Innovative Design of a New Intraosseous-Subperiosteal Combined Implant for Severe Atrophic Edentulous Dentition: A Finite Element Analysis

doi:10.21203/rs.3.rs-5294556/v1

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Innovative Design of a New Intraosseous-Subperiosteal Combined Implant for Severe Atrophic Edentulous Dentition: A Finite Element Analysis

https://doi.org/10.21203/rs.3.rs-5294556/v1

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Background: To develop a new combined intraosseous-subperiosteal implant for severely atrophic edentulous mandibles and analyze its biomechanical properties via finite element analysis.

Methods: We reconstructed the bone model using CBCT data from a patient with an edentulous mandible. Subsequently, we designed intraosseous implants based on the bone volume within the 3-matic software, and the superstructure abutments were designed on top of it. Then, a subperiosteal titanium mesh base was designed on the surface of the mandible. Finally, the intraosseous implants, the abutments, and the subperiosteal titanium mesh base were integrated to obtain a new intraosseous-subperiosteal combined implant. Four groups of finite element models were assembled, varying in implant design and abutment count. Four loading modes were identified: anterior vertical, unilateral molar vertical, bilateral molar vertical, and unilateral molar lateral occlusions. Finite element analysis was used to analyze the maximum and minimum principal stresses in the peri-implant bone and the von Mises stresses in the implants, abutments, screws, and titanium nails.

Results: A new intraosseous-subperiosteal combined implant for an extremely atrophic edentulous mandible with severe jaw was successfully constructed, which consisted of three main components: a subperiosteal titanium mesh base combining mesh and ribbon morphology, the endosteal implant, and the abutment. The results of finite element analysis demonstrated that the maximum and minimum principal stresses among all groups remained below the yield strength of 140 MPa, while the von Mises stresses in the implant component groups were within the material’s tolerable limits. The surrounding bone stress can be reduced with the novel-designed implant. Increasing the number of abutments can decrease the stress on the implant components.

Conclusions: The new implant developed in this study demonstrated enhanced biomechanical properties in simulated applications for dental implant prosthetics in severely atrophic edentulous mandibles. This innovative design offers a promising alternative for overcoming the challenges associated with dental implant prosthetics in patients with severely atrophic mandibles, potentially improving outcomes in this patient population.

Combined intraosseous-subperiosteal implant

Dental implant

Finite element analysis

Implant designs

Implant-supported prosthetic rehabilitation for edentulous patients is a well-established and highly predictable treatment modality^{[1, 2]}. For severely resorbed mandibles, extensive bone augmentation procedure is needed for a dental implant supported edentulous prosthesis ^[3]. However, this process can be challenging for the edentulous population, predominantly composed of the elderly, who may struggle to endure extensive bone augmentation surgeries, leading to a lower long-term success rate of implantation^[4–6]. An alternative approach is to use short implants^[7]. However, a meta-analysis showed that the long-term stability of short implants is inferior to that of standard implants^[8], and the use of short implants in severely atrophic edentulous mandible can lead to pathological fractures^[9]. Therefore, a safer and more stable method with a shorter treatment period is urgently needed for edentulous patients with severe atrophy mandibles.

In 1940s, Gustav Dahl firstly developed the concept of the “subperiosteal implant” and applied it in cases of severe mandibular atrophy^[10]. Subperiosteal implants are less invasive than regular implants as they are placed on the bone surface and covered by the periosteum instead of being inserted into the alveolar bone. These customized implants have demonstrated positive outcomes in terms of function and success rates ^[11–16]. Although early subperiosteal implants were difficult to attach securely to the bone surface, additively manufactured subperiosteal implants have addressed this problem ^{[13, 16]}. Additionally, these implants have enhanced biocompatibility, minimized the metal base area covering the alveolar ridge^[17], and boosted osseointegration capabilities.

However, some complications remain associated with the use of additively manufactured subperiosteal implants. Dimitroulis et al.^[18] summarized 21 cases of severe atrophic bone restoration using subperiosteal implants. Interestingly, they found that implant exposure (occurring in five cases) was the most frequent complication. Additionally, research has shown that subperiosteal implants are unstable when subjected to lateral forces^[19]. This instability can result in the loosening of titanium nails, causing micromotion of the implant and compromising its long-term stability. The lack of research focusing on enhancing the structure of subperiosteal implants has hindered their broad clinical utilization due to unresolved complications.

In this study, a new combined intraosseous-subperiosteal implant for dental prosthetics in severe atrophic edentulous jaws was designed based on the existing subperiosteal implant design. the biomechanical properties of the mandibular principal and von Mises stresses of the implant components were analyzed using finite element analysis (FEA). The aim was to provide a new treatment concept and establish a reference for the clinical diagnosis and treatment of patients with severely atrophic edentulous mandibles.

Construction of geometric models

Four groups of three-dimensional finite element models were established (Fig. 1). Two parameters were considered: the implant design and the number of abutments. The groups included a new implant group with four abutments (NI-4), a new implant group with six abutments (NI-6), an ultra-short implant group with four abutments (USI-4), and an ultra-short implant group with six abutments (USI-6).

The edentulous mandible was simulated by reconstructing cone-beam computed tomography data using commercial modeling software (Mimics 21.0, Materialise Group, Leuven, Belgium; Geomagic Wrap 2017, 3D Systems, Rock Hill, SC, USA), with a cortical bone thickness of 2 mm. The prosthetics were designed and generated using exocad DentalCAD 3.1 (Exocad GmbH, Darmstadt, Germany) and Geomagic Wrap 2017 (3D Systems) software.

The new implant design included a subperiosteal titanium mesh base, intraosseous implants, abutments, screws, and titanium nails. The intraosseous implants, abutments, screws, and titanium nails were modeled using UG NX 10.0 software (Siemens PLM Software, Munich, Germany). The titanium mesh structure was covered around the abutment at the top of the alveolar ridge using the 3-matic 13.0 software (3-matic 13.0, Materialise Group). The titanium mesh structure was designed with a porosity of 65% and a pore size of 0.45 mm. Then, a band structure with a 1-mm thickness was designed around the edges of the titanium mesh structure. These two components were combined to form the subperiosteal titanium mesh-based structure. To simplify calculations, the titanium nails used in this study were not designed with threads, and five titanium nails were designed and placed in the buccal region of the mandible (Fig. 1a, b).

Similarly, all implant components of the ultra-short implant group were modeled using UG NX 10.0 software (Siemens). The ultra-short implants had a length of 4 mm and diameters of 4.1 mm and 5.3 mm, which were placed in the anterior and posterior regions, respectively. The dimensions of the upper screws and abutments were the same as those in the new implant design group, while the lower screws had a length of 6 mm and a diameter of 1.8 mm (Fig. 1c, d).

Boundary and loading conditions

All models were assembled using UG NX 10.0 software (Fig. 1e–h). Table 1 lists the number of elements and nodes in each model. Table 2 summarizes the material properties of the model components based on previous studies^[24–28]. All the materials were homogenous, linearly elastic, and isotropic. The interfaces between the ultra-short implant and the bone, the new combined intraosseous-subperiosteal implant with the bone, and the titanium nail with the bone were defined as "ties." The interfaces between the prosthesis and the screw, the prosthesis and the abutment, the abutment and the ultra-short implant, the abutment and the screw, and the titanium nail and the new implant were set as "contacts.” The coefficient of friction was set at 0.3. Fixed constraints were applied to the lower edge of the mandible^[20–22].

Table 1

Number of elements and nodes used for each model
Group	Elements	Nodes
NI-4 NI-6 USI-4 USI-6	493747 565033 649306 823196	785510 892418 1011224 1279996

Table 2

Material properties of finite element model
Material	Elastic modulus (MPa)	Poisson's ratio	Reference
Pure titanium (new implant, ultra-short implant)	110000	0.33	^{[23, 24]}
Titanium (titanium nail, abutment, screw)	110000	0.33	^{[23, 24]}
Cortical bone	13700	0.3	^[25]
Cancellous bone	1600	0.3	^[26]
PMMA (restoration)	8300	0.28	^[27]

Four loading modes were established (Fig. 2)^{[28, 29]}; Type I loading involved 100 N applied to bilateral mandibular anterior teeth in the vertical direction; Type II loading involved 150 N applied to unilateral molars in the vertical direction; Type III loading involved 300 N applied to bilateral molars in the vertical direction; and Type IV loading involved 105 N applied to unilateral molars inclined at 45° inward.

Stress analysis

The FEA process was completed using the ANSYS Workbench 19.2 software (Ansys Inc., Canonsburg, PA, USA). We measured both the maximum and minimum principal stresses on the mandible to assess the tensile and compressive stresses on the peri-implant bone. A maximum stress of 140 MPa can cause bone resorption^[29–31]. The von Mises stress of each implant component was recorded to assess its biomechanical behavior. The implants used in this study were pure titanium, whereas the abutments, screws, and titanium nails were titanium alloys. The yield strength of pure titanium is 690 MPa^[32], while that of titanium alloy is 897 MPa^[28]. This study found a dependability factor of 2. Plastic deformation occurs when the von Mises stress of the implant component exceeds 50% of the material's yield strength^[28].

Figures 3–9 depict the stress distributions in the bone and implant components, while Figs. 10–15 illustrate the peak stress values for these components. Under a unilateral oblique force of 105 N applied to the posterior region, all components reached their maximum stress levels. At this point, both the maximum and minimum principal stresses in the bone model groups remained below the yield strength of 140 MPa. Similarly, the von Mises stresses within each implant component stayed within the material's allowable limits. However, the abutments and screws in the ultra-short implant groups experienced higher stresses, indicating a greater risk of implant components during prolonged use.

Stress in bone

Compressive stress in the bone covered a wider range than tensile stress, with their distribution ranges being opposite (Figs. 3, 4). In the new implant design group, the distribution of tensile stresses in the bone was more decentralized. In the ultra-short implant group, tensile stress distribution was concentrated at the implant and bone junction.

Under vertical loading, the principal stresses in the surrounding bone were generally lower in the new implant group compared to the corresponding in the ultra-short implant group. Increasing the number of abutments in the new implant design group reduced the tensile and compressive stresses on the surrounding bone during loading in the posterior region (Figs. 10, 11).

Stress in implants

In the new implant designs, stress concentrations were observed at the connection point between the abutment and the base of the subperiosteal titanium mesh (Figs. 5, 6). For ultra-short implants, the stress was primarily distributed in the cervical region (Fig. 5). The peak von Mises stress in the six -abutment design was lower than that in the four-abutment design across all loading modes. Increasing the number of abutments resulted in a reduction in von Mises stress peaks, with a decrease of approximately 25.5% in the new implant design group and 15.5% in the ultra-short implant group during posterior region loading (Fig. 12).

Stress in screws

The von Mises stresses in the screws were mainly concentrated on the unthreaded rods (Fig. 7). In the new implant design groups, the von Mises stress peaks in the screws were lower compared to those in the ultrashort implant groups across all loading modes. When subjected to posterior region loading, the stress peaks decreased by an average of 33% as the number of abutments increased in the new implant design group, and by 26.3% on average in the ultrashort implant group (Fig. 13).

Stress in abutments

In the ultrashort implant groups, stresses were mainly distributed at the abutment-implant junction (Fig. 8). The maximum von Mises stress peak in the abutments was 400.58 MPa, the highest stress value among all models. The von Mises stress peaks in the abutments decreased by an average of 27.5% as the number of abutments increased (Fig. 14).

Stress in titanium nails

In the titanium nails, von Mises stress peaks were consistently located farthest from the center (Fig. 9). As the number of abutments increased, the stress peaks in the titanium nails also increase. However, the von Mises stresses in the titanium nails were substantially lower compared to those observed in other implant components (Fig. 15).

Currently, additively manufactured subperiosteal implants are employed for edentulous patients with severe atrophy jaw ^{[12, 13, 30, 33–35]}. However, the long-term stability of such implants became an issue under the lateral force, which can lead to titanium nail loosening. Additionally, subperiosteal implants generally have a reduced osseointegration area, which is mostly concentrated around the titanium nails that secure the implant^[36]. A clinical case study by Dimitroulis et al.^[18] identified the implant exposure as a common complication with customized subperiosteal implants. Despite these challenges, there is limited research on the structural modification of subperiosteal implants.

We aimed to address these issues by developing a new combined intraosseous-subperiosteal implant for severely atrophic edentulous mandibles and evaluating its biomechanical properties using FEA. Inadequate implant design can lead to stress concentration and imbalance in stress distribution, potentially causing complications and impacting the success rate of implant prosthetics^[37].

The new implant design incorporates a subperiosteal titanium mesh base, intraosseous implants, abutments, screws, and titanium nails for enhanced retention. The titanium mesh base features a mesh and band structure: the mesh is designed to maintain good blood supply around the abutments, while the band structure ensures the overall strength of the implant^[38]. This design aims to improve stress transfer to the bone and reduce stress on the implant components ^[15]. Previous studies have suggested that porosity and pore size of the titanium mesh are critical for osseointegration, with optimal values being a porosity of 60–70%^[39] and a pore size was 0.3–0.6 mm^[40]. In this study, the titanium mesh had a porosity of 65% and a pore size of 0.45 mm, based on these guidelines.

Several studies have shown that the subperiosteal implant is unstable when subjected to lateral forces^{[36, 41]}. To enhance stability under lateral forces and increase the osseointegration area, this study added an intraosseous component to the subperiosteal implant. The abutment attachment design follows a screw-retained restoration concept, with configurations of either four or six abutments, inspired by the all-on-4^[42] and all-on-6^[43] edentulous prosthesis concepts.

In our work, the structural design of the implant significantly impacted the stresses experienced by the surrounding bone, with the new implant design resulting in lower stress levels in the bone compared to other designs. The new implant design featured a larger contact area with the bone and a more uniform contact surface, facilitating improved stress distribution. In contrast, stress was predominantly concentrated at the neck of the implant in the ultra-short implant group. Literature reviews, including one by Raheleh et al., have indicated that resorption of short implants often occurs at the implant neck^[44]. a finding supported by several other studies and FEA investigations ^[44–47].

In this study, the von Mises stress peaks in the implant components varied across different implant designs. The new implant design, which incorporated a subperiosteal titanium mesh base and an intraosseous component, effectively distributed stresses to the bone, even under lateral loading. The highest stress concentrations were observed at the junction between the subperiosteal titanium mesh base and the abutment, suggesting potential areas for design optimization. Titanium nails experienced von Mises stresses ranging from 2.28–10.39 MPa, which were the lowest among all components. This low stress may be attributed to the assumption of 100% osseointegration between the implant and bone, leading to reduced stress on the titanium nails during loading.

Comparative studies, such as that conducted by Wagner et al.^[48] which involved finite element modeling of short implants, found that stresses in implant components were higher than those in short implants, aligning with our findings. Generally, a higher crown height-to-implant length ratio leads to increased leverage, resulting in greater forces on the abutment and screw^[49]. In this study, the ultra-short implants, with a 4-mm length, experienced the highest stresses in the screws and abutments under oblique loading, particularly in the group with four abutments. This indicates that components of ultra-short implants are more prone to damage, in consistency with our findings^{[50, 51]}.

Pandey et al.^[52] used FEA to evaluate the biomechanical behavior of two different edentulous implant restorations, “all-on-4” and "all-on-6.” The six-abutment design group exhibited a more favorable biomechanical behavior, consistent with the results of this study and several other studies^[52–54]. The new six-abutment implant design proved to be a successful strategy for reducing the von Mises stress experienced by implants under various loading conditions. Increasing the number of abutments provided more stress points and transfer pathways in the implant and a wider range of stress distribution. Clinically, the new intraosseous-subperiosteal implant design with six abutments presents an alternative restorative option for edentulous patients, especially those with poor oral habits.

Lateral loading was a critical factor in the FEA, as it increased the lever arm effect when the implant was subjected to lateral forces, resulting in higher stress levels. All four implant groups, whether new or ultra-short, experienced peak stress under a 105-N oblique loading condition. To mitigate the impact of lateral forces on prostheses, it is advisable to reduce the inclinations of the tooth cusps appropriately^[55].

In this study, we introduced a novel implant design combining intraosseous and subperiosteal components. A preliminary biomechanical analysis was conducted to assess stress distribution under various loading conditions. Nonetheless, the study had several limitations. First, the standard model used consisted of edentulous mandibles with adequate bone volume, which may not fully represent the severely atrophic edentulous mandibles commonly encountered in clinical settings. Additionally, the simplified model structure might not capture the full complexity of the actual mandibular anatomy and stress distribution. Future research should employ grayscale assignment to create more specific finite element models that better simulate stress in severely atrophic edentulous mandibles. Furthermore, subperiosteal implants come with diverse design principles and patterns, with key parameters lacking standardized benchmarks^[33]. Future studies should focus on optimizing implant design, thickness, and titanium nail configurations to develop personalized implants that meet individual patient needs.

Within the scope of this study, several conclusions can be drawn. A newly customized combined intraosseous-subperiosteal implant was developed for patients with severely atrophic edentulous mandibles. This innovative implant design demonstrated superior biomechanical properties compared to ultrashort implants used in similar cases. Notably, the combined intraosseous-subperiosteal implant with a six-abutment configuration exhibited enhanced biomechanical performance. This design represents a promising alternative prosthetic method for addressing severe atrophic mandibular edentulism.

FEA

Finite element analysis

CBCT

Cone beam computed

New intraosseous-subperiosteal combined implant

USI

Ultra short implants

Contributions

The study's conception and design were contributed by Yantai Tang, Wenjuan Zhou, and Zhonghao Liu. Material preparation, data collection, and analysis were performed by Yantai Tang and Huimin Nie. The original draft of the manuscript was written by Yantai Tang and Huimin Nie. The manuscript was reviewed by Wenjuan Zhou and Zhonghao Liu. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Author Contribution

Availability of data and materials

All data were calculated by the software itself. The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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No competing interests reported.

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Innovative Design of a New Intraosseous-Subperiosteal Combined Implant for Severe Atrophic Edentulous Dentition: A Finite Element Analysis

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Abstract

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Background

Materials and Methods

Construction of geometric models

Stress analysis

Results

Stress in bone

Stress in implants

Stress in screws

Stress in abutments

Stress in titanium nails

Discussion

Conclusions

Abbreviations

Declarations

Contributions

Author Contribution

Availability of data and materials

References

Additional Declarations

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Version 1