Standard of disocclusion in complete dentures supported by implants without free distal ends: analysis by the finite elements method
Identifieur interne : 000174 ( Pmc/Corpus ); précédent : 000173; suivant : 000175Standard of disocclusion in complete dentures supported by implants without free distal ends: analysis by the finite elements method
Auteurs : Gustavo Diniz Greco ; Estevam Barbosa De Las Casas ; Tulimar P. Machado Cornacchia ; Cláudia Silami De Magalhães ; Allyson Nogueira MoreiraSource :
- Journal of Applied Oral Science [ 1678-7757 ] ; 2012.
Abstract
The occlusal patterns are key requirements for the clinical success of oral rehabilitation supported by implants. This study compared the stresses generated by the disocclusion in the canine guide occlusion (CGO) and bilateral balanced occlusion (BBO) on the implants and metallic infrastructure of a complete Brånemark protocol-type denture modified with the inclusion of one posterior short implant on each side.
A three-dimensional model simulated a mandible with seven titanium implants as pillars, five of them installed between the mental foramen and the two posterior implants, located at the midpoint of the occlusal surface of the first molar. A load of 15 N with an angle of 45º was applied to a tooth or distributed across three teeth to simulate the CGO or BBO, respectively. The commercial program ABAQUS® was used for the model development, before and after the processing of the data. The results were based on a linear static analysis and were used to compare the magnitude of the equivalent stress for each of the simulations.
The results showed that the disocclusion in CGO generated higher stresses concentrated on the working side in the region of the short implant. In BBO, the stresses were less intense and more evenly distributed on the prosthesis. The maximum stress found in the simulation of the disocclusion in CGO was two times higher than that found in the simulation of the BBO. The point of maximum stress was located in the neck of the short implant on the working side.
Under the conditions of this study, it was concluded that the BBO pattern was more suitable than CGO for the lower complete denture supported by implants without free distal ends.
Url:
DOI: 10.1590/S1678-77572012000100012
PubMed: 22437680
PubMed Central: 3928774
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PMC:3928774Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Standard of disocclusion in complete dentures supported by implants
without free distal ends: analysis by the finite elements method</title><author><name sortKey="Greco, Gustavo Diniz" sort="Greco, Gustavo Diniz" uniqKey="Greco G" first="Gustavo Diniz" last="Greco">Gustavo Diniz Greco</name><affiliation><nlm:aff id="aff01"> PhD student, Dental School, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.</nlm:aff></affiliation></author><author><name sortKey="De Las Casas, Estevam Barbosa" sort="De Las Casas, Estevam Barbosa" uniqKey="De Las Casas E" first="Estevam Barbosa" last="De Las Casas">Estevam Barbosa De Las Casas</name><affiliation><nlm:aff id="aff02"> PhD, Professor, Structural Engineering Department, School of Engineering, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Cornacchia, Tulimar P Machado" sort="Cornacchia, Tulimar P Machado" uniqKey="Cornacchia T" first="Tulimar P. Machado" last="Cornacchia">Tulimar P. Machado Cornacchia</name><affiliation><nlm:aff id="aff03"> DDS, MS, PhD, Associate Professor, Department of Restorative Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.</nlm:aff></affiliation></author><author><name sortKey="De Magalhaes, Claudia Silami" sort="De Magalhaes, Claudia Silami" uniqKey="De Magalhaes C" first="Cláudia Silami" last="De Magalhães">Cláudia Silami De Magalhães</name><affiliation><nlm:aff id="aff03"> DDS, MS, PhD, Associate Professor, Department of Restorative Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Moreira, Allyson Nogueira" sort="Moreira, Allyson Nogueira" uniqKey="Moreira A" first="Allyson Nogueira" last="Moreira">Allyson Nogueira Moreira</name><affiliation><nlm:aff id="aff03"> DDS, MS, PhD, Associate Professor, Department of Restorative Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">22437680</idno><idno type="pmc">3928774</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3928774</idno><idno type="RBID">PMC:3928774</idno><idno type="doi">10.1590/S1678-77572012000100012</idno><date when="2012">2012</date><idno type="wicri:Area/Pmc/Corpus">000174</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000174</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Standard of disocclusion in complete dentures supported by implants
without free distal ends: analysis by the finite elements method</title><author><name sortKey="Greco, Gustavo Diniz" sort="Greco, Gustavo Diniz" uniqKey="Greco G" first="Gustavo Diniz" last="Greco">Gustavo Diniz Greco</name><affiliation><nlm:aff id="aff01"> PhD student, Dental School, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.</nlm:aff></affiliation></author><author><name sortKey="De Las Casas, Estevam Barbosa" sort="De Las Casas, Estevam Barbosa" uniqKey="De Las Casas E" first="Estevam Barbosa" last="De Las Casas">Estevam Barbosa De Las Casas</name><affiliation><nlm:aff id="aff02"> PhD, Professor, Structural Engineering Department, School of Engineering, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Cornacchia, Tulimar P Machado" sort="Cornacchia, Tulimar P Machado" uniqKey="Cornacchia T" first="Tulimar P. Machado" last="Cornacchia">Tulimar P. Machado Cornacchia</name><affiliation><nlm:aff id="aff03"> DDS, MS, PhD, Associate Professor, Department of Restorative Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.</nlm:aff></affiliation></author><author><name sortKey="De Magalhaes, Claudia Silami" sort="De Magalhaes, Claudia Silami" uniqKey="De Magalhaes C" first="Cláudia Silami" last="De Magalhães">Cláudia Silami De Magalhães</name><affiliation><nlm:aff id="aff03"> DDS, MS, PhD, Associate Professor, Department of Restorative Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.</nlm:aff></affiliation></author><author><name sortKey="Moreira, Allyson Nogueira" sort="Moreira, Allyson Nogueira" uniqKey="Moreira A" first="Allyson Nogueira" last="Moreira">Allyson Nogueira Moreira</name><affiliation><nlm:aff id="aff03"> DDS, MS, PhD, Associate Professor, Department of Restorative Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Applied Oral Science</title><idno type="ISSN">1678-7757</idno><idno type="eISSN">1678-7765</idno><imprint><date when="2012">2012</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Objective</title><p>The occlusal patterns are key requirements for the clinical success of oral
rehabilitation supported by implants. This study compared the stresses generated
by the disocclusion in the canine guide occlusion (CGO) and bilateral balanced
occlusion (BBO) on the implants and metallic infrastructure of a complete
Brånemark protocol-type denture modified with the inclusion of one posterior short
implant on each side. </p></sec><sec><title>Material and Methods</title><p>A three-dimensional model simulated a mandible with seven titanium implants as
pillars, five of them installed between the mental foramen and the two posterior
implants, located at the midpoint of the occlusal surface of the first molar. A
load of 15 N with an angle of 45º was applied to a tooth or distributed across
three teeth to simulate the CGO or BBO, respectively. The commercial program
ABAQUS<sup>®</sup> was used for the model development, before and after the
processing of the data. The results were based on a linear static analysis and
were used to compare the magnitude of the equivalent stress for each of the
simulations. </p></sec><sec><title>Results</title><p>The results showed that the disocclusion in CGO generated higher stresses
concentrated on the working side in the region of the short implant. In BBO, the
stresses were less intense and more evenly distributed on the prosthesis. The
maximum stress found in the simulation of the disocclusion in CGO was two times
higher than that found in the simulation of the BBO. The point of maximum stress
was located in the neck of the short implant on the working side. </p></sec><sec><title>Conclusions</title><p>Under the conditions of this study, it was concluded that the BBO pattern was more
suitable than CGO for the lower complete denture supported by implants without
free distal ends.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Assif, D" uniqKey="Assif D">D Assif</name></author><author><name sortKey="Marshak, B" uniqKey="Marshak B">B Marshak</name></author><author><name sortKey="Horowitz, A" uniqKey="Horowitz A">A Horowitz</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Br Nemark, Pi" uniqKey="Br Nemark P">PI Brånemark</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Christensen, C" uniqKey="Christensen C">C Christensen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Eskitascioglu, G" uniqKey="Eskitascioglu G">G Eskitascioglu</name></author><author><name sortKey="Usumez, A" uniqKey="Usumez A">A Usumez</name></author><author><name sortKey="Sevimay, M" uniqKey="Sevimay M">M Sevimay</name></author><author><name sortKey="Soykan, E" uniqKey="Soykan E">E 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Appl Oral Sci</journal-id><journal-id journal-id-type="iso-abbrev">J Appl Oral Sci</journal-id><journal-id journal-id-type="publisher-id">J. Appl. Oral. Sci.</journal-id><journal-title-group><journal-title>Journal of Applied Oral Science</journal-title></journal-title-group><issn pub-type="ppub">1678-7757</issn><issn pub-type="epub">1678-7765</issn><publisher><publisher-name>Faculdade de Odontologia de Bauru da Universidade de São
Paulo</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">22437680</article-id><article-id pub-id-type="pmc">3928774</article-id><article-id pub-id-type="doi">10.1590/S1678-77572012000100012</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Articles</subject></subj-group></article-categories><title-group><article-title>Standard of disocclusion in complete dentures supported by implants
without free distal ends: analysis by the finite elements method</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>GRECO</surname><given-names>Gustavo Diniz</given-names></name><xref ref-type="aff" rid="aff01">1</xref></contrib><contrib contrib-type="author"><name><surname>de LAS CASAS</surname><given-names>Estevam Barbosa</given-names></name><xref ref-type="aff" rid="aff02">2</xref></contrib><contrib contrib-type="author"><name><surname>CORNACCHIA</surname><given-names>Tulimar P. Machado</given-names></name><xref ref-type="aff" rid="aff03">3</xref></contrib><contrib contrib-type="author"><name><surname>de MAGALHÃES</surname><given-names>Cláudia Silami</given-names></name><xref ref-type="aff" rid="aff03">3</xref></contrib><contrib contrib-type="author"><name><surname>MOREIRA</surname><given-names>Allyson Nogueira</given-names></name><xref ref-type="aff" rid="aff03">3</xref></contrib></contrib-group><aff id="aff01"><label>1</label> PhD student, Dental School, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.</aff><aff id="aff02"><label>2</label> PhD, Professor, Structural Engineering Department, School of Engineering, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.</aff><aff id="aff03"><label>3</label> DDS, MS, PhD, Associate Professor, Department of Restorative Dentistry, School of Dentistry, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil.</aff><author-notes><corresp id="c01"><bold>Corresponding address:</bold> Gustavo Diniz Greco - Rua Pedra Bonita, 924 -
Barroca - 30360-390 - Belo Horizonte, MG - Brazil - Phone/fax: 55-31-3334-3673 - Cel:
31-84551945 - e-mail: <email>gustavodgreco@yahoo.com.br</email></corresp></author-notes><pub-date pub-type="ppub"><season>Jan-Feb</season><year>2012</year></pub-date><volume>20</volume><issue>1</issue><fpage>64</fpage><lpage>69</lpage><history><date date-type="received"><day>16</day><month>11</month><year>2006</year></date><date date-type="rev-recd"><day>29</day><month>4</month><year>2010</year></date><date date-type="accepted"><day>26</day><month>10</month><year>2010</year></date></history><permissions><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc/3.0/"><license-p>This is an Open Access article distributed under the terms of the Creative
Commons Attribution Non-Commercial License which permits unrestricted
non-commercial use, distribution, and reproduction in any medium, provided the
original work is properly cited. </license-p></license></permissions><abstract><sec><title>Objective</title><p>The occlusal patterns are key requirements for the clinical success of oral
rehabilitation supported by implants. This study compared the stresses generated
by the disocclusion in the canine guide occlusion (CGO) and bilateral balanced
occlusion (BBO) on the implants and metallic infrastructure of a complete
Brånemark protocol-type denture modified with the inclusion of one posterior short
implant on each side. </p></sec><sec><title>Material and Methods</title><p>A three-dimensional model simulated a mandible with seven titanium implants as
pillars, five of them installed between the mental foramen and the two posterior
implants, located at the midpoint of the occlusal surface of the first molar. A
load of 15 N with an angle of 45º was applied to a tooth or distributed across
three teeth to simulate the CGO or BBO, respectively. The commercial program
ABAQUS<sup>®</sup> was used for the model development, before and after the
processing of the data. The results were based on a linear static analysis and
were used to compare the magnitude of the equivalent stress for each of the
simulations. </p></sec><sec><title>Results</title><p>The results showed that the disocclusion in CGO generated higher stresses
concentrated on the working side in the region of the short implant. In BBO, the
stresses were less intense and more evenly distributed on the prosthesis. The
maximum stress found in the simulation of the disocclusion in CGO was two times
higher than that found in the simulation of the BBO. The point of maximum stress
was located in the neck of the short implant on the working side. </p></sec><sec><title>Conclusions</title><p>Under the conditions of this study, it was concluded that the BBO pattern was more
suitable than CGO for the lower complete denture supported by implants without
free distal ends.</p></sec></abstract><kwd-group><kwd>Dental occlusion</kwd><kwd>Dental implants</kwd><kwd>Biomechanics</kwd></kwd-group></article-meta></front><body><sec><title>INTRODUCTION</title><p>A complete mandibular fixed denture with five or six implants as pillars and free
bilateral distal ends was proposed by Brånemark<sup><xref rid="r02" ref-type="bibr">2</xref></sup> (1983). Since then, researchers have tried to identify and
demonstrate the most appropriate occlusal factors capable of providing a smooth and
efficient disocclusion and also to understand their relationships with the
stomatognathic system<sup><xref rid="r04" ref-type="bibr">4</xref>,<xref rid="r09" ref-type="bibr">9</xref>,<xref rid="r16" ref-type="bibr">16</xref>,<xref rid="r18" ref-type="bibr">18</xref>,<xref rid="r25" ref-type="bibr">25</xref></sup>. During this
period, the associations between the occlusal factors and the mastication muscles,
chewing efficiency, bruxism, temporomandibular joint and adjacent tissues have been
investigated. The canine guide is frequently used as a standard in the physiological
movements of the natural dentition<sup><xref rid="r21" ref-type="bibr">21</xref>,<xref rid="r24" ref-type="bibr">24</xref></sup>. Otherwise, few consistent conclusions
and minimal scientific support concerning the occlusal patterns applied to the complete
denture supported by implants are available.</p><p>The occlusal pattern can be considered a critical factor for the longevity of the
components of stomatognathic system, including integrated implants. In the natural
dentition, the periodontal ligament acts as a damping system that improves the
absorption of occlusal stresses. Because there is no periodontal ligament at the
implant-bone interface, stress distribution in the prosthesis, its components, the
implants and the implant-bone interface is simpler than in the natural dentition. If the
occlusal forces exceed the capacity of the system, oral rehabilitation fails due to
overload and a poor load distribution<sup><xref rid="r04" ref-type="bibr">4</xref>,<xref rid="r18" ref-type="bibr">18</xref>,<xref rid="r25" ref-type="bibr">25</xref></sup>.</p><p>The Brånemark protocol was developed to be the antagonist of conventional complete
denture<sup><xref rid="r02" ref-type="bibr">2</xref></sup>. The technological
evolution applied to surgical techniques and to the design and surface treatment of
implants has allowed the use of this type of prosthesis with antagonists supported by
implants, teeth or joint prostheses. There are clinical reports that the stress
distribution generated in the functional loads may surpass the implant's strength and
cause, with some frequency, fracture of prostheses with free distal ends<sup><xref rid="r14" ref-type="bibr">14</xref>,<xref rid="r20" ref-type="bibr">20</xref>,<xref rid="r25" ref-type="bibr">25</xref></sup>.</p><p>Using finite element methods (FEM), Greco, et al.<sup><xref rid="r08" ref-type="bibr">8</xref></sup> (2009) investigated the stresses generated by different patterns
of disocclusion - canine guide occlusion (CGO) and bilateral balanced occlusion (BBO) -
in a three-dimensional (3D) model of a mandibular complete denture supported by implants
with free distal ends. The results showed the following: (I) the pattern of disocclusion
in CGO led to increased stresses in the implant in the region of the canine on the
working side, and (II) in the BBO, stresses were high throughout the infrastructure. It
was concluded that the pattern of disocclusion in CGO was ideal for the mandibular
complete denture supported by implants of the Brånemark protocol type.</p><p>Currently, unlike at the time when the traditional protocol was developed, the option of
including bilateral short implants is available, eliminating the free distal ends. When
a bilateral free distal end is eliminated, this prosthesis approaches the concept of the
fixed rehabilitation setting and deviates from the removable rehabilitation concept.
However, the question remains as to the pattern of disocclusion to use. Disocclusion in
CGO follows the philosophy applied to fixed prostheses, occlusal adjustments in the
natural dentition and orthodontic treatment<sup><xref rid="r22" ref-type="bibr">22</xref>,<xref rid="r23" ref-type="bibr">23</xref></sup>, whereas a BBO follows
the philosophy applied to removable complete dentures, seeking a better distribution of
stresses and a consequent balance of the prosthesis<sup><xref rid="r03" ref-type="bibr">3</xref>,<xref rid="r10" ref-type="bibr">10</xref>,<xref rid="r13" ref-type="bibr">13</xref></sup>.</p><p>Consequently, it was hypothesized in this that the disocclusion in CGO would generate a
more suitable stress distribution than the BBO in a modified Brånemark protocol
prosthesis. This study compared the distribution of stresses generated by disocclusion
in CGO and BBO in the implants and metallic infrastructure of a modified Brånemark
protocol prosthesis without bilateral free distal ends.</p></sec><sec sec-type="materials|methods"><title>MATERIAL AND METHODS</title><p>The SolidWorks program was used as a graphics tool to modify an existing geometric model
developed by Greco, et al.<sup><xref rid="r07" ref-type="bibr">7</xref></sup> (2009) and
to insert the small implants. The new model was exported to the finite element program
Abaqus<sup>®</sup> 2008 (CAE Version 6.7, Providence, RI, USA) for the simulations.
In this program, the whole model was meshed with tetrahedral elements. The previous
mandible base model<sup><xref rid="r06" ref-type="bibr">6</xref></sup> was also
developed using Solid Works<sup>®</sup> and then edited with Abaqus CAE in order to
include the proposed system geometry and denture support.</p><p>Each component of the model had its mesh set separately and subsequently joined to
obtain the complete model. The junction between each component pair (jaw-implants,
implants-metallic infrastructure and metallic infrastructure-artificial teeth) was
generated using the TIE command in the Abaqus commercial finite element program. As a
consequence, each node in the contact surface of one component was constrained to move
together with the adjacent node of the other component. This model contained 148,399
elements and 33,964 nodes. The mesh was tested and refined in the areas of interest
until the response did not change significantly.</p><p>The new model simulated a mandible with seven titanium implants as pillars, five of them
installed between the mental foramen, with a distance of 4 mm between their platforms.
All of these types of implants were cylindrical, 13 mm in height and 3.75 mm in diameter
(Brånemark System<sup>®</sup> Mk III Groovy; Nobel<sup>®</sup> Biocare,
Zürich-Flughafen, Switzerland). The drawings of the two posterior implants, located at
the midpoint of the occlusal surface of the first molar, were cylindrical, 5 mm in
height and 5 mm in diameter (Titamax WS<sup>®</sup>; Neodent<sup>®</sup>, Curitiba, PR,
Brazil). The simulated prosthetic components made of titanium were 3 mm in height
(Multi-unit Abutment<sup>®</sup>; Nobel Biocare<sup>®</sup>), providing a distance of 3 mm
between the base of the infrastructure of the prosthesis and the bone surface (<xref ref-type="fig" rid="f01">Figure 1</xref>).</p><fig id="f01" orientation="portrait" position="float"><label>Figure 1</label><caption><p>Model of the three-dimensional finite elements</p></caption><graphic xlink:href="jaos-20-01-0064-g01"></graphic></fig><p>A complete denture supported by implants was designed with a nickel-chromium
infrastructure (Wiron<sup>®</sup> BEGO, Goldschlangerar, Bremen, Germany), a thickness
of 6 mm, a height of 4 mm and a total length of 112 mm with free distal ends. On this
structure, the twelve elements in artificial dental acrylic resin (the first mandibular
left first molar to the lower right) and a range of 2 mm gingival from the resin and
without mucosal contact tissue were designed (<xref ref-type="fig" rid="f01">Figure
1</xref>).</p><p>Implants 1 and 7 with lengths of 5 mm were considered the short implants near to the
first molar on the working and balancing sides, respectively. Implants 2 and 6 with
lengths of 13 mm were situated close to the canine area on the working and balancing
sides, respectively. Implants 3, 4 and 5 were situated at the mental area between
implants 2 and 6.</p><p>The Poisson's ratio and elasticity modulus of different materials that make up the
models were determined according to the literature<sup><xref rid="r05" ref-type="bibr">5</xref>,<xref rid="r07" ref-type="bibr">7</xref>,<xref rid="r08" ref-type="bibr">8</xref>,<xref rid="r18" ref-type="bibr">18</xref></sup> (Table 1).</p><p>Patterns of disocclusion were simulated by applying a nodal load of 15 N with an angle
of 45º to the canine tooth near implant 2. On the standard of the canine guide, the
point of contact was the vestibular incisal region of the canine on the working side. In
the bilateral balanced occlusion, the points were distributed among the canine on the
working side in the same region as that in the simulation of the CGO, the external part
of the buccal mesial and distal vestibule of the first molar on the working side and the
internal aspects of the mesial buccal atrium and distal first molar on the balancing
side.</p><p>A load of 15 N in the simulation of the CGO was applied to one tooth, and the load in
the simulation of the BBO was distributed across three teeth. Because the stress
distribution in the teeth was not relevant for the analysis, no special precaution was
taken regarding the local stress concentration at the point of load application.</p><p>The results were based on a linear elastic static analysis and were used to compare the
magnitude of the equivalent stress for each of the simulations.</p></sec><sec sec-type="results"><title>RESULTS</title><p>The stress distributions generated by disocclusion in CGO and BBO on the complete model
are shown in <xref ref-type="fig" rid="f02">Figures 2a</xref> and <xref ref-type="fig" rid="f02">2b</xref>. In CGO, the equivalent stresses were concentrated at implants 1
and 2 on the working side. In BBO, the equivalent stresses were distributed among
implants 1, 6 and 7.</p><fig id="f02" orientation="portrait" position="float"><label>Figure 2</label><caption><p>Distribution of the equivalent stress generated by disocclusion in canine guide
occlusion (CGO) (a) and bilateral balanced occlusion (BBO) (b) on the complete
model</p></caption><graphic xlink:href="jaos-20-01-0064-g02"></graphic></fig><p>The stress distributions generated by disocclusion in CGO and BBO on the implants and
metallic infrastructure are shown in <xref ref-type="fig" rid="f03">Figures 3a</xref>and <xref ref-type="fig" rid="f03">3b</xref>. In the CGO, the equivalent stresses were
concentrated in decreasing order at the neck of implant 1, on the infrastructure on the
working side and at the fixing screw of implant 4. In BBO, the equivalent stresses were
concentrated in decreasing order at implants 1 and 7, at the neck of implant 6, on the
infrastructure on the working side and balancing side and at the fixing screw at implant
4.</p><fig id="f03" orientation="portrait" position="float"><label>Figure 3</label><caption><p>Distribution of the equivalent stress generated by disocclusion in canine guide
occlusion (CGO) (a) and bilateral balanced occlusion (BBO) (b) on the implants and
metallic infrastructure. Frontal view</p></caption><graphic xlink:href="jaos-20-01-0064-g03"></graphic></fig><p>The stress distributions generated by disocclusion in CGO and BBO on the implants and
metallic infrastructure are shown in <xref ref-type="fig" rid="f03">Figures 3a</xref>and <xref ref-type="fig" rid="f03">3b</xref>. In CGO, the equivalent stresses were
concentrated at the infrastructure on the working side. In the BBO, the equivalent
stresses were distributed among the infrastructure on the working and balancing
sides.</p><p><xref ref-type="fig" rid="f05">Figure 5</xref> illustrates the equivalent stress
distribution in each of the seven implants. In CGO, the peak of maximum stress occurred
at implant 1, followed by intermediate values at implant 2 and lower stress at the
others implants. In BBO, implants 1 and 7 received the maximum stress values. Implants 1
and 2 received approximately two-fold more stress in the CGO than in the BBO. Implants 1
and 7 received similar stresses in the BBO as shown by a regular curve of stress
distribution.</p><fig id="f05" orientation="portrait" position="float"><label>Figure 5</label><caption><p>Values of the equivalent stress found in the implants</p></caption><graphic xlink:href="jaos-20-01-0064-g05"></graphic></fig><p>The value of the maximum stress found in the simulation of the pattern of disocclusion
in CGO was two times greater than that in the simulation of BBO. This point of maximum
stress in the two models was found at the neck of the short implant on the working side,
located in the region of the first molar (<xref ref-type="fig" rid="f06">Figure
6</xref>).</p><fig id="f06" orientation="portrait" position="float"><label>Figure 6</label><caption><p>Values of the maximum stress in the patterns of disocclusion</p></caption><graphic xlink:href="jaos-20-01-0064-g06"></graphic></fig></sec><sec sec-type="discussion"><title>DISCUSSION</title><p>Several authors support the use of the BBO standard in complete denture conventional
rehabilitation<sup><xref rid="r03" ref-type="bibr">3</xref>,<xref rid="r06" ref-type="bibr">6</xref>,<xref rid="r17" ref-type="bibr">17</xref>,<xref rid="r23" ref-type="bibr">23</xref>,<xref rid="r29" ref-type="bibr">29</xref></sup>, whereas
unclamping in CGO is devoted to rehabilitation supported by teeth<sup><xref rid="r10" ref-type="bibr">10</xref>,<xref rid="r13" ref-type="bibr">13</xref>,<xref rid="r22" ref-type="bibr">22</xref>,<xref rid="r26" ref-type="bibr">26</xref>,<xref rid="r27" ref-type="bibr">27</xref></sup>.</p><p>The implant-supported prosthesis is the union of the concepts of the conventional
complete denture and the fixed prosthesis supported by teeth. Originally, the pattern of
chosen for disocclusion was BBO<sup><xref rid="r02" ref-type="bibr">2</xref></sup>. In a
previous study using FEM, it was observed that the complete denture supported by
implants with bilateral free ends of the Brånemark protocol type should be designed to
receive the pattern of disocclusion in CGO, for which stresses were three times smaller
than in BBO. For this type of prosthesis, the concentration of contact in the region of
the canines was more favorable because it did not generate contact in the extreme areas
of the free ends<sup><xref rid="r08" ref-type="bibr">8</xref></sup>.</p><p>It is observed, both qualitatively and quantitatively, that the literature still has
poor evaluations of the effects of stresses generated on bone structures. The modeling
of these structures by image processing and FEM biomechanical analyses is an alternative
to address this issue. These approaches have the advantage of not being invasive,
therefore contributing to studies such as the calculation of stress, strain and
displacement at the bone-implant interface that would be impractical without
them<sup><xref rid="r05" ref-type="bibr">5</xref>,<xref rid="r07" ref-type="bibr">7</xref></sup>. However, the FEM analysis of the distribution and absorption of
generated tensions by the standards of occlusion and disocclusion in a prosthesis
supported by implants should be treated with caution. The methodological limitations of
a virtual simulation of the stress distribution in a prosthetic system must be
considered<sup><xref rid="r04" ref-type="bibr">4</xref>,<xref rid="r05" ref-type="bibr">5</xref>,<xref rid="r12" ref-type="bibr">12</xref>,<xref rid="r15" ref-type="bibr">15</xref>,<xref rid="r30" ref-type="bibr">30</xref></sup>. Some
methodological aspects should be highlighted. The load (15 N) was determined by
convenience not to compromise the qualitative analysis of the stress distribution. If
the load of disocclusion applied was 150 N, the distribution of qualitative strains
would be similar, whereas the quantitative analysis would show proportionally larger
values. Other authors have been concerned with the evaluation of the occlusion, limiting
the analysis of stresses at the distal free ends<sup><xref rid="r11" ref-type="bibr">11</xref>,<xref rid="r19" ref-type="bibr">19</xref>,<xref rid="r21" ref-type="bibr">21</xref></sup>. Most of these studies carry loads directly onto the
free end in spite of the coating material over the metallic infrastructure<sup><xref rid="r01" ref-type="bibr">1</xref>,<xref rid="r11" ref-type="bibr">11</xref>,<xref rid="r19" ref-type="bibr">19</xref>,<xref rid="r21" ref-type="bibr">21</xref>,<xref rid="r28" ref-type="bibr">28</xref></sup>. The analysis of the
stress distribution in this new model of implants showed a higher stress concentration
in the CGO simulation than in the BBO. This result can be explained because the BBO
contact points are distributed across three points, whereas in the CGO, the contact is
concentrated at the canine on the working side.</p><p>When we analyzed the maximum stresses found on each of the implants, we noticed that the
curve of the stress distribution in the BBO was concave, with the ends of the prosthesis
suffering more stress than intermediate implants. Moreover, the curve with the pattern
of disocclusion in the CGO generated a stress peak in the implants on the working side
and a steep drop towards the intermediate implants and those on the balancing side.</p><p>This difference in stress behavior between the two patterns of disocclusion can be
better measured by considering that the working and balancing sides take turns as the
individual switches the movement side. This means that, in any contact movement that the
individual performs with the BBO, the intermediate implants will be preserved, while the
implants located in regions of two canine strain quadrants will receive light stresses,
and the short implants located in the posterior regions will receive slightly higher
stresses than the others. However, none of the implants in any kind of contact movements
receive a high peak of stress.</p><p>In the CGO, the implants on the working side receive greater stresses than the
intermediate implants and the implants on the balancing side. The short implant on the
working side showed the highest level of stress. When the stresses are alternated
between the working and balancing sides, there will be a wide variation among the
magnitudes of stress on the short implants, with a peak of very high stress at some time
and very low stress at other times. This pattern of stress distribution with maximum
peaks at the short implants on the working side could compromise the longevity of these
implants.</p><p>If the stresses on the intermediate implants are lower than those within the areas of
the canine and both distal short implants in the CGO and the unclamping in the BBO,
perhaps the three intermediate implants could be removed to combine this model with the
concepts of the "on all four" system. This system offers a simplification in the design
of clinical cases of complete dentures supported by implants, with the help of
prototyping and guide surgery, which allows the use of only four implants as pillars of
the mandible and maxilla prosthesis. These implants have a distal tip in order to
minimize the extension of the distal free ends<sup><xref rid="r14" ref-type="bibr">14</xref>,<xref rid="r20" ref-type="bibr">20</xref>,<xref rid="r25" ref-type="bibr">25</xref></sup>. Reducing the number from seven to four implants would
be a new possibility for anchoring the complete denture with biological and economic
advantages if confirmed by <italic>in vitro</italic> and <italic>in vivo</italic>studies.</p><p>The mechanism by which stresses are absorbed and distributed by the implants and the
supporting structures is essential to the longevity of the prosthesis. The dimension of
the implants affects the absorption system of stresses. It seems that the use of wider
rather than longer implants is more important because stresses are located at the neck
of the implant. The larger the diameter of the implants, the lower the stresses in the
region of the implant neck, whereas an increase in the implant length does not interfere
with the significant reduction of the resulting stresses<sup><xref rid="r10" ref-type="bibr">10</xref></sup>. In this study, the maximum stresses found in the two
simulations were located in the neck of the short implant on the working side. Despite
its larger diameter (5 mm), this is an implant of only 5 mm in height, which can be a
critical factor to the longevity of oral rehabilitation. As shown in <xref ref-type="fig" rid="f04">Figure 4</xref>, this implant suffers high stresses on
almost its entire surface. The previous implants of 13 mm in height receive tensions
located on their coronal portion, whereas their apical part suffers much smaller
stresses or are hardly affected.</p><fig id="f04" orientation="portrait" position="float"><label>Figure 4</label><caption><p>Distribution of the equivalent stress generated by disocclusion in canine guide
occlusion (CGO) (a) and bilateral balanced occlusion (BBO) (b) on the implants and
metallic infrastructure. Bottom view</p></caption><graphic xlink:href="jaos-20-01-0064-g04"></graphic></fig><p>The comparison between the results of this study and those of Greco<sup><xref rid="r08" ref-type="bibr">8</xref></sup> (2009) shows that the stresses generated
in the implant region of the canine on the working side are larger in the simulation of
the prosthesis with the free ends than on the prosthesis with no free ends for either
BBO or CGO. When using the distal implants, modifying the Brånemark protocol, the stress
distribution is lower across the entire infrastructure and in all the implants, which
would justify their indication.</p><p>The results of the present study rejected the hypothesis that the disocclusion in CGO
generates a stress distribution more suitable than the bilateral balanced occlusion with
a modified Brånemark protocol prosthesis. The standard of choice for the modified
Brånemark protocol should be BBO because it generates less stress on the implant
abutments. Further studies, especially <italic>in vivo</italic> investigations, are
required of this new proposed protocol before it can be safely included in the arsenal
of prosthetic rehabilitation.</p></sec><sec sec-type="conclusions"><title>CONCLUSION</title><p>According to the criteria and limitations established in this study, it is possible to
conclude that the disocclusion in BBO induced lower tensions than those in CGO in a
mandibular complete denture supported by implants without free distal ends (the modified
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