RESEARCH

Effects of Occlusal Scheme on All-on-Four Abutments,

Screws, and Prostheses: A Three-Dimensional Finite
Element Study
Nurullah Türker, DDS, PhD*
Hümeyra Tercanlı Alkisx, DDS, PhD
Steven J. Sadowsky, DDS, PhD
Ulviye xSebnem Büyükkaplan, DDS, PhD

An ideal occlusal scheme plays an important role in a good prognosis of All-on-Four applications, as it does for other implant therapies,
because of the potential impact of occlusal loads on implant prosthetic components. The aim of the present 3D finite element analysis
(FEA) study was to investigate the stresses on abutments, screws, and prostheses that are generated by occlusal loads via different occlusal
schemes in the All-on-Four concept. 3D models of the maxilla, mandible, implants, implant substructures, and prostheses were designed
according to the All-on-Four concept. Forces were applied from the occlusal contact points formed in maximum intercuspation and
eccentric movements in canine guidance occlusion (CGO), group function occlusion (GFO), and lingualized occlusion (LO). The von Mises
stress values for abutment and screws and deformation values for prostheses were obtained, and results were evaluated comparatively. It
was observed that the stresses on screws and abutments were more evenly distributed in GFO. Maximum deformation values for
prosthesis were observed in the CFO model for lateral movement both in the maxilla and mandible. Within the limits of the present study,
GFO may be suggested to reduce stresses on screws, abutments, and prostheses in the All-on-Four concept.

Key Words: All-on-Four concept, implant, occlusion, finite element analysis

INTRODUCTION with 4 implants was foreshadowed by Branemark.8 Implant

tilting suitable for the remaining bone anatomy has been

B
ecause of the superior properties of implant applica-
documented by Mattson et al9 and Krekmanov et al.10 Malo et
tions in achieving aesthetic and functional needs, there
al11,12 introduced the popular concept called ‘‘All-on-Four’’ that
has been a burgeoning demand. However, various
allows immediate function with a complete arch implant-
biological and mechanical problems may arise in
supported fixed prosthetic treatment. In this concept, the
implant-supported prostheses.1–3 Although there persists a
implants in the posterior region are placed with an inclination
controversy in the role implant loading plays in peri-implant into the distal side of up to 45 degrees. This angle in the
disease, prosthetic complications have been related to nonop- posterior region allows the placement of the implant by
timal occlusal designs.4 Hyperloading during functioning may avoiding anatomical formations such as the maxillary sinus and
cause mechanical complications in the abutments, screws, and the mandibular nerve. Thus, the surgical procedure becomes
prostheses.1,3 These complications can be minimized by safer and more economical.11,12
providing an ideal occlusion that is designed with a sufficient In the All-on-Four concept, fixed prosthetic treatment is
number of implants. However, the type of occlusion to be used in performed with fewer implants compared with other concepts.
treatment with implants is still not established in the literature.5–7 Intraoral occlusal loads are transferred to the implants by using
Factors such as deficiencies in bone tissue, the presence of fewer abutments and screws, underscoring the importance of
patients in whom complex surgical procedures cannot be distributing occlusal stress equitably in the implant prosthetic
performed, the obstacles caused by anatomical formations, and design. In All-on-Four treatments, it is studied which occlusal
economic reasons have directed clinicians to seek methods scheme is more ideal in terms of the distribution of stresses that
performing full-arch fixed prosthetic restorations with fewer will occur in bone tissue.13 However, there is not any
implants. In this respect, the basis of the treatments in which information about which type of occlusion is preferred in the
complete arch fixed prosthetic restorations were performed All-on-Four concept to create more ideal stresses in abutments,
screws, and prostheses.5,7 Thus, the aim of this finite element
analysis (FEA) study is the investigation of the different stress
Department of Prosthodontics, Akdeniz University Faculty of Dentistry,
Antalya, Turkey.
distributions on abutments, screws, and prostheses generated
* Corresponding author, e-mail: [email protected] by various occlusal schemes, in accordance with the All-on-Four
https://doi.org/10.1563/aaid-joi-D-19-00334 technique on both arches.

18 Vol. XLVII / No. One / 2021

 Türker et al

MATERIALS AND METHODS

Three separate models were prepared within the scope of the

study: CGO, a model in which the occlusal scheme is prepared
according to canine-guided occlusion; GFO, a model in which
the occlusal scheme is prepared according to group function
occlusion; LO, a model in which the occlusal scheme is
prepared according to lingualized occlusion.
The methodology of the present study was reviewed by an
independent statistician.

Obtaining the models

Modeling of the Bone and the Gingival Tissues
The modeling of the maxilla and mandible was performed
using a head and neck anatomy book as a reference.14 After
these structures were modeled, trabecular bone, cortical bone
(thickness of 2 mm), and gingiva (thickness of 1 mm) were
formed via the ‘‘shell’’ and ‘‘subtract’’ commands.

Modeling of the Prosthetic Restoration

FIGURE 1. Maxillary and mandibular models with completed design
To represent the maxilla and mandible alveolar crest, a and assembly.
standard plaster model was used. Tooth setting for prosthetic
restorations to be created in different occlusal schemes was Tech) for the anterior regions and angular abutments (Angled
performed on these models. Wax occlusal rims were prepared Abutment 3.5/4.0, Astra Tech) for the posterior regions were
on the registration bases, adapted, and polymerized to the designed. The designs were produced in actual sizes with
plaster model. In all 3 types of occlusion, the interarch distance reference to the demonstration models of the relevant
was set to 30 mm, and the occlusion plane was positioned in company. The implants, abutments, screws, and prostheses
the middle of the maxillary and mandibular crest. The closure designed were located within the bone tissue model in
relationship between the models was provided to be standard accordance with the All-on-Four concept. The distal inclination
on all 3 models, and the models were thus mounted on a of the implants in the posterior region, which is characteristic
semiadjustable articulator (Stratos 200, Ivoclar Vivadent, for the All-on-Four concept, was adjusted to be 40 degrees
Schaan, Liechtenstein). Although anatomical artificial teeth both in the maxilla and mandible. The distance between the 2
were used for CGO and GFO, anatomical teeth in the maxillar anterior implants in the maxilla was 30.8 mm, and the distance
prosthesis and modified nonanatomic teeth (Ivostar, Ivoclar between the posterior implant and the anterior implant was 31
Vivadent) in the mandibular prosthesis were used for LO. The mm. The distance between the 2 anterior implants in the
second molars were not included. Cuspal contacts and mandible was 28.4 mm, and the distance between the posterior
eccentric relationships were provided in accordance with the implant and the anterior implant was 30.2 mm. The bars were
standards of each occlusion type. Three-dimensional images of designed with a width of 5 mm and a height of 3 mm to cover
prostheses separated from plaster models were obtained using
the entire arch; the abutments were set in the buccolingual
a scanning device (D250, 3Shape). Then, the point cloud
center of the bar. The length of the bar was 95 mm in the
models of the scanned prostheses were arranged using the
maxilla and 94 mm in the mandible. The cantilever extension
Autodesk meshmixer software (Autodesk Inc) and transferred
was 6.3 mm in the maxillary prostheses and 7.1 mm in the
into the Space Claim software (Version 14.5.7, ANSYS Inc),
mandibular prostheses. All these designs were performed in the
which is a module of the Ansys software. The base sections of
Space Claim module of the Ansys software. Figure 1 shows the
the prostheses were made exactly the same using this software
designed maxilla and mandible, implants, abutments, screws,
and adapted into the mandible and maxilla. The dimensions of
and prostheses.
the maxillary prosthesis in the frontal direction and the sagittal
direction were 41 and 56 mm, respectively, whereas in the Describing the meshing process and the material
mandibular prosthesis, these sizes were 39 and 51 mm. characteristics
Although it varies by region, the average thickness of the
maxillary prosthesis was approximately 16 mm and the SOLID187 tetrahedral elements were used to compose the
thickness of the mandibular prosthesis was 15 mm. mesh. In the present study, the number of total elements was
1,250,334 for the maxilla and 1,517,477 for the mandible (Figure
Modeling the Implant and Implant Parts
2). Elasticity modulus and Poisson’s ratio values of the materials
Root-shaped implants were designed with sizes of 4 3 13 mm were identified as in Table 1. Physical properties of type 3 bone
for the posterior regions and 4 3 10 mm for the anterior regions were preferred for trabecular bone.15 All the models were
(OsseoSpeedtx 4.0 S, Astra Tech). In accordance with these accepted as linear elastic, 100% homogenous, isotropic, and
implants, linear abutments (208 UniAbutment 3.5/4.0, Astra completely bonded.16,17

Journal of Oral Implantology 19

All-on-Four With Different Occlusal Schemes

Analyses and outputs

Equivalent (von Mises) stress values were obtained from the

screws and abutments. Total deformation amounts of the
prostheses were recorded. For the standardization of the
images according to the prosthetic deformation amounts, the
upper limit was 0.14 mm for the mandible and 0.2 mm for the
maxilla in the color-deformation bar. The results are compared
in Tables 2 and 3 and Figure 3.

RESULTS

Stresses were recorded in megapascals (MPa). The right side was

the rotating side in the lateral movement and the left side was the
nonrotating side. Although different amounts of stress formed on
the right and left sides of the maxilla and mandible in lateral
movement, equal stresses occurred on the left and right sides in
maximum intercuspation and protrusive movement. Therefore,
only the values of the right side for maximum intercuspation and
protrusive movement were written in the table. The stresses
observed on the screws and abutments in the mandible were
generally higher than the maxilla. Tables 2 and 3 show the
stresses observed in the screws and abutments and the total
deformation amounts observed in the prostheses, respectively.
FIGURE 2. A cross section from the model to which the mesh process When Table 2 is evaluated considering all values, the
is applied. maximum stress values in the screws and abutments were
observed in the GFO model in the lateral movement of the
maxilla. In the mandible, the maximum values observed in the
Determining the boundary and loading conditions
screws were equal in the CGO and GFO models in protrusive
The models were fixed by considering some muscle anchor movement; however, maximum values were observed in the
points in the mandible and bone junction points in the maxilla. abutments of the LO model in lateral movement.
The loading conditions were formed with regard to the When the stresses on the screws and abutments were
examined at maximum intercuspation, the maximum values for
maximum intercuspation and the forces in eccentric move-
the maxilla and mandible were observed in the LO model. The
ments in 3 different types of occlusion. The forces were
stress amounts were greater in the posterior regions compared
directed through the tubercle contact points formed on each
to the anterior regions.
occlusion type and perpendicular to the surface where they
When the stresses on the screws were evaluated in lateral
were applied. The load applied to each tooth was equally movement, the maximum stresses were observed in the CGO
distributed to the occlusal contact points of the tooth. The model for the maxilla and in the LO model for the mandible.
applied force values were consistent with the literature and Again, in lateral movement, the maximum stresses on the
listed as follows13,18–23: screws were observed in the right anterior region of the maxilla
and in the left posterior region of the mandible. In the
CGO: 450 N in the centric relation, 93 N in the lateral abutments, the maximum stresses in the lateral movement
movement, and 94 N in the protrusive movement. were observed in the GFO model in the maxilla and in the LO
GFO: 450 N in the centric relation, 200 N in the lateral model in the mandible. Generally, higher stresses were
movement, and 94 N in the protrusive movement. observed on the rotating side in lateral movement.
LO: 450 N in the centric relation, 400 N in the lateral movement, When the stresses on the screws were evaluated in the
and 400 N in the protrusive movement. protrusive movement, maximum stresses were observed in the

TABLE 1
Material properties used in the finite element model
Component Material Elastic Modulus (GPa) Poisson Ratio References
Cortical bone — 13.70 0.30 13
Trabecular bone — 1.37 0.30 13
Gingiva — 0.0028 0.40 14
Base and teeth Acrylic 8.30 0.28 14
Implants, components, and bar Titanium 115.00 0.35 13

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 Türker et al

TABLE 2
Equivalent (von Mises) stresses observed in the screws and abutments*
Maximum Protrusive
Intercuspation Lateral Movement Movement
Jaw, Component
and Occlusal Scheme RP RA RP RA LA LP RP RA
Maxilla
Screw
CGO 32.4 7.1 40.5 95.1 25.5 16.1 14.3 27.1
GFO 32.4 7.1 79.5 56.9 18 6.4 14.3 27.1
LO 34.8 18.2 37.8 14.6 23 63.9 21.15 10.3
Abutment
CGO 99.7 27 192.6 219.3 83.2 62.9 28.3 113.9
GFO 99.7 27 260.1 197.9 72 32.7 28.3 113.9
LO 129.1 63.7 119.9 53.9 96.8 244.1 104.4 45.7
Mandible
Screw
CGO 56.7 28.8 76.7 90.6 62.8 98.8 31.8 131.4
GFO 56.7 28.8 72.9 62.3 22.9 16.7 31.8 131.4
LO 72.9 46.8 66.2 54.5 116.9 60 68 32.7
Abutment
CGO 140.3 62.3 122.1 123 52.9 50.1 56.7 150.7
GFO 140.3 62.3 195.2 138.3 30.7 27.3 56.7 150.7
LO 151.7 90.4 213.8 199.3 135.4 166.2 144.9 136.5

*LA indicates left anterior; LP, left posterior; RA, right anterior; RP, right posterior; CGO, canine guidance occlusion; GFO, group function occlusion; LO,
lingualized occlusion.

LO model in the maxilla and in the CGO and GFO models in the
mandible. In the abutments, the maximum stresses were equal in
the CGO and GFO models for both the maxilla and mandible. The
changes observed in the stress values were similar in the maxillary
and mandibular models. However, maximum stress values in
lateral movement in the abutments were observed in the GFO
model in the maxilla and in the LO model in the mandible.
When the deformation values in Table 3 were considered,
the maximum deformation values were observed in the CGO
model in lateral movement both in the maxilla and mandible.
The lowest deformation values were equally observed in the
CGO and GFO models in maximum intercuspation.

DISCUSSION

FEA, has been used extensively in dental research in recent

years. It is a useful tool in the examination of stresses occurring

TABLE 3
Total deformations observed in prosthetic structure (mm)*
Jaw,
Component and Maximum Lateral Protrusive
Occlusal Scheme Intercuspation Movement Movement
Maxilla
CGO 0.02 0.15 0.04
GFO 0.02 0.09 0.04
LO 0.04 0.07 0.03
Mandible
CGO 0.14 0.16 0.15
FIGURE 3. Distribution of the deformations occurring in the maxillary
GFO 0.14 0.12 0.15
and mandibular prostheses. Red shows the regions with maximum
LO 0.15 0.14 0.13
deformation, and blue shows the regions with minimum deforma-
*CGO indicates canine guidance occlusion; GFO, group function occlusion; tion. CGO indicates canine guidance occlusion; GFO, group
LO, lingualized occlusion. function occlusion; LO, lingualized occlusion.

Journal of Oral Implantology 21

All-on-Four With Different Occlusal Schemes

in the peri-implant bone, which otherwise would be clinically In lateral movement, the stresses on the screws and
difficult to detect.24,25 In this method, the three-dimensional abutments did not show similar distributions for the maxilla
design of the clinical situation is made. Then, the effect of the and mandible. The maximum stress value in the maxilla was
desired factors is observed by considering all the other factors observed in the anterior screw on the working side in CGO,
as standard. In this aspect, this method is advantageous whereas the maximum value in the mandible was observed in
compared with the standardization difficulties of clinical trials. the anterior region on the nonrotating side in LO. The main
With detailed comparison and interpretation of visual and reasons for this difference observed in standardized models
numerical data obtained through FEA studies, valuable may be differences in tubercle contacts, masticatory forces in
information about complex clinical situations can be ob- lateral movement, and anatomy of the bony structures of the
tained.26 maxilla and mandible. It is worth noting that relatively high-
In the present study, the stresses on the screws and stress values were observed in CGO, although less force was
abutments in the mandible were generally higher compared applied compared with the other 2 types of occlusion. The
with the maxilla. When this difference was taken into chewing forces are transmitted to the prosthetic parts through
consideration, it could be inferred that the mechanical the tubercle contact points. The forces transmitted cyclically
complications in the maxilla and mandible occurred from throughout the chewing processes cause periodically stress in
different processes. One of the issues to be considered here is rigidly interconnected fixed prosthetic components. The
the FEA model. The more realistic imitation of the clinical presence of cyclic stresses accelerates the fatigue in the
situation provides the more accurate results in FEA studies. material structure.34 This situation may lead to the occurrence
Ideally, although modeling the maxilla and mandible, changes of mechanical complications in prosthetic structures in the long
in bone tissue in each axial dimension should be reflected in term.35–37 In this context, this may mean that screw loosening
the model. Although various methods have been reported for and fractures in screws and abutments are more likely to be
this type of modeling, these methods have not been observed in All-on-Four restorations applying CGO. Forces were
adequately tested and have not been proven to provide distributed more equitably among teeth in GFO, Thus, GFO
accurate findings.27,28 A changed jaw bone structure by regions seems to have advantages for maintaining the stability of the
may cause alterations in the distribution of stresses. However, screws and abutments. This was demonstrated as well with
the main study subject of the present study was to investigate lower prosthetic deformations with GFO in lateral and
the stress distribution caused by different occlusal schemes on protrusive movements.
the same bone and implant structure. The main variable in the In the present study, bar structures were designed similarly
study is the type of occlusion and the comparison of target to the standard designs used in many studies.16,23 However,
occlusion types. In the case of comparison in the finite element case-specific bars, not standard bars, may be used in an
analysis, a comparison can be made between independent implant-supported prosthetic design. These bar structures
variables by providing similarity among the models. There are usually contain retentive reinforcement in each tooth. Such
many similar studies conducted in the literature.23,29 Neverthe- modifications may reduce the likelihood of mechanical
less, bone tissue can be modeled more realistically in further complications,38,39 and such conditions can cause different
studies. However, differences in findings in the maxilla and results in terms of mechanical problems in different types of
mandible may be associated with the differences in interim- occlusion. However, in this study, the effects of occlusion types
plant distance, cantilever lengths, and anterior/posterior span on stress formation were evaluated by keeping the model
of the mandible and maxilla. Several authors have reported designs as standard. This is related to the principle of FEA that
more mechanical problems in full-arch implant-supported comparing some factors by keeping all other features constant.
maxillary resin prostheses compared with those in the From this point of view, it is thought that the findings obtained
mandible.30–33 However, the findings in these studies were in this study do not cover all the implant-supported prosthetic
obtained from a large data set including fixed prostheses designs in the All-on-Four concept but contribute to the
supported by 5, 6, and or 8 implants and the cases where the literature in terms of comparison among different occlusal
opposite arch can be composed of natural teeth. In the present schemes.
study, only the cases where both maxillary and mandibular Proper treatment planning and proper occlusion prevent
prostheses were prepared with the All-on-Four concept, and overload on the prosthetic parts, and this situation minimizes
ideal occlusal relations were examined. In addition, cantilevers the incidence of loosening and fracture of the screws.31
of the prostheses prepared with the All-on-Four concept are Sakaguchi et al40 evaluated the biomechanical performance
mostly positioned in the area of the first molar teeth, which is of the restorative components of dental implants via FEA and
the center of chewing. In the models prepared in this study, the concluded that uneven loading caused a separation between
cantilever length in the mandibular prosthesis is longer. This the crown and the abutment and between the crown and the
may also explain the discrepancy in the results. screw. Alkan et al41 investigated the stress on the screws in 3
When the stresses occurring in the screws and abutments different implant-abutment systems via FEA and showed that
were considered in maximum intercuspation, higher stresses the loads coming from different angles caused different
occurred in LO. In CGO and GFO, the forces were applied at the stresses.
tubercle contact points and divided into more parts than LO. In Based on the results of a review, Abduo et al42 reported
LO, the loads were distributed from a single point to the that there was no difference between CGO and GFO in terms of
prosthesis for each tooth. The formation of higher stresses in restoration life. Miralles et al43 stated that both CGO and GFO
LO could be attributed to this force distribution state. were equally acceptable for both natural teeth and implant-

22 Vol. XLVII / No. One / 2021

 Türker et al

supported prostheses. Some authors have suggested that LO is 2. Higher deformation values were generally observed in CGO
more suitable for implant-supported prostheses.42,44 However, in lateral and protrusive movements, which may influence
these studies were not limited to All-on-Four prosthetic the incidence of mechanical complications in the implant
designs. The results obtained in the present study show that prosthesis over the long term.
higher stresses occurred in implant-supported components,
especially in CGO. Among the 3 occlusion types, lower stress
values were generally observed in GFO. However, in a previous
ABBREVIATIONS
study, in the prosthetic restorations produced with 5 different
occlusion types in accordance with the All-on-Four concept, the CGO: canine-guided occlusion
stresses formed on implants and bone tissue were evaluated FEA: finite element analysis
and the lowest stresses were observed in CGO.13 Thus, GFO: group functioned occlusion
considering the results of both studies, it can be observed LO: lingualized occlusion
that different stress values, and therefore, different findings
were obtained for the different parameters examined. There-
fore, the result of the 2 studies shows that occlusion types NOTE
cause different effects on different components (bone, implant,
The authors declare no conflict of interest.
abutment, screw, prosthesis). All-on-Four prosthesis in the low-
quality bone may be best served by CGO, and when the bone is
not type 3 or 4, GFO may be prudent. Further in vitro and in
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24 Vol. XLVII / No. One / 2021

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