Three-dimensional finite-element analysis of functional stresses in different

bone locations produced by implants placed in the maxillary posterior region

of the sinus floor
Omer Lutfi Koca, DDS, PhD,a Gurcan Eskitascioglu, DDS, PhD,b and Aslihan Usumez, DDS, PhDc
Selcuk University, Faculty of Dentistry, Konya, Turkey
Statement of problem. Implants placed in the posterior maxilla have lower success rates compared to
implants placed in other oral regions. Inadequate bone levels have been suggested as a reason for this differential
success rate.
Purpose. The purpose of this study was to determine the amount and localization of functional stresses in
implants and adjacent bone locations when the implants were placed in the posterior maxilla in proximity to the
sinus using finite element analysis (FEA).
Material and methods. A 3-dimensional finite element model of a maxillary posterior section of bone (Type 3)
was used in this study. Different bony dimensions were generated to perform nonlinear calculations. A single-
piece 4.1 3 10–mm screw-shaped dental implant system (ITI solid implant) was modeled and inserted into
atrophic maxillary models with crestal bone heights of 4, 5, 7, 10, or 13 mm. In some models the implant
penetrated the sinus floor. Cobalt-Chromium (Wiron 99) was used as the crown framework material placed onto
the implant, and porcelain was used for occlusal surface of the crown. A total average occlusal force (vertical load)
of 300 N was applied at the palatal cusp (150 N) and mesial fossa (150 N) of the crown. The implant and
superstructure were simulated in finite element software (Pro/Engineer 2000i program).
Results. For the porcelain superstructure for bone levels, maximum von Mises stress values were observed on the
mesial fossae and palatal cusp. For the bone structure, the maximum von Mises stress values were observed in the
palatal cortical bone adjacent to the implant neck. There was no stress within the spongy bone. High stresses
occurred within the implants for all bone levels.
Conclusion. The maximum von Mises stresses in the implants were localized in the neck of implants for 4- and
5-mm bone levels, but for 7-, 10-, and 13-mm bone levels more even stresses occurred within the
implants. (J Prosthet Dent 2005;93:38-44.)

CLINICAL IMPLICATIONS
The results of this finite element study indicated that implants supported by 7-, 10-, or 13-mm
bone levels demonstrate more even von Mises stresses, localized in smaller areas of cortical bone,
than implants with 4- or 5-mm bone levels. However, long-term clinical trials are required to
determine the validity of the effects of bone levels in the maxillary posterior region on the long-
term success of implant treatment.

T he therapeutic regimen for treating patients with

missing teeth has been significantly expanded by mod-
ern implant methods. The prosthesis supported by os-
seointegrated implants has become an integral part of
restorative therapy for both completely and partially
edentulous patients.1-3 However, a prerequisite for suc-
cessful oral implants is sufficient bone volume.4 In using
osseointegrated dental implants for partially edentulous
patients, clinicians frequently are confronted with ana-
tomic variations of the premolar and molar areas, one
a
Research Fellow, Department of Prosthodontics.
b
Professor and Chair, Department of Prosthodontics.
c
Assistant Professor, Department of Prosthodontics.
of which is the maxillary sinus. Thus, implant placement
in the maxilla can be difficult for many reasons, includ-
ing inadequate posterior alveolus, increased pneumati-
zation of maxillary sinus, and close approximation of
sinus to crestal bone.5 The thickness of bone beneath
the maxillary sinus correlates with the degree of pneu-
matization.5 Sinus pneumatization may minimize or
completely eliminate the amount of vertical bone avail-
able.5,6 In addition to the problem of a compromised al-
veolar ridge, the maxillary sinus can vary in size and
shape, making implant placement impossible without
surgical modification.7
Several techniques and a variety of materials have
been reported to increase posterior maxillary bone
height to permit successful dental implant placement.8,9

38 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 93 NUMBER 1

KOCA, ESKITASCIOGLU, AND USUMEZ
Table I. Elastic properties of materials modeled
Modulus of
elasticity, Poisson’s
Material E (MPa) ratio, v
Titanium46 110,000 0.35
Cr-Co alloy45 218,000 0.33
Porcelain43 68,900 0.28
Cortical bone44 13,400 0.30
Spongy bone44 1370 0.30
Bruschi et al10 described a surgical technique for aug-
menting an atrophic alveolus beneath the maxillary sinus
without utilizing bone grafts or membranes and termed
it localized management of the sinus floor (LMSF). As de-
scribed, the LMSF technique offered the advantage of
placing implants in a single stage in the posterior maxilla
with as little as 5 mm of residual bone.10 Winter et al7
evaluated the clinical success of placing titanium im-
plants in the maxillary posterior with less than 4 mm
of alveolar bone, utilizing the surgical principles of the
LMSF technique. Ellegaard et al11 placed implants
into a minimum of 3 mm of alveolar bone with implants
protruding more than 5 mm into the maxillary sinus,
without bone grafts.
Adequate bone volume available for maxillary im-
plant placement and loading is necessary to achieve
long-term function of implant-supported restorations.
Increased problems of bone and implant loss have
been reported in the posterior maxilla.12 Animal experi-
ments13,14 and clinical studies2,3,15-17 have shown that,
in the absence of plaque-related gingivitis, bone loss
around implants is associated with unfavorable loading
conditions. One of the reasons for short-term implant
failure is lack of primary stability.
Impaired bone height and a paucity of dense cortical
bone contribute significantly to such diminished im-
plant survival.14 While late implant failures are primarily
related to biomechanical complications, the major factor
leading to such failures may be lack of understanding of
biomechanical factors.18,19 The contribution of several
factors, including biomechanical overload,20 direction
and amplitude of forces,21-24 inadequate bone vol-
ume,11,25-27 bone density,28-30 number of supporting
implants,23,31 angulation of implants in bone,32 and
type of prosthesis33,34 make the in vivo examination of
biomechanical factors related to implants too complex.
The load transferred to bone through the prosthesis
and implant, and careful planning and execution of the
prosthetic therapy, are important factors in achieving
appropriate stress distribution in the bone.35,36 The
manner in which bone is loaded may be essential to its
response. Bone is usually subjected to cyclic loads,
with results that differ from static loads.34 If a sufficient
number of repetitive load cycles are applied, stress mi-
crofractures in bone may occur. After bone microfrac-
JANUARY 2005
THE JOURNAL OF PROSTHETIC DENTISTRY
Table II. Models consisted of elements and node
Bone level Elements Node
4 mm 141,153 27,510
5 mm 156,916 29,843
7 mm 182,318 33,485
10 mm 189,541 34,313
13 mm 192,645 34,721
tures occur, microdamage caused by stress greater
than normal levels may stimulate osteoclastic activity
to remove the damaged bone.34
The distribution of forces in peri-implant bone has
been investigated by finite element analyses in several
studies.25,26,28,29,34,35,37 Recently, stress distribution
in bone correlated with implant-supported prosthesis
design has been investigated primarily by means of 2-di-
mensional (2-D) and 3-dimensional (3-D) finite ele-
ment analyses (FEAs).38 Studies comparing the
accuracy of these analyses found that, if detailed stress
information is required, then 3-D modeling is neces-
sary.38,39 The 3-D FEA is considered an appropriate
method for investigation of the stress throughout a
3-D structure, and therefore this method was selected
for bone and implants stress evaluation in this study.
The purpose of this study was to determine the amount
and localization of functional stresses in implants placed
in different bone levels (4, 5, 7, 10, or 13 mm) in the
atrophic posterior maxilla using FEA. The hypothesis
tested was that the amount and localization of func-
tional stresses in implants placed in different bone levels
in the posterior maxilla is similar.
MATERIAL AND METHODS
A 3-D finite element model of a maxillary section of
bone with a missing second premolar and its superstruc-
ture was used in this study. According to the classifica-
tion system by Lekholm and Zarb,40 a maxillary bone
model, simulating D3-type bone (thin porous cortical
bone on the crest and trabeculer bone within) was se-
lected. Average and atrophic maxillary alveolar crests
were modeled according to measurements of Misch.41
Therefore, different bone dimensions were generated
to perform nonlinear calculations. The implant was
placed into an atrophic maxilla, with crestal bone heights
of 4, 5, 7, 10, or 13 mm. Spongy bone was modeled as
a solid structure in cortical bone.28,42 Cortical bone
thicknesses used in this study were an internal thickness
of 0.35 mm and external thickness of 0.7 mm beneath
the maxillary sinus for all bone levels.
A single-piece, 4.1 3 10–mm screw-shaped dental
implant system (solid implant, ITI; Institut Straumann
AG, Waldenburg, Switzerland) was selected for this
study. Cobalt-Chromium (Wiron 99; Bego, Bremen,
Germany) was simulated as a crown framework material,
and feldspathic porcelain was used for the occlusal
39
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. Values and distribution of loads applied to finite
element model.
Fig. 2. Finite element model (4-mm bone level).
surface. The implant and its superstructure were simulated
using finite element software (Pro/Engineer 2000i;
Parametric Technology Corp, Needham, Mass). The
metal thickness used in this study was 1.0 mm with a por-
celain thickness of 0.35 mm. Cement thickness layer was
not modeled.42 All materials were presumed to be linear
40
KOCA, ESKITASCIOGLU, AND USUMEZ
Fig. 3. Localization areas of bone structure. CR-BCB, Crestal
ridge-buccal cortical bone; CR-PCB, crestal ridge-palatal
cortical bone; CR-MCB, crestal ridge-mesial cortical bone;
CR-DCB, crestal ridge-distal cortical bone; LW-MT, lateral
wall-middle third; LW-AT, lateral wall-apical third.
elastic, homogenous, and isotropic.26,28,29,34,43 The
corresponding elastic properties such as Young’s modu-
lus (E) and Poisson ratio (m) were determined from the
literature43-46 and are summarized in Table I. Models
consisting of elements and nodes are summarized in
Table II. A fixed bond between the bone and the im-
plant along the interface was presumed. An average oc-
clusal force of 300 N was used.20,38 A vertical load was
applied at the palatal cusp (150 N) and mesial fossa
(150 N) locations (Fig. 1).47
The final element on the x-axis for each design was as-
sumed to be fixed, which defined the boundary condi-
tion. The geometry of the tooth model has been
described by Wheeler.48 The applied forces were static.
Stress levels were calculated using von Mises stresses49
values. The von Mises stresses are the most commonly
reported in FEA studies to summarize the overall stress
state at a point.22-26,28,29,34,34 The analyses were per-
formed on a computer (Dual Pentium IV 2.0 GHz;
Toshiba Information Equipment, Manila, Philippines)
using software (COSMOSM, version 2.5; Structural
Research and Analysis Corp, Los Angeles, Calif and
Pro/Engineer 2000i; Parametric Technology Corp).
Boundary conditions, loading, and mathematical mod-
els were prepared with finite element software. The out-
puts were transferred to the COSMOSM program to
display stress values and distributions. Data for stresses
were produced numerically and color-coded. Figure 2
displays the FE-model.
VOLUME 93 NUMBER 1
KOCA, ESKITASCIOGLU, AND USUMEZ THE JOURNAL OF PROSTHETIC DENTISTRY

Fig. 4. Distribution of stresses within implant and cortical bone.

Fig. 5. Distribution of stresses within cortical bone for all bone levels.

Table III. Maximum stress values in all localizations (MPa)

Bone
Levels CR-BCB CR-PCB CR-MCB CR-DCB LW-MT LW-AT

4 mm 50 50 31 25 12 18
5 mm 50 50 25 18 12 18
7 mm 31 50 18 12 12 12
10 mm 25 50 12 12 12 12
13 mm 16 44 12 6 6 6
CR-BCB, Crestal ridge-buccal cortical bone; CR-PCB, crestal ridge-palatal
cortical bone; CR-MCB, crestal ridge-mesial cortical bone; CR-DCB, crestal
ridge-distal cortical bone; LW-MT, lateral wall-middle third; LW-AT, lateral
wall-apical third.

Bone structure was specified for 6 localized areas:

ridge crest, buccal cortical bone adjacent to implant
neck (CR-BCB); palatal cortical bone adjacent to im-
plant neck (CR-PCB); mesial cortical bone adjacent to
implant neck (CR-MCB); distal cortical bone adjacent
to implant neck (CR-DCB); the middle third of the lat-
eral wall of the sinus (LW-MT); the apical third of lateral
wall of the sinus, close to zygomatic process (LW-AT)
(Fig. 3).
Fig. 6. Maximum von Mises stress values in cortical bone, in
all bone levels and in all localization areas.
RESULTS
Figure 4, A, represents stress distribution within the
porcelain superstructure. For all bone levels, maximum
von Mises stress values of 84 to 168 MPa were observed,

JANUARY 2005 41
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 7. Distribution of stresses within implants and abutments in all bone levels.
particularly on the mesial fossae and palatal cusp where
the stresses were applied. Figures 4, B, and 5 represent
the stress distribution within the bone structure. There
was no stress within the spongy bone. The maximum
von Mises stress values were observed in the cortical
bone adjacent to the implant neck.
For the buccal cortical bone on the ridge crest, the
maximum von Mises stress value was observed at the
4-mm and 5-mm bone levels (50 MPa), and the low-
est stress value was observed at the 13-mm bone level
(18 MPa). For the palatal cortical bone on the ridge
crest, the maximum stress value was observed at 4-,
5-, 7-, and 10-mm bone levels (50 MPa), and the
lowest stress value was observed at the 13-mm bone
level (44 MPa). For the mesial cortical bone the max-
imum stress value was observed at the 4-mm bone
level (31 MPa), and the lowest stress value was ob-
served at the 10- and 13-mm bone levels (12 MPa).
For the distal cortical bone the maximum stress value
was observed at the 4-mm bone level (25 MPa), and
the lowest stress value was observed at the 13-mm
bone level (6 MPa).
For the middle third of the lateral wall of the sinus,
the maximum stress value was observed at the 4-, 5-,
7-, and 10-mm bone levels (12 MPa), and lowest stress
value was observed at the 13-mm bone level (6 MPa). In
the apical third of the lateral wall of the sinus, the max-
imum stress value was observed at the 4-mm and 5-mm
bone levels (18 MPa), and the lowest stress value was ob-
served at the 13-mm bone level (6 MPa). The maximum
stress values of localization areas shown in Table III and
Figure 6.
Figure 7 represents stress distributions within the im-
plant and abutment. At the 4- and 5-mm bone levels, the
maximum stresses were localized at the neck of the im-
plant, but at the 7-, 10-, and 13-mm bone levels,
more even stresses were observed within the implants.
DISCUSSION
The results obtained do not support the research hy-
pothesis of an expected similar amount and localization
of functional stresses in implants placed in different bone
42
KOCA, ESKITASCIOGLU, AND USUMEZ
levels in the posterior maxilla. The 7-, 10-, and 13-mm
bone levels predicted more even von Mises stresses
within the implant, and the stresses were localized in
smaller areas at cortical bone than 4-mm and 5-mm
bone levels.
In the past 2 decades, FEA has become an increas-
ingly useful tool for the prediction of the effects of stress
on the implant and surrounding bone. Vertical and
transverse loads from mastication induce axial forces
and bending moments and result in stress gradients in
the implants, as well as in the bone. A key factor for
the success or failure of a dental implant is the manner
in which stresses are transferred to surrounding bone.
FEA allows investigators to predict stress distribution
in the contact area of implants with cortical bone and
around the apex of implants in spongy bone.36
The model used in the present study made several as-
sumptions regarding the simulated structures. The
structures in the model were all assumed to be homoge-
neous, isotropic, and to possess linear elasticity. The
properties of the materials modeled in this study, partic-
ularly the living tissues, however, are different.
Additionally, a 100% implant-bone interface was simu-
lated, which does not necessarily simulate clinical situa-
tions.20 Also, it is important to note that the stress
distribution patterns may have been different depending
on the materials and properties assigned to each layer of
the model and the model used in the experiments.
Furthermore, the cement layer was not modeled.
Thus, the inherent limitations in this study should be
considered.
When applying FEA to dental implants, it is impor-
tant to consider not only axial loads and horizontal
forces (moment-causing loads) but also a combined
load (oblique occlusal force), because the latter repre-
sents more realistic occlusal directions and, for a given
force, will result in localized stress in cortical bone.22
In the current study, only vertical loads were considered.
The design of the occlusal surface of the model can
influence the stress distribution pattern. In the present
study, the locations for the force applications were spe-
cifically described as cusp tip and mesial fossa.
However, the geometric form of the tooth surface can
VOLUME 93 NUMBER 1
KOCA, ESKITASCIOGLU, AND USUMEZ
produce a pattern of stress distribution that is specific for
the modeled form. The pattern could be different with
even moderate changes to the occlusal surface of the
crown. Although this occlusal form exists for this model,
the same form would not represent all premolar teeth. In
the present study, a 4.1 3 10-mm screw ITI dental im-
plant was selected because no report on ITI standard
4.1-mm diameter solid screw implant fractures could
be found in literature.21
Crestal bone loss is often seen clinically and is
a phenomenon which has been observed in different
stages of implant loading as a decrease of radiological
marginal bone level.26 In a number of radiological
long-term studies,17 FEA analyses,22-26,28,29,34,37-39
and photoelastic analyses,11,24 loaded implants
showed typical bone loss around the implant neck.
The results of the current study indicated that maxi-
mum von Mises stresses occurred mainly at the palatal
surfaces of cortical bone adjacent to implant necks for
all models. Only at 4-mm and 5-mm bone levels did
maximum von Mises stresses occur on both the buccal
and palatal surfaces.
The stresses were concentrated in the neck of implant
and were probably due to the rigid connection between
the implant and bone. The elastic modulus of cortical
bone is higher than spongy bone and for this reason cor-
tical bone is stronger and more resistant to deforma-
tion.12,30,35 A consistent observation from the current
study was the concentration of maximum stress at the
bone-implant interface and at the level of cortical
bone. According to the results of the present study, it
is suggested that loading an implant with low-volume
bone beneath the sinus floor might cause increased
stress concentration in the cortical bone, especially
around the coronal portion of the implant.
Subsequently, marginal bone resorption might be initi-
ated, if the load-bearing capacity of bone is surpassed.
This may explain the decreased success rates that result
when implants are placed in posterior sites with less
than 5 mm of bone.
For all bone levels tested, the highest stresses oc-
curred within implants. This is likely due to the higher
modulus of elasticity of titanium that peaked at 155
MPa (Fig. 7). As titanium alloys are known to tolerate
stresses of up to 900 MPa without irreversible deforma-
tion,37 the force of 300 N applied to the system was un-
likely to cause implant failure.
Many finite element and photoelastic studies were
based on block-shaped, nonanatomic models that
showed principal stress concentration at the apex of cyl-
inder-shaped implants on axial loading. These models
did not simulate the hollow intricate anatomy of the
maxilla and facial skeleton.24 In the present study, differ-
ent patterns of stress distributions were demonstrated
around a maxillary implant with simulated maxillary si-
nus geometry.
JANUARY 2005
THE JOURNAL OF PROSTHETIC DENTISTRY
CONCLUSIONS
Within the limitations of this study the following
conclusions were drawn:
1. For supporting bone levels of 4 and 5 mm, the
maximum stresses were localized in wide areas, and for
levels of 7, 10, and 13 mm, the maximum stresses
were localized in narrow areas.
2. At 4- and 5-mm bone levels, the maximum
stresses were localized at the neck of implant, but at 7-,
10-, and 13-mm bone levels, more even stresses oc-
curred within the implants.
3. The maximum stresses were localized on the pala-
tal cortical bone for all bone levels. Only at the 4-mm
and 5-mm bone levels did maximum von Mises stresses
occur on both buccal and palatal surfaces.
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Copyright Ó 2005 by The Editorial Council of The Journal of Prosthetic
Dentistry
doi:10.1016/j.prosdent.2004.10.001
VOLUME 93 NUMBER 1