Hanako Suenaga

A comparative study on complete and implant retained denture treatments – A biomechanics perspective

Although implant-retained overdenture allows edentulous patients to take higher occlusal forces than the conventional complete dentures, the biomechanical influences have not been explored yet. Clinically, there is limited knowledge and means for predicting localized bone remodelling after denture treatment with and without implant support. By using finite element (FE) analysis, this article provides an in-silico approach to exploring the treatment effects on the oral mucosa and potential resorption of residual ridge under three different denture configurations in a patient-specific manner. Based on cone beam computerized tomography (CBCT) scans, a 3D heterogeneous FE model was created; and the supportive tissue, mucosa, was characterized as a hyperelastic material. A measured occlusal load (63N) was applied onto three virtual models, namely complete denture, two and four implant-retained overdentures. Clinically, the bone resorption was measured after one year in the two implant-retained overdenture treatment. Despite the improved stability and enhanced masticatory function, the implant-retained overdentures demonstrated higher hydrostatic stress in mucosa (43.6kPa and 39.9kPa for two and four implants) at the posterior ends of the mandible due to the cantilever effect, than the complete denture (33.4kPa). Hydrostatic pressure in the mucosa signifies a critical indicator and can be correlated with clinically measured bone resorption, pointing to severer mandibular ridge resorption posteriorly with implant-retained overdentures. This study provides a biomechanical basis for denture treatment planning to improve long-term outcomes with minimal residual ridge resorption.

Development of in vivo measuring system of the pressure distribution under the denture base of removable partial denture

PURPOSE To develop a system to measure the pressure distribution under the base of a removable partial denture (RPD) and to apply it in vivo. METHODS A tactile sensor sheet with 100 sensing points and a measuring system (I-SCAN, Nitta, Osaka, Japan) were used. The sensor was calibrated before being applied in vivo. A subject with a mandibular RPD (Kennedy class II, division 1) participated in this study, and the RPD was duplicated as the experimental denture. The basal surface at distal extension was accommodated to the sensor in a manner similar to direct relining. Measurements were performed with three patterns of occlusal rest design (mesial and distal rests, mesial rest only, and without a rest) during maximal voluntary clenching (MVC) and gum chewing. RESULTS The calibration measurements showed that the output value from each sensing point and total output of sensing points were positively correlated with the applied load. The pressures recorded in vivo varied depending on the locations of sensing points on the basal surface of the denture. During MVC the pressure distribution changed with the clenching level, and the highest pressure was registered near the residual ridge crest. The pressure distribution also changed according to the number of occlusal rests. The load center shifted about 2mm during MVC and about 4mm during gum chewing. CONCLUSION The measuring system developed here enabled us to measure the pressure distribution under the denture base of RPD. The pressure distribution varied along with the design of the occlusal rest.

Deterioration of polymethyl methacrylate dentures in the oral cavity

Polymethyl methacrylate (PMMA)-made prostheses used in the oral cavity were evaluated by multimodal assessment in order to elucidate the biodeterioration of PMMA. In used dentures (UD), the micro-Vickers hardness of the polished denture surface and denture basal surface was lower than that of the torn surface (p<0.05), whereas the shaved surface approximately 100 µm from the polished surface showed a similar value to the torn surface. By contrast, there were no differences among these surfaces in new resin (NR). The volatile content of UD was higher than that of NR (p<0.05). Component analysis by ATR-FTIR showed specific spectra (1,700-1,400 cm(-1)) only in UD. This study revealed that PMMA deteriorated during long-term use in the oral cavity in terms of hardness and volatile content with component alteration, and suggests the involvement of biodeterioration, possibly due to saliva and oral microbiota.

Shape Optimization for Additive Manufacturing of Removable Partial Dentures - A New Paradigm for Prosthetic CAD/CAM

With ever-growing aging population and demand for denture treatments, pressure-induced mucosa lesion and residual ridge resorption remain main sources of clinical complications. Conventional denture design and fabrication are challenged for its labor and experience intensity, urgently necessitating an automatic procedure. This study aims to develop a fully automatic procedure enabling shape optimization and additive manufacturing of removable partial dentures (RPD), to maximize the uniformity of contact pressure distribution on the mucosa, thereby reducing associated clinical complications. A 3D heterogeneous finite element (FE) model was constructed from CT scan, and the critical tissue of mucosa was modeled as a hyperelastic material from in vivo clinical data. A contact shape optimization algorithm was developed based on the bi-directional evolutionary structural optimization (BESO) technique. Both initial and optimized dentures were prototyped by 3D printing technology and evaluated with in vitro tests. Through the optimization, the peak contact pressure was reduced by 70%, and the uniformity was improved by 63%. In vitro tests verified the effectiveness of this procedure, and the hydrostatic pressure induced in the mucosa is well below clinical pressure-pain thresholds (PPT), potentially lessening risk of residual ridge resorption. This proposed computational optimization and additive fabrication procedure provides a novel method for fast denture design and adjustment at low cost, with quantitative guidelines and computer aided design and manufacturing (CAD/CAM) for a specific patient. The integration of digitalized modeling, computational optimization, and free-form fabrication enables more efficient clinical adaptation. The customized optimal denture design is expected to minimize pain/discomfort and potentially reduce long-term residual ridge resorption.

Mechanobiological Bone Reaction Quantified by Positron Emission Tomography

While nuclear medicine has been proven clinically effective for examination of the change in bone turnover as a result of stress injury, quantitative correlation between tracer uptake and mechanical stimulation in the human jawbone remains unclear. This study aimed to investigate the relationship between bone metabolism observed by 18F-fluoride positron emission tomography (PET) images and mechanical stimuli obtained by finite element analysis (FEA) in the residual ridge induced by the insertion of a removable partial denture (RPD). An 18F-fluoride PET/CT (computerized tomography) scan was performed to assess the change of bone metabolism in the residual ridge under the denture before and after RPD treatment. Corresponding patient-specific 3D finite element (FE) models were created from CT images. Boundary conditions were prescribed by the modeling of condylar contacts, and muscular forces were derived from the occlusal forces measured in vivo to generate mechanobiological reactions. Different mechanobiological stimuli, e.g., equivalent von Mises stress (VMS), equivalent strain (EQV), and strain energy density (SED), determined from nonlinear FEA, were quantified and compared with the standardized uptake values (SUVs) of PET. Application of increased occlusal force after RPD insertion induced higher mechanical stimuli in the residual bone. Accordingly, SUV increased in the region of residual ridge with higher mechanical stimuli. Thus, with SUV, a clear correlation was observed with VMS and SED in the cancellous bone, especially after RPD insertion (R2 > 0.8, P < 0.001). This study revealed a good correlation between bone metabolism and mechanical stimuli induced by RPD insertion. From this patient-specific study, it was shown that metabolic change detected by PET in the loaded bone, in a much shorter duration than conventional x-ray assessment, is associated with mechanical stimuli. The nondestructive nature of PET/CT scans and FEA could potentially provide a new method for clinical examination and monitoring of prosthetically driven bone remodeling.

Bone metabolism of residual ridge beneath the denture base of an RPD observed using NaF-PET/CT

PATIENT A 66-year-old woman, who had a bilateral free-end edentulous mandible and no experience with dentures, was examined for the chief complaint of masticatory dysfunction on left side of dental arch. A unilateral distal extension removable partial denture (RPD) replacing lower-left molars was selected. Tomographic images were obtained using Fluorine-18 NaF positron emission computerized tomography (NaF-PET)/computed tomography (CT) before the RPD use and at 1, 6, and 13 weeks after the RPD use to observe the metabolic changes in residual bone caused by the RPD use. PET standardized uptake values (SUVs) and CT values were calculated for lower-left edentulous site (test side) and lower-right edentulous site (control side). As a result, SUVs on the control side remained static after the RPD use, whereas those on the test side increased at 1 and 6 weeks after the RPD use and then decreased. However, CT images showed no obvious changes in the bone shape and structure beneath RPD, and CT values both on the control and test sides did not change either. DISCUSSION This report shows that NaF-PET could detect bone metabolic changes soon after the RPD use, which cannot be detected by clinical X-rays. The SUV changes may be a mechanobiological reaction to the pressure due to the RPD use, and wearing of the RPD may increase the bone turnover beneath denture. CONCLUSION This report demonstrates that wearing of an RPD increases bone turnover beneath denture immediately after the RPD use without clinically detectable changes in bone structure or volume.

Effects of occlusal rest design on pressure distribution beneath the denture base of a distal extension removable partial denture-an in vivo study.

This study aimed to investigate the pressure distribution beneath the denture bases of removable partial dentures (RPDs) with different occlusal rest designs (ORDs) by in vivo measurement. Four types of detachable occlusal rests (mesial and distal, distal, mesial, and nonrest) were placed on the direct abutment teeth of distal extension RPDs in four patients with free-end edentulous mandibles. Pressure measurements were obtained by using thin and flexible tactile sensors. The results showed significant variances with different ORDs in all four patients (P < .05), leading to the conclusion that the pressure distribution on the residual ridge beneath the RPD base was dependent on the ORD.

Determination of oral mucosal Poisson's ratio and coefficient of friction from in-vivo contact pressure measurements

Despite their considerable importance to biomechanics, there are no existing methods available to directly measure apparent Poisson’s ratio and friction coefficient of oral mucosa. This study aimed to develop an inverse procedure to determine these two biomechanical parameters by utilizing in vivo experiment of contact pressure between partial denture and beneath mucosa through nonlinear finite element (FE) analysis and surrogate response surface (RS) modelling technique. First, the in vivo denture–mucosa contact pressure was measured by a tactile electronic sensing sheet. Second, a 3D FE model was constructed based on the patient CT images. Third, a range of apparent Poisson’s ratios and the coefficients of friction from literature was considered as the design variables in a series of FE runs for constructing a RS surrogate model. Finally, the discrepancy between computed in silico and measured in vivo results was minimized to identify the best matching Poisson’s ratio and coefficient of friction. The established non-invasive methodology was demonstrated effective to identify such biomechanical parameters of oral mucosa and can be potentially used for determining the biomaterial properties of other soft biological tissues.

Validate Mandible Finite Element Model under Removable Partial Denture (RPD) with In Vivo Pressure Measurement

This study aims to analyze the functional contact pressure induced by Removable Partial Denture (RPD) by using a 3D finite element (FE) model constructed based on patient specific CT scans. This model was validated against the in vivo test results. The outcomes demonstrate that the finite element simulation has the capability of quantifying localized stress distribution in a complicated denture-mucosa contact problem, with a reasonable matching to clinical measurements of occlusal force and pressure distribution. The methodology is of considerable clinical implication to improve the long term outcomes of the denture treatment.

Comparing Contact Pressure Induced by a Conventional Complete Denture and an Implant-Retained Overdenture

Implant-retained overdenture has been widely applied as a solution to edentulous ageing; however, a major concern for the denture wearers is bone resorption induced by the prosthetic interaction with soft tissue and bone. Early studies have revealed that the bone resorption is associated with the disturbance to the mucosa blood flow. This study aimed to investigate the contact pressure induced by an implant-retained overdenture, compared to a conventional complete denture without implants, which implies the potential bone resorption for clinical investigation. A three-dimensional finite element model of a full jaw, including mandible bone, mucosa, and denture, was created through a reverse engineering method based on CBCT images, in which the hyperelastic behaviour of mucosa was determined by curve-fitting to the clinical measurement, for a more realistic response. It is found that the location of the bone loss differed between the implant retained and non-implant complete dentures. With the implants, the denture displaced more at posterior ends towards the mucosa bearing area, leading to higher contact pressure accounted for more severe local bone loss.