materials
Article
Evaluation of Stresses on Implant, Bone, and Restorative
Materials Caused by Different Opposing Arch Materials in
Hybrid Prosthetic Restorations Using the All-on-4 Technique
Feras Haroun * and Oguz Ozan






Citation: Haroun, F.; Ozan, O.
Evaluation of Stresses on Implant,
Bone, and Restorative Materials
Caused by Different Opposing Arch
Materials in Hybrid Prosthetic
Restorations Using the All-on-4
Technique. Materials 2021, 14, 4308.
https://doi.org/10.3390/ma14154308
Academic Editor: Bruno Chrcanovic
Received: 26 June 2021
Accepted: 28 July 2021
Published: 1 August 2021
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This article is an open access article
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Attribution (CC BY) license (https://
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4.0/).
Materials 2021, 14, 4308. https://doi.org/10.3390/ma14154308
Department of Prosthodontics, Faculty of Dentistry, Near East University, Near East Boulevard, Nicosia 99138,
Mersin 10, Turkey; oguz.ozan@neu.edu.tr
* Correspondence: feras.haroun@neu.edu.tr; Tel.: +90-548-828-66-79 or +90-542-888-99-90 or +965-97170419
Abstract: The long-term success of dental implants is greatly influenced by the use of appropriate
materials while applying the “All-on-4” concept in the edentulous jaw. This study aims to evaluate
the stress distribution in the “All-on-4” prosthesis across different material combinations using
three-dimensional finite element analysis (FEA) and to evaluate which opposing arch material has
destructive effects on which prosthetic material while offering certain recommendations to clinicians
accordingly. Acrylic and ceramic-based hybrid prosthesis have been modelled on a rehabilitated
maxilla using the “All-on-4” protocol. Using different materials and different supports in the
opposing arch (natural tooth, and implant/ceramic, and acrylic), a multi-vectorial load has been
applied. To measure stresses in bone, maximum and minimum principal stress values were calculated,
while Von Mises stress values were obtained for prosthetic materials. Within a single group, the use of
an acrylic implant-supported prosthesis as an antagonist to a full arch implant-supported prosthesis
yielded lower maximum (Pmax) and minimum (Pmin) principal stresses in cortical bone. Between
different groups, maxillary prosthesis with polyetheretherketone as framework material showed the
lowest stress values among other maxillary prostheses. The use of rigid materials with higher moduli
of elasticity may transfer higher stresses to the peri implant bone. Thus, the use of more flexible
materials such as acrylic and polyetheretherketone could result in lower stresses, especially upon
atrophic bones.
Keywords: All-on-4® ; hybrid prosthesis; finite element analysis; implant
1. Introduction
Due to the current disadvantages of traditional complete dentures, advancing technol-
ogy and science have been redirected to producing new solutions. Utilizing the current
advances in dental implants in conjunction with the All-on-4 treatment concept generally
reduces the treatment time, the risk of morbidity, and other possible risks in the edentulous
patient. This protocol, which emerged specially to overcome the complicated prosthetic
and surgical problems caused by anatomical limitations, has increased its prevalence and
has been used frequently [1].
One of the key factors for long-term clinical success is correct planning of the substruc-
ture and superstructure materials that support the implant prosthesis. The properties of the
material and spatial geometric configuration model of each component have a significant
impact on the transference of functional loads and stress distribution in a bone–implant–
prosthesis assembly [2]. In the oral environment, these components act in unison with each
other, and thus the combination of the materials used is important. Since the nature and
magnitude of the intraoral loads are unknown, it is recommended that these stresses are
kept to a minimum. Thus, finding suitable dental materials that overcome biomechanical
deficiencies and optimize function and aesthetics are desired by many clinicians [3].
https://www.mdpi.com/journal/materials
Materials 2021, 14, 4308 2 of 18

A variety of prosthetic materials have been used in the manufacturing of implant-

supported fixed full dentures, the most well documented of which is metal-acrylic [4,5].
Long-term follow-up has revealed that this type of restoration is difficult to maintain owing
to prosthetic tooth attrition and acrylic fracture [6,7]. With the advent of computer-aided
design and computer-aided manufacturing (CAD-CAM) technology, various alternative
designs have become possible for implant-supported fixed prosthesis, including Toronto
hybrid prosthesis, monolithic zirconia, and porcelain veneered zirconia prosthesis. The
Toronto bridge includes the cementation of full veneer restorations on milled titanium or
zirconia substructure [8]. As a result, long-term prognosis has been yielded due to superior
aesthetics and biomechanics, in addition to the ease of hygienic care [9–12]. Even though
the survival rate is generally high, prosthesis with zirconia substructures can also have a
high incidence of minor mechanical complications [13]. Another material that has gained
popularity in recent years due to its biocompatibility and favoured physical properties
is Polyether-ether-ketone (PEEK) [14]. Veneered PEEK with Polymethylmethacrylates
(PMMA) or light-cured composite resins tends to preserve its elastic properties, thus
reducing occlusal forces against the restoration in addition to the forces transferred to the
restoration, the tooth root, and the opposing dentition [15].
When planning an implant-retained prosthesis, the clinical implication could change
drastically depending on the surrounding conditions as intra-oral conditions are not
always perfect. While some materials have been found to increase the amount of stress
transmitted to the opposing prosthesis, other materials have been shown to transfer lower
stresses [3,7,16–18]. As a result, it has been believed that the type of opposing structure
influences the level of crestal bone change and the amount of stresses that are being
transferred [19].
Appropriate selection of implant and prosthetic materials is very important for the
longevity, stability, and proper function of the implant-supported prosthesis. In the field of
dentistry, the use of finite element analysis has gained its popularity due to its ability to
provide useful information about stress values and patterns in the “All-on-4” concept [20].
Using three-dimensional finite element analysis, this study aims to examine the stress
distribution in the maxillary “All-on-4” prosthesis across different material combinations
to offer certain recommendations to clinicians.

2. Materials and Methods

A 3D model of an edentulous maxilla was built using data collected from the Visible
Human Project (US National Library of Medicine, Bethesda, MD, USA). Utilizing the
software programs VRMESH version 6.1 (Bellevue, WA, USA) and Rhinoceros 4.0 (Robert
McNeel & Associates, Seattle, WA, USA), the geometry model was modified with a 2 mm
cancellous bone layer around the spongious bone with 2 mm-thick mucosa. An optical
scanner (SmartOptics 3D scanner, Bochum, Germany) was used to scan implants and
prosthetic components within a 10 µm accuracy ratio, and data were reconstructed with
VRMESH software in conjunction with Rhinoceros 4.0 to model the structures.
Anteriorly, the vertical implants were modelled in the lateral incisal area based on the
dimensions of a NobelActive RP implants (Nobel Biocare, Zurich, Switzerland) (with a
diameter of 4.3 mm and a length of 13 mm). Posteriorly, standard length implants were
modelled at an angle of 30◦ and placed into the second premolar region. Anterior implants
were fitted with straight multi-unit abutments while posterior implants were fitted with
angled multi-unit abutments (Nobel Biocare, Sweden).
According to superstructure material and framework design, three main models were
created in the maxillary jaw. For analysis, each maxillary model was opposed by four
different models in the lower jaw to simulate different loading scenarios (Table 1 and
Figure 1). The materials used in this study were considered to be homogeneous, linearly
elastic, and isotropic. The characteristics of the materials used in our study are shown in
(Table 2).
 Materials 2021, 14, 4308 3 of 18

Table 1. Element and node numbers of maxillary and mandibular models.

Maxilla Mandible Number of Elements Number of Nodes

1.1 Natural tooth 1,173,283 265,982

Model 1: Titanium bar with acrylic 1.2 Full ceramic crown 1,214,741 279,924
teeth 1.3 Acrylic All-on-4 1,502,434 365,627
1.4 Implant-supported ceramic crown 1,347,938 299,558
2.1 Natural tooth 1,256,911 283,379
Model 2: Titanium bar with resin
composite gingiva and ceramic 2.2 Full ceramic crown 1,298,424 297,321
superstructure with zirconium 2.3 Acrylic All-on-4 1,586,062 383,002
(Toronto bridge)
2.4 Implant-supported ceramic crown 1,431,626 316,955
Materials 2021, 14, x FOR PEER REVIEW 3.1 Natural tooth 1,256,927 283,379 3 of 19
Model 3: PEEK bar with composite
resin gingiva and ceramic 3.2 Full ceramic crown 1,298,373 297,321
superstructure with zirconium 3.3 Acrylic All-on-4 1,586,062 383,002
(Toronto bridge) elastic,and isotropic. The characteristics
3.4 Implant-supported ceramic crown of the materials
1,431,566 used in our study
316,955are shown in
(Table 2).

Figure 1. Maxillary
Figure 1. Maxillaryand
andmandibular modelsused
mandibular models usedininthe
the study.
study.

For2.each
Table model,
Mechanical an occlusal
Properties load was
of the Materials. delivered to the left first molar area using a
spherical solid substance (12 mm in diameter) that simulated foodstuff (Figure 2). To
Material Elastic Modulus Poisson Ratio
closely simulate the forces exerted while chewing, weighting factors have been assigned
to each muscleTempro-mandibular disk
of the primary masticatory muscles for44.1 0.4
the five clenching tasks [21] (Table
Cortical bone 13,700 0.3
3). Spongy bone 1370 0.3
To avoid displacement, the midsagittal, posterior,
Periodontal ligament 68.9and top cutting planes
0.45 were con-
Mucosa
strained in all three directions 1
x, y, and z (Figure 3). Complete 0.37
osseointegration between
Dentin 18,600 0.32
Implant and bone surfacesEnamel was presumed. All the bodies 84,100 were assumed to be perfectly
0.33
bonded together through the
Acrylic resin contact surfaces with no relative
2200 movement along
0.31 their en-
tire interfaces. Titanium (Grade 4) 105,000 0.37
The maximum principal stress (Pmax) and minimum principal stress0.33
Titanium (Grade 5) 114,000
(Pmin) stresses
Zircon 210,000 0.3
were computed for the cortical bone.
Poly-Ether Ether Keton (PEEK) Prosthetic components
4100 and implants0.4 were consid-
ered as ductile materials and had their Von Mises stress values calculated.
Composite (Gradia) 50,000 0.3
Feldspathic ceramic 82,800 0.35
Food stuff 84.1 0.33
Table 1. Element and node numbers of maxillary and mandibular models.

Maxilla Mandible Number of Elements Number of Nodes

1.1 Natural tooth 1,173,283 265,982

1.2 Full ceramic crown 1,214,741 279,924

Model 1: Titanium bar with
 Enamel 84,100 0.33
Acrylic resin 2200 0.31
Titanium (Grade 4) 105,000 0.37
Titanium (Grade 5) 114,000 0.33
Materials 2021, 14, 4308 4 of 18
Zircon 210,000 0.3
Poly-Ether Ether Keton (PEEK) 4100 0.4
For eachComposite
model, an(Gradia)
occlusal load was delivered to the left first molar area
50,000 0.3 using a
spherical solid substance (12 mm in diameter) that simulated foodstuff (Figure 2). To
Feldspathic
closely simulate the forcesceramic 82,800factors have been0.35
exerted while chewing, weighting assigned to
each muscle of theFood
primary
stuffmasticatory muscles for the five
84.1 clenching tasks [21]
0.33(Table 3).

Figure
Figure 2.
2. Spherical
Spherical solid
solid material
material simulating
simulating foodstuff
foodstuff located
located on
on the
the left
left first
first molar
molar region.
region.

Table 3. Node number and weighting factor allocated to the masticatory muscles responsible for
Table 3. Node number and weighting factor allocated to the masticatory muscles responsible for the
the five clenching tasks.
five clenching tasks.
Node Number
Node Number Weighting Factor
Muscles Weighting Factor
Muscles (Newton)
Right Right (Newton)
Superficial
Superficial masseter
masseter 67 67 190.4190.4
Deep masseter 38 81.6
Deep
Medial masseter
pterygoid 51 38 174.881.6
Anterior
Medial temporalis
pterygoid 43 51 158174.8
Middle temporalis 18 95.6
Posterior temporalis 15 75.6
Inferior lateral pterygoid 5 66.9
Superior lateral pterygoid 4 28,7
Anterior digastric 8 40

To avoid displacement, the midsagittal, posterior, and top cutting planes were con-
strained in all three directions x, y, and z (Figure 3). Complete osseointegration between
Implant and bone surfaces was presumed. All the bodies were assumed to be perfectly
bonded together through the contact surfaces with no relative movement along their entire
interfaces.
The maximum principal stress (Pmax) and minimum principal stress (Pmin) stresses
were computed for the cortical bone. Prosthetic components and implants were considered
as ductile materials and had their Von Mises stress values calculated.
 Middletemporalis
Middle temporalis 1818 95.6
95.6
Posteriortemporalis
Posterior temporalis 1515 75.6
75.6
Inferiorlateral
Inferior lateralpterygoid
pterygoid 55 66.9
66.9
Superiorlateral
Superior lateralpterygoid
pterygoid 44 28,7
28,7
Materials 2021, 14, 4308 5 of 18
Anteriordigastric
Anterior digastric 88 4040

Figure
Figure 3. 3. Boundary conditions
Boundary and force directions used
inin the analysis.
Figure 3. Boundary conditions
conditions and force
and force directions
directions used
used in the
the analysis.
analysis.

3.3. Results
3. Results
Results
3.1. StressesininPeri-Implant
3.1. Peri-Implant CorticalBone
Bone
3.1. Stresses
Stresses in Peri-Implant Cortical
Cortical Bone
Thestress
The stressdistribution
distributionininthe
thecortical
corticalbone
bonearound
aroundthe
theposterior
posterior implantregion
implant regionofofthe
the
loadedside
loaded sideisisillustrated
illustratedinin (Figures 4–11).
(Figures 4–11).

Figure 4. Maximum principal stresses (N/mm2 ) on cortical bone.

Figure
Figure 4. 4. Maximum
Maximum principal
principal stresses
stresses (N/mm
(N/mm
2) on cortical bone.
2) on cortical bone.
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Materials 2021, 14, x FOR PEER REVIEW 6 of 19

Figure 5. Pmax stress distribution in cortical bone for group 1, titanium bar with acrylic teeth. (A) Model 1.1, opposing
5. Pmax
Figurenatural stress distribution in cortical bone for group 1, titanium bar with acrylic teeth. (A) Model 1.1, opposing
tooth. (B) Model 1.2, opposing tooth-supported full ceramic crown. (C) Model 1.3, opposing acrylic prosthesis
Figure
natural tooth.
with 5. (B)
Pmax
titanium stress1.2,
Model
framework.distribution
opposing intooth-supported
(D) Model cortical bone for
1.4, opposing group
full 1, titanium
ceramic
implant-supported bar
crown.
full with
(C) acrylic
Model
ceramic teeth.
1.3,
crown. (A) Model
opposing 1.1, prosthesis
acrylic opposing with
natural tooth. (B) Model 1.2, opposing tooth-supported full ceramic
titanium framework. (D) Model 1.4, opposing implant-supported full ceramic crown. crown. (C) Model 1.3, opposing acrylic prosthesis
with titanium framework. (D) Model 1.4, opposing implant-supported full ceramic crown.

Figure 6. Pmax stress distribution in cortical bone for group 2, titanium bar with resin composite gingiva and ceramic
superstructure with zirconium (Toronto bridge). (A) Model 2.1, opposing natural tooth. (B) Model 2.2, opposing tooth-
Figure 6. Pmax stress distribution in cortical bone for acrylic
group 2, titaniumwith
bar with resinframework.
composite (D)
gingiva and2.4,ceramic
Figuresupported
6. Pmax full ceramic
stress crown. (C)inModel
distribution 2.3,bone
cortical opposing
for group prosthesis
2, titanium bartitanium
with resin compositeModel
gingiva oppos-
and ceramic
superstructure with zirconium (Toronto
ing implant-supported full ceramic crown. bridge). (A) Model 2.1, opposing natural tooth. (B) Model 2.2, opposing tooth-
superstructure
supported full ceramic crown. (C) Model 2.3, opposing acrylic prosthesis with titanium framework. (D) Model 2.4, oppos- tooth-
with zirconium (Toronto bridge). (A) Model 2.1, opposing natural tooth. (B) Model 2.2, opposing
supported full ceramic crown.
ing implant-supported full(C) Model
ceramic 2.3, opposing acrylic prosthesis with titanium framework. (D) Model 2.4, opposing
crown.
implant-supported full ceramic crown.
 Materials 2021, 14, x FOR PEER REVIEW 7 of 19

Materials 2021, 14, 4308 7 of 18

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Figure
Figure 7. Pmax stress distributioninincortical
cortical bone for group 3,3,
PEEK barbar
with composite resinresin
gingiva and ceramic super- super-
Figure 7.7. Pmax
Pmax stress
stress distribution
distribution in corticalbone boneforfor
group
group PEEK
3, PEEK with
bar composite
with composite gingiva
resin and ceramic
gingiva and ceramic
structure
structure withwith zirconium
zirconium (Torontobridge).
(Toronto bridge). (A)
(A) Model
Model3.1,
3.1,opposing
opposingnatural
naturaltooth. (B) Model
tooth. 3.2, opposing
(B) Model tooth-sup-
3.2, opposing tooth-sup-
superstructure
ported with zirconium (Toronto bridge). (A)acrylic
Model 3.1, opposing naturalframework.
tooth. (B)(D)
Model 3.2,
3.4,opposing tooth-
ported full full ceramic
ceramic crown.
crown. (C)
(C) Model3.3,
Model 3.3, opposing
opposing acrylicprosthesis with
prosthesis titanium
with titanium framework. Model
(D) Model opposing
3.4, opposing
supported full ceramic crown.
implant-supported (C) Model
crown.3.3, opposing acrylic prosthesis with titanium framework. (D) Model 3.4, opposing
implant-supported fullfull ceramic
ceramic crown.
implant-supported full ceramic crown.

Figure 8. Minimum principal stresses (N/mm2) on cortical bone.

Figure 8. Minimum principal stresses (N/mm2 ) on cortical bone.

Figure 8. Minimum principal stresses (N/mm2) on cortical bone.
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Figure 9. Pmin stress distribution in cortical bone for group 1, titanium bar with acrylic teeth. (A) Model 1.1, opposing
Figure 9. Pmin stress distribution in cortical bone for group 1, titanium bar with acrylic teeth. (A) Model 1.1, opposing
natural tooth. (B) Model 1.2, opposing tooth-supported full ceramic crown. (C) Model 1.3, opposing acrylic prosthesis
naturalFigure
tooth.9.(B)
Pmin stress1.2,
Model distribution
opposing intooth-supported
cortical bone for full
group 1, titanium
ceramic bar(C)
crown. with acrylic
Model teeth.
1.3, (A) Model
opposing 1.1, prosthesis
acrylic opposing with
with titanium framework. (D) Model 1.4, opposing implant-supported full ceramic crown.
natural tooth. (B) Model 1.2, opposing tooth-supported full ceramic crown. (C) Model 1.3, opposing acrylic prosthesis
titanium framework. (D) Model 1.4, opposing implant-supported full ceramic crown.
with titanium framework. (D) Model 1.4, opposing implant-supported full ceramic crown.

Figure 10. Pmin stress distribution in cortical bone for group 2, titanium bar with resin composite gingiva and ceramic
superstructure with zirconium (Toronto bridge). (A) Model 2.1, opposing natural tooth. (B) Model 2.2, opposing tooth-
Figure 10. Pmin stress distribution in cortical bone for group 2, titanium bar with resin composite gingiva and ceramic
10. Pminfull
Figuresuperstructure
supported stress distribution
ceramic crown. (C)in cortical
Model 2.3, bone for acrylic
opposing groupprosthesis
2, titanium bar
with with resin
titanium composite
framework. gingiva
(D) Model 2.4, and ceramic
oppos-
with zirconium (Toronto bridge). (A) Model 2.1, opposing natural tooth. (B) Model 2.2, opposing tooth-
ing implant-supported
superstructure full ceramic crown.
supported full ceramic crown. (C) Model 2.3, opposing acrylic prosthesis with titanium framework. (D) Model 2.4, oppos- tooth-
with zirconium (Toronto bridge). (A) Model 2.1, opposing natural tooth. (B) Model 2.2, opposing
ing implant-supported
supported full ceramic crown. full(C)
ceramic
Modelcrown.
2.3, opposing acrylic prosthesis with titanium framework. (D) Model 2.4, opposing
implant-supported full ceramic crown.
Materials 2021, 14, 4308 9 of 18
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Figure 11. Pmin stress distribution in cortical bone for group 3, PEEK bar with composite resin gingiva and ceramic su-
Figure 11. Pmin stress distribution in cortical bone for group 3, PEEK bar with composite resin gingiva and ceramic
perstructure with zirconium (Toronto bridge). (A) Model 3.1, opposing natural tooth. (B) Model 3.2, opposing tooth-sup-
superstructure
ported fullwith zirconium
ceramic crown. (C)(Toronto bridge).
Model 3.3, (A)acrylic
opposing Model 3.1, opposing
prosthesis naturalframework.
with titanium tooth. (B)(D)
Model 3.2,
Model 3.4,opposing
opposing tooth-
supported full ceramic crown.
implant-supported (C) Model
full ceramic crown.3.3, opposing acrylic prosthesis with titanium framework. (D) Model 3.4, opposing
implant-supported full ceramic crown.
3.1.1. Maximum Principal Stresses (Pmax)
3.1.1. Maximum Principal
For all three Stresses
groups, the lowest(Pmax)
value (23.2 N/mm2) was recorded in group 3 (PEEK
andFor all threefollowed
Zirconia), groups,by thegroup
lowest value (23.2
1 (Titanium N/mm
and PMMA) 2 ) was
(32.2recorded in group
N/mm 2) and group32(PEEK
and Zirconia), followed by group 1 (Titanium and PMMA) (32.2 N/mm2 ) and group 2
(Titanium and Zirconia) (34.3 N/mm 2), respectively, all when opposed by a mandibular

acrylic All-on-4
(Titanium with titanium
and Zirconia) framework
(34.3 N/mm prosthesis in the
2 ), respectively, all lower
whenjaw. The highest
opposed value
by a mandibular
(72.7 N/mm 2) was found in group 2 (Titanium and Zirconia) and group 3 (PEEK and Zir-
acrylic All-on-4 with titanium framework prosthesis in the lower jaw. The highest value
conia) (68.7 2N/mm2) when opposed by an implant-supported full ceramic crown Followed
(72.7 N/mm ) was found in group 2 (Titanium and Zirconia) and group 3 (PEEK and
by group 2 (Titanium and Zirconia) (65.7 N/mm2) when opposed by tooth-supported full
Zirconia) (68.7 N/mm2 ) when opposed by an implant-supported full ceramic crown
ceramic crown. Opposing the prosthesis by a natural tooth or a tooth-supported ceramic
Followed by group 2 (Titanium and Zirconia) (65.7 N/mm2 ) when opposed by tooth-
crown did not show major difference in results across all groups.
supported full ceramic crown. Opposing the prosthesis by a natural tooth or a tooth-
supported ceramic
3.1.2. Minimum crown Stresses
Principal did not (Pmin)
show major difference in results across all groups.
A similar stress pattern has been observed across all the groups. The lowest values (-
3.1.2. Minimum Principal Stresses (Pmin)
39.5 N/mm ) were found to be when group 3 (PEEK and Zirconia) models were opposed
2

byA similar
acrylic stresswith
All-on-4 pattern hasframework,
titanium been observed across
followed all the1 (Titanium
by group groups. Theand lowest
PMMA)values
(-39.5 N/mm 2 ) were found to be when group 3 (PEEK and Zirconia) models were opposed
then group 2 (Titanium and Zirconia) respectively. The highest value (−156.2 N/mm2) was
by acrylic All-on-4 with titanium framework, followed by group 1 (Titanium and PMMA)
observed in group 2 (Titanium and Zirconia) opposing an implant-supported full ceramic
crown in the lower jaw,and
followed by tooth-supported fullhighest
ceramicvalue
crown(−(−146.8 2)2
then group 2 (Titanium Zirconia) respectively. The 156.2 N/mm
N/mm ) was
of the same group.
observed in group 2 (Titanium and Zirconia) opposing an implant-supported full ceramic
crown in the lower jaw, followed by tooth-supported full ceramic crown (−146.8 N/mm2 )
3.2. Stresses in Implants
of the same group.
Maximum equivalent stress values and their distribution in the implants of each
model are in
3.2. Stresses illustrated
Implantsin Figures 12–15. Within each group, maxillary prostheses opposed
by implant-supported full ceramic crown registered the highest stress values in the im-
Maximum equivalent stress values and their distribution in the implants of each
plant body mesially near the neck of the implant across all groups. The highest value
model are illustrated in Figures 12–15. Within each group, maxillary prostheses opposed
by implant-supported full ceramic crown registered the highest stress values in the im-
plant body mesially near the neck of the implant across all groups. The highest value
(2229.8 N/mm2 ) was found in group 2 (Titanium and Zirconia) followed by group 1 (Tita-
nium and PMMA) (2027 N/mm2 ). The lowest value (687.6 N/mm2 ) was found in group 3
(PEEK and Zirconia) when opposed by the tooth-supported ceramic crown followed by
 Materials 2021, 14, x FOR PEER REVIEW 10 of 19

Materials
Materials 2021,
2021, 14, 14, x FOR PEER REVIEW
4308 10 of 1910 of 18
(2229.8
N/mm2) was found in group 2 (Titanium and Zirconia) followed by group 1 (Tita-
nium and PMMA) (2027 N/mm2). The lowest value (687.6 N/mm2) was found in group 3
(PEEK and Zirconia) when opposed by the tooth-supported ceramic crown followed by
(2229.8 N/mm2) was found in group 2 (Titanium2 and Zirconia) followed by group 1 (Tita-
natural tooth as an antagonist2 (828.3 N/mm2 ), and when opposed by an acrylic All-on-4
natural
nium tooth as an antagonist
and PMMA) (2027 N/mm(828.3
). The N/mm
lowest ), and
value when
(687.6 opposed
N/mm 2) was by an in
found acrylic
groupAll-on-4
3
with titanium framework (855.2 N/mm 22), all within the same group.
with titanium framework (855.2 N/mm ), all within the same group.
(PEEK and Zirconia) when opposed by the tooth-supported ceramic crown followed by
natural tooth as an antagonist (828.3 N/mm2), and when opposed by an acrylic All-on-4
with titanium framework (855.2 N/mm2), all within the same group.

Figure 12. Von Mises stress values on posterior implants under loads.
Figure
Figure12.
12.Von
Von Mises stressvalues
Mises stress valuesonon posterior
posterior implants
implants under
under loads.loads.

Figure 13. Implant stress distribution for group 1, titanium bar with acrylic teeth. (A) Model 1.1, opposing natural tooth.
Figure 13. Implant stress distribution for group 1, titanium bar with acrylic teeth. (A) Model 1.1, opposing natural tooth.
(B) Model 1.2, opposing tooth-supported full ceramic crown. (C) Model 1.3, opposing acrylic prosthesis with titanium
(B) Model 1.2, opposing
framework. (D) Model tooth-supported full ceramic crown.
1.4, opposing implant-supported (C) Model
full ceramic crown.1.3, opposing acrylic prosthesis with titanium
Figure 13. Implant
framework. (D) Modelstress
1.4, distribution for group 1, titanium
opposing implant-supported bar withcrown.
full ceramic acrylic teeth. (A) Model 1.1, opposing natural tooth.
(B) Model 1.2, opposing tooth-supported full ceramic crown. (C) Model 1.3, opposing acrylic prosthesis with titanium
framework. (D) Model 1.4, opposing implant-supported full ceramic crown.
Materials 2021, 14, 4308 11 of 18
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Materials 2021, 14, x FOR PEER REVIEW 11 of 19

FigureFigure 14. Implant

14. Implant stressstress distribution
distribution for group
for group 2, titanium
2, titanium barbar with
with resin
resin compositegingiva
composite gingiva and
and ceramic
ceramic superstructure
superstructure with
with zirconium (Toronto bridge). (A) Model 2.1, opposing natural tooth. (B) Model 2.2, opposing tooth-supported full
zirconium (Toronto
Figure 14. bridge).
Implant (A) Model 2.1, opposing naturalbartooth. (B) Model 2.2, opposing tooth-supported full ceramic
ceramic crown. (C) stress
Modeldistribution
2.3, opposingfor acrylic
group 2, titanium
prosthesis withwith resin
titanium composite
framework.gingiva and
(D) Model ceramic
2.4, superstructure
opposing implant-
crown.supported
(C) zirconium
with Model full2.3, opposing
(Toronto
ceramic acrylic
bridge).
crown. (A)prosthesis
Model 2.1,with titanium
opposing framework.
natural tooth. (B) (D) Model
Model 2.4, opposing
2.2, opposing implant-supported
tooth-supported full
ceramiccrown.
full ceramic crown. (C) Model 2.3, opposing acrylic prosthesis with titanium framework. (D) Model 2.4, opposing implant-
supported full ceramic crown.

Figure 15. Implant stress distribution for group 3, PEEK bar with composite resin gingiva and ceramic superstructure with
zirconium (Toronto bridge). (A) Model 3.1, opposing natural tooth. (B) Model 3.2, opposing tooth-supported full ceramic
Figure 15.
(C)Implant stress distribution forprosthesis
group 3, PEEK bar with composite
(D)resin gingiva and ceramic superstructure with
Figurecrown.
15. Implant Model 3.3,
stress opposing
distributionacrylic
for group withbar
3, PEEK Ti framework.
with composite Model 3.4, opposing
resin gingiva implant-supported
and ceramic full with
superstructure
zirconium
ceramic (Toronto bridge). (A) Model 3.1, opposing natural tooth. (B) Model 3.2, opposing tooth-supported full ceramic
crown.
zirconium (Toronto bridge). (A) Model 3.1, opposing natural tooth. (B) Model 3.2, opposing tooth-supported
crown. (C) Model 3.3, opposing acrylic prosthesis with Ti framework. (D) Model 3.4, opposing implant-supported full full ceramic
crown.ceramic
(C) Model
crown.3.3, opposing acrylic prosthesis with Ti framework. (D) Model 3.4, opposing implant-supported full
ceramic crown.
Materials 2021,
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14, 4308
x FOR PEER REVIEW 12
12 of 19
of 18

3.3. Stresses in Framework

3.3. Stresses in Framework
The von Mises stresses in the framework and stress distribution for each model are
The von Mises stresses in the framework and stress distribution for each model
shown in Figures 16–19. Generally, the PEEK framework showed the lowest stress values
are shown in Figures 16–19. Generally, the PEEK framework showed the lowest stress
when compared
values to titanium.
when compared PEEK framework
to titanium. opposed by
PEEK framework an acrylic
opposed by anAll-on-4
acrylicprosthesis
All-on-4
in the mandible registered the lowest value (91.4 N/mm 2) followed by group 2 (Titanium
2
prosthesis in the mandible registered the lowest value (91.4 N/mm ) followed by group 2
and Zirconia)
(Titanium and(137.7 N/mm
Zirconia)
2) when opposed by an acrylic All-on-4 prosthesis followed by
(137.7 N/mm2 ) when opposed by an acrylic All-on-4 prosthesis
group 3 (PEEK and Zirconia) (154.4
followed by group 3 (PEEK and Zirconia) N/mm(154.4
2) when opposed by an implant supported ce-
N/mm2 ) when opposed by an implant
supported ceramic crown in the lower jaw. Thevalue
ramic crown in the lower jaw. The highest stress wasstress
highest found in the
value titanium
was found frame-
in the
work of group 2 (Titanium and Zirconia) (568.6 N/mm 2) followed by group
titanium framework of group 2 (Titanium and Zirconia) (568.6 N/mm ) followed 2 1 (Titanium
by
and PMMA),
group bothand
1 (Titanium when the maxillary
PMMA), jawthe
both when was opposed
maxillary jawbywas
an opposed
implant-supported full
by an implant-
ceramic crown.
supported full ceramic crown.

Figure 16. Values of Von Mises stresses on Framework under loads.

Figure 16. Values of Von Mises stresses on Framework under loads.
Materials 2021, 14, 4308 13 of 18
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Figure 17.
Figure 17. Stress
Stress distribution in the
distribution in the framework for group
framework for group 1,
1, titanium
titanium bar
bar with
with acrylic
acrylic teeth.
teeth. (A)
(A) Model
Model 1.1,1.1, opposing natural
opposing natural
tooth. Figure
(B) Model 1.2,
17. Stress
opposing
distribution
tooth-supported full
in the frameworkfull
ceramic
forceramic
crown.
group 1, crown.
titanium(C)
(C) Model
barModel
1.3,
with acrylic
opposing acrylic
teeth. (A) Model
prosthesis with tita-
tooth. (B) Model 1.2, opposing tooth-supported 1.3, opposing acrylic1.1, opposingwith
prosthesis natural
titanium
nium framework.
tooth. (B) (D) Model 1.4, opposing implant-supported full ceramic crown.
framework. (D)Model
Model1.2, opposing
1.4, opposing tooth-supported full ceramic
implant-supported crown. (C)
full ceramic Model 1.3, opposing acrylic prosthesis with tita-
crown.
nium framework. (D) Model 1.4, opposing implant-supported full ceramic crown.

FigureFigure 18. Stress distribution in the framework for group 2, titanium bar with resin composite gingiva and ceramic super-
18. Stress distribution in the framework for group 2, titanium bar with resin composite gingiva and ceramic
structure with zirconium (Toronto bridge). (A) Model 2.1, opposing natural tooth. (B) Model 2.2, opposing tooth-sup-
superstructure
Figureported
18. Stresswith zirconium
distribution
full ceramic (Toronto
crown.in(C)
the bridge).
framework
Model 2.3, for(A) Model
group
opposing 2.1, opposing
2, prosthesis
acrylic titanium bar
withwithnatural tooth. (B)(D)
resinframework.
titanium composite Model
gingiva2.2,
Modeland opposing
2.4, ceramic tooth-
opposingsuper-
supported
structure full ceramic
with crown.
zirconium
implant-supported (C) Model
full(Toronto
ceramic 2.3, opposing
bridge).
crown. (A) Modelacrylic prosthesisnatural
2.1, opposing with titanium
tooth. framework. (D)opposing
(B) Model 2.2, Model 2.4,tooth-sup-
opposing
ported full ceramic full
implant-supported crown. (C) Model
ceramic crown.2.3, opposing acrylic prosthesis with titanium framework. (D) Model 2.4, opposing
implant-supported full ceramic crown.
Materials 2021, 14, 4308 14 of 18
Materials 2021, 14, x FOR PEER REVIEW 14 of 19

FigureFigure 19. Stress distribution in the framework for group 3, PEEK bar with composite resin gingiva and ceramic super-
19. Stress distribution in the framework for group 3, PEEK bar with composite resin gingiva and ceramic superstruc-
structure with zirconium (Toronto bridge). (A) Model 3.1, opposing natural tooth. (B) Model 3.2, opposing tooth-sup-
ture with zirconium (Toronto
ported full ceramic crown. bridge).
(C) Model(A)
3.3,Model 3.1,acrylic
opposing opposing natural
prosthesis withtooth. (B)framework.
titanium Model 3.2,(D)
opposing tooth-supported
Model 3.4, opposing
full ceramic crown. (C)full
implant-supported Model
ceramic3.3, opposing acrylic prosthesis with titanium framework. (D) Model 3.4, opposing
crown.
implant-supported full ceramic crown.
4. Discussion
4. Discussion
The recent advances in CAD/CAM technology over the last decade have enabled cli-
The recent
nicians advancesmaterial
to use different in CAD/CAMcombinations. technology
Researchover
showing the last decade
the effect of have enabled
different
prosthetic
clinicians material
to use on stress
different distribution
material in implant-supported
combinations. Research showingcompletethearch prosthesis
effect of different
is well documented;
prosthetic material on however, the number
stress distribution inof researches discussing
implant-supported the effect
complete of the
arch op-
prosthesis is
posing arch material is close to none. In this study, FEA has been
well documented; however, the number of researches discussing the effect of the opposing utilized to mechanically
evaluate
arch theisresponse
material close toof different
none. prosthetic
In this study, FEAdesigns
haswith
beendifferent
utilizedmaterial combinations
to mechanically evaluate
for manufacturing an implant-supported full-arch dental prosthesis opposing different
the response of different prosthetic designs with different material combinations for manu-
materials and various abutments (tooth/implant).
facturing an implant-supported full-arch dental prosthesis opposing different materials
The evolution of the biomechanical properties of the bone-implant interface is key to
andthe
various abutments (tooth/implant).
surgical success of implant procedures. Studies have shown that functional loading of
the implant aids inof
The evolution the the biomechanical
formation properties
of bone [22]. of thehand,
On the other bone-implant
mechanicalinterface
overloadingis key to
thecould
surgical success
result in the of implant
failure of theprocedures. Studies have
implant in conjunction shown
with that functional
host-related problems loading
[23]. of
theBone
implant
loss aids
during in the formation
the first year ofof thebone [22].could
implant On the be other hand,
attributed tomechanical
the surgical overloading
proce-
could result
dures; in theinfailure
however, of the implant
the following in conjunction
years it could be caused bywith host-related
immunological, problems
surgical, or [23].
Bone loss during
prosthetic reasonsthe [24].
first year
It hasofbeen
the implant
found that could be attributed
supra-occlusal to thesignificantly
contacts surgical procedures;
in-
creasedin
however, bone
theresorption
followinginyears the presence
it couldof beinflammation response in the peri-implant
caused by immunological, surgical, or bone
prosthetic
[25]. Thus,
reasons [24]. Itit has
has been
been suggested
found thattosupra-occlusal
keep these occlusal stresses
contacts within the increased
significantly biological bone
boundaries
resorption of the
in the human of
presence bone.
inflammation response in the peri-implant bone [25]. Thus, it
Chewing forces are undeniably
has been suggested to keep these occlusal transmitted to the
stresses restoration,
within and these boundaries
the biological forces do not of the
diminish but rather change their form, which is disseminated throughout the restoration-
human bone.
implant complex. Restorative materials, cement layer, abutment, screw, implants, and
Chewing forces are undeniably transmitted to the restoration, and these forces do not
peri-implant bone might all receive the energy of the chewing force. It has been suggested
diminish butauthors
by several rather change
that the theiruse ofform,
rigid which
materialsis disseminated
could result in throughout the restoration-
a better distribution of
implant complex. Restorative materials, cement layer, abutment,
stresses [3,16,26,27]. However, in our study, the use of acrylic in combination with screw, implants,
tita- and
peri-implant
nium showed bone might
fairly all receive
low stresses thebone
in the energy of the
localized chewing
around force. Itwhen
the implant has been suggested
compared
by several authors that the use of rigid materials could result in a better distribution of
stresses [3,16,26,27]. However, in our study, the use of acrylic in combination with titanium
showed fairly low stresses in the bone localized around the implant when compared to
zirconium. In addition to that, all the maxillary prosthesis showed lower stresses in the
bone surrounding the implant when opposed by a mandibular implant-supported acrylic
Materials 2021, 14, 4308 15 of 18

prosthesis. These results correlate to the result obtained by other authors [18,28,29]. An-
other study showed that the use of acrylic resins resulted in a lower stress distribution when
compared to ceramics [17]. This might be caused by the acrylic resin’s modulus of elasticity
(2.2 GPa) which is lower than both the ceramic (82 GPa) and zirconia (210 GPa), which
enables greater absorption and lower stresses transference to the supporting bone. [28–30].
In a similar study conducted by Elsayed et al. [31], it has been shown that stresses were
lower in the peri-implant bone when the prosthesis was opposed by acrylic denture in
comparison to natural teeth. In our study, using an implant-supported ceramic crown as
an antagonist resulted in the highest stress values among all the groups. These findings
have been confirmed by various in vivo research by emphasizing the increased presence
of mechanical complications when the prosthesis is opposed by an implant-supported
crown [9,32–35]. In addition, authors have noticed lower bone loss around the implant
(0.2 mm) in instances with natural tooth and higher bone loss (0.6 mm) when it is opposed
by an implant restoration at the same time [19]. These findings could be attributed to
the lack of proprioception by the patient and/or the lack of shock-absorbing capacity
by the prosthesis or the lack of periodontal ligament which aids in stress release during
function [9,36,37]. Natural teeth in occlusion with an implant would experience a slight
intrusion during function but the same amount of vertical/lateral displacement will not be
observed for the implant [38]. The rigid bone-implant interface and the lack of stress releas-
ing implant components does not provide physioelasticity and are incapable of detecting
forces such as teeth [39].
Framework material has been thought to affect the amount of stresses transferred to
surrounding components by some of the authors [16,40,41], while others stated that it has
no significant effect [42]. Studies comparing PEEK to titanium and zirconia showed higher
stress concentration within the framework in stiffer materials such as zirconia, followed
by titanium [16,40]. Despite the increased stresses in zirconia frameworks, some authors
have claimed that increased stiffness of the frameworks may help in transferring lower
loads to the implant and prosthetic components than less rigid ones, avoiding prosthesis
failure [16,27,43]. In our study, the use of PEEK yielded a reduction in the stresses located
in the framework followed by titanium with acrylic and titanium with zirconia respectively.
Our results concur with the findings of Lee et al. [43]. Sirandony et al. [44] also reported
lower stress values in the framework when using PEEK material but with higher stresses
in bone. The difference in the results when comparing it with our study could be due to the
fact that the authors tested the framework material only without the use of any prosthetic
material over the framework. The use of superstructure material in combination with the
framework materials could act as a stress dampener hence lower stress values in the bone
observed when using PEEK in comparison to titanium frameworks in our study.
Due to the irregular nature of the biological materials, finite element analysis (FEA)
has been proved to be a valid approach for assessing the mechanical behaviour of materials
in the oral cavity in the field of dentistry [45]. FEA gives the ability to visualize structures
that are superimposed and it allows the establishment of the location, magnitude, and
direction of an applied force at any given point. Since FEA does not alter the physical
properties of the material it is also easily repeatable [46,47]. Intraoral forces are known to
be multi vectorial and differ in value in relation to their direction [48]. It has been noticed
that the use of implant-supported full arch prosthesis affects the thickness of the masseter
muscle, chewing efficiency, and biting force [49]. Similar studies have used alternating
force vectors (vertical and horizontal) with fixed loadings directed to the tubercle [16,50].
However, in our study, the five muscles of clenching have been modeled and each muscle
has been given a corresponding weighting factor in order to simulate intra-oral forces as
closely as possible [21]. It is worth mentioning that selecting the proper occlusion scheme
and making the necessary occlusal modifications and adjustments have a significant impact
on the amount of forces generated in the prosthesis’ components. [1,51,52]. Due to the
complexity of adjusting the occlusion in each model and to standardize the process in our
study, the use of a spherical solid object that contacts the cusps of the posterior molars has
Materials 2021, 14, 4308 16 of 18

been suggested. Moreover, it guarantees the exertion of forces in vertical, horizontal, and
oblique directions [53]. The models analyzed using FEA are considered to be homogeneous,
isotropic, and linear. It is important to consider these restrictions when elucidating the
results as oral tissues are more complex and aniscopic. In addition, these experiments were
made at the in-vitro level, and therefore, the actual representation of osseointegration and
functions of the periodontal ligament could not be simulated. Because the assumption of
full osseointegration may not exist under actual clinical settings, finite element analysis
may not entirely mimic the true clinical scenario. Although our study followed the classic
All-on-4 configuration by tilting posterior implants to a 30◦ angle, changing the angle or
the configuration of the implants could result in different results from a biomechanical
standpoint. Due to the rapid advancements in dental materials technology, long-term
in-vivo studies are necessary. New clinical studies with variable implant number such as
six or eight implants, different implant configurations and sizes, and different prosthetic
material combinations can support this study and provide better understanding of the
bone behavior in the future.

5. Conclusions
Within the scope of this research, there are certain limitations; however, the following
has been concluded:
(1). The use of materials with a low modulus of elasticity such as acrylic and PEEK could
reduce the amount of stresses transmitted to the bone.
(2). The use of implant-supported ceramic prosthesis as an antagonist to another implant-
supported full arch prosthesis increases the amount of stresses transmitted to the
bone.
(3). There is no difference in the amount of stresses transmitted when comparing natural
tooth to tooth-supported ceramic restorations as an antagonist for a full arch implant-
supported prosthesis.

Author Contributions: Conceptualization, F.H. and O.O.; methodology, F.H. and O.O.; software,
F.H. and O.O.; validation, F.H. and O.O.; formal analysis, F.H. and O.O.; investigation, F.H. and
O.O.; resources, F.H.; data curation, F.H.; writing—original draft preparation, F.H.; writing—review
and editing, F.H., O.O.; visualization, F.H.; supervision, O.O.; project administration, O.O.; funding
acquisition, F.H. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

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