidity, and expensive; there-
fore, many patients are unwilling to
undergo invasive surgical techniques.
The second option is adaptation of the
implant to the existing anatomy by using
implants with modied dimensions.
Short implants are much less complex
and involve less invasive treatment than
longer implants in severely resorbed
mandibles requiring prior adjunctive
vertical ridge augmentation or inferior
mandibular nerve repositioning.41 How-
ever, short implant failures occur

Fig. 6. Stress distribution for each model.
Fig. 7. Stress concentrations around cervical bone.
primarily after prosthetic loading ac-
cording to many reports.41,42
Increased C/I ratio, higher bite
forces, and bone density in posterior
area are common factors that increase
stress and may explain the reasons of
the higher failure rates of short
implants.43
During this study, the partially
edentulous posterior mandible was mod-
eled with different C/I ratios and implant
dimensions. In general, patients consult
their dentists late or may not select
implant-supported restorations initially.
Therefore, severe vertical resorption and
improper C/I ratios are frequently
IMPLANT DENTISTRY / VOLUME 22, NUMBER 4 2013
encountered challenging conditions in
the posterior mandible.
In such cases, biomechanical eval-
uation of the risks and application of the
necessary precautions may improve the
survival of implant-supported restora-
tions. The literature shows many meth-
ods such as photoelastic, strain gauge,
and FEA-based techniques to investi-
gate the stress in the periimplant
region.44,45 FEA is a numerical stress
analysis method generally used in engi-
neering to solve biomechanical prob-
lems before they occur. A nite
element model is constructed by divid-
ing solid objects into several elements.
409
Each element is assigned appropriate
material properties corresponding to
the properties of the real object. This
method allows simulated force applica-
tion and stress analysis in the periim-
plant region according to the models
for every treatment alternative.46,47
In this study, nite element models
were constructed to evaluate the effects
of mainly the implant length, implant
diameter, and C/I ratios.
In our study, an increase in the C/I
ratio was generally associated with high-
er stress values in the periimplant region,
with the highest stress values being
detected for the 2:1 ratio in all models.
Excessive C/I ratios have been reported
as being detrimental to the long-term
stability of periimplant bone and implant
survival.1921,48 However, disproportion-
ate C/I ratios have also been associated
with predictable long-term prognosis. In
a 10-year prospective study, Blanes et al49
concluded that a C/I ratio of 2:3 was
acceptable for long-term stability of peri-
implant bone. In another clinical study, it
was reported that an increased C/I ratio
had no effect on crestal bone but more
restorative complications were observed
over time.50 The results of the present
study suggest that a C/I ratio of 1.5 or 2
can produce lower stress values whether
standard- or wide-diameter (4.0 and
5.0 mm, respectively) implants are used.
In one of the studies, higher C/I ratios
showed lower bone loss than lower C/I
ratios.49 This may be attributed to the
stimulation of the alveolar ridge and the
result of bone physiology.49 If stress on
periimplant bone increases, the bone will
remodel and adapt itself overtime to
become stronger to resist that loading.51
In contrast, for lower C/I ratio restora-
tions, if the loading on a bone decreases,
the bone will become weaker due to turn-
over and there will be no stimulus for
continued remodeling that is required to
maintain bone mass. This may increase
periimplant bone loss and inuence the
survival of the implant. In the present
study, the stress values associated with
3 different C/I ratios have been deter-
mined and the results have been evalu-
ated from a biomechanical point of view.
Optimum stimulus threshold of periim-
plant bone may change not only from one
person to another but also in different
regions of the same jaw. This might be
410 PERIIMPLANT STRESS OF SPLINTED IMPLANT-SUPPORTED CROWNS
the reason for the conicting results in
different clinical studies related to C/I
ratios.
It is important to mention that all the
models used in the study were splinted
restorations. Splinted restorations shared
the occlusal loads and distributed the
stresses more evenly between the im-
plants when force was applied.52 To cir-
cumvent the difculty of fabrication of
a passively seating splinted prosthesis
on several implants and achievement of
interproximal oral hygiene, some authors
have suggested that multiple adjacent im-
plants be restored individually.53,54 Non-
splinted restorations have numerous
interproximal contacts that require metic-
ulous adjustments in the clinic. The
importance of achieving a passive ideal
contact between implants is more crucial
than between natural teeth because the
former is associated with diminished
dynamic response. In addition, off-axis
loading of implants was evenly shared
in splinted prosthesis.52 In this present
study, off-axis loadings were applied on
all models. Clinically, splinting exces-
sive C/I ratio restorations may help
decrease restorative complications such
as abutment loosening and recurrent de-
cementation of the restoration.16,19,24
Therefore, all models were prepared as
splinted in this study.
As the crestal height of the ridge is
resorbed, available bone height is
reduced. This condition increases the
prosthetic crown height. As a conse-
quence, shorter implants are often used
in a situation where the crown height is
greater than ideal.42 Another important
piece of information successfully derived
from this analysis is that the crown height
has a greater effect on stress than the C/I
ratio. Implant length had less inuence on
the periimplant bone stress than the crown
height. Kotsovilis et al55 performed a sys-
tematic review of studies describing the
effect of implant length on the survival of
rough-surface dental implants. Their
meta-analyses revealed no statistically
signicant difference in survival between
short-length (#8 or ,10 mm) and stan-
dard-length ($10 mm) rough-surface im-
plants placed in totally or partially
edentulous patients.55 In another study,
Romeo et al56 demonstrated that short
implants had the same survival rate
as standard-length implants in various
 BAYRAKTAR
situations. These ndings support and cor-
roborate the results of the present study.
Therefore, the risks associated with
high C/I ratios of 1.5 or 2, such as severe
ridge resorption, should be more care-
fully evaluated than the implant length.
Crown height is a vertical cantilever.4043
In the present study, we found that as
long as the crown height is 12 mm or less,
the stress in the periimplant bone was not
detrimental, irrespective of the implant
length. This result is more prominent
for standard- and wide-diameter im-
plants. In other words, if 2 models with
the same C/I ratio (eg, 2) are compared,
for example, a model with a 6-mm-long
implant with a 12-mm-long crown versus
that with a 10-mm-long implant length
and a 20-mm-long crown, crown height
inuences the periimplant bone stress
more signicantly. By decreasing the
crown height in comparison to increasing
the implant length, the periimplant bone
stress reduces to a great extent.
We found that higher C/I ratios
increased the stress in the periimplant
region when used with narrow-diameter
(3.5 mm) implants. These values were
lowered when standard- and wide-
diameter implants were used. In par-
ticular, even when 16-mm-long or
20-mm-long crowns were modeled
because of the higher C/I ratio, no re-
markable alterations in the stress values
were observed with wide-diameter im-
plants. Esposito et al57 reported that
short implants (6 mm long) with a con-
ventional diameter of 4 mm achieved
similar results as longer implants placed
in the posterior mandible. They also
pointed out that short- and wide-diameter
($4 mm) implants might be preferable
for vertical bone augmentation, espe-
cially in the posterior mandible, because
the treatment was faster, cheaper, and
associated with less morbidity.57 In a
similar study, Fugazzotto58 revealed that
when implants of 6 to 9 mm in length
were utilized appropriately with conven-
tional diameter implants, survival rates
under function would be comparable to
those reported for longer implants.
The results of the present study
are in accordance with those of Esposito
et al57 and Fugazzotto.58 For wide-
diameter implants, even in those with
long crowns, lower stress values were
detected with the 6-, 8-, and 10-mm-long
ET AL
implants. According to the present
results, in patients with excessive C/I
ratios due to severe vertical bone resorp-
tion, the stress values will not be detrimen-
tal to the periimplant bone irrespective of
whether short or standard-length and
wide-diameter implants are used. The dif-
ference in implant length did not change
the stress values in the periimplant bone
dramatically, but increasing the implant
diameter led to a remarkable reduction
in the stress values. The results of this
FEA study have shown that implant diam-
eter was more important for improved
stress values than implant length. This
likely results from the fact that greater
amount of stress is located in the cortical
bone around the neck, and therefore,
increasing the load-supported area of the
implant body may decrease the effect of
loading forces.59 Many published FEA-
based studies have shown that wide-
diameter implants with large surface
area diminish stress in the periimplant
region.6062 Therefore, from a biomechan-
ical point of view, it can be concluded that
the survival rate of these implants may be
higher when compared with standard- or
narrow-diameter implants. However,
some clinical studies have shown more
failures with wide-diameter implants.19,63
This is especially true when primary
stabilization cannot be achieved with
standard-diameter implants because of
low-density bone or in immediate implant
cases when the diameter of the extraction
socket is greater than the standard implant
diameter, wide-diameter implants can be
used. Clinically, the use of wide-diameter
implants in risky situations may decrease
the total success rate. In the present study,
wide-diameter implants were simulated
in exactly the same physical conditions
as narrow- and standard-diameter im-
plants. Therefore, when these implants
were compared under the same ideal con-
ditions and time points, wide-diameter
implants yielded more successful results.
As long as resorption progresses around
implants after loading because of differ-
ent reasons, such as biologic width forma-
tion, periimplantitis, lack of adequate
hygiene, and parafunctional habits, the
risk of failure will increase with a few
millimeters of bone loss around wide-
diameter and short-length implants.42
For narrow-diameter implants with
standard crown height (,12 mm), no

great difference in the stress values was
noted regardless of whether short or stan-
dard-length implants were used. How-
ever, establishing crown heights of 16 or
20 mm, especially with narrow-diameter
implants, largely increased the stress val-
ues in the periimplant region. Therefore,
if narrow-diameter implants with crown
heights of less than 12 mm are used, the
C/I ratio will not affect the stress values
signicantly.
In this study, the model components
were considered homogeneous, isotro-
pic, and linearly elastic. The models
were assumed to be completely osseoin-
tegrated, and the components were
totally bound to each other. Only oblique
load was applied, and vertical loading
was not simulated. Therefore, the num-
ber of models was reduced. As shown in
published studies, because crestal bone
is less resistant to deformation in non-
axial loading, variable C/I ratio and
implant dimension models play a more
important role in evaluating the results of
oblique loading.64,65 These simplica-
tions were made for all the simulated
models; therefore, the accuracy of the
analysis from the stress distribution
viewpoint is not affected, as long as the
models are compared with each other in
the same study.
The most common drawback of
FEA from the clinical perspective is
overemphasis on the precise stress val-
ues in the models. While achieving these
results from simulated models, many
factors directly affecting clinical fea-
tures, such as loading conditions, mate-
rial properties, and boundary conditions,
are neglected or ignored. Therefore,
correlating FEA results with results from
preclinical and clinical studies may help
validate the results of the present study.
CONCLUSIONS
Within the limitations of this study,
the following conclusions can be drawn
for splinted 2-unit implant-supported
xed restorations:
1. The crown height is a more impor-
tant factor affecting the periim-
plant bone stress than the C/I ratio.
2. The implant length has less inu-
ence on the periimplant bone
stress than the implant diameter.
IMPLANT DENTISTRY / VOLUME 22, NUMBER 4 2013
By increasing the length rather
than the diameter, less stress
reduction can be observed in the
periimplant region.
3. An increase in the C/I ratio is asso-
ciated with higher stress values in
the periimplant region for all
models.
4. In the case of adequate bone vol-
ume, short (,10 mm) and standard-
or wide-diameter implants ($4
mm) cause similar stress as long
implants.
DISCLOSURE
The authors claim to have no
nancial interest, either directly or
indirectly, in the products or informa-
tion listed in the article.
ACKNOWLEDGMENT
This study was supported by Sci-
entic Research Projects Coordination
Unit of Istanbul University. Project
number: 4292.
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