In recent times, the replacement of missing teeth is quite

routinely being done upon implants acting as an analog to root in

almost all surgically indicated cases. After loss of teeth, the

remaining alveolar and basal bone provides the anchorage over

endosteal implants for retaining and supporting the prosthesis. The

success of such implant therapy, depends mainly upon

biomechanical aspects upon loading the implants.

The behaviour of bone in the peri-implant region is closely

related to the direction, magnitude and concentration of stresses

transmitted by the implant 1 . The angulation of the implant abutments

is one of the many mechanical variables involved in implant

dentistry.

The implant cannot be placed ideally where the root was at all

times. At such times, the implants are placed according to the

availability of bone buccally and lingually or palatally. There are

instances such as resorption of cortical plates, knife-edge ridges or

iatrogenic errors in positioning implants parallel to each other in

order to have a common path of insertion of the supra-structure.

There may also be instances of unfavourable placement of the

implant fixture due to operator variability. 26 Due to these anatomic

and surgical constraints, and the survivability and longevity of

1
osseointegration during the surgical phase, the implants are placed in

their optimum position for osseointegration.

Anatomic constraints which make it necessary to surgically

position implants at angles that are not optimal for prosthesis

restorations are the width, height and the angle of the residual bony

ridge, the presence of bony undercuts, the shape of the ridge in cross

section and its position in the arch and maxillomandibular arch

relationships. The position of the mandibular canal and ridge

proximity to the paranasal sinuses are additional factors that may

influence implant alignment. Clinical management of these

circumstances may include surgical correction such as bone

augmentation of the alveolar ridge, sinus elevation or nerve

repositioning. Another possibility is implant placement in the area

with the greatest available bone with the intention of correcting the

mesiodistal and buccolingual alignment at the time of implant

restoration 11 .

During the prosthetic phase, in order to obtain a common path

of insertion of the suprastructure, either very short abutments e.g.

Mira-one esthetic cone of Branemark system or various types of

angulated abutments are placed. However, due to change in the long

axis of the suprastructure, and the implant, the stresses generated in

response to the masticatory or vertical load may be different in type,

2
magnitude and direction. This may affect resorption of the bone at

the cervical cortical region or loss of osseointegration, if the stresses

are in excess of either the mechanical properties of the luting cement

or those which leads to loosening of the prosthesis retaining screw

and / or abutment retaining screw or a fracture at various levels of

implant system.

Angled implants may be used in single tooth replacements in

the frontal region of the maxilla, distal extension cases in the

maxillary arch, overdentures in the edentulous maxilla, distal

extension cases in the mandibular arch and occasional anatomic

problems for placement of straight implants. In such cases it may

become necessary to use angulated abutments than to compromise on

the longevity of success of osseointegration of the implants 7 .

In Dental literature there are studies reporting about the stress

distribution around implants in a variety of situations.

1. Irfan Akpinar et al (1996) 1 : conducted a study to determine

the stress and strain patterns around two rigid implant designs

used as an abutment and the displacement of natural teeth was

investigated. The F.E.M. was utilized to determine the stress and

strain distributions. The results were evaluated in terms of the

maximal tensile and compressive stress and strain in the bone

around the abutment tooth and implants. The results indicated that

3
the ITI 1 (hollow screw) implant led to high stress concentration

particularly in the apical region. The stress transferring

characteristics of ITI 2 (solid screw) implant were found to be

more suitable than were those of ITI 1.

2. Seney Canay et al (1996) 18 : conducted a study to evaluate the

distribution of stress around implants placed in the first molar

region of the mandible which was biomechanically analysed in a

two-dimensional mathematical model. Two types of implants,

vertical and angled, were subjected to a vertical load of 100 N

and a horizontal load of 50 N in turn. The magnitude and contours

of compressive and tensile stress within the surrounding bone

were determined. For the sake of comparison, maximal

compressive stress and maximal tensile stress in the surrounding

bone were calculated. There were no measurable differences in

stress values and contours when a horizontal load was applied to

the vertical and angled implants. However, with the vertical

loading, the compressive stress values were 5 times higher around

the cervical region of the angled abutment than around the same

area in the vertical implant.

4
 The stresses can be evaluated by using one of the following

methodologies.

1. Finite Element Method / Analysis

2. Strain gauge analysis

3. Photoelastic method

FEM/FEA is a numerical method of structural analysis based

on the principle of dividing a structure into a finite number of small

elements that are connected to each other at the corner points or

nodes. For each element, its mechanical behaviour can be written as

a function of the displacement of the nodes. It represents one of the

most significant developments in the history of computational

methods. It is convenient as it can simulate oral conditions in which

various modifications can be done at a command.

As there is limited information in the literature regarding the

clinical success of angulated abutments 11 , it was considered

appropriate to undertake the study of stresses generated in response

to loading in and around implants with abutments having different

angulations to the long axis of the implant by Finite Element

Modeling and Analysis. The location of concentration of stresses

and the type of stresses would give insight to the favourable or

unfavourable results.

5
 M.S. Block 2 in his textbook “Endosseous implants for

maxillofacial reconstruction” has stated that dental implants have

become one of the most exciting and rapidly developing aspects of

dental practice in the past three decades. These years have witnessed

a plethora of scientific breakthroughs and sweeping changes

regarding old concepts and approach towards the subject.

Bryant R.S. 6 in his article “The effects of age, jaw site and

bone condition on oral implant outcomes” has stated that attempts

to replace lost teeth with endosteal implants have been traced to

ancient Egyptian and South American civilizations. Examples from

these cultures have been described in ancient writings and found in

skeletal remains recovered by archaeologists. The medieval period

(18 th century) witnessed implants made from ivory, shells and bone,

or human teeth being used extensively. Eventually, the procedure

diminished in popularity towards the beginning of the 19 th century as

the procedures and materials being used for the purpose were not

satisfying the requirements for teeth replacements.

Sennerby L. et al 19 in his review article “Surgical

determinants of clinical success of osseointegrated oral implants”

stated that there was a resurgence in implantation procedures in the

6
late 19 th century. Early design attempts were intuitive and were

based on achieving functional stability through mechanical retention.

These early implants utilized a broad spectrum of screw, coil and

spiral geometries fabricated using various materials. While initial

retention was acceptable, subsequent long term loss of fixation and

implant failure was reported.

Turner et al (1956) 29a , (a cross reference cited in “Stress analysis

of porous rooted dental implants” by Weinstein A.M. et al 29 )

proposed for the first time the use of finite element analysis which

was subsequently used extensively in engineering design for many

years to follow. It’s use in dental research was reported about 20

years later.

The review of Dental literature pertaining to the FEM /

analysis and effects of load on various implants / abutments,

designs, longevity etc. has been presented below in chronological

order.

Gupta R. & Gremoble H. (1972) 29b , (a cross reference cited in

“Stress analysis of porous rooted dental implants” by Weinstein

A.M. et al 29 ) published a series of papers in the development of

three dimensional finite element model of the human mandible. They

concluded that most of the load was carried by the thin shell of bone

that surrounds the natural tooth root. They demonstrated that, since

7
the biomechanical response to tooth loading is highly localized in

the region of tooth support, careful mathematical simulation of the

anatomical structure surrounding the tooth is required.

Weinstein A.M. et al (1976) 29 , conducted a FEM study to determine

the magnitude and distribution of stress in porous rooted cobalt-

chromium-molybednum alloy dental implants and in the surrounding

bone tissue. The authors stated that finite element stress analysis

offered the potential of evaluating the design without the risks and

expenses associated with implantation trial and error. In an effort to

validate the modeling assumptions, experimental data were obtained

to compare with the results of the analytical treatment. A six-month

implant was harvested by killing an animal specimen (Dog) and

removing the section of jaw containing the implant. After storage

and potting procedures, the specimen was subjected to mechanical

testing using a constant strain testing machine to obtain load

displacement curves.

It was found that a model based on a continuously bonded

interface predicts high punching stresses at the apex of the implants

and low stresses in the cortical plates. A model based on a tissue in-

growth bonded interface predicts uniform distribution of stress

around the implant. This kind of a model predicted an implant

displacement ratio close to the ratio measured with actual implant

8
specimens. This was true for cobalt-chromium-molybednum alloy

dental implants.

Takahashi N., Kitagami T. and Komori T. (1978) 24 , conducted a

FEM study of stress distribution in a mandibular posterior fixed

partial denture constructed on a natural tooth and a blade-vent

implant abutment. The results were compared with the findings of a

fixed partial denture constructed on two natural tooth abutments. A

vertical load and an inclined load 45 degrees distal to the vertical

axis were created at the pontic with a 1 kg weight. Deflections and

stresses under each condition were computed mathematically with a

two dimensional finite element method.

It appeared from the results that deflection of the implant

fixed partial denture were less than those of the natural tooth fixed

partial denture in vertical and inclined loads. In the implant fixed

partial denture stress induced in the surrounding bone became higher

around the posterior abutment and became lower around the

premolar retainer than the stress produced with the natural tooth

fixed partial denture. Therefore, it was suggested that, to relieve

stress concentration in the surrounding bone around the implant

abutment, occlusal force loaded to the implant fixed partial denture

has to be more concentrated on the premolar abutment.

9
Cook D., Weinstein A. M. and Klawitter J.J (1982) 10 , conducted a

research with the objective of developing a finite element model

which would accurately depict the results of mechanical tests

performed on bone sections from the canine region in the mandible

containing porous rooted cobalt-molybednum alloy dental implants.

The implants modeled in this study were of a cylindrical

design, 17mm in length and 5.5mm in diameter. In addition,

implants were also placed bilaterally in a surgical modification of

the distal roots of the fourth premolar of twenty two adult mongrel

dogs. Animals were subsequently sacrificed after two tears and the

implants in sites were used in the study. Thus, the objectives of this

research included the verification of the finite element model

through experimental research.

It was found that :

a) Three dimensional finite element analysis was capable of

accurately depicting the gross geometric structure of the

implant mandible system.

b) A direct bone to implant interface assumption for porous

rooted cobalt-chromium-molybednum alloy dental implants

is a poor representation of implant retention mechanics.

10
Borchers L. and Reichart P. (1983) 3 , conducted a research with the

objective to simulate different stages of normal and pathological

interface development to calculate stress distribution in the bone

surrounding the implant. For this study, a section of the molar region

of the mandible which was made of Al 2 O 3 - ceramic, was modeled for

stress analysis by means of the finite element analysis method. Four

possible stages of implant bone interface were simulated in the

model by varying the mechanical properties.

i) First situation represented the implant surrounded by

cancellous bone- i.e., immediately following surgery.

ii) Second situation represented the implant surrounded by

lamina dura.

iii) Proliferation of connective tissue into the gap between

implant and spongy bone increasing implant mobility was

represented in the third situation.

iv) After formation of lamina dura, connective tissue migration

along the implant surface was represented by the fourth

situation.

It could be inferred from the results that high stress peaks

were present in the crestal region of the alveolar bone, especially

with transverse loading. It was added that these areas of stress

11
concentration might in turn cause bone resorption, connective tissue

ingrowth and subsequent implant failure.

Branemark P.I (1983) 4 , in his review article “Osseointegration

and its experimental background” attempted to present an

overview of the conceptual development and the experimental and

clinical application of osseointegration. He quoted long term in vivo

microscopic studies of bone and marrow response to titanium

chambers of a screw-shaped design starting in the early 1960’s. The

results suggested the possibility of osseointegration since the optical

chambers could not be removed from the adjacent bone once they

had healed in. Many other long term experimental studies suggested

the possibility of achieving and maintaining bone anchorage under

loading conditions of dental prosthesis attached to osseointegrated

fixtures.

It was added that different procedures in the past have been

advocated to anchor dental prosthesis in the soft or hard tissues.

However, long term clinical follow-ups indicated that such

procedures do not provide predictable and good long term function.

It is stated in the bone reconstruction literature that direct

anchorage of bone of load bearing implants sacrifices the prognosis

of implant procedures. Contrary to this concept, the author has

suggested the edentulous jaw can be provided with jaw bone

12
anchored prosthesis according to the principle of osseointegration

with good and predictable long-term prognosis.

Lucchini JP, Brunel D, Jenny R, Lavigne J. (1990) 13 , in their

review article “Fixed partial denture on osseointegrated screw

implants” - reviewed articles comparing the load on Branemark

implants over full dentures and fixed partial dentures on the same

type of implants. They have said that due to some more critical

anatomical conditions, the choice of number, position and length of

the implants is more delicate; e.g. the need of an harmonious crown-

gingival tissue relationship; higher occlusal forces than in

edentulous cases; difficulty in satisfying esthetic requirements and

ease of hygiene. The surgical treatment plan, a pre-requisite to any

surgery, permits to determine the length of implants, their number,

their position, their long axis direction and the design of the surgical

guide, which will indicate to the surgeon the location and the axis

for drilling. If this axis is nearly parallel to the sagittal plane for

mandibular implants, it will be angulated to that same plane for

maxillary implants. In the latter cases, it is often necessary to use

angulated transepithelial abutments in order to prevent the abutment

screw from having an occlusal access. In order to perform the

prosthetics, an impression should be taken with the transepithelial

abutments. The final reconstruction can be preceded by a temporary

13
prosthesis, then (or) transitory to await gingival stabilization and not

overload the implant immediately after it has been connected with

the abutment. The fixed partial denture can be secured with screws

or cemented when it is of small size and it must satisfy the esthetic

requirements of the patient. The choice of the material used on the

occlusal surface is very important and varied depending on the case.

These objectives are not reached at the time the prosthesis is made

but during the course of the surgical and prosthetic treatment. Single

restorations are subjected to the rules pertaining to any fixed partial

denture on implants, but have particular characteristics, such as the

almost systematic elimination of the abutment and the absolute

necessity of the correct placement of the implant. The single units

are more easily subject to unscrewing for mechanical reasons.

Although the use of implants is a valuable aid in cases of partial

fixed restoration, it requires particular attention with regard to

precision.

Van Rossen I.P. et al (1990) 25 , attempted to analyse three loading

situations with dental implants:

a) loading a free standing implant.

b) loading an implant connected with a natural tooth.

c) loading two implants connected with each other.

14
 In this study, the first two situations were analyzed to

ascertain with finite element analysis which of the concepts

mentioned, or which of the combinations of concepts, gave the most

equal stress distribution in bone when using a stress absorbing

element (SAE).

The two models constructed were:

i) an axisymmetric model to simulate a free standing single

implant in vertical load.

ii) a model to simulate an implant connected with a natural tooth,

also in vertical load. A force of 500 Newtons was applied to

the single implant and a force of 160 Newtons was applied to

the tooth connected implant.

The results of the study suggested that:

i) a stress absorbing element (SAE) in a free standing implant

may function as a damping element but not as a stress

distribution device.

ii) a stress absorbing element in an implant that is connected to a

natural tooth causes the bone around the implant to be loaded

more uniformly.

15
Meijer H.J.A. et al (1992) 14 , conducted a study to determine the

influence of the length of the implant, the height of the mandible,

and the type of supra structure on the stress distribution pattern in

and around the implant upon loading conditions. The stress

distribution was calculated in a two dimensional model representing

the frontal section of an edentulous mandible provided with two

implants.

It appeared from the results of the study that the main stress

peaks arise around the neck of the implant in the upper cortical

layers. The authors also added that the length of the implant had

little influence on the amount of stress in vertical loading and the

height of the mandible had a large influence on the amount of stress

because of the overall deformation of the bone as a reaction to

loading.

Christiaan M. ten Bruggenkate et al (1993) 7 , in their review article

“Indications for angled implants” stated the need for angled

implants as angulation problems due to anatomic limitations always

remained.

They suggested the use of angled implants in single tooth

replacements in the maxillae, a distal extension especially in the

maxillae, mandibles with severely slanted frontal regions that need

implants with bar splint constructions to give retention to

16
overdentures, situations in which misjudged directions of

preparations need correction, and alignment problems resulting from

the shape of the jaw.

Clelland NL, Gilat A, Mcglumphy EA, Brantley W A. (1993) 8 ,

conducted a study to determine the effect of abutment angulation on

the stress field near a specific dental implant. He casted photoelastic

resin directly to five 3.8 x 10mm Steri-Oss implants in 50 x 70 x

13mm molds. Cementable abutments of 0, 15 and 20° angulation

were used. Photoelastic stress analysis was used as a method of

investigation. Complete osseointegration was presented by allowing

the resin to polymerize directly to the implants. After

polymerization, the blocks were examined with a circular

polariscope to ensure that they were stress free. The blocks were

mounted on metal cradles with predetermined angulations of 0, 15

and 20° so that the applied load was along the long axis of the

abutment. A dyanometer was used to apply a load of 178N to the top

of each implant abutment. Compressive stress nearly doubled on the

side of the fixture opposite to the applied load as the angulation was

changed from 0 to 20°. Although there was a statistically significant

increase in stress and strain as abutment angulation increased, all the

three abutment angulations produced strains that appeared to be

within the physiologic zone for the bone.

17
Weinberg L.A. (1993) 27 in his review article “The biomechanics of

force distribution in implant supported prosthesis” stated that

force distribution with natural teeth depends on micro-movement

induced by the periodontal ligament. It was demonstrated that the

location and cusp inclination of the tooth qualitatively alter the force

pattern. The author has pointed out that the difference between the

force distribution of implants and natural teeth is essentially because

of the periodontal ligament, which in case of a osseointegrated

implant is non existent. It was added that vertical and lateral forces

on implants would produce crestal force distribution. This concept is

consistent with bone loss found in implants, which is almost always

initiated at the crest of the ridge. It has been advised to use acrylic

artificial teeth with shallow cuspal inclines for a more optimal force

distribution.

Clelland N.L. et al (1995) 9 conducted a study to determine the

stresses and strains produced by an abutment system capable of three

abutment angulations. For this, he developed a three dimensional

mathematical model of the maxilla and used computed tomography

to derive the density values used for the model. A 3.8 x 10mm

cylindrical implant was embedded in the right central incisor

position at a 35° angle to the horizontal plane and parallel to the

angulation of the bone site. All the necessary geometric and elastic

18
properties for the implant fixture and the surrounding bone were

included in the model and a simulated occlusal load of 178N was

applied along the long axis of the 0, 15 and 20° abutments. The

results were interpreted by the Cray Y/MP Ohio Super computer

(Cray, Eagan, MN) using the ABAQUS software programe (Hibbitt,

Karlsson and Sorenson, Providence, RI). Results were interpreted as

maximum tensile and minimum compressive stresses and strains.

Results of this study show that principle stresses occurred

predominantly in the cortical bone layers, whereas, strains occurred

mostly in the cancellous bone. He concluded that, there was an

increase in the magnitude of stress and strain as the abutment

angulation was increased although reported stress and strain for all

the three angulations were within or slightly above the physiologic

zone derived from animal studies.

Irfan Akpinar et al (1996) 1 conducted a study to compare the stress

and strain patterns around two rigid implant designs used as an

abutment and to investigate the displacement of natural teeth. The

FEM was used to determine the stress distribution and the model

geometries were digitalized using the design programme AutoCAD

(AutoDesk) and Intel based 486 IBM PC and a digitizer tablet. The

models were preprocessed in ANSYS (Swanson Analysis System) to

generate the meshed structure, to placed the necessary boundary

19
conditions and to carry out the loadings. A vertical total force of 7.5

Kg was applied on 5 cusp points, each point having 1.5 Kg. Results

were processed with Silicon Graphics Showcase Programme.

The results were interpreted as maximum tensile and

maximum compressive stresses and strains in the region around the

abutment tooth and the implant in addition to the displacement of the

abutment teeth. The results indicated that the ITI-1 (Hollow screw)

implant led to high stress concentrations in the apical region. The

stress transferring characteristics of the ITI-2 (Solid screw) implant

were found to be more suitable than were those of ITI-1.

Canay S. et al (1996) 18 conducted a two dimensional FEM study to

biomechanically analyze the distribution of stress around implants

placed in the first molar region of the mandible. Two types of

implant designs, vertical and angled, were subjected to a vertical

load of 100N and a horizontal load of 50N. The results were

evaluated as maximal tensile and compressive stress.

The results revealed that the vertical load applied to the

vertical implant was distributed evenly on the buccal and lingual

side. As for the angled implant, excessive compressive stress was

formed in the buccal cervical region and excessive tensile stress was

formed on the lingual surface. The stress values on horizontal

loading were found to be quite close in both the implant designs.

20
The stresses induced in the bone surrounding vertical and angled

implants were found to be higher around the cervical region and

lower around the middle third and apical regions.

Brosh Tamar, Raphael Pilo and David Sudai (1998) 5 conducted a

study to show that preangled abutments produce different stress

distribution compared to straight abutments. The objectives of this

study were (1) to test the hypothesis that preangled abutments

produce different stress distribution than straight abutments by using

strain gauges attached to implants embedded in a medium simulating

bone to determine strain distribution along the implant/bone

interface; (2) to test this hypothesis by photoelastic method; and

(3) to compare the two experimental techniques. Five Integral

Omniloc cylindrical implants 13 x 4 mm were polished to remove

the hydroxyapatite coating, then six linear miniature strain gauges

were attached, three on each side of the implant's surface. Two

similar implants were embedded in a photoelastic material. Three

abutments, straight, 15°, and 25°, were connected to each implant;

strain versus applied compressive forces were recorded. Strain

response to force parameter was defined as the slope of the strain

force curve. Isochromatic fringe patterns were also recorded. The

strain gauge measurements showed higher, threefold and 4.4-fold,

compressive strain concentration in the coronal zone of the implant

21
when 15° and 25° angulated abutments were used, respectively,

compared with the straight abutment; whereas the photoelastic

method showed an increase of only 11% in fringe order. Tensile

strains were also measured from the coronal contralateral position on

the implant, where photoelastic models did not show a change in

stress type. Data obtained from strain gauges bonded to implants

embedded in a medium can represent a precise simulation of the

clinical condition when analyzing stress distribution along the

implant/ bone interface. Photoelastic method provides different

information and therefore should be regarded as a complementary

method.

Sennerby L. and Roos J. (1998) 19 in their review article “Surgical

determinants of clinical success of osseointegrated oral implants”

stated that self tapping implants had a higher survival rate than that

of pre-tapped standard implants, which indicated that self tapping

leads to better implant stability. The authors have quoted several

studies where the screw type implant showed a long term survival

rate and minimal marginal bone resorption for most indications.

A few studies have also proved that short implants fail more

often than longer implants. The authors also added that bicortical

anchorage may be one way to improve implant stability.

22
 Thus, the authors concluded that implant stability is the key to

success. Implant stability for better understanding has been divided

into two categories:

a. Primary stability is determined by the density

and quantity of the bone, the surgical technique, and the

design of the implant.

b. Secondary stability may be achieved after

primary healing and is determined by the degree of primary

stability and the possible gain in the stability as result of bone

formation and remodeling at the implant bone interface.

Thus, it was stated that any factor that negatively influence

primary and secondary implant stability may also have an impact on

the results of implant treatment.

Weinberg L.A. (1998) 28 in his review article “Reduction of

implant loading with therapeutic biomechanics” stated that all

physiologic biomechanical processes are interrelated and, therefore,

reactive, which produces an accumulative effect that can cause

implant overload. A new approach called "therapeutic biomechanics"

suggests using corrective procedures to reduce implant loading. The

head of the implant is positioned as close to the midline of the

restoration as possible. Implant inclination may be required, but it

23
produces less torque (moment) than horizontal implant offset.

Posterior cross occlusion should be used where possible to decrease

horizontal implant offset. Angulated or re-angulated abutments

provide access or parallelism as needed. The posterior cusp

inclination should be markedly reduced. When a vertical overlap is

present anteriorly, a horizontal stop on the maxillary lingual surface

redirects harmful lateral force to be vertical toward the implant and

supporting bone. Because of physiologic variability, creating a

modified centric occlusion that contains a 1.5-mm fossa will produce

vertical resultant force within this range of motioin rather than

lateral force.

Walton J.N., Sylvia C. Huizinga and Christopher C. Peck

(2001) 26 conducted a study,

1) To develop a technique to measure the angle between

two implants and between each implant and the reference

planes.

2) To analyze the relationship between the maintenance of

the ball – attachment mandibular implant overdentures and

implant angles and

3) To see if there is any correlation between surgeon

experience and implant orientation.

24
 For this study mandibular final casts of 44 subjects who had

received two-implant ball-attachment mandibular overdentures were

used to measure implant angulation using digital photographs and

plane geometry. The measured angles were compared with the

number of adjustments and repairs of the prosthesis and analyzed by

surgeon experience for any trends. He found no significant

relationship between the number of adjustments and repairs and the

interimplant angles. However, he came across higher number of

repairs when the lingual inclination of the implant was greater than

or equal to 6° or if the facial inclination was less than 6.5°. Also, he

inferred that, less experienced surgeons had a significantly greater

tendency to place implants that diverged from each other in the

frontal plane and with a facial or lingual inclination in the sagittal

plane.

Dorothy E. Eger, John C. Gunsolley and Sylvan Feldman (2000) 11

conducted a study to compare the success of implants restored with

angled abutments to implants restored with standard abutments.

Twenty-four patients between ages of 15 to 74 received atleast one

implant that required a pre-angled or custom angled abutment for

appropriate fabrication of an implant restoration. Clinical

measurements consisted of probing depth, gingival level, gingival

index and mobility. Measurements were made to the nearest

25
millimeter with a Maryland standard periodontal probe. Probing

depths were measured at four sites around the implant: mesial,

distal, buccal and lingual. From the results it was inferred that

endosseous implants may be restored with angled abutments without

compromise of function or esthetics. A comparison of clinical and

demographic variables, evaluated for implants restored with angled

and standard abutments yielded no significant differences for any

parameter at any time period, which suggests that angled abutments

may be considered a suitable restorative option when implants are

not placed in the ideal axial position.

Jian-Ping Geng, Keson B. C. Tan, and Gui-Rong Liu (2001) 12 in

their review article “Application of Finite element analysis in

implant dentistry: Review of the literature” stated the use of

Finite element analysis (FEA) to predict the biomechanical

performance of various dental implant designs as well as the effect

of clinical factors on implant success. By understanding the basic

theory, method, application, and limitations of FEA in implant

dentistry, the clinician will be better equipped to interpret results of

FEA studies and extrapolate these results to clinical situations. This

article reviews the current status of FEA applications in implant

dentistry and discusses findings from FEA studies in relation to the

26
bone-implant interface, the implant-prosthesis connection, and

multiple-implant prostheses.

Seong W.J., Korioth T.W. and Hodges J.S. (2000) 20 conducted a

study to determine the effect of three single-molar implant designs

on implant strains under a variety of homologous loading conditions.

On each implant abutment, 4 strain gauges were placed axially at

90° to each other on the buccal, lingual, mesial, and distal surfaces.

Effects of implant design, load location, direction, and magnitude

were tested on axial and bending (buccolingual and mesiodistal)

strains of 3 single-molar implant designs: (1) single, 3.75-mm

(regular) diameter implant, (2) single, 5-mm, (wide) diameter

implant, and (3) two 3.75-mm diameter (double) implants connected

through a single-molar crown. Results were analyzed with ANOVA.

Variations in loading conditions induced 3-dimensionally complex

abutment strains on the tested implant designs. Peak absolute strains

in mesiodistal direction were 6493 microepsilon for design 1 and

3958 microepsilon on design 2, and 3160 microepsilon in

buccolingual direction on design 3. For all loading conditions, the

single 3.75-mm diameter implant consistently experienced the

largest strains compared with wide-diameter and double implant

designs. Changes in centric contact location affected implant

abutment strains differently among the 3 designs. Angulated force

27
direction resulted in larger bending strains. For single-molar implant

designs, an increase in implant number and diameter may effectively

reduce experimental implant abutment strains.

Sethi A., Kaus T, and Sochor P. et al (2000) 21 conducted a study to

determine the survivability of implants used with angled abutments

ranging from 0-45°. For this study 2,261 two-stage implants were

placed in 467 patients in combination with the angulated abutments

ranging from 0-45°, which were observed over a period of upto 96

months. From the results of the study it was observed that the

survival function rates of the implants with angulated abutments was

the same.

Misch C.E., Bidez M.W. and Sharawy M. (2001) 16 in their review

article “A bioengineered implant for a predetermined bone

cellular response to loading forces”. A literature review and case

report - stated that the presence of fibrous tissue has long been

known to decrease the long-term survival of a root-form implant.

Excessive loads on an osseointegrated implant may result in mobility

of the supporting device, and excessive loads may also fracture an

implant component or body. Although several conditions may cause

crestal bone loss, one of these may be prosthetic overload. Excessive

loads on the bone cause strain conditions to increase. These

microstrains on the bone may affect the bone remodeling rate in a

28
direct relationship. When strain conditions to the interfacial bone are

in the mild overload zone, an increased bone remodeling response

occurs, which results in a reactive wove bone formation that is less

mineralized and weaker. Greater stresses may cause the interfacial

strain to reach the pathologic overload zone and may cause

microfracture of the bone, fibrous tissue formation, and/or bone

resorption. Recent reports suggest that the bone remodeling rate next

to an implant may used to evaluate biomechanical conditions and

their influence on the implant to-bone interface. These include a

number of factors, such as loading conditions, implant body surface

conditions, and implant design. For a given load condition, the

implant design is one of the primary factors that determine the

resultant strain at the interface. A predetermined goal was

established to bioengineer a dental implant to load the bone at the

interface in a predetermined stress strain relationship, in order to

maintain lamellar bone at the interface. A case report is presented of

2 bioengineered implants loaded for 1 year, which demonstrates that

the bone was primarily lamellar structure, the bone turnover rate

was less than 5 microns/day, and was the same as the bone away

from the interface. These findings corroborate those observed in a

prior animal study reported with the same implant design. Although

the number of implants evaluated in those 2 reports is few, they

support a predetermined histological outcome.

29
Storum K., Carrick J.L. (2001) 23 stated in the journal Dental

Clinics of North America in the chapter of “Implant-osseous

osteotomy for correction of the misaligned anterior maxillary

implant” about the trend of using angled abutment to compensate

for implants that have poor emergence profiles. He said that this

trend has resulted in increasing unfavourable forces being placed on

the implant, poor soft tissue emergence and contours or creation of

areas that the patients cannot maintain properly which ultimately

lead to an esthetic compromise and ultimately implant failure.

Sethi A. et al (2002) 22 conducted a study in which he used the

concept of selecting the abutment at the first stage surgery and he

presented clinical data accumulated over 14 years of the use of this

concept with angulated abutments. He used this concept for implants

using internal and external hexed connection and it has now evolved

in its used for implants using a Morse taper connection as a result of

the considerable clinical advantages that this type of connection

offers. He restored 1301 implants with abutments ranging from 0-

45° and observed them over a period of 151 months. From the

results of the study, it was clear that the magnitude of the angles did

not influence the survival rate and, the need to refine the implant

position in terms of the depth to which it was placed and the

angulation and rotational orientation as well as the size and pivot

30
point of the final abutment were recognized as contributing to the

harmonious emergence profile of the restoration.

31
 Research has been the foundation for the development and

progress of science. Structural analysis is one of the methodology of

research which has found wide application in prosthodontics

responsible for bringing the field to its present level of advancement.

Although analytical and experimental methods of structural

analysis have commonly been used, the numerical method is yet to

seek a new ground. Lately, one of the numerical methods which is

currently being used extensively in various areas of prosthodontics

is FINITE ELEMENT ANALYSIS. However, it becomes imperative

to know the basis of this method to understand its subsequent

applications as well as limitations.

To put into basic terms FINITE ELEMENT ANALYSIS is a

numerical method of structural analysis based on the principle of

dividing a structure into a finite number of small elements that are

connected with each other at the corner points or nodes. For each

element its mechanical behaviour can be written as a function of the

displacement of the nodes. These nodes are subjected to certain

loading conditions resulting in a behaviour of the model similar to

the structure it represents. When a computer analysis is performed, a

system of simultaneous equations can be solved to relate all forces

and displacements at the nodes. From this, the stress and strain

32
contour can be established in each element and thus the whole body.

Thus, since it has been established that FEM is best suited for

analyzing the stresses in a multicomponent assembly, it merits a

brief description before its actual application to this study is

presented.

CONCEPT OF FEM

The concept of FEM is given below, based on the description

given by Ibrahim Zeid. 30 The solution of a complex problem by the

FEM follows an orderly step by step procedure.

1. Discretization of the given problem.

The basic principle of the FEM is to divide a problem domain

(a structure) into nonoverlapping finite number of small elements.

This is called discretization of a domain. It is achieved by replacing

the continuum by a set of key points, called nodes, which when

properly connected, form the elements. The collection of nodes and

elements forms the finite element mesh. This mesh generation can be

carried out either manually or automatically. The number of

elements used in a problem depends mainly on the element type and

accuracy desired. As a general rule, the larger the number of nodes

and elements, the more accurate is the finite element solution.

33
2. Developing element properties.

After the mesh generation is successfully completed, the

properties of the material in question are assigned to the elements

and nodes. By applying a basic principle of mechanics, the

relationship between the forces and displacement at each node of the

element is then analyzed. Hence, for each element, its mathematical

behaviour can be written as a function of the displacement of the

nodes. Thus, the behaviour of the structure is obtained by

considering the collective behaviour of the discrete elements.

3. Imposition of boundary conditions.

Before applying the geometric boundary conditions, the

system of equations is not completely defined. This is because, any

model which is generated, has to be constrained depending upon the

requirements of the study. Thus, boundary conditions are applied to

have enough fixed nodal displacements to prevent the structure from

moving in space as a rigid body when external loads are applied.

4. Solution of the assembled equation.

The next step involves the application of forces or loads to the

model. Two types of loads exist: concentrated or distributed. To

apply concentrated loads, it is necessary to create a node at the point

of application of each load. Distributed loads may be applied at

various nodes in which the load is split between many nodes. The

34
direction of the load application is primarily dictated by the

coordinate system. In a three dimensional study, the force

application can be executed in any direction so as to closely simulate

the actual clinical situations.

4. Post-processing of the results.

This includes plotting contours of displacement, computing

element strains and stresses and plotting them, displaying location of

maximum or minimum stress and plotting contours of failure index.

FEM TERMINOLOGY 30

GEOMETRIC MODEL: A geometric model is defined as the

complete representation of an object that includes both its graphical

and non graphical information.

Elements: A geometrically complex domain is represented as a

collection of geometrically simple subdomains called elements.

Nodes: The points of connection between the elements are called as

the nodes.

Boundary conditions: The boundary conditions are the constraints

applied to the solid to prevent it from moving in space as a rigid

body when external loads are applied.

35
MATERIAL PROPERTIES 30

a) Modulus of Elasticity: The mechanical property that determines

the load deflection rate of a material.

b) Poisson's Ratio: describes the amount of transverse strain per

unit of longitudinal strain in a material.

Pre-processing: involves the preparation of data such as nodal co-

ordinates, connectivity, boundary condition, loading and material

information.

Post-processing: involves presentation of the results.

METHODOLOGY

The study was conducted at Technocraft, Mumbai. It was

carried out on a powerful computer (P4 processor with a speed of

1.7GHz and 512MB RDRAM) using a sophisticated software.

At first the entire model was created using the Pro-Engineer

(Pacific Telecommunications Council – PTC, Needham USA. PTC is

maker of MCAD solutions including PE, Pro mechanics, ICEM Surf,

CADDS5 and Pro-desktop) software (Color plates 6-17). Then the

ANSYS software (Ansys Inc. Corporate, South Pointe, Canonsburg,

PA. 15317) was used for the FEM study.

36
METHOD USED FOR MODELLING

The study was divided into three problems. The first problem

involved the construction of a section of the mandibular bone, the

second problem involved the modeling of the implant and the

superstructure. The third problem involved the computation of stress

in all the components of the structure when subjected to forces in

three axes by FEM. Two-dimensional FEM is amenable for simple

structures, but this study used three dimensional FEM because:

1) The basic structure was not axis symmetric

2) 3D FEM accurately calculates the stress/strain distribution

patterns.

The analysis was linear static and assumed that materials were

isotropic and homogeneous.

MANDIBLE

It has been observed in numerous investigations 14,24 that to

assess stress distribution around dental implants in the mandible, it

is not necessary to build an FE model of the entire lower jaw. A

three dimensional model representing the region of interest is

preferable due to its much simpler modeling procedure. Because of

its complicated and individually different geometry, the jaw bone

was not completely modeled, but idealized by way of a cylindrical

37
section around the implant (Color plates- 13, 15, 17). Using this

model, it is not possible to determine actual stresses in the bone

quantitatively; however, it provides the basis for relative evaluation

of the particular implant design in question.

The bone was modeled as a cancellous core surrounded by a

2mm cortical layer, except in the superior and labial aspects where it

was flattened to I mm of thickness.

The dimensions and properties of the models were similar to

those found in the human mandible. Models were meshed with

tetrahedral elements (Color plates 18-24). A finer mesh was

generated at the material interfaces to ensure accuracy of force

transfer.

38
TABLE-A
Thickness of cortical layer :

Cranial 1mm.
Caudal 4mm
Labial 1mm
Lingual 2mm

TABLE-B
4, 23
Properties of cortical bone :

Modulus of Elasticity 1.34 x 10 4 Pa (Cook et al)

Poisson's ratio 0.30

TABLE-C
Properties of cancellous bone : 4, 23

Modulus of Elasticity 1.37 x 10 3 Pa (Borchers and Reichart)

Poisson's ratio 0.31

TABLE-D
4, 23
Properties of implant (Titanium) :

Modulus of Elasticity 103 GPa

Poisson’s ratio 0.35

TABLE-E
4, 23
Properties of superstructure (porcelain) :

Modulus of Elasticity 70 GPa

Poisson’s ratio 0.22

39
IMPLANT

In accordance with the commercial implant system developed

by ORALTRONICS, Germany, 1 Pitt-Easy screw implant was

modeled having a length of 8mm (Color plate 1). The contour data

and design was obtained with the help of a profile projector, which

provided an enlarged view of the implant.

In accordance with the concept of the design of the implant

system, the apical part of the implant was in full contact with the

inferior cortical plate. To simulate ideal Osseointegration, a fixed

bond between the bone and implant was assumed. The close

apposition of titanium and bone means that under any subsequent

loading, the interface moves as a unit without any relative motion

between bone and titanium.

Three abutments were procured. One having no inclination;

i.e., 0°, the second having 15° angulation and the third having an

angulation of 25° (Color plates 2-5).

LOAD APPLICATION

Load application constituted this part of the procedure where

an attempt was made to simulate actual clinical situations. During

occlusal loading of implants, the principal stress is demonstrated in

the cortical bone and von mises stresses were therefore used for this

analysis. Where the von mises stresses is at its lowest, the force

40
application is the most favourable. Von mises stresses are most

commonly reported in FEM studies to summarize the overall stress

state at a point.

A vertical load of 4N was applied to the occlusal surface of

the tooth (Color plate 25), and von mises, compressive and tensile

stresses were calculated and summarized by means of a colour coded

chart which was then converted to numerical values.

Interpretation of Results

Stresses were interpreted as Von Mises, compressive and

tensile and were evaluated at the neck, (represented by the

implant-abutment interface) body and apex of the implant as well as

at the crest, middle portion and lower border of the bone. The

respective numerical values of the stresses in MPa have been given

in the appendix using the color code for the respective conditions.

Three groups of models were analyzed. In the first group, the

implant was placed in the section of the bone described earlier and

the 0° abutment was placed onto it. A unit load of 4N was applied to

this straight abutment and the von mises, compressive and tensile

stresses were calculated. Similarly, in the second and third groups,

15 and 25° abutments were used on the same implant configuration

and the same load was applied to the implant.

41
 The Von Mises stresses, compressive stresses and tensile

stresses in MPa in respect to a load of 4N observed in the neck

(represented by the implant-abutment interface), body and apex of

the implant as well as in the adjacent bone respectively in the crest,

middle portion and lower border form the basic data for the study.

These values of the different stresses in different areas have been

presented in the following tables.

Table no. 1 represents the maximum stress values in MPa

under a unit load of 4N with respect to selected areas in the implant

itself on using a 0° abutment (Color plates 26-28, 38-40).

TABLE - 1a

Maximum Von Mises stresses recorded in different regions in the

implant having a 0° abutment in response to a load of 4N

Location of stresses in the

Stresses in MPa
implant having 0° abutment

Neck 0.1321

Body 1.0413

Apex 0.8007

42
 TABLE - 1b

Maximum Compressive stresses recorded in different regions in

the implant having a 0° abutment in response to a load of 4N

Location of stresses in the

Stresses in MPa
implant having 0° abutment

Neck 0.1101

Body 0.4786

Apex 0.4652

TABLE - 1c
Maximum Tensile stresses recorded in different regions in the
implant having a 0° abutment in response to a load of 4N

Location of stresses in the

Stresses in MPa
implant having 0° abutment

Neck 0.0932

Body 0.2064

Apex 0.9222

43
 Table no. 2 represents the maximum stress values in MPa

under a unit load of 4N with respect to selected areas in the bone on

using a 0° abutment (Color plates 29 & 41).

TABLE - 2a

Maximum Von Mises stresses recorded in different regions in the

bone adjoining the implant having a 0° abutment in response to a
load of 4N

Location of stresses in the bone

surrounding the implant having Stresses in MPa
0° abutment

Crest 0.1176

Middle portion 0.2559

Lower border 0.2436

44
 Table no. 2b and 2c reveal the maximum compressive and
tensile stresses occurring in the bone on using the 0° abutment with
a unit vertical load of 4N.

TABLE - 2b

Maximum compressive stresses recorded in different regions in

the bone adjoining the implant having a 0° abutment in response
to a load of 4N

Location of stresses in the bone

surrounding the implant Stresses in MPa
having 0° abutment

Crest 0.0452

Middle portion 0.6756

Lower border 0.5012

TABLE - 2c

Maximum tensile stresses recorded in different regions in the

bone adjoining theimplant having a 0° abutment in response to a
load of 4N

Location of stresses in the bone

surrounding the implant Stresses in MPa
having 0° abutment

Crest 0.2945

Middle portion 0.1018

Lower border 0.638

45
 Table no. 3 represents the maximum stress values in MPa

under a unit load of 4N with respect to selected areas in the implant

itself on using a 15° abutment (Color plates 30-32 & 42-44).

TABLE - 3a

Maximum Von Mises stresses recorded in different regions in the

implant having a 15° abutment in response to a load of 4N

Location of stresses in the

Stresses in MPa
implant having 15° abutment

Neck 0.7927

Body 1.694

Apex 0.759

46
 Table no. 3b and 3c show the compressive and tensile stresses

in all the three regions of the implant body i.e. the neck, body and

apex with the use of 15° abutment and a unit vertical load of 4N.

TABLE - 3b
Maximum compressive stresses recorded in different regions in
the implant having a 15° abutment in response to a load of 4N

Location of stresses in the

Stresses in MPa
implant having 15° abutment

Neck 0.1520

Body 0.6556

Apex 0.4987

TABLE - 3c
Maximum tensile stresses recorded in different regions in the
implant having a 15° abutment in response to a load of 4N

Location of stresses in the

Stresses in MPa
implant having 15° abutment

Neck -0.1028

Body 0.1024

Apex 0.1579

47
 Table no. 4 represents the maximum stress values in MPa

under a unit load of 4N with respect to selected areas in the bone on

using a 15° abutment (Color plates 33 & 45).

TABLE - 4a

Maximum Von Mises stresses recorded in different regions in the

bone adjoining the implant having a 15° abutment in response to
a load of 4N

Location of stresses in the bone

surrounding the implant Stresses in MPa
having 15° abutment

Crest 0.1368

Middle portion 0.3125

Lower border 0.1126

48
 Table no. 4b and 4c reveal the maximum compressive and
tensile stresses occurring in the bone on using the 15° abutment with
a unit vertical load of 4N.

TABLE - 4b
Maximum compressive stresses recorded in different regions in
the bone adjoining the implant having a 15° abutment in
response to a load of 4N

Location of stresses in the bone

surrounding the implant Stresses in MPa
having 15° abutment

Crest 0.2340

Middle portion 0.6556

Lower border 0.3982

TABLE - 4c
Maximum tensile stresses recorded in different regions in the
bone adjoining the implant having a 15° abutment in response to
a load of 4N

Location of stresses in the bone

surrounding the implant Stresses in MPa
having 15° abutment

Crest 0.1777

Middle portion 0.1024

Lower border 0.1143

49
 Table no. 5 represents the maximum stress values in MPa

under a unit load of 4N with respect to selected areas in the implant

itself on using a 25° abutment (Color plates 34-36 & 46-48).

TABLE - 5a

Maximum Von Mises stresses recorded in different regions in the

implant having a 25° abutment in response to a load of 4N

Location of stresses in the

Stresses in MPa
implant having 25° abutment

Neck 0.3185

Body 1.0493

Apex 0.8526

50
 Table no. 5b and 5c show the compressive and tensile stresses

in all the three regions of the implant body i.e. the neck, body and

apex with the use of 25° abutment and a unit vertical load of 4N.

TABLE - 5b
Maximum compressive stresses recorded in different regions in
the implant having a 25° abutment in response to a load of 4N

Location of stresses in the

Stresses in MPa
implant having 25° abutment

Neck 0.2537

Body 0.4802

Apex 0.4578

TABLE - 5c
Maximum tensile stresses recorded in different regions in the
implant having a 25° abutment in response to a load of 4N

Location of stresses in the

Stresses in MPa
implant having 25° abutment

Neck 0.7032

Body 0.3274

Apex 0.9384

51
 Table no. 6 represents the maximum stress values in MPa

under a unit load of 4N with respect to selected areas in the bone on

using a 25° abutment (Color plates 37 & 49).

TABLE - 6a

Maximum Von Mises stresses recorded in different regions in the

bone adjoining the implant having a 25° abutment in response to
a load of 4N

Location of stresses in the bone

surrounding the implant Stresses in MPa
having 25° abutment

Crest 0.3185

Middle portion 1.0593

Lower border 0.8526

52
 Table no. 6b and 6c reveal the maximum compressive and
tensile stresses occurring in the bone on using the 25° abutment with
a unit vertical load of 4N.

TABLE - 6b
Maximum compressive stresses recorded in different regions in
the bone adjoining the implant having a 25° abutment in
response to a load of 4N

Location of stresses in the bone

surrounding the implant Stresses in MPa
having 25° abutment

Crest 0.2537

Middle portion 0.4802

Lower border 0.4578

TABLE - 6c
Maximum tensile stresses recorded in different regions in the
bone adjoining the implant having a 25° abutment in response to
a load of 4N

Location of stresses in the bone

surrounding the implant Stresses in MPa
having 25° abutment

Crest 0.7032

Middle portion 0.3274

Lower border 0.9384

53
 TABLE - 7

Comparison of the Von Mises stresses in different areas of the

implant using varying degrees of the angulated abutment in
response to a unit vertical load of 4N.

Angulation
Von Mises stress in
of the Area of the implant
MPa
abutment

0° Neck 0.1321

15° Neck 0.7927

25° Neck 0.3185

0° Body 1.0413

15° Body 1.694

25° Body 1.0493

0° Apex 0.8007

15° Apex 0.759

25° Apex 0.8526

54
 TABLE - 8

Comparison of the compressive stresses in different areas of the

implant using varying degrees of the angulated abutment in
response to a unit vertical load of 4N.

Angulation
Von Mises stress in
of the Area of the implant
MPa
abutment

0° Neck 0.1101

15° Neck 0.1520

25° Neck 0.2537

0° Body 0.4786

15° Body 0.6556

25° Body 0.4802

0° Apex 0.4652

15° Apex 0.4987

25° Apex 0.4578

55
 TABLE - 9

Comparison of the tensile stresses in different areas of the

implant using varying degrees of the angulated abutment in
response to a unit vertical load of 4N.

Angulation
Von Mises stress in
of the Area of the implant
MPa
abutment

0° Neck 0.0932

15° Neck -0.1028

25° Neck 0.7032

0° Body 0.2064

15° Body 0.1024

25° Body 0.3274

0° Apex 0.9222

15° Apex 0.1579

25° Apex 0.9384

56
 TABLE - 10

Comparison of the Von Mises stresses in different areas of the

bone surrounding the implant using varying degrees of the
angulated abutment in response to a unit vertical load of 4N.

Angulation
Von Mises stress in
of the Area of the implant
MPa
abutment

0° Crest 0.1176

15° Crest 0.1368

25° Crest 0.3185

0° Middle portion 0.2559

15° Middle portion 0.3125

25° Middle portion 1.0593

0° Lower border 0.2436

15° Lower border 0.1126

25° Lower border 0.8526

57
 TABLE - 11

Comparison of the compressive stresses in different areas of the

bone surrounding the implant using varying degrees of the
angulated abutment in response to a unit vertical load of 4N.

Angulation
Von Mises stress in
of the Area of the implant
MPa
abutment

0° Crest 0.0452

15° Crest 0.2340

25° Crest 0.2537

0° Middle portion 0.6756

15° Middle portion 0.6556

25° Middle portion 0.4802

0° Lower border 0.5012

15° Lower border 0.3982

25° Lower border 0.4815

58
 TABLE - 12

Comparison of the tensile stresses in different areas of the bone

surrounding the implant using varying degrees of the angulated
abutment in response to a unit vertical load of 4N.

Angulation
Von Mises stress in
of the Area of the implant
MPa
abutment

0° Crest 0.2945

15° Crest 0.1777

25° Crest 2.7713

0° Middle portion 0.1018

15° Middle portion 0.1024

25° Middle portion 0.3274

0° Lower border 0.638

15° Lower border 0.1143

25° Lower border 0.9384

59
 The permucosal position of the implant abutment is of

particular importance for FP-1 (a fixed prosthesis which replaces

only the crown and resembles the natural tooth) prosthesis. An

implant placed in the improper position can compromise the final

results in esthetics, biomechanics and hygiene maintenance. The

most compromising position for an implant is too far facial. In the

resulting final restoration esthetics, phonetics, lip position and

function is compromised. An angled abutment may help improve the

condition if the improper placement is not severe, but the facial

gingival contour remains compromised. Also, the angled abutment

does not affect the increase in forces exerted at the crest of the bone.

The labial cortical plate is much thinner than the lingual and the thin

cortical bone must resist greater force 15 . These critical aspects call

upon a greater understanding of the bone tissue and its behaviour

that surrounds and supports an endosseous implant. The behaviour of

the bone in the peri-implant region is closely related to the direction,

magnitude and concentration of stresses transmitted by the implant.

The angulation of the implant abutments is one of the many

mechanical variables involved in implant dentistry. This study was

conducted to gain more insight under the influence of different

60
angulated implant abutments on the stress distribution in the alveolar

bone surrounding the implant and within the implant body itself.

FEA was initially developed in the early 1960’s to solve

structural problems in the aerospace industry but has since been

extended to solve problems in heat transfer, fluid flow, mass

transport and electromagnetics. 12

In 1976, Weinstein et al were the first to use FEA in implant

dentistry; 29 subsequently FEA was applied rapidly in that field.

Atmaram and Mohamed analyzed the stress distribution in a single

tooth implant to understand the effect of elastic parameter and

geometry of the implant, implant length variation and pseudo-

periodontal ligament incorporation. 12 Borchers and Reichart

performed a three dimensional FEA of an implant at different stages

of bone interface development 3 . Cook et al applied FEA to porous

rooted dental implants 10 . Merouch et al performed an FEA for an

osseointegrated cylindrical implant 12 . Williams et al carried out FEA

on cantilevered prostheses on dental implants 12 . Akpinar et al used

FEA to simulate the combination of a natural tooth and an implant 1 .

The FEM has been established as a standardized procedure for

qualitative as well as quantitative assessment of the stress

distribution in various structures. With the FEM, the mechanical

behaviour of the bone and implant system can be evaluated. The

61
validity of the FEM results depends on the precision, whether the

geometry, the material proportion, the interface condition, support

and loading are in accordance with the biomechanical reality 14 .

In this study a segment of the human jaw bone with its

associated restraints was modelled for the study. An implant, was

embedded in this section of the jaw bone. Three abutments used for

this study were a standard 0° abutment, a 15° angulated abutment

and a 25° angulated abutment (Color plate 2). A suprastructure was

modeled (Color plate 18) and placed on each of the three abutments

and a unit vertical load of 4N was applied onto the suprastructure

(Color plate 25) in each of the situations of different abutment

angulations. The results were interpreted as Von mises, compressive

and tensile stresses using colour codes for respective situations.

Stresses were evaluated in and around the implant assembly in

different conditions as stated above.

From the results of the study (Tables 1 to 6) it was

consistently observed that there was concentration of maximum Von

Mises stresses at the body and apical portion of the implant

irrespective of angulation of the abutment. For e.g. from Table No.

1a it can be observed that on application of a unit vertical load of 4N

on the implant with a 0° abutment, maximum stresses were seen to

be in the body region (1.0413MPa) followed by the apical region

62
(0.8007MPa). This was consistently seen with the compressive

stresses in the body (0.4786MPa) as well as the apex (0.4652MPa)

(Table No. 1b).

From Table No. 1c it observed that the tensile stresses were

maximum in the apical region of the implant (0.9222MPa).

From Table No. 2a it was observed that the when the implant

abutment angulation was kept at 0°, the Von Mises stresses

generated in the surrounding bone too, remained maximum in the

middle portion (0.2559 MPa) followed by the lower border of the

bone (0.2436 MPa). The same was consistently seen with the

compressive stresses in the middle portion (0.6756 MPa) as well as

the apex (0.5012 MPa) (Table No. 2b).

From Table No. 2c it was however seen that the tensile

stresses were maximum in the lower border of the bone (0.638 MPa).

These results were consistently observed in the other two

cases where abutments having 15 and 25° angulations were used

(Tables 3 to 6). They implicated maximum stresses values in the

body region of the implant and the middle portion of the bone

irrespective of the angulation of the implant abutment i.e. the

stresses in all conditions were concentrated more at the body region

of the implant and the middle portion of the bone with all the three

63
angulations of the implant abutment. The tensile stresses were

concentrated in the apical portion of the implant and the lower

border of the bone.

From Table No. 7 it is observed that the least magnitude of the

Von mises stresses in the implant was observed for the 0° angulation

in the neck region (0.1321 MPa) and the maximum magnitude was

observed in the body region for the 15° angulated abutment

(1.694MPa).

From Table No. 8 it is observed that the least magnitude of the

compressive stresses in the implant was observed for the 0°

angulation in the neck region (0.1101MPa) and the maximum

magnitude was observed in the body region for the 15° angulated

abutment (0.6556 MPa).

From Table No. 9 it is observed that the least magnitude of the

tensile stresses in the implant was observed for the 15° angulation in

the neck region (-0.1028 MPa) and the maximum magnitude was

observed in the apex region for the 25° angulated abutment

(0.9384MPa).

From Table No. 10 it is observed that the least magnitude of

the Von mises stresses in the bone surrounding the implant was

observed for the 15° angulation at the lower border (0.1126MPa) and

64
the maximum magnitude was observed in the middle portion for the

25° angulated abutment (1.0593MPa).

It was also observed from tables 8 and 10 that the Von Mises

stresses were of a greater magnitude in the implant as compared to

the bone in the corresponding regions. This denotes that the implant

acts as a stress absorbing element, and this finding is in agreement

with the results indicated in the study by I.P. Van Rossen 25 .

From Table No. 11 it is observed that the least magnitude of

the compressive stresses in the bone surrounding the implant was

observed for the 0° angulation at the crest region (0.0452 MPa) and

the maximum magnitude was observed in the middle portion for the

0° angulated abutment (0.6756 MPa).

From Table No. 12 it is observed that the least magnitude of

the tensile stresses in the bone surrounding the implant was observed

for the 0° angulation at the middle portion (0.1018 MPa) and the

maximum magnitude was observed in the crest region for the 25°

angulated abutment (2.7713 MPa).

Statistical analysis of the different stress values obtained in

this study was not possible as the parameters incorporated for this

study did not entail a possibility for it. Only a static vertical load of

4N was applied onto the implants with the three varieties of

65
abutments used i.e. 0°, 15° and 25°. However, for a statistical

analysis to be performed, a comparison between stress values

obtained under different loading conditions had to be made.

Ashok Sethi et al (2000) 21 conducted a study in which 2,261

two-stage implants were placed in 467 patients in combination with

angled abutments ranging from 0-45°. They were observed over a

period of upto 96 months with a mean observation time of 28.8

months. It was observed then, that there was no difference in the

mean survival rate of implants based on the use of angulated

abutments ranging from 0-45°.

Lawrence et al 27 reviewed that the modulus of elasticity of

bone permits a degree of deflection measured in microns. However,

osseointegrated implants have no micromovement (such as that

permitted by a periodontal ligament) sufficient enough to cause

distribution of force equal to that of natural teeth. He suggested that

vertical forces on cyclindrical implants would be concentrated at the

apex, while threaded implants would produce crestal and apical

force on the bone.

Irfan Akpinar et al (1996) 1 conducted a study to compare the

stress and strain patterns around two rigid implant designs used as

an abutment and the displacement of natural teeth was investigated

The finite element method was utilized to determine the stress and

66
strain distributions. The results were evaluated in terms of the

maximal tensile and compressive stress and strain in the bone around

the abutment tooth and implants. The results indicated that the ITI-1

(hollow screw) implant led to high stress concentrations particularly

in the apical region. The stress-transferring characteristics of ITI-2

(solid screw) implant were found to be more suitable than were those

of ITI-1.

Tamar Brosh, Raphael Pilo and David Sudai (1998) 5

conducted a study on pre-angled abutments to show that they

produce different stress distribution compared to straight abutments,

the objectives of this study were (1) test the hypothesis that pre-

angled abutments produce different stress distribution than straight

abutments by using strain gauges attached to implants embedded in a

medium simulating bone to determine strain distribution along the

implant/bone interface; (2) test this hypothesis by photoelastic

method; and (3) compare the two experimental techniques.. The

strain gauge measurements showed higher, threefold and 4.4-fold,

compressive strain concentration in the coronal zone of the implant

when 15-degrce and 25-degree angulated abutments were used,

respectively, compared with the straight abutment; whereas the

photoelastic method showed an increase of only 11% in fringe order.

Tensile strains were also measured from the coronal contralateral

67
position on the implant, where photoelastic models did not show a

change in stress type.

Data obtained from strain gauges bonded to implants

embedded in a medium can represent a precise simulation of the

clinical condition when analyzing stress distribution along the

implant / bone interface. Photoelasticity provides different

information and therefore should be regarded as a complementary

method.

68
Limitations of Finite Element Method

1) The Finite Element analysis of the stresses gives us a

range rather than the actual magnitude of the stresses over the

coloured area, though, at a particular node, the exact

magnitude can be sought, it cannot be used for determining its

effect on the surrounding structure.

2) FEA has proved to be an extremely accurate and precise

method for analyzing structures. However, living structures

are more than mere objects. FEA is based on mathematical

calculations based on simulation of the structure in its

environment. But living tissues are beyond the confines of set

parameters and values. Biology is not a computable entity.

Therefore, although FEA provides a very sound theoretical

basis of understanding the behaviour of a structure in a given

environment, it should not be considered alone. Actual

experimental techniques and clinical trials should follow the

FEA to establish the true nature of the biologic system.

Limitations of the study

1) Despite best efforts to model the structure accurately

the model had several limitations. Though the dimensions,

geometry and properties of this three dimensional model and

69
the support at both ends simulate the human mandible to a

limited extent, it does not give insight in the geometric

behaviour of bone as a result of chewing forces.

2) Chewing forces are dynamic in nature, whereas this

study was conducted under static loads.

3) Force was applied on a flat plane and not with the actual

morphology of the tooth.

4) Model construction was simplified for simplification of

meshing.

5) Further, bone is a viscoelastic, anisotropic, and

heterogenous material, whereas, in the model used for the

study, all materials were assumed to be linearly elastic and

homogenous in nature. The resultant stress values obtained

may not be accurate quantitatively but are generally accepted

qualitatively. 14

6) The merging of colours could not lead to ascertaining

the definitive range. So, the subjective variation though

consistent could not be eliminated.

7) The location and magnitude of stresses generated in

response to the load applied in the study are pertaining to the

70
 Finite Element model design in this study. This may vary if

there are alterations in model design, properties incorporated

and direction of forces applied.

Historically, the need to change the abutment angle has been

recognized, as a result of the difference in angle between the bone

available for implant placement and the long axis of the planned

restoration. However, there have been concerns expressed about the

adverse effect of non-axial forces on the survival of implants. There

seems to be no great danger in the use of these angulated abutments.

Although stresses do tend to increase in certain areas of the implant

and the bone at times.

Due to the limitations pertaining to this study, further research

regarding three dimensional FEA combined with long term clinical

evaluation has been suggested. This would correlate the findings

from the study with the findings in actual clinical situation where in

the implant with different angulated abutments are osseointegrated

to the surrounding bone and loaded with the suprastructure.

71
 This study was conducted to assess the stress distribution in

and around the cylindrical and threaded dental implant as a function

of change in the angulation of the implant abutments. The implant

and bone dimensions were obtained by means of a pro-engineer

software and were subsequently generated on the computer. FEA in

three dimensions was used as the research tool for the study. In the

first situation a model comprising the implant, its abutment, the

suprastructure and the surrounding bone was created and a unit load

of 4N was applied on to the suptrastructure and the peri-implant

stress as well as the stresses within the implant were evaluated and

interpreted as Von Mises, compressive and tensile stresses. In the

second and third situations, the implant abutment angulation was

changed to 15° and 25° other parameters being same. The post

processed results were studied with the help of colour plots and the

stress pattern was thus assessed.

From the results of the study it can be concluded that

1) The Von Mises stresses were of a greater magnitude in the

implant than in the surrounding bone in the corresponding

areas.

72
 2) The Von mises and compressive stresses in the implant were

concentrated more in the middle and apical third of the

implant in response to the vertical load applied.

3) The Von mises and compressive stresses in the bone too, were

more in the middle portion and the lower border of the bone.

4) The tensile stresses were more in the apical portion of the

implant irrespective of the angulation of the abutment used.

5) The tensile stresses in the bone surrounding implant too were

more in the lower border of the bone irrespective of the

angulation of the abutment used.

It was concluded that, the change in the angulation of the

abutment would not affect the longevity of osseointegration as a

very narrow range of variation was observed in the magnitude of

stresses in the implant as well as in the surrounding bone when

abutments with different angulations are used as the situation

demands.

73
1. Akpinar Irfan, Figen Demirel, Levend Parnas and Saime

Sahin, “Comparison of stress and strain distribution characteristics

of two different rigid implant designs for distal-extension fixed

posthesis”. Quintessence Int, 1996; 27:11-17.

2. Block M.S., Kent J.N. 1995 “Endosseous implants for

maxillofacial reconstruction”. W.B. Saunders Company,

Philadelphia, 1-12.

3. Borchers L. and Richard P. “Three-dimensional stress

distribution around a dental implant at different stages of interface

development”. J. Dent. Res, 1983; 62(2) : 155-159.

4. Branemark P.I. “Osseointegration and its experimental

background”. J. Prosthet Dent. 1983; 50(3):399-410.

5. Brosh Tamar, Raphael Pilo and David Sudai “The influence

of abutment angulation on strains ands stresses along the

implant/bone interface: Comparison between two experimental

techniques”. J Prosthet Dent, 1998;79:328-34.

6. Bryant R.S. “The effects of age, jaw site and bone condition

on oral implant outcomes”. Int. J Prosthodont, 1988; 11(5): 170-190.

74
7. Christiaan M., Franz Sutter, Hermanus S. Oosterbeek and

Andre Schroeder, “Indications for angled implants”. J Prosthet

Dent, 1992;67:85-93.

8. Clelland N.L., Amos Gilat, Edwin A. McGlumphy and

William A. Brantley, “A photoelastic and strain gauge analysis of

angled abutments for an implant system”. Int J Oral Maxillofac

Implants, 1993;8:541-548.

9. Clelland N.L., Lee J.K., Bimbenet O.C. and Brantley W.A.

“A three-dimensional finite element stress analysis of angled

abutments for an implant placed in the anterior maxilla”. J

Prosthodont, 1995;4(2):95-100.

10. Cook D., Weinstein A.M., Klawitter J.J. “A three-

dimensional FEA of porous rooted Co-Cr-Mo alloy dental implant”.

J Dent Res, 1982; 61(1): 25-29.

11. Dorothy E. Eger, John C. Gunsolley and Sylvan Feldman

“Comparison of angled and standard abutments and their effect on

clinical outcomes: A preliminary report”. Int J Oral Maxillofac

Implants, 2001;15:819-823.

12. Jian-Ping Geng, Keson B.C. Tan and Gui-Rong Liu

“Application of finite element analysis in implant dentistry: A

review of the literature”. J Prosthet Dent, 2001; 85:585-98.

75
13. Lucchini J.P. et al “Fixed partial denture on osseointegrated

screw implants.” Cah Prothese. 1990; 70:34-49.

14. Meijer H.J.A. et al “Stress distribution around dental

implants: Influence of superstructure, length of implants and height

of mandible”. J Prosthet Dent, 1992; 68(1): 96-102.

15. Misch C.E. “A contemporary of implant dentistry”.

16. Misch C.E., Bidez M.W. and Sharawy M. “A bioengineered

implant for a predetermined bone cellular response to loading forces.

A literature review and case report”. J Periodontal, 2001; 72(9):

1276-86.

17. Reiger M.R., Adams W.K., Kinzel G.L. “A finite element

survey of eleven endosseous implants”. J. Prosthet Dent.

1990;63(4):457-465.

18. Senay Canay, Nur Hersek, Irfan Akpinar and Zulfa Asik,

“Comparison of stress distribution around vertical and angled

implants with finite-element analysis”. Quintessence Int, 1996;

27:591-598.

19. Sennerby L., Roos J. “Surgical determinants of clinical

success of osseointegrated oral implants: A review of the literature”.

Int. J. Prosthodont. 1998; 11(5): 408-420.

76
20. Seong W.J., Korioth T.W. and Hodges J.S. “Experimentally

induced abutment strains in three types of single-molar implant

restorations”. J Prosthet Dent, 2000;84(3): 318-26.

21. Sethi A., Thomas Kaus, Peter Sochor “The use of angulated

abutments in implant dentistry: Five-year clinical results of an

ongoing prospective study”. Int J Oral Maxillofac Implants,

2000;15: 801-810.

22. Sethi A., Kaus T., Sochor P., Axmann-Kremar D. and

Chanavaz M. “Evolution of the concept of angulated abutments in

implant dentistry: 14-year clinical data”. Implant Dent,

2002;11(1):41-51.

23. Storum K., Carrick J.L. “Implant-osseous osteotomy for

correction of the misaligned anterior maxillary implant”. Dent Clin

North Am, 2001;45(1): 181-7.

24. Takahashi N., Kitagami T., Komori T. “Analysis of stress

on a fixed partial denture with a blade-vent implant abutment”. J.

Prosthet Dent. 1978;40(2):186-191.

25. Van Rossen I.P. et al. “Stress-absorbing elements in dental

implants”. J. Prosthet Dent. 1990; 64(2):198-205.

26. Walton J.N., Sylvia C. Huizinga and Christopher C. Peck

“Implant angulation: A measurement technique, implant

77
 overdenture maintenance, and the influence of surgical

experience”. Int J Prosthodont, 2001;14:523-530.

27. Weinberg L.A. “The biomechanics of force distribution in

implant supported prosthesis”. Int. J. Oral Maxillofac. Im-

plants. 1993;8(1):19-31.

28. Weinberg L.A. “Reduction of implant loading with therapeutic

biomechanics”. Implant Dent, 1998; 7(4): 277-85.

29. Weinstein A.M. et al “Stress analysis of porous rooted dental

implants”. J Den Res 1976; 55(5):772-777.

30. Zeid I. “CAD/CAM Theory and practice”. Mc Graw-Hill

International editions.

78