Biomechanical Comparison Of Diffirent Framework Materials In Mandibular Overdenture Prosthesis Supported With Implants Of Different Sizes: A Finite Element Analysis

doi:10.21203/rs.3.rs-2604708/v1

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Research Article

Biomechanical Comparison Of Diffirent Framework Materials In Mandibular Overdenture Prosthesis Supported With Implants Of Different Sizes: A Finite Element Analysis

https://doi.org/10.21203/rs.3.rs-2604708/v1

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published 05 Jul, 2023

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Backgrounds:

The aim of this study was to evaluate the stresses on the supporting bone, implants, and framework materials under masticatory forces in mandibular overdenture prostheses modeled with different framework materials and different implant types, using the finite element analysis (FEA).

Methods:

For the finite element modeling, two identical mandibular jaw models were created, one with two standard (diameter:4.1 mm/12mm length) and the other two mini-implants (diameter:2.4 mm/12mm length) placed in the canine teeth region. The PMMA denture was modeled on them, supported by Cobalt Chromium alloy (CoCr), Poly-ether ether ketone (PEEK), and Zantex materials with framework. No framework was added as a control model; only Polymethilmetacrilate (PMMA) overdenture prosthesis was modeled.

Results:

Regardless of the framework materials of the overdenture prostheses, the stress values on mini-implants in all models yielded approximately two times higher results compared to standard implants. More stress transmission was observed in the support bone and implants in PMMA prostheses and overdenture prostheses supported with PEEK, Zantex, CoCr alloy frameworks, respectively. In the framework materials, more stress occurred on CoCr, Zantex, PEEK in that order.

Conclusion:

In light of this study, the use of mini-implants as an alternative to standard implants is not promising in terms of distribution and transmission of chewing stresses. As an framework material, standard rigid metal alloys were found to be more advantageous than polymer materials in terms of stress distribution.

Finite element analysis

Implant supported overdenture

Mini implants

PEEK

One of the biggest problems in edentulous patients is the stability, retention, and mobility of traditional prostheses. In addition to these problems, pain, speech difficulties, and chewing problems are also seen in patients who use conventional mandibular dentures with excessive bone loss [1]. Implant-supported overdenture prostheses significantly increase the quality of life of patients who are not satisfied with traditional prostheses. Overdenture prosthesis treatment supported by two implants in the edentulous mandible is recommended as a standard treatment protocol [2,3]. In recent studies, mini dental implants have also been recommended to support overdenture prostheses in mandibular crests with severe bone resorption and in patients who cannot handle surgical procedures [1–4]. Mini-implants are generally produced in diameters between 1.8 and 2.4 mm and as a one-piece system. Compared to traditional implants, it is less invasive, surgically placed on the jawbone, has fewer complications, and they are cheaper and more comfortable [3]. There are studies using 2 or 4 implants to support overdenture prostheses [1,2,5].

Studies on clinical complications such as acrylic base deformation and prosthesis fractures in implant-supported overdenture prostheses tend to deform at weak points such as the abutment circumference and the midline of overdenture prostheses during use [5]. It has been reported that supporting the overdenture denture base with a cast metal framework would be effective in dispersing chewing stresses and preventing base fractures [6,5]. However, the difficulty of the construction stages of metal alloys, the risk of allergy, metallic color, and metallic taste are disadvantages for use. In addition, there are studies in which the denture base is supported by fiber materials. Fiber materials are a simpler and more aesthetic option than metal framework materials [7–9]. Metal frameworks and Poly-ether ether ketone (PEEK) materials are used as prosthetic base materials. In addition, recent polymer materials that are lighter than metal produced with CAD/CAM and that have a modulus of elasticity closer to bone have been used as an alternative to metal frameworks [6,10,11].

PEEK is a semi-crystalline organic polymer with high chemical and mechanical properties [10,12]. It is used in prosthetic treatments due to its high heat resistance, biocompatibility, resistance to oral fluids, and ease of use [6,12]. The risk of plaque involvement and allergy formation is higher than that of metal and other resins. It can be an alternative to metal frameworks in removable prostheses [12]. Zantex is a material containing a high-performance polymer matrix with three-dimensional dense glass fiber added. It has mechanical properties close to bone and is biocompatible. It demonstrates high fracture resistance when used as an framework material in partial and total removable dentures. Zantex is a newly produced material with limited studies on it [11–13].

Finite element analysis (FEA), is a reliable and convenient method to evaluate stress occurring around the bone and implant. This analysis can be used to obtain baseline data for new methods used in the clinic and to determine potential effects. This analysis generates computational data that reveal the behavior of new materials or techniques under simulated clinical conditions [14].

To the authors’ knowledge, no study has been reported in which polymer framework materials (PEEK, Zantex) that have recently appeared on the market in overdenture prostheses made on mini and standard implants are compared with metal frameworks Cobalt Chromium alloy (CoCr) and acrylic base without framework Polymethilmetacrilate (PMMA). In addition, there are no publications on framework material for removable prostheses in relation to Zantex. Our null hypothesis is that prostheses supported by polymer materials create less stress on the bone than metal frameworks, and conventional implants increase the stress distribution on tissues and create less destructive forces than mini-implants.

In this study, FEA models with two dental mini-implants (M1) (Straumann, Institute Straumann AG, Basel, Switzerland) and two standard implants (M2) placed in the canine tooth region were created on the same two mandibular bone models. Four overdenture prostheses with PMMA, PEEK, Zantex (Biofunctional materials, Florida, USA), and CoCr frameworks without a framework were modeled with FEA.

(M1-PMMA, M1-PEEK, M1-Zantex, M1-CoCr; M2-PMMA, M2-PEEK, M2-Zantex, M2-CoCr).

M1-(2.4 mm diameter/12mm length) conventional implant M2- (4.1 mm diameter/12mm length). Straumann one-piece mini-implant systems implants were planned. The O-ring ball abutment was modeled on conventional implants. In the overdenture models, the framework materials were modeled as 1 mm PMMA at the top − 0.5 mm framework material in the middle, with − 0.5mm PMMA at the bottom. The framework materials were modeled along the mandibular crest. Von misses and principle stresses on implants, framework materials, and supporting bone were evaluated with FEA. The created models and their components are shown in Fig. 1.

Modeling of bones

The mandibular bone model used in the study was based on the tomography of a completely toothless adult individual. Tomography data were reconstructed with a slice thickness of 0.1 mm. The tomography data obtained as a result of the reconstruction were transferred to 3DSlicer software in DICOM (.dcm) format. CT data in DICOM format were separated according to appropriate Hounsfield values in 3DSlicer software and converted into a three-dimensional model by segmentation. The model was exported in .stl format The three-dimensional CAD model was imported into ALTAIR Evolve (ALTAIR, Troy, MI, USA) software, where the appropriate mandibular bone was designed. Trabecular bone was obtained by taking the inner surface of the three-dimensional cortical bone of the mandible as a reference, the thickness of which was adjusted. A 2 mm thick mucosa was modeled with reference to the outer surface of the cortical bone. Bone tissues were considered to be isotropic, linear, homogeneous, and 100% osseointegrated into the implants [15,16]. The denture and implant were provided with bonded contact. A flat surface was created underneath and boundary conditions were applied to stabilize the base of the mandible.

Modeling of implants and overdentures

The implants used in the study were modeled using ALTAIR Evolve software based on the measurements. The three-dimensional scanning process of the created overdenture model was performed with a Panda P2 (Pingtum, Suzhou, CHINA) scanning device. To ensure force transfer between the models, the matching process was performed between the mesh structures. The linear material properties of materials given elastic modulus and Poisson's ratio were used in the analyses. The material properties of the analyzed model are defined numerically [1,6,17]. (Table 1)

Creation of mathematical models

Mathematical models were formed by dividing geometric models into simple and small pieces called meshes. After the modeling process was completed in the ALTAIR Evolve software, the models were mathematically created with ALTAIR Hypermesh software and made ready for analysis. Models prepared in ALTAIR Hypermesh software were transferred to the ALTAIR Optistruct analysis program in .fem format to perform the analysis. Quantitative model information for the two different analysis models created is depicted in Table 2.

Loading Scenarios and Boundary Conditions

For both models, a load of 50 N was applied at a 90-degree angle over the foodstuff to simulate the chewing force on the canine and first molars. A total of six linear static analyzes were performed for the two models under the single loading condition. With the use of foodstuff in the chewing force simulation, the loads are distributed and the stress singularity is prevented in the loading zones. The foodstuff force application scenario is shown in Fig. 2.

The models were fixed by restricting all degrees of freedom from the nodal points in the lower regions of the cortical bone and mucosa, preventing movement in all three axes. All parts in the model; Boundary condition was applied on the X-axis normal to be symmetrical with respect to the Y-Z plane.

Stress values on implants, framework materials, and cortical and trabecular bone are shown in Fig. 3–6

Regardless of which framework was supported, higher stress values were observed in all M1 models compared to M2 models.

The highest stress values on the bone and implants were seen in the M1-PMMA model. This was followed by M1-PEEK, M1-ZANTEX, and M1-CoCr, respectively. This sequence is the same for the M2 models: M2-PMMA, M2-PEEK, M2-ZANTEX, and M2-CoCr (Fig. 3,4–6). The highest stress value on the implants occured in M1-PMMA (11.25 N/mm2). The lowest stress value on the implants was seen in M2-CoCr (3.36 mm/N2), as seen in Fig. 3.

The framework materials arranged in descending order, regardless of M1 and M2, according to stress values occurring in them were as follows: CoCr, Zantex, and PEEK. The highest stress value was observed CoCr alloy in M2-CoCr (13,97 N/mm2) and the lowest stress value was observed PEEK in M1-PEEK (1,85 N/mm2). (Fig. 4)

This study revealed that prosthetic models supported with mini-implants created higher stress values in the bone when compared to models created with standard implants in mandibular overdenture treatments. Our null hypothesis regarding framework materials was rejected, and polymers as prosthetic framework materials were found to be disadvantageous in terms of stress transmission compared to metal frameworks. Regardless of implant size, dentures supported with Zantex transmitted less stress to the bone than dentures supported with PEEK. The highest stress values in support bone and implants were observed in PMMA prostheses without framework material.

Completely edentulous patients often suffer from inadequate retention and stability in their mandibular prostheses. Most of these patients preferred over-implant prosthesis as an economical, aesthetically acceptable, and feasible treatment method. Today, the use of mini-implant overdentures is becoming a quick and technically easier alternative to traditional implant overdentures [1,2]. Lemos et al. [18] reported in their systematic review that mini-implant overdentures may be an alternative treatment option for patients who cannot undergo standard implants, considering the high survival rates, acceptable marginal bone loss, and patient satisfaction rates. Pasini et al. [15] evaluated the stresses on the supporting tissue and implants in single- and standard two-implant-supported overdenture prostheses in a FEA study and reported that there was more movement under chewing forces in mini-implant supported overdenture prostheses, but less stress on them. Souza et al. [19] observed that implant survival rates were 82%, 89%, and 99%, respectively, in overdenture treatments supported by two mini-implants, four mini-implants, and two standard implants, respectively. They also stated that mini-implant treatments showed comparable patient satisfaction rates to those of standard implants. Enkling et al. [20] suggested that overdenture prostheses supported by four mini-implants are a minimally invasive and economical treatment alternative that improves chewing function and quality of life in patients with mandibular ridges with reduced bone support. Solberg et al. [1] compared overdenture prostheses supported by two standard implants and four to five mini-implants in terms of stress distribution in the mandible. They stated that the resulting stress values were below the critical limits, regardless of the number and type of implants. By contrast, Chang et al. [4] compared the mechanical effects of overdenture prostheses supported by four mandibular mini-implants and two standard implants on bone, and their results indicated that the stress occurring around the implant in overdenture prostheses supported by mini-implants was higher than critical values and bone damage may occur around the implant in the long term. Patil et al. [2] biomechanically compared two standard and two mini-implant-supported locator attachment overdenture prostheses in the mandible, and they observed that mini-implant-supported overdenture prostheses placed approximately twice as much stress on the mandibular bone compared to standard implants. In the current study, similar to these publications, significantly higher stress values were observed in the implants and support bone, regardless of the framework material of the prosthesis, under chewing forces in overdenture prosthesis models supported by mini-implants. Protesta et al. [21] evaluated overdenture prostheses retained by mini-dental implants (MDIs) as a treatment option for complete edentulism during a 3-year follow-up period, in which MDI overdentures applied to the mandible had better survival rates and health status than those applied to the maxilla. However, they found serious prosthetic complications such as overdenture base fracture, matrix detachment, and instability of the maxillary antagonist prosthesis. Fractures are usually caused by bending fatigue and impact. Continuous exposure to chewing pressure causes fatigue in the acrylic base, which creates microcracks in the polymer. Microcracks enlarge over time and cause failure of the base [14,22]. The abutment neck of the implant is also the region with the most fractures in overdenture prostheses on implants. This can be explained by the insufficient thickness of the overdenture base at the fulcrum [23,24]. Even with a small denture base thickness, metal bases with their long axis placed perpendicular to the static forces strengthen the flextural properties of the prosthesis. Therefore, the denture base supported by metal alloys can prevent base fractures in clinical use [9,25]. Reinforcement of the mandibular implant-supported overdenture has been suggested as a method to increase fracture resistance and improve the denture's dimensional stability [24]. It has been reported to reduce stress on implants. In addition, it has been reported that the denture base supported by rigid metal spreads the chewing forces more evenly on the alveolar crest. In addition, metals are used as framework material in overdenture prostheses, and the stresses on the implants can be reduced [26, 27].

The use of CoCr frameworks in mandibular overdenture prostheses has been found to be positive in terms of the distribution of stress on implants and bone [24]. However, metal framework materials are heavy, their adhesion to the acrylic base is not strong, the construction stages are laborious, and there is a possibility of allergy in some mouths [25]. To avoid the negative properties of metal alloys, fiber materials have also been used as prosthetic reinforcement. However, the construction phases of these materials take time and form a less sensitive structure than the materials that can be produced with CAD/CAM. As an alternative to alloys, it has recently been used as support material in fixed and removable prostheses. PEEK's high-performance polymer molecular chain configuration has improved physical and mechanical properties compared to other polymers. It has mechanical properties similar to enamel and dentin [28]. However, as a denture base material, polymethyl methacrylate may not show sufficient mechanical strength and may be sensitive to deformation during the chewing process. Reinforcing materials can be used to improve their mechanical properties [8]. PEEK material can be combined with ceramic materials and fiber materials to improve its strength or aesthetic properties [28,29]. Removable denture bases can be produced from PEEK using injection molding or CAD/CAM systems [29]. Zantex is a newly introduced polymer matrix reinforced with dense glass fibers. It is produced as an framework material for prosthetic treatment in edentulous patients. Although it is a low-density material, it has superior mechanical properties. The modulus of elasticity is lower than CoCr alloy and higher than PEEK material. With composite and PMMA, connections can be established by sandblasting and bonding and by milling and adding directly. It is recommended that the areas in contact with the gums be covered with a glaze [17]. One study stated that Zantex had a better bonding capacity to acrylic than PEEK [13]. Further scientific research on Zantex is needed. In this study, we also compared the Zantex material, which has not been used as a framework in removable prostheses, as a framework material in overdenture prostheses.

Ameral et al. [14] reported that overdenture prostheses supported with CoCr alloy create 62% less stress on the attachment implant and bone compared to unsupported acrylic bases in a FEA study performed on single-implant overdenture prostheses. Gomes et al. [30] compared Ti and stainless steel implant analogs and argued that the higher the elastic modulus of the stainless steel analogs, the lower the stress. Durand et al. [31] compared the restorations they made with inlay materials with different modulus of elasticity with FEA, claiming that materials with high elastic modulus created more stress in the cavity. Materials with a high elastic modulus tend to accumulate stresses on themselves, while materials with a lower elastic modulus tend to transfer stresses to neighboring materials with a higher elastic modulus [30,31]. In parallel, higher stress values were observed on the CoCr framework material with the highest elastic modulus compared to the PEEK and Zantex framework in this study. In addition, the stress values occurring in the supporting bones and implants in the M1-CoCr and M2-CoCr models are the lowest. We also declare that the CoCr framework material, with its high elastic modulus, absorbs the stresses and transmits less stress to the support material and bone.

Kelkar et al. [32] used PEEK, Zir, and Ti materials as a framework for prostheses and compared the stress distribution in the supporting tissue. They reported that the Zir frameworks provided the best stress distribution. They attributed this result to the high deformation of PEEK material due to its low elastic modulus. Similarly, in a study comparing Ni-Cr and PEEK as framework material, higher values were observed in PEEK-supported prostheses over support bone and implants [33]. Diego et al. [34] conducted a biomechanical evaluation of Zir, PEEK, carbon fiber, and titanium framework materials in mandibular fix implant-supported prostheses. They reported that unsupported PMMA- and PEEK-supported prostheses transmit stress on the bone at critical values and provide more successful results than titanium- and Zirconium-supported prostheses. In our study, the highest stress values were observed in the M1M2-PMMA models. The M1-M2 PMMA models gave similar or similar stress results to M1-PEEK and M2-PEEK. This behavior may be related to the fact that the elastic modulus of PEEK material is closer to PMMA compared to other framework materials, and the framework material we used in our study is 0.5 mm thin. Since there are no studies in the literature where Zantex is evaluated as a framework material in a removable prosthesis, we could not find the opportunity to discuss this material.

Although many previous studies on framework materials used in implant-supported prostheses support the results of this study [14,20,31–34] some studies have reported opposite results [7,11,36,37]. In a photoelastic stress analysis study conducted by Anehosur et al. [7], they compared the use of only heat cure acrylic, Ni-Cr, PEEK, and fiber mesh supported acrylic as a base in two-implant overdenture prostheses and reported that the overdenture prosthesis supported with PEEK material gave the best results in terms of stress distribution. In a clinical study by Kortam et al.[36] which compared metal and PEEK material as framework material in maxillary overdenture prostheses, the survival rates of implants supporting PEEK-based overdenture prostheses were found to be higher. Zodis et al.[37] in a clinical report that compared PEEK and metal alloys mandibular overlay dentures argued that PEEK was more advantageous with lower stress transmission to the teeth due to the elasticity modulus of PEEK being similar to dentin. Frank et al.[11] compared PEEK, ZANTEX, and Ni-Cr as framework material for a fixed implant-supported prosthesis in osteoporotic and normal bone models. Their results revealed that PEEK and Zantex provided better results than Ni-Cr. These differences can be explained by the use of different types of prostheses, the use of different bone variants, and the use of different stress measurement methods.

The limitations of finite element studies [14–16,31,32,34,35] are the assumption that the materials used have isotropic linear elasticity, that the jawbone is homogeneous and that the implants are 100% osteointegrated into the bone. Although not seen in a clinical scenario, these are inherent in finite element studies due to limitations in biological simulation. Further clinical studies are needed on this subject.

Within the limitations of this FEA study, the following conclusions were drawn:

It has been observed that in overdenture implants, rigid framework materials concentrate the chewing forces and transmit less stress to the supporting tissue and bone.

In addition, we observed that mini-implants produce significantly higher stress values in the supporting tissues and implant neck than standard implants.

FEA

Finite element analysis

CoCr

Cobalt Chromium alloy

PEEK

Poly-ether ether ketone

PMMA

Poly-methyl metacrilate

Ethics approval and consent to participate

This study received approval from the Hamidiye Scientific Research Ethics Committee of the University of Health Sciences (no:22/447). We confirm that all methods are performed in accordance with relevant guidelines and regulations. Ethics committee of University of Health Sciences Hamidiye Scientific Research Ethics waived the need for informed consent as all the work is done in computer environment.

Consent for publication

Not applicable.

Availability of data and materials

The data sets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The author received no financial support for this article.

Author’s contributions

The design, writing and arrangement of the study have done by E Guzelce S.

Acknowledgments

I would like to thanks Dr. Ebru Sağlam for reviewing and criticising to this article.

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Table 1

Elastic modulus and Poisson’s ratios of the materials used in the study.
Materials	Young modulus (GPa)	Posison’s ratio	Referances
Mini and conventional implants/ball atachment/housing (Ti 6Al 4V)	110	0,35	6
Trabecular bone	1,37	0,30	6
Cortical bone	13,7	0,30	6
Naylon	0,005	0,4	1
Mucosa	0,34	0,45	6
Acrilic resin teeth	2,94	0,30	6
Acrilic resin base	1,96	0,30	6
Cobalt- cronium cast metal	275	0,33	17
PEEK	4	0,40	17
ZANTEX	35	0,40	17

Table 2

Quantitative model information of FE.
Nodes and Elements	M1	M2
Total of Nodes	495906	651659
Total of Elements	1982471	2634695

No competing interests reported.

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Biomechanical Comparison Of Diffirent Framework Materials In Mandibular Overdenture Prosthesis Supported With Implants Of Different Sizes: A Finite Element Analysis

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