The impact of bite force on the stability of dental implants

Nawres Bahaa Mohammed; Zina Ali Daily; Mohammed Rhael Ali; Noor Fathi Kazim; Hashim Mueen Hussein; Athraa Ali Mahmood

doi:10.1371/journal.pone.0340355

. 2026 Jan 20;21(1):e0340355. doi: 10.1371/journal.pone.0340355

The impact of bite force on the stability of dental implants

Nawres Bahaa Mohammed ¹, Zina Ali Daily ², Mohammed Rhael Ali ³, Noor Fathi Kazim ⁴, Hashim Mueen Hussein ^5,^*, Athraa Ali Mahmood ⁶

Editor: Antonio Riveiro Rodríguez⁷

PMCID: PMC12818635 PMID: 41557632

Abstract

Background

Since dental implants (DI) are endo-osseous implants that are inserted into the bone and periodontium, which ultimately support the occlusal load, a patient’s bite force (BF) may overburden the supporting DI, leading to bone loss and DI failure. The purposes of this study were to explore the effect of the BF on DIs in different locations of jaws, of both genders during three visits, to investigate DI stability in different locations of jaws, of both genders during three visits, and to assess the association of BF and DI stability(ISQ) with the influence of variables (time, implant location, and gender).

Methods

The current cohort study involved 80 individuals of both genders who had lost some teeth and needed DIs for the anterior and posterior regions of the jaws. After the insertion of the DIs, their BF was examined by the Loadstar™ sensor, and the DI stability was monitored at three visits of these individuals. First visit during the day of insertion of the crown on the abutment of the implant (immediately loading), second visit at six months following insertion, and third visit after 18 months following insertion.

Results

The data on the anterior and posterior bite forces (BFs) for the male and female participants after the insertion of the DIs were analysed at three visits. On average, the males exhibited a significantly higher posterior BF compared to the females at the respective three visits. Similarly, the average posterior ISQ in the males was significantly increased than in the females at the respective three visits. Results of the two-way ANOVA of all groups for the implant BF and ISQ values were significantly influenced by the interaction of time, locations of the implants, and gender. The association between the BF and DI stability was significant in using the difference in the regression coefficient (b), which was impacted by time, implant location, and gender.

Conclusions

This study found the significantly complex interaction of factors (time, location, gender) influencing on change of BF and ISQ, by affecting the process of ossteointegration. The significantly higher BF in the posterior regions of males, and significantly greater stability of DIs, could have a potential role in the best DIs therapy. In addition, the association of the BF and DI stability is significantly established with the most important factors influencing the change in BF and DI stability. It varies in a dynamic manner as the interface between the bone and the implant matures, and the patient’s gender, time, and anatomical location all play a significant role in its context. The DIs that are loaded early is dependent on the BF. The BF may be crucial in determining the best DI stability.

Introduction

Dental implants (DIs) have become a popular and effective option for replacing missing teeth [1,2]. One of the most important factors that affects the success of DIs is the occlusal force (OF) or the force that is applied to the DI by opposing teeth during biting and chewing [3,4]. The bite force (BF) can have both positive and negative effects on the DI, depending on the amount and direction of the force [5,6]. Early loading of a DI, which involves placing the DI rapidly after surgery, is significantly popular in the field of DI dentistry [7]. Several studies indicate that initiating early loading with a carefully regulated OF can improve the process of osseointegration and result in favourable results for the DI [8–10]. Nevertheless, an excessive or unregulated BF can lead to the failure of the DI, bone resorption, and fracture of the DI. The impact of the BF on an early-loaded DI can be influenced by several factors, including the DI design, DI site, bone quality, and the nature and intensity of the BF [11]. Dental implants (DIs) inserted into soft bones are more prone to injury due to the BF compared to those inserted into thick bones [12,13]. Applying a regulated amount of pressure on the teeth can improve the integration of the DI with the surrounding bone and increase the chances of a good outcome. However, an excessive or unregulated force might cause the DI to fail and lead to bone loss [14].

Bite force (BF) is the pressure applied by the jaws while chewing and biting. It is impacted by variables such as the quantity and arrangement of the teeth, the force exerted by the muscles involved, and the general oral well-being of an individual. An optimal BF is essential for effective chewing and ensuring the durability of dental restorations, such as DIs. It differs from person to person and greatly impacts the DI system [15,16]. The DI abutment transmits the BF to the DI, which in turn transfers it to the crown denture or other prosthetic parts. It is crucial to assess and take into consideration the BF when planning and creating DI-supported restorations [17].

The BF is determined by several factors, including the characteristics relating to the patient and the prosthesis. The factors that are dependent on the patient are the patient’s age, gender, occlusal habits, parafunctional behaviours, such as teeth grinding, and overall health of the stomatognathic system [18–20], while the prosthesis-related factors include the design, material, occlusal arrangement, and number of teeth supported by the DI [21]. A restored DI transmits multidirectional forces that alter the amount of axial, nonaxial, and transversal loads throughout the chewing process and movements of the jaw, affecting the connection between the DI and the bone [22]. Modifications to the design of the neck of the DI, which give rise to bone reabsorption, often take place in this area of highly concentrated mechanical forces [23]. The changes made to the neck of the DI are intended to lessen pressures like the forces of tension and shear in the cortical area [24,25].

While DIs offer numerous benefits, such as improved aesthetics and functionality [26,27]. The correlation of the BF with the DI stability is undetected until now. The research question is the BF associated with the stability of DIs. This study aims to explore the effect of the BF on DIs in different locations of jaws, of both genders, during three visits, to investigate DI stability in different locations of jaws, of both genders, during three visits, and to assess the association of BF and DI with the influence of variables (time, implant location, and gender). The hypothesis is that there was a change in BF and ISQ of DIs during 18 months, followed insertion of the crown on the abutment of the implant. The null hypothesis is that there was no change in BF and ISQ of DIs during 18 months, following the insertion of the crown on the abutment of the implant.

Materials and methods

Study design, this cohort study used a prospective approach to analyse the clinical information and records of a group of patients who needed DI placements between February 2021 to June 2024. All procedures performed in this study involving human participants were in accordance with the Declaration of Helsinki and its later amendments for human research. The study was conducted in accordance with and approved by the Ethics Committee of the College of Dentistry, University of Al-Ameed, Iraq (#52017, 20 February/2021). Written informed consent was obtained from all subjects and/or their legal guardian (s), where all adult participants entered the study after they received full information about the nature, aims, processes of the study, data sharing, the anonymization of participants in deposited data and publication of raw data (without containing the name of participants) before signing an informed written Consent form. The current study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines in terms of the study design and reporting of results.

Sample size power analysis

The sample size, calculated by G power, comprised 18 individuals in each group at a power of 80 and an α probability of 0.05 that it depended on the pilot study resulting of 12 patients with DIs placed, three in each group (3 patients placed DIs for anterior regions of male, 3 patients placed DIs for posterior regions of male, 3 patients placed DIs for anterior regions of female and 3 patients placed DIs for posterior regions of female) that BF and ISQ measured during three visited interval (first visit during the day of insertion of the crown on the abutment of the implant (immediately loading), second visit at six months following insertion, and third visit after 18 months following insertion. Then the data was analyzed and resulting in a significant effect size of F at 0.4, and four groups. The total number of participants was around 80 to avoid patient dropouts, and these were divided into four groups. 80 individuals of both genders who had lost some teeth and needed DIs for the anterior and posterior regions of the jaws.

Study population

The study included 80 patients at the Maxillofacial Surgery Department of the Dentistry College at the University of Al-Ameed who needed DIs during the study period, with three follow-up visits. First visit during the day of insertion of the crown on the abutment of the implant (immediately loading), second visit at six months following insertion, and third visit after 18 months following insertion. The inclusion criteria were male and female patients aged 25–40 years, who had sufficient bone volume for DI placements instead missing number of natural teeth and had natural occlusions, opposed natural teeth should present to implants that needed inserting, understood and signed an informed consent form, and were followed up at postoperative visits. Patients with a history of systemic diseases affecting bone metabolism, periodontitis, cigarette smoking, or drinking alcohol were excluded from the study. Moreover, the exclusion criteria included: they had missing permanent teeth which replaced by an implant, and a restoration with a crown of opposing occlusion, delayed loading, and parafunctional habits.

Data collection

State data structure, subjects measured at 3 time points; BF and ISQ measured at the anterior/posterior area; gender as a between-subjects factor. Relevant clinical information, such as the patient’s characteristics after placement with a DI by a specialist, medical background, X-ray pictures, and scans of the inside of the mouth, was obtained from the computerised medical records and documents of the patient. A Loadstar™ sensor was used to collect the BF values of posterior and anterior implant areas [28]. This sensor offers various force-measuring solutions with updated data rates of up to 50 KHz, making it suitable for applications that require the BF to be noted soon after the operation and during consultation intervals. Regular monitoring of the BF and DI stability was crucial in the post-implantation phase. Loadstar™ sensor records were utilised to assess the OF and identify any abnormalities or imbalances. While Osstell Implant Stability Quotient (ISQ) technology was used to evaluate the DI stability by examining the resonance frequency of the DI. The patients were also educated on proper oral hygiene practices, including avoiding excessive BF on the DI, maintaining regular dental visits, and promptly addressing any signs of discomfort or changes in the bite. The data availability was presented in supporting information files.

Dental Implant (DI) characteristics

Information on the DIs of the research population, which were specifically manufactured by Straumann and Medintika (Straumann® Dental Implant System, USA, Medintika® Dental Implant, Germany), was carefully recorded, including their size (4.0*10, 3.5*11, 3.3*10, or 3.8*9), surface features, and prosthetic elements. Any alterations to the shape of the DI by modifications to the design of the neck of the DI or the process of surgery for improving the spread of the load and enhancing the stability were observed.

Surgical procedure

The implants distributed were placed in the anterior and posterior regions of the jaws (Table 1). Following dental cone-beam computed tomography (CBCT), the quantity and quality of bone were assessed, and a stent was created for implantation at the proper location for each patient. No bone augmentation treatment was used throughout the implant placement process. As instructed by the manufacturer, the location was drilled using a point Lindemann drill first, then surgical drills. A skilled researcher meticulously drilled every dental implant bed at a consistent length and angles in order to produce comparable insertion torque values (ITV) of about 35 Ncm amongst the implants. A drilling machine specifically made for implant surgery was used for measuring ITV as much as 35 Ncm at around 20 rpm and 8 Hz. The drill unit’s handpiece was the only tool used to put each implant. Following surgery, CBCT was utilized to assess the integrity of the osseous tissue surrounding the implant [28].

Table 1. Demographic data.

Variables in groups	DIs for the anterior regions of males	DIs for the posterior regions of males	DIs for the anterior regions of females	DIs for the posterior regions of females	p value
Number of patients (total)	20	20	20	20	0.11
Age	35	37	36	34	0.18
Gender	20	20	20	20	0.21
Number of implants (total)	45	76	43	71	0.79
Implant diameter
3.3 mm	8	10	7	12	0.122
3.5 mm	19	22	23	21	0.084
3.8 mm	14	24	11	30	0.056
4 mm	4	20	2	8	0.077
Length
9 mm	13	49	15	42	0.095
10 mm	25	22	19	23	0.082
11 mm	7	5	9	6	0.112

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Significant (p-values ≤ .05), non-significant (p-values > 05).

Bite Force (BF) assessment

Bite force (BF) assessments were acquired utilising a Loadstar™ sensor (Loadstar sensor, DI-100U,16-bit load cell interface, Fremont, California) (Fig 1), which offers various force measurement devices with updated data rates of up to 50 KHz. This capability might be advantageous for applications such as failure-strength testing or material characterisation. The BF values were tested within the range of 100–400 N at particular time intervals. This systematic method was observed to guarantee standardization and dependability in the assessment of the BF. The protocol of maximum bite force estimation. The individual was told to sit on a dental seat without a head support, erect, comfortable, and unstrained. A Loadstar sensor was used for determining the maximum force of biting (MBF) and vertically inter-occlusal BF on both sides. A USB cable is used to link the sensor to the PC. The first molars region (right and left) was where the load sensor was placed horizontally. Participants were instructed to bite as heavily as they could onto the load sensor for a brief period of time. A new record—the greatest—was established every second. Ten measurements of the recording table were selected. This method was performed three times on both sides, separated by two minutes, and the average result for every side was obtained as MBF. We calculated the maximal BF in Newtons [29]. The reliability of measurements was estimated by intra-operator evaluation and repeated test with the method of MBF.

Stability measurements

The method for monitoring implant stability during healing and immediately loading is based on resonance frequency analysis (RFA) applied to the implant–bone interface. Devices using this method contain a transducer peg, which is connected to the implant and excited by magnetic waves over a range of frequencies. The frequency of the resultant vibration is automatically translated into an index called the implant stability quotient (ISQ), with values ranging between 0 and 100. The RFA values are a measure of the deflection of the implant–bone complex by the lateral forces applied by the transducer and reflect the multidirectional fixation strength. The stability of each implant (one measurement from each of the 3 different directions) was measured with the Osstell (Integration Diagnostics AB, Göteborg, Sweden). The Osstell system is a magnetic detection device. RFA devices after the transducer (Smartpeg) was screwed to the implant to obtain the ISQ. The protocol of measurement of DI stability, an experienced, right-handed investigator, assessed the ISQ. ISQ was assessed using the Osstell in order to keep the fixing force of the implant from altering when the healing abutment was being installed and released. The smart peg was manually attached to the implant fixture in order to use the Osstell ISQ Mentor for evaluation. Every equipment was operated in compliance with the guidelines provided by the manufacturer. The Osstell ISQ mentor’s manufacturer advises holding the gadget tip at a 45-degree angle and close (2.0–4.0 mm) to the smart peg surface, avoiding contact with it. The implants in each location were evaluated one after the other since testing a single implant twice could increase the precision of measurements. After the measurements with the Osstell ISQ Mentor, healing abutments were connected to the implant with 30 Ncm torque, using a torque ratchet, by selecting a height that could expose about 2.0 mm from the gingival level [30].

Outcome measures

The main objective of the study was to determine the relationship between the BF and the stability of DIs during the 18 months that followed. The secondary outcomes included the influence of time, gender, and the DI location in the jaws on the BF and the DI stability.

Statistical analyses

Descriptive statistics through GraphPad® Prism 9.5.1 were used to summarize the patient demographics, BF measurements, and DI stability measurements. The normality of distribution (parametric) was significantly result by used the Shapiro–Wilk. The parametric data was analyzed. Then the continuous variables were expressed as the mean standard deviation (±), while the categorical variables were presented as frequencies and percentages. Comparative analyses, such as an analysis of variance (One-Way Repeated-Measures ANOVA), were performed to assess differences in the BF and DI stability in males and females at the anterior and posterior areas of the jaws among three postoperative time points. The two-way and three-way ANOVA of all groups for the implant BF and ISQ values between the time, locations of the implants, and gender. The sphericity (Mauchly) and handling of violations (Greenhouse-Geisser) were employed. For comparisons between more than two groups, the Bonferroni test in BF and ISQ was used. A Pearson correlation was done to investigate the relationship between the BF and DI stability, and P < 0.05 was considered statistically significant. The mixed-effects regression to model ISQ ~ BF + time + location + gender, and 95% CIs. If any patient in this study missed a follow-up visit, the author would call the patient to revisit with a new appointment.

Results

The current study enrolled 128 individuals, and the inclusion criteria were present in 80 individuals needing DIs for the anterior and posterior regions of the jaws in both genders (Fig 2). Descriptive data of patient demographics (number of patients, age, gender, number of implants, implant diameter, and length. The age and gender of participants and implant number, diameter, and length were non significantly different between study groups (Table 1).

Table 2 presents the data on the anterior and posterior BF for the male and female participants after receiving the DI. On average, the male participants exhibited a significantly higher posterior BF compared to the females. Similarly, the average posterior BF in the female patients was significantly lower than in the males at the three visits (Fig 3). These findings suggested that the difference in the OF was based on gender.

Table 2. The Anterior & Posterior Bite Forces in Males & Females.

NO. of visit	Gender	Anterior Bite Forces(N) mean ± SD n = 20	Posterior Bite Forces(N) mean ± SD n = 20	Gender	Anterior Bite Forces(N) mean ± SD n = 20	Posterior Bite Forces(N) mean ± SD n = 20
1 First	Males	172.3 ± 10.011	32o ± 4.475	Females	152.9 ± 9.573	274.2 ± 2.636
2 Second		175.4 ± 8.212	324 ± 6.832		156.1 ± 8.325	279.2 ± 6.221
3 Third		179.4 ± 6.243	337 ± 5.728		159.4 ± 6.436	283.5 ± 3.241
Repeated-Measures ANOVA		21.202	39.831		12.638	34.122
p value		0.0502	0.033		0.0422	0.043

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NO: number; Significant (p-values ≤ .05), non-significant (p-values > 05), ± SD: standard deviation, N: Newton, 1 st visit: during the day of insertion of the crown on the abutment of the implant (immediately loading), 2^nd vist: second visit at six months following insertion, 3 rd visit: third visit after 18 months following insertion.

The stability at the anterior and posterior DIs for the male and female participants at the three visits is shown in Table 3. The present finding showed that the stability of the anterior DI significantly increased for the male participants compared to the females. Likewise, the average stability of the posterior DIs in the male participants was significantly superior to that of the females, as illustrated in the respective three visits. The result showed that gender differences may have played a potential role in the stability of DIs (Fig 4).

Table 3. The Anterior and Posterior Dental Implant Stability in Males and Females.

NO. of visit	Gender	Anterior Stability(ISQ) mean ± SD n = 20	Posterior Stability(ISQ) mean ± SD n = 20	Gender	Anterior Stability(ISQ) mean ± SD n = 20	Posterior Stability(ISQ) mean ± SD n = 20
1 First	Males	74.6 ± 5.35	78.9 ± 3.62	Females	70.3 ± 4.3	75.5 ± 2.11
2 Second		77.8 ± 4.112	86.3 ± 3.22		72.4 ± 1.324	78.3 ± 2.512
3 Third		79.2 ± 4.861	89.6 ± 1.734		74.5 ± 1.453	80.1 ± 2.382
Repeated-Measures ANOVA		26.023	36.122		23.282	29.017
p value		0.053	0.044		0.051	0.037

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NO: number; Significant (p-values ≤ .05), non-significant (p-values > 05), ± SD: standard deviation, ISQ: implant stability quotient, 1 st visit: during the day of insertion of the crown on the abutment of the implant (immediately loading), 2^nd vist: second visit at six months following insertion, 3 rd visit: third visit after 18 months following insertion.

Results of the two-way ANOVA of all groups for the implant BF and ISQ values between the time, locations of the implants, and gender (Table 4). The BF results showed statistically significant differences in the correlations between time at the 2nd visit (p = 0.051) and between the locations of the implants at the 3rd visit (p = 0.042), the correlations between time × location at the 2nd visit and 3rd visit (p = 0.016; 0.048), respectively. The BF finding revealed a statistically significant difference in the correlations between gender ×time at the 2nd visit (p = 0.007), and the correlations between gender × location at the 2nd visit and 3rd visit (p = 0.032;0.052), respectively. Time × location× gender interaction is significantly correlated with BF.

Table 4. Results of the two-way and three-way ANOVA of all groups for the bite forces and implant stability values between the time, locations of the implants, and gender.

Residual variables	Influence variables	1 First visit	2 Second visit	3 Third visit
Bite forces(N)	Time	0.750	0.051*	0.075
	Locations of implants	0.657	0.534	0.042*
	Time × Location	0.134	0.016 *	0.048 *
	Gender	0.119	0.052	0.157
	Gender × Time	0.250	0.007 *	0.870
	Gender × Location	0.720	0.032*	0.052*
	Time × Location× Gender	0.003*	0.052*	0.000*
StabilityISQ	Time	0.923	0.809	0.162
	Locations of implants	0.185	0.043*	0.137
	Time × Location	0.977	0.011*	0.051*
	Gender	0.170	0.162	0.259
	Gender × Time	0.186	0.044 *	0.199
	Gender ×Location	0.472	0.019*	0.028*
	Time × Location× Gender	0.001*	0.004*	0.000*

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* denotes a significant difference, with p < 0.05.

The ISQ results showed statistically significant differences in the correlations between location at the 2nd visit (p = 0.043) and the correlations between lime × location at the 2nd visit and 3rd visit (p = 0.011; 0.052), respectively. The ISQ outcomes revealed statistically significant differences in the correlations between gender ×time at the 2nd visit (p = 0.044), and the correlations between gender × location at the 2nd visit and 3rd visit (p = 0.019;0.028), respectively. Time × location× gender interaction is significantly correlated with ISQ.

Results of the sphericity (Mauchly) and handling of violations (Greenhouse-Geisser) were employed (Table 5). The Bite forces results showed statistically non-significant differences in the correlations between time of the 3 visits, the P-value is 0.071, so time has no significant effect on subjects’ implant, while locations of the implants have (P_value = 0.018). For interaction Time × Location, we can still proceed with the test by using the Greenhouse-Geisser correction and conclude that interaction Time × Location has a significant effect (P_value = 0.001).

Table 5. Results of the sphericity (Mauchly), and handling of violations (Greenhouse-Geisser).

Residual variables	Influence variables	1 First visit	2 Second visit	3 Third visit	Mauchly	Greenhouse-Geisser
Bite forces(N)	Time	0.750	0.051*	0.075	0.071	0.052
	locations of the implants	0.657	0.534	0.042*	0.018*	0.001
	Time × Location	0.134	0.016 *	0.042 *	0.001*	0.000
	gender	0.119	0.052	0.157	0.093	0.076
	gender × Time	0.250	0.007 *	0.870	0.024*	0.001*
	gender × Location	0.072	0.032*	0.052*	0.001*	0.000*
Stability ISQ	Time	0.923	0.809	0.162	0.063	0.099
	locations of the implants	0.0185	0.0436	0.0137	0.0591*	0.003*
	Time × Location	0.097	0.011*	0.051*	0.022*	0.000*
	gender	0.170	0.162	0.259	0.001*	0.001*
	gender × Time	0.186	0.044 *	0.191	0.007*	0.000*
	gender × Location	0.472	0.019*	0.028*	0.004*	0.000*

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* denotes a significant difference, with p < 0.05.

The Bite forces results showed statistically non-significant differences in the correlations between gender for the three visits, the P-value is 0.093, so gender has no significant effect on subjects’ implant, while the interaction of gender × Time has a P-value of 0.024. For interaction Time × Location, we can still proceed with the test by using the Greenhouse-Geisser correction and conclude that the interaction gender × Location has a significant effect (P_value = 0.000).

The ISQ results showed statistically non-significant differences in the correlations between time of the three visits, the P-value is 0.063, so time has no significant effect on subjects’ implants, while locations of the implants have (P-value 0.059). For interaction Time × Location, we can still proceed with the test by using the Greenhouse-Geisser correction and conclude that interaction Time × Location has a significant effect (P-value = 0.000).

The ISQ results showed statistically non-significant differences in the correlations between gender at the three visits, the P-value is 0.001, so gender has no significant effect on subjects’ implant, while the interaction of gender × Time has (P-value of 0.007. For interaction Time × Location, we can still proceed with the test by using the Greenhouse-Geisser correction and conclude that the interaction gender × Location has a significant effect (P_value = 0.000).

By using the Bonferroni test in intergroup comparisons of mean anterior BF in males, posterior BF in males, anterior BF in females, and posterior BF in females showed significant differences were found among these groups. Intergroup comparisons of mean anterior DI stability in males, posterior DI stability in males, anterior DI stability in females, and posterior DI stability in females showed significant differences among these groups (Table 6).

Table 6. Intergroup Comparisons of Mean Bite Force and Stability in both genders by using the Bonferroni test after adjustment of other factors.

Variable	Groups	Groups	Bonferroni test	p value
Bte Force	Anterior BF in males	Posterior BF in males	23.84	0.008
		Anterior BF in females	11.922	0.042
		Posterior BF in females	33.42	0.055
	Posterior BF in males	Anterior OF in females	39.21	0.057
	Posterior BF in males	Posterior BF in females	18.22	0.013
	Anterior BF in females	Posterior BF in females	28.63	0.034
Stability	Anterior DIs stability in males	Posterior DIs stability in males	32.08	0.011
		Anterior DIs stability in females	21.46	0.028
		Posterior DIs stability in females	28.36	0.046
	Posterior DIs stability in males	Anterior DIs stability in females	31.68	0.003
	Posterior DIs stability in males	Posterior DIs stability in females	19.22	0.005
	Anterior DIs stability in females	Posterior DIs stability in females	39.114	0.001

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Significant at (p< 0.05); Bonferroni test.

The data showed that the correlation between the BF and DI stability was significant in the male and female participants (Table 7).

Table 7. The Correlation between Bte Forces and Dental Implant Stability in Males and Females.

Gender	Bite force	Stability	r	p value
Males	243.1	75.4	0.309	0.002*
Females	186.2	79.8	0.323	0.012*

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r: Pearson correlation coefficient; *: Significant (p-values ≤ .05), and non-significant (p-values > 05).

The difference in the regression coefficient (b) for BF and ISQ is influenced by time, implant location, and gender. The relationship was observed over time change in three visits, which influenced (BF and ISQ), it was significantly higher BF, ISQ value (3 third visit) when compared (1 first visit, 2nd visit). Such a straightforward association was detected in implant location change in anterior and posterior areas at three visits where effected on (BF and ISQ), where it was significantly higher ISQ value (3 third visit), and BF value (2nd visit) when compared to the 1st visit. The association was illustrated by gender change between males and females at three visits, impact (BF and ISQ), it was significantly greater ISQ value and BF value (3 third visit) when compared (1 first visit, the 2nd visit. The ratios of the regression coefficients for BF and implant ISQ thus suggest that a unit increase of BF changes ISQ, and BF might prove a more reliable factor for implant stability in differences (time, implant location, and gender) (Table 8).

Table 8. Differences in regression coefficients (b) for BF and implant ISQ between the Time, Location of Implants, and Gender. b illustrated the mean percentage change in one unit of influencing variables (Time, Location of Implants, and Gender) That is based on the change in BF and implant ISQ. Significant differences in the regression coefficients (b) are denoted by * (p < 0.05). The term ratio reflects the quotient of bISQ/ bBF.

Variables			1 First visit		2 Second visit		3 Third visit
Influencing variables	Residual varibles	b (%)	95% CI	b (%)	95% CI	b (%)	95% CI
Time	BF	12.4 *	(10.7-13.8)	16.1*	4.6 10.2	19.8*	13.5 17.9
	ISQ	39.3 *	(25.5-56.9)	49.2	66.7 107.6	58.4*	70.2 97.1
	Ratio	3.1		3.0		2.9
Location of Implants	BF	19.4 *	(12.6- 17.6)	22.8*	5.5 10.1	24.6	3.9 5.8
	ISQ	40.8 *	(79.2- 86.0)	56.2*	127.3 83.2	66.4*	44.0 58.5
	Ratio	2.1		2.4		2.6
Gender	BF	16.4 *	12.6 17.6	24.5*	13.5 17.9	30.2*	14.4 18.4
	ISQ	62.5*	79.2 86.0	78.3	82.2 97.1	88.1*	53.7 102.3
	Ratio	3.8		3.1		2.9

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* denotes a significant difference, with p < 0.05.

Discussion

The bite force (BF) may be a crucial factor in prosthetic design and stability of DIs, particularly in individuals who can produce extremely high occlusal loads [31]. This study found a significant complex interaction of influencing factors (time, location, gender) on the change of BF and ISQ by affecting the process of ossteointegration. The significant changes of (time, location, gender) during 18 months influence an increase in BF, and change ISQ with (primary, secondary) stability. The significantly higher mean BF in the posterior regions of males after delivery of dental implant restoration, and the significantly greater mean stability of DIs in the posterior regions during the 18 months following insertion of the crown, within three follow-up visits, could play a potential role in great DIs therapy. This study found a significant association between BF and DI stability with the impact of time, location of implants, and gender. Therefore, the null hypothesis is that there was no change in BF and ISQ of DIs during 18 months, following insertion of the crown on the abutment of the implant was rejected.

The current study found that the BF in the posterior DIs of males and females was higher than in the anterior DIs. Thus, the BF of the patient may be a concern for a good result in in the DI therapy, especially in the maxillary anterior DI in both genders, since the facial cortical bone may be most susceptible to overload. The bite force (BF) could be a crucial planning factor. The size, quantity, and occlusal design elements of the DI that can effectively withstand the load may be required for a patient who creates an excessive load [32,33]. A high BF capacity may indicate a high risk for a late component fracture [34]. The BF on the posterior regions of males and females is always larger than on the anterior regions. Different occlusion circumstances primarily influence the amplitude and direction of the BF. The DI and the entire mandible underwent noticeably increased stress under occlusion [35]. The DI length, location, an anterior-directed occlusal scheme, splinting, and ridge expansion augmentation may be used to improve osseous support or deflect or reduce the BF [36]. Even with poor anatomical bone characteristics, a patient with a moderate BF may be able to have a satisfactory long-term result [37,38].

The study revealed that there was an increase in the stability of the posterior DIs of the male and female participants compared to the anterior DIs. Hence, to effectively incorporate the DI into the bone, it is first necessary to establish the primary and secondary stability of the DI. The success rate of dental implants (DIs) may be highly dependent on the stability of the patient’s DI [39]. However, early failure can happen in a DI for several reasons, even before the restorative component is inserted. Factors that have been positively associated with a higher risk of failure include advanced age, diabetes, cigarette smoking, and lengthier DIs [40].

There are two types of DI stability: primary stability, which involves the mechanical connection of the DI to the bone around its placement, and secondary stability, which involves the tissue reaction to the DI and the subsequent bone remodelling events [41]. The posterior region of the mouth consists of dense trabecular bone with a thick cortical plate compared to the anterior part of the mouth. Therefore, the primary stability is higher in this region of the mouth [42].

The correlation between the OF and DI stability was significant in males and females concerning how the BF initiates bone loss around the DI or how it relates to DI stability. Even after the DI has been joined with the bone, the BF can affect the DI-bone contact and the cells that rebuild the bone in various ways, which can affect whether or not the integration is maintained [43,44].

This study found a significantly complex interaction of factors (time, location, gender) influencing on change of BF and ISQ by affecting the process of osseointegration. The significant changes of (time, location, gender) during 18 months influence an increase in BF, and changeISQ with (primary, secondary) stability. It varies in a dynamic manner as the interface between the bone and the implant matures, and the patient’s sex, time, and anatomical location all play a significant role in its context. Accordingly, bite force with influencing variables, BF, frequently rises when patients adjust to implants over time (healing/adaptation), with notable alterations occurring within as little as three months after operation and persisting until osseointegration occurs and strengthens [45]. Bite force is greatly influenced by location across the jaws; forces rise from the anterior to the posterior region (molars have the greatest BF). Optimum biting BF is significantly influenced by gender, with men often using higher forces than women. In addition, the interaction of variables, including the considerable time x location interaction, indicates that BF increases as time passes in different ways at different locations [46]. Time has a different influence on men and women, according to the gender x time interaction. There is a considerable difference in bite force between males and females at different regions due to the gender x location interaction, with males having a more posterior BF. The influence of time varies between males and females, according to the gender x time interaction [47]. The strong interaction between time, location, and gender may indicate that the impact of the position of DI on biting force as time passes differs for males and females.

Time (duration) was estimated to have a significant positive main effect on ISQ; over time, ISQ usually rises as osteous tissue remodelling. The position in the jaw has a major impact because the posterior portion has harder bone than the anterior region, which typically provides superior primary ISQ. Males frequently have more BF, but ISQ varies greatly by sex; yet, some research indicates that females exhibit higher ISQ rises with time. Moreover the interaction of variables, including the considerable time x location interaction, indicates that ISQ improvements as time passes vary depending on the location of the jaw (e.g., more rapid improvement in the posteror area) [48]. The interplay between gender and location may indicate that males and females possess distinct jaw region stability patterns. The gender x time interaction may show that the sexes’ progressions in ISQ improvement as time passes vary [28,49]. The most complicated is the three-way interaction between time, location, and gender on ISQ, which illustrates how all three variables interact (e.g., stability increases as time passes in the posterior region differently in males vs. females). A thorough knowledge of the factors involved can be obtained by employing a three-way ANOVA to assess the separate as well as combined impacts of time, site, and sex on implant ISQ.

Differences in the regression coefficient “b” (showing the strength of the relationship) for BF and ISQ can be seen based on time, location of the implant, and gender, as these factors significantly impact the variables that are dependent variables. Bite force associated time, BF on implant-retained crowns, is considerably less than on actual teeth at first, but rises significantly during the preliminary 6 to 18 months’ post-implantation as osseointegration improves and patients adjust [50]. The regression coefficient “b” for time would be positive, demonstrating an increase in force during visits, particularly in the initial phases. Bite force associated location, BF, is typically greater in the posterior molar region than in the incisor portion. Thus, the regression coefficient “b” for location would show a stronger association in the posterior regions [51]. Bite force is associated with gender; males often have much greater BF and pressures of biting than females. The regression coefficient for gender would reveal the stronger association with greater BF in males [52].

Dental implant stability is associated with time. At the time of operation, the main stability is mostly mechanical. Lateral stability varies between visits and is a result of physiological osseointegration as time passes.ISQ readings typically fluctuate, occasionally declining at first, later rising once more. And the regression coefficient “b” for time between insertion and exposure is positive, representing a rise in ISQ through the healing period [53]. Dental implant stability is associated with location; the posterior jaw region has an ISQ that is typically higher than the anterior portion. And, as a result of denser bone quality. Dental implant stability is associated with gender; the impact of gender on ISQ results is indicated by a substantial difference in the regression coefficient “b” for ISQ in males and females [54].

Differences in Regression Coefficients “b” ratio of dental implant, ISQ coefficient “b” to bite BF coefficient “b” with change of time is positively increases ISQ with recovery time to positively increases BF with time, especially 6-18 months [55]. The ratio of b ISQ/ b BF with different locations is a higher “b” value, greater initial ISQ for the posterior vs. anterior region of jaw over time, and posterior implants frequently had greater BF values. The ratio of b ISQ/ b BF with gender (male, female), a high ISQ of males was found as a result to have a substantial effect, to a higher BF “b” value for males vs. females [56].

Primary stability has also been demonstrated to be influenced by the diameter, surface features, and length of implants. The present study used dental implants with sizes (4.0*10, 3.5*11, 3.3*10, or 3.8*9) that showed highly primary and secondary stability. More surface area and a stronger mechanical connection to the tissue around it are provided by rough surfaces of implants [57]. Sandblasted implant surfaces facilitate osteogenesis by increasing osteoblast proliferation and cellular metabolism, according to research conducted in vitro [58,59]. Research has demonstrated the presence of surface response and interaction of cells [60]. Compared to implants with a machining surface, those with acid-etched coatings can achieve a much better bone-to-implant contact in areas with low-quality bone [61]. Experimental evidence has demonstrated that in situations when the amount of bone is limited and implants with diameters below 3.0 millimeters offer adequate initial stability [62]. According to Aparicio et al.‘s study on RFA procedures, variables such as supracrestal implant length, abutment length, and upper or lower jaw bone density appear to affect RFA values [63]. The dimensions of implant outcome influence on stability are consistent with the Raz et al. study’s findings, which show that the stability evaluations show greater values for longer implants than for shorter ones, and for densely embedded bone as opposed to softer bone [41].

Implants with a severe thread pattern may improve initial stability [27]. The stability values of tapering implants were consistently higher than those of cylinder implants [32]. These changes involve platform switching and microthreads of DIs used in this study. Compared to non-platform switching designs, platform-switching setups have demonstrated efficient stress performance and reduced the possibility of overloading [64]. The maximum von Mises, compressive, and tensile stresses are reduced when oblique forces are applied to a DI with a platform-switching design compared to a traditional design [65]. The palatal side of the platform and the entire implant surface get a redistribution of the pressures that are moved from the compact bone area to the cancellous bone area [20]. The maximal stresses at the cortical region were lower with platform-switching implants than with conventional implants. Implants with platform switching decreased stress by 40% when subjected to oblique loads and 36% when subjected to axial stresses [21].

After osseointegration and throughout the duration of their use, it is acknowledged that all implants exhibit some degree of loss of bone. According to several claims, the addition of microthreads or “retention grooves” to the implant’s neck may help to distribute stress and lessen the amount of bone loss that occurs after installation [66]. In practice, the surgical method and the use of platform switching are linked to the preservation of crestal bone [67]. Additionally, it appears that the progressive thread pattern reduces the crestal bone compression process, hence preventing crestal bone loss [67].

The von Mises stress distribution on the DI system demonstrated that the high stresses on the DI resulted from the action of external forces that primarily occurred close to the DI, where it made contact with the abutment [68]. As a result, when the tooth experienced external stress, the neck of the DI was immediately deformed. Hooke’s law predicted that a lot of tension would be produced in this region [69]. The alveolar bone of the DI, next to those that were impacted by external forces, was also discovered to be subject to significant stress as a result of deformation [70]. Additionally, it was clear from looking at the tension on the abutment and abutment screw that the significant stress on the abutment originated from its intersection with the DI [71,72]. The high stress on the abutment screw developed at the point where the screw head was attached to the abutment and where the geometric shape of the screw head and screw bent [73,74]. Therefore, excessive stress caused by the BF should be avoided in the design of the abutments and abutment screws. Otherwise, the DI system may be worn down since the patient will be chewing with it for a prolonged period. By analysing the BF, dental experts can better understand the functional strain exerted on the DI system [75]. This will facilitate the choice of suitable DI parts and materials that can withstand the stresses generated during chewing and biting [76,77]. Clinicians can avoid premature mechanical failures such as screw loosening, abutment fracture, or even DI failure by taking into account the patient’s BF [78–80]. Understanding the distribution of the BF can also help to achieve occlusal stability, reduce possible issues, and enhance patient comfort [81,82]. The limitation of this study was that patients who smoked and were hypertensive were not included to avoid bias. The small sample size was included in this study, which caused non-significant differences between study groups, and the increase in subject numbers required more time for work and follow-up visits over the period of the study decision. This study was absent of a control group to compare with because the inclusion criteria of the cohort subjects were not specified. The old age patients, bone quality/density, implant [maxilla/mandible], and delayed loading were not recorded in the data collection because these were not contained within the study criteria. The reaction force on the fixed top end of the DI system can serve as a biomechanical reference for future work on DI designs. Further studies of dental implant stability require follow-up visits for 5-10 years to improve the success of implants.

Conclusion

This study found a significant complex interaction of influencing factors, time, location, and gender on the change of BF and ISQ by effect on the process of osseointegration. The significant changes of time, location, and gender during 18 months influence an increase in BF, and changeISQ with (primary, secondary) stability. The significantly higher mean BF in the posterior regions of males after delivery of dental implant restoration, and the significantly greater mean stability of DIs during the 18 months following insertion of the crown, within three follow-up visits, could play a potential role in great DIs therapy. This study found a significant association between BF and DI stability with the impact of time, location of implants, and gender. The BF was higher on the posterior DIs area in males due to different occlusion circumstances primarily affect the amplitude and direction of the BF. Besides, the result of DI stability revealed that it increased in the posterior regions of males compared to the anterior regions due to denser bone quality. It clarified that the effective incorporation of the DI into the bone was important for the establishment of the primary and secondary stability.

In addition, the relationship between the BF and DI stability is significantly established with the most important factors influencing the change in BF and DI stability. It varies in a dynamic manner as the interface between the bone and the implant matures, and the patient’s sex, time, and anatomical location all play a significant role in its context. Moreover, understanding of the BF impact and ensuring the stability, can implement appropriate treatment strategies and best therapy for DIs.

Supporting information

S1 File. Data for analysis.

doi: https://doi.org/10.6084/m9.figshare.29369663.v1. The data contains the recording of the bite force of the male and female participants after the insertion of dental implants for the anterior and posterior regions of the jaws. The dental implants’ stability was monitored at the anterior and posterior regions of both genders’ jaws. Data are available under the terms CC0.

(XLSX)

pone.0340355.s001.xlsx^{(12.3KB, xlsx)}

S2 File. STROBE statement checklist.

doi: https://doi.org/10.6084/m9.figshare.29364278.v1.

(DOCX)

pone.0340355.s002.docx^{(40.8KB, docx)}

S1 Data. Data in figshar.

(XLSX)

pone.0340355.s003.xlsx^{(12.3KB, xlsx)}

Acknowledgments

The authors would like to thank Mustansiriyah University/College of Dentistry, Baghdad, Iraq (www.uomustansiriyah.edu.iq), and the University of Al-Ameed/College of Dentistry for their support during work.

Data Availability

The data that support the findings of this study are available in the Supporting Information files. This project contains the following underlying data the data contains the recording of bite force of the male and female participants after the insertion of dental implants for the anterior and posterior regions of the jaws. The dental implants’ stability was monitored at the anterior and posterior regions of both genders’ jaws. For determining the impact of the BF on the stability of dental implants. Data are available under the terms CC0. All participants entered the study after they received full information about the nature, aims, processes of the study, data sharing, the anonymization of participants in deposited data, and publication of raw data (without containing the name of participants) before signing an informed written consent form.

Funding Statement

The author(s) received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0340355.r001

Decision Letter 0

Antonio Riveiro Rodríguez

6 May 2025

Dear Dr. Hussein,

Please submit your revised manuscript by Jun 20 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
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Antonio Riveiro Rodríguez, PhD

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: No

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: I Don't Know

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: No

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: No

**********

Reviewer #1: Author has made a good attempt to study . However the study lacks standardisation to categorically observe the effect of bite force and stability.

The introduction is too long. it should be written around the problem. There should be a problem statement. what was the research question? What were the objectives? Was there any hypothesis?

Methodology: The instrument used can only be used to assess the bite force of posteriors. It is not suitable for use in anteriors since it does not imitate the anterior force direction on Implants.

Consider to use how this instrument was used in the methodology. There is no need to explain the mechanism of action of ostell ISQ instrument. Was the study done on Immediately loaded or immediate placement and loading ? please add clarification.

All the instrument and materials shall be mentioned the commercial name, company of manufacture and country of manufacture in brackets as mentioned for first time.

consider rewriting the methodology

Limitations of the study and further scope for the study need to be mentioned.

conclusion shall not be descriptive . It has to be written in brief and against the objectives of the study

Reviewer #2: Thank you for the interesting manuscript, however, one issue needs to be addressed, which is the type of opposing occlusion, please mention this and include it in the statistical analysis as a group comparison if some patients had natural occlusions and others had artificial occlusion opposing the implants.

Also, please correlate your findings with studied implants dimensions

please clearly explain the impact of using different thread designs in the tested implants.

please have your manuscript edited by a linguistic professional.

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Reviewer #2: No

**********

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PLoS One. 2026 Jan 20;21(1):e0340355. doi: 10.1371/journal.pone.0340355.r002

Author response to Decision Letter 1

21 Jun 2025

Thank you for your letter and for the reviewers’ comments concerning our manuscript entitled “. The impact of bite force on the long-term success of dental implants”. Those comments are all valuable and very helpful for revising and improving our paper, as well as the important guiding significance to our research. We have studied comments carefully and have made corrections which we hope meet with approval. The revised portion is marked green and yellow in the paper. The main corrections in the paper and the responses to the reviewer’s comments are as follows:

Academic Editor of PLOS ONE: Thank you for providing information to enhance the manuscript about the Journal Requirements

1-Response to comment: Please ensure that your manuscript meets PLOS ONE's style requirements

Response: Thank you for your comment. I checked and modified the manuscript according to PLOS ONE's style.

2. Response to comment: The goal of ensuring long-term data availability to provide all interested researchers

Response: Thank you for pointing that out.. We were adding Data Availability Statement, the data that support the findings of this study are available on request from the corresponding author and emails address, Drdhuhahhaziz@gmail.com, dr.rabeemajeed@gmail.com

Responds to the reviewers’ comments:

Reviewer #1: Thank you for your valuable feedback. I will revise the manuscript to include a clear sentence in green.

1- Response to comment: Author has made a good attempt to study. However, the study lacks standardisation

Response: Thank you for your comment. I clarify that this study has pre-inserted implant measurements, and these readings depend on digital measurements that gave a standardized measurement of bite force to the natural anterior and posterior teeth, but these readings did not show significant differences from the bit force record after primary loading of a crown on abutment of implant and started function.

Moreover, this study has pre-inserted abutment (initial) stability measurements, and these readings were not significantly different from the stability record after primary loading of the crown on the abutment of the implant and started function.

2- Response to comment: The introduction is too long. it should be written around the problem. There should be a problem statement. what was the research question? What were the objectives? Was there any hypothesis?

Response: Thank you for your comment. You're correct that the research question, objectives, and hypothesis were written at the end of the introduction and shortening the introduction too.

The research question is whether the BF impact on stability and longevity of DIs. This study aims to explore the effect of the BF on DIs of different genders, to investigate DI stability in both genders, and to assess the correlation between BF and DI stability. The null hypothesis was that the BF could not have a significant impact on the stability and longevity of DIs

3- Response to comment: Methodology: The instrument used can only be used to assess the bite force of posteriors. It is not suitable for use in anterior since it does not imitate the anterior force direction on Implants

Response: Thank you for pointing that out. I will revise the instrument in Methodology to make it clearer and more explicit with references that the loadstar sensor was used to collect the BF values of posterior and anterior implant areas [28].

4- Response to comment: Consider to use how this instrument was used in the methodology. There is no need to explain the mechanism of action of ostell ISQ instrument. Was the study done on Immediately loaded or immediate placement and loading ? please add clarification.

Response: Thank you for your comment. The method for monitoring implant stability during healing and immediately loading. The mechanism of action of the Ostell ISQ instrument is very important to give information on how it works and obtain measurements.

5-Response to comment : All the instrument and materials shall be mentioned the commercial name, company of manufacture and country of manufacture in brackets as mentioned for first time.

Response: Thank you for your suggestion. The Osstell (Integration Diagnostics AB, Göteborg, Sweden).Loadstar sensor, DI-100U, 16-bit load cell interface, Fremont. California. Straumann, Dental Implant System. USA. Medintika, Dental Implant.Germany.

6-Response to comment: Consider rewriting the methodology.

Response: Thank you for pointing that out. I will revise the i methodology to make it clearer and more explicit. The manuscript methodology was modified according guidelines of the PLOS One journal.

7-Response to comment: Limitations of the study and further scope for the study need to be mentioned.

Response: Thank you for pointing that out. The limitations and further scope were added at the end of the discussion.

The limitation of this study was that patients who smoked and were hypertensive were not included to avoid bias. The small sample size was included in this study, which caused non-significant differences between study groups, and the increase in subject numbers that required more time for work and follow-up visits throughout the study decision. This study was absence of a control group to compare with because the inclusion criteria of the cohort subjects were not met. The reaction force on the fixed top end of the DI system can serve as a biomechanical reference for future work on DI designs. Further studies of dental implant stability that require follow-up visits for 5-10 years to improve the success of implants.

8-Response to comment: Conclusion shall not be descriptive. It has to be written in brief and against the objectives of the study

Response: Thank you for your comment. We modified the conclusion to clarify the result of the study and explained these results with the objectives.

Reviewer #2: Thank you for your important comments. I will revise the manuscript to include a clear sentence in yellow.

1. Response to comment: one issue needs to be addressed, which is the type of opposing occlusion, please mention this and include it in the statistical analysis as a group comparison if some patients had natural occlusions and others had artificial occlusion opposing the implants.

Response: Thank you for pointing this out. It was clarified by adding to the inclusion criteria, they had natural occlusions opposing their implants that needed to be inserted. Moreover, the exclusion criteria included: they had missing permanent teeth, an implant, and were restored with a crown of opposing occlusion.

2. Response to comment: Also, please correlate your findings with studied implants dimensions

Response: Thank you for your suggestion. We correlate the study findings with implant dimensions by adding clear sentences.

Primary stability has also been demonstrated to be influenced by the diameter, surface features, and length of implants. The present study dental implants used with size (4.0*10, 3.5*11, 3.3*10, or 3.8*9) showed high primary and secondary stability. More surface area and a stronger mechanical connection to the tissue around it are provided by rough surfaces of implants [42]. Sandblasted implant surfaces facilitate osteogenesis by increasing osteoblast proliferation and cellular metabolism, according to research conducted in vitro [43,44]. Research has demonstrated the presence of surface response and interaction of cells [45]. Compared to implants with a machining surface, those with acid-etched coatings can achieve a much better bone-to-implant contact in areas with low quality of bone [46]. Experimental evidence has demonstrated that in situations when the amount of bone is limited and implants with diameters below 3.0 millimeters offer adequate initial stability [47]. According to Aparicio et al.'s study on RFA procedures, variables such as supracrestal implant length, abutment length, and upper or lower jaw bone density appear to affect RFA values [48].

The dimensions of implant outcome on stability are consistent with the Raz et al. study's findings, which show that the stability evaluations show greater values for longer implants than for shorter ones, and for densely embedded bone as opposed to softer bone [39].

3. Response to comment: please clearly explain the impact of using different thread designs in the tested implants.

Response: Thank you for your suggestion.

Implants with a severe thread pattern may improve initial stability [27]. The stability values of tapering implants were consistently higher than those of cylinder implants [29]. These changes involve platform switching and microthreads of DIs used in this study. Compared to non-platform switching designs, platform-switching setups have demonstrated efficient stress performance and reduced the possibility of overloading [49]. The maximum von Mises, compressive, and tensile stresses are reduced when oblique forces are applied to a DI with a platform-switching design compared to a traditional design [50]. The palatal side of the platform and the entire implant surface get a redistribution of the pressures that are moved from the compact bone area to the cancellous bone area [20]. The maximal stresses at the cortical region were lower with platform-switching implants than with conventional implants. Implants with platform switching decreased stress by 40% when subjected to oblique loads and 36% when subjected to axial stresses [21].

After osseointegration and throughout the duration of their use, it is acknowledged that all implants exhibit some degree of loss of bone. According to several claims, the addition of microthreads or "retention grooves" to the implant's neck may help to distribute stress and lessen the amount of bone loss that occurs after installation [51]. In practice, the surgical method and the use of platform switching are linked to the preservation of crestal bone [52]. Additionally, it appears that the progressive thread pattern reduces the crestal bone compression process, hence preventing crestal bone loss [52].

4. Response to comment: please have your manuscript edited by a linguistic professional.

Response: Thank you for pointing that out. We send the manuscript for proofreading and have a certificate for it.

Special thanks to you for your good comments.

We tried our best to improve the manuscript and made some changes in the manuscript. These changes will not influence the content and framework of the paper. And here we highlight the changes marked in yellow and green in the revised paper.

We appreciate for Editors and Reviewers’ warm work, and hope that the correction will meet with approval.

Once again, thank you very much for your comments and suggestions.

We look forward to hearing from you. If you have any queries, please don’t hesitate to contact me anytime at the address below.

Thank you and best regards.

Yours sincerely,

Attachment

Submitted filename: Response to Reviewers.docx

pone.0340355.s004.docx^{(21.5KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0340355.r003

Decision Letter 1

Antonio Riveiro Rodríguez

18 Aug 2025

Dear Dr. Hussein,

Please, address all the comments made by the reviewers, in particular, improve the presentation and the statistical analysis.

Please submit your revised manuscript by Oct 02 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Antonio Riveiro Rodríguez, PhD

Academic Editor

PLOS ONE

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Yes

Reviewer #3: No

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #2: Yes

Reviewer #3: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: Yes

Reviewer #3: No

**********

Reviewer #2: Author have responded to all comments and I have no further comments. the authors have adequately addressed your comments raised in a previous round of review and I feel that this manuscript is now acceptable for publication.

Reviewer #3: some commets to make your paper clearer

1.Unclear and incomplete results presentation. The data tables do not define the meaning of multiple numbers reported in each cell (e.g., whether they represent mean ± SD, confidence limits, or another metric), preventing independent interpretation.

2.Figures suggest non-linear patterns, yet only linear fits are superimposed without justification, obscuring true relationships.

3.Inappropriate and insufficient statistical methodology. Normality‐ or variance-homogeneity checks were not reported, so the suitability of parametric tests is unverified.

4.A one-way ANOVA was applied to compare first, second, and third observations, although a repeated-measures ANOVA (or a mixed model) is required for dependent data.

5.Correlations were assessed with simple linear regression despite visual evidence of non-linearity and the absence of diagnostic plots or residual analyses.

6.Mismatch between stated aims and executed analyses. Also not stattic the hyposthes as suggested.

7.The aim explicitly includes gender comparison (“…effect of BF on DIs of different genders…”), yet no direct gender stratification or interaction term appears in the statistical model.

8.Unsupported and overstated conclusions. The conclusion section reiterates some findings (results) and speculates on gender differences without empirical support.

9.Several claims (e.g., superiority of one gender in long-term stability) extend beyond the study’s data and timeframe.

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #2:Yes: MOHAMED AHMED ALKHODARY

Reviewer #3: No

**********

PLoS One. 2026 Jan 20;21(1):e0340355. doi: 10.1371/journal.pone.0340355.r004

Author response to Decision Letter 2

31 Aug 2025

Response to the comment of Reviewer 3

1. Response to comment: 1. Unclear and incomplete results presentation. The data tables do not define the meaning of multiple numbers reported in each cell (e.g., whether they represent mean ± SD, confidence limits, or another metric), preventing independent interpretation.

Response: Thank you for your valuable feedback. I will revise the data tables to include a clear sentence in yellow and add the mean ± SD in the tables for further clarification.

This is revised tables:

Table 1. The Anterior and Posterior Occlusal Forces in Males and Females

NO.

of visit Gender Anterior Occlusion

mean ± SD Posterior Occlusion

mean ± SD Gender Anterior Occlusion

mean ± SD Posterior Occlusion mean ± SD

1 st males 175.3

± 10.011 324

± 4.475 females 154.9

± 9.573 274.2

± 2.636

2 nd 172.4

± 8.212 322

± 6.832 153.1

± 8.325 272..2

± 6.221

3 rd 174.4

± 6.243 323

± 5.728 153.4

± 6.436 273..5

± 3.241

Repeated-Measures ANOVA 21.202 39.831 12.638 34.122

p value 0.0502 0.033 0.0422 0.043

Significant (p-values ≤.05), non-significant (p-values > 05), ± SD: standard deviation.

Table 2. The Anterior and Posterior Dental Implant Stability in Males and Females

NO.

of visit Gender Anterior Stability

mean ± SD Posterior Stability

mean ± SD Gender Anterior Stability

mean ± SD Posterior Stability

mean ± SD

1 st Males 75.5

± 4.3 72.3

± 2.11 Females 79.9

± 5.35 74.6

± 3.62

2nd 72.3

± 4.112 72.8

± 2.512 82.3

± 1.324 75.4

± 3.221

3 rd 74.1

± 4.861 73.2

± 2.382 82.6

± 1.453 76.5

± 1.734

Repeated-Measures ANOVA 29.017 26.023 36.122 31.282

p value 0.0532 0.044 0.0518 0.037

Significant (p-values ≤.05), non-significant (p-values > 05), ± SD: standard deviation.

2. Response to comment: 2. Figures suggest non-linear patterns, yet only linear fits are superimposed without justification, obscuring true relationships.

Response: Thank you for your suggestion. I was explaining of mean value levels of Occlusal Force and Dental Implant Stability in both genders in Figures 2 and 3. The scatter plot should be explicitly stated for clarity.

This is revised:

(a)

(b)

Figure 2. The mean value differences of anterior occlusal forces and posterior occlusal forces in males (a); The mean value differences of anterior occlusal forces and posterior occlusal forces in females (b).

(a)

(b)

Figure 3. The mean value differences of anterior implant stability and posterior implant stability in males (a); The mean value differences of anterior implant stability and posterior implant stability in females (b).

3. Response to comment: 3. Inappropriate and insufficient statistical methodology. Normality‐ or variance-homogeneity checks were not reported, so the suitability of parametric tests is unverified.

Response: Thank you for your comment. I was adding detailed reporting of how these analyses were conducted in the revision. I will rewrite the statistical analyses methodology of normality, another test for comparisons between more than two groups, and P < 0.05 was considered statistically significant.

This is revised:

Statistical Analyses

Descriptive statistics through GraphPad® Prism 9.5.1 were used to summarize the patient demographics, BF measurements, and DI stability measurements. The normality of distribution was checked by the Shapiro–Wilk and D’Agostino’s tests. The continuous variables were expressed as the mean standard deviation (±), while the categorical variables were presented as frequencies and percentages. Comparative analyses, such as an analysis of variance (Repeated-Measures ANOVA), were performed to assess differences in the BF and DI stability in males and females at the anterior and posterior areas of the jaws among three postoperative time points. For comparisons between more than two groups, Tukey’s honestly significant difference Post Hoc tests were used. A Pearson correlation was done to investigate the relationship between the BF and DI stability, and P < 0.05 was considered statistically significant. If any patient in this study missed a follow-up visit, the author would call the patient to revisit with a new appointment.

4- Response to comment: 4. A one-way ANOVA was applied to compare first, second, and third observations, although a repeated-measures ANOVA (or a mixed model) is required for dependent data.

Response: Thank you for your question. I was writing a new analysis of these data, depending on repeated-measures ANOVA and p-value in Tables 1 and 2 in revision.

This is revised:

Table 1. The Anterior & Posterior Occlusal Forces in Males & Females

NO.

of visit Gender Anterior Occlusion

mean ± SD Posterior Occlusion

mean ± SD Gender Anterior Occlusion

mean ± SD Posterior Occlusion mean ± SD

1 st males 175.3

± 10.011 324

± 4.475 females 154.9

± 9.573 274.2

± 2.636

2 nd 172.4

± 8.212 322

± 6.832 153.1

± 8.325 272..2

± 6.221

3 rd 174.4

± 6.243 323

± 5.728 153.4

± 6.436 273..5

± 3.241

Repeated-Measures ANOVA 21.202 39.831 12.638 34.122

p value 0.0502 0.033 0.0422 0.043

Significant (p-values ≤.05), non-significant (p-values > 05), ± SD: standard deviation.

Table 2. The Anterior and Posterior Dental Implant Stability in Males and Females

NO.

of visit

Gender Anterior Stability

mean ± SD Posterior Stability

mean ± SD Gender Anterior Stability

mean ± SD Posterior Stability

mean ± SD

1 st Males 75.5

± 4.3 72.3

± 2.11 Females 79.9

± 5.35 74.6

± 3.62

2nd 72.3

± 4.112 72.8

± 2.512 82.3

± 1.324 75.4

± 3.221

3 rd 74.1

± 4.861 73.2

± 2.382 82.6

± 1.453 76.5

± 1.734

Repeated-Measures ANOVA 29.017 26.023 36.122 31.282

p value 0.0532 0.044 0.0518 0.037

Significant (p-values ≤.05), non-significant (p-values > 05), ± SD: standard deviation.

5- Response to comment: 5. Correlations were assessed with simple linear regression despite visual evidence of non-linearity and the absence of diagnostic plots or residual analyses.

Response� Thank you for this suggestion. A Pearson correlation was done to investigate the relationship between the BF and DI stability in both genders Table 4. As well as the relationship was illustrated in a diagnostic scatter plot between the OF and DI stability.

This is revised:

(a)

(b)

(c)

(d)

(e)

(f)

(g)

Figure 4 Scatter plot showing the relationship between Anterior OF in males and Anterior DIs stability in males (a); Scatter plot showing the relationship between Posterior OF in males and Posterior DIs stability in males (b); Scatter plot showing the relationship between Anterior OF in females and Anterior DIs stability in females (c ); Scatter plot showing the relationship between Posterior OF in females and Posterior DIs stability in females (d); Scatter plot showing the relationship between OF in males and DIs stability in males (e); Scatter plot showing the relationship between OF and DIs stability in females (f); and Scatter plot showing the relationship between OF and DIs stability (g).

6- Response to comment: 6. Mismatch between stated aims and executed analyses. Also, not static the hypothesis as suggested.

Response: Thank you for your valuable feedback. I will revise the stated aims and executed analyses to include a clear sentence for further clarification.

This is revised:

This study aims to explore the effect of the BF on DIs of different genders, to investigate DI stability in both genders, and to assess the correlation between BF and DI stability in both genders. The null hypothesis is that the BF could not have a significant impact on the stability of DIs. As well as the relationship was illustrated in a diagnostic scatter plot between the OF and DI stability in both genders.

7- Response to comment: The aim explicitly includes gender comparison (“…effect of BF on DIs of different genders…”), yet no direct gender stratification or interaction term appears in the statistical model.

Response: Thank you for pointing that out. I was adding details of the test for comparisons between more than two groups, Tukey’s honestly significant difference Post Hoc tests were used in revision in Table 3.

Table 3. Intergroup Comparisons of Mean Occlusal Force and Stability in both genders.

Variable Groups Groups Tukey’s HSD Post Hoc test p

Occlusal Force Anterior OF in males Posterior OF in males 22.490 0.000

Anterior OF in females 17.349 0.003

Posterior OF in females 38.205 0.001

Posterior OF in males Anterior OF in females 24.859 0.041

Posterior OF in females 15.715 0.027

Anterior OF in females Posterior OF in females 30.856 0.002

Stability Anterior DIs stability in males Posterior DIs stability in males 29.268 0.002

Anterior DIs stability in females 18.824 0.003

Posterior DIs stability in females 34.179 0.000

Posterior DIs stability in males Anterior DIs stability in females 36.557 0.001

Posterior DIs stability in females 17.911 0.000

Anterior DIs stability in females Posterior DIs stability in females 43.355 0.004

Significant at (p <0.05); Tukey’s HSD Post Hoc test: Tukey (honestly significant differences

8- Response to comment: 8. Unsupported and overstated conclusions. The conclusion section reiterates some findings (results) and speculates on gender differences without empirical support.

Response: Thank you for your question. I revised the conclusion, which comprises a clear sentence for further clarification, depending on the strength of correlation between OF and DIs stability in both genders, and the potential impact in both genders.

This is revised:

Conclusion

The significant correlation between BF and DI stability in both genders plays a noteworthy role in the long-term success of DIs. The significantly lower BF in the anterior regions of females and males may have an impact role in the significantly greater stability of DIs. The OF was lower on the anterior DIs area in both genders due to the use of implants for aesthetic purposes, and less functionally. Besides, the result of DI stability revealed that it increased in the anterior regions of females and males compared to the posterior regions, it clarified that the effective incorporation of the DI into the bone was important for the establishment of the primary and secondary stability.

In addition, the inverse relationship between the OF and DI stability may have been due to the positioning of the posterior DI and the greater masticatory BF, which represented the most important factors influencing the increased OF and decreased DI stability. Moreover, the understanding of the BF impact, performing a thorough OF analysis, can implementing appropriate treatment strategies are essential for ensuring the stability and longevity of DIs.

9- Response to comment: 9. Several claims (e.g., superiority of one gender in long-term stability) extend beyond the study’s data and timeframe.

Response: Thank you for your question. This study found a significant correlation between BF and DI stability in both genders. The significantly lower mean BF in the anterior regions of females and males after delivery of dental implant restoration could play a potential role in the significantly greater mean stability of DIs during the one half year following insertion, with three follow-up visits. The significant correlation between BF and DI stability in both genders plays a noteworthy role in the long-term success of DIs.

Special thanks to you for your good comments.

We tried our best to improve the correction of the manuscript and made some changes in the revision manuscript. These changes will not influence the content and framework of the paper. And here we highlight the changes marked in yellow in the revised paper.

We appreciate for Editors and Reviewers’ warm work earnestly, and hope that the correction will meet with approval.

Once again, thank you very much for your comments and suggestions.

We look forward to hearing from you. If you have any queries, please don’t hesitate to contact me anytime at the address below.

Thank you and best regards.

Yours sincerely,

Attachment

Submitted filename: respons to reviwer.docx

pone.0340355.s005.docx^{(926.8KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0340355.r005

Decision Letter 2

Antonio Riveiro Rodríguez

30 Oct 2025

Dear Dr. Hussein,

Please submit your revised manuscript by Dec 14 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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We look forward to receiving your revised manuscript.

Kind regards,

Antonio Riveiro Rodríguez, PhD

Academic Editor

PLOS ONE

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Please, address all the comments from reviewers.

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Reviewer's Responses to Questions

Comments to the Author

Reviewer #4: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #4: No

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #4: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #4: No

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Reviewer #4: Overall appraisal

The revised manuscript addresses an important clinical question — whether patients’ bite force (BF) influences dental implant (DI) stability — using a prospective cohort design with repeated BF and ISQ measurements. The topic is relevant to implant planning and prosthetic design. However, major methodological, statistical, and reporting problems limit confidence in the presented conclusions. The manuscript requires focused revision before it is acceptable for publication.

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Major strengths

==========

- Clear, clinically relevant question with direct implications for implant loading and prosthetic planning.

- Prospective cohort design with repeated measurements (three time points) and use of objective tools: Loadstar sensor for force and Osstell ISQ for stability.

- Inclusion of both anterior and posterior implant sites and sex-stratified reporting.

- Availability of underlying data and STROBE checklist as supporting files.

Major weaknesses that must be fixed

======================

1. Study population and inclusion/exclusion inconsistency

- Textual contradictions about exclusion criteria (e.g., “Patients with … missing permanent teeth” appears in exclusion list but is central to implant patients). Inclusion/exclusion must be unambiguous and justified.

2. Sample size and group structure

- Power analysis stated 18 per group but no clear definition of the groups (4 groups mentioned). Provide exact group definitions, how 80 participants map to groups, and the assumptions used in the G*Power calculation (effect size, SD, correlation for repeated measures).

3. Statistical methods and reporting

- Normality and homoscedasticity results are asserted but diagnostic outputs and decisions (parametric vs nonparametric) are not shown.

- Choice and implementation of repeated-measures models are unclear: reported ANOVA tables look inconsistent with repeated-measures design, no within-subjects factor structure or sphericity checks (Mauchly) are reported, no correction (Greenhouse-Geisser) if sphericity violated.

- Multiple testing and post hoc strategy are unclear; interaction tests (time × sex × site) are absent.

- Correlation and regression: Pearson r reported despite apparent nonlinearity and use of aggregated values (means) rather than within-subject paired BF–ISQ observations; regression diagnostics and model fit not provided.

4. Outcome definitions and timing

- “Success” described qualitatively but no objective failure events, thresholds, or censoring are reported; ISQ change is used as a surrogate but this must be justified and pre-specified.

- Timing description ambiguous: “second visit at six months” and “third visit after one-half year” — clarify exact intervals (e.g., baseline = day of crown insertion; 6 months; 12 months).

5. Data presentation problems

- Tables contain inconsistent entries, typographical errors and unclear numeric formats (e.g., “272 .. 2”, multiple stray symbols, inconsistent ± placement), making independent verification impossible.

- Figures include linear fits where scatter suggests nonlinearity; many axis labels and units missing and figure quality is poor.

6. Interpretation overreach

- Authors make causal-sounding statements and broad claims about long-term implant success based on short (1 year) observational data and correlational analyses.

- Gender statements are speculative without interaction tests or adjustment for confounders.

7. Confounding and covariates

- Key confounders (age as continuous, bone quality/density, implant length/diameter, implant location [maxilla/mandible], surgical technique, immediate vs delayed loading, opposing dentition, parafunction/bruxism, medication, periodontal status) are either not reported or not adjusted for in analyses.

8. Ethics and data availability statements

- Ethics approval and consent are claimed but supporting documentation (ethics ID is given) should be consistent with institutional format; the data availability statement needs to specify how readers access the dataset and what identifiers are included/removed to preserve anonymity.

---

Required edits (ordered by priority)

======================

1. Methods — participants

- Clarify inclusion/exclusion precisely and remove contradictory phrasing.

- Provide a flow diagram (enrolment → allocation → follow-up → analysis) with numbers lost to follow‑up and reasons.

2. Methods — sample size

- Report the exact G*Power inputs (effect size f or d, α, power, correlation among repeated measures, number of groups/time points) and how 80 participants were chosen.

3. Methods — statistical analysis (revise and expand)

- State data structure: subjects measured at 3 time points; BF and ISQ measured at anterior/posterior sites; sex as between-subjects factor.

- Use an appropriate repeated-measures model: mixed-effects model (preferred) or two-way repeated-measures ANOVA including time (within), site (within) and sex (between), and their interactions.

- Report checks: normality (Shapiro-Wilk) on residuals, homogeneity, sphericity (Mauchly), and handling of violations (Greenhouse-Geisser or mixed model). Show test statistics and p-values.

- For correlations use within-subject paired analyses (e.g., compute BF–ISQ correlation across measurements per subject and use mixed-effects regression to model ISQ ~ BF + time + site + sex + random intercept(subject)). Report fixed effects, 95% CIs, p-values, and model diagnostics (residuals, influence).

- Correct for multiple comparisons or justify not doing so.

4. Reporting of results

- Clean all tables: each cell must show mean ± SD (or median [IQR] if nonparametric). Remove typographical artifacts and ensure consistent units (N for force, ISQ units for stability).

- Report sample sizes for each stratum/time point (n per cell).

- Report effect sizes (partial eta-squared for ANOVA; regression coefficients with 95% CI; r and adjusted R^2 for correlations/regressions).

- Replace aggregated scatter/regression plots using subject-level paired points and overlay appropriate model fits; include residual/diagnostic plots in supplement.

5. Confounder adjustment

- Include implant-level and patient-level covariates in models: implant length/diameter, jaw (maxilla/mandible), bone quality rating (if available), immediate vs delayed loading, opposing dentition, age, and parafunctional habits. Present adjusted analyses and compare to unadjusted.

6. Hypothesis framing and interpretation

- Restate primary and secondary hypotheses, predefined primary outcome (e.g., change in ISQ at 12 months), and avoid causal language; discuss directionality and limits of observational data.

- Tone down claims about long-term success unless long-term (≥5 years) data exist.

7. Figures

- Improve figure clarity: label axes including units, show individual subject points, plot repeated-measures trajectories where helpful, and include legend and sample sizes.

- Replace simple linear fits with fitted mixed-model predictions if modeling repeated measures.

8. Tables of implants and procedural details

- Provide a table summarizing implant characteristics (brand, diameter, length, surface, site distribution) and surgical/prosthetic protocol (immediate loading protocol details, abutment type, whether platform switching used).

9. Data and ethics

- Confirm anonymization procedures for shared data and provide clear instructions for accessing supporting files; ensure consent wording matches data sharing.

- Include ethics committee name, reference number, and date of approval as per journal requirements.

10. Language and editing

- Correct typographical errors and awkward phrasing throughout; standardize use of terms: bite force (BF), occlusal force (OF) — choose one term and use consistently.

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Statistical issues explained and required changes

=============================

- Model selection: Repeated observations per subject violate independence; simple one-way ANOVA or separate ANOVAs per group are inappropriate. Use linear mixed-effects models with random intercept (subject) and, if warranted, random slope (time) to account for within-subject correlation and unequal spacing, and include interaction terms (time × sex, time × site, BF × site).

- Sphericity: For ANOVA approaches report Mauchly’s test and apply Greenhouse-Geisser correction when violated.

- Correlation vs regression: Pearson r on aggregated mean values is misleading. Use subject-level paired BF–ISQ data and mixed regression to quantify association while adjusting for covariates. Report regression coefficient (β) interpreted as ISQ change per unit N BF, with 95% CI.

- Nonlinearity and heteroscedasticity: Inspect scatterplots and residuals; consider transformation or generalized additive models if relationship is non-linear. Report diagnostic plots (residual vs fitted, QQ-plot).

- Multiple testing: Many comparisons presented (sex, site, time, post hoc) — control false discovery (e.g., Bonferroni or report adjusted p-values) or focus on prespecified primary comparison.

---

Ethics, consent, data sharing — required clarifications

=================================

- Confirm ethics committee approval number and date; include statement that protocol was prospectively registered if applicable.

- Consent: clarify whether consent included data sharing and the form of anonymization for deposited data.

- Data availability: provide the exact repository link and DOI (supporting files are referenced but specify where and how to access raw data and code to reproduce analyses).

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My comments on this paper ordered according to the manuscript sections:

==============================================

1. Title and abstract

- Abstract must mirror revised primary outcome and analytic approach (state adjusted analyses and main effect estimates with CIs). Avoid causal phrasing (“impact on long-term success”) unless supported by study duration.

2. Introduction

- Tighten literature synthesis and explicitly identify the primary hypothesis and primary outcome measure.

3. Methods — participants

- Clarify exact inclusion/exclusion items and present a CONSORT-style (STROBE-adapted) flow diagram.

- Provide rationale for age range and reasons for excluding smokers/systemic disease (possible selection bias).

4. Methods — implants and procedures

- Give per-implant details: number of implants per patient, jaw (maxilla/mandible), tooth position, implant brand/size distribution, abutment type, immediate loading protocol specifics. State whether ISQ measured before and after prosthetic insertion.

5. Methods — BF measurement

- Describe Loadstar calibration, sensor placement protocol (how measured for anterior vs posterior), number of repeated bites averaged, and units (N). Report measurement reliability (intra-operator / test-retest) if available.

6. Methods — stability measurement

- Describe ISQ measurement protocol (Smartpeg type, measurement directions, operator blinding) and handling of multiple ISQ readings per implant.

7. Statistical analysis

- Replace current description with explicit mixed-effects model plan: formula, fixed and random effects, covariates, model selection, diagnostics, and multiple testing control. Provide software and package versions used. Report how missing data were handled (e.g., mixed models assume MAR; list any imputation).

8. Results — descriptive

- Provide baseline table with patient characteristics by sex and by implant site; include implant-level counts and per-timepoint sample sizes.

- Clean up Tables 1–3: ensure all values are mean ± SD with units, n per cell, and clear p-values and test statistics.

9. Results — main analyses

- Present adjusted mixed-model estimates (effect of BF on ISQ) with β, 95% CI, p-value. Provide interaction tests (BF × sex, BF × site). If interaction non-significant, present pooled estimates and exploratory stratified analyses.

10. Results — figures

- Provide subject-level scatterplots (BF vs ISQ) with model-predicted lines and 95% CI; include residual diagnostics in supplement.

11. Discussion

- Restructure: start with main findings (with adjusted estimates), compare to prior studies, discuss biological plausibility, limitations (selection bias, short follow-up, residual confounding, measurement error), and implications.

- Remove causal wording; state that BF is associated with ISQ changes and that further longer-term and interventional studies are needed.

12. Limitations

- Expand: explain possible selection bias from excluding smokers/systemic disease, limited follow-up for “long-term” claims, and lack of randomization.

13. Conclusion

- Rephrase to reflect association rather than causation; avoid overreaching on “long-term success”.

14. Supplementary material

- Provide cleaned dataset and analysis script (R, SAS, SPSS) or at least provide sufficient summary statistics to reproduce results.

---

Overall Suggestion:

- Major revision required. The manuscript addresses an interesting question and has useful primary data, but the issues in methods, statistical analyses, data presentation, and interpretation are substantial and must be corrected before re-review. Recommend resubmission only after the authors implement the required methodological/statistical revisions and provide cleaned tables, improved figures, and appropriately adjusted analyses.

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Reviewer #4: No

**********

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PLoS One. 2026 Jan 20;21(1):e0340355. doi: 10.1371/journal.pone.0340355.r006

Author response to Decision Letter 3

12 Dec 2025

Dear Editors and Reviewers:

Thank you for your letter and for the reviewers’ comments concerning our manuscript entitled “The impact of bite force on the stability of dental implants”. Those comments are all valuable and very helpful for revising and improving our paper, as well as the important guiding significance for our research. We have studied comments carefully and have made corrections which we hope will meet with approval. The revised portion is marked green in the paper.

Response to the comment of Reviewer 4

1. Response to comment: 1. Methods — participants

- Clarify inclusion/exclusion precisely and remove contradictory phrasing.

- Provide a flow diagram (enrolment → allocation → follow-up → analysis) with numbers lost to follow‑up and reasons.

Response: Thank you for your valuable feedback. I will revise the inclusion/exclusion precisely and remove contradictory phrasing to include a clear sentence in green and add a flow diagram.

This is revised

The inclusion criteria were male and female patients aged 25-40 years, who had sufficient bone volume for DI placements instead missing number of natural teeth and had natural occlusions, opposed natural teeth should be presented to implants that needed to be inserted, understood and signed an informed consent form, and were followed up at postoperative visits. Patients with a history of systemic diseases affecting bone metabolism, periodontitis, cigarette smoking, or drinking alcohol were excluded from the study. Moreover, the exclusion criteria included: they had missing permanent teeth which replaced by an implant, and a restoration with a crown of opposing, delayed loading, and parafunctional habits.

2. Response to comment: 2. Methods — sample size

- Report the exact G*Power inputs (effect size f for d, α, power, correlation among repeated measures, number of groups/time points) and how 80 participants were chosen.

Response: Thank you for your suggestion. I was explaining sample size calculation by using G*Power inputs (effect size f, α, power, correlation among repeated measures, number of groups/time points) and how 80 participants were chosen. It depended on the pilot study resulting of 12 patients with DIs placed, three in each group (3 patients placed DIs for anterior regions of male, 3 patients placed DIs for posterior regions of male, 3 patients placed DIs for anterior regions of female and 3 patients placed DIs for posterior regions of female) that BF and ISQ measured during three visits interval (first visit during the day of insertion of the crown on the abutment of the implant (immediately loading), second visit at six months following insertion, and third visit after 18 months following insertion. Then these data were analyzed and resulted in a significant effect size of F at 0.4, and four groups. The total number of participants was around 80 to avoid patient dropouts, and these were divided into four groups.

This is revised

Sample Size Power Analysis

The sample size, calculated by G power, comprised 18 individuals in each group at a power of 80, an α probability of 0.05 that it depended on the pilot study resulting of 12 patients with DIs placed, three in each group (3 patients placed DIs for anterior regions of male, 3 patients placed DIs for posterior regions of male, 3 patients placed DIs for anterior regions of female and 3 patients placed DIs for posterior regions of female) that BF and ISQ measured during three visits interval (first visit during the day of insertion of the crown on the abutment of the implant (immediately loading), second visit at six months following insertion, and third visit after 18 months following insertion. Then these data were analysed and resulted in a significant effect size of F at 0.4, and four groups. The total number of participants was around 80 to avoid patient dropouts, and these were divided into four groups. 80 individuals of both genders who had lost some teeth and needed DIs for the anterior and posterior regions of the jaws.

3. Response to comment. Methods — statistical analysis (revise and expand)

A- State data structure: subjects measured at 3 time points; BF and ISQ measured at anterior/posterior sites; sex as a between-subjects factor.

B- Use an appropriate repeated-measures model: mixed-effects model (preferred) or two-way repeated-measures ANOVA including time (within), site (within), and sex (between), and their interactions.

C- Report checks: normality (Shapiro-Wilk) on residuals, homogeneity, sphericity (Mauchly), and handling of violations (Greenhouse-Geisser or mixed model). Show test statistics and p-values.

D- For correlations, use within-subject paired analyses (e.g., compute BF–ISQ correlation across measurements per subject and use mixed-effects regression to model ISQ ~ BF + time + site + sex + random intercept(subject)). Report 95% CIs, p-values, and model diagnostics (residuals, influence).

E- Correct for multiple comparisons or justify not doing so.

Response: Thank you for your comment.

A-I was adding the state data structure in the data collection part of the article.

B-I was adding detailed reporting of repeated-measures model in two-way repeated-measures ANOVA, including time (within), site (within), and sex (between), and their interactions. These analyses were conducted in the revision of Table 4.

C- I was explaining how to check the normality (Shapiro-Wilk) on residuals and homogeneity. The sphericity (Mauchly) and handling of violations (Greenhouse-Geisser on mixed model) were analysed in Table 5.

D-I was added to table 8 using mixed-effects regression to model ISQ ~ BF + time + site + sex + random intercept (subject) and 95% CIs, p-values

E – I corrected the multiple comparisons with the Bonferroni test in bite force and stability after justifying other factors.

This is revised

A-Data Collection

State data structure, subjects measured at 3 time points; BF and ISQ measured at anterior/posterior sites; sex as a between-subjects factor. Relevant clinical information, such as the patient’s characteristics after placement with a DI by a specialist, medical background, X-ray pictures, and scans of the inside of the mouth, was obtained from the computerised medical records and documents of the patient. A Loadstar™ sensor was used to collect the BF values of posterior and anterior implant areas [28]. This sensor offers various force-measuring solutions with updated data rates of up to 50 KHz, making it suitable for applications that require the BF to be noted soon after the operation and during consultation intervals. Regular monitoring of the BF and DI stability was crucial in the post-implantation phase. Loadstar™ sensor records were utilised to assess the OF and identify any abnormalities or imbalances. While the Osstell Implant Stability Quotient (ISQ) technology was used to evaluate the DI stability by examining the resonance frequency of the DI. The patients were also educated on proper oral hygiene practices, including avoiding excessive BF on the DI, maintaining regular dental visits, and promptly addressing any signs of discomfort or changes in the bite. The data availability was presented in supporting information files.

B- Table 4. Results of the two-way ANOVA of all groups for the implant occlusal forces and stability values between the time, locations of the implants, and gender.

Value 1st 2nd 3rd

Bite forces(N) Time 0.750 0.051* 0.075

locations of the implants 0.657 0.534 0.042*

Time × Location 0.134 0.016 * 0.042 *

gender 0.119 0.052 0.157

gender × Time 0.250 0.007 * 0.870

gender × Location 0.720 0.321 0.520

stabilityISQ Time 0.923 0.809 0.162

locations of the implants 0.185 0.436 0.137

Time × Location 0.977 0.811 0.516

gender 0.170 0.162 0.259

gender × Time 0.186 0.044 * 0.199

gender × Location 0.472 0.199 0.289

* denotes a significant difference, with p < 0.05.

C-. The Shapiro-Wilk test was used to detect whether the quantitative data were normally distributed. The normality of distribution (parametric)was significantly result by used the Shapiro–Wilk. The parametric data was analyzed.

Table 5. Results of the sphericity (Mauchly), and handling of violations (Greenhouse-Geisser

Residual variables Influence variables 1 First visit 2 Second visit 3 Third visit Mauchly Greenhouse-Geisser

Bite forces(N) Time 0.750 0.051* 0.075 0.071 0.052

locations of the implants 0.657 0.534 0.042* 0.018* 0.001

Time × Location 0.134 0.016 * 0.042 * 0.001* 0.000

gender 0.119 0.052 0.157 0.093 0.076

gender × Time 0.250 0.007 * 0.870 0.024* 0.001*

gender × Location 0.072 0.032* 0.052* 0.001* 0.000*

Stability ISQ Time 0.923 0.809 0.162 0.063 0.099

locations of the implants 0.0185 0.0436 0.0137 0.0591* 0.003*

Time × Location 0.097 0.011* 0.051* 0.022* 0.000*

gender 0.170 0.162 0.259 0.001* 0.001*

gender × Time 0.186 0.044 * 0.191 0.007* 0.000*

gender × Location 0.472 0.019* 0.028* 0.004* 0.000*

* denotes a significant difference, with p < 0.05.

D- Table 8. Differences in regression coefficients (b) for BF and implant ISQ between the Time, Location of Implants, and Gender. b illustrated the mean percentage change in one unit of influencing variables (Time, Location of Implants, and Gender) based on the change in BF and implant ISQ. Significant differences in the regression coefficients (b) are denoted by * (p < 0.05). The term ratio reflects the quotient of bISQ / bBF.

Variables 1 First visit 2 Second visit 3 Third visit

Influencing variables Residual

varibles b (%) 95% CI b (%) 95% CI b (%) 95% CI

Time BF 12.4 * (10.7-13.8) 16.1* 4.6 10.2 19.8* 13.5 17.9

ISQ 39.3 * (25.5-56.9) 49.2 66.7 107.6 58.4* 70.2 97.1

Ratio 3.1 3.0 2.9

Location of Implants BF 19.4 * (12.6- 17.6) 22.8* 5.5 10.1 24.6 3.9 5.8

ISQ 40.8 * (79.2- 86.0) 56.2* 127.3 83.2 66.4* 44.0 58.5

Ratio 2.1 2.4 2.6

Gender BF 16.4 * 12.6 17.6 24.5* 13.5 17.9 30.2* 14.4 18.4

ISQ 62.5* 79.2 86.0 78.3 82.2 97.1 88.1* 53.7 102.3

Ratio 3.8 3.1 2.9

* denotes a significant difference, with p < 0.05.

E- Table 6. Intergroup Comparisons of Mean Occlusal Force and Stability in both genders. the Means Comparison tab, select the Bonferroni test for bite force and stability

Variable Groups Groups Bonferroni test p value

Bte Force Anterior BF in males Posterior BF in males 23.84 0.008

Anterior BF in females 11.922 0.042

Posterior BF in females 33.42 0.055

Posterior BF in males Anterior OF in females 39.21 0.057

Posterior BF in females 18.22 0.013

Anterior BF in females Posterior BF in females 28.63 0.034

Stability Anterior DIs stability in males Posterior DIs stability in males 32.08 0.011

Anterior DIs stability in females 21.46 0.028

Posterior DIs stability in females 28.36 0.046

Posterior DIs stability in males Anterior DIs stability in females 31.68 0.003

Posterior DIs stability in females 19.22 0.005

Anterior DIs stability in females Posterior DIs stability in females 39.114 0.001

Significant at (p <0.05); Bonferroni test.

4- Response to comment:4- Reporting of results

A- Clean all tables: each cell must show mean ± SD (or median [IQR] if nonparametric). Remove typographical artifacts and ensure consistent units (N for force, ISQ units for stability).

B- Report sample sizes for each stratum/time point (n per cell).

C- Report effect sizes (ANOVA; regression coefficients with 95% CI; r and adjusted R^2 for correlations/regressions).

Response: Thank you for your question.

A-I was the clear mean ± SD of parametric data in cells of Table 2,3. I added the consistent units (N for force, ISQ units for stability).

B-I was reporting the sample sizes for each stratum/time point (n per cell) in table 2,3.

C- I was writing a new analysis of these data, depending on ANOVA, regression coefficients with 95% CI; r and adjusted R^2 for correlations/regressions.

5- Response to comment: 5. Confounder adjustment: Include implant-level and patient-level covariates in models: implant length/diameter, jaw (maxilla/mandible), bone quality rating (if available), immediate vs delayed loading, opposing dentition, age, and parafunctional habits.

Response� Thank you for this suggestion. I was clarifying the details of implant-level and patient-level covariates in models in Table 1.

This is revised

Table 1. Demographic data.

DIs for the anterior regions of males DIs for the posterior regions of males DIs for the anterior regions of females DIs for the posterior regions of females p value

Number of patients (total) 20 20 20 20 0.11

Age 35 37 36 34 0.18

Gender 20 20 20 20 0.21

Number of implants (total) 45 76 43 71 0.79

Implant diameter

3.3 mm 8 10 7 12 0.122

3.5 mm 19 22 23 21 0.084

3.8 mm 14 24 11 30 0.056

4 mm 4 20 2 8 0.077

Length

9 mm 13 49 15 42 0.095

10 mm 25 22 19 23 0.082

11 mm 7 5 9 6 0.112

Significant (p-values ≤.05), non-significant (p-values > 05

6- Response to comment: 6. Hypothesis framing and interpretation

- Restate primary and secondary hypotheses, predefined primary outcome (e.g., change in ISQ at 12 months), and avoid causal language; discuss directionality and limits of observational data.

- Tone down claims about long-term success unless long-term (≥5 years) data exist.

Response� Thank you for this suggestion. I was corrected primary outcome, secondary outcome, and hypotheses.

This is revised

The hypothesis is that there was a change in BF and ISQ of DIs during 18 months, followed insertion of the crown on the abutment of the implant. The null hypothesis is that there was no change in BF and ISQ of DIs during 18 months, following the insertion of the crown on the abutment of the implant.

Outcome Measures

The main objective of the study was to determine the relationship between the BF and the stability of DIs during the 18 months that followed. The secondary outcomes included influencing time, gender, and the DI location in the jaws on the BF and the DI stability.

7- Response to comment: 7. Figures

- Improve figure clarity

Response: Thank you for your valuable feedback. I added Figure 2. The CONSORT 2010 flow diagram, and clear other figures.

8- Response to comment: 8. Tables of implants and procedural details

Provide a table summarizing implant characteristics (brand, diameter, length, surface, site distribution) and surgical/prosthetic protocol (immediate loading protocol details, abutment type, whether platform switching was used).

Response� Thank you for this suggestion. I added Table 1 summarizing implant characteristics (diameter, length, and number of implants in each size and group). Further surgical procedure (immediate loading protocol details.

This is revised

Table 1. Demographic data.

DIs for the anterior regions of males DIs for the posterior regions of males DIs for the anterior regions of females DIs for the posterior regions of females p value

Number of patients (total) 20 20 20 20 0.11

Age 35 37 36 34 0.18

Gender 20 20 20 20 0.21

Number of implants (total) 45 76 43 71 0.79

Implant diameter

3.3 mm 8 10 7 12 0.122

3.5 mm 19 22 23 21 0.084

3.8 mm 14 24 11 30 0.056

4 mm 4 20 2 8 0.077

Length

9 mm 13 49 15 42 0.095

10 mm 25 22 19 23 0.082

11 mm 7 5 9 6 0.112

Surgical Procedure

The implants distributed were placed in the anterior and posterior regions of the jaws (Table 1). Following dental cone-beam computed tomography (CBCT), the quantity and quality of bone were assessed, and a stent was created for implantation at the proper location for each patient. No bone augmentation treatment was used throughout the implant placement process. As instructed by the manufacturer, the location was drilled using a point Lindemann drill first, then surgical drills. A skilled researcher meticulously drilled every dental implant bed at a consistent length and angles in order to produce comparable insertion torque values (ITV) of about 35 Ncm amongst the implants. A drilling machine specifically made for implant surgery was used for measuring ITV as much as 35 Ncm at around 20 rpm and 8 Hz. The drill unit's handpiece was the only tool used to put each implant. Following surgery, CBCT was utilized to

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The impact of bite force on the stability of dental implants

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Data Availability Statement

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PERMALINK

The impact of bite force on the stability of dental implants

Nawres Bahaa Mohammed

Zina Ali Daily

Mohammed Rhael Ali

Noor Fathi Kazim

Hashim Mueen Hussein

Athraa Ali Mahmood

Roles

Abstract

Background

Methods

Results

Conclusions

Introduction

Materials and methods

Sample size power analysis

Study population

Data collection

Dental Implant (DI) characteristics

Surgical procedure

Table 1. Demographic data.

Bite Force (BF) assessment

Fig 1. Load star sensor.

Stability measurements

Outcome measures

Statistical analyses

Results

Fig 2. The CONSORT flow diagram.

Table 2. The Anterior & Posterior Bite Forces in Males & Females.

Fig 3. The mean value differences of anterior bite forces and posterior bite forces in males (a); The mean value differences of anterior bite forces and posterior bite forces in females (b).

Table 3. The Anterior and Posterior Dental Implant Stability in Males and Females.

Fig 4. The mean value differences of anterior implant stability and posterior implant stability in males (a); The mean value differences of anterior implant stability and posterior implant stability in females (b).

Table 4. Results of the two-way and three-way ANOVA of all groups for the bite forces and implant stability values between the time, locations of the implants, and gender.

Table 5. Results of the sphericity (Mauchly), and handling of violations (Greenhouse-Geisser).

Table 6. Intergroup Comparisons of Mean Bite Force and Stability in both genders by using the Bonferroni test after adjustment of other factors.

Table 7. The Correlation between Bte Forces and Dental Implant Stability in Males and Females.

Discussion

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Antonio Riveiro Rodríguez

Roles

Author response to Decision Letter 1

Decision Letter 1

Antonio Riveiro Rodríguez

Roles

Author response to Decision Letter 2

Decision Letter 2

Antonio Riveiro Rodríguez

Roles

Author response to Decision Letter 3

Decision Letter 3

Antonio Riveiro Rodríguez

Roles

Acceptance letter

Antonio Riveiro Rodríguez

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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