INTRODUCTION

The clinical success and longevity of endosteal dental implants as

load-bearing abutments are controlled largely by the mechanical setting
in which they function. The treatment plan is responsible for the design,
number and position of the implants. After achievement of rigid fixation,
proper crestal bone contour, gingival health, mechanical stress, and/or
strain beyond the physical limits of hard tissues have been suggested as
the primary cause of initial bone loss around implants. After successful
surgical and prosthetic rehabilitation with a passive prosthesis, such
noxious stresses and loads applied to the implant and surrounding tissues
result primarily from occlusal contacts. Complications (prosthetic and/or
bony support) reported in follow-up studies underline occlusion as a
determining factor for success or failure.
The choice of an occlusal scheme for implant-supported prostheses
is broad and often controversial. Almost all concepts are based on those
developed with natural teeth and are transposed to implant support
systems with almost no modification. No controlled clinical studies have
been published comparing the various implant occlusal theories.

RISK FACTORS - Implant prostheses with extended cantilevers

have been successful, however, biomechanical factors clearly
demonstrate an increased risk.
Biomechanical parameters are excellent indicators of the increased
risk because they are objective and can be measured. One can determine
which condition presents greater risk, and by how much the risk is
increased. Hence the occlusal concepts developed in this chapter stem
from biomechanical risk factors.

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 The restoring dentist has specific responsibilities to minimize
overload to the bone-to-implant interface. These include a proper
diagnosis leading to a treatment plan providing adequate support, based
on the patient’s individual force factors, a passive prosthesis of adequate
retention and form and progressive loading to improve the amount and
density of the adjacent bone and further reduce the risk of stress beyond
physiologic limits. The final element is the development of an occlusal
scheme that minimizes risk factors and allows the restoration to function
in harmony with the rest of the stomatognathic system.

TERMINOLOGY (GPT 1999)

Anterior protected articulation

A form of mutually protected articulation in which the vertical and

horizontal overlap of the anterior teeth disengage the posterior teeth in all
mandibular excursive movements.

Balanced articulation

The bilateral, simultaneous, anterior, and posterior occlusal contact

of teeth in centric and eccentric positions.

Canine protected articulation

A form of mutually protected articulation in which the vertical and

horizontal overlap of the canine teeth disengage the posterior teeth in the
excursive movements of the mandible.

Implant Prosthodontics

The phase of Prosthodontics concerning the replacement of

missing teeth and / or associated structures by restorations that are
attached to dental implants.

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Lingualized occlusion

First described by S. Howard Payne, DDS, in 1941, this form of

denture occlusion articulates the maxillary lingual cusps with the
mandibular occlusal surfaces in centric working and nonworking
mandibular positions. The term is attributed to Earl Pound.

Payne SH. : A posterior set up to meet individual requirements.

Dent. 1941; 47:20-2.

Pound E. Utilizing speech to simplify a personalized denture

service. J. Prosthet Dent. 1970;24:585-600.

Linguo occlusion

An occlusion in which a tooth or group of teeth is located lingual to

its normal position.

Mutually protected articulation

An occlusal scheme in which the posterior teeth prevent excessive

contact of the anterior teeth in maximum intercuspation, and the anterior
teeth disengage the posterior teeth in all mandibular excursive
movements.

Occlusion (1645) :

1. The act or process of closure or of bring closed or shut off

2 : the static relationship between the incising or masticating surfaces of

the maxillary or mandibular teeth or tooth analogues

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Spherical form of occlusion

An arrangement of teeth that places their occlusal surfaces on the

surfaces of an imaginary sphere (usually 8 inches in diameter) with its
center above the level of the teeth .

Implant protective occlusion

A proper occlusal scheme is a primary requisite for long-term
survival, especially when parafunction or marginal foundations are
present. A poor occlusal scheme both increases the magnitude of loads
and intensifies mechanical stresses (and strain) at the crest of the bone.
Implant Protective Occlusion (IPO) was previously known as medial
positioned-lingualized occlusion. This occlusal concept refers to an
occlusal plane that is often unique and specifically designed for the
restoration of endosteal implant, providing an environment for improved
clinical longevity of both implant and prosthesis.

OCCLUSAL CONSIDERATIONS:
Natural Tooth vs. Implant Mobility:
In comparison to an implant, the support system of a natural tooth
is designed to reduce the forces distributed at the crestal bone. The
fibrous tissue interface (periodontal ligament) surrounding natural teeth
acts as a viscoelastic “shock absorber”, serving to both decrease the
magnitude of stress to the bone at the crest, as well as extend the time in
which the load is dissipated.

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 The presence of a periodontal membrane around natural teeth
significantly reduces the amount of stress transmitted to the bone,
especially at the crestal region. Compared with a tooth the direct bone
interface with an implant is not as resilient, so the energy imparted by an
occlusal force is not partially dissipated (the displacement of the
periodontal membrane dissipates energy), but rather transmits a higher
intensity to the contiguous bone. An analogy of this is hitting a nail with a
steel hammer compared with a rubber hammer.
The mobility of a natural tooth can increase with occlusal trauma.
This movement dissipates stresses and strains otherwise imposed on the
adjacent bone interface or the prosthetic components. After the occlusal
trauma is eliminated, the tooth can return to its original condition with
respect to the magnitude of movement. Mobility of an implant can also
develop under occlusal trauma. However, after the offending element is
eliminated, an implant rarely returns to its original rigid condition.
Instead, its health is compromised, and failure is usually eminent.
The width of almost every natural tooth is greater than the width of
the implant used to replace the tooth. The greater the width of a
transosteal structure (tooth or implant), the lesser magnitude of stress
transmitted to the surrounding bone. The cross-section shape of the
natural tooth at the crest is biomechanically optimized to resist lateral
(buccolingual) loads because of the tooth’s bending fracture resistance
(moment of inertia) and the direction of occlusal forces. Implants are
almost all round in cross-section, which is less effective in resisting
lateral bending loads and consequent stress concentration in the crestal
region in the jaws.
The elastic modulus of a tooth is closer to bone than any of the
currently available dental implant biomaterials. The greater the flexibility
difference between two materials (metal and bone or tooth and bone), the

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greater the potential relative motion generated between the two surfaces
at the transosteal region. Hence under similar mechanical loading
conditions, implants generate greater stresses and strains at the crest of
bone compared with a tooth.
The precursor signs of occlusal trauma on natural teeth are usually
reversible and include hyperemia and occlusal or cold sensitivity.
Condition often results with the patient seeking professional treatment to
reduce the sensitivity, usually by occlusal adjustment and a reduction in
force magnitude. If the patient does not have an occlusal adjustment, the
tooth often further increases in mobility to dissipate the occlusal forces. If
the patient still fails to seek professional treatment for the increased
mobility, the tooth may orthodontically migrate away from the cause of
the occlusal stress. Even excess tongue or oral habits can cause tooth
migration away from the causative element.
The initial reversible signs and symptoms of trauma on natural teeth
do not occur with endosteal implants. The magnitude of stress may cause
bone microfractures, place the surrounding bone in the pathologic loading
zone causing bone loss, and lead to the mechanical failure of prosthetic or
implant components. Unlike the reversible signs and symptoms exhibited
by natural teeth, implant bone loss or unsecured restorations most often
occur without any warning signs. Implant occlusal sensitivity is
uncommon and signifies more advanced complications. The loss of
crestal bone around the implant is not reversible without surgical
intervention and results in a decreased implant support and increased
sulcus depth around the abutment. As a result, unless the density of bone
increases or the amount or duration of force decreases, the condition is
likely to progress and even accelerate until implant loss. In addition,
implants cannot move orthodontically away from the offending force.

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 The tooth can show clinical signs of increased stress such as
enamel wear facets, stress lines, lines of Luder (in amalgam fillings),
cervical abfraction, and pits on the cusps of teeth. An implant crown
rarely shows clinical signs other than fatigue fracture. As a result, fewer
diagnostic signs are present to warn the practitioner to reduce the stress
on the support system.
When teeth oppose each other, an interference perception is
approximately 20m. An implant opposing a natural tooth has an
interference perception of 48m, therefore more than twice as poor. An
implant opposing implant has an interference perception of 64m, and
when a tooth opposes an implant overdenture the awareness is 108m (5
times poorer than teeth opposing each other). As a result, premature
occlusal contacts on teeth are usually associated with a modification of
arc of closure and with a decreased force, before centric occlusion or full
interdigitation. In addition, the mandible may close in a different position
to avoid the premature contact and result in centric occlusion different
from centric relation occlusion. Unfortunately, because of the decreased
occlusal awareness of implants, the premature contact does not trigger
such as an adaptation. In addition, premature contacts are often on
smaller areas of load and therefore result in greater stress (S=F/A). They
are most often on inclines of posterior teeth, which also generates an
angled load of reater stress to the implant bone interface.

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 Implants and teeth also have different proprioceptive information
relayed by both entities. Teeth deliver a rapid, sharp pain sensation under
high pressure that triggers a protective mechanism. On the other hand,
implants deliver a slow, dull pain that triggers a delayed reaction, if any.
Clinical evidence of occlusal trauma on teeth includes an overall
increase in the periodontal membrane thickness and an increased
radiopacity and thickness of the cribriform plate around the tooth,
observed on radiographs and not just localized at the crest. There are no
generalized radiographic signs around an implant under excess occlusal
force, except at the crestal region, which demonstrates bone loss but may
be misdiagnosed as periimplant disease from bacteria.
The tooth slowly erupts into occlusion and is present in the mouth
from childhood. The surrounding bone has developed in response to the
biomechanical loads. The permanent teeth are gradually introduced, while
others are present. Hence periodontal tissues have had time to organize in
order to sustain increasing loads, including those brought to bear by an
attached prosthesis. The only progressive bone loading around an implant
is performed by the dentist, and in a much more rapid and intense
fashion.
A lateral force on a natural tooth is rapidly dissipated away from the
crest of bone toward the apex of the tooth. The healthy, natural tooth
moves almost immediately 56 to 108m and pivots two-thirds turn
toward the tapered apex with a lateral load. This action minimizes crestal
loads to the bone. An implant does not exhibit a primary immediate
movement, but a secondary movement 10 to 50m under similar lateral
loads. In addition, it does not pivot (as a tooth) toward the apex but
instead concentrates greater forces at he crest of surrounding bone.
Therefore if an initial angled load of equal magnitude and direction is
placed on both an implant and a natural tooth, the implant sustains a

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higher proportion of the load that is not dissipated to the surrounding
structures.
The natural tooth, with its modulus of elasticity similar to bone,
periodontal ligament, and unique cross-sections and dimensions
constitutes a near perfect optimization system to handle stress. In fact, the

stress is handled so well, bacteria-related disease is the weak link. An

implant handles stress so poorly (capturing the stress at the crest of the
ridge), has an elastic modulus 5 to 10 times that of bone, and is unable to
increase mobility without failure that stress is the weakest link in the
system. As a result, ways to decrease stress are a constant concern to
minimize the risk of implants complications.

Occlusion on Natural Teeth and Implants:

There has been an ongoing controversy regarding whether a rigidly
fixated implant may remain successful when splinted to natural teeth.
Because the implant has no periodontal membrane, concerns center
around the potential for the “nonmobile” implant to bear the total load of
the prosthesis when joined to the “mobile” natural tooth. The actual

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mobility of potential natural abutments may influence the treatment more
than any other factor. In the implant tooth fixed prosthesis, four important
components may contribute movement to the system, the implant, bone,
tooth, and prosthesis

The sudden, initial tooth movement ranges from 8 to 28m in a

vertical direction under a 3 to 5 lb load, depending on the size, number,
and geometry of the roots and the time elapsed since the last load
application. Once the initial tooth movement occurs, the secondary tooth
movement reflects the property of the surrounding bone and is very
similar to the bone implant movement. The axial movement of an implant
has no initial, sudden movement ad ranges from 3 to 5 m with little
correlation to the implant body length.
When teeth oppose each other, the combined intrusive movements
of the contacting elements may be 56m (28m + 28m). When a tooth
opposes an implant, the combined intrusive movement is 33m (28m +
5m). When implant prostheses oppose each other, the biomechanical

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mismatch between teeth in the rest of the mouth and implants increase.
The total combined movement may be 10m, compared with 56m in the
rest of the mouth, and contrary to the teeth that move immediately, even
with light loads, the implants only move this amount under a heavy
occlusal load. A lighter load may generate a total implant movement of
less than 3m.
Vertical movement of teeth and implants in the same arch, the
existing occlusion is evaluated before implant reconstruction. Occlusal
prematurities are ideally eliminated on teeth before implant
reconstruction. Thin articulating paper (less than 25m thickness) is then
used for the initial implant occlusal adjustment in centric relation
occlusion under a light tapping force. The implant prosthesis should
barely contact, and the adjacent teeth should exhibit greater initial
contacts. Only axial occlusal contacts should be present on the implant
crown. Once the equilibration with a light bite force is completed, a
heavier centric relation occlusal force is applied. The contacts should
remain axial over the implant body and may be of similar intensity on the
implant crown and the adjacent teeth under greater bite force to allow all
elements to react similar to the occlusal load. Hence to harmonize the

occlusal forces between implants and teeth, a heavy bite force occlusal

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adjustment is used because it depresses the natural teeth, positioning them
closer to the depressed implant position and equally sharing the load.
If healthy anterior teeth and/or natural canines are present, the
occlusion allows those teeth to distribute horizontal loads in excursions,
while the posterior teeth disocclude during excursions. Anterior,
compared with posterior bite force measurements and electromyographic
studies provide evidence that the stomatognathic system elicits
significantly less force when the posterior segments are not in contact. As
a result, all lateral excursions of IPO opposing fixed prostheses or natural
teeth should disocclude the posterior components. The resultant lateral
forces are thus distributed only to the anterior segments of the jaws,
resulting in a decrease in overall occlusal force magnitude because of
diminished muscle firing and recruitment.
This occlusal scheme should be followed whether or not anterior
implants are in the arch. However, if anterior implants must disocclude
the posterior teeth in excursion, two or more implants splinted together
should help dissipate the lateral forces.
Anterior implants and teeth are not connected. The initial lateral
movement of healthy anterior teeth ranges from 68 to 108m before
secondary tooth movement. Anterior implant movements are not
immediate and range from 10 to 50m. Because of the greater
discrepancies in lateral movement, the occlusal adjustment in this
direction is more critical to implant success and survival. Light force and
thin articulating paper are first used to ensure that no implant crown
contact occurs during the initial occlusal or lateral movement of the teeth.
A heavier force during centric occlusion and excursions is then used to
ensure that no implant crown contact occurs during the initial occlusal or
lateral movement of the teeth. A heavier force during centric occlusal
contacts on both anterior implants and natural teeth.

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 Unlike teeth, implants do not extrude, rotate, or migrate under
occlusal forces. Natural teeth do exhibit mesial drift, and slight changes
in occlusal position do occur over time. The proposed occlusal
adjustment does not encourage additional tooth movement because
regular occlusal contacts occur. The teeth opposing implants are not taken
out of occlusion. Brief occlusal contacts on a daily basis maintain the
tooth in its original position (similar to the rest of the mouth). In addition,
because most teeth occlude with two teeth, the opposing teeth positions
are even more likely to remain the same.
No occlusal scheme will prevent mesial drift and minor tooth
movement from occurring. An integral part of the IPO philosophy is the
regular evaluation and control of occlusal contacts at each regularly
scheduled hygiene appointment. This permits the correction of minor
variations occurring during long-term function and also helps prevent
porcelain fracture and other stress-related complications on the remainder
of the natural teeth.
Implants joined to natural teeth and a similar scenario is used for
the occlusal equilibration. A light force and thin articulating paper are
used, and the implant crown exhibits minimum contact compared with
the natural abutment crown. A gradient of force is designed on the
pontics. A heavy bite force is ten used to establish equal occlusal contacts
for all abutments and the entire prosthesis, whether implant or natural.

Implant Orientation and Influence of Load Direction:

Forces acting on dental implants are referred to as vectors (defined
in both magnitude and direction). Occlusal forces are typically three-
dimensional, with components directed along one or more of the clinical
coordinate axes.

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 Implants are designed for a long axis load to the implant body.
Stress contours were primarily concentrated at the transosteal (crestal)
region. An axial load over the long axis of an implant body generates a
greater proportion of compressive stress than tension or shear forces.

Any load that is applied at an angle may be separated into normal

(compressive and tensile) and shear forces. The greater the angle of loads
to the implant long axis, the greater the compressive, tensile and shear
stresses. When FEA evaluates the direction of the force changed to a
more angled or horizontal load, the magnitude of the stress is increased
by 3 times or more. In addition, rather
than a compressive type of force
primarily, greater tensile and shear
forces are also demonstrated and
increase more than 10 times compared
with the amount found with an axial
force. These stress contours resemble
the pattern of early crestal bone loss on
implants
.

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BONE MECHANICS AND OCCLUSION
The effect of offset or angled loads to bone is further exacerbated
because of the anisotropy of cortical bone. Aniosotropy refers to the
character of bone, whereby its mechanical properties, including ultimate
strength, depend on the direction in which the bone is loaded. Cortical
bone of human long bones has been reported as strongest in compression,
30% weaker in tension, and 65% weaker in shear. Therefore IPO attempts
to eliminate or reduce all shear loads to the implant to bone interface.

A force applied at a 30-degree angle decreased the bone strength

limits by 10% under compression and 25% with tension. A 60-degree
force reduced the strength 30% under compression and 55% under
tension. Therefore not only does the crestal bone load increase around the
implant with angled forces, but the amount of stress the bone may
withstand is also decreased. The greater the angle of load, the lower the
ultimate strength.

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 The primary component of the occlusal force should therefore be
directed along the long axis of the implant body, not on an angle or
following an angled abutment post. Angled abutments are used only to
improve the path of insertion of the prosthesis or the final esthetic result.
The angled abutment, which is loaded along the abutment axis, will
transmit a significant moment load to both the implant crestal region and
abutment screw, proportional to its angle of inclination. In addition, the
angled implant often requires an angled abutment. Angled abutments are
fabricated in two pieces and are weaker in design than a one-piece post.
Furthermore, a larger transverse load component develops at the crest as a
result of angled loads. An angled load to the implant long axis increases
the compressive forces at the crest of the ridge on the opposite side of the
implant in which the force is directed, increasing the tension component
of force along the same side. The greater the angle of force to the long
axis of the implant body, the greater the potentially damaging load at the
crest of the bone.
Hence the angled load increases the amount of crestal stresses
around the implant body, transforms a greater percentage of the force to
tensile and shear force, and reduces bone strength in compression and

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tension. In contrast, the surrounding implant body stress magnitude is
least and the strength of bone is greatest under a load axial to the implant
body.
Premature occlusal contacts result in localized lateral loading of the
opposing contacting crowns. Because the surface area of a premature
contact is small, the magnitude of stress in the bone increases
proportionately (i.e., stress=force/area). All the occlusal force is applied
to one region rather than being shared by several abutments and/or teeth.
In addition, the premature contact is most often on an inclined plane,
therefore creating a greater horizontal component to the load and
increasing compressive and tensile crestal stresses. Therefore occlusal
evaluation and adjustment in partially edentulous implant patients are
more important than in the natural dentition because the premature
contacts can result in more damaging consequences on implants
compared with teeth.

The elimination of premature contacts is more important than in

natural teeth because the implant is less mobile and often cannot
effectively dissipate the forces. In addition, the teeth benefit from a

17
greater occlusal awareness (proprioception) or oral tactile function than
implants.
Once the natural teeth are removed, the bone remodels to the
height at or below the lowest level of the lateral cortical plates. Hence the
implant crown height is often greater than the original natural anatomic
crown, even in Division A bone. Crown height, with a lateral load, is a
magnifier of stress to an implant to bone interface. The greater the crown
height, the greater the resulting crestal moment with any lateral
component of force that develops as a consequence of an angled load.
Angled abutments loaded in the direction of the abutment with an
increase in crown height are subject to even greater crestal moment loads
because of both the lateral load and the increased lever effect from the
crown height.
In the anterior maxilla, labial concavities may require that the
implant be angled away from the labial bone and the abutment toward the
facial crown contour. These implant bodies are more frequently loaded at
an angle, and an angled prosthetic abutment is required. As a result,
larger diameter implants or a greater number of implants are indicated to
minimize the crestal bone stress on each abutment. IPO aims at reducing
the force of occlusal contacts, increasing implant number, and/or
increasing implant diameter for implants subjected to angled loads or
with an increased crown height or on the cantilever portion of a
prosthesis.

Occlusal schemes:
A primary goal of an occlusal scheme is to maintain the occlusal
load that has been transferred to the implant body within the physiologic
limits of each patient. These limits are not identical for all patients or
restorations. The forces generated by a patient are influenced by

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parafunction, masticatory dynamics, tongue size, implant arch position
and location, and implant arch form and crown height. The implant
dentist can best address these force factors by selecting the proper
implant size, number, and position, using stress-relieving elements,
increasing bone density by progressive loading and selecting the
appropriate occlusal scheme.

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CLASSIFICATION OF OSSEOINTEGRATED PROSTHESIS
Hobo et al
1. Fully bone anchored bridge
2. Overdenture
3. Freestanding bridges
a. Kennedy class I
b. Kennedy class II
c. Kennedy class III
d. Kennedy class IV
4. Bridge connected to the natural teeth.
5. Single tooth replacement.

Misch C.E et al
TYPE DEFINITION
FP-1 Fixed prosthesis, replaces only the crown, looks like
a natural tooth
FP-2 Fixed prosthesis, replaces the crown and a portion
of the root, crown contour appears normal in the
occlusal half is elongated or hypercontoured in the
gingival half
FP-3 Fixed prosthesis, replacing missing crowns and
gingival colour and a portion of the edentulous site,
prosthesis must often use denture teeth and acrylic
gingiva, but may be porcelain to metal
RP-4 Removable prosthesis, overdenture supported
completely by implant
RP-5 Removable prosthesis, overdenture supported by
both soft tissue and implants

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IMPLANT PROTECTIVE OCCLUSION
When teeth are present, the maxillary dentate posterior ridge is
positioned slightly more facial than its mandibular counterpart. Once the
maxillary teeth are lost, the edentulous ridge resorbs in a medial direction
as it evolves from Division A to B, Division B to C, and Division C to D.
As a result, the maxillary permucosal implant site gradually shifts toward
the midline as the ridge resorbs. As a result of ridge resorption in width
the maxillary posterior implant permucosal site may even be lingual to
the opposing natural mandibular tooth. The posterior mandible also
resorbs lingually as the bone resorbs from Division A to B. As a
consequence, endosteal implants are also more lingual than their natural
tooth predecessors.

Occlusal Table Width:

A wide occlusal table favors offset contacts during mastication or
parafunction. Narrower implant bodies are even more vulnerable to
occlusal table width and offset loads. Wider root form implants can
accept a broader range of vertical occlusal contacts while still
transmitting lesser forces at the permucosal site under offset loads.
Therefore in IPO the width of the occlusal table is directly related to the
width of the implant body.

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 During mastication, the amount of force used to penetrate the food
bolus is also related to occlusal table width. For example, less force is
required to cut a piece of meat with a sharp knife (narrow occlusal table),
than with a dull knife (wider occlusal table). The greater surface area
requires greater force to
achieve a similar result.
Hence the wider the occlusal
table, the greater the force
developed by the biologic
system to penetrate the bolus
of food.
The posterior narrow occlusal table also facilitates daily home care.
The laboratory technician often attempts to fabricate occlusal facial and
lingual contours similar to that of natural teeth. This often results in ridge
laps or porcelain extension at the facial gingival margin of the implant, to
create an occlusal table approximately 8 to 10 mm wide. As a result,
home care in the sulcular region of the implant is impaired by the
overcontoured crown design. On the contrary, a narrow occlusal table
combined with a reduced buccal contour (in the posterior mandible)
permits easier sulcular oral hygiene in manner similar to a tooth and
improves axial loading.
The narrower occlusal contour also reduces the risk of porcelain
fracture. A facial profile similar to a natural tooth on the smaller diameter
implant results in cantilevered restorative materials. The facial porcelain
is most often not supported by a metal substructure because the gingival
region of the crown is also porcelain. As a result, shear forces result on
the buccal cusp on the mandibular crown or lingual cusps in the maxillary
crown, and are more likely to increase the risk of porcelain fracture.

22
 Restorations mimicking the occlusal anatomy of natural teeth often
result in offset loads (increased stress), complicated home care and
increased risk of porcelain fracture. As a result, in nonesthetic regions of
the mouth, the occlusal table should be reduced in width compared with
natural teeth.

DIVISION OF AVAILABLE BONE:A,B,C&D (MISCH)

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24
CROWN CONTOUR:
Division A Bone:
The primary component of the occlusal force is evaluated during the
treatment-planning phase. In an edentulous ridge with abundant height
and width and little resorption, the implant may be placed in a more ideal
position for occlusion and esthetics.
Offset loads are used to describe cantilevered buccal or lingual
occlusal contacts, not directed along the long axis of the implant body.
When offset loads are generated at an angle, the distance between the
offset contact and the long axis acts as a moment arm that magnifies the
effect of the lateral force.
The most common implant placement corresponds to a central
position in the residual ridge. The implant osteotomy begins in the center
of the crest and is gradually increased to the optimal width indicated win
relation to the recipient bone. Facial concavities are avoided, and the

25
thinner facial cortical bone is protected, to limit surgical complications
such as labial dehiscence. As a consequence, whether in the maxilla or
the mandible, the implant is frequently placed under the central fossa
region of the former natural tooth. To load the implant body in an axial
direction, the primary occlusal contact should therefore be the central
fossa region in Division A bone. Thus for maxillary implant opposing
mandibular natural teeth, the mandibular buccal cusp acts as the primary
tooth contact.

Because bone loss occurs at the expense of the facial plate, a

modified buccal contour anatomy may need to be generated in Division A
or B mandibles. The occlusal table width is reduced to favor an axial load
on the implant in nonesthetic regions. The Division A mandibular implant
is placed under the central fossa region of the natural tooth. When
opposing a natural maxillary molar, the primary contacting cusp becomes
the maxillary lingual cusp opposing the mandibular implant crown, with
the mandibular buccal cusp of decreased height and width over the
implant body. Hence all contacts are situated medially compared with
those on natural teeth.
The lingual contour of the mandibular implant crown is similar to
the original natural dentition in position, complete with horizontal overlap

26
to the maxillary lingual cusp to prevent tongue biting during function.
There is no occlusal contact on the lingual cusp, so offset loads during
parafunction are eliminated.

The posterior maxillary crown is reduced only from the lingual

aspect, compared with a natural maxillary molar, to reduce the occlusal
table width. such a reduction increases the lingual overjet when the teeth
are in occlusion. Narrower opposing mandibular occlusal tables are
desirable to direct occlusal forces over the maxillary implant body. As a

27
result, when opposing maxillary implants, the buccal cusps of natural
mandibular teeth (or crowns on implants) should be recontoured to
minimize offset loads in centric relation occlusion. The maxillary buccal
cusp may then be retained for esthetics, but the functional occlusal table
is reduced.
When esthetics are not a concern the distal one half of the first
molar and / or the entire second molar is often restored in cross bite to
improve the direction of forces. In the posterior esthetic regions of the
maxilla with facial bone resorption and / or lingually placed implants, a
wider occlusal table is required to project the facial contours for ideal
esthetics. Bone grafting to increase bone width may be required in these
esthetics zones, so a larger diameter implant may be placed that permits
restorations of the buccal contours with maintenance of cervical contours
with emergence profiles, which permit proper hygiene of the sulcular
regions.
Posterior implants opposing each other attempt to axially load both
entities. The facial cusp of the maxillary crown is required for esthetics.
The other contours of the opposing crowns are reduced in width to
minimize the occlusal table width and axially load the implants.
Whenever possible the portions of an implant crown that are not
supported by an axially positioned implant should be recontoured so they
do not receive occlusal loads. Alternatively, several additional implants
should be used to dissipate the force.

Division B Bone:
Division B bone has maxillary and mandibular implants positioned
under the lingual cusp when compared with the original natural tooth
position. As a result, mandibular crowns require even more reduced
buccal contours to avoid offset occlusal contacts. The primary contact of

28
occlusion on an opposing natural posterior maxillary tooth is the lingual
cusp, which is reshaped to axially load the implant. The buccal cusp of
the mandibular implant crown is located near the original central fossa of
the natural tooth. The medially positioned Division B mandibular implant
crown may have a central fossa, but it is more lingual than the original
position. The lingual contour of the crown is similar to that of the original
natural tooth and has an overjet with the opposing natural tooth to prevent
biting the tongue during function. The mandibular posterior implant may,
on occasion, be angled medially because of the sub mandibular fossa. As
a result, an angled abutment and a lingual straight emergence crown
profile to minimize the lingual volume of the restoration are indicated.
Augmentation of the mandibular Division B ridge is often required when
stress factors are moderate to improve the implant position and prosthetic
guidelines.

A Division B maxillary implant is often placed under the palatal

cusp region of the original natural tooth. The maxillary occlusal table
cannot always be reduced from the facial aspect for esthetic reasons;
therefore the buccal cusp is offset facially but left completely out of
occlusion (as with natural teeth) in centric relation occlusion and during
all mandibular excursions. The buccal cusp of the opposing natural tooth
is recontoured in width and height to reduce offset loads to the opposing
crown on the maxillary implant. The primary occlusal contact is centric

29
relation occlusion is the maxillary palatal
cusp over the implant body and the central
fossa region of the mandibular natural
tooth. Bone augmentation for larger
implant width is more indicated in the
maxilla because of the less dense bone and
the prosthetic needs to replace an esthetic
buccal crown contour.
When Division B implants are placed in both arches, the maxillary
and mandibular prostheses are similar to
that described in the previous scenario.
However, it is usually not possible to load
both arches with an axial load. When axial
loads to both arches are not possible, the
weakest implant in bone density, width, or
prosthesis type (fixed vs. removable)
determines the axial load, because it is the
most vulnerable arch.
In conclusion, the implant body should be
loaded in an axial direction. In a division A maxillary ridge the implant
can be placed under the central fossa region of the natural teeth. As a
result, the buccal cusp of the natural tooth in the mandibular arch is the
dominant occluding cusp. The palatal contour of the maxillary posterior
implant crown is reduced to eliminate offset loads. The position of the
buccal cusp should remain similar to that of the original tooth for proper
esthetics and should remain out of occlusion in centric relation and all
mandibular excursions. When further resorption occurs and the ridge
evolves into Division B, C or D, the maxillary palatal cusp becomes the
primary contact area, situated directly over the implant body. Hence the

30
occlusal contacts differ from those of a natural tooth and may even be
positioned more medial than the natural palatal cusp when the implant is
placed in Division C or D bone.
In mandibular Division A bone, the implant is located under the
central fossa, whereas in Division B, it is located under the lingual cusp
region of the preexisting natural tooth. As a result, mandibular endosteal
implants are always positioned more medial than the original buccal cusp.
All occlusal contacts are more medial than those on natural mandibular
teeth.

Influence of Surface Area:

An important parameter in IPO is the adequate surface area to
sustain the load transmitted to the prosthesis. It is important to remember
that mechanical stress, in its simplest form, can be defined as the force
magnitude divided by the cross sectional area over which that force is
applied.
When implants of decreased surface area are subject to angled or
increased loads, the magnified stress and strain magnitudes in the
interfacial tissues can be minimized by placing an additional implant in
the region of concern.
Thus when narrow diameter implants are used in regions that
receive greater forces, additional splinted implants are even more
indicated to compensate for their narrow design and to help decrease and
distribute the load over a broader region. When forces are increased in
magnitude, direction, or direction, or duration (e.g., parafunction), ridge
augmentation maybe required to improve implant placement, reduce
crown height, and increase implant width and number to compensate for
the increased loads.

31
 The prosthesis type may also be modified from a fixed restoration
(FP-1 to FP-3) to a removable prosthesis (RP-4). This is most effective
when nocturnal parafunction is present because the restorations may then
be removed while sleeping. In addition, stress relieving elements may be

32
included in the removable restoration, and additional support may be
gained from the soft tissue (RP-5 restorations).
Wider diameter root form implants have a greater area of bone
contact at the crest than narrow implants (resulting from their increased
circumferential bone contact areas). As a result, for a given occlusal load,
the mechanical stress at the crest is reduced with wider implants
compared with narrow ones.
Natural teeth follow similar principles of diameter and surface area
as just described. The anterior region of the mouth is characterized by
reduced bite force compared with the posterior region. Consequently, the
anterior tooth cross section is smaller, and the surface area is reduced
compared with the greater diameter and surface area of posterior teeth.

Design to the Weakest Arch:

Any complex engineering structure will typically fail at its
“Weakest link”, and dental implant structures are no exception.
The amount of force distributed to a system can be reduced by
stress relieving components that may dramatically reduce impact loads to
the implant support. The soft tissue of a traditional completely removable
prosthesis opposing implant prosthesis is displaced more than 2 mm and
is an efficient stress reducer. Lateral loads do not result with as great a
crestal load to the implants because the opposing prosthesis is not rigid.
The most common implant treatment, which includes a traditional
soft tissue supported complete denture, is a maxillary denture opposing a
mandibular implant supported restoration. The occlusal scheme for this
condition raises the posterior occlusal plane, uses a medial positioned
lingualized occlusion, and has a bilateral balanced scheme. Whether the
mandibular restoration is FP-1, FP-2, FP-3, RP-4, or RP-5, the maxillary
denture follows these guidelines.

33
 The mandibular implant supported restoration may exert greater
force on the premaxilla than a mandibular denture and cause accelerated
bone loss. Therefore modification of the occlusal scheme aims at
protecting the premaxilla under a maxillary denture by the total
elimination of anterior contacts with the mandibular anterior teeth in
centric occlusal relation.
Reduced occlusal forces with an absence of lateral contacts in
excursions are recommended on posterior cantilevers or anterior offset
pontics whenever possible. This minimizes the moment forces on the
abutments.
It is better for mandibular cantilever pontics to oppose maxillary
implants than the reverse situation.

FULL – ARCH FIXED PROSTHESES

(FP-1 to RP-4)
Fixed prostheses on natural teeth opposing FP-1 to RP-4 implant
restorations should follow mutually protected occlusal schemes whenever
possible. In protrusion, there should be total absence of posterior
contacts, especially for cantilevered posterior units. The masticatory force
generated during lateral excursions is decreased in absence of posterior
contacts. This assists in reducing the noxious effect of lateral forces on
the anterior implants. Two or more implants should share any lateral
force, and lateral excursions should occur as far forward as it practical
and include the canine.
Minimal occlusal contact in the cantilevered regions and the total
absence of posterior lateral contacts during excursions are indicated when
opposing the natural dentition or a fixed restorations.
Seven to eight implants to support a complete implant prosthesis in
two separate units are suggested in the mandible for a fixed restoration

34
opposing a fixed prosthesis or natural teeth with inadequate to severe
stress factors.

In the edentulous maxilla, flexure of the bone is not a concern. A

full arch prosthesis may be fabricated in one section.
Eight to ten maxillary implants most often are required for a twelve
unit fixed prosthesis opposing a fixed dentition on teeth and / or implants
with moderate to severe stress factors. Posterior implants are more critical
in the maxilla, in order to eliminate cantilevers and increase the
anteroposterior implant distance, which further decreases stress to the
maxillary anterior implants.

Implant supported overdenture (RP-5)

Anterior Tooth Position

Centric stops or pressure from the tongue and muscle positions
usually prevent continued extrusion of anterior natural teeth. maxillary
anterior prosthetic teeth are positioned forward of the anterior supporting
bone to satisfy phonetic and esthetic requirements. Moment forces result
from contact with the anterior teeth, which may cause instability of the
maxillary prosthesis. Therefore the maxillary denture usually does not
have anterior incisal centric stops. This helps protect the premaxilla from
excess forces in centric occlusion relation and initial excursions of the
mandible, as the premaxilla is vulnerable to resorption from external
stresses.

35
Posterior Tooth Position
The maxillary edentulous posterior ridge resorbs in a medial
direction s it transforms from Division A to B, Division B to C, and
Division C to D. therefore the maxillary denture tooth gradually becomes
more cantilevered off the bone support, even when positioned in the same
spatial location. The mandibular edentulous posterior ridge also resorbs in
a medial redirection as it transforms from Division A to B, but then
resorbs laterally from Division B to C, and more lateral as it resorbs from
Division C to D. In complete dentures, the position of the mandibular
posterior teeth is often determined first. Bone support concepts of
occlusion often position the mandibular teeth perpendicular to the
edentulous ridge. This positions the central fossa of the posterior
mandibular teeth more medial than that of their natural predecessors in
Division B, but more facial in Division C, and very facial in Division D
compared with the natural tooth placement.
The maxillary teeth are then situated farther facially than the
original teeth, if a normal cusp fossa relation is maintained.
Consequently, maxillary denture teeth are always placed lateral to the
resorbing bony support, and the condition is compounded in cases of
advanced atrophy (Division C or D bone).
The basic, concept of lingualized occlusion was first introduced by
Gysi. Later Payne suggested the maxillary buccal cusps of posterior teeth
should be reduced, so only the lingual cusps would be in contact. Pound
discussed a similar concept, but reduced the buccal cusp of the mandible
and introduced the term “lingualized” occlusion. Pound also placed the
lingual cusp of the mandibular posterior teeth between lines drawn from
the canine to each side of the retromolar pad. Consistent in the
Philosophy of Payne and Pound, was the belief that the palatal cusp

36
should be the only area of maxillary tooth contact. These occlusal
schemes were designed to narrow the occlusal table and improve
mastication, reduce forces to the underlying bone, and help stabilize a
lower denture. The techniques of Payne and Pound may be modified
further to a medial positioned lingualized occlusion, proposed by the
author.

Medial Positioned Lingualized occlusion : Laboratory steps

1. Mount the upper cast using a face bow record. Mount the lower
cast using the centric relation record. Set the horizontal condylar
guidance according to the protrusive record
2. Set the maxillary and mandibular anterior teeth for esthetics,
phonetics, and lip support.
3. Cut back the posterior flange of the lower record base to expose
the retromolar pad. Outline the retromolar pad in pencil. Draw a
line from the lingual border of the pad to the mesial aspect
cuspid. The central fossa of mandibular posterior teeth will be set
along this line.
4. Using a flat plane or 10 degree mold, set the mandibular posterior
teeth in a compensating curve. The curve should have both a
mediolateral and anteroposterior dimension that progressively
develops as the teeth are set posteriorly. The curve starts with the
first premolar and becomes more accentuated in the molar region
(closer to the condyle) (i.e., first premolar 0 to 5 degrees, second
premolar 5 to 10 degrees, first molar 15 to 20 degrees, second
molar 20 to 25 degrees). The anteroposterior angle of the curve
is the second molar region and should ideally approximate the
horizontal condylar guidance (i.e., 20 to 25 degrees).
5. Drop the incisal pin of the articulator 1 to 2 mm.

37
 6. Using a 30 to 33 degree mold, set the maxillary posterior teeth
with the buccal cusp tilted out facially. The lingual cusp should
contact the central groove of the mandibular teeth (this will be the
only tooth contact point). There should be no contact between the
mandibular or buccal cusp and the opposing maxillary tooth.
7. Return the incisal pin to the original position (up 1 to 2 mm).
8. Using articulating paper to check the contacts, grind a small fossa
in the mandibular tooth for the maxillary lingual cusp tip.
Continue to adjust the occlusion until the incisal pin touches the
incisal table. Check for balanced occlusion in excursions.
9. Festoon the set up for the try in appointment.

OCCLUSAL MATERIALS
The materials selected for the occlusal surface of the prosthesis
affect the transmission of forces and the maintenance of occlusal
contacts. In addition, occlusal material fracture is one of the most
common complications for restorations on natural teeth or implants.
Therefore it is wise to consider the occlusal material for each individual
restoration. Occlusal materials maybe evaluated by esthetics, impact
force, a static load, chewing efficiency, fracture, wear, interarch space
requirements, and accuracy of castings. The three most common groups
of occlusal material are fixed prostheses on implants are reviewed with
relevance to the previous eight criteria.

Esthetics:
Esthetics is a major concern for patients. The most esthetic material
available today is porcelain. Acrylic is acceptable for esthetics, and metal
is a poor choice of materials when esthetics is the chief criterion.
However, there are many situations in which esthetics is not an important

38
aspect of the restorations. For example, when a maxillary second molar is
restored, most patients do not expose this area when smiling or laughing.

Forces:
The materials on the occlusal aspect of the prostheses affect the
transmission of force to the bones. Impact loads give rise to brief
episodes of increases force, primarily related to the speed of closure and
the dampening effect of the occlusal material. The hardness of material is
related to its ability to absorb stress from impact loads. All porcelain
occlusal surface exhibits hardness 2.5 times greater than that of natural
teeth. Acrylic resin has a Knoop hardness of 17 kg/mm 2, and enamel has
a 350 kg/mm2 hardness. A composite resin may exhibit a hardness of
85% that of enamel. Therefore impact loads are lowest with acrylic,
increase with composite and metal occlusals, increase even more with
enamel, and further increase with porcelain. As a consequence, it has
been suggested to use resin because of its dampening characteristics.
Clenching patients do not have a considerable amount of stress
reduction when acrylic versus porcelain materials are used on the occlusal
surfaces.
Progressive bone loading is performed with acrylic transitional
prostheses. This material may reduce the impact force on the early
implant bone interface. As the bone matures and its density increases, the
need for force reduction decreases.

Chewing efficiency:
Fixed prostheses exhibit an improve efficiency compared with
removable soft tissue borne prostheses, regardless of the occlusal
material.

39
 Acrylic was 30% less efficient than porcelain or metal, whereas
there was no difference between gold and porcelain.

Wear:
The definition of wear is the deterioration, change or loss of a
surface caused by use. The factors affecting the amount of wear include
magnitude, angle, duration, speed, hardness, and surface finish of the
opposing force and surface, together with the lubricant, temperature, and
chemical natural of the surrounding environment. Most occlusal wear
occurs as a result of bruxism. An intuitive feeling is the harder the
occlusal material, the less the wear. However, surface hardness has been
shown to be a poor indicator of wear rate. Acrylic resin wears 7 to 30
times faster when opposing gold, resin, enamel, or polished porcelain,
compared with gold opposing gold, enamel or porcelain. Gold occlusal
surface exhibit less volume loss (sum of loss of opposing occlusal
surfaces) than any other combination of materials. Porcelain opposing
porcelain wears more than porcelain opposing gold or metal.

The wear rate of occlusal materials, especially in the partially

edentulous patient with unrestored teeth, should be similar to enamel. In
this way, occlusal changes will not dramatically change the occlusal
scheme. Lambrechts et al in an in vivo investigation reported vertical
wear of premolar and molar tooth enamel to be 20 to 40 um per year
when opposing the enamel of natural teeth.
In principle, for the partially edentulous patient it would be better
to have more occlusal wear on implants, rather than less, because the
additional forces on the teeth are better tolerated than on implant
prostheses. As a result, total volume wear may favor porcelain opposing
enamel for the implant prosthesis opposing teeth in the partially

40
edentulous patient and metal opposing enamel in the other regions of the
mouth that require restorations of natural teeth.
The use of gold, regardless of the opposing combination, always
provides the least total volume loss.
Adhesive wear occurs when one hard surface slides over a surface
of lesser hardness. As a result, wear fragments of one material adhere to
the other material. Gold occlusal surfaces are observed to have gold
particles adhered to enamel. This may account for less total volume loss
when opposing other materials.

For full arch implant supported prostheses, the restoring doctor

may consider metal occlusal to minimize wear and prolong the accuracy
of occlusal scheme long term. Porcelain in esthetic regions opposing gold
in the more nonesthetic area or metal occlusal in both arches when
parafunction or marginal interarch space is present are the material most
often selected as implant occlusal materials.

Materials fracture:
Materials fracture is one of the more common factors that lead to
refabrication of a prosthesis. Porcelain, acrylic and composite fractures
occur under excessive loads or even with a lesser load of longer duration,
angulation, or frequency. Acrylic or composite materials fracture more
easily. The compressive strength of acrylic resin is 11,000 psi, compared
with 40,000 psi for enamel. Composite resin is 3 times stronger than
acrylic.
Porcelain opposing porcelain is not suggested with extreme
parafunction, because it may fracture more often than porcelain opposing
metal. Metal occlusals do not easily fracture, provide good wear
resistance, and have minimum impact load compared with porcelain.

41
Accuracy:
Metal shrinkage is 10 times less than porcelain or acrylic and
therefore permits the fabrication of a more passive casting. When
accuracy of the casting is paramount, as with screw retained restorations,
the occlusal material may make a significant difference. This is most
important in regions of long spans and / or with a large volume of
materials.

Interarch space:
Acrylic restorations receive their strength from bulk and therefore
require greater interarch space. Metal occlusals require the least amount
of space. In addition, when increased retention of cement retained
prosthesis is required, a high abutment and greater retention may be
accomplished with a metal occlusal. Porcelain is intermediate in the
interarch space requirement.

Therefore when all seven criteria are evaluated, metal is an

excellent occlusal material, with improved properties in accuracy, wear,
fracture resistance, abutment retention, and good qualities for impact or
static force. Esthetics is best satisfied with porcelain, which has improved
properties compared with acrylic concerning fractures and retention.

42
SUMMARY

Osseointegrated supported prosthesis (ISP) have shown high

standard of success. This success rate depends not only on
meticulous surgical protocol but also on understanding concept of
occlusion.
Occlusion should be a key factor to overall success rate. The
concept of occlusion suitable for implant supported prosthesis is
basically the same as gnathological occlusion.
In Centric contact of the Osseo integrated crown or fixed prosthesis
should be slightly more open than natural teeth.
In centric Osseo integrated crown or fixed prosthesis should not
contact with opposing teeth under the soft bite pressure (to avoid
the occlusal load on the I.S.P. which leads overload the bone
structure)
Under the strong bite pressure Osseo integrated supported
prosthesis should contact after the natural tooth intrudes
approximately 30µm.
To avoid overloading of the occlusal surface, the I.S.P. should not
have plane-to-plane contact.
Point contact especially cusp-to-fossa tripodal contact is preferred.
During eccentric movement, in order to minimize horizontal
movement, the concept of disocclusion is generally recommended.
Anterior segments of the osseointegrated prosthesis should guide
the mandible to produce posterior disocclusion.
Canine guided occlusion is not recommended for the Osseo
integrated prosthesis to avoid excessive occlusal forces into the
single implant fixture which is placed in the canine area. Group

43
function is recommended to distribute the stress over the entire
fixture.
The ideal place to bear the horizontal load is the trapezoid area,
which is surrounded by the osseointegrated fixtures.
Load transmitted to the fixture is not so destructive when extended
mesially in the anterior region, whereas more destructive when
extended distally.

44
REVIEW OF LITERATURE
In 1984, J.B. Brunskin and J.A. Hipp studied the in vivo forces
on dental implants. Methods are presented for measuring vertical force
components or bridged titanium dental implants in dog mandibles. These
methods have included custom made strain gauge transducers, plus hard
wiring and telemetric schemes for data collection. The essential
components of the measurements system are described, and typical bite
force data are illustrated.

In 1989, B. Rangert, T. Jemt and L. Jorneus carried out a study

on the forces and moments on Branemark implants. The placement of
fixture (implants) in relation to the geometry of a prosthetic restoration
has a great influence on the mechanical loading of the implant. Based on
Theoretic consideration and clinical experiences with the Brenamark
system, this article gives simples guidelines for controlling these loads.
The emphasis is on design rules that can be used in clinical practice. With
the class I lever as a reference. Various clinical implant prosthesis
situations are discussed and evaluated.
In 1991, M.W. Parker reviewed the occlusal considerations in
restorative dentistry. The major topics include the assessment and
treatment of occlusal wear, the controversies surrounding treatment
position of the mandibular condyles, occlusal considerations in
osseointegrated prosthesis, the two way relationship between occlusal
factors and temporomandibular disorders, design criteria and longevity
studies in resin bonded, fixed partial denture.
In 1993, James De Boer discussed the edentulous implants an
emphasized that the occlusal contacts of the final fixed restoration are
affected significantly by implant position. Lateral occlusal forces, may
lead to abutment screw fracture. They may be due to either excessive

45
lateral occlusal pressure or a malposed implant that requires non axial
loading during normal function.
In 1994, C.E. Misch and M.W. Bidex discussed an implant
protected occlusal on a biomechanical rationale. The clinical success and
longevity of endosteal dental implants are controlled, in a large part, by
the mechanical milieu within which they function. The occlusion is a
critical component of such a mechanical environment. “Implant protected
occlusion” refer to an occlusal scheme that is often uniquely specific to
the restoration of endosteal implant prosthesis. Implant orientation and
the influence of load direction, the surface area of implants, occlusal table
width, and protecting the weakest area are blended together from a
biomechanical rationale to provide support for a specific occlusal
philosophy.

46
CONCLUSION

The local occlusal considerations in implant dentistry include the

transosteal forces, bone biomechanics, basic biomechanics, differences in
natural teeth and implants, muscles of mastication and occlusal force, and
bone resorption. The incorporation of all these factors lead to an occlusal
scheme (IPO) developed by the author.
Occlusal schemes consider the weakest component, full or partial
edentulous arches, and posterior or anterior teeth and / or implants. An
IPO is a consistent approach for implant occlusal schemes.
The material from which the occlusal regions are fabricated may
affect implant loading and also affect implant reaction forces to the
opposing arch. These occlusal materials also affect wear and fracture,
which affects the occlusal contacts, vertical occlusal dimension, and
esthetics. This chapter blends experience and biomechanical principles
for a consistent approach to occlusal considerations.

47
REFERENCES

1. Bidez MW, Misch CE : Force transfer in implant dentistry;

basic concepts and principles, Oral implant 18: 264-274, 1992.
2. Chee WWL, Cho GC : A rationale for not connecting implants
to natural teeth, J. Prosthod.6(1) :7-10, 1997.
3. Chibirka RM, Razzoog ME, Lang BR et al : determining the
force absorption, quotient for restorative materials used in implant
occlusal surfaces, J. Prosthet Dent 67 (3): 361-364, 1992.
4. Clelland NL, Lee JK, Bimbenet OC et al : A three dimensional
finite element stress analysis of angled abutments for an implant
placed in the anterior maxilla, J. Prosthodont 4(2):95-100, 1995.
5. Cowin SC : Bone mechanics, Boca Raton , Fla 1989, CRC
Press.
6. De Marco TL, Paine S : Mandibular flexure in opening and
closure movements, J Prosthet Dent. 31:482-485, 1974.
7. Goldstein GR : the relationship of canine protected occlusion to
a periodontal index, J. Prosthet. Dent. 41:277-283, 1979.
8. Hudson JD, Goldstein GR, Georgescur M. Enamel wear caused
by three different restorative material, J. Prosthet 74:647-654, 1995.
9. Isidor F : Loss of osteointegration caused by occlusal load of
oral implants, Clin Oral Implant Res.7:143-152, 1996.
10. Jemt T, Linden B, Lekholm U : failures and complications
in127 consecutively placed fixed partial prostheses supported by
Branemark implants ; from prosthetic treatments to first annual check
up , Int. J. Oral Maxillofac Impl. 7;40-44, 1992.
11. Ko CC DH, Hollister SJ : Micromechanics of implants /tissue
interfaces, J oral implantol 18: 220, 1992.

48
12. Krejci I,Lutz F,Reimer M et al: Wear of ceramic inlays, their
enamel antagonist and luting cements, J. Prosthet Dent 69: 425-431,
1993.
13. Manns A, Chan C, Miralles R : influences of group function and
canine guidance on electromyographic activity of elevator muscles, J.
Prosthet Dent 57:494-501, 1987.
14. Misch CE: Three dimensional finite element analysis of two
plate form neck designs, Master’s thesis, University of Pittsburgh,
1989.
15. Misch CE , Bidaz MW : Implant protected occlusion, a
biomechanical rationale, Comp Cont. Dent Educ. 15(11):1330-1343,
1994.
16. Misch CE : Dentistry of bone and effect on treatment plans,
surgical approach, healing and progressive loading. Int. J. Oral
implantol 6:23-31, 1990.
17. Misch CE : early crestal bone loss etiology and its effect on
treatment planning for implants, post Grad Dent. (2)3:3-17, 1995.
18. Misch CE : Medial positioned lingualized occlusion, Misch
Institute Manual, Birmingham, Mich, 1991.
19. Misch CE : Occlusal considerations for implant supported
prostheses. In Misch CE, editior: contemporary implant dentistry, pp
705-733, St. Louis 1993, Mosby.
20. Misch CE : Progressive bone loading, Pract Periodontics
Aesthet Dent. 2:27-30, 1990.
21. Misch CE : Progressive bone loading. In Misch CE, editor;
Contemporary implant dentistry, pp 623-650, St. Louis, 1993, Mosby.
22. Monasky GE, Tough DF: Studies of wear of porcelain, enamel
and gold, J Proshet Dent 25(3):299-306, 1971.

49
23. Muhlemann HR : Tooth mobility : review of clinical aspects
and research findings, J. Periodontal 38:686 1967.
24. Naert I, Quirynen M, Van Steenberghe D et al : A six year
prosthodontic study of 509 consecutively inserted implants for the
treatment of partial edentulism. J. Prosthet Dent 67:236-245, 1992.
25. Okesm JP : Management of Temporomandibular disorders and
occlusion, pp 259-260, St. Louis, 1989, Mosby.
26. Papavasillou G, Kamposiora P et al : Three dimensional finite
element analysis of stress distribution around single tooth implants as
a function of bony support prosthesis type and loading during
function, J. Prosthet Dent 76: 633-640, 1996.
27. Parein AM, Eckert SE, Wollan PC et al : Implant reconstruction
in the posterior mandible : a long term retrospective study. J. Prosthet
Dent 78:34-42, 1997.
28. Reilly DT, Burstein AH : The elastic and ultimate properties of
compact bone tissue, J Biomech 80:393-405, 1975.
29. Schupe RJ et al : effects of occlusal guidance on jaw muscles
activity, J Prosthet Dent 51:811-818, 1984.
30. Seghi RR, Daher, Caputo A : Relative flexural strength of
dental restorative ceramics, Dent. Mater 6:181-184, 1990.
31. Shultz AW : comfort and chewing efficiency in dentures, J.
Prosthet Dent. 65:38-48, 1951.
32. Van Steenbergh D : A retrospective multicenter evaluation of
the survival rate of fixed prosthesis on four or six implants and
modum Branemark in full edentulism. J. Prosthet Dent. 61:217-223,
1989.
33. Williamson EH, Lundquist DO: Anterior guidance its effect on
electromyographic activity of the temporal and masseter muscles, J.
Prosthet Dent. 49:816-823, 1983.

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