Medical Engineering and Physics 37 (2015) 431–445

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Medical Engineering and Physics

journal homepage: www.elsevier.com/locate/medengphy

Number and localization of the implants for the fixed prosthetic

reconstructions: On the strain in the anterior maxillary region
Nilüfer Bölükbaşı∗, Sinem Yeniyol
Istanbul University, Faculty of Dentistry, Department of Oral Implantology, Istanbul, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Resorption following tooth loss and poor bone quality affect the success of implants in the anterior maxilla.
Received 21 October 2013 Inappropriate planning can cause implant loss and aesthetics problems that are difficult to resolve. There is
Revised 23 January 2015
a limited literature on the optimum number and location of implants in anterior maxilla for fabricating fixed
Accepted 16 February 2015
prosthesis in biomechanical terms. This study investigated the effect of dental implant localizations in anterior
maxilla on the strain values around implants using a three dimensional finite elements analysis method.
Keywords: Obtained strain values were compared to the data in Frost’s mechanostat theory. The entire totally edentulous
Finite element analysis maxilla was modeled using computer tomography images and five models were prepared representing
Dental implant different implant localizations. The distribution of implants in the models was as follows: two canines in
Anterior maxilla the first model, two canines and one central incisor in the second model, two canines and central incisor in
Biomechanics the third model, two canines and one lateral incisor in the fourth model and two canines and two lateral
Strain
incisors in the fifth model. Anatomic abutments with a gingival height of 2 mm and angle of 15° were used
as the abutments to fabricate one piece cemented metal fused to porcelain restoration. A chewing strength
of 100 N was applied to the cingulum of all crowns at a 45° angle. Maximum strain values in all models were
measured in cortical bone in implant necks. The highest strain value was measured in the first model at the
cortical bone area (3037 microstrain). Except the first model, all models showed micro strain values within
1000–3000 microstrain. The fifth model was the least risky method in biomechanical terms. The results of
this study should be compared with different clinical scenarios (for example different implant designs and
sizes). Due to the limitations of three-dimensional finite elements analysis studies, the findings of the study
need to be supported by clinical studies.
© 2015 IPEM. Published by Elsevier Ltd. All rights reserved.

1. Introduction
Implants in aesthetically important areas are defined as advanced
or complex treatments [1]. Previous studies showed that the success
of implants in the anterior maxilla was similar to that in other re-
gions of the mouth [2,3]. However, there is a limited literature on
the success of fixed implant supported prostheses in edentulous an-
terior maxilla. Furthermore, there is no consensus on the number
and location of implants that should be placed in anterior maxilla.
The bone in the vestibule sites of the teeth generally breaks dur-
ing tooth extraction in anterior maxilla. Following the extraction,
25% is resorbed during the first year and 40–60% after 3 years [4].
Particularly due to these resorptions from vestibular to palatinal, it
was necessary to localize narrow-diameter implants in more superior
and palatinal locations than for natural teeth. The success of dental
∗
Corresponding author. Tel.: +90 2125323218; fax: +90 2125323254.
E-mail address: dr.niluferbolukbasi@hotmail.com, nlfrbolukbasi@hotmail.com (N.
Bölükbaşı).
implants can also be affected by the spongiosis structure of the bone
in the region in most cases, and by occlusal loads transmitted dur-
ing movement of the mandible. Therefore, it is recommended that
a minimum of three implants – two canines and one lateral or two
canines and one central – should be applied on edentulous anterior
maxilla [5,6].
Occlusal loads are transferred to the bone around the dental im-
plants via the implant-supported prostheses. The loads that are trans-
ferred to the implants cause stress in the implant-bone contact area
depending on the occlusal load type, size of implants, implant sur-
face properties and structural characteristics of the bone on which
the implants were applied; and implant location and prosthesis type
[7]. Stress is defined as the force applied per unit area. The force that
causes stress also causes strain. Strain refers to the resulting deforma-
tion or dimensional change in the bone relative to the real dimension
of the bone [8]. Frost’s mechanostat hypothesis proposed that me-
chanical stress applied to bone cells results in the constructing of new
bone or resorption [9,10]. According to Frost, at 50–1500 microstrain,
remodeling is balanced; when microstrain value is 1500–3000, mild
overload occurs. At this stage, any damage occurring in the bone can

http://dx.doi.org/10.1016/j.medengphy.2015.02.004
1350-4533/© 2015 IPEM. Published by Elsevier Ltd. All rights reserved.
432 N. Bölükbaşı, S. Yeniyol / Medical Engineering and Physics 37 (2015) 431–445

Fig. 1. Strain distribution in the Model 1. Implants were placed in both canine sites.

Fig. 2. Strain distribution in the Model 2. Implants were placed in both canine sites and one central incisor sites.
 N. Bölükbaşı, S. Yeniyol / Medical Engineering and Physics 37 (2015) 431–445 433

Fig. 3. Strain distribution in the Model 3. Implants were placed in both canine and central incisor sites.

be repaired by remodeling activity. Osseous adaptation by formation
of bone can be provided. In contrast, it was reported that microstrain
values of more than 3000 can cause micro cracks in the bone that
cannot be repaired by remodeling.
Occlusal loads that exceed the mechanical or biological load-
bearing capacity of dental implants are defined as “overload” [11].
Clinical computation of the direction and magnitude of occlusal loads
is difficult. In recent years, finite elements analysis (FEA) has been
used to identify the loads transferred to dental implant, and the level
and distribution of load in the bone around the implant. FEA analysis
allows for the evaluation of various biomechanical risk factors that
can affect the success of dental implants in scenarios where clinical
evaluation is not possible.
This study analyzed the amount and localization of deformation
(strain) for implant retained fixed prosthesis with differing numbers
and localizations of dental implants in anterior maxilla by means
of three-dimensional finite elements analysis. The strain values
obtained in the study were compared with data for Frost’s mechano-
stat theory.
2. Materials and methods
2.1. Model design
Computed tomography (CT) images of a totally edentulous adult
patient taken from routine implant treatment planning were used
to form the geometric model of the maxilla. The patient provided
written consent to use the CT images in the study. The use of pa-
tient data was carried out according to the policies and procedures
of the Istanbul University, Faculty of Dentistry, Department of Oral
Implantology. Cone-beam Tomography (ILUMA, Orthocad, CBCT, 3M
Imtec, Oklahoma, USA) was used to scan the jaw. A total of 601 cross-
sections were obtained at 120 kvp, 3.8 mA in 40 s. The scan was
then reconstructed with volumetric data with 0.2 mm cross-section
434 N. Bölükbaşı, S. Yeniyol / Medical Engineering and Physics 37 (2015) 431–445
Fig. 4. Strain distribution in the Model 4. Implants were placed in both canine and one lateral incisor sites.
thickness. The cross-sections obtained after reconstruction were ex-
ported in DICOM 3.0 format. Exported cross-sections were transferred
to 3D-Doctor software (Able Software Corp., MA, USA). Bone tissues
on the cross-sections were separated using the “interactive segmen-
tation” method in 3D-Doctor. Separated cross-sections were turned
into a three-dimensional model using the “Complex Render” method.
The obtained three-dimensional model was converted to a smooth
surface using purification methods in 3D-Doctor. The resulting model
consists of elements with proper ratios of modeling elements, thereby
completing the modeling of the totally edentulous maxilla. The three
dimensional model was exported from 3D-Doctor software in stl
format.
VRMesh software (VirtualGrid Inc, Bellevue City, WA, USA) was
used to make dimensional and topographic arrangements on the
jaw model. An arch model of the maxilla was made, based on the
arch measurements conducted by Bilgin [12] on 400 Turkish pa-
tients. According to that study, the most common arch form among
the Turkish population was U-shaped, medium-large and medium-
long alveolar arch. The same form was used in the present study.
The alveolar crest was taken as 62.5 mm wide and 50.5 mm long.
An alveolar arch of 130.68 mm was calculated. The width of the
alveolar crest in the vestibular–palatinal direction was prepared as
6 mm, and the distance between the head of the crest was taken
as 25 mm.
Implant holes were prepared in anterior maxilla for 5 models with
different implant distributions. Posterior parts of the maxilla were
modeled as extended edentulous areas. The distribution of implants
in the models was as follows: two canines in the first model, two
canines and one central incisor in the second model, two canines and
central incisor in the third model, two canines and one lateral in-
cisor in the fourth model and two canines and two lateral incisors in
the fifth model. Implant and prosthesis parts supplied in the study
were scanned using a SmartOptics (Sensortechnik GmbH, Bochum,
Germany) three-dimensional scanner. The models were obtained in
stl format and sent to Rhinoceros 4.0 software (Seattle, WA 98103,
USA). Implants (Straumann Bone Level, Switzerland) with a diame-
ter of 4.1 mm and length of 12 mm were used for the canines and
central incisors; implants with a diameter of 3.3 mm and length of
12 mm were used for lateral incisors. Anatomic abutments with a
gingival height of 2 mm and angle of 15° were used as the abut-
ments to be applied on implants. In the present study, the angle of
the implants with the alveolar bone in frontal plane was planned
as 10° for the canine region, 20° for the lateral incisors and 30° for
the central incisors. A direct proportion formula was used to localize
 N. Bölükbaşı, S. Yeniyol / Medical Engineering and Physics 37 (2015) 431–445 435

Fig. 5. Strain distribution in the Model 5. Implants were placed in both canine and lateral incisor sites.

dental implants mesiodistally on the arc and to identify the distance
between the implants. The alveolar arch length in the constructed
jaw models was multiplied by the mean mesio-distal diameter of
the crowns in natural dentition and the resulting value was divided
by the mean alveolar arch length in natural dentition to calculate
the mesio-distal diameter of the crowns in the constructed models.
Mesio-distal diameters of the crowns in natural dentition were ob-
tained from a study by Wheeler [13]. Mean alveolar arch length in nat-
ural dentition was obtained by the addition of mesio-distal diameters
of the crowns. Based on the addition of mean mesio-distal diameters
of the teeth in maxilla using the data from Wheeler, mean alveo-
lar arch length was calculated as 128 mm. Considering mesio-distal
dimensions of the teeth, the implants were located on the alveolar
crest, leaving a minimum distance of 3 mm between the implants,
and a minimum of 1 mm in vestibule and palatinal regions of the
implants.
3. Material properties
The maxilla was modeled as 1-mm cortical bone in the exterior,
and as spongiosis bone in the interior according to the structural
properties of type III bone [14]. In modeling of implant-supported
prostheses, chromium–cobalt alloy (Wiron 99; Bego, Bremen, Ger-
many) was used as the lower structure and feldspathic porcelain was
used as the upper structure (Ceramco II; Dentsply, Burlington, ABD).
Metal thickness was prepared as 0.8 mm; porcelain thickness was
taken as minimum 2 mm considering crown dimensions. The modu-
lus of elasticity and Poisson’s ratios of the materials used in this study
and reference studies are presented in Table 1.
3.1. Contact management and loading
The modeling performed in the Rhino program was transferred
to Algor Fempro software (ALGOR, Inc., PA, USA) using three-
436 N. Bölükbaşı, S. Yeniyol / Medical Engineering and Physics 37 (2015) 431–445

Fig. 6. Strain distribution and values in the cortical bone in the Model 1.

Table 1 regions in the jaw models make analysis difficult, and were therefore
Mechanical properties of materials.
cleaned from linear elements and thus made regular. In order to ob-
Material and olacak Elastcity Poisson’s References tain realistic results, we selected the maximum number of elements
modulus (GPa) ratio permitted by the program, considering the dimensions of the jaw
Titanium implant and abutment 110 0.35 [15–17]
model. The numbers of elements and nodes that were used to model
Cortical bone 13.7 0.3 [15–18] the scenarios are presented in Table 2.
Trabecular bone (D3) 1.37 0.3 [15,18] All models were considered as linear, homogenous and isotropic
Chromium–cobalt alloy 218 0.33 [15,18] materials. Upper and lower prosthesis parts, implant screws and bone
Feldspathic porcelain 82.8 0.35 [15]
tissues were harmonized using the Boolean method in Rhino software
and force transfer was provided.
The model was fixed from the upper region of the jaw bone in such
a way to have zero movement at each degree of freedom. In vertical
dimensional coordinates. The models were converted into solid model loading, force was applied on all crowns from cingulum at an angle of
as bricks and tetrahedral elements. As many 8-node elements as pos- 45°. Chewing force was taken as 100 N.
sible that could be constructed in the Fempro model were used in The three-dimensional finite element program provided linear
the bricks and tetrahedral solid-modeling system. Steep and narrow statistical analysis (AlgorFempro, Algor Inc., PA, USA). Strain levels
 N. Bölükbaşı, S. Yeniyol / Medical Engineering and Physics 37 (2015) 431–445 437

Fig. 7. Strain distribution and values in the cortical bone in the Model 2.

Table 2 Maximum strain values in all models were measured in cortical

The numbers of elements and nodes in
bone in the neck region of the implants. Lower strain values were
5 models.
measured in trabecular bone than in cortical bone. Between the five
Elements Nodes models, the highest strain value was measured in the first model, in
Model 1 380,260 69,506
which the implants were placed in two canines. It was observed that
Model 2 908,485 163,919 strain values ranged between 1967 microstrain and 3037 microstrain
Model 3 501,838 91,758 in the cortical bone; while 714 microstrain and 2312 microstrain in
Model 4 925,840 166,771 the trabecular bone around the implants neck. Strain was especially
Model 5 524,828 94,263
concentrated at the mesiobuccal area (Figs. 1, 6, 11).
When three implants are planned on the anterior maxilla rather
than two, application on lateral teeth rather than central incisors will
yield more advantageous results in biomechanical terms. Maximum
were evaluated in accordance with the bone remodeling thresholds strain values observed at the buccal site of the central incisor (1973
suggested by Frost’s mechanostat hypothesis. microstrain and 1612 microstrain at the cortical and trabecular bone
respectively) in the second model whereas maximum values were
4. Results located at the canine site adjacent to lateral incisor in the fourth
model (Figs. 2, 4, 7, 9, 12, 14).
Distributions of strain in the models following loading are pre- When four implants are planned in the anterior region of the max-
sented in Figs. 1–5. Strain values in cortical and trabecular bone are illa, localization of the implants in both lateral teeth regions in the
presented in Figs. 6–15. It was found that strain was especially higher canine region causes less strain than localization of the implants on
in the buccal region. both central teeth regions. On the other hand, the implants localized
438 N. Bölükbaşı, S. Yeniyol / Medical Engineering and Physics 37 (2015) 431–445

Fig. 8. Strain distribution and values in the cortical bone in the Model 3.

in central incisors cause higher strain values than those localized in
lateral teeth region.
The minimum and maximum strain values calculated in cortical
and trabecular bone in the jaw were 203 and 900 microstrain re-
spectively, located in the regions between the implants. Evaluation
of the findings according Frost’s mechanostat hypothesis revealed
that bone remodeling in the regions between the implants (edentu-
lous crest) was in balance. In the first model, in which the implants
are localized on both canines, microstrain values exceeded 3000 in
the vestibular region in cortical bone, which suggests that resorp-
tion can occur especially in this region. In all other models, micros-
train values were within the range 1000–3000 and active remodeling
continued.
5. Discussion
Long-term aesthetic and functional success in rehabilitation of the
maxilla with dental implants depend on a detailed treatment plan-
ning. In this study, the effect of implant localizations on implant health
in anterior maxilla was analyzed using FEA. A review of the literature
shows a limited research on FEA of the maxilla compared with stud-
ies of the mandible. This is mainly because the maxilla cannot be
realistically modeled, due to its complex anatomic structure. There-
fore, previous three-dimensional FEA analyses of the maxilla used
segmental models with few elements and nodes in order to simplify
the models [19,20].
Okumura et al. [21] modeled the entire maxilla with conventional
segmental models and compared strain distributions. They found that
 N. Bölükbaşı, S. Yeniyol / Medical Engineering and Physics 37 (2015) 431–445
Fig. 9. Strain distribution and values in the cortical bone in the Model 4.
strain distribution was similar with FEA analysis that modeled the
entire maxilla in segmental models. However, studies that reported
significant strain values and strain distribution also revealed that it
would be appropriate to model the entire maxilla. In the present
study, we modeled the entire maxilla to obtain realistic data that can
be applied to clinic.
The aim of our study was to provide biomechanical reference to
clinicians in planning implant numbers and localizations in the an-
terior maxilla for the treatment of totally and partially edentulous
patients. Prosthetic planning is generally achieved in three segmen-
tal prosthetic planning (anterior maxilla and the bilateral posterior
maxilla segments) for the full edentulous individuals. There is ad-
equate clinical data in terms of implant number and localization
for esthetic demands in the anterior edentulous maxillary segment,
whereas no biomechanical evidential data are present for biomechan-
ical construction.
In cases of maxillary full or partial edentulism, various treatment
options can be planned according to the implant numbers and local-
izations. It is almost impossible to evaluate each of these biomechan-
ical analyses and publish them in a whole in one manuscript. For this
reason, we chose to plan a biomechanical analysis for the anterior
edentulous maxillary segment since there is no evident data about
the implant number and localizations specific to this segment of the
439
maxillary arch. In our study, the implants were placed in the ante-
rior maxilla and posterior sites were modeled as edentulous areas.
In this regard, our study should be further evaluated to contribute to
a better understanding for the biomechanical performance of bilat-
eral edentulous maxillary segments clinically. In addition, this type
of modeling reduced the element and node numbers, and, simplified
the model for an effective analysis.
Recent studies using FEA commonly use CT images to model the
dimensions and forms of the jaw [20,22–26]. CT images with 0.2-mm
cross-section, obtained from an individual with edentulous maxilla,
were used to precisely represent the anatomy of the maxilla. Stud-
ies using tomography images risk producing erroneous results if the
models reproduce deformations in the jaw of the patient. It was be-
lieved that performing the study on an appropriate ideal jaw model
rather than the jaw model of a specific person would yield results
that were more appropriate for clinical use. Therefore, a new up-
per jaw model was prepared based on the tomography image. As
the present study used specific dimensions and a U-shaped alveolar
arch, which is the most common shape among the Turkish popula-
tion, the results can be compared with prospective data from other
alveolar arch forms in future studies. Sagat et al. [27] reported that,
because the distance between implants differs for prostheses im-
planted in arches with different dimensions and forms, the strain
440 N. Bölükbaşı, S. Yeniyol / Medical Engineering and Physics 37 (2015) 431–445

Fig. 10. Strain distribution and values in the cortical bone in the Model 5.

values measured on peri-implant bone can vary. The researchers
used FE strain analysis to determine the most advantageous implant
localizations in fixed-implant-supported prostheses that were sup-
ported by 6 or 8 implants in edentulous maxilla with different alve-
olar arch forms. Among all alveolar arch models, the most favorable
strain values were obtained for implant groups on canines and lateral
incisors.
Comparison of the present findings with values from Frost’s
mechanostat theory showed that strain values for edentulous areas
that were not supported by an implant (edentulous areas) were within
physiologic limits. This study evaluated 5 implant localizations that
are commonly used in clinic. Apart from these models involving im-
plant localizations on incisors and canines (a total of 6 implants), other
scenarios can be modeled. It is presumed that the strain value per im-
plant and the implant value will decrease. However, considering the
distance between implants and the resorption pattern in the anterior
maxilla, this type of a planning can give rise to aesthetic problems.
Sano et al. [24] evaluated the number of implants and the stress on the
bone caused by localizations in an edentulous maxilla, and reported
that the level of stress was determined by whether the implants were
connected to each other. In that study, dental implants were placed
in the locations as 14 unsplinted implants (S14), 6 splinted implants
(canine, premolar, and molar regions S6), 4 splinted implants (S4),
and 6 anterior implants (incisors and canines, A6). The S6 model
showed similar levels of stress and deformation to the US 14 and
S14 models.
Resorption following the loss of natural teeth makes it difficult
to achieve ideal implant applications in the anterior maxilla. Dental
implants must be located on more palatinal and superior positions
than natural teeth. Sadrimanesh et al. [26] analyzed stress distribution
 N. Bölükbaşı, S. Yeniyol / Medical Engineering and Physics 37 (2015) 431–445 441

Fig. 11. Strain distribution and values in the trabecular bone in the Model 1.

around implants in the anterior maxilla with different labial angles;
they reported that as fixture angle increased, stress value measured
on cortical bone in the labial of implants increased. In our study,
considering resorption following tooth loss, the angle of the implants
to frontal places was planned as 10° in canines, 20° in lateral incisors
and 30° in central incisors. Taking into account the localization angles
of the implants, abutments with 15° angle were preferred. Tian et
al. [28] conducted a three-dimensional FEA and reported that the
use of angled abutments decreased stress when the implants could
not be localized in ideal positions. It should be remembered that
the abutment angles used in different clinical scenarios—including
implants localized at ideal positions or different positions—will affect
the level of stress imposed on the peri-implant bone.
There is a limited clinical and radiological study in the litera-
ture on the localization of dental implants in vestibule–palatinal and
mesial–distal directions. It is considered that the distance between
the implants should be minimum 3 mm in order to prevent potential
resorption in bone [29]. Tarnow et al. [29] reported that when the
distance between two implants exceeds 3 mm, crestal bone loss is
0.45 mm; when it is less than 3 mm, crestal bone loss is 1.04 mm.
It is suggested that a minimum of 1 mm of bone should be left in
the vestibule and palatinal surfaces of implants in order to ensure an
appropriate exit profile of the implant from the alveolar crest; and
for sufficient feeding of the bone. Spray et al. [30] reported that re-
sorptions decreased and even bone apposition was observed when
there is 1.8 mm or more of bone in the vestibule surfaces of implants.
Bidez and Misch reported that strain in bone was lower in cases with
3 implants when compared to those with 2 implants [31,32]. Con-
sidering the above factors and clinical practices, the present study
modeled 5 different implant localizations leaving a minimum dis-
442 N. Bölükbaşı, S. Yeniyol / Medical Engineering and Physics 37 (2015) 431–445
Fig. 12. Strain distribution and values in the trabecular bone in the Model 2.
tance of 3 mm between the implants and a minimum of 1 mm in
vestibule and palatinal regions of implants.
There is a large body of research analyzing the amount of stress
transferred to dental implants and peri-implant bone by the ma-
terials used in implant-supported prostheses [33–37]. Considering
previous research and clinical practices, the present study chromium–
cobalt alloy (Wiron 99; Bego, Bremen, Germany) [33,38,39] sup-
ported feldspastic porcelain (Ceramco II; Dentsply, Burlington, ABD)
[33,34,40] were used as implant supported prosthesis.
FE studies in oral implantology applied various occlusal forces
of 100–2000 N [18,22,27,41–43]. In our study, 100 N mean vertical
chewing force was used [42]. There are a limited number of previous
studies on loading in different regions of the anterior maxilla. Clelland
et al. [22] applied occlusal loads in the direction of the longer axis of
implants. Saab et al. [43] applied occlusal loads from the cingulum
region, and Hsu et al. [44] applied the occlusal loads at angles of 0°,
30° and 60° to the longer axis of the implant. Forces applied along
the longer axis of implants represent the situation when the upper
and lower incisors are closed. This type of closing during chewing
is observed in a small proportion of patients with distorted upper–
lower jaw relationship. Furthermore, the measured chewing force is
lower when the mandible is in eccentric position and the posterior
teeth do not contact [43]. The application of vertical loads in buccal
and apical direction from the cingulum regions of crowns reflects the
location of mandibular incisors closest to the palatinal surfaces of
maxillary incisors; in other words, centric occlusion location. Centric
occlusion position is the appropriate area in which to make exam-
ine the magnitude of vertical loading applied to the anterior maxilla
[43]. Therefore, in the present study, vertical chewing forces were
applied at a 45° angle from cingulum regions. Force application over
dental implants, abutment or crowns affects the reliability of the re-
sults. Application of chewing forces to the crowns provides realistic
results [44]. For this reason, the present study applied loads to the
crowns.
It is difficult to make calculations according to permanent de-
formations in order to analyze an element. Instead, the analysis
treats the systems as linear elastic; in other words, it is more con-
venient to analyze an idealized model of the system. In the present
 N. Bölükbaşı, S. Yeniyol / Medical Engineering and Physics 37 (2015) 431–445 443

Fig. 13. Strain distribution and values in the trabecular bone in the Model 3.

study, the upper jaw was considered as linear elastic for all calcu-
lations. Furthermore, the maxilla was considered as homogenous
and isotropic, but is not a homogenous structure in practice. Simi-
larly, there are varying opinions on whether the jaws are isotropic
or orthotropic [23,45,46]. In a study that modeled the jaw as or-
thotropic, stress increased by 25%. In this study, osseointegration
was assumed to be 100% in order to reduce calculation time. How-
ever, osseointegration and stress in peri-implant bones is propor-
tional [47]. Spivey et al. [47] reported that when osseointegration
was 83.3% strain measured in peri-implant bone increased by 5%
compared to the situation when osseointegration was considered
as 100%.
One limitation of our study is the fact that Frost’s mechanostat
theory was not specifically developed for dental implants. Compre-
hensive researches are still needed to determine bone strain values
under occlusal loads for peri-implant bone, although Frost himself
notified that human load-bearing bones adapt to mechanical changes
[7–9].
The most important disadvantage of FEA analyses is that the re-
sults are only valid for the selected model. For example, assumptions
are made for variable data such as the dimensions of dental implants,
cortical bone thickness, trabecular bone density and amount of os-
seointegration. Therefore, it should be remembered that the results
will vary when the input data change.
6. Conclusion
This study evaluated biomechanical behavior for implant localiza-
tions of fabricating implant retained fixed prostheses, in the anterior
maxilla. Our findings reveal that increasing the number of implants
444 N. Bölükbaşı, S. Yeniyol / Medical Engineering and Physics 37 (2015) 431–445

Fig. 14. Strain distribution and values in the trabecular bone in the Model 4.

Fig. 15. Strain distribution and values in the trabecular bone in the Model 5.
 N. Bölükbaşı, S. Yeniyol / Medical Engineering and Physics 37 (2015) 431–445
reduced the risk of bone resorption. Different model types should be
evaluated and prospective clinical studies with long-term follow-up
are required for definitive conclusions.
Conflict of interests
None declared.
Funding
None.
Ethical approval
The use of patient data was carried out according to the policies
and procedures of the Istanbul University, Faculty of Dentistry, De-
partment of Oral Implantology. The patient gave written consent to
use the CT images for the purposes of this study.
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