RESEARCH

Influence of Implant Positions and Occlusal Forces on Peri-

Implant Bone Stress in Mandibular Two-Implant
Overdentures: A 3-Dimensional Finite Element Analysis
Angel Alvarez-Arenal, MD, DDS, PhD1*
Ignacio Gonzalez-Gonzalez, MD, DDS, PhD1
Hector deLlanos-Lanchares, DDS, PhD1
Aritza Brizuela-Velasco, DDS, PhD2
Elena Martin-Fernandez, DDS, PhD2
Joseba Ellacuria-Echebarria, MD, DDS, PhD4

The aim of this study was to evaluate and compare the bone stress around implants in mandibular 2-implant overdentures depending on
the implant location and different loading conditions. Four 3-dimensional finite element models simulating a mandibular 2-implant
overdenture and a Locator attachment system were designed. The implants were located at the lateral incisor, canine, second premolar,
and crossed-implant levels. A 150 N unilateral and bilateral vertical load of different location was applied, as was 40 N when combined
with midline load. Data for von Mises stress were produced numerically, color coded, and compared between the models for peri-implant
bone and loading conditions. With unilateral loading, in all 4 models much higher peri-implant bone stress values were recorded on the
load side compared with the no-load side, while with bilateral occlusal loading, the stress distribution was similar on both sides. In all
models, the posterior unilateral load showed the highest stress, which decreased as the load was applied more mesially. In general, the
best biomechanical environment in the peri-implant bone was found in the model with implants at premolar level. In the crossed-implant
model, the load side greatly altered the biomechanical environment. Overall, the overdenture with implants at second premolar level
should be the chosen design, regardless of where the load is applied. The occlusal loading application site influences the bone stress
around the implant. Bilateral occlusal loading distributes the peri-implant bone stress symmetrically, while unilateral loading increases it
greatly on the load side, no matter where the implants are located.

Key Words: overdenture, mandible, implants, locator attachments, bone stress, occlusal load

INTRODUCTION Furthermore, the old debate about how many implants are
necessary to retain mandibular overdentures seems to have

P
rosthetic rehabilitation of a totally edentulous mandible
been solved. The McGill and York international consensus
has always been a major challenge for dentists.
established that 2 interforaminal location implants are sufficient
Edentulous patients, with more or less severe mandib-
and are the minimum option to retain an overdenture with a
ular alveolar bone resorption, often relate functional and
good degree of stability and masticatory function.7,8 The dental
psychosocial problems with the use of a conventional denture
literature in recent years has supported this option, with an
associated with a lack of stability and denture retention.
overwhelming majority of studies supporting the proposal that
Currently, the high predictability and survival of dental implants
the 2-implant overdenture has become the preferred choice of
solve these problems, meaning the treatment of a fully
treatment for the edentulous mandible.9–15 Most clinical and
edentulous mandible using an implant-retained overdenture
biomechanical studies choose the interforaminal region,
has become a routine therapy. Thus, an overdenture retained by
especially at the canine level, as the preferred location for the
2 or more implants is a highly predictable treatment with implant
2 implants. However, other implant distributions are possible.
success and survival rates above 95.5%.1,2 This method also
Bone availability factors may require the clinician to place the
provides high levels of satisfaction, comfort, and quality of life for
implants near the mandibular symphysis (at the lateral incisor
patients compared with a complete conventional denture.3–6
level); biomechanical considerations related to the stress
transferred to the peri-implant bone and implant/attachment
1
Department of Prosthodontics and Occlusion, School of Dentistry, complex during overdenture movements may make it neces-
University of Oviedo, Spain. sary to place implants more distally, at the premolar level, or to
2
Department of Oral Stomatology I, Faculty of Medicine and Dentistry,
University of Basque Country, Bilbao, Spain.
combine one anterior and another contralateral posterior. At
* Corresponding author, e-mail: arenal@uniovi.es present there is insufficient scientific evidence available
DOI: 10.1563/aaid-joi-D-17-00170 regarding the effect of any of these locations on the

Journal of Oral Implantology 419

Mandibular Overdenture, Implant Positions, and Occlusal Forces
distribution of stress around implants. The lowest stress is
reported when implants are inserted in lateral incisor areas, and
this position is recommended,16 while other studies have found
lower stress levels with the implants at the first premolar site
compared with lateral incisor and canine sites.17 This question
requires clarification.
On the other hand, after loading and during masticatory
functional activities and parafunctional clenching and grinding,
complex occlusal forces of different intensity, location, and
direction occur. These forces are transmitted to the over-
denture, attachment/implant complex, and peri-implant bone.
When the stress/strain, transferred to the peri-implant bone as
a consequence of the occlusal forces, exceeds the physiological
adaptation limits, bone remodeling and resorption processes
are initiated, leading to bone loss around the implant. The
taking into consideration of the application site, direction, and
intensity of the occlusal force required to avoid overload and
bone loss becomes a matter of prime consideration for the
dentist when carrying out occlusal adjustment of an over-
denture. Although under discussion, the bilateral balanced
occlusion criteria are normally the recommended occlusal
scheme for overdentures.18–20 However, empirical clinical
practice shows that this is not the case, with a large number
of dentists completing a patient’s treatment with an over-
denture using other occlusal criteria or random occlusal contact
distribution that leads to the predominance of guides or
unilateral contacts. Such behavior can change the bone stress/
strain distribution and concentration around implants, resulting
in bone loss. Several biomechanical studies have tested the
effect on peri-implant bone stress of different attachment
designs, implant location, and unilateral or bilateral occlusal
load characteristics of a mandible overdenture.16,17,21–26 Most
of these studies, with unilateral load, relate higher peri-implant
bone stress on the load side compared with the contralateral
side16,21–24 and a more balanced distribution with bilateral
load.16,25,26 However, this information is not conclusive. With
the exception of one study that applies bilateral and unilateral
posterior load in 3 different implant positions,16 there is no
single study with sufficient data to clarify and compare the
effect on bone stress of unilateral and bilateral loads applied at
different points for 2 implants in different positions. More
information is needed to provide practitioners with information
about the implant and occlusal load locations that favor the
best biomechanical environment and thus enable them to
make appropriate clinical decisions. In agreement with the
aforementioned, the aim of this study was to evaluate and
compare the effect on bone stress around implants in
mandibular 2-implant overdentures depending on the implant
location and occlusal load application sites and to give dentists
a comparative insight into the influence of these factors.
MATERIALS AND METHODS
Finite element models design
Three-dimensional (3D) finite element models were created to
evaluate the bone stress distribution around implants in a
mandibular 2-implant overdenture retained by a self-aligning
attachment system. An arch structure was modeled to simulate
420 Vol. XLIII / No. Six / 2017
the symphysis and body of a fully edentulous mandible with
the following dimensions: 60 mm mandibular body length from
the middle line, 20 mm inferosuperior height, and 12 mm
buccolingual width. Bone quality type 2 was assumed in the
symphysis and type 3 in the mandibular body according to the
Lekholm and Zarb classification27 and 2 mm thick cortical bone
surrounding the cancellous bone. In addition, a threaded
implant was modeled, using as a reference the geometry of a
Stark D Active internal connection implant (Sweden & Martina,
Due Carrere, Italy), 4.2 mm body diameter, and 10 mm length.
Furthermore, a self-aligning attachment brand Locator (Zest
Anchor Inc, Escondido, Calif) was modeled, with abutment
(matrix) of 4 mm gingival height and metallic cap with nylon
insert (patrix). The matrix was screwed to the implant and the
patrix was attached to the overdenture.
The overdenture was a superstructure made of acrylic resin,
10.7 mm high and similar in shape, width, and length to the jaw
bone. Four different finite element models were created. The
Implants at Laterals model simulated an overdenture retained
by 2 implants placed at the lateral incisor level and with a
center-to-center separation of 15 mm. In the Implants at
Canines model, the centers of the 2 implants were separated by
27 mm. In the Implants at Second Premolars model, the
distance between centers was 53 mm (26.5 mm from the
mandibular midline). In the Crossed Implants model, one
implant was placed on the left side, 13.5 mm from the midline
(canine level), and the other in the contralateral arcade, 26.5
mm from the midline (second premolar level).
Material properties and interface conditions
The jaw bone and all the materials used in these models were
considered to be linearly elastic, homogeneous, and isotropic.
Values for elastic moduli and Poisson ratio of the bone and
different materials were taken from published data16,28,29 (Table
1). A continuous bone-implant interface, flawless and with
100% osseointegration, was assumed. All other interfaces
between the rest of the different materials and structures were
also assumed to be continuous (matrix-implant, patrix-matrix.
and patrix-overdenture). Moreover, a passive fit without friction
was assumed between the overdenture and the jaw bone,
without gingival mucosa interface.
Loading and boundary conditions
In the 4 models, a vertical occlusal bilateral or unilateral static
load of 150 N was applied under 6 different loading conditions.
The unilateral single load (150 N) was applied at midline, at the
left canine level, at the first left molar (10 mm from the distal
implant) and combined at midline (40 N) and first molar level
(150 N). The bilateral load was applied at the level of the first
molars (75 N on each side) and also combined with 40 N at
midline. The data for von Mises stresses were produced
numerically, and the stresses in the finite element analysis
were color coded to allow comparison of the biomechanical
differences between models.
All elements were modeled with Pro/Engineer Wildfire v4.0
(Parametric Technology Corp, Needham, Mass) software of
computer-aided design. The finite element models were
created and meshed using Ansys 11.0, a commercial 3D finite
 Alvarez-Arenal et al

TABLE 1
Mechanical properties of modeled materials and structures

Material Structure Young’s Modulus (GPa) Poisson Ratio References

Titanium Ti6Al4V Implant 135.00 0.30 Daas et al28
Titanium grade 4 Abutment and metallic cap attachment 114.0 0.30 Daas et al28
Acrylic resin Overdenture 2.94 0.30 Geng et al29
Nylon Insert plastic patrix attachment 2.55 0.30 Hong et al16
Cortical bone Peri-implant bone 13.70 0.30 Daas et al28
Trabecular bone Peri-implant bone 1.37 0.30 Daas et al28

element software (Ansys Inc, Canonsburg, Pa). In order to
generate the meshes, the following 4 different kinds of
elements were employed: 3D 10-node tetrahedral structural
solid, 3D 20-node structural solid, 3D 8-node surface-to-surface
contact, and 3D target segment. As a result, the smallest model
has 844 000 nodes and 97 003 elements while the largest has
964 132 nodes and 108 802 elements.
RESULTS
Table 2 shows the von Mises stress in the bone around implants
for each model and occlusal load application site. In all models,
when a unilateral load (at the canine level or first molar
location) or combined load (combination of unilateral first
molar and midline load) was applied, the highest peri-implant
bone stress values were recorded around the load-side implant,
with values that increased the peri-implant stress of the
contralateral implant between 2 and 6 times. However, a
symmetrical stress distribution on both sides was recorded with
midline unilateral load or bilateral first molar load or combined
bilateral first molar and midline position loads. In general, of all
the models, the best peri-implant bone biomechanical envi-
ronment was found in the premolar implant model, including
the crossed-implant model when applying the load on the side
of the implant placed at second premolar level. Even with this
model and loading site, with some exceptions, the stress values
were lower compared with the second premolar level implant
model. However, this crossed-implant model revealed the
worst biomechanical environment when occlusal load was
applied on the most mesial implant side at canine level. Lateral
incisor and canine level implant models revealed the next worst
biomechanical environment, with slight differences for each
occlusal load application site. On the load side and in all
models, unilateral load, except for midline load, showed the
highest peri-implant bone stress values compared with bilateral
posterior load alone or combined with midline load. With
certain exceptions, the data also showed a progressive
decrease in stress on the load side as the unilateral load was
applied more mesially. However, the combined unilateral
midline and posterior (first molar) load caused similar stress
values to those recorded with unilateral posterior load. In each
and every model, bilateral posterior load not only distributed
stress symmetrically but also generally revealed lower stress
values than in the case of unilateral load at any location, except
when applied at midline.
In general, regardless of the model and the load application
site, with unilateral load the stress was located in the peri-
implant crestal bone area of both implants, but with greater
stress concentration in the load-side implants, toward the
distal/distolingual implant area. This stress extended and was
dissipated toward the neck and first threads of the implant
body as well as to the alveolar bone located distally to the
implant. In the bone surrounding the implant apex, stress was
also recorded, especially in the load-side implants and in the
canine-level and crossed-implant models (Figures 1 through 4).
In all models, the midline load also showed stress in the most
distal areas of the support alveolar ridge bone. No significant
differences have been found in the stress distribution and
location with bilateral posterior load alone or combined with
midline. With the exception of the crossed-implant model,

TABLE 2
Von Mises stress (MPa) on the peri-implant bone stress for each overdenture model and occlusal load application site
Overdenture Models

Implant Laterals Implant Canines Second Premolar Implants Crossed Implants

Occlusal Load Application Site Right Side Left Side Right Side Left Side Right Side Left Side Right Side Left Side
Unilateral posterior (first molar) 10.80 37.82 16.50 35.84 2.25 15.74 12.18 43.89
Unilateral posterior right side 5.81 2.24
Unilateral canine 6.10 28.25 4.39 24.17 3.08 6.15 9.35 30.36
Unilateral canine right side 2.67 6.94
Unilateral anterior (midline) 11.12 11.12 10.05 10.05 18.29 18.29 11.61 8.94
Unilateral posterior and midline 11.10 38.65 16.53 35.89 2.41 11.25 16.53 42.87
Unilateral posterior and midline right side 1.88 4.88
Bilateral posterior 26.38 26.38 26.37 26.37 9.00 9.00 6.85 22.21
Bilateral posterior and midline 27.14 27.14 26.46 26.46 4.63 4.63 8.17 21.21

Journal of Oral Implantology 421

Mandibular Overdenture, Implant Positions, and Occlusal Forces
FIGURE 1. Peri-implant bone stress location in second premolar level implant overdenture model according to the application load site. (a–
c) Left posterior unilateral load. (d–f) Unilateral midline load. (g–i) Unilateral load at left canine level.
which showed the highest stress concentration in the most
mesial implant at canine level, in all other models stress was
located symmetrically in the peri-implant crestal bone area of
both implants, with the highest concentration toward the
distolingual area. This bone stress spread and dissipated, as
with the unilateral load, to the implant neck, a coronal third of
the implant body, and the alveolar bone located distally to the
2 implants, except in the case of the premolar model, which did
not show this distal stress extension. With this load, the bone
surrounding the implant apex also registered stress (Figures 1
through 4).
DISCUSSION
Using 3D-Finite Element Analysis, this study evaluated bone
stress distribution around implants in mandibular overdentures
retained by 2 implants at different locations, applying unilateral
422 Vol. XLIII / No. Six / 2017
or bilateral occlusal load in several places. When dentists plan a
mandibular overdenture design, the choice of the number and
position of implants in the mandible is an important decision
that can limit the survival of the restoration. The question of
whether there is an optimal number of implants for retaining a
mandibular overdenture has been under discussion for many
years. Recent clinical literature reviews9,30 show that there is
overwhelming evidence to support the McGill and York
consensus proposals, which state that 2 implants should
become the first choice of treatment. Furthermore, randomized
controlled trial results evaluated by means of meta-analyses
show minimal differences in implant loss risk and average peri-
implant bone loss between the use of 2 or 4 implants,30
although none of these trials used the Locator attachment
system. These data may lead the dentist to choose 2 implants.
However, the location of the 2 implants in the mandible that
provide the best biomechanical environment and survival is still
an unresolved question.

FIGURE 2. Peri-implant bone stress location in second premolar level implant overdenture model according to the application load site. (a–
c) Left unilateral posterior and midline combined loads. (d–f) Posterior bilateral load. (g–i) Midline and bilateral posterior combined loads.
In a fully edentulous patient, the anterior mandible tends
to have substantial residual alveolar bone; thus, it is the most
favorable site for implants. Despite the heterogeneity of
different clinical studies, placing 2 implants in the canine area
is common. Although other options are possible, no clinical
and very few biomechanical studies16,17 have as yet reported
data comparing clinical outcomes or stress/strain distribution
related to 2 implants in different positions for mandibular
overdentures. This makes it more difficult for dentists to
decide. In the present study, for most applied loads, the worst
biomechanical environment was found with the lateral incisor
and the crossed-implant overdenture models with maximum
peri-implant bone stress levels of 38.65 MPa and 43.89 MPa,
respectively. Although these stress values (equivalent to
approximately 1850 and 2200 microstrains, assuming that 1
MPa equals to 50 microstrains) are below the physiological
tolerance threshold of bone31,32 clinicians should not risk
placing the 2 implants in the incisal area. However, this is a
Alvarez-Arenal et al
controversial issue. Data from other biomechanical studies16,17
support the advantage of placing implants in the lateral
incisor areas, as they show less peri-implant bone stress
compared with 2 implants placed more posteriorly. Addition-
ally, anatomical features related to a higher trabecular bone
ratio and thickened cortical bone33,34 and recommendations
related to mechanical advantages of lower posterior rotation
and greater area of denture/mucosa contact that reduce
implant stress16,28,35 have been reported to support this
option. However, taking into account the data from the
present study on stress distribution, the position of the 2
implants in the mandible is an important variable; the second
premolar level is the best biomechanical environment site,
worsening as the implants become more mesial, whether
bilateral or unilateral load is applied. The exception is when
the load is applied at the midline, perhaps due to a greater
length of the lever arm and increase in the bending moment.
While this trend does not agree with findings of other
Journal of Oral Implantology 423
Mandibular Overdenture, Implant Positions, and Occlusal Forces

FIGURE 3. Peri-implant bone stress location in canine-level implant overdenture model according to the application load site. (a–c) Left
posterior unilateral load. (d–f) Unilateral midline load. (g–i) Unilateral load at left canine level.

biomechanical studies,16,17 the results support the placement
of 2 implants in the premolar area to retain a mandibular
overdenture.
At the same time, the main causes of bone loss around
implants are mechanical factors (occlusal overload), biological/
infectious events (peri-implantitis), or a combination of both.
During chewing, complex force patterns of varying magnitude,
direction, and application site occur, transferring stress to the
overdenture, attachment/implant/bone system, and alveolar
ridge without the dampening effect of the periodontal
ligament. Moreover, as found in patients,36 the overdenture
moves and rotates around one or more rotation axes that can
change, causing lever arms and bending moments that may
increase the stress around implants. Clinicians should pay
attention to occlusal harmony control to prevent overload and
excessive movement of the denture and so minimize the peri-
implant bone stress. This study supports the balanced occlusal
scheme for the 2-implant supported mandibular overdentures.
Data show that the bilateral posterior loading and unilateral
loading at the incisor level transfer at similar relatively low peri-
implant bone stress levels to each implant, whereas the
unilateral load exhibits high peri-implant bone stress levels in
the load-side implants and substantial stress differences with
respect to the no-load side. This is a constant reported in
numerous different biomechanical designs of 2-implant sup-
ported mandibular overdentures,16,21,23,24,28,37 and it provides
another argument for recommending that dentists use an
occlusal adjustment with the bilateral balanced occlusion
scheme and patients chew on both sides simultaneously.
When a unilateral load is applied, an overdenture anchored by

424 Vol. XLIII / No. Six / 2017


FIGURE 4. Peri-implant bone stress location in canine-level implant overdenture model according to the application load site. (a–c) Left
unilateral posterior and midline combined loads. (d–f) Posterior bilateral load. (g–i) Midline and bilateral posterior combined loads.
2 implants rotated over the implant from one side to another,
bending randomly to the load side and away from the no-load
side, causing bending moments in the implant/bone complex
with the bending plane orientation varying according to the
load situation,28 all of which increases the stress on the load
side. Furthermore, when a vertical unilateral load is applied in
mandibular posterior areas, it might cause a denture base
mesial movement that could result in greater bone stress/strain
throughout the distal area of the load-side implant.37 In any
case, the resilient configuration of the Locator attachment
could dampen this excess stress for any unilateral load location,
causing a rocking motion in the lower denture base. In
addition, a greater vertical displacement occurs, leading to
greater contact surface compression between denture and
mucosa, thus decreasing the implant/bone system stress. The
special dual-retention mechanism of these self-aligning attach-
ments, compared with other resilient ball-type attachments,23
would favor the phenomena described.
Since the loading site is an important factor that affects the
Alvarez-Arenal et al
stress distribution throughout the system,17 the behavior in this
study of the midline load that would simulate the action of
cutting food with incisor teeth requires some clarification. With
this load, the data show low stress values compared with any
other unilateral or bilateral applied load, and they further show
symmetrical stress distribution on both sides for any implant
location, especially those placed in canine and lateral areas.
Although this result suggests a better biomechanical environ-
ment with incisal level load with implants placed at lateral
incisor or canine levels and could influence the clinical decision
to promote contacts in the anterior teeth during occlusal
adjustment, it must be taken with caution. With design
differences, meaning the data are not exactly comparable,
several biomechanical studies17,23,28 report similar results, while
others show greater peri-implant bone stress with anterior
midline load compared with unilateral and bilateral load at a
more posterior location.21,24
As reported in all biomechanical studies, regardless of
independent variables of the design, this study also found that
Journal of Oral Implantology 425
Mandibular Overdenture, Implant Positions, and Occlusal Forces
the peri-implant stress location and distribution in the crestal
bone surrounding the neck and first threads of the implant is a
constant for any type of load and model. This fact is explained
by the complex beam analysis mechanical principle, which says
that when 2 bodies with very different moduli of elasticity (eg,
bone/implant titanium) come into contact, the highest stress is
located at the beginning of the contact surface. It is widely
known that the pattern of resorption and peri-implant bone
loss reported in clinical studies matches the aforementioned
biomechanical stress concentration location. In this study the
distal or distolingual peri-implant areas were the main sites of
compressive or tension stress concentration, making them the
most likely areas for bone loss. This is similar to what has been
reported in other biomechanical studies regarding overden-
tures with different designs and attachments.16,38–40 However,
other different locations are cited for buccal or lingual,
depending on the compressive or tensile stress nature22,23,41,42
or for mesial with Locator attachments and 2 anterior-level
implants.24,37 As in previous studies,43–45 stress is also recorded
in the implant apex bone, more often on the load side and with
greater concentration in implants in the canine area. This can
be explained by a fulcrum effect in the attachment/implant
system caused by a load applied near the attachment, which
tends to compress the apical area. In any case, apical stress can
induce bone resorption or alter vascular apical flow, thereby
affecting the modeling and remodeling bone processes, even
leading to bone necrosis.
Furthermore, knowing the stress distribution pattern on the
alveolar ridge becomes an important issue, given that just over
half (63%) of the posterior bilateral load (simulating mastica-
tion) in an overdenture is transferred to the mucosa/alveolar
bone,46 added to the fact that resilient attachments, such as the
Locator, can occupy a greater denture/mucosa contact area
than rigid ones can.28 All of this favors less peri-implant bone
stress. In this study, regardless of the bone stress around
implants, the highest alveolar ridge bone stress concentration
and extent were found in the posterior mandible regions, more
frequently with unilateral load in all models but especially in
lateral and canine level implant models. Although this result
shows a possible reduced risk of peri-implant bone loss
through an increase in the denture/alveolar bone contact area,
based on the remaining data this implant and load position
cannot be recommended as that of the lowest biomechanical
risk for a mandibular overdenture. This is also supported by the
fact that similar stress distribution has been reported with
different occlusal loading conditions25,46 or different stress
location in the anterior alveolar ridge between the 2
attachments.24,28
On the other hand, the variability in biomechanical studies
regarding the intensity, angle and position of the occlusal load,
location and inclination of the implants, type and height of
attachments, and overdenture and mandible designs makes it
difficult to compare data between such studies in a way that
allows us to choose the implant and load position offering the
lowest biomechanical risk. It is therefore necessary to stan-
dardize these factors.
Finite element analysis is a widely employed method in
dentistry to estimate the stress/strain distribution in peri-
implant bone, prostheses and prosthetic components in many
426 Vol. XLIII / No. Six / 2017
diverse situations. However, with a mathematical and compu-
tational model it is not possible to model and simulate all
prosthetic restoration, ground support, masticatory function,
and oral environment design features and responses. It is
necessary, therefore, to assume a number of simplifications
related to material properties, geometry, interface, load, and
contour conditions, which are limitations that mean the data
obtained do not correspond exactly to the clinical results, they
are only an approach to the clinical situations. So when this
method is used, a qualitative comparison between models and
variables is recommended rather than a focus on quantitative
data. Material properties and structure geometries have a great
influence on the stress/strain distribution, but as in similar
studies,23,24,16 it was assumed that all materials were homoge-
neous and linearly isotropic. It was also assumed that the
interfaces between different materials and structures were
continuous and had a passive fit without any friction; in clinical
reality this is not so and can be a limitation.
A curved overdenture of uniform height and thickness was
modeled, as was a jaw of similar uniform morphology but
different dimensions, without gingival mucosa interface,
condylar anchorage, or other restrictions on movement;
although these factors may be a limitation, they will not
influence the attachment stress distribution because these
structures remained constant for all models and loading. In
accordance with Liu,24 the plastic insert of the matrix was made
of nylon (polyamide); polymethylmethacrylate was used in
another study.23 Although the elastic properties are not very
different, the differences in stiffness between the 2 materials
may influence the attachment/implant/bone system stress
distribution. Several different studies show how plastic matrices
of different stiffness influence the stress transfer to the
attachment/implant/bone system or residual ridge.26,28,38,41
This may be a limitation and should be taken into consider-
ation. During chewing, complex force patterns of variable
magnitude and direction take place, from one area of the
mouth to another and between subjects, which is impossible to
mathematically reproduce and simulate. In this study, a 150 N
vertical force was applied, which is considered an occlusal load
very close to masticatory forces and similar to that used other
overdenture finite element analysis studies.39,47,48 Also, since
contacts between all teeth are established during mastication
and an overdenture can combine straight and angled implants
or abutments, a strictly vertical load design of unilateral or
bilateral posterior location may be a limitation that the clinician
should consider when comparing and discussing the clinical
implications of a finite element analysis. Although unilateral
and bilateral occlusal load combinations are cited in some
studies,16,22–26, the dental literature concerning overdenture
and finite element analysis reports a great variability in the
direction, application site, and magnitude of occlusal loads,
which per se is a limitation for the comparison of results; it is
therefore necessary to standardize these factors.
CONCLUSIONS
In accordance with the results and within the limitations of a
finite element analysis, the following conclusions may be
drawn. (1) Overall, the worst biomechanical environment in the

bone around implants was registered in the overdenture model
with implants at lateral incisor level, which means this model
cannot be recommended. (2) Overall, the second premolar level
implant overdenture should be the chosen design, regardless
of the load application site. (3) If a crossed-implant overdenture
model is chosen, this must be used together with occlusal load
on the most distal implant side to provide a better environment
compared with other models. (4) Since the application load site
influences the stress, when occlusal adjustment of an over-
denture is made, clinicians should be aware that bilateral
occlusal load distributes the peri-implant bone stress symmet-
rically while the one-side load increases it greatly on the loaded
side, whatever the implant situation.
ABBREVIATIONS
3D: 3-dimensional
ACKNOWLEDGMENTS
The authors wish to thank Sweden & Martina and Nisa-Tet SL
for providing the materials used in the modeling and Dr
Fernando Sanchez-Lasheras, who provided the computer-aided
design data for the finite element analysis.
NOTE
The authors declare that they have no proprietary, financial,
professional, or other personal interest of any kind in any
product, service, and/or company that could be construed as
influencing the position presented in the manuscript.
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