ABSTRACT Objective: This work aims to evaluate the clinical efficacy of dental implantation combined with photodynamic therapy (PDT) in patients with tooth loss due to severe periodontitis. Methods: This study was a single-center, randomized controlled trial. Ninety patients with severe periodontitis–induced tooth loss were randomly allocated to the observation group (dental implantation combined with PDT) and the control group (dental implantation alone) (n=45 each). Primary outcome measures: periodontal parameters (PLI, SBI, PD, AL). Secondary outcome measures: detection rates of periodontal pathogens, inflammatory cytokine levels in gingival crevicular fluid (GCF), OHIP-14 scores, implant survival, and postoperative complication rates. Results: At 3 months postoperatively, both groups showed significant reductions in PLI, SBI, PD, AL, pathogen detection rates, and GCF IL-6, IL-8, and TNF-α levels, with more pronounced improvements in the observation group (all P < 0.05). OHIP-14 scores decreased in both groups, with lower values in the observation group (P < 0.05). At 3 months postoperatively, implant survival (100.0% vs. 97.7%) and complication rates (12.2% vs. 18.6%) did not differ significantly between groups (all P > 0.05). Conclusion: During the 3-month follow-up, compared with dental implantation alone, dental implantation combined with PDT improved periodontal status, reduced periodontal pathogens and GCF inflammatory factors, and enhanced oral health-related quality of life in patients with tooth loss due to severe periodontitis, while showing comparable implant survival and complication rates between the two approaches. This combined regimen demonstrated good safety and offers an effective therapeutic option for these patients, though long-term efficacy requires further observation.
ABSTRACT Background Periimplant soft tissue augmentation has been proposed to improve peri-implant tissue stability and influence marginal bone level (MBL) changes around dental implants. However, evidence comparing autogenous soft tissue grafts and soft tissue substitutes in delayed implant placement protocols remains limited. Objective This systematic review examined whether autogenous soft tissue grafts and soft tissue substitutes differ in their influence on marginal bone level changes beyond physiologic remodeling around delayed implants. The review addressed whether the two treatment approaches produce different marginal bone level outcomes. The null hypothesis was that no significant differences exist between treatment modalities. Materials and Methods MEDLINE (via PubMed) and manually identified studies were screened according to predefined eligibility criteria. Randomized controlled trials evaluating marginal bone level changes following peri-implant soft tissue augmentation in delayed implant protocols were included. Risk of bias was assessed, and quantitative synthesis was performed when sufficient data were available. Standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated, and heterogeneity was evaluated using the I² statistic. Results Among 1207 identified records, five randomized controlled trials met the inclusion criteria. The evaluated soft tissue substitutes included volume-stable collagen matrix, collagen matrix, and acellular dermal matrix. Two studies (40 patients per group) were eligible for meta-analysis. No significant difference in marginal bone level changes was observed between autogenous soft tissue grafts and soft tissue substitutes (SMD = 0.04; 95% CI, −0.48 to 0.39; P > .05). Heterogeneity was not detected (I² = 0%), and no subgroup effects were identified. The magnitude of the pooled effect suggested little clinical difference between the treatment approaches. Conclusion The available evidence does not indicate a significant difference in marginal bone level changes beyond physiologic remodeling between autogenous soft tissue grafts and soft tissue substitutes around delayed implants–the small number of eligible studies available for quantitative synthesis limits interpretation of these findings. Additional comparative studies are required to define better the relationship between soft tissue augmentation materials and peri-implant bone stability.
ABSTRACT This letter explores the variety of clinical complications attributed to dental implant placement, while focusing on peri-implantitis and implant periapical lesions. Through the presentation of a clinical case of a 60-year-old healthy male patient receiving an implant in the mandibular right first molar region (#46), this letter explains the occurrence, diagnosis, and management of this case. Despite successful initial placement of a 4.8 × 9 mm Astra EV implant with a primary stability of 25 Ncm and an ISQ of 74, radiographic evaluation at three months revealed a periapical radiolucency with reduced ISQ values, while soft tissues remained healthy and asymptomatic. The case discusses a form of retrograde peri-implantitis, with possible contributing etiological factors including previous remaining infections, overheating during osteotomy preparation, residual infections, bacterial contamination, and other potential local or systemic influences. Subsequently, a surgery involving full-thickness flap elevation, mechanical debridement of granulation tissue, implant surface decontamination using a titanium brush and chlorhexidine irrigation, followed by guided bone regeneration using xenograft particles and a resorbable membrane was performed. Three months after surgery, ISQ values increased to 84, and radiographic evaluation demonstrated absence of the periapical lesion, allowing for successful restoration and long-term stability at one- and two-year follow-ups. These findings highlight the importance of recognizing early signs of peri-implant complications and demonstrate that appropriate surgical intervention and follow-up can preserve implant stability and restore peri-implant bone support.
ABSTRACT Static computer-aided implant surgery (s-CAIS) is widely used for prosthetically driven implant placement; however, in free-end partial edentulism, surgical guides are often supported unilaterally by remaining teeth, which may compromise accuracy. This in vitro study evaluated the influence of surgical guide length and implant position on the trueness of implant placement in distal free-end partial edentulism. Sixty mandibular radiopaque models with distal edentulous spans (#28–31) were used. Surgical guides were designed with three tooth-supported lengths: short (#25–27), medium (#22–27), and long (#18–27). One implant was placed per model at site #28 or #30 (n = 10 per group). Planned and postoperative implant positions were superimposed using DICOM and STL data to assess angular deviation, 3D offset at the crest and apex, and vertical deviation. Two-way ANOVA with Tukey post hoc tests was performed; the sample size provided 80% power to detect clinically relevant linear (≥0.3–0.8 mm) and angular (≥3.1°) differences. Implants placed at site #30 using short guides exhibited the greatest deviations (angular: 5.7 ± 1.1°; crest offset: 1.28 ± 0.60 mm; apex offset: 2.1 ± 0.7 mm). In contrast, implants placed at site #28 using medium-length guides demonstrated the highest trueness (angular: 2.4 ± 1.2°; crest offset: 0.38 ± 0.13 mm; apex offset: 0.70 ± 0.30 mm; vertical deviation: 0.16 ± 0.15 mm). Implant location significantly affected all deviation outcomes (p < .001), and surgical guide length significantly influenced 3D offset at the crest and apex (p ≤ .005), with no interaction between factors. Both implant position and surgical guide length influence the trueness of implant placement in distal free-end sites. Although limited by its in vitro design, these findings suggest that extending tooth support without full-arch coverage may optimize accuracy in posterior guided implant surgery.
Abstract Objectives: Peri-implantitis (PI) is a complication that can gradually lead to implant loss if untreated. Primary diagnosing methods include clinical evaluation and conventional radiographs. Cone beam CT (CBCT) is especially useful for complex cases where superimposition on conventional radiographs is problematic. However, metal artifacts degrade image quality in CBCTs, which may result in missed early diagnoses of peri-implantitis (PI). This phantom study compares five CBCT devices with the metal artifact reduction method (MAR) when applicable, and conventional radiographs to detect PI defects. Methods: The phantom consists of two titanium (Ti) implants and two zirconia (Zr) implants placed in a Teflon block. A PI defect was drilled around one Ti and one Zr implant site. The phantom was employed with CBCT, and intraoral devices, obtaining 28 CBCT images, four panoramic images, and two intraoral images. MAR was used when applicable in the CBCT device. The visibility of the defects, the material between the implants, and the implant threads were analysed by three oral radiologists. Fleiss’ Kappa was used to assess overall agreement in evaluating implant defects. Results: The defect of the Zr implant could be identified in only 32% of the CBCT images. The defect of the Ti implant was identified in 71% of the CBCT images. False defects were observed in both the Zr and the Ti implants in the CBCT images. In most of the panoramic images (3 out of 4) and in all the intraoral images, the defects of the Zr and Ti implants were visible. No false defects were observed in the panoramic or intraoral images. Conclusions: Identifying the defect of a Zr implant is untrustworthy in CBCT images. According to the results, intraoral images are suggested when detailed information on the peri-implant condition is needed.
Zygomatic and pterygoid implants are essential tools in the rehabilitation of the severely atrophic maxilla, yet they often result in prosthetic emergence in unfavorable posterior or palatal locations. This article introduces a novel 2-piece zygoma extension system, available in straight and angled (12°, 20°, 25°) configurations, designed to redirect emergence to the alveolar crest with improved biomechanics and prosthetic accessibility. Three patients with varying degrees of maxillary atrophy underwent treatment using MegaGen BLUEDIAMOND implants combined with precision-milled titanium straight or angled extensions. Standardized surgical protocols were followed, with cone beam computerized tomography (CBCT)-based planning, intraoperative guide use, cortical engagement strategies, and immediate loading protocols. Across all cases, implants achieved high primary stability (70-80 Ncm), and extensions allowed prosthetic emergence in ideal posterior or second molar positions. Postoperative CBCT confirmed accurate implant placement, stable trajectories, and favorable abutment orientation. Immediate previsualization was successful in all patients with no intraoperative or early postoperative complications. The 2-piece zygoma extension system provides a safer, simpler, and more prosthetically advantageous alternative to conventional zygomatic and pterygoid approaches. Decoupling implant trajectory from prosthetic emergence expands treatment possibilities for complex maxillary atrophy and improves restorative outcomes.
Abstract Reduced peri-implant keratinized mucosa width (KMW), particularly when KMW < 2 mm and accompanied by brushing discomfort, plaque-control difficulty, or shallow vestibular anatomy, may complicate long-term implant maintenance. This report describes a 68-year-old man with an edentulous maxilla and markedly limited peri- implant KMW (0.5–1.0 mm) around four implants. Keratinized mucosa augmentation was performed using a combination of strip free gingival grafts (SGGs) and a xenogeneic collagen matrix (XCM). A screw-retained, implant-supported provisional prosthesis was adapted and relined with a soft relining material to serve as a postoperative splint to support graft stability and maintain vestibular depth. Healing was uneventful, and the patient reported acceptable postoperative comfort. At 6 months, descriptive clinical measurements showed a mean buccal KMW of 8.92 ± 0.42 mm across the four implants. Three-dimensional surface analysis showed a 26.2% reduction in the area of keratinized mucosa between 1 and 6 months. Within the limitations of a single case report, this approach appeared to be clinically feasible for postoperative splinting after combined SGG/XCM augmentation in an edentulous maxilla.
ABSTRACT A compromised extraction socket in the maxillary esthetic zone presents challenges for achieving predictable ridge preservation and soft-tissue stability. This case describes the management of a maxillary left central incisor with a history of endodontic and apical surgery, including alveolar ridge preservation, delayed implant placement, and soft-tissue augmentation, and evaluates dimensional changes using superimposition of intraoral scanner images. Following extraction, ridge preservation was performed with deproteinized bovine bone mineral and a collagen membrane. After 3 months of healing, the implant was placed with additional grafting, followed by the application of a volume-stable collagen matrix at second-stage surgery to enhance buccal contour and soft-tissue thickness. Intraoral scans were obtained at baseline and at 1, 3, 6, 12, and 18 months, and surface-distance changes at predefined regions of interest were assessed by digital superimposition. The greatest dimensional reduction occurred during the early healing period (baseline to 3 months). Yet ridge preservation effectively limited buccal contour loss despite compromised socket morphologythe collagen matrix produced localized buccal augmentation that remained stable for 18 months. Within the limitations of a single case, this combined approach supported ridge-contour maintenance and soft-tissue stability in a compromised socket. Intraoral scanner superimposition proved to be an effective, noninvasive method for monitoring dimensional changes over time.
ABSTRACT This randomized controlled clinical trial aimed to determine the post-restorative soft tissue changes associated with the minimally invasive vestibular access and conventional trapezoidal mucoperiosteal flap designs, while using an identical guided bone regeneration protocol to augment the defective buccal bone of type II sockets. The outcomes included midfacial mucosal level change, buccal bone plate changes, and the pink esthetic score after 6 months of implant loading with the final prosthetic placement. Twenty-two participants presenting with compromised class II fresh extraction sockets in the maxillary anterior region were treated with immediate implant placement using two flap designs (conventional trapezoidal mucoperiosteal and vestibular access). Peri-implant midfacial mucosal level changes, pink esthetic score, and buccal bone plate changes were evaluated 6 months after final prosthetic placement. Statistically significant differences in midfacial mucosal level change were observed between the groups (p = 0.02), while no statistically significant difference in pink esthetic score was found between the groups (p = 0.07). Regarding buccal bone plate changes, statistically significant gains in width were observed in both groups, with no statistically significant intergroup difference (p = 0.72). Soft tissue stability was statistically and clinically more favorable when using the minimally invasive vestibular access flap design compared with the conventional trapezoidal mucoperiosteal flap.
ABSTRACT Bone regeneration in critical-sized defects, such as knife-edge ridges, is considered a challenging reconstructive task in implant dentistry. In addition to the technical difficulty, these defects commonly require the use of autografts, which can lead to significant postoperative morbidity. To overcome these issues, a surgical device that allows 3D reconstructions, called the Barbell Technique, combined with stem cells derived from the palate periosteum, was used. This is the first report on the use of cells harvested from the palatal periosteum for this purpose. This report describes the use of the palate periosteum stem cells, mixed with a xenograft, in conjunction with the Barbell Technique® for bidirectional horizontal bone reconstruction of the anterior maxilla. Two months before the bone augmentation surgery, approximately 3mm 3 piece of soft tissue was harvested from the palate, with the aid of a disposable 3 mm diameter tissue punch. This tissue was transferred into a tube containing transport medium and delivered to the laboratory for periosteum stem cell isolation and culture, after discarding the epithelium and the connective tissue. Once the number of stem cells reached 6x10 6 , the cells were cryopreserved and later used in the graft surgery. After defrosting the cells (30 minutes), they were combined with the xenograft and compressed around the Barbell Technique® devices, thereby maintaining space for bone formation and reconstruction. The grafted area was covered with an occlusive collagen membrane, and the soft-tissue flap was advanced to enable primary closure. After 5 months, dental implants were placed, and after an additional 3 months for implant healing, an implant-supported prosthesis was delivered. This case report demonstrates bidirectional horizontal bone augmentation of a critical-size defect in the anterior maxilla, showing the possibility to overcome this challenging situation by using palate periosteum stem cell harvesting and the Barbell Technique® for space maintenance.
ABSTRACT Purpose Although type 2 diabetes mellitus (T2DM) has been associated with implant failure, evidence regarding its effect on peri-implant bone microarchitecture remains inconsistent. Therefore, this retrospective study aimed to quantitatively evaluate peri-implant bone microarchitecture in individuals with T2DM compared with systemically healthy controls using fractal analysis and radiomic features derived from panoramic radiographs. Methods Panoramic radiographs of 66 patients (164 implants) were retrospectively analyzed. Fractal dimension (FD) values were calculated from mesial and distal peri-implant regions using the White and Rudolph box-counting method, with measurements independently performed by two observers. Radiomic feature extraction was conducted by a single experienced investigator using 3D Slicer, and features were extracted via the PyRadiomics platform. Feature dimensionality was reduced using the least absolute shrinkage and selection operator (LASSO) algorithm. Group comparisons were performed using appropriate parametric or non-parametric statistical tests. All analyses were conducted at the implant level and interpreted as exploratory. A priori power analysis was performed using G*Power software. Results Mean FD values differed significantly between the T2DM and control groups in both mesial (p = 0.006; Cohens d = 0.45, 95% CI: 0.140.76) and distal (p = 0.024; Cohens d = 0.21, 95% CI: 0.020.40) peri-implant regions. No statistically significant differences were observed when maxillary and mandibular implants were analyzed separately (p > 0.05). Among 874 extracted radiomic features, 97 showed significant intergroup differences. Following LASSO-based feature selection, 16 radiomic features related to texture heterogeneity and intensity distribution were retained. Conclusions FA and radiomic analysis revealed modest but statistically significant differences in peri-implant bone texture characteristics between individuals with T2DM and healthy controls that may not be detectable by visual assessment alone. These findings should be interpreted as exploratory and hypothesis-generating, rather than predictive, and further longitudinal studies using three-dimensional imaging modalities are warranted to clarify their potential clinical relevance.
ABSTRACT Bisphosphonates are the drug class of choice for the treatment of bone resorptive diseases, directly affecting bone tissue. Oral rehabilitation with dental implants is fundamentally dependent on successful osseointegration. This study aimed to evaluate the mechanical properties of bone tissue formed around implants with different surface characteristics and to analyze the proteomic profile of bone formed around hydrophilic implants in animals treated with bisphosphonates. Building on prior work, the present investigation included sixty-four male rats allocated into two major groups: CG (systemically healthy controls) and BP (chronic sodium alendronate administration). Each group was subdivided according to implant surface (HFL – hydrophilic; HFB – hydrophobic) and experimental period (15 or 45 days). After euthanasia, tibiae were collected for nanoindentation testing, proteomic, and immunohistochemical analyses. No statistically significant differences were observed in hardness or elastic modulus between the experimental groups. However, substantial differences were observed in the abundance of proteins related to bone metabolism, including upregulation of histone H4, SPARC, and periostin in the early stages of osseointegration in the BP-HFL 15 day group. Despite differences in the proteomic profiles among experimental groups, their mechanical properties remained similar.
Abstract Medication-related osteonecrosis of the jaw (MRONJ) is a multi-factorial condition that is increasingly reported around dental implants in patients undergoing antiresorptive or antiangiogenic treatments. Although systemic risk factors are well established, the potential influence of local biomechanical factors, such as occlusal overload, has not been thoroughly studied. In this research, we examined the link between occlusal overload and peri-implant MRONJ. Patients diagnosed with peri-implant MRONJ underwent clinical and radiographic assessments, as well as computerized occlusal evaluations using the T-Scan III system. We analyzed key occlusal parameters, including relative occlusal force, load force discrepancy, and center of force movement, and compared these with clinical findings. The study included five patients. In all cases, MRONJ lesions were located in areas with high occlusal force. The patient with the highest asymmetry index (95.4%) also had the highest LOFD (97.7%) and the most extensive bone damage. Notably, several force imbalances detected by computerized analysis were not observable with traditional articulating paper. Despite the limitations of this small case series, the findings indicate that localized occlusal overload may relate to the appearance or progression of lesions in peri-implant MRONJ, but do not establish causation. Computerized occlusal analysis could be a helpful tool for identifying at-risk sites in vulnerable patients and developing personalized maintenance plans.
Abstract This study was conducted to evaluate the effect of titanium mesh exposure on the augmented bone volume and implant stability in patients undergoing guided bone regeneration with autogenous bone grafts. In this retrospective cohort study, 30 patients underwent alveolar ridge augmentation between 2013 and 2023; 2 patients were excluded for early postoperative infection, leaving 28 patients for analysis (exposed, n = 13; unexposed, n = 15). Approximately 5 months after augmentation, computed tomography was used to assess the augmented bone volume and density. Volumetric and linear measurements were performed, and implant stability quotients were recorded at the time of implant placement. Between-group comparisons were performed using appropriate parametric and nonparametric tests; the significance level was set to p < 0.05, and 95% confidence intervals were calculated. The augmented bone volume was significantly smaller in the exposed group than in the unexposed group ( p = 0.01; 95% CI, 0.23 to 0.81). The vertical and horizontal augmentation rates at 3 mm from the alveolar apex did not differ between groups ( p = 0.21; 95% CI, −0.90 to 0.18 and p = 0.39; 95% CI, −0.77 to 0.30, respectively). The mean computed tomography attenuation values and implant stability quotients were 497 ± 91 and 523 ± 87 Hounsfield units ( p = 0.64; 95% CI, –1.22 were placed successfully at all intended sites. Thus, titanium mesh exposure was associated with a significant reduction in three-dimensional augmented bone volume but no change in computed tomography density, primary implant stability, or linear augmentation metrics. Careful soft-tissue management to minimize exposure may help to optimize guided bone regeneration outcomes. This study has several limitations, including its retrospective design, small sample size, and single-center setting. Clinically, minimizing TiME exposure may help optimize bone augmentation outcomes, and further prospective studies are needed to confirm these findings.
ABSTRACT Medication-related osteonecrosis of the jaw (MRONJ) is a rare but serious complication linked to antiresorptive therapy. Although peri-implant MRONJ (PI-MRONJ) is considered uncommon, its early signs can appear as nonspecific peri-implant inflammatory changes, making diagnosis difficult. As implant therapy becomes more common in patients with osteoporosis and in cancer patients on high-dose antiresorptive medications, understanding how PI-MRONJ progresses in patients treated with denosumab (DMB) is crucial. This report describes two cases of PI-MRONJ in patients with different DMB histories. The first patient developed PI-MRONJ after only two doses of DMB for osteoporosis, with no prior bisphosphonate (BP) exposure. Implant placement occurred about one month after the last injection—at the time of maximal suppression of osteoclast activity—and was followed by ongoing peri-implant inflammation and rapid necrosis. This case differs from most previous reports, which usually involve longer or higher-dose antiresorptive use. The second patient had previous BP exposure, then three years of DMB therapy. After implant placement at a local clinic, the patient experienced persistent pain, swelling, and bleeding around the implant site, needing sequestrectomy and soft-tissue reconstruction. These cases highlight key clinical considerations: PI-MRONJ can develop even after short-term osteoporosis-dose DMB when implant surgery coincides with the drug’s peak effect. Furthermore, early PI-MRONJ may appear as peri-implant inflammation, making timely detection difficult. Therefore, clinicians should consider PI-MRONJ in the differential diagnosis when peri-implant inflammatory changes occur unusually. A thorough review of medical history, collaboration with prescribing physicians, and careful surgical planning are crucial to reduce risk and enable prompt intervention.
ABSTRACT Background: Dental implants, primarily made of titanium alloys, are widely used in restorative dentistry. However, their success can be compromised by metal ion release, which can lead to cytotoxicity, inflammation, and peri-implantitis. Comparative evidence on how implant–abutment materials influence these responses remains limited. Objective: To compare metal ion release and cytotoxic effects of Grade V titanium implants with titanium abutments versus titanium–zirconium implants with lithium disilicate (Emax) abutments on human gingival fibroblasts (HGFs). Methods: Six implants were divided into two groups: Grade V titanium with titanium abutments (Group A) and titanium–zirconium with lithium disilicate (Emax) abutments (Group B). Implants were immersed in cell culture medium for 7, 14, and 21 days. Metal ion concentrations (titanium [Ti], aluminum [Al], vanadium [V]) were measured using inductively coupled plasma mass spectrometry (ICP-MS), and cytotoxicity was assessed using the 3-(4,5 dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. Statistical analysis included analysis of variance (ANOVA) and effect size estimation. Results: Group A released significantly higher Ti and V levels than Group B (p < 0.001), with concentrations decreasing over time. Al release was higher in Group B at 21 days, potentially affecting cell responses. Cytotoxicity testing showed lower fibroblast viability in Group A, while Group B maintained higher proliferation and biocompatibility. Conclusion: Titanium–zirconium implants with lithium disilicate abutments release fewer cytotoxic ions and support better fibroblast viability, emphasizing the importance of material selection to reduce adverse peri-implant tissue responses.
The sinus lift procedure, first introduced in the 1970s to address insufficient bone height in the posterior maxilla for dental implants, has greatly evolved over the years. Traditional invasive techniques, such as the lateral window approach, posed a high risk of complications, including membrane perforation. Recent developments have led to the creation of the hydraulic sinus lift, introduced in 2005, which uses hydraulic pressure to gently lift the sinus membrane, lowering risks and increasing precision. Studies have shown its high success rates, minimal postoperative discomfort, and improved surgical outcomes. Innovations such as the crestal approach sinus kit have further improved the technique, allowing better control, faster surgeries, and improved implant stability. This review traces the history of sinus lift methods, focusing on hydraulic techniques, and discusses potential future improvements in tools and materials. As technology advances, these innovations are set to make sinus lift procedures safer, more effective, and more efficient, leading to better results for patients needing dental implants.
ABSTRACT Variations in prosthetic framework materials may influence the dissipation of compressive loads and their biomechanical repercussions on supporting bone, especially in posterior mandibular regions subjected to high masticatory demands. This study analyzed and compared minimum principal stresses (TMiP – compressive) in friable structures (cortical and medullary bone) using finite element analysis (ANSYS Workbench 10.0) to assess variations in framework materials among three-unit implant-supported fixed partial dentures (FPDs) with an intermediate pontic. The experimental groups were cobalt–chromium (CoCr), nickel–chromium (NiCr), titanium (Ti), zirconia (Zr), lithium disilicate (LD), type IV gold (Au), and acrylic resin (AR). The results showed that, based on regional stress patterns and average values, stiffer frameworks tended to be associated with slightly lower stress concentrations in cortical bone. Conversely, greater framework stiffness was associated with marginally higher localized stress values in medullary bone, although these differences were minimal and numerically small. Stresses developed in cortical bone were consistently higher than those in medullary bone and were mainly concentrated in the cervical region surrounding the implants, particularly the most posterior implant. In medullary bone, stress concentrations were predominantly observed in the apical implant region. It can be concluded that variation in framework material resulted in minimal differences in TMiP, except for acrylic resin, which presented slightly higher cortical bone stress values. Within the limitations of this simplified model, the stresses developed in the supporting bone tissue did not reach levels considered harmful to either cortical or medullary bone.
