ORIGINAL ARTICLE

Finite Element Analysis to Compare Complete Denture and Implant-Retained Overdentures With Different Attachment Systems
o, DDS, MSc,* Wirley Gon0alves Assun0a o, DDS, PhD,* Valentim Adelino Ricardo Bara Lucas Fernando Tabata, DDS, MSc,* Juliana Aparecida Delben, DDS,* rica Alves Gomes, DDS, MSc,* Edson Antonio Capello de Sousa, PhD, E and Eduardo Passos Rocha, DDS, PhD*
Abstract: This nite element analysis compared stress distribution on complete dentures and implant-retained overdentures with different attachment systems. Four models of edentulous mandible were constructed: group A (control), complete denture; group B, overdenture retained by 2 splinted implants with bar-clip system; group C, overdenture retained by 2 unsplinted implants with oring system; and group D, overdenture retained by 2 splinted implants with bar-clip and 2 distally placed oring system. Evaluation was performed on Ansys software, with 100-N vertical load applied on central incisive teeth. The lowest maximum general stress value (in megapascal) was observed in group A (64.305) followed by groups C (119.006), D (258.650), and B (349.873). The same trend occurred in supporting tissues with the highest stress value for cortical bone. Unsplinted implants associated with the oring attachment system showed the lowest maximum stress values among all overdenture groups. Furthermore, oring system also improved stress distribution when associated with bar-clip system. Key Words: Dental implants, complete denture, overdenture, attachment, nite element analysis (J Craniofac Surg 2009;20: 1066Y1071) ment, such as retention and stability improvement, increased comfort and chewing efciency,2Y4 greater satisfaction, and an improved patients quality of life.5Y7 In comparison to implantsupported prosthesis, the implant-retained overdentures require fewer implants, less invasive and expensive surgical procedure, and simplied laboratory procedures by using a premanufactured retention system with lower costs, thus making the treatment more accessible to a higher number of edentulous patients.8Y10 Such characteristics associated with the high success rate in implant treatment make the overdenture retained by 2 implants the rstchoice treatment for the edentulous mandible.11 Despite the reported high success rate of implants, implant failure remains a source of frustration and disappointment for both patient and clinician. Biomechanics evaluations suggest that the implants overload12 as a factor for the cortical bone loss. The loads generate stress that is dissipated from attachment system to implants and supporting tissue. The intensity and amplitude of bone loss are determined by mechanisms of stress transmission and distribution by each attachment system.13 A favorable prognosis requires a correct selection of the attachment system based not only on retention or cost aspects but also in biomechanics aspects, once it is the most fragile link between prosthesis and implant.14 Bioengineering studies have demonstrated the biomechanical characteristics of implants and the prosthesis, and engineering tools may be used to evaluate and quantify the stress on implants and the deformations of prosthetic components. Clinically, it is still not possible to assess stress/strain distribution of implant-retained overdentures at bone level but only at abutment level through strain gauge analysis.15 Furthermore, there are other methods based on simulation, such as photoelastic method4,16 and nite element analysis (FEA),17Y20 which allow better understanding of transfer and distribution mechanisms of stress via implants to supporting tissue.21 However, these mechanisms are not completely understood in overdenture treatments, and the necessity of splinted implants remains inconclusive.10 Thus, this study aimed to compare stress distribution on conventional complete dentures and implant-retained overdentures with different attachment systems (bar-clip, oring, and bar-clip associated with distally placed oring) using a 2-dimensional FEA.

mplant therapies have increased the range of prosthodontic options for the treatment of edentulism.1 The implant-retained overdenture treatment shows some advantages over the complete denture treat-

From the *Department of Dental Materials and Prosthodontics, Ara0atuba Dental School, and Department of Mechanical Engineering, Bauru Engineering School, Sa o Paulo State University (UNESP), Sa o Paulo, Brazil. Received February 23, 2009. Accepted for publication March 3, 2009. Address correspondence and reprint requests to Wirley Gon0alves Assun0a o, DDS, PhD, Department of Dental Materials and Prosthodontics Ara0atuba Dental SchoolYUNESP Jose o Bonifa cio, 1193, Ara0atuba, Sa Paulo Brazil 16015-050; E-mail: wirley@foa.unesp.br This study was supported by the State of Sa o Paulo Research (FAPESP) (grant numbers: 06/52230-6 and 06/59770-6). The authors did not receive funding for research on which their article is based from any of the following organizations: National Institutes of Health, Wellcome Trust, Howard Hughes Medical Institute, or others. Copyright * 2009 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3181abb395

MATERIALS AND METHODS Finite Element Models

Four nite element (FE) models were constructed reproducing a frontal section of edentulous mandible. The models were divided into 4 groups: group A (control), a model of edentulous

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Stress FEA in Complete and Overdentures

FIGURE 1. Finite element mesh of edentulous mandible. A, Conventional complete dentureVgroup A (2826 elements and 5848 nodes). B, Overdenture retained by 2 splinted implants with bar-clip systemVgroup B (9778 elements and 20,494 nodes). C, Overdenture retained by 2 unsplinted implants with oring systemVgroup C (7890 elements and 16,350 nodes). D, Overdenture retained by 2 splinted implants with bar-clip system associated with 2 distally placed oring systemVgroup D (8872 elements and 18,686 nodes). mandible supporting a complete denture; group B, a model of edentulous mandible supporting an overdenture retained by 2 splinted implants with bar-clip system; group C, a model of edentulous mandible supporting an overdenture retained by 2 unsplinted implants with oring system; and group D, a model of edentulous mandible supporting an overdenture retained by 2 splinted implants with bar-clip system associated with 2 distally placed oring system. The denture contour was obtained from a frontal photographic image of the demonstration model of a mandibular complete denture. The mucosa and cortical bone were reproduced as 1- and 0.5-mm layers, respectively. Trabecular bone was reproduced as a 20-mm layer in which 2 implants of 3.75 mm in diameter and 11.5 mm in length (Master Screw; Conexa o Sistemas de Pro o Paulo, SP, Brazil) were positioned at the anterior tese Ltd, Sa region for groups B, C, and D. The interimplant distance between 2 implants was 20 mm. Two plastic cylinders UCLA type (055021; Conexa o Sistemas de Pro tese Ltd) and plastic bar-clip attachment (204000; Conexa o Sistemas de Pro tese Ltd) were used for bar fabrication. The bar, with a round shape, was cast in Co-Cr alloy (CNG Solu0o es Prote o Paulo, SP, Brazil) according to standard laboratory ticas, Sa procedures. The plastic clip was connected to the bar, and this set was screwed to the implants characterizing group B. In group C, the oring attachment system (049071; Conexa o Sistemas de Pro tese Ltd) was connected to the implant. Group D was characterized by the association of groups B and C models. The sets were embedded in a cold acrylic resin (Jet; Artigos Odontolo o Paulo, SP, Brazil) using an gicos Cla ssico Ltd, Sa embedding machine (Arotec PRE 30S; Arotec S. A. Ind e Com, Cotia, SP, Brazil). The implant-attachment complex was longitudinally sectioned using a saw machine (Isomet 1000 Precision Saw; Buehler, Lake Bluff, IL) and then scanned (HP scanjet 2400; Hewlett-Packard Company, Palo Alto, CA). The scanned images * 2009 Mutaz B. Habal, MD were imported into image analysis software (AutoCAD 2005; Autodesk Inc, San Rafael, CA). The outline of the models images was manually quoted, and each point was converted into x and y coordinates. The coordinates were nally imported into the FE software (Ansys 11.0; Swanson Anlysis System, Houston, PA) as key points of denitive images. Ten different types of materials were assigned for the models of the 4 groups: acrylic tooth, acrylic resin, mucosa, cortical bone, trabecular bone, titanium alloy, Co-Cr alloy, stainless steel, plastic clip, and oring rubber. Each object was then subdivided in smaller elements. The elements shapes were 2-dimensional 6-node, triangular, plane strain element (plane 2). The models had a total number

TABLE 1. Materials Mechanical Properties Materials Youngs Poisson Modulus, MPa Ratio (Y) Reference

Acrylic tooth 3000 Acrylic resin 3000 Mucosa 680 Cortical bone 13,700 Trabecular bone 1370 Implant (Ti-6Al-4V) 103,400 Co-Cr alloy 218,000 Stainless steel 19,000 Plastic clip 3000 Oring rubber 5

0.35 Tanino et al22 0.35 Tanino et al22 0.45 Ko et al23 0.3 Barbier et al24 0.3 Barbier et al24 0.35 Sertgoz and Guvener25 0.33 Caglar et al26 0.31 Bara o et al20 0.28 Bara o et al20 0.45 Chun et al19

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FIGURE 2. First principal stress distribution (MPa). A, group A (conventional complete denture). B, group B (overdenture: bar-clip system). C, group C (overdenture: oring system). D, group D (overdenture: bar-clip associated with distally placed oring system).

of 2826 elements and 5848 nodes in group A (Fig. 1A), 9778 elements and 20,494 nodes in group B (Fig. 1B), 7890 elements and 16,350 nodes in group C (Fig. 1C), and 8872 elements and 18,686 nodes in group D (Fig. 1D).

Loading Conditions, Constraints, FE Analysis, and Postprocessing Results

Static load of 100 N17 was applied perpendicular to the incisal surface of lower central incisors to simulate vertical loading condition. Boundary conditions were established by constraining the models at the left and right sides to allow bending of the mandible.16 The FE analysis solver, Ansys 11.0, was used for processing the situations. All materials used in this study were considered to be isotropic, homogeneous, and linearly elastic. Models were assumed to be in a plane strain condition (?z = 0, and Rz m 0). Table 1 shows the materials properties. In addition, 100% bone-implant contact

was assumed. A screw joint was established between implants and prosthetic components, and the prostheses contact was dened as resting on the mucosa. Data for rst principal stresses were produced numerically, color coded, and compared among the models.

RESULTS
After data processing by the FE program, the stress maps were obtained for groups A, B, C, and D (Fig. 2). Punctual stress areas at the left and right edges of cortical bone were observed mainly for group A. The condition of fastening the models on the lateral sides allows bending of the mandible during load application. Consequently, upper and lower cortical bones are more requested, which leads to a higher stress concentration at the border of this structure. Because these areas would not be so evident clinically, they should be carefully evaluated. Therefore, a broader evaluation

TABLE 2. Maximum and Minimum Stress Values and Locations for Groups A, B, C, and D Stress Maps, MPa Group A B C D Maximum Stress 64.305 349.873 119.006 258.65 Location Upper cortical bone Contact area between left implant medial platform and bar retainer Left oring capsule Contact area between left implant medial platform and bar retainer Minimum Stress 0.452 0.003 0.013 0 Location Lower cortical bone Bar superior area, above left implant Left oring rubber Bar superior area, above right implant * 2009 Mutaz B. Habal, MD

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Stress FEA in Complete and Overdentures

groups B and D, whereas in group C, these stress areas were noted at the distal and medial side of the implants.

DISCUSSION
All in vitro analyses to simulate a physical problem present an inherent limitation to accurately reproduce the properties and characteristics of in vivo structures. For this reason, the stress values provided by FE models are not necessarily identical to actual ones.17 In addition, it is unknown at which amount of stress biologic changes, such as resorption or deposition of the bony structures, take place.17,27 Thus, this study aimed to compare stress distribution on conventional complete dentures and implant-retained overdentures with different attachment systems. Considering maximum stress values between groups, overdenture groups (groups B, C, and D) showed higher stress values than complete denture group (group A) (Table 2; Fig. 2). This may result from the presence of implant and attachment system in overdenture groups that decrease the amplitude of prosthesis movement. Overdenture treatment improves denture retention and stability leading to a higher comfort and chewing efciency.2,3 However, this better chewing efciency may result in a higher articial denture teeth wearing.28,29 Regarding the stress distribution with different attachment systems, bar-clip attachment (group B) showed the highest stress values followed by bar-clip attachment with distally placed oring attachment (group D) and oring attachment system (group C) (Table 2). Mericske-Stern et al30 compared force transmission onto implants supporting overdentures with bar connectors and single telescopic crowns by piezoelectric transducers. The authors found a general tendency to higher forces with telescopes and a positive effect of rigid bars for load sharing. Similar results were observed by Assun0a o et al,31 which compared stress distribution in implantretained overdentures with different attachment systems in FE models. Nevertheless, Kenney and Richards5 evaluated photoelastic models of implant-retained overdentures and stated that oring attachment system transferred lower stress for the implants in comparison to bar-clip system. This nding is in agreement with Tokuhisa et al.15 Other studies17,18,27,32 also showed stress optimization in overdenture with unsplinted implants (eg, oring

FIGURE 3. Maximum rst principal stress values (in MPa) in supporting tissues, implants, and prosthetic component for the 4 groups. of cortical bone was performed, restricted not only to the lateral side of models. The values and location of maximum and minimum stress for all groups are presented in Table 2. Group B (bar-clip attachment system) showed the highest maximum stress values followed by groups D (bar-clip associated with distally placed oring attachment system), C (oring attachment system), and A (conventional complete denture) (Table 2). The same behavior regarding stress values was observed in supporting tissues (mucosa, upper cortical bone, lower cortical bone, and trabecular bone), implants, and prosthetic components, although the differences in stress values among the overdenture groups (groups B, C, and D) have been slight in the supporting tissues (Fig. 3). Considering only supporting tissues, cortical bone showed the highest stress values for all groups (Fig. 4). Cortical bone stress concentrations were noted at the distal side of the implants for

FIGURE 4. First principal stress distribution (MPa) in supporting tissues for groups A, B, C and D. * 2009 Mutaz B. Habal, MD

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attachment system) corroborating with the results of the current study. In the current study, the lower stress values with oring attachment system (Table 2) may result from the exibility and resiliency provided by the oring rubber and the spacer in the oring system assembly. Moreover, the stress-breaking effect of the oring rubber can also decrease the stress in implants, prosthetic component, and supporting tissues15 (Figs. 3 and 4). On the other hand, Celik and Uludag33 comparing the effect of different attachment systems on stress distribution of implantretained overdentures found that the splinting of implants optimized stress distribution. The authors reported lower stress values for bar associated with distally placed ball attachment system when compared with bar-clip attachment system, corroborating with the results of the current study (Table 2 and Fig. 3). The use of distally attachments on bar-clip system creates a fulcrum line in this portion. The prosthesis rotates anteroposteriorly around the fulcrum line and, due to the elastic modulus of the resilient matrices that t around the ball attachments, the stress magnitude on the implants is reduced.20,33 This result is in agreement with the study of Ben-Ur et al.34 Concerning stress location, in group A, the stress was observed at applied load area, whereas in groups B, C, and D, the stress was located mainly in the implants and cortical bone surrounding implants (Fig. 2). These might be explained as result of the stress-transferring mechanism that occurs in the implant-bone complex.35 Stresses induced by occlusal loads are initially transferred from implant to cervical bone, whereas a small amount of remaining stress is spread to trabecular bone at apical region. It is also possible that higher strain values are observed in cortical bone because it presents higher elastic modulus compared with trabecular bone17,35 and thus greater ability to transfer stress.35 These ndings are in accordance with in vitro studies17Y19,36 that found higher stress concentration in cortical bone around implant neck and in vivo studies24,37 that have demonstrated that bone loss is initiated in the region around the implant neck. In the comparison of stress values in the cortical bone among different overdenture groups, higher peak of stress concentration in the groups with splinted implants (groups B and D) was observed (Fig. 4). This can be indirectly related to mandibular deformation during load application, which creates torsion in the central part of the mandible.18 In group C, the 2 implants are independent and can follow the bone distortion without affecting it.18 Nevertheless, with the bar-clip system, the rigid bar connecting the 2 implants tends to counteract this movement and leads to more stress in the periimplant bone.18 In FE models, there was higher stress in the cortical bone at the distal side of the implants (Figs. 4B, D) when the implants were connected by the bar (groups B and D). This location may be explained by the fact that the bar prevents implants movement during bending of the mandible as a result of vertical load.17 On the other hand, when the implants are unsplinted (group C), they are able to approach each other when the mandible bends.17 So the stress is equally high at the medial and distal sides of the implants16,18 (Fig. 4C). This tendency corroborated with the results obtained by Hobkirk and Schwab,38 who conducted an in vivo study on mandibular deformation in subjects with osseointegrated implants connected by rigid superstructure, and by Meijer et al17 and Meniccuci et al18 in their studies using FE models. Because the stress distribution is an important factor for bone resorption during implant rehabilitation,19 the attachment system should present an adequate stress transfer to avoid bone resorption and improve treatment prognosis. Although the ball attachment system has shown better biomechanic behavior than bar-clip system, other aspects should

be reached during overdenture attachment system selection such as intermaxillary space,39 implant arrangement,40 and required maintenance,41 which according to MacEntee et al42 is more frequently required for ball attachment when compared with other systems.

CONCLUSION
Within the limitations of this in vitro study, the following conclusions can be drawn: & Higher stress values were observed in implant-retained overdenture groups when compared with conventional complete denture group. & Attachment systems produced different stress distribution characteristics, and in the supporting tissues, the stresses were mainly concentrated in the cortical bone surrounding the implants. & The use of unsplinted implants associated with the oring attachment system (group C) showed the lowest maximum stress values followed by bar-clip with distally placed oring system (group D) and bar-clip system (group B).

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Stress FEA in Complete and Overdentures

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