Int. J. Med. Sci. 2024, Vol.

21 1672

Ivyspring
International Publisher International Journal of Medical Sciences
2024; 21(9): 1672-1680. doi: 10.7150/ijms.91620
Research Paper

Evaluation of Different Subperiosteal Implant

Thicknesses on Mechanical Strength and Stress on Bone
by Finite Element Analysis
Abdulsamet Kundakcioglu, Mustafa Ayhan
Istanbul University Faculty of Dental Medicine Department of Oral and Maxillofacial Surgery, Istanbul, Turkey

 Corresponding author: [email protected].

© The author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/).
See http://ivyspring.com/terms for full terms and conditions.

Received: 2023.10.28; Accepted: 2024.05.28; Published: 2024.06.17

Abstract
Implants have always been within the interest of both clinicians and material scientists due to their places
in reconstructive and prosthetics surgery. Excessive bone loss or resorption in some patients makes it
difficult to design and manufacture the implants that bear the necessary loads to carry the final
prosthetics.
With this study; we tried to determine the minimum material thickness of the subperiosteal implants that
can withstand the physiological forces. We have created a digital average bone structure based on actual
patient data and designed different subperiosteal implants with 1, 1.5, and 2mm material thicknesses (M1,
M2, M3) for this digital model.
The designed implant models are subjected to 250 Newtons (N) of force, and the implant and bone are
tested for the stress they are exposed to, the pressure they transmit to, and their mechanical strength
with Finite Element Analysis with the physical parameters boot for the implant material and human bone.
Results show us that under specific design parameters and thicknesses, the 1mm thickness design failed
due to exceeding the yield stress limit of 415MPa with a 495,44MPa value. The thinnest implant showed
plastic deformation and transmitted excessive forces, which may cause bone resorption due to residual
stress.
We determined that thinner subperiosteal implants down to 1.5mm that have the necessary material
parameters for function and tissue support can be designed and manufactured with current technologies.
Keywords: Custom Made Implant, Subperiosteal Implant, Bone Resorption

1. Introduction
Adentia associated with severe bone resorption the jaw bones with iliac grafting is a successful
is one of the most challenging conditions to treat in method, it has some disadvantages, such as a more
maxillofacial surgery. The significant loss of bone in extended treatment period, the impossibility of using
patients' jaws makes implant-supported prostheses a temporary prosthesis, the fact that a second surgical
either very difficult or impossible, as well as using site is involved, and the patient's temporary walking
removable prostheses extremely uncomfortable. Since difficulty.
endosseous implants need sufficient bone tissue to In cases of reconstruction with zygoma implants,
surround them, grafting operations are required zygomatic implants have their own specific problems.
before implant applications in cases of bone We can list these problems as sinus-related infections,
resorption. soft tissue problems, prosthetic issues, and implant
Various surgical techniques, such as onlay iliac failures.4, 5 On the other hand, digital developments in
grafting and zygoma implants, have been described to computer-aided design and production software in
treat this condition. 1–3 Although the reconstruction of oral and maxillofacial surgery offer various solutions

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to the difficulties in subperiosteal implant patients who underwent the application was
applications. transferred to digital media. One patient was not
The aperture piriformis and zygomatic buttress included in the study because post-op follow-ups
regions of the upper jaw, which are the areas where could not be performed for reasons unrelated to the
subperiosteal implants would be placed, remain intact study.
enough to carry occlusal loads and are not affected by During the period spanning from 2018 to 2021,
bone resorption, even in patients with severe bone our clinic assessed 49 patients who sought implant
atrophy.6 Today, with the well-known laser sintering treatment but were deemed ineligible due to
technique currently used in clinical settings, it is insufficient bone tissue based on clinical and
possible to make customized titanium subperiosteal radiographic evaluations. Subsequently, these
implants that are highly compatible with the bone.7 patients were considered for custom subperiosteal
With these implants, which can be designed implant treatment. Upon further examination, 33
specifically for the patient, fixed prosthetic treatments individuals were identified as unsuitable candidates
can be designed by taking support from the due to uncontrolled comorbidities, bisphosphonate
appropriate parts of the upper jaw with mini-screws.8 usage, history of cleft lip and palate, or smoking
Since the implants are placed subperiosteally, they habits, making them ineligible for subperiosteal
become susceptible to infection in cases of gingival implant placement. All eligible candidates were aged
recession; thus, it is crucial to design the implants as over 60 years. However, four patients declined
thin as possible, various studies are in literature treatment voluntarily despite meeting the criteria.
achieve this problem.9 Eventually, subperiosteal implant treatment was
We aimed to determine the minimum thickness administered to 12 patients at various time points.
that can be used for the designs clinically without Radiographic data, both pre-operative and
compromising the necessary material strength or post-operative, were digitally documented for 11 of
causing any loads to the supporting bone tissue by these patients. One patient was excluded from the
evaluating the behavior of implants with 3 different study due to the inability to conduct post-operative
thicknesses (1mm, 1.5mm, 2mm) under the follow-ups, unrelated to the research.
predetermined normal occlusal force using the finite
Numerical Data Processing
element analysis method.
CT (Computed Tomography) scans for 11
2. Materials and Methods patients as volumetric binary files (VBF), first
grouped as one file cluster. Model to Model Distance
Study Type and Location Module of 3DSlicer (Open Source) was performed on
This experimental laboratory study was carried the file cluster, and a distance map between 11 models
out in Istanbul University Faculty of Dentistry, was computed. This distance map creates
Department of Oral and Maxillofacial Surgery corresponding point-to-point distance tables with
(Turkey) with the partnership of BioTecnica anatomically selected points. Using a
Engineering, Medical Company (Turkey). Ethical principal-component analysis module with
approval of the study is issued by İstanbul University computation of the mean group selected a mean value
Local Ethics Committee with the number of 2023/12 is determined for the group. After the mean value
Rev-1. determination for the group, this data is used to
generate a template model with the Shape Variation
Patient and Data Selection Analyzer module of the 3DSlicer (Open Source). The
Between 2018 and 2021, 49 patients who applied Shape Population module visualizes the generated
to our clinic for implant treatment but were found to model, and the resulting 3D model is used for all the
have insufficient bone tissue for conventional implant following subperiosteal implant designs. This
treatment in clinical and radiographic examinations re-generated 3D model is based on all the mean
were examined for custom subperiosteal implant values of the 11 patient’s data and contains all
treatment. In further examinations, 33 patients with anatomically relevant points.
uncontrolled comorbid factors, bisphosphonate use,
cleft lip and palate history, or smoking were Construction of Geometric Models
evaluated as unfavorable regarding a subperiosteal Models in Stereolithography (STL) format
implant. All patients are over 60 years old or above. designed with BioTechnica medical engineering
Despite the indication, four patients refused to be company were imported into CAD (Computer Aided
treated voluntarily. Subperiosteal implant treatment Design) software. The reverse engineering module of
was applied to 12 admitted patients at different times. the CAD software was used to convert the 3D models
Pre-op and post-op radiographic information of 11 taken as point clouds into solid models. CATIA

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software was used for CAD applications. The 3D solid modulus of elasticity on bone and implant, and the
model required to analyze the implant geometry was poison ratios of the materials used are given in Table 1
obtained (Figure 1,2,3). Minimizing the deviation and Table 2. Fixation considered immobile and
between the obtained 3D model and the point cloud osseointegration of implant frame were denied. The
data is imperative. For this, deviation analysis has solution matrix is calculated as a tetrahedron mesh
been made for all surfaces (Deviation Analysis) type and as a parabolic element. The mesh size was
obtained by region definitions. The amount of calculated as 0.5mm.
deviation was determined as 0.05 mm.
FEA (Finite Element Analysis) was used to Load Conditions and Stress Analysis
determine the stress distribution, overall, consisting of In our study, stress distribution and analysis
bone and implant. The 3D solid model obtained with were performed for 3 different models under a
CAD was transferred to FEA, and a 3D solution mesh vertical load of 250 newtons. The stress distribution
was created with Mesh Generation. The finite element and effects on the implants were calculated with the
method is a numerical method that allows us to obtain Von-Misses yield criterion, but since the bone is not in
information about the structure by dividing the a homogeneous structure and von Misses can only be
structure into a finite number of small elements and used in homogeneous structures, the stress analysis
solving a finite number of equations instead of an on the bone was calculated according to the Piola–
infinite number of equations. For this reason, the Kirchhoff stress tensors theorems. Although the
established solution network is vital for the calculations of implant and bone stress values were
calculation result. ANSYS software was used for FEA done separately, stress measurements were made
applications. An adaptive mesh was applied in the based on bone-implant contact points to obtain
finite element model that was established. The mesh meaningful results.
sizes used in the parts forming the whole, the

Table 1. Mechanical properties of Ti6Al4V material and Bone (D2)

Materials Tensile Strength (MPa) Modulus of Elasticity (GPa) Yield Strength (MPa) Poisson Ratio Density(kg/m3) Hardness (Hv)
Ti6A14V 960-1270 100-120 830 0.33 4430 320-370
Bone (D2) 120 15 120 0.25 1908 33-43

Table 2. Number of elements used in finite element analysis

Model Mass(gr) Volume(mm3) Mesh size (mm) Number of Nodes Number of Elements
M1 – T:1.0mm 2.52 565 0.5mm 105392 62235
M2 – T:1.5mm 3.66 822 124187 75454
M3 – T:2.0mm 4.80 1076 142020 87879

Figure 1. Implant models 3D CAD geometry and boundary conditions.

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Figure 2. CAD model image of the implant integrated into the maxilla bone.

Figure 3. Implant and maxilla bone geometry mesh model image.

Residual stress is the internal stresses that occur material, irreversible plastic defects occur in the
in the material at the point where the response of the material.
internal structure of the material to this force at the In our study, the reliability coefficient was
molecular level is equal to the external force as a result determined as 2 to evaluate the plastic deformation to
of a force applied to a homogeneous material in a be detected in the material, and according to this
static position. These internal stresses remain below safety coefficient, the von-Misses stress value on the
the modulus of plasticity, where the material does not implant should be less than half the yield strength of
lose its plastic properties until a certain point, and the material to avoid plastic deformation. The yield
when the external force is removed, the internal strength of the Ti6Al4V material is 830 MPa and
stresses formed in the material disappear, and the values below 415 MPa, and it is assumed that it does
material returns to its original state. If the residual not undergo plastic deformation.
stress in the material exceeds the yield strength of the

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Vairo G 10 it is accepted that the physiological lowest was 22.15 MPa in the M3 model with a
residual stress limit at which the bone will not be thickness of 2.0 mm. The highest value was 26.63 Mpa
damaged is 170 Mpa for cortical bones in compression in the M1 model with 1.0 mm thickness (Figure 4,5).
and 100 Mpa when tensile forces are applied. The thinness of the implant harmed residual stresses
Accordingly, when calculated according to the since the pressure on the bone created a displacement
constant of 2, our safety factor in our study, the force. In addition, this effect will increase the stress on
residual stress in the bone should be below 50 MPa. If the implant.
these values are exceeded, irreversible collagen In Figure 6, the displacement value on the M3
destruction and resorption in the bone are possible. model, which has the least residual stress on the bone,
is given. When the axial and total displacement values
3. Results were examined, the highest displacement values on
When the highest residual stress values formed the implants were 1.44 mm in the M1 configuration.
in the bone as a result of vertical loading were The lowest displacement value is 0.46 mm in the M3
examined in all models, it was observed that the implant formed with a 2 mm thickness (Figure 6).

Figure 4. Residual stress changes on bone according to different thicknesses.

Figure 5. Changes in maximum residual stresses on bone with implants with different thickness.

Figure 6. Displacement values on the bone with M3 configuration.

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Figure 7. View of von Mises stress values on implants in different thickness.

Figure 8. General view of von-Mises stress values on fasteners with M3 configuration.

When the von Mises stress results in the implant the implant. However, the increase in thickness also
are examined, it is seen that the highest stresses occur increases the weight of the material at a significant
at the screw connection interfaces in all models rate. The lightest and heaviest implant weights are
(Figure 7). It was determined that the lowest stresses 2.50 g (M1) and 4.80 g (M3), respectively.
occurred in the M3 model with a thickness of 2 mm,
and the highest stresses occurred in the M1 model 4. Discussion
with a thickness of 1 mm. This is due to the high In the discussion, we highlight the historical
accumulation of stresses at the thin-walled connection context of subperiosteal implants dating back to the
interfaces. On the other hand, with the decrease of the 1940s and their decline before 3D production
implant thickness, the stress accumulated connection techniques due to clinical challenges.11-14
interface also changed. As seen in Figure 8, the Endosseous implants replaced them with the
highest stresses occurred around the H2 hole in the advent of osteointegration, particularly for
M1-M2 geometries, while in the M3 geometry, they edentulous patients requiring fixed prosthetic
occurred around the H1 hole (Figure 8). treatment.15,16
It is seen that the stresses occurring in implants However, severe bone deficiency often
with thicknesses of 1.5 mm and 2.0 mm under necessitates bone augmentation techniques like iliac
chewing loads are lower than the yield strength of the bone grafting (IBG) or zygoma implants, each with its
material. For M2-M3 models, plastic deformation will own set of complications. 17–19 Bone grafting using
not occur under static load. It has been observed that cranial bone yields better long-term results in terms of
the stresses are distributed more homogeneously on resorption compared to iliac bone grafting. However,
the body with increased material thickness and both techniques exhibit similarly high rates of
decreased by 3 times compared to the highest stress post-operative complications.20
value. It has been determined that the highest stress These bone augmentation techniques may be
regions change with the increase in the thickness of painful and require longer treatment periods. To

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avoid such bone augmenting procedures, zygoma maximum support from the bone and be resistant to
implants have been suggested as a treatment lateral movements.27
alternative. However, this method has various With 3D imaging and production methods,
problems, including sinus infections, eye-related designs have been made virtually. One of the essential
complications, and prosthesis attachment points at advantages of this method in the literature is that we
undesirable points. 21,22 can determine the regions where the screws will be
Subperiosteal implants have been used for the placed to increase stabilization.28 In this way, the
fixed prosthetic rehabilitation of partially edentulous volume of the implants is ensured to be smaller and
patients with severe bone loss.8 Therefore, we stress can be reduced.29,30
performed our study on a model with bone resorption In the first trials of this method, the implants are
in the form of Cawood-Howell type 4. The use of produced as resin in the 3D printer and cast as metal
subperiosteal implants, first applied by Dahl in the in the dental laboratory. In the laser sintering method,
40s, has increased in recent years with the which comes into use later, the production of the
development of imaging and production techniques. implant is made directly by producing the metal in
Today, they are digitally designed and produced by a the 3D printer. This production technique is vital in
3D laser sintering method that provides fast and terms of preventing the mistakes that will be
effective treatment for patients with severe bone encountered in the laboratory stages.31
deficiencies and started to become popular again.8,23 In the literature review, although there is
Modern production techniques ensure information about the required thickness of the old
compatibility with bone, with stability enhanced type subperiosteal implants produced on the model,
through screw placement and fixation under local such a study for the implants produced by the laser
anesthesia.24 In our study, the implants were designed sintering method has yet to be observed.32
to be fixed with 4 screws in each half jaw so that the In our study, the stresses and movements on the
implants had stable results; although they were made implant and bone are measured by applying a force of
without screws in the past, they can be easily applied 250N to the implant. The strength of the implants
under local anesthesia. against this force is evaluated. Three subperiosteal
One of the significant disadvantages of implants (1mm, 1.5mm, 2mm) with the same design
subperiosteal implants is that they are in direct are modeled in different thicknesses. Residual and
contact with the periosteum. This can cause a gingival Von Mises forces on the implants under 250N occlusal
recession or exposure or even implant infection. force, displacement amounts, and residual stresses in
Patient selection should be considered to avoid such the bone are measured. For the stresses on the
complications, and factors such as diabetes and implants, the equivalent value of 415 MPa is exceeded
smoking should be avoided.25 It is thought that one of by the 1 mm thick implant, which shows us that the 1
the reasons for this complication is the metal thickness mm thick implant will undergo plastic deformation
of the implants.26 To prevent openings in the gingiva, under occlusal forces. It is predicted that plastic
we evaluated the stresses and pressures on the deformation problems may be encountered in implant
implants and prosthesis under the chewing force geometries with a thickness of 1.0 mm. Implants with
using the finite element analysis method. Our 1.5 mm and 2 mm thicknesses are safe in terms of
research determines how much the implant thickness plastic deformation as they remain below 415MPa.
can be reduced. We aimed to achieve a design that is When we look at the movements that occur
resistant enough to withstand chewing forces and thin under the force in our study, it is seen that the most
enough to prevent gingival recessions. extensive movement occurs in the occlusal region of
To ensure that the implants can be applied under the implant, which is 1mm thick, and the amount of
local anesthesia, they must be placed in the zygomatic movement is determined as 1.4mm. A minor
prominence and apertura piriformis area without movement occurs in the 2mm-thick implant and the
requiring much flap reflection. Subperiosteal implants same area. The movement value is 0.42mm. Minimal
are designed as two separate parts, as they will be movements are acceptable in intraoral applications,
easier to place in the operation and sufficient to but a movement of 1.4 mm cannot be considered
elevate the soft tissue in a smaller area surgically.8,23 minimal. This amount of movement can cause stress
Many different designs have been proposed for the accumulation on the implant, fractures in the
subperiosteal implant in the literature. In the old prosthesis, and resorption in the bone on which it is
designs, some implants are designed to get support placed.33-35
from the apertura piriformis, zygomatic prominence, Stress on the bone is one of the causes of bone
and palatal dome, also spread over the entire occlusal resorption, and using a proper thickness subperiosteal
surface. This way, it aims that the implant will receive implant can aid in the avoidance of this resorption.36

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In our study, 1mm implants are seen as the reconstruction patients with severe bone atrophy,
implants that cause the most stress on the bone, and especially compared to other treatment options such
the slightest stress occurs with the 2 mm-thick as iliac bone augmentation and zygomatic implants.
implants. Considering the von Mises stresses on the However, since laser-sintering custom subperiosteal
implants, the highest stress is seen at 1 mm and the implant use is a relatively recent advancement, the
least stress at 2 mm. When we look at the stresses on number of studies on this subject and the clinical
the implants in our study, it is seen that the maximum experience of physicians is limited. In our study, we
stress areas of the implants of different thicknesses are tried to determine the minimum implant thickness for
different. When we look at the stresses occurring at clinical use, and according to the results we obtained,
the bone connection points of the implants, it is seen the 1.5 mm thick implant showed sufficient strength.
that the screw hole in the apertura piriformis inferior Of course, this result, which we obtained with the
to the 2mm-thick implant is under maximum stress. finite element method, should be evaluated clinically
In 1.5 and 1 mm implants, the screw at the inferior with long-term studies.
part of the zygomatic prominence is observed to be
exposed to maximum tension. As we know from Competing Interests
surgical experience, the bone quality of the zygomatic The authors have declared that no competing
prominence region is higher than the aperture interest exists.
piriformis. For this reason, it should be preferred that
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