Stress Treatment Theorem for

Implant Dentistry

NIRANJANA R
I YEAR POSTGRADUATE
DEPARTMENT OF PROSTHODONTICS
TABLE OF CONTENTS
 INTRODUCTION
 Dentistry – science and art form.
 The dental sciences may be separated into a biological component and a
biomechanical component.
 A combination of biological and biomechanical factors is responsible for
the failure of tooth-supported fixed prostheses.

 The biological complications occur with greater frequency (11%–22%)

compared with the biomechanical (7%–10%), but both aspects should be
understood by clinicians.
Compared with an implant, Implant dentistry
the support system of a primarily involves the
natural tooth is better replacement of teeth.
designed to reduce the When implant
biomechanical forces complications are
distributed to the reported, the vast
tooth/restoration and the majority of problems are
crestal bone region. The related to the implant
periodontal membrane, sciences. However,
biomechanical design, unlike natural teeth, the
nerve and blood vessel biological aspects of
complex, occlusal material implant dentistry have
and surrounding type of fewer complications. On
bone blend to decrease the the other hand,
risk of occlusal overload to biomechanical related
the tooth system. As a problems may affect
consequence, the biologic more than 30 percent of
factors of caries and the implant restorations.
endodontic failure are a
greater risk.
 The most common causes for implant-related complications are
centered around stress.
 Thus, the overall treatment plan should
(1) assess the greatest force factors in the system
(2) establish mechanisms to protect the overall implant-bone-
prosthetic system.
 SURGICAL FAILURE
 There are many reasons for the failure of an implant to integrate
initially with the bone.
 The primary causes of failure relate to excessive heat during the
preparation of the osteotomy or excessive pressure at the implant-
bone interface at the time of implant insertion.
 An additional cause of surgical failure is micromovement of the
implant while the developing interface is established.
 Movement as little as 20 microns has been reported to cause a
fibrous interface to form at the fracture site.

 The original Branemark protocol used a two stage surgical

approach. One of the main reasons for this concept was to place the
implant at or below the crestal bone region to decrease the risk of
implant movement during initial bone healing.
 Occlusal forces applied to a removable prosthesis over a healing
implant may also cause incision line opening of the soft tissue and
delay soft tissue healing.
 These occlusal forces may also affect the marginal bone around the
developing implant site.

 The surgical component of implant failure is often the least risk

associated with the overall implant treatment.
 EARLY LOADING FAILURE
 On occasion, an implant may fail shortly after it has initially
“integrated” to the bone.
 However, once the implant is loaded, the implant becomes mobile
within 6 to 18 months. This has been called early loading failure by
Misch and Jividen.
 Cause- excessive stress for the bone-implant interface.
 Early loading failure is related to the amount of force applied to the
prosthesis and the density of the bone around the implants, and it
may affect 15% of implant restorations.
 IMPACT OF OCCLUSAL OVERLOAD
ON
MECHANICAL
SCREW COMPONENTS
LOOSENING
overall average of 6% of implant prostheses.
The greater the stress applied to the prostheses
(single tooth versus overdentures), the greater the
risk of abutment screw loosening.
Cantilevers also increase the risk of screw
loosening, as they increase the forces in direct
relationship to the length of the cantilever.
The height or depth of an antirotational
component of the implant body also can affect the
amount of the force applied to the abutment screw.
(higher or deeper the hex height, less stress
applied).
Platform dimension - Larger-diameter implants,
with larger platform dimensions, reduce the forces
applied to an abutment screw and change the arc of
displacement of the abutment on the crest module.
 FATIGUE FRACTURE
 if a lower force magnitude repeatedly hits an object, it will still fracture.
 Prosthesis screw fracture – mean incidence of 4%.
 Metal framework fracture – 3%
 Implant body fracture has the least incidence of this type of
complication, with an occurrence of 1% .
 MARGINAL BONE LOSS
 Crestal bone loss has been observed around the permucosal portion of
dental implants for decades.
 It can range from loss of marginal bone to complete failure of the implant.
• The initial transosteal bone loss around an implant forms a V- or a U-
shaped pattern, which has been described as ditching or saucerization
around the implant.
 Causes of crestal bone - loss have ranged from reflection of the periosteum
during surgery, preparation of the implant osteotomy, the position of the
microgap between the abutment and implant body, micromovement of the
abutment components, bacterial invasion, the establishment of a biological
width, and factors of stress.
 Marginal crestal bone loss may influence esthetics,
as the height of the soft tissue (e.g., interdental papilla)
is directly related to the marginal bone.
 PERIOSTEAL REFLECTION
HYPOTHESIS
 Periosteal reflection causes a transitional change in the blood supply to the
crestal cortical bone.
 When the periosteum is reflected off the crestal bone, the cortical bone
blood supply is affected dramatically, causing osteoblast death on the
surface from trauma and lack of nutrition.
 These events have fostered the periosteal reflection theory as a cause for
early bone loss around an endosteal implant.
 Although crestal bone cells may die from the initial trauma of periosteal
reflection, the blood supply is reestablished once the periosteum
regenerates.
 In addition, the underlying trabecular bone is also a vascular source because
its blood supply often is maintained in spite of crestal periosteal reflection.
 The greater the amount of trabecular bone under the crestal cortical bone,
the less crestal bone loss is observed.

Therefore, the periosteal

loss of entire residual ridge reflected reflection hypothesis does not
appear as a primary causal agent
of marginal crestal bone loss
Generalized bone loss is rarely observed around an implant.
in second-stage uncovery surgery .
 Implant osteotomy hypothesis
 The implant osteotomy causes trauma to the bone in immediate contact
with the implant, and a devitalized bone zone of about 1 mm is created
around the implant.

Crestal region more susceptible to bone loss

Limited blood supply greater heat generated in this denser bone

 This condition supports implant osteotomy preparation as a causal agent
for marginal crestal bone loss around the implant.
 However, if heat and trauma during implant osteotomy preparation were
responsible for marginal crestal bone loss, the effect would be noticeable at
the second stage uncovery surgery 4 to 8 months later.
 Most implants at Stage II uncovery do not demonstrate any bone loss.
 Therefore the implant osteotomy hypothesis for marginal crestal bone loss
cannot be primarily responsible for this routinely observed phenomenon.
Autoimmune response of host hypothesis
 The primary cause of bone loss around natural teeth is bacteria induced.
 Occlusal trauma may accelerate the process, but trauma alone is not
deemed a determining factor.
 The implant sulcus depth progressively increases from the early bone loss,
impairing hygiene and making anaerobic bacteria more likely as the cause
of bacteria related bone loss.
 However, when most bone loss occurs in the first year and less bone loss is
observed afterward, the hypothesis of bacteria as the primary causal agent
for the early crestal bone loss cannot be substantiated.
 Biological width hypothesis
 For a natural tooth, an average biological width of 2.04 mm exists between
the depth of the sulcus and the crest of the alveolar bone
 Wallace and Tarnow stated that the biological width also occurs with
implants and may contribute to some of the marginal bone loss observed.
 Eleven different gingival fiber groups are observed around a natural tooth
whereas in a typical implant gingival region, only two of these gingival
fiber groups and no periodontal fibers are present.
 These fibers do not insert into the implant body below the abutment margin as
they do into the cementum of natural teeth.
 Instead, the collagen fibers in the CT attachment around an implant run
parallel to the implant surface, not perpendicular, as with natural teeth.

 The biological seal around dental implants can prevent the migration of
bacteria and endotoxins into the underlying bone.
 The amount of bone loss from the biological width occurs within 1 month,
whether the implant is loaded or not, and is related to the crest module implant
design and the position of the abutment-implant connection in relation to the
bone but is unrelated to the density of the bone.
 Occlusal trauma
• Marginal bone loss on an implant may be from occlusal trauma.
• Occlusal trauma may be defined as an injury to the attachment apparatus
as a result of excessive occlusal force.
• A number of authors conclude trauma from occlusion is a related factor in
bone loss, although bacteria is a necessary agent.
 Cellular biomechanics

Engineering principles

To establish further a
correlation between Mechanical properties of bone
marginal bone loss
and occlusal overload Implant design biomechanics

Animal studies

Clinical reports
 Cellular biomechanics
 Bone remodeling at the cellular level is controlled by the mechanical
environment of strain.
 Strain is defined as the change in length divided by the original length, and
the units of strain are given in percentages.
 The amount of bone strain at the bone-implant interface is directly related to
the amount of stress applied through the implant prosthesis.
 Mechanosensors in bone respond to minimal amounts of strain, and
microstrain levels 100 times less than the ultimate strength of bone may
trigger bone remodeling.
 Frost reported on the cellular reaction of bone to different
microstrain levels.
 He observed that bone fractures at 10,000 to 20,000 microstrain
units (1% to 2% deformation).
 However, at levels 20% to 40% of this value (4000 units), bone cells
may trigger cytokines to begin a resorption response.
 In other words, excessive bone strain may not only result in physical
fracture, but may also cause bone cellular resorption.
 Engineering principles
 The relationship between stress and strain determines the modulus of
elasticity (stiffness) of a material.
 The modulus of elasticity of titanium is five to ten times greater than that
of cortical bone.
 Composite beam analysis - when two materials of different elastic moduli
are placed together with no intervening material and one is loaded, a stress
contour increase will be observed where the two materials first come into
contact.
 In an implant-bone interface, these stress contours are of greater magnitude
at the crestal bone region.
 the marginal bone loss observed clinically and
radiographically around implants follows a
similar pattern as the stress contours
 Biomechanical properties
 Bone density is directly related to the strength and elastic modulus of bone.
 In denser bone, there is less strain under a given load compared with softer
bone.
 As a result, there is less bone remodeling in denser bone compared with
softer bone under similar load conditions.
 A decrease in bone remodeling can result in a reduction of bone loss.
 The initial peri-implant bone loss from implant insertion to uncovery was
similar for all bone qualities.
 The more dense the bone, the less peri-implant bone loss was observed
after prosthesis delivery (6 months).
Animal studies
Several animal studies in the literature
demonstrate the ability of bone tissue to
respond to a dental implant.
Miyata et al. loaded integrated implants for
4 weeks with premature contacts on crowns
of 100 mm, 180 mm, and 250 mm. The
implants with 180 mm premature contacts
demonstrate a V-shaped crestal bone loss. The
implants with 250-mm premature contacts
demonstrated greater bone loss than the 180-
mm group. The 250-mm premature contact
for 4 weeks lost the most bone.
The higher stresses resulted in more crestal
bone loss.
This animal report imply dynamic occlusal
loading may be a factor in crestal bone loss
around rigid fixated dental implants
 Clinical reports
 Clinical reports have shown an increase in marginal bone loss
around implants closest to a cantilever used to restore the lost
dentition.
 Cantilever length and an increase in occlusal stress to the nearest
abutment are directly related.
 Quirynen et al. evaluated 93 implant patients with various implant
restorations and concluded that the amount of crestal bone loss was
definitely associated with occlusal loading.
 A clinical report by Leung et al. indicates bone loss from occlusal
overload is not only possible,
but may even be reversible
when found early in the process.
 Rangert et al. have noted that occlusal loads on an implant may act
as a bending moment, which increases stress at the marginal bone
level and can cause implant body fracture.
 Before the fracture of the implant body, marginal bone loss was
noted in this retrospective clinical evaluation.
 The same stress that caused implant fracture is the logical cause of
the peri-implant bone loss before the event.
 Implant design biomechanics
 Different amounts of marginal bone loss have been reported for different
implant body designs.
 The implant design and surface condition affect the amount of stress
transferred to the bone, one of the reasons for a different amount of bone
loss for different implant designs may be related to the stress transmitted to
the bone.
 Zechner et al. evaluated the peri-implant bone loss around
functionally loaded screw-type implants with machined surfaced V-
threads or a sandblasted/acid-etched square-thread design and
observed that the average bone loss was 2.4 mm (V-thread) versus
1.6 mm (square thread). The three most probable factors that
influenced the amount of crestal bone loss in this report are the
amount of force applied to the prosthesis, the quality of the bone to
resist these forces, and the implant body design. All three of these
conditions implicate occlusal overload as the cause of marginal bone
loss around an implant.
 discussion
 Limited marginal bone loss during the first year of function after Stage II
surgery has been observed around the permucosal portion of dental
implants for decades.
 Occlusal overload may be an etiology for crestal bone loss does not mean
other factors are not present - the microgap position of the implant
platform and abutment and the biological width often affect the marginal
bone during the first month after the implant becomes permucosal.
 Implant crown height - measured from the occlusal plane to the crest of
the bone - a vertical cantilever, which may magnify the stresses applied to
the prosthesis - if occlusal loading forces can cause crestal bone loss, the
resulting increased moment forces should further promote the loss of bone
until the implant fails.

bone physiology
 2 reasons
Implant design
mechanics
 Bone physiology
 The bone is less dense and weaker at Stage 2 implant surgery than it is 1
year later after prosthetic loading.
 As functional forces are placed on an implant, the surrounding bone can
adapt to the stresses and increase its density, especially in the crestal half of
the implant body during the first 6 months to 1 year of loading.
 Piatelli et al. reported reactions to unloaded and loaded nonsubmerged
implants in monkeys. The bone changed from a fine trabecular pattern after
initial healing to a more dense and coarse trabecular pattern after loading,
especially in the crestal half of the implant interface. When the stresses are
too great, bone loss occurs. When the stresses are within the physiologic
range, the bone density increases.
 The stresses applied to the peri-implant bone may be great enough to cause
bone resorption during the first year, because bone strains are greatest at
the crest.
 However, the stresses applied below the crest of bone are of less magnitude
and may correspond to the physiologic strain that allows the bone to gain
density and strength.
 As a result, the occlusal load that causes bone loss initially (overload) is
not great enough to cause continued bone loss once the bone matures and
becomes more dense.
 Implant design biomechanics
 Implant design may affect the magnitude or type of forces applied to the
bone-implant interface.
 A smooth collar at the crest module may transmit shear forces to the bone.
 The first thread or a roughened surface condition of the implant is where
the type of force changes from primarily shear to compressive or tensile
loads.
 Therefore, in many situations the 35% to 65% increase in bone strength,
through changes from shear to compressive and/or tensile loads, is
sufficient to halt the bone loss process.
 Implant crest module designs may affect the amount of bone loss,
and the implant design contributes to the force transfer of the bone-
implant interface.
 The increase in bone mineralization and organization during the first
year, the increase in bone density at the implant interface, and the
type of force changes at the first thread of the implant body all are
factors that may halt the bone loss phenomenon after the initial
marginal loss.
 Effect of treatment planning
• The Stress Treatment Theorem, states that most all treatment related to the
science of implant dentistry should be centered around the biomechanical
aspects of stress.
• Stress-related conditions that affect the treatment planning in implant
dentistry
1. bone volume lost after tooth loss
2. bone quality decrease after tooth loss
3. complications of surgery
4. implant positioning 11.implant failure
5. initial implant interface healing 12. component fracture
6. initial loading of an implant 13. prosthesis fracture
7. implant design 14. implant fracture.
8. occlusal concepts
9. prosthesis fixation
10. marginal bone loss
 Understanding the relationships of stress and related complications
provides a basis for a consistent treatment system. The Stress
Treatment Theorem has evolved into a particular sequence of
treatment planning:
Patient force factors:
 The factors that influence the amount of patient stress may influence treatment
more than several other factors combined.
 Because stress equals force divided by the area to which the forces are applied,
the amount of force is directly related to the amount of stress.
 There are several force factors to consider, including: (1) bruxism, (2)
clenching, (3) tongue thrust, (4) crown height, (5) masticatory dynamics, and (6)
the opposing arch.
 The clinician should evaluate the number of force conditions and their
influencing severity factors.
 As the overall number increases, the risks increase, and the overall treatment
plan should be modified to decrease the increased force or by increasing the area
of support.

Bone density :
 The density of bone is directly related to the strength of the bone.
 The denser the bone, the stiffer the bone, and the less biomechanical mismatch
to titanium during loading.
 Progressive bone loading changes the amount and density of the implant-bone
contact
Key Implant Positions and Implant/Abutment Number :
 there are implant positions that are more important from a stress
management perspective.
 In one- or two-unit prostheses, an implant should be placed in each
prospective tooth position, without a cantilever crown contour in any
direction (e.g., facial, lingual, mesial, or distal).
 In a three- to four-unit restoration, the most important abutments
are the terminal abutments.
 In a 5- to 14-unit prosthesis, intermediary abutments are important
in order to limit the edentulous spans to less than three pontics.
 It is suggested that multiple missing adjacent teeth be replaced in a
staggered position (tripod effect),or a larger intermediary implant be
inserted.
edentulous mandible - the anterior (canine
to canine) and the bilateral posterior regions
(premolar and molars).
edentulous maxilla - the anterior region
(laterals and centrals), bilateral canines, and
the bilateral posterior (premolar and molars).
The overall stress to the implant system
may be reduced by increasing the area over
which the force is applied. The most
effective method to increase the surface area
of implant support is by increasing the
number of implants used to support a
prosthesis.
The number of pontics should be reduced
and the number of implant abutments should
be increased whenever forces are increased,
compared with a treatment plan for an ideal
patient with minimal force factors.
IMPLANT SIZE
 extra length does little to decrease the stress that occurs at the crest of the
ridge during occlusal loading.
 The surface area of each implant is directly related to the width of the
implant.
 an increase in implant diameter may be more effective than implant
staggering to reduce stress.

IMPLANT DESIGN:
 Implant macrodesign may affect surface area even more than an increase in
width.
 A cylinder (bullet-shaped) implant provides 30% less surface area than a
conventional threaded implant of the same size.
 Implant design may be the easiest method to increase surface area
significantly and decrease overall risk to the implant interface .
 summary
 An understanding of the etiology of the most common implant
complications has led to the development of a stress-based treatment
plan theorem.
 To decrease stress :
additional implants
increase in implant width and height
use of more implants to decrease the number of pontics.