Materials Science and Engineering C 71 (2017) 35–42

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Materials Science and Engineering C

journal homepage: www.elsevier.com/locate/msec

Effect of different types of prosthetic platforms on stress-distribution in

dental implant-supported prostheses
Lurian Minatel a, Fellippo Ramos Verri b, Guilherme Abu Halawa Kudo a, Daniel Augusto de Faria Almeida b,
Victor Eduardo de Souza Batista b, Cleidiel Aparecido Araujo Lemos b,
Eduardo Piza Pellizzer b, Joel Ferreira Santiago Junior a,⁎
a
Pró-Reitoria de Pesquisa e Pós-graduação (PRPPG), Universidade do Sagrado Coração, USC, 10–50 Irmã Armindal, Jardim Brasil, Bauru, 17011–160, SP, Brazil
b
Department of Dental Materials and Prosthodontics, Araçatuba Dental School, UNESP - Univ Estadual Paulista, 1193 José Bonifácio Street, Vila Mendonça, Araçatuba 16015–050, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: A biomechanical analysis of different types of implant connections is relevant to clinical practice because it may
Received 31 March 2016 impact the longevity of the rehabilitation treatment. Therefore, the objective of this study is to evaluate the Morse
Received in revised form 17 September 2016 taper connections and the stress distribution of structures associated with the platform switching (PSW) concept.
Accepted 27 September 2016
It will do this by obtaining data on the biomechanical behavior of the main structure in relation to the dental im-
Available online 28 September 2016
plant using the 3-dimensional finite element methodology. Four models were simulated (with each containing a
Keywords:
single prosthesis over the implant) in the molar region, with the following specifications: M1 and M2 is an exter-
Dental implant nal hexagonal implant on a regular platform; M3 is an external hexagonal implant using PSW concept; and M4 is
Bone tissue a Morse taper implant. The modeling process involved the use of images from InVesalius CT (computed tomog-
Mechanical stress raphy) processing software, which were refined using Rhinoceros 4.0 and SolidWorks 2011 CAD software. The
Finite element analysis models were then exported into the finite element program (FEMAP 11.0) to configure the meshes. The models
were processed using NeiNastram software. The main results are that M1 (regular diameter 4 mm) had the
highest stress concentration area and highest microstrain concentration for bone tissue, dental implants, and
the retaining screw (P b 0.05). Using the PSW concept increases the area of the stress concentrations in the
retaining screw (P b 0.05) more than in the regular platform implant. It was concluded that the increase in diam-
eter is beneficial for stress distribution and that the PSW concept had higher stress concentrations in the retaining
screw and the crown compared to the regular platform implant.
© 2016 Elsevier B.V. All rights reserved.

1. Introduction The platform switching concept is obtained when using a prosthetic

component (abutment) that is narrower than the diameter of the im-
Different types of implant connections can be used for oral rehabili- plant [11]. The literature on the topic indicates that this concept can pro-
tation [1–3]. The identification of the best connection profile is particu- vide better preservation of the bone tissue than the regular platform can
larly relevant to implantology. Current research seeks to determine [6,12,13]. Furthermore, studies have suggested that this type of implant
connections that can distribute stresses more efficiently in the bone tis- may reduce the magnitude of stress in the cortical bone [14–16].
sue and structures linked to the implant-supported prosthesis. [4,5]; Recent analyses of the cortical and trabecular bone tissue, which are
peri-implant bone preservation is also a point of extensive discussion the main focus of studies in this area, indicate that the PSW concept de-
[2,3]. creases the concentration of deformation in bone tissue around dental
Clinically controlled trials and systematic reviews have indicated implants [16,17]. However, a definitive consensus on this issue has not
that the use of implants with the PSW (PSW) concept can reduce peri- been reached, as some reports indicate that the lowest concentration
implant bone loss [6–8]. This situation would ensure the maintenance of stresses on the cortical bone may not be observed [18,19]. Further-
of the gingival soft tissue and bone tissue, both of which are very impor- more, there is still not enough data in the literature to evaluate the
tant aesthetic factors [9,10]. screw and implant abutments using the PSW [16,20]. This issue is very
important because complications in implant-supported prostheses,
which are common in rehabilitation treatments—for example, screw
loosening—are an unpleasant factor associated with implant rehabilita-
⁎ Corresponding author at: Pró-Reitoria de Pesquisa e Pós-graduação (PRPPG),
Universidade do Sagrado Coração, USC, 10–50 Irmã Arminda, Jardim Brasil, Bauru,
tion [21].
17011–160, SP, Brazil. Although studies indicate that using the PSW concept reduces the
E-mail address: [email protected] (J.F. Santiago). concentration of stress in the peri-implant implant region [14,15], this

http://dx.doi.org/10.1016/j.msec.2016.09.062
0928-4931/© 2016 Elsevier B.V. All rights reserved.
36 L. Minatel et al. / Materials Science and Engineering C 71 (2017) 35–42

technique has some disadvantages because the prosthetic abutment re- stress distribution on the retaining screw using the PSW concept com-
duction can result in a shift in stress in the screws and the prosthetic pared to an external hexagon with a regular-diameter abutment. The
abutments [14] and can even lead to a fracture because of the reduction models are shown in Table 1.
of the abutment wall. This situation would be detrimental biomechani-
cally because it can deform the prosthetic screw beyond the material's 2.2. Description of the models
tolerable limit of elasticity [14]. Furthermore, some biomechanical stud-
ies have indicated the possibility of greater stress concentration in the Four models were designed for this research. The models were sim-
settlement region of the implant-supported prosthesis, in the abut- ulated to present a bone block with a section of trabecular and cortical
ment-implant interface, and in the platform region [22,23]. bone tissue in the second molar region and a single, fixed prosthesis
The diameter of the implant is another important factor to consider over the implant (Connection Implant Systems, Arujá, São Paulo, Brazil).
[24]. An increase in the diameter has been associated with a reduced The models were designed according to the diameters of the implants
magnitude of the stresses around the dental implants, mainly in the cor- (external hexagons of 4 or 5 mm in diameter and 10 mm in length) to
tical bone [16,19,24]. However, there is no consensus as to the existence support a screwed crown. Also, a comparative model was designed
of an advantage from the use of the PSW concept in stress distribution using a Morse taper implant with the dimensions of 5 × 10 mm (Con-
for wide-diameter implants, especially in relation to the stress concen- nection Implant Systems, Arujá, São Paulo, Brazil). The mechanical
tration in implant prostheses and the retaining screw [19,25]. properties of the bone tissue and the metal-ceramic crown dimensions
Different types of implant connections can generate diverse biome- were constant, varying only in the abutment configuration
chanical behavior. An external hexagonal implant has the advantage (PSW × conventional use), in accordance with Table 1 and Figs. 2 and 3.
of reversibility [16,26] and an ease of implementation with regard to
the implant-supported prosthesis. Implants with external hexagonal
2.3. Metal-ceramic crown
geometry have been associated with concentrated stresses in the first
threads (uppers threads) of the implant and in the implant-abutment
The external surface of the metal-ceramic crown was obtained
interface [24]. On the other hand, dental implants with Morse taper con-
through surface scanning of a dental mannequin's second molar, as pre-
nections have shown a higher stress concentration near the long axis of
viously described [24,27]. The model was finalized and simplified using
the implant [16,26] and a better locking of the abutment with the inner
Rhinoceros 4.0 software to fit into the proposed abutments [27].
surface of the implant [26], thus reducing micromovements. Therefore,
there is a need to study the effect of a narrow-diameter abutment of the
implant-supported prosthesis (both the PSW concept and the Morse 2.4. Bone tissue geometry
taper) in the retaining screw. Thus, the aim of this study is to evaluate
the stress distribution associated with the use of the PSW, the external The cancellous and cortical bone tissues were obtained from the de-
hexagon, and the Morse taper connections (Fig. 1) by analyzing the ef- composition of a computed tomography (CT) scan of the second molar
fect that reducing the abutment platform has on the screw, the abut- region with the aid of InVesalius 3.0 software. The external surface of
ment, and the bone tissue. It is also an aim of this study to evaluate the bone tissue was simplified using 3D software (Rhinoceros 4.0) and
the variation in the implant's diameter (4 vs. 5 mm) and the loading simulated bone type III, a cortical bone with a thickness of 1 mm around
type. the trabecular bone, which is commonly found in this region [28].
The study's first null hypothesis is that the PSW concept would lead
to similar values and areas of stress concentration for the fixation 2.5. Dental implants and prosthetic components
screws and the implant-supported prostheses compared to the im-
plants using the regular platform. The second null hypothesis is that The simulated implants were external hexagons and Morse tapers
regular-diameter implants (4 mm) would present a similar stress distri- (Connection Implant Systems, Arujá, São Paulo, Brazil). The implant de-
bution as the large-diameter implants (5 mm). Finally, the third null hy- signs were simplified with the assistance of Solidworks 2011 software,
pothesis is that the Morse taper implants would show the same stress so that the dimensions of the implants' internal and external shapes
distribution as the external hexagonal implants on bone tissue and the and their components could be reproduced with sufficient reliability
crown. to develop a finite element method.
The abutments were simulated using universal castable long abut-
2. Material and methods ment (UCLA) components (Connection Implant Systems, Arujá, São
Paulo, Brazil). The component for the PSW model was simulated using
2.1. Experimental design a UCLA 4 mm in diameter in an external hexagonal implant of
5 × 10 mm. This abutment was similar to the implant model of
This research was designed to consider four study factors: (1) the ef- 4 × 10 mm. A UCLA 5.0 mm in diameter was inserted over an external
fect of the diameter of the implants on the external hexagonal implant hexagonal implant of 5 × 10 mm (regular use). An implant-supported
(4 vs. 5 mm); (2) the effect of the different connection types: external prosthesis using a Morse-taper dental implant was modeled with an
hexagon (PSW concept or regular platform) and Morse taper; (3) the ef- abutment component for the Morse taper dental implant (Connection
fect of the loading type: axial and oblique loading; and (4) the effect of Implant Systems, Arujá, São Paulo, Brazil).

Fig. 1. Schematic drawing of the implants, connections, and abutments.

 L. Minatel et al. / Materials Science and Engineering C 71 (2017) 35–42 37

Table 1
Description of the models.

Model Loading Diameter Description

M1 Axial 4 × 10 External hexagonal implant with screwed metal-ceramic crown, regular abutment platform.
M2 5 × 10 External hexagonal implant with screwed metal-ceramic crown, regular abutment platform (wide dental implant).
M3 5 × 10 External hexagonal implant with screwed metal-ceramic crown, platform switching concept (wide dental implant vs. 4.1 mm abutment).
M4 5 × 10 Morse taper dental implant with screwed metal-ceramic crown.
M1 Oblique 4 × 10 External hexagonal dental implant with metal-ceramic crown screwed, regular platform.
M2 5 × 10 External hexagonal dental implant with metal-ceramic crown screwed, regular platform (wide dental implant).
M3 5 × 10 External hexagonal dental implant with metal-ceramic crown screwed, platform switching concept (wide dental implant).
M4 5 × 10 Morse taper dental implant with metal-ceramic crown screwed.

Model: M.

After modeling the implants and components, all the designs were The loads were applied in the axial direction in relation to the
exported to the Rhinoceros 3D 4.0 software to fit the metal-ceramic long axis of the implant (200 N divided into 4 applications of 50 N
crown of the molars over the designs; finally, the entire set was inserted per cusp) and in the oblique direction (100 N divided into 2
into the bone tissue using the same software. applications of 50 N per lingual cusp), in accordance with previous
research [16,24,31]. The analyses were linear, and all the materials
were considered isotropic, homogeneous, and linearly elastic.
2.6. Development of finite element models
2.7. Criteria of analysis and statistical analysis
After modeling, the models were exported to a finite element pro-
gram (FEMAP 11) for discretization; linear shape functions were used. Qualitative (maps of stress concentration) and quantitative anal-
Meshes were generated in each simulated structure using parabolic tet- yses were used in this research [4,16,31]. Stress concentration indi-
rahedral solid elements (stress elements with 10 nodes) (Fig. 3). The cates a specific area in which stress is increased and concentrated
number of nodes for each model (M1: 506,290; M2: 407,172; M3: compared to other specific regions being analyzed. For the analysis
443,390; M4: 575,211) and the number of elements for each model of the implant types, the screw and implant-supported prosthesis
(M1: 290,918; M2: 268,800; M3: 293,720; M4: 377,627) were deter- used a distribution of von Mises stresses (measured in MPa) [32].
mined. Furthermore, the mechanical properties of the simulated mate- Maximum principal stress (MPS; measured in MPa) and microstrain
rials were incorporated into each structure: cancellous bone (modulus (measured in “strain”: μm/m, usually designed as με, and usually
of elasticity: 1.370 GPa; Poisson's ratio: 0.30) [29]; cortical bone (mod- shown as “microstrain”) were used for the bone tissue [16]. The
ulus of elasticity: 13.700 GPa; Poisson's ratio: 0.30) [29]; titanium (mod- data from the maps (i.e., the points with maximum stress) were or-
ulus of elasticity: 110 GPa; Poisson's ratio: 0.35) [30]; feldspathic ganized in an Excel table (Microsoft Office Excel, Redmond, WA,
porcelain (modulus of elasticity: 82.80 GPa; Poisson's ratio: 0.35) [29]; USA) and were submitted to SigmaPlot software version 12.0
and zinc phosphate cement (modulus of elasticity: 22.4 GPa; Poisson's (SigmaPlot, San Jose, CA, USA) to be analyzed for normal distribution
ratio: 0.35) [30]. (Shapiro-Wilk test and equal variance) [4,16,31]. Subsequently, the
The boundary conditions of the models were created in the x, y, and z diameter of the implant was studied using two-way analysis of vari-
directions for the mesial and distal surfaces of the sectioned bone tissue ance (factors: diameter and implant region), under oblique and axial
(cortical and trabecular); the three space directions were considered loadings. The statistical analysis of the diameter was performed by
fixing movements (Fig. 2). All of the contacts were simulated as bonded collecting the maximum values of the von Mises stress for each im-
except for the contact between the base of the implant-abutment con- plant thread (10 screw threads: left and right side) of the dental im-
nection and the implant that was juxtaposed in a symmetric contact. plant. The 50 most representative (highest) values of the von Mises

Fig. 2. A, Mesh of a finite element for the dental implant. B, Proposed models: dental implant with regular diameter and external hexagon (M1), dental implant with large diameter and
external hexagon (M2), dental implant with the PSW concept and external hexagon (M3), and Morse taper implant (M4), main regions analyzed: cortical bone and retaining screw
prosthesis. C, Cortical bone and abutments screw. D, Boundary conditions. Asterisk indicates change in platform.
38 L. Minatel et al. / Materials Science and Engineering C 71 (2017) 35–42

Fig. 3. Finite element mesh finalized in the proposed models.

stresses in the different screws were collected to analyze the stresses 3. Results
in each screw. The retaining screw was assessed using a Kruskal-
Wallis one-way analysis of variance on ranks (factor: type of 3.1. Diameter
retaining screw of implant-supported prosthesis) under both axial
and oblique loadings. For the analysis of the bone tissue, the 50 Analysis of the diameter factor revealed that an increase in diameter
most representative values of MPS and microstrain in the different from 4 to 5 mm (from M1 to M2, M3, or M4) led to a distribution of
models were collected. The bone tissue in the peri-implant region stress that extended the dissipation area (dental implant) for the 5-
was analyzed using a Kruskal-Wallis one-way analysis of variance mm diameter models under both axial and oblique loadings. See Fig.
on ranks (factor: type of connections of dental implants). The 4A and B.
Tukey test and Dunn's method were adopted as posttests to indicate A specific analysis of the regular-diameter (4 mm) and wide-diame-
the differences between the groups, using a 5% significance level for ter (5 mm) models of the external hexagons (M1 and M2) showed that
analysis. A linear regression and a Pearson correlation analysis were the increase in diameter significantly favored a reduced magnitude of
performed to compare the effect of increasing the diameter of the stress in the implant-thread region (P b 0.001) under both axial and
implant (from 4 to 5 mm). oblique loadings. See Fig. 4C and D.

Fig. 4. Analysis of the distribution of von Mises stress in all 4 models (M1, M2, M3, and M4) under axial loading (A) and oblique loading (B); effect of implant diameter on stress distribution
under axial loading (C) and oblique loading (D).
 L. Minatel et al. / Materials Science and Engineering C 71 (2017) 35–42 39

Fig. 5. Analysis of the distribution of von Mises stress in different retaining screw prostheses for all 4 models (M1, M2, M3, and M4) under axial loading (A) and oblique loading (B); effect of
stress distribution in the retaining screw under axial loading (C) and oblique loading (D). E, effect of the retaining screw (both regular and PSW). A, B: P b 0.05. A,B,C,D: P b 0.05.

Under both axial and oblique loadings, the higher stress concentra- data from the previous qualitative analysis; M1 had the greatest magni-
tions were located mainly up to the sixth thread of the implant in the tude of stresses, followed by M4 (the Morse taper), M3 (the PSW con-
regular implant and up to the fourth thread in the wide implant (Fig. cept), and M2 (the regular platform of abutment), as shown in Table 2.
4A-D). The specific analysis of the maximum stress concentrations for the
retention screws under axial loading (M1-M4) showed a significant dif-
3.2. Retaining screw ference (P b 0.001) between M1 (mean: 20.03 MPa) and the other
models: M2 (mean: 0.94 MPa); M3 (mean: 2.28 MPa); and M4
In the analysis, under axial loading, the retaining screws showed (mean: 8.96 MPa). Therefore, a significant difference existed in the com-
greater areas of stress concentration for M1 (regular diameter), the stress parison between all the models (P b 0.001). See Fig. 5C.
extended across the screw compared to the other models (10 MPa), as When comparing the models under oblique loading, the screw in M1
shown Fig. 5A. had a higher concentration of stress (mean: 565.1 MPa) than the other
Under oblique loading, a higher magnitude of stress and an extended models (mean: M2: 11.03 MPa; M3: 13.03 MPa; M4: 76.05 MPa), with
stress area were observed for all models (80 MPa) but mainly for M1 P b 0.001, according to Fig. 5D.
followed by M4. In a specific analysis of oblique loading, the comparison of the large-
A comparative analysis of M2 and M3 showed that M3 (the PSW con- diameter models showed a significant difference (P b 0.001). Tukey's
cept) had a higher stress area in the screw, mainly near the neck area of posttest identified the Morse taper dental implant as having the highest
the implant (Fig. 5A and B). This quantitative analysis confirmed the mean stress magnitude (M4: 76.05) of the models.

Table 2
Von Mises stress for different situations in screw retained prosthesis.

Load Connection Size (mm) Minimum (MPa) Median (MPa) Average (MPa) Standard Deviation Maximum (MPa)

Axial External hexagon (M1) 4 × 10 1.53 19.56 20.03 2.29 2.08

External hexagon (M2) 5 × 10 0.9 0.92 0.94 0.04 1.05
Platform switching (M3) 5 × 10 2.15 2.22 2.28 0.14 2.75
Morse taper (M4) 5 × 10 6.89 8.38 8.96 1.99 15.55
Oblique External hexagon (M1) 4 × 10 461.07 532.66 565.1 99.32 814.17
External hexagon (M2) 5 × 10 8.38 10.70 11.03 2.16 16.72
Platform switching (M3) 5 × 10 10.18 12.62 13.03 2.35 10.18
Morse taper (M4) 5 × 10 57.03 67.299 76.05 23.86 158.12
40 L. Minatel et al. / Materials Science and Engineering C 71 (2017) 35–42

Fig. 6. Analysis of the distribution of von Mises stress in all 4 crowns (M1, M2, M3, and M4) under axial loading (A) and oblique loading (B).

In addition, the large-diameter model with the standard platform of followed by the PSW concept (M3) and the regular platform (M2), as
the abutment (M2: 11.03 MPa) showed a significant and favorable dif- shown in Tables 3 and 4.
ference in mean stress magnitude of the retaining screw relative to
that of the PSW model (M3: 13.03 MPa), as shown in Fig. 5E. 4. Discussion

The PSW concept has been studied using the finite elements method
3.3. Crowns
[18–20,23,25,33]. Studies analyzing peri-implant bone tissue have indi-
cated some biomechanical advantage in using this type of connection
A specific analysis of the crowns showed a significant increase in the
[18,20,23,33]; in some cases, the peri-implant bone loss has already
concentration of von Mises stresses for the regular-diameter model
begun, and this type of connection can present a biomechanical advan-
(M1) relative to the others (Fig. 6A and B). In a comparison of large-di-
tage [18]. Other studies have indicated that the PSW concept has the
ameter models, M4 had the most favorable situation biomechanically.
same pattern of stress distribution as the large-diameter implant on a
Furthermore, M2 (regular platform) had more favorable results than
regular platform [19]. One of the possible disadvantages of using the im-
M3 (PSW) in terms of stress distribution, as shown in Fig. 6A and B.
plants with the PSW concept is an increase in stress in the abutments
[23], but this has not been demonstrated completely in the literature
3.4. Bone tissue [25]. This study aims to analyze the stress distribution in implants
using the PSW concept and to analyze the effect this stress has on the
The stress concentration around the implants was verified in a spe- structures of bone and the implant-supported prosthesis.
cific analysis of the cortical bone around the implants. Data on the max- The first null hypothesis of this study was rejected because the PSW
imum principal stress and the microstrain were collected. In a concept caused larger areas of stress concentration for the retaining
comparative analysis of the groups, the regular-diameter model (M1) screw and the implant-supported prosthesis compared to those found
was identified as showing the greatest magnitude of stresses; this dif- in the implants with the regular platform (P b 0.05). These data confirm
ference was statistically significant in comparison to the other groups the indications of a previous study that showed the possibility of in-
(M2, M3, and M4) under both axial loading (mean: 1.40 MPa; creased stress concentrations in structures associated with prostheses
P b 0.05) and oblique loading (mean: 20.14 MPa, P b 0.05), according and implants that used the PSW concept [14]. On the other hand, a re-
to Table 3. cently published study has indicated that the PSW concept is favorable
As well as the analysis of the MPS of the bone tissue, the model M1 for stress and microstrain reduction in cortical bone [16]. These data
showed a greater magnitude of microstrain than the other models showed that, despite a favorable outcome with regard to the bone, rig-
(M2, M3, M4) under axial loading (mean: 1509.63 με, P b 0.05) and orous control and maintenance of the implant-supported prostheses are
oblique loading (mean: 5020.32 με, P b 0.05), according to Table 4. required; this is because using the PSW concept shifts the stress to the
When comparing models with implants of large diameter, the most fa- area of the retaining screw and abutment, which can increase the possi-
vorable result was identified as belonging to the Morse taper (M4), bility of fracture or failure in the prosthetic components [14,33].

Table 3
Maximum Principal Stress in cortical bone for different models.

Loading Connection Size Minimum (MPa) Median (MPa) Average (MPa) Standard Deviation Maximum (MPa)

Axial External hexagon (M1) 4 × 10 mm 0.74 1.30 1.4 0.47 2.29

External hexagon (M2) 5 × 10 mm 0.05 0.11 0.12 0.07 0.34
Platform switching (M3) 5 × 10 mm 0.03 0.08 0.1 0.06 0.32
Morse taper (M4) 5 × 10 mm 0.02 0.03 0.05 0.05 0.29
Oblique External hexagon (M1) 4 × 10 mm 16.72 19.34 20.14 2.44 25.15
External hexagon (M2) 5 × 10 mm 3.38 4.20 4.51 0.97 8.17
Platform switching (M3) 5 × 10 mm 3.2 4.08 4.41 1.02 8.2
Morse taper (M4) 5 × 10 mm 2.67 3.10 3.28 0.57 5.42
 L. Minatel et al. / Materials Science and Engineering C 71 (2017) 35–42 41

Table 4
Microstrain (με) analysis for different models.

Loading Connection Size (mm) Minimum (με) Median (με) Average (με) Standard Deviation Maximum (με)

Axial External hexagon (M1) 4 × 10 1263.5 1484.65 1509.63 194.38 1840

External hexagon (M2) 5 × 10 142.68 159.1 165.35 20.08 224.27
Platform switching (M3) 5 × 10 111.03 124.75 129.7 18.68 194.57
Morse taper (M4) 5 × 10 98.61 112.19 114.87 12.57 152.36
Oblique External hexagon (M1) 4 × 10 2639.5 3935.15 5020.32 2199.62 9700.5
External hexagon (M2) 5 × 10 446.39 650.04 650.02 132.10 978.23
Platform switching (M3) 5 × 10 363.4 465.83 476.38 82.53 770.35
Morse taper (M4) 5 × 10 295.09 346.905 355.46 46.29 464.45

Clinically, a recently published systematic review with a meta-anal- high masticatory stress. Regarding the magnitude of von Mises stress
ysis indicated that implants that use the PSW concept better preserve identified in the retaining screw made of titanium (Ti–6Al–4V), the ten-
bone tissue in the peri-implant region relative to implants with a regu- sion values were within a range that is limiting for tensile strength
lar platform (P b 0.05) [6]. In this study, increased complications within (860–965 MPa) [39], as indicated in Table 2. However, the regular-di-
the area of the implant-supported prosthesis were not identified. How- ameter model again had the highest average peak tension among the
ever, it is important to emphasize that the clinical study that evaluated models analyzed.
the PSW concept showed a reduced time to follow-up [6]. Therefore, Finally, the limitations of the study must be discussed. The method-
rigorous clinical monitoring of patients is necessary, as there is the pos- ology included a computer simulation, in which all of the results were
sibility of increased stresses arising in the structures associated with the identified using linear analysis in the elastic range. In the same way,
implant-supported prosthesis. all the bone tissue was simulated in the form of solid structures, as in
The second null hypothesis was rejected because the regular-diam- previous studies [32,34]. All bone tissue is anisotropic [40] and nonho-
eter implants (4 mm) showed a higher stress concentration than the mogeneous, showing non-linear structures [41]. However, the literature
large-diameter implants (5 mm). A previous study qualitatively indicat- has demonstrated that the results of FEA can be extrapolated (with cau-
ed that larger-diameter (5 mm) implants had a more favorable distribu- tion) to the clinical daily use; all results obtained in the study should be
tion of stress than the regular-diameter implants (4 mm) in cortical supported by other clinical studies. Therefore, in addition to these re-
bone [24]. The current study quantitatively indicated that the increase sults, it is important to conduct more relevant clinical studies on this
in the implant's diameter was a very important factor in the biomechan- subject and to analyze the advantages that the biomechanical results
ics of the bone tissue, the dental implant, and the retaining screw be- of this subject might have in clinical practice.
cause it reduced the magnitude of the MPS and the microstrain on the
bone tissue and the magnitude of the von Mises stress on the dental im- 5. Conclusion
plant and the prosthetic components.
The third null hypothesis (that the Morse taper implants would The external hexagonal implants with regular diameter (4 × 10 mm)
show the same biomechanical efficiency as the external hexagonal im- provided the most unfavorable biomechanical situation among the
plants) was rejected because the Morse taper implants showed better models tested.
stress distribution in the cortical bone. These results are consistent For bone tissues, the Morse taper implants presented the best bio-
with recently published studies, which have indicated the best biome- mechanical results among the models (P b 0.001). On the other hand,
chanical profile for this type of connection [4,16,34]. However, unlike this model also showed a higher stress concentration in the prosthetic
previous studies that evaluated only bone tissue [16], this study indicat- abutment than the other large-diameter implants did.
ed a significant increase in stresses among the abutments of the Morse The implants that used the PSW concept had higher stress concen-
taper implants. These results can be justified by the geometry of the trations in the retaining screw and the crown relative to the other
Morse taper implants (an internal connection), which leads to the cen- large dental implants.
tralization of stresses along the axis of the implant itself and adequate
stability [4,34,35]. Therefore, it causes an increase in stresses in the Acknowledgements
abutment-implant interface and a reduction of the magnitude of ten-
sions in the cortical bone, as demonstrated in this study.
Thus, the best distribution of biomechanical stress in the bone tissue - State of Sao Paulo Research Foundation (FAPESP): Grant Support
was accomplished through the use of the Morse taper implants. However, (2015/20827-2); Scholarship: 2015/09073-6, 2010/15734-1.
the biomechanical analysis does not preclude the use of external hexago- - Conselho Nacional de Desenvolvimento Científico e Tecnológico
nal implants with the PSW concept, as, in bone tissue, the distribution of (CNPq - 303874/2010-4).
the stresses and microstrains was more effective than it was for the regu- - Renato Archer Research Center, Campinas, SP, Brazil.
lar platform. Nevertheless, the PSW concept (model 3) showed an in- - Conexao Sistemas de Prótese, Arujá, São Paulo, Brazil.
crease in stresses in the crowns and the retaining screw; therefore, a
constant clinical monitoring of these patients is needed to increase the
longevity of the implant-supported prosthesis in this type of restoration
to ensure an adequate control of occlusal masticatory forces. References
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