Finite Element Analysis of Subperiosteal Implants: A Systematic Review of Biomechanical Performance and Stress Distribution

Vincenzo Ronsivalle, Paola Lo Giudice, Simona Santonocito, Salvatore Bocchieri, Roberta Giudice, Salvatore Battaglia, Salvatore Crimi, Alberto Bianchi, Marco Cicciù

Full text link: https://pubmed.ncbi.nlm.nih.gov/40399179/

Finite Element Analysis of Subperiosteal Implants: A Systematic Review of Biomechanical Performance and Stress Distribution

1. Scientific Reference

• Study title: Finite element method of subperiosteal implants: a systematic review on biomechanical performance and stress distribution
• Authors: Vincenzo Ronsivalle, Paola Lo Giudice, Simona Santonocito, Salvatore Bocchieri, Roberta Giudice, Salvatore Battaglia, Salvatore Crimi, Alberto Bianchi, Marco Cicciù
• Journal: Journal of Cranio-Maxillofacial Surgery
• Year: 2025
• DOI: 10.1016/j.jcms.2025.04.018

2. Scientific Background

Managing patients with severe jaw atrophy remains one of the greatest challenges in implant dentistry and oral surgery. In cases where residual bone volume is insufficient for conventional dental implants, treatment often requires alternative reconstructive strategies. Modern subperiosteal implants, manufactured through digital workflows that integrate CBCT imaging, CAD/CAM design, and additive manufacturing, have re-emerged as a potential solution for these complex clinical situations.

Alongside these technological advances, finite element method (FEM) analysis has become an important research tool for investigating the biomechanical behavior of implant-supported rehabilitations before clinical application. By simulating stress transmission and structural deformation under functional loading, FEM provides valuable insight into implant design optimization. This systematic review consolidates current evidence from computational studies evaluating the biomechanical performance of subperiosteal implants, with particular emphasis on stress distribution and comparisons with conventional implant systems.

3. Study Objective

The primary objective of this systematic review was to evaluate finite element studies investigating the biomechanical behavior of subperiosteal implants. The authors aimed to determine how these patient-specific implants distribute mechanical stresses under loading conditions and to compare their biomechanical performance with that of conventional endosseous implants used for rehabilitation of severely atrophic jaws.

4. Methodology

This investigation was designed as a systematic review conducted according to PRISMA guidelines. Electronic searches were performed in Web of Science, PubMed, Scopus, and Lilacs through February 2025.

Only studies using finite element analysis to assess stress distribution in subperiosteal implants were eligible for inclusion. Twelve studies fulfilled the selection criteria. Risk of bias was evaluated using an adaptation of the ROBINS-I tool specifically designed for in silico investigations. The abstract does not provide additional methodological details regarding model standardization, loading protocols, or inclusion criteria beyond those described.

5. Main Findings

The available computational evidence consistently indicates that subperiosteal implants tend to distribute mechanical stresses more evenly than conventional implant systems. Across the included FEM simulations, lower stress concentrations were observed at the bone–implant interface, suggesting a more favorable biomechanical load transfer.

The review also found that dual-configuration implant designs demonstrated superior biomechanical stability compared with alternative configurations. Implant performance was influenced by several design-related variables, including construction material (such as titanium or PEEK), fixation with screws, and implant thickness. In addition, oblique loading conditions generated greater implant displacement than axial loading, highlighting the influence of loading direction on mechanical behavior.

6. Clinical Interpretation

Rather than providing direct clinical outcomes, this review offers an overview of the current biomechanical evidence supporting digitally designed subperiosteal implants. The findings suggest that customized implant frameworks may improve load distribution in patients with severe jaw atrophy, potentially reducing localized stress concentrations that could compromise mechanical performance.

From a clinical perspective, the review emphasizes the importance of implant design optimization. Material selection, structural thickness, and fixation strategy appear to play significant roles in determining biomechanical stability, indicating that successful rehabilitation depends not only on the concept of subperiosteal implantation but also on engineering considerations during digital planning and manufacturing.

Nevertheless, these findings should be interpreted cautiously. All included studies were based on computational simulations rather than clinical investigations. Consequently, the reported biomechanical advantages cannot be directly translated into improved implant survival, reduced biological complications, or superior long-term clinical outcomes. The authors therefore stress the need for standardized finite element methodologies and well-designed clinical studies to validate these computational observations before broader clinical conclusions can be drawn.

7. Clinical Applications

The findings summarized in this review may assist clinicians and researchers involved in the rehabilitation of patients with severe maxillary or mandibular atrophy, particularly when conventional implant placement is not feasible. The review supports the role of digital implant planning, CAD/CAM workflows, CBCT-based customization, and biomechanical simulation in the development of patient-specific subperiosteal implants.

In addition, the reported biomechanical observations may help guide future optimization of implant geometry, fixation methods, and material selection. However, the current evidence does not support definitive clinical recommendations regarding treatment protocols or superiority over alternative implant rehabilitation strategies.

8. Level of Evidence, Limitations, and Transparency

This publication is a systematic review of in silico finite element studies. While systematic reviews generally provide a relatively high level of evidence, the overall strength of the conclusions is inherently limited by the computational nature of the included investigations rather than clinical outcome data.

The authors acknowledge the need for standardized FEM methodologies and prospective clinical validation to confirm the long-term relevance of the observed biomechanical behavior. Additional methodological limitations are not detailed within the available abstract.

No conflicts of interest or financial relationships with implant manufacturers are reported in the information provided.

9. Key Study Highlights

• Study type: Systematic review
• Level of evidence: Systematic review of finite element (in silico) studies
• Number of studies included: 12
• Number of patients or implants: Not specified in the available information
• Follow-up period: Not specified in the available information
• Primary outcome: Biomechanical performance and stress distribution of subperiosteal implants
• Main finding: FEM simulations demonstrated more homogeneous stress distribution and improved biomechanical stability for certain subperiosteal implant configurations.
• Scientific conclusion: Subperiosteal implants represent a promising option for rehabilitation of severely atrophic jaws, although clinical validation remains necessary.
• Limitations: Evidence is based exclusively on computational simulations; standardized FEM protocols and clinical studies are still required.

10. Scientific Impact

This systematic review provides an updated synthesis of finite element evidence concerning customized subperiosteal implants and their biomechanical behavior in challenging implant rehabilitation scenarios. Rather than introducing new clinical outcome data, it consolidates current computational knowledge regarding stress distribution and structural performance in digitally manufactured implant frameworks.

The review also identifies critical design variables—including implant material, thickness, fixation strategy, and loading direction—that may influence mechanical stability. By highlighting these parameters, the study contributes to the ongoing refinement of patient-specific implant design and supports future research aimed at bridging computational modeling with clinical validation. Ultimately, it reinforces the growing role of digital engineering and biomechanical simulation in contemporary implant dentistry while emphasizing that long-term clinical evidence remains essential before these findings can be fully translated into routine practice.

11. Editorial Conclusion

This systematic review underscores the value of finite element analysis as a powerful research tool for evaluating the biomechanical behavior of modern subperiosteal implants in patients with severe jaw atrophy. The available computational evidence suggests favorable stress distribution characteristics and identifies several design factors that influence mechanical performance. However, because the conclusions are derived exclusively from simulation studies, their clinical significance should be interpreted with caution until supported by standardized methodologies and robust long-term clinical investigations.