J Stomatol Oral Maxillofac Surg 124 (2023) 101290

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Original Article

Finite element analysis of the biomechanical effects of titanium and

Cfr-peek additively manufactured subperiosteal jaw implant (AMSJI)
on maxilla
Nur Altıparmak, Serhat Polat, Selen Onat*
Baskent University Faculty of Dentistry Department of Oral and Maxillofacial Surgery, 06490, Cankaya, Ankara, Turkey

A R T I C L E I N F O A B S T R A C T

Article History: The aim of this study is to examine the stresses that will occur under occlusal forces on the cortical bone,
Received 3 June 2022 spongious bone and the subperiosteal implant systems made of Titanium and%60 Carbon fiber reinforced
Accepted 15 September 2022 Polyether ether ketone (PEEK) material. Two different models of subperiosteal implant systems on maxilla
Available online 21 September 2022
made of Titanium and %60 Carbon fiber reinforced Polyether ether ketone (PEEK) material. As a result of ver-
tical and oblique forces, the stress values and distributions on the subperiosteal implant systems and bone
Keywords:
were examined. After applying the three different force protocols, von Mises stress, Maximum principal
Subperiosteal implant
stress and Minimum principal stress values and distribution on the subperiosteal implant body, fixation
Finite element method
Titanium
screws, cortical and spongious bone were analyzed by finite element analysis. In all scenarios, the von Mises
Polyether ether ketone values on the Titanium subperiosteal implant system were found to be approximately twice on the 60% car-
bon fiber reinforced PEEK subperiosteal implant system plates. Subperiosteal implants produced from tita-
nium and carbon fiber reinforced PEEK material exhibited similar stress values on cortical and spongious
bone. According to the results of this study, 60% Carbon fiber reinforced PEEK material can be considered as
an alternative material to titanium since it exhibits similar biomechanical behavior with titanium subperios-
teal implants on cortical and spongious bone. In order to be routinely used as dental subperiosteal implant
material, it should be supported by long-term in vivo studies.
© 2022 The Author(s). Published by Elsevier Masson SAS. This is an open access article under the CC BY
license (http://creativecommons.org/licenses/by/4.0/)

1. Introduction extent of the subperiosteal degloving and the stretching of the

Subperiosteal implants were first introduced in 1940 and then
used worldwide for the treatment of edentulous maxilla or mandible
with advanced bone atrophy. A subperiosteal implant is a custom-
made titanium infrastructure extending over the bone under the
periosteum [1,2].
The additively manufactured subperiosteal jaw implant (AMSJI)
was conceived as an alternative to zygoma implants or the extensive
bone transplantation necessary for Cawood and Howell class V−VI
bone atrophy [3].
The concept of the AMSJI for the maxilla is unique in many ways.
Left and right subunits of the ASMJI are inserted submucosally/sub-
gingivally and are then connected intraorally to a third subunit, a
temporary connector, and then later to a definitive hybrid bridge or a
definitive primary matrix structure. The titanium alloy structure is
split into one intraoral and two subgingival segments to increase pro-
cedure comfort levels for both the patient and surgeon. Reducing the
* Corresponding author.
E-mail address: selen_onat95@hotmail.com (S. Onat).
wound flaps reduces pain and edema and allows for all procedures to
be performed on an ambulatory basis, whether using local anesthesia,
nasotracheal intubation, or intravenous sedation [3].
An ideal implant biomaterial requires biocompatibility, tough-
ness, strength, corrosion resistance, wear, and fracture resistance
[4,5]. Dental implants are divided into three groups—metals,
ceramics and polymers [6].
Ti and Ti alloys are currently the most commonly used materials
for the construction of implants. One of the most popular Ti alloys is
Ti6Al4V, designed as Ti grade 5. This alloy exhibits a satisfactory bal-
ance between mechanical strength and corrosion resistance after a
long period of exposure with the body environment. However, con-
taining vanadium, it causes more toxicity because it releases more
ions than pure titanium implants. [7].
Polyether ether ketone (PEEK) is a member of the polyarylether-
ketone (PAEK) family. High-molecular PEEK was first synthesized in
England in 1978 [8]. It is a semicrystalline material with high
mechanical and chemical resistance and a melting point of around
335°C [9,10]. A low Young’s modulus (3−4 GPa) is the major property
of pure PEEK implants, which is close to the level of human bones.

https://doi.org/10.1016/j.jormas.2022.09.011
2468-7855/© 2022 The Author(s). Published by Elsevier Masson SAS. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)
N. Altıparmak, S. Polat and S. Onat Journal of Stomatology oral and Maxillofacial Surgery 124 (2023) 101290

PEEK can be modified easily by incorporating other materials, such as

carbon fibers. Modification with carbon fibers can increase the elastic
modulus up to 18 GPa.
Stress shielding is the reduction in the volume of the bone around
an implant due to the shielding of normal loads by the implant. The
elastic modulus of carbon-fiber-reinforced (Cfr) PEEK is comparable
to those of cortical bone so it could exhibit less stress shielding when
compared with titanium, which has significantly higher elastic mod-
ulus than bone and results in severe stress-shielding and failure.
In recent years, stress analysis in dental structures has been an
interesting issue to determine the stresses and improve the mechani-
cal resistance of these structures. Finite element analysis, which was
first applied to dental implants by Tesk and Widera in 1973, is fre-
quently used in oral surgery and implantology [11].
This study aims to assess the stresses that occurred in customized
titanium and Cfr-PEEK subperiosteal implant (AMSJI), cortical and
spongious bone with a new protocol for single-stage rehabilitation of
the severely atrophic maxilla by using finite element analysis.

2. Materials and methods

The study was approved by the Başkent University Medical and

Health Sciences Research Board (Project no: D-DA 19/06) and sup-
ported by the Başkent University Research Fund. Two different AMSJI
models made of titanium and Cfr-PEEK were created with the same
prosthetic parts.
A 3D image of an edentulous maxilla bone was derived from a
computed tomography scan of an adult patient and saved as “.stl”
data. The solid geometry of the maxilla, including the cortical and
spongious bone, was rebuilt from the “.stl” data into the Digital Imag-
ing and Communications in Medicine (DICOM) format with 3D-Doc-
tor (Able Software Corp., MA, USA).
With the Boolean method, force loading was achieved between
prosthetic parts, subperiosteal implant screws and bone tissues.
Models were placed in the correct coordinates in the three-dimen-
sional space. The modeling process was completed using Rhinoceros
4.0 (3670 Woodland Park Ave N, Seattle, WA 98103 USA) three-
dimensional modeling software. A three-dimensional mesh consist-
ing of 556,365 nodes and 2972,897 elements with VRMesh Studio
(VirtualGrid Inc, Bellevue City, WA, USA) was used in the program.
The properties of all materials included in this study are listed in
Table 1. All materials were assumed to be isotropic and linear elastic.
Three different loading protocols were applied to the prosthetic
Fig. A.1. Forces applied vertically to the maxillary posterior.
structure. In the first loading protocol, a vertical 150 N force was
applied to the first, second premolars and first molars reciprocally
(Fig. A.1). A 30° oblique 100 N force was applied to the same teeth in
the maxillary posterior region in the second loading protocol
(Fig. A.2), and in the third protocol a total of 150 N force was applied
to the central and lateral incisors vertically (Fig. A.3).
Three different loading protocols were applied to the models
while model 1 refers to titanium AMSJI and model 2 refers to Cfr-
PEEK AMSJI. A total of six cases were analyzed through finite element
analysis. The Von Mises stresses occurred in cortical and spongious
bone and maximum/minimum principal stresses that occurred in
subperiosteal implant and fixation screws caused by the loading
forces were evaluated.
Fig. A.2. . Forces applied obliquely to the maxillary posterior region.
Table 1
Summary of the material properties used for the finite element analysis.
3. Results
Material Young’s Modulus (Mpa) Poisson’s Ratio

Cortical bone 13,700 0.3 3.1. Stresses are caused by posterior vertical forces (Tables 2 and 3)
Spongious bone 1500 0.3
Polymethyl methacrylate 3000 0.35
The maximum Von Mises stress on the subperiosteal implant and
%60 Cfr-PEEK 150,000 0.356
Titanium 110,000 0.34 fixation screws were measured as 101.579 MPa and 5.97596 MPa in
model 1 and 57.0768 MPa and 2.36163 MPa in model 2, respectively.
2
N. Altıparmak, S. Polat and S. Onat Journal of Stomatology oral and Maxillofacial Surgery 124 (2023) 101290

2.91361 MPa in model 1 and 11.5963 MPa and 1.55603 MPa in

model 2, respectively.

4. Discussion

The main purpose of this study was to compare the biomechanical

Fig. A.3. . Forces applied vertically to the maxillary anterior region.
The maximum principal stresses on the cortical and spongious bone
were 4.34911 MPa and 1.02835 MPa in model 1 and 4.76748 MPa
and 0.968582 MPa in model 2, respectively. The minimum principal
stresses on the cortical and spongious bone were 6.46994 MPa and
10 de 4.02832 MPa in model 1 and 10.2343 MPa and
2.80387 MPa in model 2, respectively.
3.2. Stresses are caused by posterior oblique forces (Tables 2 and 4)
The maximum Von Mises stress on the subperiosteal implant and
fixation screws were measured as 88.4967 MPa and 1.9272 MPa in
model 1 and 49.069 MPa and 0.611475 MPa in model 2, respectively.
The maximum principal stress on the cortical and spongious bone
was 6.14525 MPa and 0.506614 MPa in model 1 and 8.85611 MPa
and 0.472745 MPa in model 2, respectively. The minimum principal
stresses on the cortical and spongious bone were 5.57116 MPa and
0.762301 MPa in model 1 and 8.44144 MPa and 1.02716 MPa in
model 2, respectively.
3.3. Stresses are caused by posterior oblique forces (Tables 2 and 5)
The maximum Von Mises stress on the subperiosteal implant and
fixation screws were measured as 90.0199 MPa and 7.99523 MPa in
model 1 and 37.772 MPa and 2.52118 MPa in model 2, respectively.
On the cortical and spongious bone, the maximum principal stresses
were 4.93589 MPa and 0.763854 MPa in model 1 and 3.53895 MPa
and 0.71419 MPa in model 2, respectively. The minimum principal
stresses on the cortical and spongious bone were 7.57283 MPa and
behavior of titanium and %60 Cfr-PEEK materials. Therefore, this
study focused on the evaluation of the mechanical properties of the
materials used in this research by applying the same number of
forces to the regions on the same model of the maxillary bone.
Plastic deformation occurs on the materials when the maximum
Von Mises stress values exceed the tensile strength of the materials.
Maximum Von Mises stress values should be less than the tensile
strength of the materials used [12,13].
In all cases, the Von Mises stress values on the titanium subperios-
teal implant were approximately twice as high as the stresses on the
Cfr-PEEK subperiosteal implant. In both types of subperiosteal
implants, the maximum Von Mises stresses were predominantly
accumulated on the abutment parts of the plate in all force loading
protocols. As a result of force loading from the anterior region of the
maxilla, the Von Mises stress value reached its highest in the anterior
abutment and anterior wing region of the titanium plate, while the
highest von Mises stresses in the PEEK plate were accumulated only
in the anterior abutment part of the subperiosteal implant.
Both titanium and Cfr-PEEK materials are suitable for manufac-
ture as subperiosteal implants because they release fewer stresses
than the tensile strength of the materials used in both types of sub-
periosteal implants. It can be stated that the use of Cfr-PEEK material
in subperiosteal implants has a high success rate, considering that
the tensile strength of the Cfr-PEEK material is approximately twice
that of titanium and the stress values accumulated in the titanium
subperiosteal are approximately twice that of the PEEK plate.
Von Mises stress was approximately twice as high in the titanium
screws as in Cfr-PEEK screws in all cases, as in the subperiosteal
implants.
Padolino et al. [14] reported similar clinical findings in titanium
and Cfr-PEEK plates and screws, while differences occurred radiologi-
cally between the two groups. It has been reported that more bone
remodeling occurs under Cfr-PEEK plates compared with titanium
plates. Additionally, statistically significant more bone resorption
was observed in the titanium group. In the same study, similar results
were obtained between titanium and Cfr-PEEK screws and these
findings were compatible with the results of this study. Many animal

Table 2
Stresses occurred by the posterior vertical forces, posterior oblique forces, and anterior vertical forces on the maxillary bone, subperiosteal implant
and fixation screws in model 1 and model 2.

Model 1 Model 2

Stresses occurred by the posterior vertical forces Subperiosteal implant − Von Mises Stress (MPa) 101.579 57.0768
Fixation screw − Von Mises Stress (MPa) 5.97596 2.36163
Cortical − Maximum Principal Stress (MPa) 4.34911 4.76748
Cortical − Minimum Principal Stress (MPa) 6.46994 10.2343
Spongious − Maximum Principal Stress (MPa) 1.02835 0.968582
Spongious − Minimum Principal Stress (MPa) 4.02832 2.80387
Stresses occurred by the posterior oblique forces Subperiosteal implant − Von Mises Stress (MPa) 88.4967 49.069
Fixation screw − Von Mises Stress (MPa) 1.9272 0.611475
Cortical − Maximum Principal Stress (MPa) 6.14525 8.85611
Cortical − Minimum Principal Stress (MPa) 5.57116 8.44144
Spongious − Maximum Principal Stress (MPa) 0.506614 0.472745
Spongious − Minimum Principal Stress (MPa) 0.762301 1.02716
Stresses occurred by the anterior vertical forces Subperiosteal implant − Von Mises Stress (MPa) 90.0199 37.772
Fixation screw − Von Mises Stress (MPa) 7.99523 2.52118
Cortical − Maximum Principal Stress (MPa) 4.93589 3.53895
Cortical − Minimum Principal Stress (MPa) 7.57283 11.5963
Spongious − Maximum Principal Stress (MPa) 0.763854 0.71419
Spongious − Minimum Principal Stress (MPa) 2.91361 1.55603

3
N. Altıparmak, S. Polat and S. Onat
Table 3
Images of showing the distribution of the loading vertical forces to the maxillary posterior region within 8 the bones, subperiosteal implant and fixation screws.
and human studies have shown that bone resorption occurs under
rigid plates [15−18]. In addition, it has been stated that Cfr-PEEK
material increases the contact area between the plate and bone due
to its high Young’s modulus.
Recent studies indicated that significantly higher Von Mises stress
values were found in cortical bone than in spongious bone [19,20]. In
light of the information stated, the cortical bone layer supports the
implant more than the spongious bone. Also in this study, the maxi-
mum and minimum stress values in the cortical bone were found to
be higher than the stresses in the cancellous bone in all cases and
these findings support recent studies. The fact that the stress is higher
in cortical bone than that of spongious bone is explained by the
4
Journal of Stomatology oral and Maxillofacial Surgery 124 (2023) 101290
different Young’s modulus of the two bone types [21−23]. Cortical
bone absorbs more stresses so it causes bone resorption around the
implant [12].
In all cases, the highest maximum principal stress values in the
cortical bone occurred in model 2 by loading the anterior forces. The
highest minimum principal stress values of cortical bone also were
found in model 2 by loading the posterior oblique forces. The same
model of maxillary bone was used in both cases, so this result can be
explained by the difference in the subperiosteal implant materials.
Similar stress values occurred in the spongious bone between the
two types of subperiosteal implants. The highest maximum and mini-
mum principal stress values in the cancellous bone occurred under
N. Altıparmak, S. Polat and S. Onat
Table 4
Images of showing the distribution of the loading oblique forces to the maxillary posterior region within the bones, subperiosteal implant and fixation screws.
the posterior vertical forces in the first model. Similar amounts of
stress accumulated in the spongious bone in both subperiosteal
implants. The reason for a similar number of stresses occurring in
spongious bone is probably due to the absorption of the occlusal
loads by cortical bone.
Naert et al. [24] stated that if the stresses occurring in corti-
cal bone are higher than 60 MPa, microcracks may occur inside
the bone, and pathological fractures of the bone may be
observed because of stress values higher than 120 MPa.
Another study reported that the physiological stress limit of the
bone was 40 MPa [25]. In all cases analyzed in this study,
the amount of stress occurring in the cortical bone was below
the physiological stress limit of the bone, which was previously
5
Journal of Stomatology oral and Maxillofacial Surgery 124 (2023) 101290
stated. Therefore, the subperiosteal implants examined in this
study have successful biomechanical results for both titanium
and 60% Cfr-PEEK materials.
The stress values that occurred in %60 Cfr-PEEK material were
found to be similar to titanium. Cfr-PEEK AMSJI similarly distributes
the stresses as a titanium subperiosteal implant. Therefore, Cfr-PEEK
material can be considered an alternative subperiosteal material to
titanium.
Further investigations, including more realistic material proper-
ties such as anisotropy, are required to achieve a better understand-
ing of the loading distribution of a Cfr-PEEK subperiosteal implant.
Clinical trials are recommended to determine the functional stability
of Cfr-PEEK AMSJI.
 N. Altıparmak, S. Polat and S. Onat Journal of Stomatology oral and Maxillofacial Surgery 124 (2023) 101290

Table 5
Images of showing the distribution of the loading vertical forces to the maxillary anterior region within the bones, subperiosteal implant and fixation screws.

Funding source Data sharing statement

This research did not receive any specific grant from funding Data sharing is not applicable to this article as no new data were
agencies in the public, commercial, or not-for-profit sectors. created or analyzed in this study.

6
N. Altıparmak, S. Polat and S. Onat
Acknowledgments
None.
References
[1] Kusek ER. The use of laser technology (Er;Cr:YSGG) and stereolithography to aid
in the placement of a subperiosteal implant: case study. J Oral Implantol 2009;35
(1):5–11. doi: 10.1563/1548-1336-35.1.5.
[2] Minichetti JC. Analysis of HA-coated subperiosteal implants. J Oral Implan-
tol 2003;29(3):111–6. doi: 10.1563/15481336(2003)029<0111:AOHCSI>2.3.
CO;2.
[3] Mommaerts MY. Additively manufactured sub-periosteal jaw implants. Int J Oral
Maxillofac Surg 2017;46(7):938–40. doi: 10.1016/j.ijom.2017.02.002.
[4] Parr GR, Gardner LK, Toth RW. Titanium: the mystery metal of implant dentistry.
Dental materials aspects. J Prosthet Dent 1985;54(3):410–4. doi: 10.1016/0022-
3913(85)90562-1.
[5] Smith DC. Dental implants: materials and design considerations. J Prosthodont
1993;6(2):106–17 PMID: 8329086.
[6] Osman RB, Swain MV. A critical review of dental implant materials with an
emphasis on titanium versus zirconia. Materials (Basel) 2015;8(3):932–58. doi:
10.3390/ma8030932.
[7] Elias CN, Lima JHC, Valiev R, Meyers MA. Biomedical applications of titanium and
its alloys. Jom 2008;60(3):46–9. doi: 10.1007/s11837-008-0031-1.
[8] Eschbach L. Nonresorbable polymers in bone surgery. Injury 2000;31
(4Suppl):22–7. doi: 10.1016/s0020-1383(00)80019-4.
[9] Najeeb S, Zafar MS, Khurshid Z, Siddiqui F. Applications of polyetheretherketone
(PEEK) in oral implantology and prosthodontics. J Prosthodont Res 2016;60
(1):12–9. doi: 10.1016/j.jpor.2015.10.001.
[10] Staniland PA, Wilde CJ, Bottino FA, Di Pasquale G, Pollicino A, Recca A. Synthesis,
characterization and study of the thermal properties of new polyarylene ethers.
Polymer (Guildf) 1992;33(9):1976–81.
[11] Tesk JA, Widera O. Stress distribution in bone arising from loading on endosteal
dental implants. J Biomed Mater Res 1973;7(3):251–61. doi: 10.1002/
jbm.820070317.
[12] Koca OL, Eskitascioglu G, Usumez A. Three-dimensional finite-element analysis of
functional stresses in different bone locations produced by implants placed in the
maxillary posterior region of the sinus floor. J Prosthet Dent 2005;93(1):38–44.
doi: 10.1016/j.prosdent.2004.10.001.
Journal of Stomatology oral and Maxillofacial Surgery 124 (2023) 101290
[13] Zampelis A, Rangert B, Heijl L. Tilting of splinted implants for improved prostho-
dontic support: a two-dimensional finite element analysis. J Prosthet Dent
2007;97(6Suppl):S35–43. doi: 10.1016/S0022-3913(07)60006-7.
[14] Padolino A, Porcellini G, Guollo B, Fabbri E, Kiran Kumar GN, Paladini P, Merolla G.
Comparison of CFR-PEEK and conventional titanium locking plates for proximal
humeral fractures: a retrospective controlled study of patient outcomes. Muscu-
loskelet Surg 2018;102(Suppl1):49–56. doi: 10.1007/s12306-018-0562-8.
[15] Patman LJ, Szalay EA. Relative osteopenia after femoral implant removal in chil-
dren and adolescents. Orthopedics 2013;36(4):e468–72. doi: 10.3928/01477447-
20130327-24.
[16] Kettunen J, Kro €ger H, Bowditch M, Joukainen J, Suomalainen O. Bone mineral den-
sity after removal of rigid plates from forearm fractures: preliminary report. J
Orthop Sci 2003;8(6):772–6. doi: 10.1007/s00776-003-0718-7.
[17] Janes GC, Collopy DM, Price R, Sikorski JM. Bone density after rigid plate fixation
of tibial fractures. A dual-energy X-ray absorptiometry study. J Bone Joint Surg Br
1993;75(6):914–7. doi: 10.1302/0301-620X.75B6.8245081.
[18] Tonino AJ, Davidson CL, Klopper PJ, Linclau LA. Protection from stress in bone and
its effects. Experiments with stainless steel and plastic plates in dogs. J Bone Joint
Surg Br 1976;58(1):107–13. doi: 10.1302/0301-620X.58B1.1270486.
[19] Kong L, Sun Y, Hu K, Liu Y, Li D, Qiu Z, Liu B. Selections of the cylinder implant
neck taper and implant end fillet for optimal biomechanical properties: a three-
dimensional finite element analysis. J Biomech 2008;41(5):1124–30. doi:
10.1016/j.jbiomech.2007.12.013.
[20] Topkaya T, Solmaz MY. The effect of implant number and position on the stress
behavior of mandibular implant retained overdentures: a three-dimensional
finite element analysis. J Biomech 2015;48(10):2102–9. doi: 10.1016/j.jbio-
mech.2015.03.006.
[21] Meijer HJ, Starmans FJ, Steen WH, Bosman F. A three-dimensional, finite-element
analysis of bone around dental implants in an edentulous human mandible. Arch
Oral Biol 1993;38(6):491–6. doi: 10.1016/0003-9969(93)90185-o.
[22] Chen J, Lu X, Paydar N, Akay HU, Roberts WE. Mechanical simulation of the
human mandible with and without an endosseous implant. Med Eng Phys
1994;16(1):53–61. doi: 10.1016/1350-4533(94)90011-6.
[23] Lozada JL, Abbate MF, Pizzarello FA, James RA. Comparative three-dimensional
analysis of two finite-element endosseous implant designs. J Oral Implantol
1994;20(4):315–21 PMID: 7643441.
[24] Naert I, Duyck J, Vandamme K. Occlusal overload and bone/implant loss. Clin Oral
Implants Res 2012;23(Suppl6):95–107 http://doi.org/10.1111/j.1600-
0501.2012.02550.x.
[25] Sugiura T, Horiuchi K, Sugimura M, Tsutsumi S. Evaluation of threshold stress for
bone resorption around screws based on in vivo strain measurement of miniplate.
J Musculoskelet Neuronal Interact 2000;1(2):165–70 PMID: 15758514.