Finite element analysis of implant-supported prosthesis with pontic and cantilever in the posterior maxilla

The aim of this study was to evaluate the influence of pontic and cantilever designs (mesial and distal) on 3-unit implant-retained prosthesis at maxillary posterior region verifying stress and strain distributions on bone tissue (cortical and trabecular bones) and stress distribution in abutments, implants and fixation screws, under axial and oblique loadings, by 3D finite element analysis. Each model was composed of a bone block presenting right first premolar to the first molar, with three or two external hexagon implants (4.0 × 10 mm), supporting a 3-unit splinted dental fixed dental prosthesis with the variations: M1 – three implants supporting splinted crowns; M2 – two implants supporting prosthesis with central pontic; M3 – two implants supporting prosthesis with mesial cantilever; M4 – two implants supporting prosthesis with distal cantilever. The applied forces were 400 N axial and 200 N oblique. The von Mises criteria was used to evaluate abutments, implants and fixation screws and maximum principal stress and microstrain criteria were used to evaluate the bone tissue. The decrease of the number of implants caused an unfavorable biomechanical behavior for all structures (M2, M3, M4). For two implant-supported prostheses, the use of the central pontic (M2) showed stress and strain distributions more favorable in the analyzed structures. The use of cantilever showed unfavorable biomechanical behavior (M3 and M4), mainly for distal cantilever (M4). The use of three implants presented lower values of stress and strain on the analyzed structures. Among two implant-supported prostheses, prostheses with cantilever showed unfavorable biomechanical behavior in the analyzed structures, especially for distal cantilever.     

Mechanical behavior of a new biphasic calcium phosphate bone graft

The aim of this study was to create a new porous calcium phosphate implant for use as a synthetic bone graft substitute. Porous bioceramic was fabricated using a foam-casting method. By using polyurethane foam and a slurry containing hydroxyapatite-dicalcium phosphate powder, water, and additives, a highly porous structure (66 ± 5%) was created. The porous specimens possess an elastic modulus of 330 ± 32 MPa and a compressive strength of 10.3 ± 1.7 MPa. The X-ray diffraction patterns show hydroxyapatite and beta-pyrophosphate phases after sintering. A rabbit model was developed to evaluate the compressive strength and elastic modulus of cancellous bone defects treated with these porous synthetic implants. The compressive mechanical properties became weaker until the second month post implantation. After the second month, these properties increased slightly and remained higher than control values. New bone formed on the outside surface and on the macropore walls of the specimens, as osteoids and osteoclasts were evident two months postoperatively. Considering these properties, these synthetic porous calcium phosphate implants could be applicable as cancellous bone substitutes.     

Effect of ill-fitting dentures on the swallowing duration in patients using polygraphy

doi: 10.1111/j.1741‐2358.2011.00536.x Effect of ill‐fitting dentures on the swallowing duration in patients using polygraphy Background: Surface electromyography (SEMG) has been widely used in the recent years to study swallowing physiology, offering a valid and reliable tool for identifying normal swallowing. The goal of our study was to assess the contribution of denture fitness in the age‐related increase of swallowing duration. Methods: Twenty denture wearers and 20 dentate individuals were analysed using SEMG and a computerised kinesiography of mandibular movement. Three spontaneous saliva swallowings were recorded for each patient with both their old and new prostheses. Three spontaneous saliva swallowings were recorded for each dentate person in two different recording sessions. Results: Old prosthesis mean swallowing time was 1.84 (SD ± 0.85) seconds while the new well‐fitting prostheses needed a 1.28 (SD ± 0.55) (p = 0.0009) swallowing time. The difference in swallowing time was significant (p = 0.01) between dentate subjects and individuals wearing an old prosthesis. No significant difference was found between dentate subjects and the same prosthesis wearers when a new well‐fitting prosthesis was worn. Conclusion: Data presented in this work suggest that part of the increased duration of swallowing showed by elderly and healthy people is because of incorrect an dental prosthesis. Prolongation of swallowing duration in the elderly population could be reconsidered in the light of the quality of dental device worn by the aged population.     

3 种不同弹性模量钛合金股骨假体在羊股骨置换模型中应力分布的三维 有限元分析

目的:通过三维有限元分析方法来观察并比较3种不同弹性模量钛合金股骨假体在羊股骨置换模型中von-Mises应力分布的情况。方法:采用64排螺旋CT对一健康成年羊的下肢股骨进行全长的CT扫描,扫描层厚为0.5 mm,扫描所得的数据存储为DICOM文件。将得到的DICOM文件导入到CT图像分析软件Mimics 10.0,然后利用Mimics 10.0软件来生成股骨的骨质点云数据,再将生成的骨质点云数据导入到Simpleware分析软件,通过机械加工反求中的复杂曲面造型技术建立起精确的三维实体模型。对三维实体模型进行网格划分,确定了髓腔的形状,并根据羊下肢股骨髓腔的形状设计了作者实验用的羊股骨假体模型,然后在ANSYS 12.1软件中进行网格划分。给予加载缓慢行走载荷以及扭转载荷,分析并比较羊股骨以及3种不同弹性模量钛合金股骨假体在股骨置换模型中von-Mises应力分布的情况。结果:在缓慢行走载荷以及扭转载荷条件下,3种不同弹性模量钛合金股骨假体von-Mises应力分布变化趋势一致,假体的柄颈结合部以及假体柄上1/3为应力集中区域。3种不同弹性模量的最大应力集中点均位于柄颈结合部,60 GPa弹性模量的股骨假体植入后假体的最大应力最小(37.8 MPa、29.1 MPa),股骨的最大应力最大(12.6 MPa、24.5 MPa);80 GPa的次之,假体的最大应力(38.4 MPa、33.4 MPa),股骨的最大应力(12.5 MPa、24.5 MPa);110 GPa的股骨假体植入后假体的最大应力最大(38.9 MPa、38.1 MPa),股骨的最大应力最小(12.3 MPa、24.5 MPa)。60 GPa弹性模量的股骨假体植入后的假体最大位移和相对位移均最小(缓慢行走载荷下假体最大位移为0.551 mm、相对位移为0.008 mm,扭转载荷下假体最大位移为0.730 mm、相对位移为0.011 mm)。结论:较低弹性模量的钛合金股骨假体(60 GPa)由于其弹性模量更接近于骨组织的弹性模量,股骨假体与股骨间的"应力遮挡"效应较小,更有利于应力在股骨假体及股骨间的传递,增加了股骨假体的早期稳定性,延长了其临床寿命。     

Using 3D finite element models verified the importance of callus material and microstructure in biomechanics restoration during bone defect repair

Background: There is lack of further observations on the microstructure and material property of callus during bone defect healing and the relationships between callus properties and the mechanical strength. Methods: Femur bone defect model was created in rabbits and harvested CT data to reconstruct finite element models at 1 and 2 months. Three types of assumed finite element models were compared to study the callus properties, which assumed the material elastic property as heterogeneous (R-model), homogenous (H-model) or did not change from 1 to 2 months (U-model). Results: The apparent elastic moduli increased at 2 months (from 355.58 ± 132.67 to 1139.30 ± 967.43 MPa) in R-models. But there was no significant difference in apparent elastic moduli between R-models (355.58 ± 132.67 and 1139.30 ± 967.43 MPa) and H-models (344.79 ± 138.73 and 1001.52 ± 692.12 MPa) in 1 and 2 months. A significant difference of apparent elastic moduli was found between the R-model (1139.30 ± 967.43 MPa) and U-model group (207.15 ± 64.60 MPa) in 2 months. Conclusions: This study showed that the callus structure stability remodeled overtime to achieve a more effective structure, while the material quality of callus tissue is a very important factor for callus strength. At the meantime, this study showed an evidence that the material heterogeneity maybe not as important as it is in bone fracture model.     

Effect of different disinfectants on the microhardness and roughness of acrylic resins for ocular prosthesis

Background: Ocular prosthesis materials should have specific properties for their indication and durability; therefore, it is important to investigate their physical behaviour when affected by several disinfectants. Objectives: This study evaluated the influence of different disinfecting solutions on the microhardness and surface roughness of acrylic resins for ocular prosthesis. Materials and Methods: Fifty samples simulating ocular prostheses were fabricated with N1 resin and colourless resin and divided (n = 10) according to the disinfectant used: neutral soap, Opti‐free, Efferdent, 1% hypochlorite (HYC) and 4% chlorhexidine (CHX). Samples were stored in saline solution at 37°C and disinfected during 120 days. Both microhardness and roughness were investigated before, after 60 days and 120 days of disinfection and storage. Microhardness was measured using a microhardner and the roughness with a roughness device. Results: N1 resin showed lower microhardness when compared with colourless resin (p < 0.05). HYC and CHX groups exhibited the highest change of microhardness and roughness values (p < 0.05). An increase in roughness and reduction in microhardness of ocular acrylic resins were observed after both periods of disinfection and storage (p < 0.05). Conclusion: Both disinfection/storage periods affected the microhardness and roughness values of the samples.     

Influence of resin cement rigidity on the stress distribution of resin-bonded fixed partial dentures

The mechanical properties of the adhesive cement used in resin-bonded fixed partial dentures (RBFPD) can modify the clinical performance of the rehabilitation. The goal of this study was to evaluate the influence of the elastic modulus of different cements on the stress distribution in RBFPD using finite element analysis. For that an anterior 3-unit prosthesis was modeled based in a stereolithography file. The model was meshed with tetrahedral elements and materials considered isotropic, linearly elastic and homogeneous. The force applied to the palatal area of the lateral incisor (pontic) at 45° was 100?N. The cements used presented 7 different elastic modulus (E): 2, 6, 10, 14, 18, 22 or 26?GPa. The total deformation, von-Mises stress and maximum principal stress criteria were used to calculate the results. The lower tensile stress occurred in the cement layer with E?=?2?GPa [25.6 (canine) and 16.32?MPa (incisor)]. For the prosthesis, the model with the lower tensile stress [287 (canine) and 248?MPa (incisor)] occurred when the cement presented E?=?26?GPa.

In this way, the stress concentration may have its magnitude modified depending on the stiffness of the cement. Since more flexible cements concentrate less tensile stress in its structure, but allow an increased displacement of the prosthesis, which is friable and rigid and ends up concentrating more tensile stress at its connector. In that way the clinician should avoid the use of adhesive cement with lower elastic modulus due to it increases the stress concentration in the ceramic.     

Influence of functionally graded pores on bone ingrowth in cementless hip prosthesis: a finite element study using mechano-regulatory algorithm

Cementless hip prostheses with porous outer coating are commonly used to repair the proximally damaged femurs. It has been demonstrated that stability of prosthesis is also highly dependent on the bone ingrowth into the porous texture. Bone ingrowth is influenced by the mechanical environment produced in the callus. In this study, bone ingrowth into the porous structure was predicted by using a mechano-regulatory model. Homogenously distributed pores (200 and 800 \(\upmu \)m in diameter) and functionally graded pores along the length of the prosthesis were introduced as a porous coating. Bone ingrowth was simulated using 25 and 12 \(\upmu \)m micromovements. Load control simulations were carried out instead of traditionally used displacement control. Spatial and temporal distributions of tissues were predicted in all cases. Functionally graded pore decreasing models gave the most homogenous bone distribution, the highest bone ingrowth (98%) with highest average Young’s modulus of all tissue phenotypes approximately 4.1 GPa. Besides this, the volume of the initial callus increased to 8.33% in functionally graded pores as compared to the 200 \(\upmu \)m pore size models which increased the bone volume. These findings indicate that functionally graded porous surface promote bone ingrowth efficiently which can be considered to design of surface texture of hip prosthesis.     

Effect of glenoid prosthesis design on glenoid bone remodeling: Adaptive finite element based simulation

Glenoid prosthesis loosening is the most common cause for revision total shoulder arthroplasty. Improved glenoid prosthesis design requires looking beyond initial post-implantation static stress analyses. Adaptive bone remodeling simulations based on Wolff’s law are needed for predicting long-term glenoid prosthesis results. This study demonstrates the capability of predicting glenoid bone remodeling produced by changing prosthesis design features. Twelve glenoid prostheses were designed to fit each of six donor human glenoids, using combinations of three peg types and four backing-peg material combinations (polyethylene and or metal). The twelve FE prosthesis models were individually combined, simulating surgical implantation, with the glenoid models. Remodeling simulations, using a validated adaptive bone remodeling simulation, commenced with homogeneous glenoid bone density. To produce bone remodeling, center, posterior-offset, and anterior-offset physiologic loads were consecutively applied to the bone–prosthesis FE models for 300 iterations. Upon completion, region-specific mean predicted bone apparent densities were compared between bone–prosthesis and intact glenoid FE models. Metal fixations significantly increased proximal-center bone density. Polyethylene fixations resulted in bone density approximately equal to intact. Two angled polyethylene peg designs with longer-anterior and shorter-posterior pegs, reflecting natural glenoid shape, best maintained mid and distal glenoid bone density. While these initial results were not validated, they demonstrate the capability and potential of adaptive glenoid bone remodeling simulation. We expect FE glenoid bone remodeling simulations to become powerful and robust tools in the design and evaluation of glenoid prostheses.     

Topological optimization in hip prosthesis design

With particular interest on total hip arthroplasty (THA), optimization of orthopedic prostheses is employed in this work to minimize the probability of implant failure or maximize prosthesis reliability. This goal is often identified with the reduction of stress concentrations at the interface between bone and these devices. However, aseptic loosening of the implant is mainly influenced by bone resorption phenomena revealed in some regions of the femur when a prosthesis is introduced. As a consequence, bone resorption appears due to stress shielding, that is to say the decrease of the stress level in the implanted femur caused by the significant load carrying of the prosthesis due to its higher stiffness. A maximum stiffness topological optimization-based (TO) strategy is utilized for non-linear static finite element (FE) analyses of the femur–implant assembly, with the goal of reducing stress shielding in the femur and to furnish guidelines for re-designing hip prostheses. This is accomplished by employing an extreme accuracy for both the three-dimensional reconstruction of the femur geometry and the material properties maps assigned as explicit functions of the local densities.     

Influence of transmucosal height in abutments of single and multiple implant-supported prostheses: a non-linear three-dimensional finite element analysis

The aim of this study was to analyze the influence of three different transmucosal heights of the abutments in single and multiple implant-supported prostheses through the finite element method. External hexagon implants, MicroUnit, and EsthetiCone abutments were scanned and placed in an edentulous maxillary model obtained from a tomography database. The simulations were divided into two groups: (1) one implant with 3.75 × 10 mm placed in the upper central incisor, simulating a single implant-supported fixed prosthesis with an EsthetiCone abutment; and (2) two implants with 3.75 × 10 mm placed in the upper lateral incisors with MicroUnit abutments, simulating a multiple implant-supported prosthesis. Subsequently, each group was subdivided into three models according to the transmucosal height (1, 2, and 3 mm). A static oblique load at an angle of 45 degrees to the long axis of the implant in palatal-buccal direction of 150 and 75 N was applied for multiple and single implant-supported prosthesis, respectively. The implants and abutments were assessed according to the equivalent Von Mises stress analyses while the bone and ceramics were analyzed through maximum and minimum principal stresses. The total deformation values increased in all models, while the transmucosal height was augmented. The transmucosal height of the abutments influences the stress values at the bone, ceramics, implants, and abutments of both the single and multiple implant-supported prostheses, with the transmucosal height of 1 mm showing the lowest stress values.     

In vivo characterization of the mechanical properties of human skin derived from MRI and indentation techniques

The human skin is an exceedingly complex and multi-layered material. This paper aims to introduce the application of the finite element analysis (FEA) to the in vivo characterization of the non-linear mechanical behaviour of three human skin layers. Indentation tests combined with magnetic resonance imaging (MRI) technique have been performed on the left dorsal forearm of a young man in order to reveal the mechanical behaviour of all skin layers. Using MRI images processing and a pre and post processor allows to make numerically individualized 2D model which consists of three skin layers and the muscles. FEA has been applied to simulate indentation tests. Neo-Hookean slightly compressible material model of two material constants (C₁₀, K) has been used to model the mechanical behaviour of the three skin layers and the muscles. The identification of material model parameters was done by applying Levenberg–Marquardt algorithm (LMA). Our methodology of identification provides a range of values for each constant. Range of values of different material properties of epidermis, dermis, hypodermis are respectively, C10_E = 0.12 ± 0.06 MPa, C10_D = 1.11 ± 0.09 MPa, C10_H = 0.42 ± 0.05 KPa, K _E = 5.45 ± 1.7 MPa, K _D = 29.6 ± 1,28 MPa, K _H = 36.0 ± O.9 KPa.     

Poly(propylene fumarate) bone tissue engineering scaffold fabrication using stereolithography: effects of resin formulations and laser parameters

Stereolithography using photo-cross-linkable polymeric biomaterials is an effective technique for fabricating highly complex three-dimensional (3D) scaffolds with controlled microstructures for tissue engineering applications. In this study, we have optimized the UV curable polymer solution composition and laser parameters for the stereolithography machine. Poly(propylene fumarate) (PPF) was used as the biomaterial, diethyl fumarate (DEF) was used as the solvent, and bisacrylphosphrine oxide (BAPO) was used as the photoinitiator. Three different weight ratios of PPF/DEF and BAPO contents were characterized by measuring the viscosities and thermal properties of the un-cross-linked solutions and the mechanical properties of the formed scaffolds. After optimizing the resin composition by satisfying both the viscosity limitation and the mechanical requirement, laser parameters such as critical exposure (Ec) and penetration depth (Dp) were determined from the working curve and the relationship between laser speed and energy by measuring the thickness of predesigned windows fabricated in stereolithography with different ranges of Ec and Dp. Three-dimensional scaffolds with various pore sizes, pore shapes, and porosities were designed in computer-aided design (CAD) software and were fabricated in stereolithography. The fabricated scaffolds were characterized by measuring external dimensions, porosities, mean pore sizes, and compressive moduli and were compared to the CAD models. Feature accuracy in the xy-plane was achieved and overcuring of the resin in z-axis was minimized. The stereolithographically fabricated scaffolds with controlled microstructures can be useful in diverse tissue engineering applications.     

Hemolytic anemia following insertion of Ionescu-Shiley mitral valve bioprosthesis.

Hemolytic anemia is a relatively common complication after the replacement of cardiac valves with mechanical prostheses; the prevalence rate varies from 38% to 85%, depending on the prosthesis implanted. However, cardiac valves fabricated from biologic material are associated with a reduced incidence of hemolytic anemia, and to the authors'' knowledge this report is the first to document hemolytic anemia in a patient who had the mitral valve replaced with an Ionescu-Shiley valve. The anemia was not associated with evidence of hemodynamically important mitral regurgitation and was ultimately controlled by iron and folate supplements.     

Biomechanical properties of the pelvic floor muscles of continent and incontinent women using an inverse finite element analysis

Pelvic disorders can be associated with changes in the biomechanical properties in the muscle, ligaments and/or connective tissue form fascia and ligaments. In this sense, the study of their mechanical behavior is important to understand the structure and function of these biological soft tissues. The aim of this study was to establish the biomechanical properties of the pelvic floor muscles of continent and incontinent women, using an inverse finite element analysis (FEA). The numerical models, including the pubovisceral muscle and pelvic bones were built from magnetic resonance (MR) images acquired at rest. The numerical simulation of Valsalva maneuver was based on the finite element method and the material constants were determined for different constitutive models (Neo-Hookean, Mooney-Rivlin and Yeoh) using an iterative process. The material constants (MPa) for Neo-Hookean (c₁) were 0.039 ± 0.022 and 0.024 ± 0.004 for continent vs. incontinent women. For Mooney-Rivlin (c₁) the values obtained were 0.026 ± 0.010 vs. 0.016 ± 0.003, and for Yeoh (c₁) the values obtained were 0.031 ± 0.023 vs. 0.016 ± 0.002, (p < 0.05). Muscle displacements obtained in the numerical simulations of Valsalva maneuver were compared with the muscle displacements obtained through additional dynamic MRI. Incontinent women presented a higher antero-posterior displacement than the continent women. The results were also similar between MRI and numerical simulations (40.27% vs. 42.17% for Neo-Hookean, 39.87% for Mooney-Rivlin and 41.61% for Yeoh). Using an inverse FEA coupled with MR images allowed to obtain the in vivo biomechanical properties of the pelvic floor muscles, leading to a relationship between them for the continent and incontinent women in a non-invasive manner.     

Mechanical properties of a biodegradable bone regeneration scaffold

Poly (Propylene Fumarate) (PPF), a novel, bulk erosion, biodegradable polymer, has been shown to have osteoconductive effects in vivo when used as a bone regeneration scaffold (Peter, S. J., Suggs, L. J., Yaszemski, M. J., Engel, P. S., and Mikos, A. J., 1999, J. Biomater. Sci. Polym. Ed., 10, pp. 363-373). The material properties of the polymer allow it to be injected into irregularly shaped voids in vivo and provide mechanical stability as well as function as a bone regeneration scaffold. We fabricated a series of biomaterial composites, comprised of varying quantities of PPF, NaCl and beta-tricalcium phosphate (beta-TCP), into the shape of right circular cylinders and tested the mechanical properties in four-point bending and compression. The mean modulus of elasticity in compression (Ec) was 1204.2 MPa (SD 32.2) and the mean modulus of elasticity in bending (Eb) was 1274.7 MPa (SD 125.7). All of the moduli were on the order of magnitude of trabecular bone. Changing the level of NaCl from 20 to 40 percent, by mass, did not decrease Ec and Eb significantly, but did decrease bending and compressive strength significantly. Increasing the beta-TCP from 0.25 g/g PPF to 0.5 g/g PPF increased all of the measured mechanical properties of PPF/NVP composites. These results indicate that this biodegradable polymer composite is an attractive candidate for use as a replacement scaffold for trabecular bone.     

The effects of total hip arthroplasty on the structural and biomechanical properties of adult bone

The responsiveness of bone to mechanical stimuli changes throughout life, with adaptive potential generally declining after skeletal maturity is reached. This has led some to question the importance of bone functional adaptation in the determination of the structural and material properties of the adult skeleton. A better understanding of age-specific differences in bone response to mechanical loads is essential to interpretations of long bone adaptation. The purpose of this study is to examine how the altered mechanical loading environment and cortical bone loss associated with total hip arthroplasty affects the structural and biomechanical properties of adult bone at the mid-shaft femur. Femoral cross sections from seven individuals who had undergone unilateral total hip arthroplasty were analyzed, with intact, contralateral femora serving as an approximate internal control. A comparative sample of individuals without hip prostheses was also included in the analysis. Results showed a decrease in cortical area in femora with prostheses, primarily through bone loss at the endosteal envelope; however, an increase in total cross-sectional area and maintenance of the parameters of bone strength, I(x), I(y), and J, were observed. No detectable differences were found between femora of individuals without prostheses. We interpret these findings as an adaptive response to increased strains caused by loading a bone previously diminished in mass due to insertion of femoral prosthesis. These results suggest that bone accrued through periosteal apposition may serve as an important means by which adult bone can functional adapt to changes in mechanical loading despite limitations associated with senescence.     

Potential Use of Porous Titanium–Niobium Alloy in Orthopedic Implants: Preparation and Experimental Study of Its Biocompatibility In Vitro

Background

The improvement of bone ingrowth into prosthesis and enhancement of the combination of the range between the bone and prosthesis are important for long-term stability of artificial joints. They are the focus of research on uncemented artificial joints. Porous materials can be of potential use to solve these problems.

Objectives/Purposes

This research aims to observe the characteristics of the new porous Ti-25Nb alloy and its biocompatibility in vitro, and to provide basic experimental evidence for the development of new porous prostheses or bone implants for bone tissue regeneration.

Methods

The Ti-25Nb alloys with different porosities were fabricated using powder metallurgy. The alloys were then evaluated based on several characteristics, such as mechanical properties, purity, pore size, and porosity. To evaluate biocompatibility, the specimens were subjected to methylthiazol tetrazolium (MTT) colorimetric assay, cell adhesion and proliferation assay using acridine staining, scanning electron microscopy, and detection of inflammation factor interleukin-6 (IL-6).

Results

The porous Ti-25Nb alloy with interconnected pores had a pore size of 200 µm to 500 µm, which was favorable for bone ingrowth. The compressive strength of the alloy was similar to that of cortical bone, while with the elastic modulus closer to cancellous bone. MTT assay showed that the alloy had no adverse reaction to rabbit bone marrow mesenchymal stem cells, with a toxicity level of 0 to 1. Cell adhesion and proliferation experiments showed excellent cell growth on the surface and inside the pores of the alloy. According to the IL-6 levels, the alloy did not cause any obvious inflammatory response.

Conclusion

All porous Ti-25Nb alloys showed good biocompatibility regardless of the percentage of porosity. The basic requirement of clinical orthopedic implants was satisfied, which made the alloy a good prospect for biomedical application. The alloy with 70% porosity had the optimum mechanical properties, as well as suitable pore size and porosity, which allowed more bone ingrowth.