Comparative Finite Element Analysis of Short Implants with

Different Treatment Approaches in the Atrophic Mandible

Ozge Doganay, DDS1/Erdem Kilic, DDS, PhD1

Purpose: This three-dimensional finite element analysis study aimed to compare the stresses transmitted to short, tilted,
and vertical implants used in different configurations and to the surrounding peri-implant bone in the atrophic mandible.
Materials and Methods: A three-dimensional model of an atrophic mandible was made using customized computer
software. Four models including short, tilted, and vertical implants were constructed with and without cantilever
extension. Four or six implants in different configurations were placed into the models and mounted with the same fixed
prosthesis. An oblique force of 200 N was bilaterally applied to the most distal part of the fixed denture. Von Mises stress
values on implants and minimum and maximum principal stress values transmitted to peri-implant bone were analyzed.
Results: The highest stress values recorded in the tilted implants (von Mises: 129 MPa), in the peri-implant bone around
the tilted implants (minimum principal stress: –40 MPa), and overall stress values were found to be higher in the model
including tilted implants with cantilever extensions. Distally placed short implants, with consequent elimination of the
cantilevers, resulted in decreased stress values for all of the treatment variabilities of an atrophic mandible. Von Mises
stress values were found as 129 MPa in tilted (model I), 48 MPa in short (model II), 47 MPa in short (model III), and 57 MPa
in vertical (model IV) at the most distal implant location. Lower compressive stress values were noted in the bone around
straight and short implants compared with the tilted implants in all models (model I, tilted: –40 MPa; model II, short:
–34 MPa; model III, short: –33 MPa; model IV, vertical: –25 MPa). Conclusion: Distally placed short implants contributed to
the reduction of stress values of the implants and the surrounding bone. The combination of two short and four straight
implants without cantilevers may be a beneficial design in the rehabilitation of posteriorly atrophic mandibles. Int J Oral
Maxillofac Implants 2020;35:e69–e76. doi: 10.11607/jomi.8122

Keywords: atrophic mandible, bone, finite element analysis, short implant, stress, tilted implant

R ehabilitation with implants in the severely atrophic

mandible has been considered to be a prosthetic and
surgical challenge due to insufficient vertical alveolar
ridge and anatomical restrictions, such as the presence
of the inferior alveolar and mental nerve.1 The close
proximity of the mandibular canal to the alveolar crest
precludes the insertion of regular dental implants in the
posteriorly atrophic mandible.1 In order to overcome
this restraint, advanced surgical techniques  such as
autogenous bone grafting, guided bone regeneration,
and distraction osteogenesis were developed to insert
an implant of standard length.1 However, all of these
procedures can be challenging, technically sensitive,
1Faculty
of Dentistry, Department of Oral and Maxillofacial Surgery,
Bezmialem Vakıf University, Istanbul, Turkey.
Correspondence to: Dr Ozge Doganay, Oral and Maxillofacial
Surgery, Adnan Menderes Bulvarı, Vatan caddesi, 34093,
Bezmialem Vakıf University, Faculty of Dentistry, Department of
Oral and Maxillofacial Surgery, Istanbul, Turkey.
Email: ozgedoganay87@gmail.com; odoganay@bezmialem.edu.tr
S ubmitted October 15, 2019; accepted February 19, 2020.
©2020 by Quintessence Publishing Co Inc.
and time consuming, and require an additional finan-
cial burden. Moreover, extremely high postoperative
graft complication rates up to 95% were reported.2
Rehabilitation of the posteriorly atrophic mandible
using tilted implants between the interforaminal re-
gion has been successfully performed for years.3,4 Tilt-
ing implants enables distribution of occlusal forces, and
aims to reduce long cantilever extensions in the pos-
teriorly atrophic mandible by engaging available bone
for the fixed prosthetic rehabilitation.5,6 However, some
authors have concerns regarding the prognosis of dis-
tally tilted implants placed in the mandible. Although
the inclination of the distally tilted implants increases
the bony contact between the bone and implant sur-
face, and hence seems to be an advantage for the load
transfer along the implant, tilted implants are extreme-
ly subjected to lateral direction of occlusal forces and
a greater possibility of bending moment.7,8 Certain
anatomical conditions, such as an anteriorly positioned
mental foramina leading to a long distal cantilever, may
restrict the beneficial biomechanical properties of us-
ing tilted implants.9,10 In fact, a distal cantilever can be
considered to be a contributing factor leading to higher
stresses around the implants and the peri-implant bone
in the tilted implant concept.11

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Doganay/Kilic
Table 1   Material Properties
Young’s modulus Poisson Tensile strength
Structure (MPa) ratio (MPa)
Compact bone 13,700 0.3 – ble for better longevity and outcomes of implants and
Cancellous bone 1,370 0.3 – implant-related prostheses still cannot be drawn due to
Ti-Zr implant 100,000 0.3 953
(Roxolid)
Framework 218,000 0.33 –
(Co-Cr)
Feldspathic 82,800 0.35 –
porcelain
Another concern is that flexural movement of the
mandible during opening and protrusion of the jaw
causes an alteration of the mandible’s shape and subse-
quently micromovement of the implant after prosthet-
ic rehabilitation, and thus, it may compromise different
stages of osseointegration.12–14
The most posterior implants would be highly prone
to microdamage, most specifically in cantilever situ-
ations due to the mandibular flexure. In other words,
anteriorly positioned implants in the intermental fora-
mens, which are supported fixed prostheses with pos-
terior cantilevers, would lead to leverage effects around
the midline of the jaw. Therefore, considerable stress
around distal implants would arise eventually.12–15
All those mentioned factors might have unfavorable
effects on the prognosis of the implant and implant-
related fixed prosthesis. Therefore, a larger number of
implants would be warranted to reduce the extrinsic
forces leading to the implant and surrounding bone
failure apart from occlusal loads.6,9 At sites where the
bone availability and implant length are compromised,
using short implants in the posterior mandible can be
considered in order to eliminate the cantilever effect,
to relieve stress of anteriorly positioned implants, and
to improve the survival of both implants and prosthetic
structures, if a residual ridge height is at least 6 mm for
the insertion.16,17
Three-dimensional finite element analysis (FEA) is
a valuable method to mimic biomechanical behav-
ior of the implant and surrounding bone that would
not be clinically possible to observe. It has been well-
established, and the effects of different connection
types, implant designs, surface morphologies, and
prosthetic components on the stress distribution
around short or tilted implants and their surrounding
structures have been studied extensively.5,18–20
In the recent past, it was believed that the amount
of bone is one of the major determinants of the suc-
cess of implant surgery.2 Yet, current approaches such
as tilted and short implants and developments in
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surface technology and designs enable clinicians to
do optimum treatment planning in accordance with
the available amount of bone.21 Nevertheless, the ideal
treatment modalities of the posteriorly atrophic mandi-
the diversity of the clinical scenarios.16,18,22,23
Given the lack of general consensus in the literature
regarding the best approach to rehabilitate the poste-
riorly atrophic mandible, the present study aimed to
build up the models including posteriorly placed short
implants. The stress transmission of short implants was
compared with tilted and vertical implants in the four
different treatment combinations supported with fixed
prostheses via three-dimensional finite element analy-
sis. This study was conducted to use as a guide in clini-
cal trials.
MATERIALS AND METHODS
The three-dimensional (3D) model of the atrophic
mandible was produced from the clinical computed
tomography data of a patient meeting the appropriate
properties. Mesh generation of the 3D simulated model
was performed with 10 noded elements to maximize
the sensitivity of the analysis.
Material Properties
Four models with different implant positions and num-
bers were analyzed. The diameters of all implants used
in the simulations were 4.1 mm; 10-mm length, bone-
level tapered (BLT) implants and 4-mm length, standard
plus short implants (titanium-zirconium alloy, Roxolid,
Institut Straumann) were simulated. The framework
and superstructure of the restoration comprised co-
balt-chromium alloys (Wirebond C, BEGO Medical) and
feldspathic porcelain (Dentsply Ceramco), respectively.
All structures were considered linearly elastic, isotro-
pic, and homogenous.24 Young’s modulus and Poisson’s
ratio of the variable elements in the designs were set in
accordance with data available in the literature.22,25 All
values related to the materials of this study are given in
Table 1.
Modeling
All structures provided in the study had been previ-
ously scanned with a digital scanner (Smart Optics
Sensortechnik). The measured data were transferred
to the Rhinoceros 4.0 program (McNeel) to construct
the solid models. The same superstructure was ap-
plied to each model in order to keep the load transfer
constant. Type II bone structure was simulated based
on Lekholm and Zarb classification.26 Compact bone
thickness was considered to be 2 mm in all regions.
 Doganay/Kilic

a b

c d
Fig 1   Illustrations of four models were generated. (a) Model I includes two vertical, two tilted implants, and bilateral cantilever. (b) Model II
includes six implants, adding two short implants distally to model I without cantilever extension. (c) Model III includes four vertical implants
between foramens and two short implants distally without cantilever extension. (d) Model IV includes six vertical implants without cantilever
extension.

The mesiodistal length of the mandibular arch was Models

determined to be 40 mm, whereas the height of the
mandible in all regions was approximately 16 mm.
After completion of the procedure, all models were
transferred to Algor Fempro (ALGOR) software in stl
format to analyze.
In this study, four different treatment modalities were
constructed. Implants 10 mm in length were placed in
the interforaminal regions, while short implants were
placed behind mental foramens in accordance with the
simulated model. All simulations are shown in Fig 1:

Boundary and Loading Conditions • Model I: Emergence profiles of two straight

Boundary conditions were modeled for fixing the low-
er border of the mandible, the mesial and distal region
of the mandibular sections, the compact and the can-
cellous bone, the insertion of the masseter and medial
pterygoid muscles, implants, and prosthetic structures
in all directions. The movements of nodes in all areas
were completely constrained, and the implants and
the prosthetic restoration were assumed to behave as
a monolith. The connection between the superstruc-
ture and the implant was considered to be tightly
bonded, and the complete osseointegration between
the bone-implant interface was assumed. Standard-
ized application of a static 45-degree oblique load of
200 N in the buccal-lingual direction was placed on the
buccal cusp of the most distal part of the prosthesis for
each model.
implants were designated to the lateral incisor
regions, while two tilted implants angled at 30
degrees and the cantilever with 11-mm length were
bilaterally inserted into the second premolars.
• Model II: Two straight implants in the lateral incisor
regions, and two tilted implants angled at 30
degrees and the cantilever with 11-mm length in
the second premolars were bilaterally inserted. In
addition, this model had two distally short implants
at the first molar areas. There was no cantilever in
the superstructure.
• Model III: The implants were placed into the lateral
incisor, first premolar, and first molar areas. This
model included four straight implants between
mental foramens and two short implants. There was
no cantilever in the superstructure.

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Table 2   Von Mises Stress, Minimum, and (models I, II, and III) were achieved in model III, includ-
Maximum Principal Stress Values of ing two short and four vertical implants (short: 47 MPa,
Each Implant (in MPa) vertical middle: 48 MPa, vertical mesial: 33 MPa). Ad-
ditionally, lower stress concentrations were obtained
Maximum Minimum with the short implants compared with the vertical or
Implant model von Mises principal stress principal stress
the tilted implants, which functioned at the most dis-
Model I tal implant location (model I, tilted: 129 MPa; model II,
 Tilted 129 9 –40
 Vertical 74 6 –3 short: 48 MPa; model III, short: 47 MPa; model IV, verti-
cal: 57 MPa). All stress concentration areas and values
Model II
 Short 48 12 –34 were demonstrated in Fig 2.
 Tilted 57 6 –8
 Vertical 34 2 –3 Principal Stresses
Model III In all models, the highest equivalent stress of the com-
 Short 47 12 –33 pact bone was found around the neck of the implants.
  Vertical middle 48 6 –7
  Vertical mesial 33 2 –3
Mean equivalent stress values of the compact bone
were greater than that of the cancellous bone. The
Model IV highest compressive stress values of the bone were
  Vertical distal 57 14 –25
  Vertical middle 49 6 –6 observed at the lingual site near the neck of the im-
  Vertical mesial 31 2 –3 plant, whereas the highest tensile stresses of the bone
occurred on the buccal side. The highest minimum
principal stress (compressive) values were obtained in
the bone surrounding the tilted implant (–40 MPa) in
• Model IV: The implants were placed into the lateral model I. Lower compressive stress values were noted in
incisor, first premolar, and first molar areas. There the bone around vertical and short implants compared
was no cantilever in the superstructure. This model with the tilted implants in all models (model I, tilted:
including six vertical implants with standard length –40 MPa; model II, short: –34 MPa; model III, short:
and diameter is generally used in the rehabilitation –33 MPa; model IV, vertical: –25 MPa) (Fig 3).
of jaws without the need for grafting and served as
control in this study.
DISCUSSION
The von Mises stress analysis was performed to de-
termine the stress values of the implants and restora- The present study aimed to investigate whether using
tions. Minimum and maximum principal stress values short implants would have an additional benefit in re-
used for the identification of local risk factors leading ducing the stress values of all components in the poste-
to bone resorption were applied to the models. All data riorly atrophic mandible. Distally placed short implants
were determined with the range scales and produced used in models II and III were found to function success-
quantitatively and color-coded on any identified loca- fully in reducing the overall stress.
tion and then compared among all models.27 Understanding the stress distribution of the bio-
materials used in implant dentistry is a key factor to
predict the success or failure rates of the methods.
RESULTS Therefore, FEA is frequently used to investigate the
effect of biomechanical properties of the dental im-
The von Mises and maximum and minimum principal plants, prosthetic structures, and the surrounding bone
stress values corresponding to the different implant in which visualization of stress distribution is clinically
configurations of four models are listed in Table 2. impossible.28
On the other hand, FEA study models represent a
Von Mises Stress simplification of the investigated structures. Data ob-
In the models, the highest stress areas were located at tained from an FEA study are not reproducible, and
the top threads of the implants. The amount of stress thus, unfavorable to perform statistical analysis. Indeed,
intensified when the tilted implants were used at the a 3D FEA only allows approximation of material behav-
most distal implant location to support fixed prostheses iors through 3D modeling in a virtual environment. It
in model I. Stress values of the tilted implants decreased is assumed that there is a complete osseointegration
due to the posteriorly placed short implants in model II between the bone and the implant interface as well as
(model I: 129 MPa, model II: 57 MPa). The lowest stress fixed boundary and loading conditions, which may not
levels among posteriorly atrophic treatment modalities fully represent clinical scenarios.5,11

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 Doganay/Kilic

Fig 2 (left)  Von Mises stress values and stress distribution of the

implants under oblique loading (MPa). (a) Stress values of model
I including two tilted and two vertical implants. (b) Stress values of
model II including two tilted, two vertical, and two short implants.
(c) Stress values of model III including four vertical and two short
implants. (d) Stress values of model IV including six vertical implants
(X = distal side; Z = occlusal side).
a
Fig 3 (below)  Minimum principal stress values (MPa) and stress dis-
tribution of mandibular compact bone under oblique load. (a) Stress
values of model I including two tilted and two vertical implants.
(b) Stress values of model II including two tilted, two vertical, and
two short implants. (c) Stress values of model III including four verti-
cal and two short implants. (d) Stress values of model IV including six
vertical implants (X = distal side; Y = buccal side).

c
c

d d

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Doganay/Kilic
In this experimental design, it was aimed to demon-
strate the maximum stress values in different regions of
the models. It should be emphasized that the theme of
the present study was not reporting the precise values
of the stress, but rather comparing the stress distribu-
tion among different treatment modalities.29,30
The tilted implant concept is one of the most com-
monly used protocols, which enables fixed prosthetic
rehabilitation of an atrophic edentulous mandible and
eliminates the need for bone grafting and/or nerve
transposition techniques.31 Moreover, the concept of-
fers some biomechanical advantages by using longer
implants, achieving a larger bone-implant interface,
and providing better load distribution on the occlu-
sal plane. This technique also avoids the presence of a
long distal cantilever, which causes higher stress lev-
els in the surrounding bone, implants, and prosthetic
components.32,33
On the other side, anatomical limitations, such as
short distance in the interforaminal region and anterior-
ly positioned mental foramens, which constitutes long
distal cantilevers, may imperil the stable environment
around the tilted implants. Moreover, the assumption
that reducing the cantilever length by using tilted pos-
terior implants improves stress transmission is debat-
able.34,35 Mandibular flexure as well as occlusal forces
on distal cantilevers cause excessive bending moments
over the implants, resulting in higher peri-implant bone
stress.12 This hinging effect caused by load application
on the cantilever may increase stress on the closest im-
plant.36,37 Although tilting the posterior implant reduc-
es the posterior cantilever length, and thereby seems to
decrease stress transmission in the atrophic jaw, it may
cause higher stresses in the peri-implant bone due to
the direction of the chewing forces as well as the afore-
mentioned drawbacks.9,38
The implant neck has a close relation to the im-
plant-abutment and abutment-framework connec-
tions. Therefore, higher stresses are possibly observed
around the neck of the implant, even though the con-
nections are designed to be rigid in most FEA stud-
ies.38–40 In corroboration with previous reports,9,34,41–43
the images of this study revealed that maximum stress
values were concentrated at the neck area of the im-
plants and at the cortical bone of the tilted implants in
all models. The cantilever extension, which was report-
ed to have deleterious effects on both the implant and
the surrounding structures,37 may be responsible for
the higher peri-implant bone stresses around the tilted
implants in this study. Accordingly, elimination of the
cantilever extension in models III and IV involving short
implants may be considered to have a primary role in
decreasing the overall stress. With regard to this, using
short implants may contribute to the long-term success
of both the prosthesis and implants in the posteriorly
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atrophic mandible if rehabilitation with the long distal
cantilever prosthesis is inevitable.
Several biomechanical factors, such as bone qual-
ity at the insertion area,44 implant shape,30 connection
type,45 occlusal conditions,46 and length and diameter
of the implants,30,47 are known to have an influence on
stress transmission from the implant to the bone. It is
well-known that increasing the length and/or the diam-
eter of the implants is essential in reducing the stress
transmission.48 Shortening the length of the implants
exhibits higher stress values in the bone as well as im-
plant components due to the limited distance for the
load distribution and increased crown height result-
ing from the excessive interocclusal distance.23 On the
other hand, it was reported that splinting the implants
located in the arch reduces the stresses of the bone and
implants. This method enables better load distribution
on the components and helps avoid loss of bone, and
thus, may positively affect the prognosis of the rehabili-
tation.49 Many reports showed higher stresses around
short implants when used in nonsplinted models.23,24
The results of the present study show that stress reduc-
tion in the models with short implants may support the
favorable effects of splinting on load distribution.
In the present study, short implants exhibited lower
stress values compared with the vertical or tilted im-
plants in models II and III despite functioning at the
most affected site during simulations. Furthermore,
short implants demonstrated greater stress reduc-
tion at the level of the most distal implant, compared
to model IV, including six vertical implants 10 mm in
length. Previous studies showed that the diameter,
length, tapers, fillet ends, and design of implants could
essentially affect equivalent stress. Also, implant design
can modify the applied forces acting on the bone.29,50
Despite short implants seeming to have biomechani-
cal disadvantages, it may be implied that the extended
contact area of the occlusal part of the short implants
used in this study contributed to the reduction of stress
values.
Considering the ultimate bone strength as a physi-
ologic limit, as the minimum compressive principal
stress exceeds 170 to 190 MPa in compression, and
the maximum tensile principal stress exceeds 100 to
130 MPa in tension, local overloading occurs at the lev-
el of compact bone.9,47 In the models, all stress values
were found under the limits of ultimate bone strength,
and there were no major differences in terms of the
magnititude and distribution of the stress transmitted
to the bone-implant interface. This is in approximate
agreement with the findings of reported studies.51,52
It might be inferred that all models can be applied to
clinical practice.
It is commonly known that accumulated microdam-
age may lead to bone resorption, even if the stress

values are below the estimated limits.53 FEA studies
have reported that a tilted implant generated higher
compressive stress in the surrounding bone compared
with the stress transmission of bone around a single
vertical implant.35,54 Although splinting the tilted im-
plants provides better stress distribution, microdam-
age in the bone and the materials due to the bending
forces may cause detrimental effects on the surround-
ing bone as well as other components in the long-term
follow-up.54 On the basis of this 3D FEA study and prior
knowledge, it may be suggested that the combination
of short and vertical implants provides favorable results
by avoiding cantilever extension in the posteriorly atro-
phic mandible.
Data from this study may contribute to a valuable
basis for the rehabilitation of the posteriorly atrophic
mandible. It may also provide a better understand-
ing of biomechanical behavior of implant designs and
treatment modalities. Configurations of the implants,
variabilities in the macrostructure, and designs would
play a decisive role in the long-term success.29,54 The
results obtained from this study can also be influenced
by other clinical demands, material properties used for
the rehabilitation of atrophic arches, and treatment
planning, which were not entirely investigated in the
present study. Even so, it seems that the use of short
implants in the tilted implant concept as a posterior
support may offer promising results in the future.
Further in vivo experiments and clinical studies
are needed to demonstrate the prognosis of the im-
plant configurations and designs in certain clinical
conditions.
CONCLUSIONS
Based on the results from this study, posteriorly placed
short implants may contribute to the stress reduction
on both implants and surrounding bone by avoiding
cantilever extension. Furthermore, the use of short im-
plants in the posteriorly atrophic mandible combined
with vertical and/or tilted implants may be beneficial
to reduce cortical bone resorption, if adequate bone
height is present for the placement of a short implant.
ACKNOWLEDGMENTS
Three-dimensional finite element analysis was carried out by Ay
Tasarım Ltd. The authors reported no conflicts of interest related to
this study.
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REFERENCES
  1. Jivraj S, Chee W. Treatment planning of implants in posterior quad-
rants. Br Dent J 2006;201:13–23.
  2. Dimitriou R, Mataliotakis GI, Angoules AG, Kanakaris NK, Giannoudis
PV. Complications following autologous bone graft harvesting
from the iliac crest and using the RIA: A systematic review. Injury
2011;42(suppl 2):s3–s15.
  3. Patzelt SB, Bahat O, Reynolds MA, Strub JR. The all-on-four treat-
ment concept: A systematic review. Clin Implant Dent Relat Res
2014;16:836–855.
  4. Malo P, de Araujo Nobre M, Lopes A. The use of computer-guided
flapless implant surgery and four implants placed in immediate
function to support a fixed denture: Preliminary results after a mean
follow-up period of thirteen months. J Prosthet Dent 2007;97(6
suppl):s26–s34.
  5. Almeida EO, Rocha EP, Freitas Júnior AC, et al. Tilted and short im-
plants supporting fixed prosthesis in an atrophic maxilla:
A 3D-FEA biomechanical evaluation. Clin Implant Dent Relat Res
2015;17(suppl 1):e332–e342.
  6. Cruz M, Wassall T, Toledo EM, da Silva Barra LP, Cruz S. Finite element
stress analysis of dental prostheses supported by straight and
angled implants. Int J Oral Maxillofac Implants 2009;24:391–403.
  7. Naini RB, Nokar S, Borghei H, Alikhasi M. Tilted or parallel implant
placement in the completely edentulous mandible? A three-
dimensional finite element analysis. Int J Oral Maxillofac Implants
2011;26:776–781.
  8. Korabi R, Shemtov-Yona K, Dorogoy A, Rittel D. The failure envelope
concept applied to the bone-dental implant system. Sci Rep 2017;
7:2051.
  9. Takahashi T, Shimamura I, Sakurai K. Influence of number and inclina-
tion angle of implants on stress distribution in mandibular cortical
bone with All-on-4 concept. J Prosthodont Res 2010;54:179–184.
10. Tawil G, Aboujaoude N, Younan R. Influence of prosthetic parameters
on the survival and complication rates of short implants. Int J Oral
Maxillofac Implants 2006;21:275–282.
11. Bhering CL, Mesquita MF, Kemmoku DT, Noritomi PY, Consani RL,
Barão VA. Comparison between all-on-four and all-on-six treatment
concepts and framework material on stress distribution in atrophic
maxilla: A prototyping guided 3D-FEA study. Mater Sci Eng C Mater
Biol Appl 2016:69;715–725.
12. Law C, Bennani V, Lyons K, Swain M. Mandibular flexure and its
significance on implant fixed prostheses: A review. J Prosthodont
2012;21:219–224.
13. Nokar S, Naini RB. The effect of superstructure design on stress dis-
tribution in peri-implant bone during mandibular flexure. Int J Oral
Maxillofac Implants 2010;25:31–37.
14. Sivaraman K, Chopra A, Venkatesh SB. Clinical importance of median
mandibular flexure in oral rehabilitation: A review. J Oral Rehabil
2016;43:215–225.
15. El-Sheikh AM, Abdel-Latif HH, Howell PG, Hobkirk JA. Midline man-
dibular deformation during nonmasticatory functional movements
in edentulous subjects with dental implants. Int J Oral Maxillofac
Implants 2007;22:243–248.
16. Geramy A, Rokn A, Keshtkar A, Monzavi A, Hashemi HM, Bitaraf
T. Comparison of short and standard implants in the posterior
mandible: A 3D analysis using finite element method. J Dent (Tehran)
2018;15:130–136.
17. Ogawa T, Dhaliwal S, Naert I, et al. Effect of tilted and short distal
implants on axial forces and bending moments in implants sup-
porting fixed dental prostheses: An in vitro study. Int J Prosthodont
2010;23:566–573.
18. Elias DM, Valerio CS, de Oliveira DD, Manzi FR, Zenóbio EG, Seraidar-
ian PI. Evaluation of different heights of prosthetic crowns supported
by an ultra-short implant using three-dimensional finite element
analysis. Int J Prosthodont 2020;33:81–90.
19. Sugiura T, Yamamoto K, Horita S, Murakami K, Kirita T. Micromotion
analysis of different implant configuration, bone density, and crestal
cortical bone thickness in immediately loaded mandibular full-arch
implant restorations: A nonlinear finite element study. Clin Implant
Dent Relat Res 2017;20:43–49.
The International Journal of Oral & Maxillofacial Implants  e75
Doganay/Kilic
20. Hanaoka M, Gehrke SA, Mardegan F, et al. Influence of implant/
abutment connection on stress distribution to implant-surrounding
bone: A finite element analysis. J Prosthodont 2014;23:565–571.
21. Huang HL, Hsu JT, Fuh LJ, Tu MG, Ko CC, Shen YW. Bone stress and
interfacial sliding analysis of implant designs on an immediately
loaded maxillary implant: A non-linear finite element study. J Dent
2008;36:409–417.
22. Tsitsiashvili AM, Silant’ev AS, Panin AM, Arutyunov SD. Short dental
implant biomechanics in the mandible bone tissue. Stomatologiia
(Mosk) 2019;98:33–36.
23. Meimandi M, Talebi Ardakani MR, Amid R, Mahmoudi Motlagh A,
Beheshti S. Comparison of stress and strain distribution around
splinted and nonsplinted 6-mm short implants in posterior man-
dible: A finite element analysis study. Implant Dent 2018;27:74–80.
24. Toniollo MB, Macedo AP, Pupim D, Zaparolli D, da Gloria Chiarello
de Mattos M. Finite element analysis of bone stress in the posterior
mandible using regular and short implants, in the same context, with
splinted and nonsplinted prostheses. Int J Oral Maxillofac Implants
2017;32:e199–e206.
25. Lemon JE, Dietsh-Misch F. Biomaterials for dental implants. In: Misch
CE (ed). Contemporary Implant Dentistry, ed 3. St. Louis: Mosby,
2007:271–302.
26. Lekholm U, Zarb GA. Patient selection and preparation. In: Bråne-
mark PI, Zarb GA, Albrektsson T (eds). Tissue-Integrated Prostheses:
Osseointegration in Clinical Dentistry. Chicago: Quintessence,
1985:199–209.
27. Petrie CS, Williams JL. Comparative evaluation of implant designs:
Influence of diameter, length, and taper on strains in the alveolar
crest. A three-dimensional finite element analysis. Clin Oral Implants
Res 2005;16:486–494.
28. Amid R, Rasoolzadeh RA, Motlagh AM, Dehnavi F, Kadkhodazadeh
M. Stress and strain distribution patterns in bone around splinted
standard and short implants placed at the crestal level and subcrest-
ally using three-dimensional finite element analysis. J Long Term Eff
Med Implants 2017;27:1–11.
29. Kong L, Sun Y, Hu K, et al. Selections of the cylinder implant neck
taper and implant end fillet for optimal biomechanical properties:
A three-dimensional finite element analysis. J Biomech 2008;41:
1124–1130.
30. Baggi L, Cappelloni I, Di Girolamo M, Maceri F, Vairo G. The influence
of implant diameter and length on stress distribution of osseointe-
grated implants related to crestal bone geometry: A three-dimen-
sional finite element analysis. J Prosthet Dent 2008;100:422–431.
31. Maló P, de Araújo Nobre M, Lopes A, Ferro A, Gravito I. All-on-4 treat-
ment concept for the rehabilitation of the completely edentulous
mandible: A 7-year clinical and 5-year radiographic retrospective
case series with risk assessment for implant failure and marginal
bone level. Clin Implant Dent Relat Res 2015;17(suppl 2):e531–e541.
32. Krekmanov L, Kahn M, Rangert B, Lindström H. Tilting of posterior
mandibular and maxillary implants for improved prosthesis support.
Int J Oral Maxillofac Implants 2000;15:405–414.
33. Grandi T, Guazzi P, Samarani R, Grandi G. Immediate loading of
four (All-on-4) post-extractive implants supporting mandibular
cross-arch fixed prostheses: 18-month follow-up from a multicentre
prospective cohort study. Eur J Oral Implantol 2012;5:277–285.
34. Maló P, Rangert B, Nobre M. All-on-4 immediate-function concept
with Brånemark System implants for completely edentulous maxil-
lae: A 1-year retrospective clinical study. Clin Implant Dent Relat Res
2005;7(suppl 1):s88–s94.
35. Peixoto HE, Camati PR, Faot F, Sotto-Maior BS, Martinez EF, Peruzzo
DC. Rehabilitation of the atrophic mandible with short implants in
different positions: A finite elements study. Mater Sci Eng C Mater
Biol Appl 2017;80:122–128.
36. Padhye OV, Herekar M, Patil V, Mulani S, Sethi M, Fernandes A. Stress
distribution in bone and implants in mandibular 6-implant-
supported cantilevered fixed prosthesis: A 3D finite element study.
Implant Dent 2015;24:680–685.
e76  Volume 35, Number 4, 2020
© 2020 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY.
NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER.
37. Mosavar A, Nili M, Hashemi SR, Kadkhodaei M. A comparative
analysis on two types of oral implants, bone-level and tissue-level,
with different cantilever lengths of fixed prosthesis. J Prosthodont
2017;26:289–295.
38. Bevilacqua M, Tealdo T, Menini M, et al. The influence of cantilever
length and implant inclination on stress distribution in maxillary
implant-supported fixed dentures. J Prosthet Dent 2011;105:5–13.
39. de Almeida EO, Rocha EP, Freitas AC Jr, Freitas MM Jr. Finite element
stress analysis of edentulous mandibles with different bone types
supporting multiple-implant superstructures. Int J Oral Maxillofac
Implants 2010;25:1108–1114.
40. Hasan I, Heinemann F, Aitlahrach M, Bourauel C. Biomechanical finite
element analysis of small diameter and short dental implant. Biomed
Tech (Berl) 2010;55:341–350.
41. Bevilacqua M, Tealdo T, Pera F, et al. Three-dimensional finite ele-
ment analysis of load transmission using different implant inclina-
tions and cantilever lengths. Int J Prosthodont 2008;21:539–542.
42. Li X, Cao Z, Qiu X, Tang Z, Gong L, Wang D. Does matching relation
exist between the length and the tilting angle of terminal implants
in the all-on-four protocol? Stress distributions by 3D finite element
analysis. J Adv Prosthodont 2015;7:240–248.
43. Fazi G, Tellini S, Vangi D, Branchi R. Three-dimensional finite element
analysis of different implant configurations for a mandibular fixed
prosthesis. Int J Oral Maxillofac Implants 2011;26:752–759.
44. Chang SH, Lin CL, Hsue SS, Lin YS, Huang SR. Biomechanical analysis
of the effects of implant diameter and bone quality in short implants
placed in the atrophic posterior maxilla. Med Eng Phys 2012;34:
153–160.
45. Pessoa RS, Muraru L, Júnior EM, et al. Influence of implant connec-
tion type on the biomechanical environment of immediately placed
implants—CT-based nonlinear, three-dimensional finite element
analysis. Clin Implant Dent Relat Res 2010;12:219–234.
46. Misch CE, Suzuki JB, Misch-Dietsh FM, Bidez MW. A positive correla-
tion between occlusal trauma and peri-implant bone loss: Literature
support. Implant Dent 2005;14:108–116.
47. Ferreira MB, Barão VA, Delben JA, et al. Non-linear 3D finite element
analysis of full-arch implant-supported fixed dentures. Mater Sci Eng
C Mater Biol Appl 2014;38:306–314.
48. Maló P, de Araújo Nobre MA, Petersson U, Wigren S. A pilot study
of complete edentulous rehabilitation with immediate function
using a new implant design: Case series. Clin Implant Dent Relat Res
2006;8:223–232.
49. Blanes RJ, Bernard JP, Blanes ZM, Belser UC. A 10-year prospec-
tive study of ITI dental implants placed in the posterior region. II:
Influence of the crown-to-implant ratio and different prosthetic
treatment modalities on crestal bone loss. Clin Oral Implants Res
2007;18:707–714.
50. Sun Y, Kong L, Hu K, et al. Selection of the implant transgingival
height for optimal biomechanical properties: A three-dimensional
finite element analysis. Br J Oral Maxillofac Surg 2009;47:393–398.
51. Natali AN. Dental Biomechanics. London: Taylor & Francis, 2003:
175–177.
52. Silva-Neto JP, Pimentel MJ, Neves FD, Consani RL, dos Santos MB.
Stress analysis of different configurations of 3 implants to support a
fixed prosthesis in an edentulous jaw. Braz Oral Res 2014;28:67–73.
53. Wang X, Masse DB, Leng H, et al. Detection of trabecular bone micro-
damage by micro-computed tomography. J Biomech 2007;40:
3397–3403.
54. Lin CL, Wang JC, Ramp LC, Liu PR. Biomechanical response of implant
systems placed in the maxillary posterior region under various con-
ditions of angulation, bone density, and loading. Int J Oral Maxillofac
Implants 2008;23:57–64.