Journal of Oral Rehabilitation 2000 27; 842845
Biomechanical effects of double or wide implants for
single molar replacement in the posterior mandibular
region
Y. SATO, N. SHINDOI, R. HOSOKAWA, K. TSUGA & Y. AKAGAWA
Prosthodontics, Hiroshima University School of Dentistry, Hiroshima, Japan
SUMMARY Double implants have been thought to
have biomechanical advantages for single molar re-
placement. To evaluate the effectiveness of double
implants versus a wide implant, the vertical forces
and torque on each implant were calculated by
three-dimensional geometric analysis. Buccal load
(100 N) perpendicular to cuspal inclination (20)
was applied at the occlusal surface of the super-
structure. The three kinds of load points (A, B, C)
were 15, 35, and 55 mm from the mesial contact
point, respectively. Three implants were compared:
mesial and distal double implants ( 33 mm), and
a wide implant ( 5 mm). The wide implant
Introduction
Lateral loads on dental implant restorations cause loos-
ening and/or fracture of the screws that retain the
prosthesis (Haack et al., 1995) and overload situations
(Rangert, Sullivan & Jemt, 1997). Single molar replace-
ments using a single implant have an especially high
risk of screw loosening, even with non-rotating abut-
ments (such as CeraOne*) (Jemt, 1986; Becker &
Becker, 1995; Balshi, Hernandez & Rangert, 1996; Bal-
shi & Wolfinger, 1997) and implant fracture (Sullivan,
1994). Suggested solutions for these problems include
double or wide implant (Bahat & Handelsman, 1996;
Balshi et al., 1996; Balshi & Wolfinger, 1997). The idea
is that double or wide implants reduce cantilevering
effects and double implants reduce rotational force.
However, this hypothesis was not proved
quantitatively.
* Nobel Biocare, Goteborg, Sweden.
2000 Blackwell Science Ltd
Department of Removable
showed torque around the long axis (18
150 N cm) whereas double implants had no
torque. On the other hand, the vertical forces on
the mesial double implant were both smaller (60%:
loaded at point C) and larger (140%: loaded at point
A) than the wide implant. Given the smaller surface
area of the mesial double implant, this large force
may generate much higher stress in the peri-im-
plant bone. These results suggest that the biome-
chanical advantage of double implants for single
molar replacement is questionable when the oc-
clusal force is loaded at the occlusal surface near
the contact point.
The present study used three-dimensional geometric
analysis to evaluate the biomechanical effectiveness of
double implants for single molar replacement com-
pared to a wide implant.
Materials and methods
Single molar replacements for the left mandibular re-
gion (no. 36: first molar) were geometrically modelled
in a simulated clinical situation. The double implant is
shown in Fig. 1a. Fixtures (Branemark system, Narrow
Platform, 33 mm, 100 mm*) and abutments
(Branemark system, Miruscone 2 mm*) were simu-
lated. Cuspal inclination was set to 20 (Weinberg &
Kruger, 1995). An occlusal load of 100 N (Lewinstein et
al., 1995) was applied to the buccal cuspal incline
24 mm from the central fossa. The three load points
(A, B, C) were 15, 35, and 55 mm from the mesial
contact point, respectively (Fig. 1a). Because of the
842
 BIOMECHANICAL EFFECTS OF DOUBLE- OR WIDE-IMPLANTS 843

symmetrical geometry, neither lingual load nor distal

load were simulated. For complete calculation of force
balance, finite-element analysis (FEA) with a mimic
shape model and the precise material properties of
every element (such as cortical bone and cancellous
bone) is necessary, but is at present not possible.
Therefore, to calculate the force balance, it was as-
sumed that deformation of all components was
negligible.
The occlusal load of 100 N in 20 was divided into
horizontal force, H (34 N), and vertical force, V (94 N)
(Fig. 1a). Then, the three-dimensional force balance at
the surface of the superstructure facing the abutments
was evaluated. Figure 1b illustrates the force balance
with the load at point A. To counter the V, tensile
forces at the gold screws (T1, T2) were produced around
the axis of rotation at the buccal edges of the abut- Fig. 2. Wide-implant for single molar replacement. (a) Configu-
ments. The force multiplied by the distance from the ration. (b) Three-dimensional force balance at the surface of the
superstructure facing the abutments.
axis is the torque, and all torques around the axis
should be balanced:
The compressive vertical forces (C1, C2) were pro-
V 40=T1 20+ T2 20 (1) duced at the buccal edges. Therefore, the balance of
vertical forces was:
In this situation, tensile force at the gold screws was
proportional to the distance from the axis: V+ T1 + T2 = C1 + C2 (4)

T1/20=T2/20 (2) The torque balance around a buccolingual axis

through the centre of the mesial implant was:
From (1) and (2):
V 20+ C2 50= T2 50 (5)
T1 = T2 = 94 N (3)
From (4) and (5): C1 226 N; C2 56 N.
The balance of horizontal force: H and lateral forces
at the gold screws (L1, L2) was:
H =L1 L2 (6)
The balance of torque around a long axis of the
mesial implant was:
L2 50= H 20 (7)
From (6) and (7): L1 47 N; L2 14 N.
The wide implant is shown in Fig. 2a. Fixtures
(Branemark system, Wide Platform, 50 mm,
100 mm*) and abutments (Branemark system,
CeraOne, 2 mm*) were simulated. The form of oc-
clusal surface, cuspal inclination, load, and load points
were the same as the double implants. Figure 2b illus-
trates the force balance with the load at point A. To
counter the V, tensile forces (Tw) were produced at the
Fig. 1. Double-implant for single molar replacement. (a)
lingual edges of the abutments. The compressive verti-
Configuration. (b) Three-dimensional force balance at the surface cal forces (Cw,) were produced at the buccal edges.
of the superstructure facing the abutments. Therefore, the balance of vertical forces was:

2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 842 845
844 Y . S A T O et al.

V+ Tw = Cw (8)

The torque balance around a buccal point was:

V 45= Cw 60 (9)

From (8) and (9): Tw 70 N; Cw 158 N.

The horizontal force was divided into radial force
(H%) and normal direction force (R) where H%=
H cos u, R =H sin u. Therefore, the lateral force on
the implant (Lw) was:

Lw = H 28 N

R (20 N) was the rotational force on the implant

around the long axis. Therefore, the rotational torque
was:
R (45+ 30)=150 N mm
For both double and wide implants, force balances
were calculated at load points A, B, and C. Total verti-
cal force against the fixture was calculated as com-
pressive force (C1, C2, Cw) minus tensile force (T1, T2,
Tw). Positive values indicate compressive forces, and
negative values indicate tensile forces.
Results
The lateral and vertical forces on the wide implants
were almost constant among the three load points
(Figs 3 and 4), but the forces on the double implants
varied over a wide range. The mesial implant received
much higher forces (lateral, 168%; vertical, 140%)
than the wide implant with the load on point A. On
Fig. 4. Vertical forces on implant. Values over the column are %
ratio to wide implant.
the other hand, there was no torque around the long
axis on the double implant (Fig. 5). The torque on the
wide implant decreased with the distance of the load
point from the mesial contact point.
Discussion
Three-dimensional geometric analysis showed that
double implants did not always decrease the lateral
and vertical forces on implants, but eliminated torque.
Position and direction of load are critical in geomet-
ric analysis. However, precise forces cannot be deter-
mined without complete knowledge of bolus
properties and chewing patterns. Therefore, the force
that resulted in the largest lateral force (Weinberg &
Kruger, 1995) was simulated for this study (Fig. 1b).

Fig. 3. Lateral forces on implant. Values over the column are %

ratio to wide implant. Fig. 5. Torque around long axis.

2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 842845

 BIOMECHANICAL EFFECTS OF DOUBLE- OR WIDE-IMPLANTS
Because the simulated model had the symmetrical
geometry in the buccolingual and mesiodistal direction,
the load was applied on only one quarter of the oc-
clusal surface. However, the torque in the wide im-
plant took different directions; tightening and
loosening. For the mandibular left molar, mesio-buccal
load can cause loosening torque in the fixture, while
mesio-lingual load causes tightening. The maximum
torque in this study was 15 N cm, which was much
lower than the removal torque of 38 N cm (Johansson
et al., 1998). However, as this torque was caused by
100 N, a greater load may be applied in some cases.
Moreover, because the effect of cyclic torque on the
fixture has not been evaluated, torque should be kept
as low as possible.
In this study, narrow implants ( 33 mm) were
used instead of standard one ( 375 mm). This was
due to the limitation of mesio-distal space. The range
of interdental space for the first molar was 10 17 mm;
the mean was 12 mm (Balshi & Wolfinger, 1997). The
necessary space for double implants placement was
125 mm for a standard implant (Bahat & Handelsman,
1996). Therefore, standard implants could not be used
in the average space.
In the double implants, load near the marginal ridge
of the superstructure generated large lateral and verti-
cal forces on the implant. These values were 140
168% of those on the wide implant. Considering the
much smaller surface area of the narrow implant (Ba-
hat & Handelsman, 1996), high stress should be
assumed between the fixture and bone. This may be
one of the reasons for higher marginal bone loss
with double implants compared to single implants
replacing a single molar (Balshi et al., 1996). Therefore,
double implants are not always biomechanically
advantageous.
The load near the marginal ridge of the superstruc-
ture generated large forces on the double implant, and
applied torque to the wide implant. Therefore, in clini-
cal situations, occlusal contact near the marginal ridge
of the superstructure should be eliminated. Moreover,
masticatory force through foods to that area should be
decreased by modifying the shape of the occlusal
surface.
Under the limited conditions of this three-dimen-
sional geometric analysis, the biomechanical advantage
of double implants for single molar replacement was
2000 Blackwell Science Ltd, Journal of Oral Rehabilitation 27; 842 845
845
questionable when the occlusal force was loaded at the
occlusal surface near the contact point. Hence, to de-
crease the forces, elimination of occlusal contact and
load through foods near the contact point might be
considered.
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Correspondence: Dr Yuuji Sato, Department of Removable
Prosthodontics, Hiroshima University School of Dentistry, Ka-
sumi 1-2-3, Minami-ku, Hiroshima 734-8553, Japan. E-mail:
sato@ipc.hiroshima-u.ac.jp