|Year : 2020 | Volume
| Issue : 5 | Page : 413-419
Biomechanical stress in removable complete dental prostheses: A narrative review of finite element studies
Mohammed Assayed Mousa1, Nafij Jamayet2, Edward Lynch3, Adam Husein2
1 Department of Prosthetic Dental Sciences, College of Dentistry, Jouf University, Sakakah, Jouf Province, Saudi Arabia; Prosthodontic Unit, School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
2 Prosthodontic Unit, School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
3 Department of Clinical Sciences, School of Dental Medicine, University of Nevada Las Vegas, Las Vegas, Nevada, United States
|Date of Submission||17-May-2020|
|Date of Decision||20-Aug-2020|
|Date of Acceptance||20-Aug-2020|
|Date of Web Publication||21-Oct-2020|
Dr. Nafij Jamayet
Prosthodontic Unit, School of Dental Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan.
Source of Support: None, Conflict of Interest: None
Aim: This review aimed to investigate the stress that arises in the conventional and implant-assisted removable complete dental prostheses (RCDPs) and supporting structures. Materials and Methods: A literature survey was conducted for the full-text English articles which only used finite element analysis to examine the stress developed in the conventional and implant-assisted RCDPs from January 2000 to May 2020. Results: In total, 1789 articles were included in the survey. Of the 1789 articles obtained, 1746 were excluded based on initial screening of the title and abstract. Finally, 24 articles were recruited for this study after excluding the duplicated articles with the same results. The significant findings and conclusions were extracted and grouped under biomechanical stress developed in complete dental prostheses, how to manage the stress developed in conventional RCDPs, and the factors affecting the development of stress in implant-assisted RCDPs. Conclusion: The RCDPs subject to different kinds of stress in the form of compressive and tensile strengths. The buccal flanges exhibit compressive strains responding to the vertical forces while labial flanges show the same type of strain responding to all force directions. The highest tensile strain concentration exists at the anterior frenum, midline, and buccal flanges when the forces were horizontal. Whilst, retention and support in implant-assisted prostheses are exceptionally improved, the implants and prostheses are subjected to stress which may result in failure of these kinds of prosthesis. This stress can be managed by increasing the number and size and by decreasing the angulation of the implants, using splinted or short collar unsplinted abutments, reinforcing the denture base, and using canine guidance occlusion.
Keywords: Complete denture, Finite element analysis, Implant-assisted removable prosthesis
|How to cite this article:|
Mousa MA, Jamayet N, Lynch E, Husein A. Biomechanical stress in removable complete dental prostheses: A narrative review of finite element studies. J Int Oral Health 2020;12:413-9
|How to cite this URL:|
Mousa MA, Jamayet N, Lynch E, Husein A. Biomechanical stress in removable complete dental prostheses: A narrative review of finite element studies. J Int Oral Health [serial online] 2020 [cited 2021 Jan 24];12:413-9. Available from: https://www.jioh.org/text.asp?2020/12/5/413/298789
| Introduction|| |
Removable dental prostheses (RDPs) have been considered an acceptable cost-effective treatment option to restore aesthetic, masticatory efficiency and maintain the rest of the dentition in partially and completely edentulous patients.,, The polymethylmethacrylate (PMMA) is still the material of choice for denture fabrication due to its pleasing appearance and easily laboratory steps. However, due to the poor flexural strength and low fatigue resistance, the frequent fracture of PMMA resin base RDPs is frequent problem. Moreover, the supporting structures of the prosthesis subject to stress during function causing bone resorption and periodontal loss around the abutments or bone loss around implants which, accordingly, can lead to failure of the prostheses.,
The implant-assisted removable complete dental prostheses (RCDPs) show many advantages comparing with the conventional one.,, There is a direct relationship between success in dental treatment and biomechanics of materials used in dentistry. The study of stress in the teeth and associated structures under RDPs has been reported with different methods such as photoelasticity, strain-gauge measurement, brittle laquer, and finite element analysis (FEA). FEA provide noninvasive reproducible qualitative and quantitative information of biomechanical characteristics of dental prostheses and supporting structures with no need for ethical considerations., FEA is carried out through constructing a finite element (FE) model(s), followed by specifying the materials’ property, loading, and boundary conditions for accurate simulation. With the advancement of digital imaging systems, FEA can be done to human bodies through exporting the data of geometry and properties of the bone, in three-dimensions (3D), from cone beam computerized tomography or magnetic resonance imaging to the FE model, thus an accurate anatomical model can be created.,,
The FEA studies of biomechanical stress developed in RDPs is a rapidly expanding, but still the one that has not yet received broad review in the dental literature. The purpose of this narrative review was to appraise the stress developed in RCDPs and supporting structures using FEA.
| Materials and Methods|| |
This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The research focused question was identified with the aid of the PICO format: (P) is for the Participants, (I) for the Intervention, (C) for the Comparison and (O) for the Outcome. (P) was the studies that only used FEA to identify the distribution of stress, the intervention (I) was the removable complete dental prostheses, the comparison (C) was the conventional and implant-assisted RCDPs fabricated using different protocols or materials, and the outcome (O) was the distribution of the stress in implants and overlying prostheses.
An electronic search was conducted in the Google Scholar, PubMed, Scopus, Web of Science and Saudi Dental Library databases. The keywords were finite element analysis, conventional and or implant-assisted removable complete denture prostheses, biomechanical stress, stress distribution, and deflection of the prostheses. Narrative review was applied because the disparate themes and data were unsuited to systematic review or meta-analysis. The research was done to find answers for three questions. The first question was “where the biomechanical stress distributed in the prostheses and supporting structures?”, the second question was “What is the factors affecting the management of the biomechanical stress in RCDPs?,” and the third question was “ What is factors affecting the management of biomechanical stress in implant-assisted RCDPs?” A survey of the literature was conducted for the full-text English articles from January 2000 to May 2020 which only used FEA to examine the stress developed in the RCDPs.
Eligibility criteria were as follows:
All the studies that used FEA to analyze the stress developed only in complete dental prostheses
The studies only conducted to manage the stress in complete dental prostheses, and
The studies conducted to identify the stress in implant-assisted RCDPs
The studies between 2000 and 2020
Exclusion criteria were as follows:
The clinical studies
The studies that used methods other than FEA
The studies before 2000
The studies conducted on fixed, removable partial, or maxillofacial prosthetic restoration
| Results|| |
During the selected times, 1789 articles were included in the survey. Out of the 1789 articles obtained, 1746 were excluded based on initial screening of the title and abstract as they did not relevant to the objectives of the present review. Finally, 24 articles were recruited for this study after excluding the old articles with the same results of the new updated articles. Due to heterogenicity of the results, a narrative review was designed rather than meta-analysis review. To be convenient to the readers, the significant findings and conclusions were extracted and grouped under biomechanical stress developed in complete dental prostheses, how to manage the stress developed in conventional RCDPs, and the factors affecting the development of stress in implant-assisted RCDPs. For answering the first question of distribution of biomechanical stress developed in complete denture prostheses, three articles were included after excluding the other factors such as partial maxillofacial, fixed, and non-FEA studies.,, For answering the second question of the factors affecting the management of biomechanical stress developed in RCDPs, five articles were picked after exclusion of the irrelevant articles.,,,, Finally, for the factors affecting the management of the stress developed in the implant-assisted RCDPs, 16 articles were finally chosen after exclusion of the articles with duplicate results and irrelevant [Figure 1].,,,,,,,,,,,,,,,
|Figure 1: Flow chart for the search process indicating numbers (n) of included and excluded studies|
Click here to view
| Discussion|| |
Besides the materials of the prostheses and hard tissue structures, FEA has proven to provide a noninvasive methodology in identifying the biomechanical behavior of oral mucosa and RDPs.
Biomechanical stress in removable complete dental prostheses
The residual ridge and overlying mucosa play a major role in the support and retention of conventional, tooth, and implant-assisted RDPs. The thickness of mucosa, denture adaptation, arrangement of artificial teeth, and amount and direction of occlusal forces can influence the load transmitted to supporting structures.,, The healthy mucosa acts as a cushion to prevent the transmission of an excessive load to the supporting structures, that cause inflammation of the mucosa and resorption of the residual ridge in different ways. Regarding bearing and limiting structures of the RCDPs, it was found that the highest tensile strain is concentrated around the anterior notch, midline, and buccal flanges when the forces were horizontal. This can help explain the frequent fracture of dentures at these points. The buccal flanges exhibit compressive strains responding to the vertical forces while labial flanges show the same type of strain responding to all force directions., With respect to the lower complete denture, the highest stress due to vertical forces was mainly concentrated on the retro-molar pad and the inclined plane of posterior alveolar ridge. When horizontal and lateral forces are applied, the main forces are compressive and are mainly concentrated on the anterior lingual alveolus which, accordingly, shows a greater tendency to resorption. Loss of denture stability leads to inadequate occlusal force distribution due to denture movement around a fulcrum line. An adequate buccolingual position of posterior teeth is crucial not only to prevent denture instability but also to decrease the excessive forces transmitted to underlying structures. Both balanced and lingualized occlusions transmit minimal pressure at the mid-palatal suture area, whilst the crest of the ridge receives the main stress concentration. During excursive movement, the working side in balanced occlusion scheme produce a greater pressure than the balancing side, whilst in the lingualized occlusion scheme the vice versa occurs.
Management of stress in RCDPs and supporting structures
To overcome the mechanical weaknesses of the PMMA resin of denture base materials and to decrease the stress on the supporting structures, a variety of different approaches have been developed.
Modifications in denture base materials approach
One of these approaches is using alternative materials such as nylon, polystyrene, and polycarbonate. Another approach involves reinforcing the PMMA resin by adding fibrous reinforcing materials such as carbon, glass, and high-performance polyethylene. A significant improvement in denture strength with high-performance polyethylene fibers compared to conventional acrylic denture base materials was reported. Adding 5% Kevlar fibers and 3% ZrO2 particles were also found to decrease the deformation of the acrylic denture base compared with a conventional one.
The type and thickness of teeth material have a great influence on fracture resistance of the denture base. The fracture resistance of the denture base was higher with composite resin teeth compared to acrylic or ceramic materials. However, this resistance is declined as the thickness of the composite resin teeth increases.
Adding soft liners was found to reduce the stress concentration on the denture supporting structures and decrease the probability of fracture of RCDPs provided the elasticity of soft liners should ideally match that of mucosa. The maximum stress in the mucosa and minimum stress in the bone decrease when the thickness of the relined material is increased to 2 mm.
Occlusal modification concept
Complete dentures with zero-degree artificial teeth show a low magnitude of elaborated stress in supporting structures when compared with the stress observed in teeth with cusp angle of 33° and 20°.
Using overdenture concepts
Teeth and implant-assisted RCDPs are considered a great option when compared to conventional RCDPs because they act not only to improve retention and stability of prostheses, but they also help preserve the residual ridge. However, the stress developed in bone is increased in implant-assisted RCDPs when compared with conventional dentures. This attributed to the integrated implant and associated attachment systems receive the loads to prevent movement of prostheses. This stress may induce mechanical failures in prostheses, failures in osseointegration, or even implant fractures.
Factors affecting stress developed in implant-assisted RCDPs
Implant–bone interface and bone quality
The bone of a higher density was found provide a better environment for implants compared to the bone with a low density. The presence of cortical bone contacting the implants, even when a bone defect is present, improves the biomechanical performance of implants in comparison with contact with only trabecular bone. The cancellous bone of a higher density also provides a better biomechanical environment for implants compared to the cancellous bone with a low density. The highest stress occurs around trabecular bone around implant-neck, whilst the least stress was recorded at the trabecular bone around the apical regions., The bone loss surrounding implants increases the stress concentration in implant fixture. The highest stress occurs around trabecular bone around implant–neck, whilst the least stress was recorded at the trabecular bone around the apical regions. The stability of the implant–bone interfaces plays a major role in the longevity and success of these prostheses. Although implant-assisted RCDPs are associated with a decrease in the load to the underlying structures, they lead to development of stress in the overlying prostheses, especially at the areas around the implant prostheses connections.
Number and location of implants
The stress developed at the bone–implant interface in implant-assisted RCDPs is inversely proportional to the number of implants. As the number of implants increases, the amount of developing stress under prostheses and in implant–bone interfaces is decreased.
The influence of the location of implants on biomechanical stress is controversial. In some studies, the more anterior placement of the implant, such as in the lateral incisor area, the least stress in the peri-implant–bone interface is recorded. This is explained with the greater length of the lever arm and increase in the bending moment in the case of implants in premolar areas. In contrary of that, other studies did not recommend the positioning of the implants in lateral incisors area from biomechanical point of view and instead of that those authors recommended positioning the implants in the premolars area.
The implant angulation can affect the stress at implant–bone interface. The inclined implants, even with small changes in inclination, cause higher stresses in the peri-implant–bone than implants placed parallel to the long axis. The greatest stress value in the implant–bone interface was recorded around, in order, distally inclined implant, then lingually inclined, then mesially inclined, whilst the least stress was recorded in the implant with buccal directions. The stress caused by inclined implants aggravates the resorption in cortical and cancellous bones leading to implant failure.
Length, diameter, and size of implant
A wide, tapered, and long implant is the most favorable choice to minimize the stress at the implant–bone interface within implant-assisted RCDPs comparing the narrow, short and tapered implants that increase the stress, especially in the bone with low density. The narrow, short taper implants were found to increase the strain in the implant–bone interfaces, especially in bone with low density.
Zygomatic implants have proven to provide high success rate in the management of severely resorbed maxillae. The exteriorized and extra-maxillary types are the most used types of zygomatic implants as they are placed external to the maxillary sinus and can help prevent possible development of sinusitis. The exteriorized technique provides more favorable stress distribution on the micro-unit screws and bone tissues. However, because of their length, they are subjected to stress and deformation of the surrounding bone. Adding two implants around the lateral incisor space provides adequate stress distribution and minimizes the stress on these implants.
Splinting and attachment system
There are different types of attachment systems usually used in implant-assisted RCDPs such as the ball and socket (O-ring attachment), bar-clips (splinted), magnetic system, and implant locator attachments. The stress developed within the supporting structures of implant-assisted RCDPs is affected by the type of implant system. The prostheses retained with bar and clips attachment system, in case of two-implant-assisted mandibular RCDPs are associated with less stress in the supporting tissues when compared with other types of attachments. Moreover, they provide more favorable stress distribution to the implant–bone interface during lateral and protrusive movements when compared with ball attachments although there were no pathological changes recorded with both types. This was interpreted by the continuous rotation of the denture around a fulcrum line passing the nonsplinted implant. However, the locator attachment was found more preferred when used with four-implant-assisted RCDPs in terms of reduction in the stresses in the peri-implant bone tissue, mucosa and implant/prosthetic components, or when compared with bar-clips with cantilever. The use of bar-clip attachment system with distally placed O-ring attachment design found optimized the distribution of the maximum stress within prostheses and implants., Comparing other types of nonsplinted implants, the locator attachments show less and more homogenous stress distribution compared with ball attachments. This is mainly due to high modulus of elasticity, metal-to-metal contact of O-ring attachments which leads to the transfer of the occlusal forces directly to the body of the implants, resulting in higher stresses at the implant–bone interfaces.
The magnetic attachment systems have three major different commercial forms, including the flat, dome, and cushion shapes. Comparing all types, the cushion and dome types are considered better choices rather than the flat types. This is mainly due to the rigidity of the flat type which is higher than the dome and cushion types. The rigidity of attachments is inversely proportional to the load on the bearing structures and directly proportional to the stress at the implant–bone interfaces. The more resilient the attachment, the more load on the denture bearing structure and less load on the implant.
The height of the attachment was found to affect the stress developed within the implant–bone interface. As the height of an attachment shortens, the stress in the prosthesis will be lower, especially when it placed parallel to the long axis of an implant.,
Thickness of the mucosa
The relieving effect of different thicknesses of mucosa beneath conventional and implant-assisted RCDPs has been established. As the thickness of mucosa increases, the stress under RCDPs and implant–bone interfaces decrease, whilst the stress around the attachments increases. This relieving effect leads to lowering bone tissue deformations.
Bilateral balanced occlusion is considered a basic requirement for denture stability. However, a variety of occlusion concepts have been developed in conventional and implant-assisted RCDPs to ensure functional and aesthetic efficiency and to provide an even distribution of the occlusal load to supporting structures. The linear occlusion develops high stress in the implant, attachment system, and prosthesis compared to the lingualized occlusion scheme. Comparing different occlusal schemes, the lowest stress value is observed with the canine-guided occlusion in different loading conditions, whilst the highest stress value is recorded with the monoplane occlusion.
| Conclusion|| |
The removable complete dental prostheses and bearing structures are subjected to stress during function which may induce bone resorption and/or failure in the prostheses. The stress is more concentrated in midline and labial notch. In implant-assisted RCDPs, although the displacement of the prostheses decreases, there is stress developed in implants, implant–bone interface and the overlying prostheses depending on the thickness, type of denture materials, and the types of occlusion. This developed stress can be controlled by controlling the loading conditions, increasing the number and size, and decreasing the angulation of the implants, using metal frameworks or fiber-inforced acrylic base and using canine-guided occlusion.
Although the FEA has been extensively used in assessment of the stress on different kinds of prosthetic restoration, there is still shortage in estimation of stress in different kinds of palatal and ridge shape, using narrow implant diameter and different kinds of base materials used in denture using FEA.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
MA Mousa: Data collection, writing, and structuring the manuscript, N Jamayet: Data collection, E Lynch: revising the final manuscript, A Husien: revising the data and revising the final manuscript.
Ethical policy and institutional review board statement
Declaration of patient consent
Data availability statement
The data set presented within this manuscript has been obtained from 42 original articles. The data already available within the articles.
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