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Shock Absorption Capacity of Restorative Materials for Dental Implant

Prostheses: An In Vitro Study

Article  in  The International journal of prosthodontics · November 2013

DOI: 10.11607/ijp.3241 · Source: PubMed

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 Shock Absorption Capacity of Restorative Materials for
Dental Implant Prostheses: An In Vitro Study
Maria Menini, DDS, PhDa/Enrico Conserva, DDSa/Tiziano Tealdo, DDSa/Marco Bevilacqua, DDSa/
Francesco Pera, DDS, PhDb/Alessio Signori, MScc/Paolo Pera, MD, DDS, PhDd

Purpose: To measure the vertical occlusal forces transmitted through crowns made of
different restorative materials onto simulated peri-implant bone. Materials and Methods:
The study was conducted using a masticatory robot that is able to reproduce the
mandibular movements and forces exerted during mastication. During robot mastication,
the forces transmitted onto the simulated peri-implant bone were recorded using nine
different restorative materials for the simulated single crown: zirconia, two glass-ceramics, a
gold alloy, three composite resins, and two acrylic resins. Three identical sample crowns for
each material were used. Each crown was placed under 100 masticatory cycles, occluding
with the flat upper surface of the robot to evaluate the vertical forces transmitted. Two-way
analysis of variance was used. Alpha was set at .05. Results: The statistical evaluation of
the force peaks recorded on the vertical z-axis showed mean values of 641.8 N for zirconia;
484.5 N and 344.5 N, respectively, for the two glass-ceramics; 344.8 N for gold alloy;
293.6 N, 236 N, and 187.4 N, respectively, for the three composite resins; and 39.3 N and
28.3 N, respectively, for the two acrylic resins. Significant differences were found between
materials (P < .0001), except for the comparison between gold alloy and one of the
glass-ceramics. Conclusion: Composite and above all acrylic resin crowns were more
able to absorb shock from occlusal forces than crowns made of zirconia, ceramic material,
or gold alloy. Int J Prosthodont 2013;26:549–556. doi: 10.11607/ijp.3241

Implant dentistry has become an increasingly effective

method for correcting edentulism, either partially or
completely. Implant treatments exhibit an overall excel-
osseointegration is controversial.5 Several authors con-
sider occlusal load a crucial factor affecting the dental
implant healing phase and the long-term survival and
lent clinical success rate in the long term.1–4 Despite its success of dental implants.6–12
rare occurrence, the reasons for peri-implant bone loss In teeth, a semi-elastic connection between the
and implant failure in some patients are not completely tooth and bone exists (periodontal tissue), whereas
understood. Multifactorial aspects (general health, in implants, a direct and relatively rigid connection
bone quality and quantity, surgical procedure, implant between the bone and implant is achieved if healing
characteristics, parafunctional habits, occlusal over- without complications has taken place.13,14 Therefore,
loading, medications, bacterial insult, etc) potentially a direct transmission of forces on the peri-implant
induce peri-implant bone damage. However, the role bone without any shock-absorbing element is conse-
of some of these aspects in reaching and maintaining quent to implant loading.14 It can usually be achieved
by the adaptation capacity of peri-implant bone ar-
chitecture toward changing load conditions.15,16
According to Frost,15,16 within the range of a physi-
aAssistant Professor, Department of Fixed and Implant
ologic loading, bone undergoes its physiologic turn-
Prosthodontics, University of Genoa, Genoa, Italy.
bLecturer, Department of Prosthodontics, University of Turin, over. In mild overloading, below bone’s microdamage
Turin, Italy. threshold, modeling drifts can begin adding to and/
cLecturer, Department of Health Sciences, Section of Biostatistics, or reshaping bone. But in the case of a pathologic
University of Genoa, Genoa, Italy. overload, bone fractures and bone resorption may oc-
dChief and Professor, Department of Fixed and Implant
cur.15,16 For these reasons, it appears to be important
Prosthodontics, University of Genoa, Genoa, Italy.
to control the forces transmitted on the bone-implant
Correspondence to: Dr Maria Menini, Department of interface. However, the amount of load defined as
Prosthodontics (Pad. 4), Ospedale S. Martino,
overload has not been quantified because the range
L. Rosanna Benzi 10, 16132 Genova, Italy.
Fax: + 39 0103537402. Email: [email protected]
of host physiologic adaptability varies. Overload can
be considered the amount of force that overextends
©2013 by Quintessence Publishing Co Inc. the host sites adaptation potential.

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Shock Absorption of Restorative Materials

Fig 1 (left)  Sensor-equipped masticatory robot.

Fig 2 (below)  Pin simulating the implant-abutment system

with a ceramic sample crown. (a) A groove was made on the
pin to match a ridge inside the sample crown, so that the crown
would sit precisely on the pin without any possibility of rotation
or other movement during testing. (b) The sample crown has
been inserted onto the pin.

Groove

Clinical evidence on the impact of overloading on and zirconia. These materials are reported to have
peri-implant bone is not available. Only some case re- excellent mechanical and biologic properties,39,40 but
ports17–19 and animal studies9,12,20 are present. In fact, their impact on peri-implant bone and on the whole
clinical trials evaluating overloading are difficult to masticatory system has not yet been investigated.
design due to ethical reasons. Moreover, it is gener- The aim of this study was to investigate in vitro the
ally impossible to identify the reason for peri-implant shock absorption capacity of nine different restor-
bone loss in clinical cases, distinguishing overload- ative materials, including both traditional and modern
ing from other potential sources of bone loss. It is the esthetic materials, using a masticatory robot.
authors’ opinion that a prudent approach to implant
prosthodontics should be aimed at avoiding the risk Materials and Methods
of overloading the implants. In vitro studies21–25 also
demonstrate that off-axial loads increase stress on A masticatory robot able to simulate human chewing
the bone-implant interface with respect to axial loads in vitro was used (Fig 1), reproducing three-dimen-
and may also be responsible for increased resorption sionally the masticatory movements and loads ex-
of crestal bone.20 erted during mastication, as described in a previous
Some authors maintain that the type of material paper.26
used for the prosthesis supported by the titanium im- The movable part of the robot is composed of a
plant could affect occlusal load.14,26–32 In particular, in Stewart platform and simulates the mandible. The
the 1980s, some investigators recommended resilient fixed upper part of the robot simulates the maxilla.
occlusal materials such as acrylic resin to reduce the A sensor-equipped base is placed on the moving
forces exerted on implants.14,33,34 platform and records the degree of force being trans-
However, contrasting results on this topic35–38 sug- mitted through the three axes (x, y, and z).
gest the need for further investigation. The role of The sensor-equipped base supports a pin that
dental materials in occlusal stress transmission onto simulates the implant-abutment system (Fig 2a).
peri-implant bone seems to be especially relevant The samples to be tested are placed on the pin and
over the past few years because of the increasing use stressed in the various directions during the robot’s
of esthetic but rigid materials, such as glass-ceramic mastication.

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 Menini et al

Table 1   Elastic Moduli of Tested Materials

Material Manufacturer Type of material Elastic modulus (MPa)
Procera Zirconia Nobel Biocare Zirconia 210,000
Empress 2 Ivoclar Vivadent Glass-ceramic 96,000
Ney-Oro CB Dentsply Gold alloy 77,000
Finesse Dentsply Glass-ceramic 70,000
Experience DEI Italia Composite resin 13,000
Adoro Ivoclar Vivadent Composite resin 7,000 ± 500
Signum Heraeus Kulzer Composite resin 3,500
Easytemp 2 DEI Italia Acrylic resin 2,300
AcryPlus V Ruthinium Acrylic resin N/A
N/A = not available.

The materials tested were yttrium cation-doped With MATLAB 6.1 (MathWorks), the maximum val-
tetragonal zirconia polycrystals (Procera Zirconia, ues of the forces recorded for each masticatory cycle
Nobel Biocare), a lithium disilicate pressable ceramic were highlighted. These values underwent statistical
(Empress 2, Ivoclar Vivadent), a low-fusing leucite- analysis using SPSS software (version 18.0, IBM). Two-
based pressable ceramic (Finesse, Dentsply), a gold way analysis of variance (ANOVA) was used to compare
alloy (Ney-Oro CB, Dentsply), a microfilled hybrid transmitted stresses between the nine materials tested
composite resin (Experience, DEI Italia), a microfilled and across the three sample crowns of each material.
composite resin (Adoro, Ivoclar Vivadent), a nano- All tests were two-tailed. Alpha was set at .05.
hybrid composite resin (Signum, Heraeus Kulzer), and Post hoc comparisons were assessed by means
two acrylic resins (Easytemp 2, DEI Italia and Acry of the Scheffe test or, alternatively, by means of the
Plus V, Ruthinium) (Table 1). Tamhane test when homogeneity of variances among
In total, 27 identical sample crowns were made materials was not satisfied.
(three for each material). The occlusal surfaces were Vertical loads were converted and are found
semispherical in shape (6.5-mm diameter) (Fig 2b). throughout the paper in Newtons.
The main axis of the sample was 11-mm long. The
sample crowns presented a single contact point at the Results
center of the occlusal surface when occluding with
the flat maxilla of the robot. At this point, the thickness The ANOVA found a significant difference between
of the material tested was 5 mm. Each sample was the forces transmitted using different materials, and
measured on its main and smaller axes. The material the Scheffe post hoc test was applied. Within the ma-
thickness at the contact point was also measured with terials, an internal comparison showed a significant
calipers to verify that all crowns were identical. difference with P < .0001. Only the difference in mean
The specimens tested were chosen at random and maximum force between Ney-Oro and Finesse was
not in a pre-established sequence. Each crown was not statistically significant (P > .999).
placed under 100 chewing cycles with the sample Comparisons within sample crowns made for each
crown occluding with the flat fixed maxilla of the ro- material did not show significant differences, and one
bot. The masticatory robot was programmed to follow unique mean was reported for each material.
a trajectory reproducing human chewing, as described The force transmitted through the simulated im-
in the previous paper.26 The masticator traced this plant onto the simulated peri-implant bone by zirco-
trajectory in all tests described and the movements nia (mean 641.8 N) was the greatest (Table 2).
were executed independently from generated force. The slope of the curve, representing the force
Vertical loads (kg) transmitted at the simulated transmitted onto the peri-implant level, showed that
peri-implant bone were recorded using strain gauges materials with greater elastic moduli have steeper
stuck on the sensorized base supporting the simu- peaks compared with other materials, that is, the
lated implant-abutment system. maximum force is reached more rapidly.

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Shock Absorption of Restorative Materials

Table 2   Comparison of the Maximum Forces (N) kinematics. Instron machines perform intermittent
Transmitted onto the Simulated Peri-implant Bone movements in only a single plane. They do not repli-
Difference of force cate the same masticatory cycle that occurs clinically
Material Mean force (SD) vs zirconia (%) P with mastication.
Procera Zirconia 641.8 (6.8) With regard to FEA, which included a virtual simu-
Empress 2 484.5 (5.5) –24.51 lation, the validity of the mathematical model is dif-
Ney-Oro CB 344.8 (5.7) –46.28 ficult to estimate objectively, and the assumptions
Finesse 344.5 (3.5) –46.32
made in the use of FEA in implant dentistry must be
taken into account when interpreting the results. In
Experience 293.6 (16.3) –54.25 < .0001
fact, during the modeling process, several simplifica-
Adoro 236 (4.2) –62.23 tions are necessary (model geometry, material prop-
Signum 187.4 (6.7) –70.80 erties, applied boundary conditions, etc) and greatly
Easytemp 2 39.3 (2.3) –93.88 affect the predictive accuracy of FEA.50
AcryPlus V 28.3 (4.2) –95.59 An experiment conducted on beagle dogs51 did
not show any clinical, radiographic, or histologic dif-
ferences between peri-implant tissues surrounding
prosthetic restorations made with composite resin
versus those made with ceramic materials. However,
Discussion this study did not control the amount of force exerted
onto the implants, and dogs do not replicate human
In this investigation, the use of different restorative mastication.
materials significantly affected stress transmission on In vivo studies41,43,49 have measured masticatory
the simulated peri-implant bone. In fact, more elastic forces transmitted through various restorative mate-
materials reduced the stress recorded. rials in patients without finding significant differences
The difference in stress transmission between the in the results.
gold alloy and one of the two glass-ceramics was the This type of test requires that sensors and connect-
only difference not statistically significant, presum- ing wires be applied intraorally, which raises several
ably because of their similar Young’s moduli (Table 1). concerns. For instance, this type of testing may al-
Zirconia and ceramic crowns also showed steeper ter the masticatory cycles of the study participants
peaks of force compared with other materials. These and therefore may distort the results. Moreover, the
were considered effects of the different elastic moduli technique is not conducive to studying humans over
of the materials tested. long experimental periods, and the masticatory cycles
According to Skalak,14 the viscoelastic behavior of are not identical. In addition, it is not possible to di-
an acrylic resin as occlusal material would be enough rectly measure the forces transmitted onto the bone-
to delay the transmission of force and reduce its peak implant interface.
compared with materials with greater elastic moduli. Using the masticatory robot, an attempt was made
An in vitro study by Gracis et al32 concluded that to overcome the limitations associated with previ-
the harder and stiffer the material, the higher the ous studies, approximating the three-dimensional
force transmitted onto the implant and the shorter nature of masticatory function by an in vitro model.
the rise time. In fact, according to Hooke’s law, the The forces were measured by strain gauges attached
higher the modulus of elasticity of a material, the less to the sensorized base to which the simulated den-
the material will deform under pressure and the more tal implant was screwed; therefore, it was considered
likely the force will be transferred through the mate- that the forces were recorded at the simulated peri-
rial.41 Conversely, the more resilient the material, the implant bone.
more easily it will deform under pressure, the longer Even though non-axial forces seem to be a more
the rise time, and the smaller the stress. relevant factor for bone maintenance compared with
However, a review of the literature over the last axial forces, in the present paper, only data regarding
20 years demonstrated that many articles refute the vertical forces have been reported. In fact, previous
existence of a shock absorption capacity of resilient papers26,27 showed that the percentage difference
dental materials.42–49 of force using different materials was superimpos-
Some of these studies have used Instron ma- able on the three axes; data for the three axes were
chines48 and some have used finite element analysis redundant. For this reason, in the present research,
(FEA).44,46,47 These studies have several limitations. the sample crowns were left to occlude with a flat
They do not accurately reproduce the mandibular surface and not with the reproduction of the maxilla.

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 Menini et al

Occluding with a flat surface, forces on the horizontal authors’ opinion that, in multiunit prostheses, a stiff
plane were near zero and only data recorded on the substructure (ie, gold alloy) rigidly splinting the im-
vertical axis were considered for statistical analysis. plants would be the best option to evenly distribute
The present in vitro setup presents several limita- loads. The shock absorption capacity of more resil-
tions in simulating the clinical situation. Namely, the ient restorative materials could be used at the lev-
moving platform and the upper part of the robot, sim- el of the occlusal surface in association with a stiff
ulating the maxilla, are rigid systems that cannot re- substructure.14
produce the inherent elasticity of human tissues. The The present paper evaluates the shock absorption
elastic properties of implant, abutment, and screws capacity of nine restorative materials, including gold
were not properly simulated. alloy and zirconia, which were not tested in previ-
Moreover, no attempt was made to simulate the oral ous studies.26,27 To the authors’ knowledge, there are
environment in terms of humidity and temperature. no published studies evaluating the shock absorp-
Comparability of the in vitro and in vivo loading tion capacity of zirconia. In the last few decades, the
conditions is limited. Therefore, the absolute values of growing patient demand for highly esthetic restora-
force recorded at the peri-implant bone in the present tions has led to the development of new all-ceramic
study cannot be directly correlated to the forces that materials such as zirconia.
would be present in vivo. Zirconia minimizes the dark color transmit-
It should also be noted that the masticatory system ted through peri-implant tissues associated with
is provided with protective and self-regulatory mecha- metal components. Moreover, zirconia restorations
nisms not simulated in the present in vitro setup. In yield higher fracture loads than alumina or lithium
fact, natural teeth are equipped with periodontal disilicate.56,57
mechanoreceptors that signal information about tooth Both the increasing industrial pressure and grow-
loads and are involved in the control of human jaw ing enthusiasm for attractive esthetic outcomes have
actions aiming at preventing accidental excessive oc- led to the widespread use of all-ceramic restora-
clusal loads.52 On the other hand, dental implants lack tions and zirconia, even though their impact on the
periodontal receptors. However, a tactile sensibility at masticatory system has not been sufficiently tested.
the level of dental implants (so-called osseopercep- The esthetic characteristics, as well as the biocom-
tion) has been demonstrated and could be responsible patibility, and the most common shortcomings of all-
for an implant-mediated sensory-motor control.53 ceramic restorations (brittleness, chipping of the ve-
Despite the limits of the present in vitro setup in neering ceramic, fracture strength) have been thor-
simulating the oral implant situation, the attempt was oughly investigated for zirconia.40,58 Zirconia is also
made to eliminate all possible variables involved. The considered to have excellent mechanical properties,59
standardized in vitro system allowed for fabrication but, so far, the biomechanical consequences of such
of identical sample crowns that were all submitted to a rigid and stiff material in the masticatory system
identical loading conditions. have not been investigated by the scientific literature.
A previous paper26 demonstrated that the mas- In fact, zirconia’s elastic modulus and coefficient of
ticatory robot is able to reproduce, several times abrasion are much higher than those of natural teeth.
over, identical masticatory cycles. The paper also Only a few studies60–62 report assessments of
confirmed the precision of the machine during data periodontal or peri-implant tissues around teeth or
collection, therefore validating the reliability of the implants supporting zirconia restorations after func-
method. In fact, the small variations found showed tional loading. To the authors’ knowledge, no clinical
that the tests are also repeatable and effective under studies report possible consequences at the level of
lengthy testing. the antagonist arch or any gnathological consider-
The only variable in the system described was the ation. Moreover, to date, the observational period for
material from which the crowns were made, which is the majority of trials on zirconia restorations is quite
mandatory for a reliable comparison of different mate- short.57
rials. The system was designed to make a comparison Two systematic reviews on all-ceramic dental
between different materials effective and repeatable. materials and zirconia also underlined the fact that
In the present study, a single crown was tested, none of the cited clinical trials took bruxism into ac-
demonstrating a shock absorption potential for acryl- count. More often, such a parafunction figured into
ic resin. However, contrasting results could be found the exclusion criteria. Consequently, the authors
using multiunit prostheses.41,44,54,55 In fact, stiff pros- suggested that, since parafunctions were not con-
thetic materials are supposed to distribute the stress sidered in any clinical investigation, they should be
more evenly to the abutments and implants. It is the regarded as a potential limitation for zirconia-based

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Shock Absorption of Restorative Materials

restorations.39,63 One reason for this suggestion could Acknowledgments

be the increased risk of chipping and fracture of
zirconia-based restorations in parafunctional pa- The construction of the masticatory robot was financed by the
tients, but evidence is lacking on possible harmful Ministry of Instruction, University and Research (MIUR), Italy,
under the auspices of the Research of National Interest Projects
effects on the masticatory system using zirconia res-
(PRIN, 2002). The authors wish to thank Prof Giambattista Ravera
torations when a parafunction is present. (Department of Health Sciences, University of Genoa) for the sta-
Larsson et al64 noticed that significantly more tistical analysis, dental technician Paolo Pagliari for the labora-
porcelain veneer fractures are reported for implant- tory support, and engineers Giuseppe Casalino, PhD, Fabio Giorgi,
supported zirconia fixed dental prostheses when Tommaso Bozzo, and Enrico Simetti (Department of Informatics
of Systems Theory and Telematics, University of Genoa, Italy). The
compared with tooth-supported restorations. One
authors reported no conflicts of interest related to this study.
explanation for this finding could be the role played
by the periodontal ligament, which allows for shock
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Literature Abstract

Identification of risk factors for fracture of veneering materials and screw loosening of implant-supported fixed partial
dentures in partially edentulous cases

The purpose of this retrospective study was to determine the risk factors for fracture of veneering materials and screw loosening of
implant-supported fixed partial dentures. A total of 182 patients had 219 suprastructures inserted. One hundred twenty patients (149
facing suprastructures) were included in a subgroup to investigate the risk factors of fracture of veneering materials, and 81 patients
(92 suprastructures) were included in a subgroup to analyze the risk factors for abutment screw loosening. A Cox proportional haz-
ards regression model was performed to identify the risk factors related to technical complications, and eight factors were regarded
as candidate risk factors. It was suggested that a screw-retained suprastructure was a significant risk factor for fracture of veneering
materials, and connection of suprastructures with natural teeth was a significant risk factor for screw loosening. Further investigations
involving dynamic factors, such as occlusal force and bruxism, should be considered as predictors that may be helpful in studying the
risk factors of fracture of veneering materials and screw loosening.

Noda K, Arakawa H, Maekawa K, Hara ES, Yamazaki S, Kimura-Ono A, Sonoyama W, Minakuchi H, Matsuka Y, Kuboki T. J Oral Rehabil
2013;40:214–220. Reprints: Takuo Kuboki, Department of Oral Rehabilitation and Regenerative Medicine, Okayama University, Graduate School
of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, 700-8525, Japan. Email: [email protected]—Arthur S. Sham,
Hong Kong

556 The International Journal of Prosthodontics

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