Importance of a distal proximal contact on load transfer by implant-supported single adjacent crowns in posterior region of the mandible: a photoelastic study
Identifieur interne : 002F77 ( Pmc/Corpus ); précédent : 002F76; suivant : 002F78Importance of a distal proximal contact on load transfer by implant-supported single adjacent crowns in posterior region of the mandible: a photoelastic study
Auteurs : Fábio Afrânio De Aguiar Júnior ; Rodrigo Tiossi ; Ana Paula Macedo ; Maria Da Gloria Chiarello De Mattos ; Ricardo Faria Ribeiro ; Renata Cristina Silveira RodriguesSource :
- Journal of Applied Oral Science [ 1678-7757 ] ; 2013.
Abstract
This study aimed to evaluate the importance of a distal proximal contact on the load transfer to the posterior region of the mandible by non-splinted adjacent implant-supported crowns using photoelastic stress analysis.
A rectangular model (68x30x15 mm) was made of polymethylmethacrylate resin to simulate half of the mandibular arch. One model was completed with resin replicas representing the first premolar and second molar and with two 3.75 mm dia.x11 mm internal hexagon threaded implants replacing the second premolar and first molar. The other model was manufactured in the same way but without the second molar. Both models were duplicated using photoelastic resin. The roots of the teeth replicas were covered with a layer of polyether impression material to simulate the periodontal ligament. Two different vertical loads were applied to the crowns as follows: 1 - single static point load alternately applied to the crowns replacing the second premolar and first molar (50 N); 2 - simultaneous static point loads applied to both of the crowns replacing the second premolar and first molar (100 N). The resulting isochromatic fringe pattern in the photoelastic model was monitored and photographed.
All loading conditions studied showed that the presence of the second molar has changed the load transmission and the pattern of stresses.
Results showed that the presence of a second molar proximal contact can help minimize the stresses around the implants.
Url:
DOI: 10.1590/1679-775720130049
PubMed: 24212984
PubMed Central: 3881849
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PMC:3881849Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Importance of a distal proximal contact on load transfer by
implant-supported single adjacent crowns in posterior region of the mandible: a
photoelastic study</title><author><name sortKey="De Aguiar Junior, Fabio Afranio" sort="De Aguiar Junior, Fabio Afranio" uniqKey="De Aguiar Junior F" first="Fábio Afrânio" last="De Aguiar Júnior">Fábio Afrânio De Aguiar Júnior</name></author><author><name sortKey="Tiossi, Rodrigo" sort="Tiossi, Rodrigo" uniqKey="Tiossi R" first="Rodrigo" last="Tiossi">Rodrigo Tiossi</name></author><author><name sortKey="Macedo, Ana Paula" sort="Macedo, Ana Paula" uniqKey="Macedo A" first="Ana Paula" last="Macedo">Ana Paula Macedo</name></author><author><name sortKey="De Mattos, Maria Da Gloria Chiarello" sort="De Mattos, Maria Da Gloria Chiarello" uniqKey="De Mattos M" first="Maria Da Gloria Chiarello" last="De Mattos">Maria Da Gloria Chiarello De Mattos</name></author><author><name sortKey="Ribeiro, Ricardo Faria" sort="Ribeiro, Ricardo Faria" uniqKey="Ribeiro R" first="Ricardo Faria" last="Ribeiro">Ricardo Faria Ribeiro</name></author><author><name sortKey="Rodrigues, Renata Cristina Silveira" sort="Rodrigues, Renata Cristina Silveira" uniqKey="Rodrigues R" first="Renata Cristina Silveira" last="Rodrigues">Renata Cristina Silveira Rodrigues</name></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">24212984</idno><idno type="pmc">3881849</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881849</idno><idno type="RBID">PMC:3881849</idno><idno type="doi">10.1590/1679-775720130049</idno><date when="2013">2013</date><idno type="wicri:Area/Pmc/Corpus">002F77</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002F77</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Importance of a distal proximal contact on load transfer by
implant-supported single adjacent crowns in posterior region of the mandible: a
photoelastic study</title><author><name sortKey="De Aguiar Junior, Fabio Afranio" sort="De Aguiar Junior, Fabio Afranio" uniqKey="De Aguiar Junior F" first="Fábio Afrânio" last="De Aguiar Júnior">Fábio Afrânio De Aguiar Júnior</name></author><author><name sortKey="Tiossi, Rodrigo" sort="Tiossi, Rodrigo" uniqKey="Tiossi R" first="Rodrigo" last="Tiossi">Rodrigo Tiossi</name></author><author><name sortKey="Macedo, Ana Paula" sort="Macedo, Ana Paula" uniqKey="Macedo A" first="Ana Paula" last="Macedo">Ana Paula Macedo</name></author><author><name sortKey="De Mattos, Maria Da Gloria Chiarello" sort="De Mattos, Maria Da Gloria Chiarello" uniqKey="De Mattos M" first="Maria Da Gloria Chiarello" last="De Mattos">Maria Da Gloria Chiarello De Mattos</name></author><author><name sortKey="Ribeiro, Ricardo Faria" sort="Ribeiro, Ricardo Faria" uniqKey="Ribeiro R" first="Ricardo Faria" last="Ribeiro">Ricardo Faria Ribeiro</name></author><author><name sortKey="Rodrigues, Renata Cristina Silveira" sort="Rodrigues, Renata Cristina Silveira" uniqKey="Rodrigues R" first="Renata Cristina Silveira" last="Rodrigues">Renata Cristina Silveira Rodrigues</name></author></analytic><series><title level="j">Journal of Applied Oral Science</title><idno type="ISSN">1678-7757</idno><idno type="eISSN">1678-7765</idno><imprint><date when="2013">2013</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Objective</title><p>This study aimed to evaluate the importance of a distal proximal contact on the
load transfer to the posterior region of the mandible by non-splinted adjacent
implant-supported crowns using photoelastic stress analysis. </p></sec><sec><title>Material and Methods</title><p>A rectangular model (68x30x15 mm) was made of polymethylmethacrylate resin to
simulate half of the mandibular arch. One model was completed with resin replicas
representing the first premolar and second molar and with two 3.75 mm dia.x11 mm
internal hexagon threaded implants replacing the second premolar and first molar.
The other model was manufactured in the same way but without the second molar.
Both models were duplicated using photoelastic resin. The roots of the teeth
replicas were covered with a layer of polyether impression material to simulate
the periodontal ligament. Two different vertical loads were applied to the crowns
as follows: 1 - single static point load alternately applied to the crowns
replacing the second premolar and first molar (50 N); 2 - simultaneous static
point loads applied to both of the crowns replacing the second premolar and first
molar (100 N). The resulting isochromatic fringe pattern in the photoelastic model
was monitored and photographed.</p></sec><sec><title>Results</title><p>All loading conditions studied showed that the presence of the second molar has
changed the load transmission and the pattern of stresses.</p></sec><sec><title>Conclusion</title><p>Results showed that the presence of a second molar proximal contact can help
minimize the stresses around the implants.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Abboud, M" uniqKey="Abboud M">M Abboud</name></author><author><name sortKey="Koeck, B" uniqKey="Koeck B">B Koeck</name></author><author><name sortKey="Stark, H" uniqKey="Stark H">H Stark</name></author><author><name sortKey="Wahl, G" uniqKey="Wahl G">G Wahl</name></author><author><name sortKey="Paillon, R" uniqKey="Paillon R">R Paillon</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Akca, K" uniqKey="Akca K">K Akça</name></author><author><name sortKey="Cehreli, Mc" uniqKey="Cehreli M">MC Cehreli</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Assuncao, Wg" uniqKey="Assuncao W">WG Assunção</name></author><author><name sortKey="Barao, Va" uniqKey="Barao V">VA Barão</name></author><author><name sortKey="Tabata, Lf" uniqKey="Tabata L">LF 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Appl Oral Sci</journal-id><journal-id journal-id-type="iso-abbrev">J Appl Oral Sci</journal-id><journal-id journal-id-type="publisher-id">J. Appl. Oral. Sci.</journal-id><journal-title-group><journal-title>Journal of Applied Oral Science</journal-title></journal-title-group><issn pub-type="ppub">1678-7757</issn><issn pub-type="epub">1678-7765</issn><publisher><publisher-name>Faculdade de Odontologia de Bauru da Universidade de São
Paulo</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">24212984</article-id><article-id pub-id-type="pmc">3881849</article-id><article-id pub-id-type="doi">10.1590/1679-775720130049</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Articles</subject></subj-group></article-categories><title-group><article-title>Importance of a distal proximal contact on load transfer by
implant-supported single adjacent crowns in posterior region of the mandible: a
photoelastic study</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>de AGUIAR JÚNIOR</surname><given-names>Fábio Afrânio</given-names></name></contrib><contrib contrib-type="author"><name><surname>TIOSSI</surname><given-names>Rodrigo</given-names></name></contrib><contrib contrib-type="author"><name><surname>MACEDO</surname><given-names>Ana Paula</given-names></name></contrib><contrib contrib-type="author"><name><surname>de MATTOS</surname><given-names>Maria da Gloria Chiarello</given-names></name></contrib><contrib contrib-type="author"><name><surname>RIBEIRO</surname><given-names>Ricardo Faria</given-names></name></contrib><contrib contrib-type="author"><name><surname>RODRIGUES</surname><given-names>Renata Cristina Silveira</given-names></name><xref ref-type="corresp" rid="c01"></xref></contrib><aff>Department of Dental Materials and Prosthodontics, School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil.</aff></contrib-group><author-notes><corresp id="c01"><bold>Corresponding address:</bold> Renata C. S. Rodrigues - Faculdade de Odontologia
de Ribeirão Preto - Universidade de São Paulo - Departamento de Materiais Dentários e
Prótese - Av. do Café, s/n - Monte Alegre - Ribeirão Preto - SP - Brasil - 14040-904
- Phone: +55 (16) 3602-4005 - Fax: +55 (16) 3633-0999 - e-mail:
<email>renata@forp.usp.br</email></corresp></author-notes><pub-date pub-type="ppub"><season>Sep-Oct</season><year>2013</year></pub-date><volume>21</volume><issue>5</issue><fpage>397</fpage><lpage>402</lpage><history><date date-type="received"><day>10</day><month>1</month><year>2013</year></date><date date-type="rev-recd"><day>29</day><month>4</month><year>2013</year></date><date date-type="accepted"><day>04</day><month>7</month><year>2013</year></date></history><permissions><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc/3.0/"><license-p>This is an Open Access article distributed under the terms of the Creative
Commons Attribution Non-Commercial License which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the
original work is properly cited. </license-p></license></permissions><abstract><sec><title>Objective</title><p>This study aimed to evaluate the importance of a distal proximal contact on the
load transfer to the posterior region of the mandible by non-splinted adjacent
implant-supported crowns using photoelastic stress analysis. </p></sec><sec><title>Material and Methods</title><p>A rectangular model (68x30x15 mm) was made of polymethylmethacrylate resin to
simulate half of the mandibular arch. One model was completed with resin replicas
representing the first premolar and second molar and with two 3.75 mm dia.x11 mm
internal hexagon threaded implants replacing the second premolar and first molar.
The other model was manufactured in the same way but without the second molar.
Both models were duplicated using photoelastic resin. The roots of the teeth
replicas were covered with a layer of polyether impression material to simulate
the periodontal ligament. Two different vertical loads were applied to the crowns
as follows: 1 - single static point load alternately applied to the crowns
replacing the second premolar and first molar (50 N); 2 - simultaneous static
point loads applied to both of the crowns replacing the second premolar and first
molar (100 N). The resulting isochromatic fringe pattern in the photoelastic model
was monitored and photographed.</p></sec><sec><title>Results</title><p>All loading conditions studied showed that the presence of the second molar has
changed the load transmission and the pattern of stresses.</p></sec><sec><title>Conclusion</title><p>Results showed that the presence of a second molar proximal contact can help
minimize the stresses around the implants.</p></sec></abstract><kwd-group><kwd>Fixed partial denture</kwd><kwd>Dental implants</kwd><kwd>Implant-supported dental prosthesis</kwd><kwd>Dental stress analysis</kwd></kwd-group><funding-group><award-group><funding-source>FAPESP - São Paulo Research Foundation</funding-source><award-id>#2008/06960-8</award-id></award-group></funding-group></article-meta></front><body><sec><title>INTRODUCTION</title><p>Despite the increased use of osseointegrated implants and the high levels of success
associated with the restoration of edentulous spaces<sup><xref ref-type="bibr" rid="r07">7</xref>,<xref ref-type="bibr" rid="r09">9</xref>,<xref ref-type="bibr" rid="r28">28</xref></sup>, the rehabilitation of a posterior edentulous space still is a
challenging biomechanical condition. Mechanical and biological factors are involved in
the long-term success of an implant-supported rehabilitation and several options are
available for the restoration of a partial posterior edentulous space; however, there is
no consensus in literature as to which would be the best prosthetic solution to be
used<sup><xref ref-type="bibr" rid="r05">5</xref>,<xref ref-type="bibr" rid="r20">20</xref>,<xref ref-type="bibr" rid="r25">25</xref>,<xref ref-type="bibr" rid="r30">30</xref></sup>. The success of dental implants has challenged the
doctrine that the extraction of a teeth should be considered undesirable<sup><xref ref-type="bibr" rid="r13">13</xref></sup>. According to Zitzman, et al.<sup><xref ref-type="bibr" rid="r31">31</xref></sup> (2010), some authors consider that the
implant is a better and more reliable abutment than the tooth itself and propose the
extraction of even salvageable teeth.</p><p>Splinting or not splinting multiple adjacent crowns is a matter of concern. Some authors
suggest that splinting multiple implants together could better distribute the functional
loads and provide higher maintenance of the marginal bone levels<sup><xref ref-type="bibr" rid="r19">19</xref>,<xref ref-type="bibr" rid="r22">22</xref>,<xref ref-type="bibr" rid="r24">24</xref></sup>. However, restoration
with multiple single implants minimizes the loosening or fracture of components under
functional loads<sup><xref ref-type="bibr" rid="r11">11</xref></sup>. Other advantages
of using non-splinted prostheses are the better esthetic outcome and more
passive-fitting frameworks<sup><xref ref-type="bibr" rid="r16">16</xref>,<xref ref-type="bibr" rid="r19">19</xref></sup>. The characteristics of the proximal
contacts are more critical for better passivity and transmission of loads because
non-ideal contacts might lead to increased stresses around the implants due to the
absence of the periodontal ligament (PDL) on the implants<sup><xref ref-type="bibr" rid="r11">11</xref></sup>. Without the information provided by the
mechanoreceptors that are present in the PDL, the fine motor control of the mandible
will be impaired. A balanced occlusal relationship is thus critical for the long-term
survival of implant-supported prostheses<sup><xref ref-type="bibr" rid="r13">13</xref></sup>.</p><p>The influence of a proximal contact on the force transfer in implant-prostheses is
rarely discussed within literature. Further knowledge about this issue may allow better
planning of implant-supported prostheses. This study aims to evaluate the influence of a
distal molar proximal contact and different loading by occlusal contacts on the load and
stress distributions around implants in the posterior region of the mandible using
photoelasticity. The null hypothesis was that the stress pattern and the stress
distribution generated by loading adjacent non-splinted screw-retained metal-ceramic
crowns would not be affected by the absence of the second molar distal contact.</p></sec><sec sec-type="materials|methods"><title>MATERIAL AND METHODS</title><p>A rectangular model (68x30x15 mm) was made of polymethylmethacrylate (PMMA) resin
(Plexiglas<sup>®</sup>, Altuglas International, Philadelphia, Pennsylvania, USA) to
simulate half of the mandibular arch. The model was completed with resin replicas
(Odontofix, Ribeirão Preto, SP, Brazil) representing the first premolar and second
molar, and with two 3.75 mm dia.x11 mm internal hexagon threaded implants (Titamax II
Plus, Neodent<sup>®</sup>, Curitiba, PR, Brazil) replacing the second premolar and first
molar. The preparation of the PMMA resin for positioning the teeth and implants was made
in an optimal mesiodistal position, allowing the rehabilitation with two
implant-supported crowns with acceptable anatomy proportional to that of the replaced
teeth.</p><p>The crowns were waxed on UCLA prosthetic components (UCLA II Plus Tilite,
Neodent<sup>®</sup>, Curitiba, PR, Brazil) that were screwed to the implants with a
20 N.cm torque, as recommended by the manufacturer. The wax patterns were reduced to
allow for the adequate shape of ceramic-veneered metal frameworks. The metal frameworks
were cast in nickel-chromium-titanium alloy (Tilite Omega, Talladium Inc, Valencia,
California, USA). A silicone (Zetalabor, Zhermack S.p.A., Rovigo, Veneto, Italy) index
was made from the initial wax pattern to standardize the application of the esthetic
veneers and the final anatomy of the crowns.</p><p>The crowns were veneered with IPS d.Sign ceramic (Ivoclar Vivadent, Schaan,
Liechtenstein) in accordance to recommendations from the manufacturer. The crowns were
then placed on the master model and the effectiveness of the proximal contacts was
checked using a 21 µm thick double-sided occlusal marking film (AccuFilm II, Parkell
Inc., Edgewood, New York, USA) and dental floss (Colgate-Palmolive, São Bernardo do
Campo, SP, Brazil), according to clinically accepted procedures that would result in
light contact tightness<sup><xref ref-type="bibr" rid="r11">11</xref></sup>.</p><p>To fabricate the photoelastic model, a silicone mold (Silicone Master, Talmax, Curitiba,
PR, Brazil) was made of the initial model to correctly transfer the position of the
teeth and implants. The roots of teeth replicas were covered with a layer of polyether
impression material (Impregum Soft, 3M ESPE AG, Seefeld, Bavaria, Germany) to simulate
the periodontal ligament<sup><xref ref-type="bibr" rid="r21">21</xref>,<xref ref-type="bibr" rid="r26">26</xref>,<xref ref-type="bibr" rid="r30">30</xref></sup>. The implants were directly embedded in the photoelastic model
without any interposed material thus assuming complete osseointegration. Teeth replicas
and implants were positioned in the silicone mold before the manipulation and pouring of
the photoelastic resin (Araldite GY279 and hardener Aradur 2963, Huntsman, Everberg,
Belgium). Another similar photoelastic model was made, differing from the first model
due to the absence of the second molar resin replica.</p><p>A polariscope (PS-100 SF Standard Field Polarimeter, Strainoptics, Inc., North Wales,
Pennsylvania, USA) was used to monitor the isochromatic fringes and a digital camera
(EOS Rebel, Canon, Tokyo, Japan) was coupled to the polariscope to photograph each load
sequence. A load application device was developed at the Department of Dental Materials
and Prosthodontics of the Ribeirão Preto School of Dentistry - University of São Paulo
(FORP/USP) using a 500 N load cell (Kratos Industrial Equipments, Cotia, SP, Brazil) and
a digital load reader (IKE-01, Kratos Industrial Equipments). Two different loads were
applied for each prosthetic configuration: 1 - single static point load alternately
applied to the crowns replacing the second premolar and first molar (50 N); 2 - static
point loads simultaneously applied to both of the crowns replacing the second premolar
and first molar (100 N). The vertical loads were applied to the crowns in an off-axis
position: dislodged from the center of the implants on the distal fossa of the first
molar (3.9 mm) and mesial fossa of the second premolar (2.4 mm). The load was
perpendicular to the occlusal plane.</p><p>The photoelastic model was inspected inside the field of the circular polariscope to
certify the absence of any residual stress before placing the crowns and before any load
was applied. The crowns were then tightened to the implants with a 20 N.cm torque and
the experimental loads were applied. After each load application and before the next
load, the photoelastic model was submitted to thermal stress relaxation. The model was
placed for 10 minutes in an incubator set at 50ºC. After removal from the incubator, the
photoelastic model was allowed to cool at ~22ºC for another 10 minutes and then checked
in the polariscope for absence of any residual stresses. No apparent distortion of the
model was detected after this procedure and, according to the manufacturer, the material
has a flash point above 200ºC.</p><p>For the qualitative analysis, the model was positioned in the polariscope adjusted to
circular polarization mode. For the quantitative analysis, the polariscope was then
adjusted to plane polarization mode, and a 10X magnification lens (Nikon, Tokyo, Japan)
was coupled to the set. Five points of interest were considered for this analysis: three
in the cervical region of the implants, near to the simulated crestal bone and teeth,
and one in the apical region of each implant (<xref ref-type="fig" rid="f01">Figure
1</xref>). In all models, the points of interest were standardized in the same
positions using an acrylic template.</p><fig id="f01" orientation="portrait" position="float"><label>Figure 1</label><caption><p>Points of interest selected for the quantitative analysis</p></caption><graphic xlink:href="jaos-21-05-0397-g01"></graphic></fig><p>Quantification of the fringe orders (N) was made using the Senarmont method<sup><xref ref-type="bibr" rid="r17">17</xref>,<xref ref-type="bibr" rid="r18">18</xref></sup>. The optical constant (K) of the photoelastic resin (3.57 Brewsters)
was previously determined through a diametral compression test of a disc (30x10 mm)
fabricated specifically for the test. Principal stresses (ς) in MPa for each point were
calculated using the stress-optical law equation: ς=(N.λ)/(b.K). The wavelength (λ) of
light passing through the photoelastic resin was 570 nm, the photoelastic model
thickness (b) was 15 mm, K was the optical constant of the photoelastic resin determined
for the study (3.57 Brewsters), and N was the value of the fringe order at each point of
interest<sup><xref ref-type="bibr" rid="r08">8</xref></sup>.</p></sec><sec sec-type="results"><title>RESULTS</title><p>After the single point load on the first molar (<xref ref-type="fig" rid="f02">Figures
2</xref> and <xref ref-type="fig" rid="f03">3</xref>), the two experimental
conditions (with and without the second molar) presented concentrating stresses around
the first molar replacing implant, near the apical and distal regions of the implant.
This finding shows that load application in the distal portion of the first molar crown
leads to a small distal cantilever extension, thus leading to higher stresses in the
distal region as opposed to the mesial region. The presence of the second molar distal
contact reduced the stress transmission to the supporting structures (<xref ref-type="fig" rid="f02">Figure 2</xref>). When compared with the missing molar
condition (<xref ref-type="fig" rid="f03">Figure 3</xref>), stresses in the distal
region of the model were reduced from 15.75 MPa to 6.28 MPa and from 5.53 MPa to 1.38
MPa in the region between the implants (<xref ref-type="table" rid="t01">Table
1</xref>).</p><fig id="f02" orientation="portrait" position="float"><label>Figure 2</label><caption><p>Vertical single point load (5 kgf) on the first molar (model with the second molar
replica)</p></caption><graphic xlink:href="jaos-21-05-0397-g02"></graphic></fig><fig id="f03" orientation="portrait" position="float"><label>Figure 3</label><caption><p>Vertical single point load (5 kgf) on the first molar (model without the second
molar replica)</p></caption><graphic xlink:href="jaos-21-05-0397-g03"></graphic></fig><table-wrap id="t01" orientation="portrait" position="float"><label>Table 1</label><caption><p>Principal stresses (MPa) in the selected points of interest</p></caption><table frame="hsides" rules="groups"><thead><tr style="background-color:#CCCCCC"><td align="center" rowspan="1" colspan="1"><bold>Points of interest</bold></td><td colspan="3" align="center" rowspan="1"><bold>With 2<sup>nd</sup> molar</bold></td><td colspan="3" align="center" rowspan="1"><bold>Without 2<sup>nd</sup> molar</bold></td></tr><tr><td rowspan="1" colspan="1"> </td><td colspan="3" align="center" rowspan="1"><bold>Location of the load application</bold></td><td colspan="3" align="center" rowspan="1"><bold>Location of the load application</bold></td></tr><tr><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"></td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"><bold>Molar</bold></td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"><bold>Simultaneous</bold></td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"><bold>Premolar</bold></td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"><bold>Molar</bold></td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"><bold>Simultaneous</bold></td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1"><bold>Premolar</bold></td></tr></thead><tbody><tr><td align="center" rowspan="1" colspan="1">1</td><td align="center" rowspan="1" colspan="1">6.28</td><td align="center" rowspan="1" colspan="1">8.83</td><td align="center" rowspan="1" colspan="1">6.17</td><td align="center" rowspan="1" colspan="1">15.75</td><td align="center" rowspan="1" colspan="1">10.54</td><td align="center" rowspan="1" colspan="1">2.66</td></tr><tr><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">2</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">1.38</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">7.13</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">10.11</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">5.53</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">4.58</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">7.77</td></tr><tr><td align="center" rowspan="1" colspan="1">3</td><td align="center" rowspan="1" colspan="1">26.93</td><td align="center" rowspan="1" colspan="1">22.99</td><td align="center" rowspan="1" colspan="1">25.33</td><td align="center" rowspan="1" colspan="1">11.07</td><td align="center" rowspan="1" colspan="1">20.01</td><td align="center" rowspan="1" colspan="1">10.54</td></tr><tr><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">4</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">15.65</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">15.43</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">4.15</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">8.2</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">13.73</td><td align="center" style="background-color:#CCCCCC" rowspan="1" colspan="1">4.47</td></tr><tr><td align="center" rowspan="1" colspan="1">5</td><td align="center" rowspan="1" colspan="1">4.04</td><td align="center" rowspan="1" colspan="1">3.51</td><td align="center" rowspan="1" colspan="1">2.77</td><td align="center" rowspan="1" colspan="1">3.09</td><td align="center" rowspan="1" colspan="1">2.43</td><td align="center" rowspan="1" colspan="1">3.62</td></tr></tbody></table></table-wrap><p>When simultaneous loads were applied on the implants replacing the second premolar and
first molar (<xref ref-type="fig" rid="f04">Figure 4</xref>, <xref ref-type="fig" rid="f05">Figure 5</xref>), higher stresses were found when compared to the single
point loads. The application of an off-axis load is then evidenced and concentrating
stresses were found at the points of interest 1 and 4 (<xref ref-type="table" rid="t01">Table 1</xref>). The presence of the second molar again reduced the stress
distribution (<xref ref-type="fig" rid="f04">Figure 4</xref>).</p><fig id="f04" orientation="portrait" position="float"><label>Figure 4</label><caption><p>Simultaneous point load (10 kgf) on the second premolar and first molar (model
with the second molar replica)</p></caption><graphic xlink:href="jaos-21-05-0397-g04"></graphic></fig><fig id="f05" orientation="portrait" position="float"><label>Figure 5</label><caption><p>Simultaneous point load (10 kgf) on the second premolar and first molar (model
without the second molar replica)</p></caption><graphic xlink:href="jaos-21-05-0397-g05"></graphic></fig><p>For the groups with a single point load applied on the implant replacing the second
premolar (<xref ref-type="fig" rid="f06">Figures 6</xref> and <xref ref-type="fig" rid="f07">7</xref>), concentrating stresses were found around the loaded implant in
both models analyzed (with and without the second molar). When the second molar replica
was present, its combination with the first molar-replacing implant was more effective
for load distribution (<xref ref-type="fig" rid="f06">Figure 6</xref>). Stresses were
concentrated around the second molar-replacing implant when the second molar distal
contact was absent (<xref ref-type="fig" rid="f07">Figure 7</xref>).</p><fig id="f06" orientation="portrait" position="float"><label>Figure 6</label><caption><p>Vertical single point load (5 kgf) on the second premolar (model with the second
molar replica)</p></caption><graphic xlink:href="jaos-21-05-0397-g06"></graphic></fig><fig id="f07" orientation="portrait" position="float"><label>Figure 7</label><caption><p>Vertical single point load (5 kgf) on the second premolar (model without the
second molar replica)</p></caption><graphic xlink:href="jaos-21-05-0397-g07"></graphic></fig></sec><sec sec-type="discussion"><title>DISCUSSION</title><p>The results found in this study suggest that the presence of a second molar distal to an
edentulous space restored by implant-supported single crowns reduces the stresses in the
supporting simulating-bone structure under different loading conditions. The presence of
an effective proximal contact influenced the stress pattern and load distribution to the
implant. This finding is in agreement with another study<sup><xref ref-type="bibr" rid="r11">11</xref></sup>, where a relation between interproximal contact
tightness increase and higher stresses were noted. The off-axis load application points
on the crowns, especially in the distal fossa of the first molar, led to a small
cantilever extension, thus showing the importance of the contact points in distributing
the stresses. It was also evident that the absence of the second molar leads to stress
concentration in the distal region of the model.</p><p>Some clinicians have a preference for restoring an edentulous space with multiple
adjacent single crowns rather than with splinted adjacent crowns, due to an easier
control of hygiene, better passivity, more comfort to the patient and easier
repair<sup><xref ref-type="bibr" rid="r14">14</xref>,<xref ref-type="bibr" rid="r19">19</xref>,<xref ref-type="bibr" rid="r24">24</xref></sup>. However,
single implants placed in posterior regions (premolar and molar regions) are more prone
to non-axial overload<sup><xref ref-type="bibr" rid="r01">1</xref></sup>.</p><p>Photoelasticity is a well-documented method that has been used in dentistry<sup><xref ref-type="bibr" rid="r03">3</xref>,<xref ref-type="bibr" rid="r23">23
</xref></sup> and provides correspondence between experimental results and clinical
findings<sup><xref ref-type="bibr" rid="r04">4</xref>,<xref ref-type="bibr" rid="r10">10</xref>,<xref ref-type="bibr" rid="r15">15</xref></sup>. It should be
stated that one of the main limitations of this study is related to the selection of the
points of interest, which must be chosen before load application. This could lead to the
selection of a point of interest outside a region with higher stress concentration found
by the qualitative analysis. Another limitation is related to the non differentiaton
between cortical and cancellous bones. However, it should be pointed that the stress
magnitudes may be modified, but the location of the stress concentration does not change
substantially<sup><xref ref-type="bibr" rid="r07">7</xref></sup>. Despite the
differences between the photoelastic models and the clinical situation, the results
found by photoelasticity can usefully assess the stress patterns and the load
distribution, enabling the detection of stress-related difficulties that may
arise<sup><xref ref-type="bibr" rid="r23">23</xref></sup>. Considering the
multiple options available to restore an edentulous space, the understanding of the
biomechanics of stress transmission of single crowns supported by multiple adjacent
implants is critical to achieve a long-term clinical outcome.</p><p>This study simulated occlusal loads that do not correspond to the condition of a
balanced and well-adjusted occlusion and showed increased stresses in some
regions<sup><xref ref-type="bibr" rid="r06">6</xref>,<xref ref-type="bibr" rid="r13">13</xref>,<xref ref-type="bibr" rid="r25">25</xref>,<xref ref-type="bibr" rid="r27">27</xref></sup>. When more unfavorable bone conditions
are present, and the use of longer or wider implants is limited, the differences found
in this study may be even more clinically significant for the long-term success of an
implant-supported rehabilitation<sup><xref ref-type="bibr" rid="r02">2</xref>,<xref ref-type="bibr" rid="r12">12</xref>,<xref ref-type="bibr" rid="r29">29</xref></sup>. Long-term longitudinal clinical studies are still needed to assess
and to understand the biomechanics of implant-supported prostheses and the actual
influence that the induced stresses have on the success of the restorative
treatment.</p></sec><sec sec-type="conclusions"><title>CONCLUSION</title><p>Within the limitations of the methodology used in this study and according to the
results found, it can be concluded that the presence of a second molar proximal contact
is important in minimizing the stresses around implants supporting metal-ceramic single
crowns, irrespective of the occlusal loading condition. This conclusion indicates that
the null hypothesis of this study should be rejected. Thus, if there is a healthy or
treatable tooth in the posterior edentulous space that could be maintained, this must be
evaluated as an important option for the treatment.</p></sec></body><back><ack><sec><title>ACKNOWLEDGEMENTS</title><p>This study was supported by research grant #2008/06960-8 from FAPESP - São Paulo
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