Implant-bone load transfer mechanisms

in complete-arch prostheses supported

by four implants: A three-dimensional
finite element approach
Luigi Baggi, DDS,a Simone Pastore, MS,b Michele Di Girolamo,
DDS,c and Giuseppe Vairo, MS, PhDd
University of Rome Tor Vergata, School of Dentistry and School
of Medical Engineering, Rome, Italy

Statement of problem. Complete-arch restorations supported by fewer than 5 dental implants can induce unbalanced
load transfer and tissue overloading, leading to excessive bone resorption and possible clinical failure. This is primarily
affected by the cantilever length, the implant design and positioning, and the morphology and properties of the bone.

Purpose. The purpose of this study was to compare 2 different restorative techniques for complete-arch rehabilita-
tions supported by 4 implants. The primary purpose was to highlight the possible risks of excessive stress and unbal-
anced load transfer mechanisms and to identify the main biomechanical factors affecting loading transmission.

Material and methods. Three-dimensional (3D) numerical models of edentulous maxillae and mandibles restored
with 2 techniques using 4 implants were generated from computed tomography (CT) images and analyzed with linear
elastic finite-element simulations with 3 different static loads. The first technique used 2 vertical mesial implants and
2 tilted distal implants (at a 30 degree angle), and the second used vertical implants that fulfilled platform switching
concepts. Bone-muscle interactions and temporomandibular joints were included in the mandibular model. Complete
implant osseous integration was assumed and different posthealing crestal bone geometries were modeled. Stress
measures (revealing risks of tissue overloading) and a performance index (highlighting the main features of the load-
ing partition mechanisms) were introduced and computed to compare the 2 techniques.

Results. Dissimilar load transfer mechanisms of the 2 restorative approaches when applied in mandibular and maxil-
lary models were modeled. Prostheses supported by distally tilted implants exhibited a more effective and uniform
loading partition than all vertical implants, except in the simulated maxilla under a frontal load. Tilted distal implants
reduced compressive states at distal bone-implant interfaces but, depending on bone morphology and loading type,
could induce high tensile stresses at distal crests. Overloading risks on mesial periimplant bone decreased when the
efficient preservation of the crestal bone through platform switching strategies was modeled.

Conclusions. Numerical simulations highlighted that the cantilever length, the implant design and positioning, and
the bone’s mechanical properties and morphology can affect both load transmission mechanisms and bone over-
loading risks in complete-arch restorations supported by 4 implants. Distally tilted implants induced better loading
transmission than vertical implants, although the levels of computed stress were physiologically acceptable in both
situations.(J Prosthet Dent 2013;109:9-21)

Clinical Implications
Within the limitations of this study, the biomechanical rationale for
using tilted distal implants to reduce cantilever mechanisms was
that, generally, they contributed to favorable load transmission and
a low risk of compressive overloads.

a
Associate Professor, INMP Department of Social Dentistry and Gnathological Rehabilitation.
b
Postgraduate student, School of Mechanical Engineering.
c
Assistant Professor, School of Medical Engineering.
d
Assistant Professor, School of Dentistry.
Baggi et al
10
Currently, the complete-arch re-
habilitation of edentulous jaws is
achieved by threaded endosseous
implants, and many protocols and
guidelines are available to those in
clinical practice.1,2 Each technique
is characterized by a specific healing
period, and the success rate is influ-
enced by patient-dependent morpho-
logical and biological conditions.3
Poor bone quality and quantity in
the molar regions, especially in eden-
tulous individuals, means that com-
plete-arch restorations generally re-
quire dental implants to be placed in
the anterior region, often resulting in
long cantilevered prostheses. The use
of long posterior cantilevers can be
directly related to the possible over-
loading of the periimplant regions.4-6
Therefore, high stress concentrations
at bone-implant interfaces may pro-
duce physiologically inadmissible
strains which then activate biologi-
cal bone resorption.7-9 Consequently,
depending on implant geometry and
placement,10 periimplant bone weak-
ening/loss and cratering can occur,
leading to possible implant failure.11-14
Clinical evidence suggests that the
cratering phenomena can be limited
when platform switching strategies
are applied.15-17 Recently, restorative
systems using tilted distal implants
have been proposed18-23 to reduce the
posterior cantilever.
Currently, 2 of the most common-
ly used systems for complete-arch
immediate loading rehabilitation of
edentulous jaws are based on the All-
on-4 (Nobel Biocare AB, Göteborg,
Sweden) and SynCone (Dentsply
Friadent, Mannheim, Germany) con-
cepts.24-26 Both systems use threaded
implants placed in the anterior region
and allow the rehabilitation of 12 to
14 teeth per arch. The All-on-4 pro-
tocol is based on 2 vertical mesial
implants and 2 tilted distal implants,
distally angled with respect to the
vertical direction of between 30 and
45 degrees. In this treatment, im-
plants are crestally positioned, and
significant cratering effects generally
occur. When the SynCone protocol
The Journal of Prosthetic Dentistry
is applied, implants are all vertical
and are designed and positioned fol-
lowing platform switching concepts.
Accordingly, a significant reduction
of crestal bone loss is expected, but
when implants are placed in the an-
terior region, a longer posterior can-
tilever is generally needed for com-
plete-arch rehabilitations. The clinical
effectiveness and reliability of these
techniques have been examined in a
number of recent studies showing the
results of both in vivo and follow-up
analyses.24,27-31 Nevertheless, the in
vivo assessment of stress and strain
distributions in the bone is difficult
in clinical practice.32,33 Therefore, a
numeric approach able to evaluate
stresses and strains induced in the peri-
implant regions could facilitate the con-
trol of those design parameters that af-
fect load transfer and overloading risk,
thereby optimizing the durability and
effectiveness of the rehabilitation.
Recently, finite element approaches
have been used successfully in prosthetic
dentistry to analyze the influence of me-
chanical and biological factors,10,34-38
and to improve many clinical treat-
ments. Numerical studies have analyzed
some effects of tilted implants and the
influence of the posterior cantilever
length.39,40 Moreover, examples of All-
on-4 applications have been simulated
through simplified numerical models.41-44
However, some biomechanical aspects
related to cantilever and tilted implants
are not completely understood.
In this study, stress-based perfor-
mances of complete-arch restorations
supported by 4 implant using All-on-4
and SynCone concepts were investi-
gated by means of a three-dimensional
(3D) finite element (FE) approach. A
numeric method able to analyze 3D
patient-based models of restored
jaws was developed and applied to
compare the 2 techniques when used
in edentulous jaws (both maxilla and
mandible). The load transmission
mechanisms and the risks of bone
overloading were evaluated by using
linear elastic static simulations that
accounted for different posthealing
crestal bone morphologies.
Volume 109 Issue 1
MATERIAL AND METHODS
Two different approaches to the
rehabilitation of completely edentu-
lous arches with endosseous implants
placed in the anterior region were
analyzed and compared. The first
(denoted as A4) was based on the
All-on-4 concept and used 4 Nobel-
Speedy Groovy implants (Nobel Bio-
care AB). The second (denoted as SC)
applied the SynCone system with 4
Ankylos implants (Dentsply Friadent).
The main geometric properties of
trapezoidal-threaded implants used
for defining numeric models relevant
to SC and A4 (Fig. 1) are summarized
in Table I. Both systems used 2 central
implants (mesial) placed vertically
and 2 lateral implants (distal). The
distal implants were vertically placed
in SC and distally tilted in A4 at a 30
degree angle in the plane orthogonal
to the buccolingual direction. In A4
different abutments by Nobel Bio-
care (Multi-unit Abutments for ver-
tical implants, 30 degree Multi-unit
Abutments for tilted implants) were
considered, and a fixed connection
with the prosthetic bar was modeled.
For Ankylos implants (SC) the abut-
ments were modeled in accordance
with the platform switching concepts,
and the abutment-bar connection was
assumed to be achieved by telescopic
crowns.
Implant models were fitted into
the models of complete bone arches,
defined by disregarding gingival soft
tissues and distinguishing cortical
and trabecular bone regions (Fig. 1).
In the mandible model, the articu-
lar disks of the temporomandibular
joints were modeled with 2 thin re-
gions mated with condyles. The max-
illa was modeled by considering the
maxilla process up to the cortical
bone at the anterior-nasal-spine level
(Fig. 1). The axes of mesial implants
were identically placed in both SC and
A4, and implant lengths were chosen
such that the in bone depth was ap-
proximately 11 mm. Tilted distal im-
plants in A4 were positioned such
that their in-bone ends belonged to
Baggi et al
January 2013 11

1 Three-dimensional (3D) numerical models of both mandibular and maxillary jaws equipped with rehabilitative
devices based on All-on-4 and SynCone concepts (c: cantilever length). Maxillary model was delimited in upper re-
gion by 2 planar cutting surfaces separated by nasal cavity. Prosthetic bar was modeled as 3 mm thick, 5 mm deep,
and 65.8 mm long. Left: cyan colored regions (inner regions of jaw models) correspond to trabecular bone tissue;
yellow colored regions (outer regions) correspond to compact bone.

Table I. Main geometrical parameters defining implants and rehabilitative

techniques analyzed in this study (SC: SynCone-based; A4: All-on-4). When
necessary, values in square brackets refer to mandibular model and values
in round brackets refer to distal implants. Notation refers to Figure 2:  is
implant length; d denotes implant maximum diameter; p is average thread
pitch; t is average thread depth; L1 denotes distance between mesial implants
(CL and CR, Fig. 2); L2 is distance between distal implants (L and R, Fig. 2); c
is cantilever length
 d p t L1 L2 c
(mm) (mm) (mm) (mm) (mm) (mm) (mm)

SC 9.5 3.5 0.9 0.45 12.0 [16.0] 29.0 [31.0] 15.0

A4 11.5 (15.0) 4.0 0.6 0.2 12.0 [16.0] 35.0 [38.0] 5.0

the vertical axes of the distal implants
in SC (Fig. 2). Because of the different
bone morphology, distances among
implants in the mandible and maxilla
were assumed to be different (Table
I). The 4-implant-supported pros-
thetic bar was modeled by consider-
ing a pseudo-parabolic middle-line
geometry (Fig. 1), and models of bar
Baggi et al
and abutments were arranged so that
the bar-bone distance was 5 mm in all
models. In a given jaw, the bar model
was the same for the 2 techniques,
and a cantilever scheme 5 mm long
for A4 and 15 mm for SC was chosen
(Table I).
To describe the physiological bone
structure after a period of healing
and function realistically, crestal bone
geometries were adapted to match
well-established clinical observations
of crestal bone loss and remodeling
(Fig. 3).10,45-47 For Nobel Biocare im-
plants a cratering morphology with a
mean crestal bone loss of about 45%
in thickness was modeled. For Anky-
los implants, because of the platform
12 Volume 109 Issue 1

B
2 Implant positioning in maxillary (on left) and mandibular (on right) models. A, SynCone-based tech-
nique using Ankylos implants. B, All-on-4 technique using Nobel Biocare implants (: implant length; d:
implant maximum diameter; p: average thread pitch; t: average thread depth; L1: distance between mesial
implants; L2: distance between distal implants; L: left implant; CL: central-left implant; CR: central-right
implant; R: right implant).

3 Geometric modeling of posthealing crestal bone morphology in functioning implants. Comparison

between local bone configurations obtained after virtual implant positioning (that is, obtained by merging
implant and bone models) and posthealing models (depending on implant shape and placement) used for
numerical simulations.

The Journal of Prosthetic Dentistry Baggi et al

January 2013 13

Table II. Elastic constants adopted for 3D finite element

analyses (E: Young modulus, : Poisson ratio)
Material Region E (GPa) ν

Titanium alloy34,48 Implants 114.0 0.34

34,48
Gold alloy Prosthetic bar 105.0 0.23
10,49
Cancellous bone Mandible 1.0 0.3
Maxilla 0.5 0.3
10,49
Cortical bone Mandible and maxilla 13.7 0.3
50
Soft tissue Articular disks (Mandible) 0.006 0.4

switching configuration and subcrest-
al positioning, a lower crestal bone
loss (about 20% in thickness) and a
bone layer apposition 0.3 mm thick
were modeled.
Models of implants and prosthetic
bars were developed by using a para-
metric computer-aided design (CAD)
software (SolidWorks 9; Dassault Sys-
temes, Concord, Mass), whereas 3D
jaw models were reconstructed from
computed tomography (CT) images
by using a commercial tool (Mim-
ics10.1; Materialise Dental NV, Leu-
ven, Belgium) that allowed the identi-
fication of the cortical and trabecular
bone regions (Fig. 1). Discrete FE
meshes were generated by using 10-
node quadratic tetrahedral elements
with 3 degrees of freedom per node
and were analyzed with a commercial
code (ANSYS 11.0; ANSYS Inc, Can-
onsburg, Pa). As a result of a prelimi-
nary convergence analysis, the mean
value of the mesh size was set to ap-
proximately 1 mm from the bone-im-
plant interfaces and to approximately
0.2 mm at the periimplant regions
(Fig. 1).
Materials were assumed to have a
linear elastic isotropic behavior (Table
II),10,34,48-50 and all material volumes
were considered as homogeneous.
Mandibular tissues were approximat-
ed by a quality-II bone,51 and the max-
illary trabecular bone was assumed to
be less dense than that of the mandi-
ble, resulting in a smaller value of the
Young modulus.49
Displacement functions were as-
sumed to be continuous at all pos-
Baggi et al
sible interfaces among contiguous
volumes, and the complete implant
osseous integration was modeled ac-
cordingly. Models of the restored jaws
were constrained by enforcing zero-
displacement conditions for all nodes
belonging to the upper surfaces of the
articular disks in the mandible and for
all nodes belonging to the virtual cut-
ting surfaces in the maxilla (Fig. 1).
Three different static loads were
considered in the FE analyses. The
first (Load 1) was a complete-mouth
loading, defined as a uniformly dis-
tributed intrusive vertical load acting
upon the free surface of the pros-
thetic bar and with a resultant value
of 300 N. The second (Load 2) was
a cantilever load, defined as a distal
concentrated load applied at the end
of the right cantilever, and the third
(Load 3) was a frontal load, defined
as a concentrated load applied at the
midspan of the central part of the bar
between mesial implants. The forces
which defined Loads 2 and 3 consisted
of an intrusive vertical component of
250 N and of a horizontal one (along
the buccolingual direction) of 100 N.
Muscular forces were included only
in the mandibular model, accounting
for masseter, temporalis, and internal
pterygoid muscles.52 Depending on the
loading type, the muscle-bone interac-
tions were modeled for each muscle
by considering a uniformly distributed
load that acted upon the muscle-bone
connection surface (Fig. 4, Table III).
Jaw models treated by using SC
and A4 were numerically compared
by analyzing stress distributions at
the simulated periimplant regions.
The von Mises equivalent stress (VM),
often used in numerical dental stud-
ies,10,34-44 was used as a global stress
indicator to characterize load transfer
and partition mechanisms. Since the
von Mises stress measure does not al-
low a distinction between tensile and
compressive local stresses, more ef-
fective and direct indications of pos-
sible overloads were obtained by ana-
lyzing principal stress measures.10,34
Accordingly, maximum compressive
(C) and maximum tensile (T) prin-
cipal stresses were used as local risk
measures of bone-implant interfacial
physiological failure or of the activa-
tion of the resorption process. There-
fore, periimplant areas where VM at-
tains high mean values correspond to
implants that transfer a great amount
of the load, whereas high local peaks
of C and/or T denote a possible risk
of local overloading. Assuming the ul-
timate bone strength as a physiologi-
cal limit, local overloading at cortical
bone occurs in compression when C
exceeds 170 to 190 MPa, in tension
when T exceeds 100 to 130 MPa,
and at trabecular bone when T or C
exceeds 5 MPa.9,10,34,49 FE-based stress
solutions were postprocessed by using
a custom-made procedure. For each
implant, mean and peak values of VM,
C, and T were computed at the tra-
becular (t) and compact (c) periim-
plant control regions, defined by con-
sidering bone layers of about 1 mm in
thickness surrounding the implant.
To analyze the loading partition
mechanisms, a performance index,
14 Volume 109 Issue 1

4 Mandibular bone surfaces that modeled bone-muscle connection areas considered for muscular force distributions.

Table III. Components of resultant muscular forces acting upon mandibular

model, referred to Cartesian frame introduced in Figure 4 and to loading situa-
tions under investigation.52 Values in (respectively, not in) parentheses indicate
force components acting upon corresponding muscle-bone connection sur-
faces at x > 0 (respectively, x < 0)

Masseter Temporalis Pterygoid

Comp. x y z x y z x y z
Load (N) (N) (N) (N) (N) (N) (N) (N) (N)

1 20.0 -31.8 82.8 9.7 19.4 77.8 -20.6 -12.5 35.7

(-20.0) (-31.8) (82.8) (-9.7) (19.4) (77.8) (20.6) (-12.5) (35.7)
2 20.0 -31.8 82.8 9.7 19.4 77.8 -20.6 -12.5 35.7
(-13.2) (-21.0) (54.6) (-8.2) (16.3) (65.3) (13.9) (-8.4) (24.1)
3 20.9 -33.3 86.6 16.8 33.5 134.1 -19.0 -11.4 32.8
(-20.9) (-33.3) (86.6) (-16.8) (33.5) (134.1) (19.0) (-11.4) (32.8)

denoted as the partition ratio P, was
introduced. For an assigned load and
on a given jaw, the index was defined
as (where P is a value
between 0 and 1), and was comput-
ed for each implant and for each re-
habilitative technique in both c and
t. For a given control region (c or
t), denotes the mean value of
VM around a given implant in that re-
gion and is the maximum value
among all values of computed
for all implants in both rehabilitative
techniques. Thereby, one prosthetic
treatment can provide better load
transmission than another if the cor-
responding values of P are more uni-
formly distributed among implants.
RESULTS
Figures 5 and 6 show the distribu-
tions of VM computed at each periim-
The Journal of Prosthetic Dentistry
plant bone region, Figure 7 shows the
values of the partition index P, and
finally Figures 8 and 9 depict mean and
peak values of C and T obtained nu-
merically at the bone-implant interfaces.
Numerical simulations highlighted
that stress concentration areas were
located at the cortical bone around
the implant necks and that Load 2
was the most severe, producing the
highest values of all stress measures
at the right periimplant interfaces.
Except in the simulated maxilla under
Load 3, A4 produced patterns of VM
more homogeneous and with smaller
values than SC. This was confirmed by
analyzing the values of the partition
index P. In the mandibular model, the
greatest differences in P values were
experienced at the right implant in the
case of Load 2 (PA4 was smaller than
PSC by about 18% in c and 60% in t)
and at the distal implants for Loads
1 and 3 (PA4 was smaller than PSC by
about 15% to 22% inc and about 30%
in t). In the maxillary model and for
Load 2, the greatest differences in P
values were again at the right implant
(PA4 was smaller than PSC by about 56%
in c and 51% in t), whereas a dif-
ferent behavior with the mandibular
model was computed for Loads 1 and
3. For the maxillary model under Load
1, distal implants in SC transferred
the greatest amount of the load (me-
sial PSC was smaller than distal PSC by
about 70% to 80%), whereas in A4 the
load was more uniformly distributed,
with a slightly greater load transferred
by the mesial implants (distal PA4 was
smaller than mesial PA4 by about 5% to
10% inc and 45% to 50% in t). On the
contrary, for the maxillary model under
Load 3, A4 performed worse than SC,
resulting in higher and less homoge-
neous P values (the difference between
Baggi et al
January 2013 15

5 Mandibular model. Von Mises stress contours (blue: 0; purple: 40 MPa) at each periimplant bone region for dif-
ferent simulated loads and referred to plane containing implant axis and orthogonal to buccolingual direction.

6 Maxillary model. Von Mises stress contours (blue: 0; purple: 40 MPa) at each periimplant bone region for differ-
ent simulated loads and referred to plane containing implant axis and orthogonal to buccolingual direction.

Baggi et al
16 Volume 109 Issue 1

P P
1.00 1.00

0.75 0.75

Load SC A4
0.50 1 0.50 Load SC A4
2 1
3 2
0.25 0.25 3

0.00 0.00
L CL CR R A L CL CR R B
P P
1.00 1.00
Load SC A4
1 Load SC A4
2 1
0.75 0.75 2
3
3

0.50 0.50

0.25 0.25

0.00 0.00
L CL CR R C L CL CR R D
7 Loading partition index P computed for both SC (SynCone-based, filled symbols) and A4 (All-on-4, unfilled sym-
bols) in mandibular and maxillary models and under different loads (Load 1: complete-mouth loading, dark blue sym-
bols; Load 2: cantilever load, black symbols; Load 3: frontal load, light blue symbols; L: left implant; CL: central-left
implant; CR: central-right implant; R: right implant). Values for A, cortical bone in mandibular model; B, trabecular
bone in mandibular model; C, cortical bone in maxillary model; D, trabecular bone in maxillary model.

mesial and distal PSC-values was smaller
than that in A4 by approximately 50%
to 60%, with the highest values of PSC-at
the mesial implants-smaller than those
of PA4 by about 40% to 50%).
The principal stress measures
computed in c under loads 1 and 3
were greater in the mandibular model
than in the maxillary one; these were
almost similar for Load 2. The oppo-
site occurred in t. Peaks and mean
values of C computed in A4 under
loads 1 and 3 were smaller than those
in SC (up to 40 to 50%) in the distal
c (both in mandible and maxilla) but
produced higher values (up to 90% to
The Journal of Prosthetic Dentistry
100%) of C in the maxillary model
at mesial t. Furthermore, tilted im-
plants in A4 produced higher peaks
and mean values (up to 180% to
200%) of T in c than SC, especially
in the mandibular model. For all the
simulated situations and within the
limitations of this study, the principal
stress measures computed never ex-
ceeded the physiological limits intro-
duced for the cortical bone, whereas
the strength value in compression for
the cancellous bone was slightly ex-
ceeded around the mesial implants in
the A4-based maxillary model under
Load 3 and around the right implant
in the SC-based mandibular model
under Load 2.
DISCUSSION
This numerical study has shown
that the 2 complete-arch rehabilita-
tive techniques based on All-on-4
(A4) and SynCone (SC) concepts
and involving 4 endosseous implants
positioned in the anterior region can
exhibit stress-based biomechanical
behavior and loading transmission
mechanisms that are different in max-
illary and mandibular models, primar-
ily as a result of the cantilever length,
Baggi et al
January 2013 17

Mandible Maxilla
20 σT 20 σT
All-on-4 SynCone All-on-4 SynCone
10 10
Load 1

Load 1
0 0
MPa

MPa
-10 -10

-20 -20
σC σC
-30 -30
L CL CR R L CL CR R

60 σT 60 σT
All-on-4 SynCone All-on-4 SynCone
40 40

20 20
Load 2

Load 2
MPa

MPa

0 0

-20 -20

-40 -40
σC σC
-60 -60
L CL CR R L CL CR R

20 σT 20 σT
All-on-4 SynCone All-on-4 SynCone
10 10
Load 3

Load 3
0 0
MPa

MPa

-10 -10

-20 -20
σC σC
-30 -30
L CL CR R L CL CR R

Mandible Maxilla

8 Principal stress measures (C compressive and T tensile) at cortical bone-implant interfaces for simulated im-
plants in A4 (All-on-4, light blue bars) and SC (SynCone-based, dark blue bars) restorations, in mandibular (on left)
and maxillary (on right) models. Average (bars) and peak (lines) values (L: left implant; CL: central-left implant; CR:
central-right implant; R: right implant).

Baggi et al
18 Volume 109 Issue 1

Mandible Maxilla
3 σT 3 σT

2 All-on-4 SynCone 2 All-on-4 SynCone

1 1
Load 1

Load 1

Load 1
MPa

MPa
0 0

-1 -1

-2 -2
σC σC
-3 -3
L CL CR R L CL CR R

4 σT 4 σT

2 2
Load 2

Load 2

Load 2
0 0
MPa

MPa

-2 -2
All-on-4 SynCone All-on-4 SynCone
-4 -4
σC σC
-6 -6
L CL CR R L CL CR R

2 σT 2 σT All-on-4 SynCone

0 0
Load 3

Load 3

Load 3
MPa

MPa

-2 -2

-4 -4
All-on-4 SynCone
σC σC
-6 -6
L CL CR R L CL CR R

Mandible Maxilla

9 Principal stress measures (C compressive and T tensile) at trabecular bone-implant interfaces for simulated im-
plants in A4 (All-on-4, light blue bars) and SC (SynCone-based, dark blue bars) restorations in mandibular (on left)
and maxillary (on right) models. Average (bars) and peak (lines) values (L: left implant; CL: central-left implant; CR:
central-right implant; R: right implant).

The Journal of Prosthetic Dentistry Baggi et al

January 2013
the implant design concepts and
positioning, the patient-dependent
morphology, and mechanical proper-
ties of bone. In agreement with other
studies,32-44 proposed 3D FE analyses
have suggested that bone overloads
can affect cortical bone around the
implant necks, mainly in compres-
sion. In addition, overloading risk can
occur in maxillary trabecular bone
around the mesial implants and in-
creases with the depth of the in-bone
implant positioning.
As clinical,4-6,18-23,28 photoelastic,33
and numerical39-44 studies have in-
dicated, the present numerical find-
ings also show that using long poste-
rior cantilevers can induce high stress
concentrations on bone, especially
at the distal periimplant regions. In
agreement with the numerical simu-
lations of Bevilacqua et al,39,40 the
present results emphasized that the
use of tilted distal implants can be
effective in reducing such effects,
thereby inducing more favorable load
transmission characteristics. Further-
more, as indicated by the numerical
results obtained by Maeda et al17 and
Baggi et al,10,34 the proposed simula-
tions showed that the stress-based
performance and long-term effec-
tiveness of a rehabilitation can be
significantly improved if the crestal
bone loss is effectively counteracted,
especially when cantilever effects
are not dominant. The mutual influ-
ence of cantilever effects and crestal
bone morphology seemed to be pri-
marily affected by the loading type.
For complete-mouth loading (Load
1) and cantilever load (Load 2), the
cantilever influence prevailed, and the
distal tilted implants in A4 (Nobel
Biocare implants) produced less risk
of compressive overload and more
uniform stress distributions than the
distal vertical implants in SC (Anky-
los). However, because of the pres-
ervation of the crestal bone modeled
for Ankylos implants in accordance
with platform switching concepts,
mesial implants exhibited opposite
comparative results. When a frontal
load (Load 3) was simulated, canti-
Baggi et al
lever mechanisms were not activated,
and the effects of platform switching
seemed to prevail. As a result, stress
distributions computed in A4-based
models were more critical than those
in SC applications. Differences in
stress distributions among maxillary
and mandibular models can be mainly
related to the different physiologically
based modeling assumptions regard-
ing bone quality and morphology.
In regard to load transfer features,
A4-based numerical models (both
mandibular and maxillary) allowed
the computation of better transmis-
sion mechanisms under loads 1 and
2 than SC, resulting in more homoge-
neous loading partition. Under Load
1 all implants contributed to the load
transmission, whereas, in the case of
Load 2, at most, the 2 implants on
the loading side were involved. Under
Load 3 the transfer mechanisms simu-
lated in the maxillary and mandibular
models were significantly different,
A4 producing better loading partition
than SC in the mandible and worse in
the maxilla. In agreement with basic
statics, this evidence can be justified
by observing that Load 3 was trans-
ferred by mainly intrusive actions
upon the mesial implants and extru-
sive actions upon the distal implants.
When L1 (Fig. 2) decreased (passing
from the mandibular to maxillary
model), the mesial intrusive forces in-
creased and the distal extrusive ones
decreased, thereby modifying the
loading partition. When the difference
between L2 and L1 (Fig. 2) increased
(passing from A4 to SC), the distal
extrusive actions further decreased,
further contributing to a nonhomoge-
neous loading partition.
The numerical results also showed
that tilted implants in A4 can induce
significant tensile stresses at distal
crests, mainly in the mandibular mod-
el. When tilted implants transferred
mostly extrusive components (Load
3), tensile stresses were computed at
the distal side of the tilted implants,
whereas when tilted implants trans-
ferred intrusive components (loads 1
and 2), tensile stresses were located
19
at the mesial side. Correspondingly,
risk of ineffective osseous integration
and bone damage (bone is 30% stron-
ger in compression than in tension9)
might arise.
Contrary to a number of recent
numerical approaches,17,34-44 the
present study accounted for the in-
fluence of the posthealing crestal
bone morphology in functioning
implants, detailed geometrical mod-
eling for maxillary and mandibular
jaws, muscle-bone static interactions,
and temporomandibular articulation.
Nevertheless, some limitations of the
modeling assumptions adopted in this
study can be found. In detail, the ideal
and unrealistic condition of 100% os-
seous integration was assumed. Stress
analyses were performed by simulat-
ing static loads and including mus-
cle-jaw interactions and temporo-
mandibular joints through simplified
approaches.50,52 Bone and articular
disks were modeled as dry isotropic
linear elastic materials, whose me-
chanical properties were assumed
to be time-independent. The space
dependence of bone density and me-
chanical response were simply de-
scribed by distinguishing trabecular
and cortical homogeneous regions.
These assumptions do not completely
describe clinical scenarios because
of possible osseointegration defects
at the periimplant regions, different
patient-dependent loading distribu-
tions, more complex and time-de-
pendent forces and muscular effects,
anisotropic, nonhomogeneous, non-
linear and inelastic response of liv-
ing tissues, and bone remodeling and
spatially graded tissue properties.
Nevertheless, in agreement with oth-
er numerical studies,4-6,10,17,34-44,48,50,52
the present assumptions can be ac-
cepted, in a computational sense, to
deduce significant and clinically use-
ful indications for the comparative
stress-based assessment of complete-
arch restorations.
Another possible limitation is that
the bar modeling was performed only
to allow suitable loading transfer to-
ward the implant-bone coupled sys-
20
tem. Moreover, in a given jaw model,
the bar was assumed to be the same
for both the complete-arch restor-
ative approaches. This could be con-
sidered a limitation because clini-
cians could adopt a shorter cantilever
length when using the SC system.
Nevertheless, such an assumption
allowed for a consistent comparison
between the 2 techniques, when for
the same number of supporting im-
plants and anterior positioning, the
length of the rehabilitated arch (the
number of the rehabilitated teeth)
was also the same. Finally, the dis-
placement boundary conditions
adopted in maxillary models and
consisting of fixing the entire virtual
cutting surfaces (not including the
nasal cavity) (Fig. 1) could seem an
excessively rigid constraint. Neverthe-
less, nodes on these surfaces belong
to the cortical bone that extends be-
yond the maxillary process described.
Therefore, because of the mechanical
properties of such a region, although
lateral implants are relatively close to
these computational boundaries, the
corresponding periimplant stress dis-
tributions should not be significantly
affected. This occurrence seems to be
confirmed by comparing the present
results with those obtained by Bevi-
lacqua et al,40 and, in view of a com-
parative assessment, such a possible
modeling limitation should not influ-
ence the main indications obtained in
this study.
To enhance the present FE ap-
proach, future studies will be devoted
to the modeling of bone as a nonlin-
ear, anisotropic, viscous, and nonho-
mogeneous regenerative tissue that
responds to stress by resorption or
regeneration under time-dependent
muscular and external loads. More-
over, a more accurate correlation be-
tween bone density and its mechani-
cal response should allow a better
description of the spatial distribution
of the material properties.
The Journal of Prosthetic Dentistry
CONCLUSIONS
Within the limitations of this 3D
finite element study, numerical simu-
lations on both maxillary and man-
dibular models have shown that both
the complete-arch rehabilitative ap-
proaches analyzed may have advan-
tages and disadvantages, primarily
because of the mutual coupling be-
tween cantilever mechanisms and cra-
tering effects. Distal tilted implants
in complete-arch prostheses allow a
reduction of compressive stresses at
the distal periimplant bone as a re-
sult of the reduction of cantilever ef-
fects on loading transmission mecha-
nisms. Nevertheless, distally tilted
implants can produce higher tensile
stresses when compared with distal
vertical implants, increasing risks of
ineffective crestal osseous integration
and bone damage. Platform switch-
ing strategies and subcrestal posi-
tioning can reduce the risk of bone
overloading, especially at the mesial
periimplant regions, where possible
cantilever mechanisms are generally
not dominant.
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Corresponding author:
Dr Luigi Baggi
INMP
Servizio di Odontoiatria Sociale
e Riabilitazione Gnatologica Via S. Gallicano
25/A 00100 Rome
ITALY
Fax: +39-0635400080
E-mail: luigi.baggi@uniroma2.it
Copyright © 2013 by the Editorial Council for
The Journal of Prosthetic Dentistry.