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Journal of Prosthodontic Research 54 (2010) 179184

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Original article

Influence of number and inclination angle of implants on stress

distribution in mandibular cortical bone with All-on-4 Concept
Takeshi Takahashi DDS, PhD*, Ichiro Shimamura DDS, PhD, Kaoru Sakurai DDS, PhD
Department of Removable Prosthodontics and Gerodontology,Tokyo Dental College,
1-2-2 Masago Mihama-ku Chiba city Chiba, 261-8502, Japan
Received 20 December 2009; received in revised form 17 March 2010; accepted 8 April 2010
Available online 10 May 2010

Abstract
Purpose: The All-on-4 is used in the therapy of edentulous mandibles. However, few studies have investigated the effect of such implants on
supporting bone. To clarify differences in stress in peri-implant cortical bone between 2-patterns of 6 implants and 8-patterns of 4 implants with
change in inclination angle based on the All-on-4.
Methods: Three-dimensional finite element analysis models based on the mean value of the Japanese edentulous mandible were constructed.
Implants 13 or 15 mm in length were inserted between the mental foramina. In the 6-implant model, implants were inserted in parallel. In the 4implant model, the 2 anterior implants were inserted in parallel and the 2 posterior implants in parallel or on a slant. Implants were splinted with a
superstructure. A 50 N load was applied to the occlusal surface under condition A, at 2 mm distal from the distal implant, or condition B, at the
distal end of the superstructure. Maximum von Mises stress on cortical bone was measured.
Results: Stress was concentrated around the posterior-most implant on the right side. Under condition A, stress increased with 4 implants and
increase in angulation. At 458, stress increased by 23% of that in the 6-implant model. Under condition B, stress increased with 4 implants, although
stress decreased with increase in angulation. At 458, stress decreased by 45% of that in the 6 implants.
Conclusions: The use of 4 implants or inclined implants increased stress on peri-implant cortical bone. However, when used in conjunction with a
short cantilever, inclined implants decreased stress on peri-implant cortical bone.
Crown Copyright # 2010 Published by Elsevier Ltd. on behalf of Japan Prosthodontic Society.
Keywords: All-on-4; Implant; Finite element analysis

1. Introduction
In implant therapy, when a fixed prosthesis is required for an
edentulous mandible, 6 implants are typically inserted between
the mental foramina, with good outcomes [1,2]. In recent years,
the All-on-4 Concept, where only 4 implants are inserted
between the mental foramina in placing a fixed prosthesis on an
edentulous mandible, has shown a high clinical success rate
[3,4]. The All-on-4 Concept offers the less invasive option, as it
requires fewer implants, with ambilateral distal implants
inserted at an inclination of 308 in order to decrease cantilever
length.
The load generated by 4 implants has been reported to be
greater than that generated by 6 implants [5]. No significant
difference, though, was observed in clinical outcomes between

* Corresponding author. Tel.: +81 43 270 3933; fax: +81 43 270 3935.
E-mail address: takahashit@tdc.jp (T. Takahashi).

angled and non-angled implants [69]. However, the combined

effects of implant number and inclination on load exerted on
peri-implant bone remain to be clarified in application of the
All-on-4 Concept. The purpose of this study was to clarify
differences in stress in peri-implant cortical bone between 6
implants and 4 implants with change in inclination angle based
on the All-on-4 Concept.
2. Materials and methods
2.1. Construction of a three-dimensional finite element
model for stress analysis

2.1.1. Construct of components

A three-dimensional finite element model was used to
analyze stress distribution in peri-implant cortical bone. The
SolidWorks 2008 software package (SolidWorks Corp., MA,

1883-1958/$ see front matter. Crown Copyright # 2010 Published by Elsevier Ltd. on behalf of Japan Prosthodontic Society.
doi:10.1016/j.jpor.2010.04.004

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2.1.4. The superstructure model

The following values were used to model the superstructure: a height of 10 mm, buccolingual width of 8 mm,
and dental arch length of 90 mm. The length of the dental
arch was defined as 90 mm, based on the sum of the mean
widths of the individual teeth from the right first molar to the
left first molar. Titanium [3] was selected for the material of
the superstructure.

Fig. 1. Three-dimensional finite element model for stress analysis: 6-implant

and 4-implant models.

Fig. 2. Cross-sectional shape of each models.

U.S.) was used to construct the mandible, implants, abutments,

and superstructure (Figs. 1 and 2).
2.1.2. The mandible model
Using a mandible model constructed using measurements
obtained from edentulous mandible casts of Japanese
individuals, Maruyama and Nishimura [10] reported that the
average shape of the residual ridge arch in conjunction with the
alveolar crest of the edentulous mandible could be represented
by the equation Y = 0.045X2 0.00161X 41.806. To construct a mandible using this parabolic function, the length of the
residual ridge arch was defined as 110 mm, based on the mean
length between the right retromolar pad and the left retromolar
pad of an edentulous mandible [10]. Based on the mean values
of edentulous mandibles [11] 25 mm was assigned as the height
and 11 mm as the width. Cortical bone thickness was defined as
2 mm at all points, based on the report by Stegaroiu et al. [12].
The position of the mental foramen as a reference point was
defined as 30 mm from the midline, based on the total width of
an average tooth crown from the mandibular central incisor to
the center of the second premolar, as the mental foramen is
located immediately below the second premolar.
2.1.3. Abutment model
In the abutment model, diameter and length were 4 mm [4].
Titanium was selected for the material of the abutments.

2.1.5. Implant conditions

Two models were constructed: one for 6 implants and the
other for 4 implants. In both models, all implants were
inserted between the mental foramina. The center of distal
end of the posterior-most implant tip was positioned 4 mm
anterior to the mental foramen to avoid contact with the
mental foramen. In the 6-implant model, all implants were
inserted in parallel, with a uniform distance of 10.4 mm
between the center of implant tip. In the 6-implant model,
implant diameter was 4 mm and length 13 or 15 mm. In the
4-implant model, two versions were constructed: one in
which all the implants parallel, and another in which the 2
anterior implants were parallel while the 2 posterior implants
were angled. In the 4-implant model, there was a uniform
distance of 17.3 mm between the center of implant tips.
Inclination angles were 158, 308, and 458. In the 4-implant
model, implant diameter was 4 mm, and length of anterior
implant was 13 or 15 mm [4]. To standardize the position of
the tip of the posterior implants in the 4-implant model, the
length of the posterior implants was changed depending on
inclination angle (Table 1). Table 2 shows the cantilever
length at each inclination angle. Titanium was selected for
the material of the implants. The mandible, implants,
abutments, and superstructure were analyzed as a continuous
structure, i.e., there were no intervening parts. Table 3 shows
the properties of all the materials used in the model, using
data from a report by Arataki [13]. Table 4 shows the
elements and nodes of each model.
2.2. Measurement of stress on cortical bone surrounding
implants
The software package COSMOSWorks 2008 software
package (SolidWorks Corp., MA, U.S.) was used to analyze
stress on peri-implant bone. The bottom of the mandible was
fully constrained in the model. A vertical load of 50 N was
applied to the superstructure, based on the report of Hotta [14]
on amount of implant displacement. To suppose interposition
of food in chewing, the unilateral loading was applied.
Loading was performed under 2 distinct environments. Under
loading condition A, the load was applied to a point 2 mm
distal to the posterior-most implant on the right side (Fig. 3).
This position assumed a cantilever length of 2 mm for the
model with an inclination angle of 458, as indicated in
Table 2. However, if 2-mm cantilevers were used in all
models, the design of the superstructure would have to
change, rendering it impossible to maintain uniform experimental conditions. If the length of the cantilever were kept at

T. Takahashi et al. / Journal of Prosthodontic Research 54 (2010) 179184

181

Table 1
Inclination angle and length of posterior implants in the 4-implant model.
Group

Inclination angle

08

158

308

458

Anterior implant 13 mm

Posterior implant (mm)

Differences in the posterior implant length (mm)

13.0
0

13.5
0.5

15.0
2.0

18.4
5.4

Anterior implant 15 mm

Posterior implant (mm)

Differences in the posterior implant length (mm)

15.0
0

15.5
0.5

17.3
2.3

21.2
6.2

Table 2
Cantilever length for each inclination angle.
Angle of inclination

Cantilever length (mm)

08

158

308

458

19

13

Table 3
Material properties.

Implant, superstructure (titanium)

Cortical bone
Cancellous bone

Youngs
modulus (GPa)

Poissons ratio

108.5
20.0
2.0

0.34
0.3
0.4

Fig. 3. Loading condition A: loading at point 2 mm distal from distal end of

distal implant.

Table 4
Elements and nodes of each models.
Anterior implant
13 mm

6
4
4
4
4

implants
implants
implants
implants
implants

08
158
308
458

Anterior implant
15 mm

Elements

Nodes

Elements

Nodes

12,409
10,541
10,889
11,067
11,236

19,299
16,589
17,203
17,425
17,676

12,696
10,654
11,053
11,303
11,524

19,725
16,755
17,524
17,727
17,965

2 mm in each model, the length of the superstructure would

change, making it impossible to maintain consistent experimental conditions. Therefore, to avoid change in the length of
the superstructure, the length of the cantilever between the
distal end of the implant and a line drawn perpendicularly
from the loading point was kept at a constant 2 mm (Fig. 3).
Under loading condition B, the loading point was kept
constant, i.e. the load was applied to the central region of the
most distal end of the superstructure where load on the
implant was at its maximum (Fig. 4). Himmlova et al. [15]
found that stress was highest in peri-implant cortical bone
during loading. Therefore, the analysis focused on maximum
von Mises stress in peri-implant cortical bone.
3. Results
Stress was observed to be concentrated in the cortical bone
surrounding the posterior-most implant on the right side. Figs. 5

Fig. 4. Loading condition B: loading at central region of most distal end of

superstructure.

and 6 show the results of the stress analysis under loading

conditions A and B. In a comparison of anterior implant lengths
of 13 mm and 15 mm, very few differences were observed in
peri-implant stress on cortical bone under either of the two
loading conditions. Under loading condition A, stress with 4
implants inserted in parallel was 9% higher than in the 6implant model due to the presence of fewer implants. In
addition, under loading condition A, stress on peri-implant
cortical bone grew with an increase in inclination angle. Stress
was 13% higher in the 4-implant model than in the 6-implant
model at an inclination angle of 158, 20% higher at an angle of
308, and 23% higher at an angle of 458(Fig. 7). Under loading

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Fig. 5. Stress distribution under loading condition A.

Fig. 6. Stress distribution under loading condition B.

Fig. 7. Stress on peri-implant cortical bone under loading condition A. The use
of 4 implants or inclined implants increased stress on peri-implant cortical bone.

Fig. 8. Stress on peri-implant cortical bone under loading condition B. Stress

increased by the decrease of implants. However, stress decreased with increase
in inclination angle.

condition B, stress was 11% higher than in the 6-implant model

for 4 implants inserted in parallel due to the presence of fewer
implants. In addition, under loading condition B, stress on periapical cortical bone showed a decrease with increase in
inclination angle. Stress was 21% lower in the 4-implant model
than in the 6-implant model at an inclination angle of 158, 34%
lower at an angle of 308, and 45% lower at an angle of 458
(Fig. 8).

4. Discussion
4.1. Analysis model
In pilot study, we therefore used the amount of displacement
reported as actual measurements when a load was applied to
implants in humans [14] and compared this value with the
amount of displacement observed in our analysis model. The

T. Takahashi et al. / Journal of Prosthodontic Research 54 (2010) 179184

displacement values from this analysis model were in close

agreement with actual measurements, which demonstrates the
validity of the present analysis model.

183

inclined implants induces an increase in stress on peri-implant

cortical bone. However, the use of inclined implants in the Allon-4 Concept in conjunction with a short cantilever decreases
peri-implant stress on cortical bone.

4.2. Implant length

Acknowledgements
The results revealed very few differences in stress with
variation in length of implant. Although implant length only
varied between 2 and 2.8 mm in this study, other studies [15,16]
using finite element analysis have noted that implant length
showed no effect on stress on peri-implant cortical bone. While
some clinical reports [17,18] have noted that rate of implant
failure decreased with increase in implant length, another report
[19] found no correlation between implant length and survival
rate. This indicates the need to investigate the relationship
between implant length and survival rate.
4.3. Number of implants and inclination angle
A single, angled implant has been shown to increase bone
stress [20,21]. However, in studies on multiple implants splinted
together on a superstructure, no difference was observed in stress
on cortical bone between angled and non-angled implants [22].
In the present study, under loading condition A, stress was higher
when the number of implants was lower, and was higher still with
angled implants, although this increase was small. This increase
in stress was due to the short distance of only 2 mm between the
implant and the line running perpendicularly from the loading
point. The length of the superstructure was selected so as to be
equivalent to that used in a clinical situation, which seems that the
result accords with clinical conditions. A comparison of stress
between loading conditions A and B at the same inclination
angles (excluding 458) revealed that stress was lower under
loading condition A, with stress showing a decrease with increase
in inclination angle under loading condition B. These results
suggest that the decrease in stress seen with shorter cantilevers
outweighs the increase in stress caused by an angled implant.
Earlier studies have shown a positive correlation between
cantilever length and load on bone [16,17,23]. In clinical
practice, it is, therefore, believed to be necessary to reduce
cantilever length when bone volume or quality has deteriorated to
reduce stress on surrounding bone. Although increasing the
inclination angle complicates clinical procedures, it should be
seen as one means to shorten cantilevers.
In this study, we therefore used an analysis model with a
simple morphology that was constructed from mean values to
obtain more broadly applicable results. Because of individual
differences in the morphology of the jaw bone, the results from
this study do not apply to all individuals. The model in this
study simulated one of the various stresses that implants make
in an actual mouth.
5. Conclusion
Within the limitations of this study, where the length
between the implant and the line running perpendicularly from
the loading position is constant, the use of 4 implants or

The authors would like to thank Associate Professor Jeremy

Williams, Tokyo Dental College, for his assistance with the
English of the manuscript. This study supported by a grant from
the Promotion and Mutual Aid Corporation for Private Schools
of Japan.
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