UNIVERSIDADE ESTADUAL PAULISTA
“JÚLIO DE MESQUITA FILHO”
Instituto de Ciência e Tecnologia
Campus de São José dos Campos
LITERATURE REVIEW DOI: https://doi.org/10.4322/bds.2023.e3637
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Biomechanics of implant-supported restorations
Biomecânica das restaurações implantossuportadas
Guilherme Schmitt de ANDRADE1 , Les KALMAN2 , Roberto LO GIUDICE3 , Dario ADOLFI4 , Albert J. FEILZER5 ,
João Paulo Mendes TRIBST5
1 - Western Paraná State University, Center for Biological and Health Sciences, Department of Dentistry, Cascavel, PR, Brazil.
2 - Western University, Schulich School of Medicine and Dentistry, London, ON, Canada.
3 - Messina University, Department of Clinical and Experimental Medicine, Messina, Italy.
4 - São Paulo State University, Institute of Science and Technology, Department of Dental Materials and Prosthodontics, São José dos
Campos, SP, Brazil.
5 - Universiteit van Amsterdam and Vrije Universiteit Amsterdam, Academic Centre for Dentistry Amsterdam, Department of Oral
Regenerative Medicine, Amsterdam, The Netherlands.
How to cite: ANDRADE GS, KALMAN L, LO GIUDICE R, ADOLFI D, FEILZER AJ, TRIBST JPM. Biomechanics of implant-supported
restorations. Braz. Dent. Sci. 2023;26(1): e3637. https://doi.org/10.4322/bds.2023.e3637
ABSTRACT
The rehabilitation of patients with dental implant-supported restorations is an ideal treatment option in
contemporary dentistry. The aim of this review was to compile and to demonstrate the mechanical response
during loading condition, on the stress distributions of implant-supported prostheses. The ndings show that the
majority of stresses were concentrated in the cervical region of the implant/abutment interface and that they
can be affected by several clinical parameters and loading conditions. Finally, the nal prosthetic design should
combine superior mechanical response, long-term survival rate and allow patient satisfaction.
KEYWORDS
Prostheses and Implants; Dental Implants; Finite element analysis; Review; Biomechanics.
RESUMO
A reabilitação de pacientes com restaurações implanto-suportadas é uma opção de tratamento ideal na odontologia
contemporânea. O objetivo desta revisão foi compilar e demonstrar a resposta mecânica durante a aplicação de
carga, na distribuição de tensão de próteses implanto-suportadas. Os achados mostram que a maioria das tensões
se concentram na região cervical da interface implante/pilar e pode ser afetada por diversos parâmetros clínicos
e condições de carregamento. Por m, o desenho protético nal deve combinar uma melhor resposta mecânica,
taxa de sobrevida a longo prazo e permitir a satisfação do paciente.
PALAVRAS-CHAVE
Próteses e Implantes; Implantes dentários; Análise por elementos nitos; Revisão; Biomecânica.
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INTRODUCTION
Based on a didactic and general explanation,
the term “biomechanics” can be defined as
mechanics applied to biology, while mechanics
is derived from the response of the structure to
forces or displacements [1-3]. Biomechanical
principles in implant dentistry remain as crucial
as the clinical parameters that must be applied
for oral rehabilitation. Ignoring or not applying
the principles will ultimately lead to clinical
failure [1]. These principles can be identied
during prototype development, production and
testing of implant-supported restorations and
during all clinical stages, including planning,
insertion, loading and maintenance [1].
The control of the clinical parameters plays
an important role in the implant therapy, since
the interactions between the soft and hard
biological tissues and synthetic structures (and
in association with external forces) generates a
mechanical response proportional to the applied
load. With endosseous implants, the load that
acts on the dental implant are transferred to the
surrounding peri-implant tissues and may be
modied from different factors [4].
Throughout the treatment plan phase, it is
mandatory to consider how these forces, which
will be applied to the dental implant, may be
generated in terms of: type, direction, magnitude,
duration and physiology [1-6]. According to the
literature, the 5-year survival rates range from
97.1% - 100% for xed prostheses and 95% -
100% for removable prostheses that are implant
supported. However, in the daily practice, high
survival rates are not the only factor to dene the
success of implant treatments, as it only represents
those prostheses remaining in use during the
follow-up period. These indices do not indicate
whether or not these prostheses were affected by
mechanical complications, which may inuence
the general success of the implant treatment [5].
A lack of understanding of mechanical principles
during the placement of implants may lead to
increased complication rates, repairs, remakes,
inefficiencies and increased cost; which may
ultimately affect the patient’s life quality [6].
The challenge of standardizing dental implant
biomechanics includes the continuous evolution
in biomaterials, implant designs, no consensus
on technical procedures and lack of control of
factors that can increase the stress magnitude.
Understanding and aiming for a more biomimetic
implant-supported prostheses can facilitate the
design of a more reliable restoration, with reduced
mechanical complications in a long-term follow-up.
In many cases, mechanical complications can
lead to implant fracture, as any object subjected to
constant loading may undergo overload conditions
and subsequent failure, resulting in a clinical
complication [4]. A common dental condition,
parafunction, can result in the production of
extreme forces. Prolonged period of parafunctional
forces may surpass the endurance limit of the
biomaterials, leading to problems such as screw
loosening, fatigue failure, prosthesis fracture and
even unwanted bone remodeling around the
implant [4]. The most common mechanical-related
complications in implant dentistry are: (1) fracture
or loosening of retaining abutment/prosthetic
screws (2) loss of crown retention and (3) chipping
or fracture of the veneered material [7].
The aim of this study is to review and to
illustrate, with stress maps, the various clinical
parameters previously reported in the literature
as signicant inuences on the biomechanics of
implant-supported restorations. Please note that
chemical and biological factors have not been
included in this study, but they also play an
important role in the biomechanics.
BACKGROUND
There are some critical fundamental concepts
and principles of biomechanics that must be
appreciated to understand how they affect the
success of implant-supported restorations.
MOMENT ARMS
In a didactic division, six rotational
moments can be found according to the three
clinical coordinate axes in an implant-supported
restoration (faciolingual, mesiodistal and vertical
axes). Due to the chewing load, micromovements
would present higher amplitude and higher
stress magnitude when aligned with any of the
rotational moments [7,8] (Figure 1).
Reducing the effect of these moment arms
is essential to decrease the restorations’ chances
of failure [7-9]. And a balance between the ideal
load distribution and the patients’ needs should
guide the final planned design for each case.
Nevertheless, the understanding of moment arms
is essential to plan predictable and successful cases.
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IMPLANT QUANTITY
One of the rst parameters that should be
observed in a patient case, prior to prosthetic
planning, is the available support for the
missing teeth. This parameter will dictate how
the prostheses can be supported. Previous
investigations have assessed the effect of the
number of implants to be used in implant-
supported prostheses [9]. Therefore, during the
treatment planning, the number of implants
required to support the prosthesis is one of the
most important factors to be considered, since
this step cannot be easily modied without a new
surgical intervention [8]. The literature indicates
that stresses are inversely proportional to the
number of implants; due to the fact that the load
can be distributed accordingly to the quantity of
endosseous implants in the arch. The mechanical
response usually demonstrates a consistent
relationship between the implant number and the
calculated strain around the bone tissue [9-11].
Although there is no consensus regarding
the quantity of implants required for an ideal
stress distribution and minimal bone microstrain,
an increase in implant number is suggested as
benecial, corresponding to a more predictable
approach for the patient rehabilitation [11].
Therefore, it is important to consider how the
load will be distributed between the implants, if
the amount of endosseous implants are suitable
to support and to retain the planned prosthesis,
or if the treatment must be delayed or modied.
For example, in clinical situations with only two
implants have been placed between the mental
foramen, the patient can properly receive a
removable overdenture, while a xed prosthesis
would increase the treatment’s failure risk [12].
However, in both conditions, the nal prosthesis
would still be able to rehabilitate the patient, with
the same number of articial teeth. Although,
the implant retained option would improve the
quality of life of the patient.
Figure 2 illustrates the rehabilitation of a
patient with the same number of missing teeth.
However, using only two implants to support a
three-unit prosthesis leads to more stress in the
abutment, as well as, in the connector region of
the bridge.
IMPLANT POSITIONING
A restorable implant is a critical requirement
for planning oral rehabilitation as well as the
osseointegrated implant needs a proper abutment
to support the prosthesis. Therefore, another
fixed parameter is the implant positioning.
The prosthesis cannot modify the position of
the implant in the bone after osseointegration.
Figure 1 - Three-dimensional moment arms according to the clinical
coordinate axes in implant-supported restorations.
Figure 2 - Stress maps showing a 3-unit fixed dental bridge supported by three or two-implants with the incidence of 100 N of loading. The
use of more implants reduced the stress magnitude at the connector and dissipate more stress to the central abutment
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However, the prosthetic design can correct the
insertion path and aesthetics, even in a non-ideal
condition. With the advent of angulated screw
channel abutments, it has allowed potential
cement-retained restorations to be converted
to screw-retained restorations. In these cases,
it is possible to use angulated screw channel
abutments to change the angle at the abutment or
at the soft tissue level. This allows the opportunity
to place angled implants, which can then
be compensated with angled screw channel
abutments [13].
According to an
in vitro
investigation, the
implant angulation did not affect the digital
impression accuracy. However, due to the lack
of supporting evidence, the extrapolation of
this statement for inclined implants for every
condition is not indicated [14]. Additionally,
errors in the impression method could generate
inaccurate models and consequently, mistted
prostheses.
Despite the preference of axial loads on
implant-supported restorations, this condition
cannot always be achieved in all cases. Situations
such as pneumatization of the maxillary sinus
and bone atrophies are obstacles to the ideal
implant placement that may sometimes require
regenerative therapies, such as bone grafts.
Therefore, depending on the bone availability
and the patient-specic anatomy, the implant
may be placed in a no-ideal position [14-17] and
consequently will receive oblique loads.
In addition to the surgical plan, different
regenerative therapies such as the split-bone
block technique and the cortico-cancellous
block graft, exhibit different healing processes
which may influence bone incorporation and
resorption [15]. After the healing process,
any modification in the bone dimensions can
compromise the ideal placement of the implant
fixture, since the bone morphology may also
guide de implant position [16].
In summary, patient’s rehabilitation with
inclined implants will require more frequent
monitoring and control of forces, as a previous
nite element analysis (FEA) demonstrated that
improperly positioned implants result in the
highest stresses for all prosthetic components [17].
Additionally, failure at the screw-joint interface
can also be associated with the presence of
inclined implants. With the presence of oblique
loads, high stress is projected in the prosthesis
and in the bone. Consequently, the maximum
fracture load of the components is lower,
increasing the chance of mechanical failure
during function [18].
CANTILEVER SPAN
After restoration placement, its durability
is a critical factor for clinical success, since
mechanical failures, in the form of fractures,
have economic consequences for both patient and
dentist. This can be of particularly concern when
considering cantilever structures, replacing more
teeth than the amount of available abutments.
Cantilever prostheses represent a projecting
structure that is supported at only one end by
the abutment. This situation may arise when it
is not possible to place another implant, due to
anatomical features, limited nances or any other
reason. The prosthetic structure must be able to
withstand the function and dissipate the forces
through its structure, implants and bone, without
visible elastic or plastic deformation [19,20].
Different reports have indicated that the
clinician should plan the implant-supported
rehabilitation to promote an axially force
transmission through the prosthetic
structures [20,21]. This recommendation is
crucial since a chewing load with equal intensity,
applied at different sites of the prosthetic
structure, can signicantly modify the mechanical
behavior of the implant and the bone. Based on
this, careful attention is needed when planning
cantilevered implant-supported rehabilitation,
since the treatment plan inherently incorporates
a compromised axial load transmission (in
the function of the presence of a horizontal
lever arm) [21]. Figure 3 illustrates a posterior
xed dental prosthesis in which the number of
prosthetic abutments is higher than the number
of cantilever elements, aiming to reduce the effect
of the cantilever.
To avoid possible damage caused by an
extremely extended lever arm, the nal dimension
of the arm should be well controlled and properly
designed by the dentist and the dental technician.
This recommendation is significant since the
cantilever increases the power arm of the
horizontal lever, and its magnitude should also
be evaluated according to the xed part of the
lever, i.e. the resistance arm [22]. Therefore,
the cantilever length should be measured from
the center of the last implant platform until the
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region of load application [23]. In addition,
the cantilever is more commonly extended to
distal side which tends to be more detrimental;
however, it can also be extended to the mesial
as presented in the Figure 3.
It is plausible that the impact of the cantilever
bending with anterior implants would be more
destructive in cases with unfavorable arch
geometry, an excessive overjet, and with inclined
implants [22]. However, for posterior implants,
the amount of stress magnitude would be
proportional to the cantilever length. The rst
option to reduce any undesired biomechanical
effect caused by a cantilever arm is simple: reduce
its extension or length. A reduced cantilever
arm can generate less stress magnitude around
the last implant, modifying the power arm in a
positive ratio (Figure 4). However, in a short-
span cantilever, fewer teeth can be placed in the
prosthetic design, sometimes requiring smaller
dental elements or modied occlusions concepts
(e.g. reduced occlusal platform) to properly
rehabilitate the arch.
Another option to reduce the cantilever
length is using a higher inclination for the implant’s
placement, an approach that can also improve the
mechanical response with lower stress magnitude
in full-arch-rehabilitations [22]. However, this
option could only be possible if the surgical
phase was planned accordingly. In addition,
inclined implants with the same cantilever
length as axial implants can negatively impact
the biomechanical behavior and compromise the
treatment longevity [21-23].
SPLINTED CROWNS
The conventional hypothesis for splinting
implant-supported crowns is to decrease stresses
and improve prostheses stability. This hypothesis
inspired several investigations in the sphere of
biomechanics in dentistry.
A previous photoelastic investigation of a
partially edentulous mandible observed that
the effect of splinting crowns, on the strain
transference to implant-supported restorations,
was that they shared the occlusal loads and
distributed the strain more homogeneously
between the implants [24].
Another
in vitro
study evaluated the
effects of two types of superstructures (splinted
and non-splinted crowns) on four vibration
Figure 3 - Rehabilitation with a four-unit posterior bridge of the first premolar using a mesial cantilever concept.
Figure 4 - Stress maps showing a posterior rehabilitation with different cantilever lengths and the incidence of 100 N load. It is illustrated that
the higher the lever arm, the higher is the stress concentration.
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characteristics (natural frequency, damping
ratio, vectors in antiphase and maximum
displacement) by using modal analysis. According
to their ndings, the crown splinting reduced the
deformation of the superstructure, the implants,
and the surrounding tissues, in comparison to
the deformation observed when no splinting was
employed [25]. The mechanical behavior reported
in these
in vitro
investigations corroborates the
ndings from the stress theory. Using a FEA, the
stress distribution in the implants, components
and the bone tissue for splinted and non-splinted
crowns were evaluated with different lengths
of implants. The authors demonstrated that the
design with splinted crowns promoted lower
stress magnitude in evaluated structures [26].
To date, there is no consensus in the scientic
literature about the ideal prosthetic design that
should be used to optimally restore multiple
implants in the posterior edentulous region,
to reduce strain during loading. However, it
seems plausible that splinted prosthetic designs
present a suitable biomechanical behavior when
compared with a fixed bridge [27]. Figure 5
shows the strain maps for the cortical bone with
non-splinted and splinted crowns. Based on this
image, the use of splinted crowns appears to be
more benecial for the central implant.
CROWN/IMPLANT RATIO
Among the biomechanical parameters that
can be cited, the crown-to-implant ratio has been
extensively investigated in biomechanical studies
and theoretical analyses. It can be generally
dened as the relationship between the crown
height and the implant lengths. The common
condition on this concept is related with the
use of short implants, since their use frequently
results in prosthetic rehabilitations with high
crowns length and unfortunately, the creation of
a deleterious fulcrum [28]. A systematic review
investigated the effect of the crown-implant ratio
on the survival rate and complication incidence of
implant-supported prostheses. According to the
authors, the collected information was insufcient
to analyze the relationship between the crown-
implant ratio and technical complications in
implant-supported prostheses [29].
In theory, the crown-implant ratio can
impact the bone level maintenance. According to
previous studies, lower crown-implant ratio may
induce lower stress magnitude on the implant-
supported prostheses; thus, reducing technical
complications in the components [30,31].
In vitro
strain gauge and photoelastic
analyses have demonstrated that different crown-
implant ratios presented no signicant differences
in buccal or palatal microstrain when the force
was applied through the long vertical axis of
the implants [31,32]. However, the prosthetic
crowns are not exclusively submitted to axial
loading. A numerical simulation evaluated the
stress distribution in the fixation screw and
bone tissue around internal hexagon implants
in single-implant supported prostheses with
crowns of different heights. According to the
investigation, the increase of the prosthetic crown
height induced higher stress concentrations in
the xation screw and in the bone tissue around
implants, under oblique load [32].
It was recommended that the occlusal
design should be carefully planned, since factors
such as a non-axial load, bruxism, bone quality
and systemic conditions, might induce loosing
and/or fracture of the fixation screw, as well
as, the initiation of progressive bone loss [32].
Figure 5 - Strain in cortical bone with a 3-unit prosthesis with individual crowns or with splinted crowns (a bridge) after the incidence of a 100
N load on each tooth. Higher strain at the central implant is visible when the crowns are not splinted.
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Nevertheless, short implants may be considered
as an alternative to standard implants, due to
their simplicity and lower-cost, since they can
be placed in different areas to avoid sinus lifts
and nerve repositioning. Another application
may be to shorten the treatment time in patients
that require faster treatments [33]. However,
further research in this eld is required due to
the lack of data regarding the success and failure
in comparison with standard implants.
Figure 6 illustrates the stress generated in
an implant-supported crown at different heights
when an oblique load is applied. It is illustrated
that the area more prone to failure is in the
implant-abutment joint and the prosthetic screw.
LOADING DIRECTION
In vivo
and
in vitro
studies have illustrated
the potential detrimental effect of excessive
mechanical load on peri-implant bone. Clinically,
certain factors are able to increase the load
effect and the incidence of no-axial loads. This
is supported by previous investigations on early
and immediate implant loading, which provided
information on the impact of mechanical loading
on the process of osseointegration. It was
demonstrated that micromotion between the
implant and peri-implant tissues compromises
the osseointegration process [34].
Corroborating with previous investigations
with FEA, histological and Immunohistochemistry
analyses, it was to demonstrated that traumatic
occlusion resulted in changes in alveolar bone
mechanobiology morphology [35]. It is common
in the implant dentistry to evaluate stress maps
generated during loading, to indicate that the
stress concentration is particularly high at the
bone–implant interface in different locations:
distal, medial and proximal zones. In addition, the
distribution and the magnitude of the equivalent
stress induced in the dental prosthesis depends
on the nature of the functional loading [36].
Figure 7 illustrates how the same posterior
crown can have different mechanical responses
by modifying the incidence of the load direction.
Note that the amount of force remains the same,
i.e., the patient is not biting harder.
Variations in macro and micro implant
design can modify the implants mechanical
response, as well as, their role in the bone tissue
mechanical response, during compressive loading.
Despite the effect of several factors, which have
been previously explored in the literature,
investigations demonstrated that each clinical
case presents unique combination of parameters
that are still necessary to be evaluated to provide
useful information for clinical practice [37]. In
most of the cases, excessive loads are concentrated
around the cervical region, causing microcracks
in the bone, resulting in implant loosening and
eventual failure. This tendency became more
pronounced with a 45° loading direction and
eccentric loading [38]. Based on this mechanical
behavior, it was reported that axial loads are less
harmful to the bone tissue, as the stresses are
distributed throughout the implant, while oblique
loads tend to create higher bone microstrain in
the bone tissue [39].
Figure 6 - Stress at the unitary posterior crown with different heights after the incidence of 100 N (45°). The stress level increases proportionally
to the height of the crown.
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It was also suggested that the distribution
of forces can mitigate implant overload, through
multiple occlusal contacts on multiple posterior
teeth, instead of a single contact in just one
crown. However, multiple contacts placed away
from the center of the implant can cause a
cantilever effect, modifying the load incidence
from purely axial to an oblique vector [40]. In
summary, occlusal contacts that occur away
from the implant’s axis generate greater implant
and peri-implant stresses and had a greater
effect on resultant stresses than increased cusp
inclination. This mechanical behavior can be
observed during a bending movement at the
implant-bone interface, as the implant lacks an
initial adaptive phase of movement, as opposed
to a natural tooth with absorption of forces by
the periodontal ligament [40].
Furthermore, an occlusal anatomy design
with reduced cusp angulation and less evident
occlusal sulcus, can reduce the stress concentration
and increase the fracture load for ceramic
posterior crowns. Therefore, less pronounced
occlusal anatomy would improve implant loading
distribution and could be beneficial for the
survival of the restoration [41-43].
CROWN-RETENTION SYSTEM
Another parameter that the clinician can
control is the crown-retention system (Figure 8).
The crown-retention system is usually divided
into cement or screw-retained [44-49]. There
is no consensus regarding the most appropriate
retention type for long-term implant survival,
since the clinician’s experience tends to be the
most important factor when selecting the type of
retention used in implant rehabilitations [43,45].
Notwithstanding, there are unique
considerations for each type of retention. The
screw-retained restoration can be easily removed
when maintenance is required; however, the
screw-access hole can negatively impact the
nal esthetics [46-49]. In addition, the screw-
access hole must be closed with resin composite,
which can suffer wear or debonding (Figure 9),
compromising the occlusal anatomy [47]. The
cement-retained restoration can improve the crown
esthetics and the nal retention will be related to
the abutment dimension [49]. Moreover, excess
of residual cement can promote inflammatory
process in the surrounding tissues, which is a
harmful condition for the oral health [43,44].
The mechanical stability of the prosthetic
components in the implant-prosthesis complex
is essential to the long-term success of the
restorations. However, little is known about the
differences in the biomechanical behavior of
Figure 7 - Stress at the unitary posterior crown after the incidence
of 100 N axially to the implant axis and oblique to it (45°).
Figure 8 - Schematic illustration showing an anterior cement-
retained and screw-retained crowns for the same case.
Figure 9 - The reversibility of screw-retained restorations is an
important advantage of this design, although the aesthetics can be
slightly impaired with the screw-access hole.
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screw or cement retained prostheses. According
to a previous study that compared the pre-load
maintenance, stresses, and displacements of
prosthetic components of screw and cement
retained implant-supported crowns, the screw-
retained prosthesis demonstrated a higher
risk of screw loosening and fracture [42].
However, other study compared the stresses and
displacements in the peri-implant bone generated
by screw and cement retained prostheses using
the FEA. Results illustrated a similar pattern in
the distribution of the principal stresses between
both prostheses [46]. The lack of consensus
in the literature is reflected by variations in
the design of the prosthesis. The retention of
implant restorations can be impacted by other
factors, such the cantilever length and the loading
direction of implant positioning. However, as
a generality for the implant and bone tissue,
the difference between both retention systems
would be insignicant in stresses, when similar
biomaterials and abutment dimensions are
compared (Figures 10 and 11).
A previous systematic review of 39 studies
aimed to assess the technical and biological
complications of screw and cement retained
implant-supported full-arch dental prostheses,
found that cemented retained restorations
exhibited more biological complications, and
that screw-retained prostheses exhibited more
technical problems [50]. Clinical outcomes were
affected by both systems in different ways. The
screw-retained restorations were more easily
retrievable than cemented ones, implying that
technical and eventually biological complications
could be prevented and/or treated more
predictably. Based on the easier retrievability
and higher biological compatibility, the authors
suggest that screw-retained restorations are
preferable [50].
PROSTHETIC CONNECTION
As previously mentioned, the crown can
be retained by either cement or using a screw.
The abutment, which can exist as two-pieces,
Figure 10 - After similar loading (100 N), there is no difference in the generated stress maps according to the crown-retention system.
Figure 11 - After similar loading (100 N), there is no difference for the strain maps generated with both crown-retention system for the cortical
bone strain.
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are usually retained by a screw and connected
with the implant with its prosthetic connection
(Figure 12).
According to a report, the implant
connection type had a greater impact compared
to the diameter on the stress in the implant and
abutment. When selecting the dental implant
type, the connection type should be considered
as an important factor, as well as, the size of
the restoration [51]. There are several type
and designs of connections; however, the most
common are the external hexagon, internal
hexagon and the Morse-taper.
Connection types were also assessed
with three-dimensional FEA. The preceding
investigation evaluated the mechanical inuences
of the implant–abutment connection type and
inter-implant distance on the bone stress. Using
computer-aided design models of implants with
external connection, internal connection and
conical connection, a previous investigation
demonstrated that the stress of the inter-implant
bone increased as the inter-implant distance
decreased [52]. Comparing only internal
connections, systems that contained a retention
screw had the disadvantage of concentrated
stress, while a solid abutment retained by friction
dissipates the load through the implant and
suggests improved performance [53]. However,
the frictional abutment is not available for every
system and is not always easily removed when
required [54].
A previous report demonstrated that the
abutment connection also affects the stress
concentration in peri-implant bone [53-55].
However, the authors considered the effect of
platform switching as a factor between models
with a similar Morse taper connection [55].
Comparing external hexagon and Morse-taper
designs, a numerical simulation with strain gauge
validation indicated no difference regarding the
prosthetic connection for the generated stress and
strain under axial load. The authors concluded
that both implant connections exhibit similar
biomechanical behavior regardless of the bone
height [39]. However, another 3D-FEA illustrated
a different mechanical behavior on the prosthetic
screws between external hexagon implants
and Morse taper implants, when different
tightening loads were present. According to their
ndings, the torque loads above the manufacturer
recommendations can cause plastic deformation
in the Morse-taper abutment screw threads. The
screws of Morse taper implants can be more
sensitive to higher loads than external hexagon
implants [55].
EMERGENCE PROFILE
The emergence profile ideally should be
designed following the soft tissue, to improve
the natural aesthetical look of the implant-
supported crown. However, to increase the
amount of peri-implant tissue, it is necessary to
reduce the volume of restorative material at the
cervical level (Figure 13). This concave silhouette
approach increases the biological benets for soft
tissue stability, such as marginal sealing, blood
supply and stable bone level. It is important to
understand that the cervical area is highly prone
to fail since fractures can occur in this area due
to high levels of stress magnitude [56].
Figure 12 - An implant-supported crown can be retained by different
implant connections that share the same clinical indication.
Figure 13 - Zirconia monolithic crown with different emergence
profile concepts. (A) After the proper soft tissue conditioning and
(B) with more ceramic volume. In this case, the CAD anatomy used
for both crowns designing was similar in the software and only the
emergence profile was modified.
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Biomechanics of Implant-supported restorations
Andrade GS et al.
Biomechanics of Implant-supported restorations
Stress concentrations associated with
fractographic analysis suggest that the emergence
profile of the restoration should always be
evaluated, due to the high prevalence of failures in
this area [56]. The reduced amount of restorative
material in the cervical level is a desirable feature
in contemporary crowns design, since the proper
emergence prole improves esthetic outcomes
and provides favorable biological response to
implant-supported restorations [57]. With the aid
of CAD/CAM technology, it is possible to design
the natural emergence prole for posterior implant
crowns, ensuring a more predictable and efcient
restoration for optimal oral hygiene. However,
the keratinized tissue, with sufcient width and
height, needs an abutment with large diameter
to ensure stability and esthetics of hard and soft
tissues around the implants [58].
In some cases of atrophic maxillary bones,
implant placement can be a challenge [59], and
this may also impair the design of the prosthesis.
It is not uncommon that recession of the peri-
implant soft tissue margin may occur after crown
placement, increasing the risk of exposition of
the implants threads [60]. A modication with
the implant/crown ratio and the limitations of
short implants, in relation to occlusal forces, can
result in torque loss and reduced survival rate.
To compensate this, the height of the abutments
should be selected with longer collars [33].
Figure 14 illustrates two molar crowns with
and without an adequate emergence profile.
When less restorative material is used, the
amount of force required to fracture the crown is
also reduced. Therefore, it is critical to assess the
cervical thickness of ceramic crowns to maximize
predictability and success of implant-supported
crowns.
OCCLUSAL SPLINT
After considering all previously mentioned
factors that can affect implant-supported
restorations’ success and longevity, it is imperative
to limit occlusal loads. A promising way to protect
implant-supported restorations is with the
recommendation and utilization of an occlusal
splint appliance. It was demonstrated that
the occlusal appliance can modify the contact
distribution on occlusal surfaces, changing the
stress distribution and displacement patterns in
implant-supported bridges [61].
With the use of an occlusal appliance, the
lowest possible stress levels at the abutment
and implant, and the most favorable stress
distribution, between the cortical and trabecular
bone, can be achieved [61]. Observing the
stress maps calculated in a prior study, under
parafunctional loading, an occlusal appliance
was effective in reducing stress concentration in
implants inserted at bone level [61].
With further corroboration, an
in vitro
photoelastic analysis demonstrated that the
strain distribution in the peri-radicular area of
teeth, supported by an occlusal appliance, can
be mitigated during parafunctional loading. In
addition, the milled occlusal appliance, made
with CAD/CAM, provided the best morphological
adaptation and transferred lower strain to the
bone areas, as compared to the other evaluated
appliances [62].
With the consideration of a 3-unit implant-
supported prostheses, a 3D-FEA investigation
evaluated the biomechanical behavior of this
treatment modality under parafunctional forces
with and without an occlusal appliance. The data
illustrated that an occlusal splint improved the
biomechanical behavior of the prostheses, by
reducing stress in the abutment screws and stress
and strain in the bone tissue. However, it was
also demonstrated that the occlusal splint was
not 100% effective to avoid the biomechanical
benets of splinting crowns [63].
Figure 15 depicts the stress generated by the
same occlusal load applied on the crowns or on
the occlusal splint. The recommendation of an
appliance use should be part of the comprehensive
treatment plan for patients rehabilitated with
implants.
Figure 14 - Stress at the unitary posterior crowns after the incidence
of 100 N oblique load (45°) to the implant axis. The crown with
adequate emergence profile demonstrates higher stress magnitude
due to the reduced volume of restorative material.
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Andrade GS et al.
Biomechanics of Implant-supported restorations
LIMITATIONS
Among the different mechanical tools that
can be applied to estimate the biomechanical
behavior of implant-supported restorations,
FEA consists in a reliable numerical method
to assess complex mechanical conditions. This
mathematical approach can identify the areas of
highest stress magnitude, which coincide to the
areas that are most prone to failure in prostheses
and implants [64,65]. Although a theoretical
method, FEA provides accurate results by dividing
a complex geometry into a finite number of
elements and using the boundary conditions
and physical properties that correspond to the
evaluated restoration [66].
In addition, this method is a non-invasive,
non-destructive analysis, with reproducibility
and provides the advantage to evaluate clinical
conditions that may be difficult with
in vitro
methods [66-68]. This report, that utilized
stress maps, illustrated important biomechanical
principles that should be considered in implant
dentistry. However, this is not a numerical study
and the present figures were made only for
illustrative purpose.
CONCLUSIONS
Due to the constant development and
expansion of implant dentistry eld, the clinician
and technician have many more decisions to make
that impact on the predictability and success of
treatment. Stress analysis provides important
insights in the rehabilitation workflow that
provides critical information regarding implant
treatment decision-making. The more information
the clinician and technician have, the better is the
decision making process, which would ultimately
improve the clinical outcome for the patient.
Author’s Contributions
GSA: Conceptualization, Methodology,
Formal Analysis, Investigation, Resources,
Data Curation, Writing – Original Draft
Preparation, Visualization. LK: Conceptualization,
Investigation, Writing – Original Draft
Preparation, Writing – Review & Editing,
Visualization. RLG: Investigation, Resources,
Writing – Original Draft Preparation and
Project Administration. DA: Conceptualization,
Investigation, Resources, Writing – Original
Draft Preparation and Visualization. AJF:
Conceptualization, Methodology, Software,
Validation, Formal Analysis, Investigation,
Resources, Data Curation, Writing – Review
& Editing, Visualization, Supervision, Project
Administration and Funding Acquisition. JPMT:
Conceptualization, Methodology, Software,
Validation, Formal Analysis, Investigation,
Resources, Data Curation, Writing – Review
& Editing, Visualization, Supervision, Project
Administration and Funding Acquisition.
Conict of interest
The authors declare no conict of interest.
Funding
This research received no external funding.
Regulatory Statement
Not applicable.
Figure 15 - Stress at a posterior bridge after 100 N load without and with a 4 mm occlusal splint made in acrylic resin.
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Biomechanics of Implant-supported restorations
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Biomechanics of Implant-supported restorations
Andrade GS et al.
Biomechanics of Implant-supported restorations
Date submitted: 2022 Sep 20
Accepted submission: 2022 Oct 25
João Paulo Mendes Tribst
(Corresponding address)
University of Amsterdam and Vrije Universiteit Amsterdam, Academic Centre for
Dentistry Amsterdam, Department of Oral Regenerative Medicine, Amsterdam, The
Netherlands
Email: j.p.mendes.tribst@acta.nl
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