IMPLANT DENTISTRY / VOLUME 24, NUMBER 5 2015
Bruxism and Dental Implants:
A Meta-Analysis
Bruno Ramos Chrcanovic, DDS, MSc,* Tomas Albrektsson, MD, PhD,† and Ann Wennerberg, DDS, PhD‡
cclusal parafunction includes
O bruxism (clenching, grinding),
lip biting, thumb sucking, and
abnormal posturing of the jaw. In con-
trast to functional behaviors such as
mastication, deglutition, or speaking,
activities classified as “parafunctions”
seem to have no functional purpose.1
Concerning the overloading related to
parafunction, it can cause various
complications, such as occlusal sur-
face wear, fracture, loosened screws,
or abutment and implant fracture.2 As
the frequency of parafunction is very
common,1 the usage of implants in pa-
tients with parafunctional habits is
unavoidable. Moreover, a significantly
high percentage of newly gained par-
afunction was reported in patients with
implant-supported superstructures.3
Some authors have suggested that
overloading of implants or abnormal
occlusal stress, as seen in patients with
bruxism habits, may contribute to fail-
ure.4 As the possible occurrence of
parafunctional habits is evident in
any stage of dental treatment, the risks
for implant therapy must be consid-
ered.2 Therefore, bruxism is often con-
*PhD Student, Department of Prosthodontics, Faculty of
Odontology, Malmö University, Malmö, Sweden.
†Retired Professor and Former Head, Department of
Biomaterials, Göteborg University, Göteborg, Sweden; Guest
Professor, Department of Prosthodontics, Faculty of
Odontology, Malmö University, Malmö, Sweden.
‡Professor and Head, Department of Prosthodontics, Faculty of
Odontology, Malmö University, Malmö, Sweden.
Reprint requests and correspondence to: Bruno Ramos
Chrcanovic, DDS, MSc, Department of Prosthodontics,
Faculty of Odontology, Malmö University, Carl Gustafs
väg 34, SE-205 06, Malmö, Sweden, Phone: +46 725
541 545, Fax: +46 40 6658503, E-mail: bruno.
chrcanovic@mah.se
ISSN 1056-6163/15/02405-505
Implant Dentistry
Volume 24
Number 5
Copyright © 2015 Wolters Kluwer Health, Inc. All rights
reserved.
DOI: 10.1097/ID.0000000000000298
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
505
Purpose: To test the null hypoth-
esis of no difference in the implant
failure rates, postoperative infection,
and marginal bone loss after the
insertion of dental implants in
bruxers compared with the insertion
in non-bruxers against the alterna-
tive hypothesis of a difference.
Methods: An electronic search
was undertaken in June 2014. Eligi-
bility criteria included clinical stud-
ies, either randomized or not.
Results: Ten publications were
included with a total of 760 implants
inserted in bruxers (49 failures;
6.45%) and 2989 in non-bruxers
(109 failures; 3.65%). Due to lack
of information, meta-analyses for the
outcomes “postoperative infection”
and “marginal bone loss” were not
sidered a contraindication for implant
treatment although the evidence for
this is usually based on clinical expe-
rience only.5
The ability to anticipate outcomes
is an essential part of risk management
in an implant practice. Recognizing
conditions that place the patient at
a higher risk of failure will allow the
surgeon to make informed decisions
and refine the treatment plan to opti-
mize the outcomes.6 The use of implant
therapy in special populations requires
consideration of potential benefits to be
gained from the therapy. To better
appreciate this potential, we conducted
a systematic review and meta-analysis
to compare the survival rate of dental
implants, postoperative infection, and
marginal bone loss of dental implants
possible. A risk ratio of 2.93 was
found (95% confidence interval,
1.48–5.81; P ¼ 0.002).
Conclusions: These results can-
not suggest that the insertion of
dental implants in bruxers affects
the implant failure rates due to
a limited number of published stud-
ies, all characterized by a low level
of specificity, and most of them deal
with a limited number of cases
without a control group. Therefore,
the real effect of bruxing habits on
the osseointegration and survival of
endosteal dental implants is still not
well established. (Implant Dent
2015;24:505–516)
Key Words: dental implants, brux-
ism, implant failure rate, meta-
analysis
inserted in bruxers and non-bruxers
patients.
MATERIALS AND METHODS
This study followed the PRISMA
Statement guidelines.7 A review proto-
col does not exist.
Objective
The purpose of this review was to
test the null hypothesis of no difference
in the implant failure rates, postopera-
tive infection, and marginal bone loss
after the insertion of dental implants in
patients being diagnosed as presenting
bruxing habits compared with the inser-
tion in non-bruxers against the alterna-
tive hypothesis of a difference. The
following focused question was raised:
In patients being rehabilitated with
dental implants, what is the effect of
 506 BRUXISM AND DENTAL IMPLANTS
CHRCANOVIC ET AL

bruxism on the implant failure rates, subject were also scanned for possible searches were read independently by
postoperative infection, and marginal additional studies. Moreover, online the 3 authors. For studies appearing to
bone loss? databases providing information meet the inclusion criteria or for which
about clinical trials in progress were there were insufficient data in the title
Search Strategies checked (clinicaltrials.gov; www. and abstract to make a clear decision,
An electronic search without time or centerwatch.com/clinicaltrials; www. the full report was obtained. Disagree-
language restrictions was undertaken in clinicalconnection.com). ments were resolved by discussion
June 2014 in the following databases: between the authors.
PubMed, Web of Science, and the Inclusion and Exclusion Criteria
Cochrane Oral Health Group Trials Eligibility criteria included clinical Quality Assessment
Register. The following terms were used human studies, either randomized or Quality assessment of the studies
in the search strategy on PubMed: not, comparing implant failure rates in was executed according to the New-
(dental implant OR oral implant [topic]) bruxers compared with non-bruxers. castle-Ottawa scale (NOS).8 The NOS
AND (bruxism OR bruxers OR paraf- For this review, implant failure repre- calculates the study quality on the basis
unctional OR clench [topic]) (dental sents the complete loss of the implant. of 3 major components: selection, com-
implant OR oral implant [topic]) AND Exclusion criteria were case reports, parability, and outcome for cohort stud-
(excessive occlusal load OR overload technical reports, animal studies, ies. It assigns a maximum of 4 stars for
[topic]) in vitro studies, and reviews articles. selection, a maximum of 2 stars for
The following terms were used in comparability, and a maximum of 3
the search strategy on Web of Science, Study Selection stars for outcome. According to that
in all databases: (dental implant OR oral The titles and abstracts of all re- quality scale, a maximum of 9 stars/
implant [topic]) AND (bruxism OR ports identified through the electronic points can be given to a study, and this
bruxers OR parafunctional OR clench
[topic]) (dental implant OR oral implant
[topic]) AND (excessive occlusal load
OR overload [topic])
The following terms were used in
the search strategy on the Cochrane
Oral Health Group Trials Register:
(dental implant OR oral implant AND
[bruxism OR bruxers OR parafunction-
al OR clench])
A manual search of dental implants-
related journals, including British Journal
of Oral and Maxillofacial Surgery,
Clinical Implant Dentistry and Related
Research, Clinical Oral Implants
Research, European Journal of Oral
Implantology, Implant Dentistry, Interna-
tional Journal of Oral and Maxillofacial
Implants, International Journal of Oral
and Maxillofacial Surgery, International
Journal of Periodontics and Restorative
Dentistry, International Journal of Pros-
thodontics, Journal of Clinical Periodon-
tology, Journal of Dental Research,
Journal of Dentistry, Journal of Oral Im-
plantology, Journal of Craniofacial Sur-
gery, Journal of Cranio-Maxillofacial
Surgery, Journal of Maxillofacial and
Oral Surgery, Journal of Oral and Max-
illofacial Surgery, Journal of Oral Reha-
bilitation, Journal of Periodontology, and
Oral Surgery Oral Medicine Oral Pathol-
ogy Oral Radiology and Endodontology,
was also performed. Fig. 1. Study screening process. The search strategy resulted in 840 articles, of which 10
The reference list of the identified were included in the study.
studies and the relevant reviews on the

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Table 1. Detailed Data Extracted From the 10 Studies Included in the Final Analysis: Part 1
Patients’ Age Antibiotics/ Healing P (for Marginal Bone
Study Design Range Follow-up Visits Mouth Period/ Failed/Placed Implant Failure Failure Loss (Mean 6
Study (Center) Patients (n) (Average) (y) (or Range) Rinse (d) Loading Implants (n) Rate (%) Rate) SD) (mm)
Naert RA (unicenter) 91 (35♂, 56♀) 15–88 (53.7) 6 y 10 mo NM 6–8 mo 7/23 (G1) 30.43 (G1) NM Reported for
et al10 (maxilla) patients with
1 or 2
prostheses
per patient
but not
distinction for
bruxers
3–5 mo 23/566 (G2) 4.06 (G2)
(mandible)
Glauser PNCS (NM) 41 (19♂, 22♀) 19–72 (52) 12 mo after 5/14 Immediate 9/22 (G1) 40.91 (G1) NM NM
et al11 loading (71%),
within 11
d (29%)
13/105 (G2) 12.38 (G2)
Engstrand PNCS 95 (5, G1; 90, 45–89 (68.5) Mean 2.5 y NM Immediate 2/15 (G1) 13.33 (G1) NM Values for all
et al12 (unicenter) G2; 53♂, (range 1–5) (73.7%), implants; no
42♀) within 40 distinction for

IMPLANT DENTISTRY / VOLUME 24, NUMBER 5 2015

d (26.3%) bruxers
16/270 (G2) 5.93 (G2)
Nedir CCT* 236 (91♂, 18–89 (NM) 7y NM TPS (mean 2/72 (G1) 2.78 (G1) NM NM
et al13 (unicenter) 145♀) mo): 4.5
maxilla, 3.9
mandible
SLA (mean 1/456 (G2) 0.22 (G2)
mo): 2.5
maxilla, 2.3
mandible
Ibañez PNCS 41 (11♂, 30♀) 38–82 (62.1) 12–74 mo 4–5/15 Immediate 0/207 (G1) 0 (G1) NM (no NM
et al14 (multicenter) failures)
0/136 (G2) 0 (G2)

(continued on next page)

507
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 508
Table 1. (Continued)
Patients’ Age Antibiotics/ Healing P (for Marginal Bone
Study Design Range Follow-up Visits Mouth Period/ Failed/Placed Implant Failure Failure Loss (Mean 6

BRUXISM
Study (Center) Patients (n) (Average) (y) (or Range) Rinse (d) Loading Implants (n) Rate (%) Rate) SD) (mm)
Bischof RA (unicenter) 212 (91♂, 22–88 (49.9) 5y 5–6/NM Mean 3.7 mo 2/56 (G1) 3.57 (G1) NM 0.71 6 0.62
et al15 121♀) (mesial)

AND
3/207 (G2) 1.45 (G2) 0.60 6 0.64
(distal)

DENTAL IMPLANTS
Values for all
implants with
RXs; no
distinction for
bruxers
Siebers CCT† 76 (24, G1; 52, 22–85 (52 6 Mean of 38 mo NM 6–8 mo 1/54 (G1) 1.85 (G1) 0.82 (log- NM
et al16 (unicenter) G2; 34♂, 13) rank

42♀)‡ test)‡

CHRCANOVIC
4/168 (G2)‡ 2.38 (G2)
Maló RA (unicenter) 221 (53, G1; 34–84 (56.8) 5y 6/NM Immediate 7/236 (G1) 2.97 (G1) NM Excessive
et al17 168, G2; (.2.8 mm) in
97♂, 124♀)‡ 37 patients;
no distinction

ET AL
for bruxers
34/759 (G2)‡ 4.48 (G2)
Ji et al18 RA (unicenter) 45 (18♂, 27♀) 25–88 (61.5) Mean 42.1 mo NM Immediate 17/58 (G1) 29.31 (G1) NM Informed, but
(range no distinction
1–125.5) for bruxers
11/239 (G2) 4.60 (G2)
Schneider RA (unicenter) 70 (17, G1; 53, 19.8–76.6 Mean 6.2 y NM Mean 12 mo 2/17 (G1) 11.76 (G1) NM Informed, but
et al19 G2; 27♂, (50.7) (range (range 10 no distinction
43♀) 4.73–11.7) d–36 mo) for bruxers
4/83 (G2)‡ 4.82 (G2)
*Study controlled for implant surface treatment (TPS vs SLA).
†Study controlled for occlusal loading (immediate vs delayed).
‡Unpublished information was obtained by personal communication with one of the authors.
♀ indicates female patients; ♂, male patients; CCT, controlled clinical trial; G1, group bruxers; G2, group non-bruxers; NM, not mentioned; NP, not performed; PNCS, prospective noncontrolled study; RA, retrospective analysis; SLA, sandblasted and acid-etched;
TPS, titanium plasma-sprayed.

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 IMPLANT DENTISTRY / VOLUME 24, NUMBER 5 2015 509

Table 2. Detailed Data Extracted From the 10 Studies Included in the Final Analysis: Part 2
Region/Prosthetic
Implant Surface Rehabilitation/Opposing
Study Bruxism Definitions Modification (Brand) Dentition Observations
Naert et al10 NM Turned (Brånemark; Maxilla, mandible/fixed full- Only completely
Nobelpharma AB, arch prostheses (n ¼ 9), edentulous patients
Göteborg, Sweden) overdentures (n ¼ 2)/
opposing dentition: fixed
full-arch implant-
supported prostheses
(15.7% maxilla; 28.5%
mandible), natural
dentition (21.2%, maxilla;
59.3%, mandible),
complete removable
denture (63.1%, maxilla),
overdenture (19.2%,
mandible)
Glauser et al11 NM Turned (Brånemark; Maxilla, mandible/single Guided bone
Nobel Biocare AB) crowns (n ¼ 28), fixed regeneration in 84
partial prostheses (n ¼ implant sites
22), fixed full arches (n ¼
3), overdentures (n ¼ 5)/
opposing dentition: NM
Engstrand et al12 NM Turned (Brånemark; Mandible/fixed full-arch 23 smokers
Nobel Biocare AB) prostheses (Brånemark
Novum Concept)/
opposing dentition:
complete removable
denture (58.9%), natural
teeth/crowns, and bridges
(31.6%), implant-
supported prostheses
(9.5%)
Nedir et al13 NM TPS, and sandblasted, Maxilla, mandible/single Smokers (106 implants),
and acid etched (TPS, crowns (32.4%), fixed insertion in fresh
n ¼ 264; SLA, n ¼ partial prostheses extraction sockets (12
264; ITI; Straumann, (38.6%), fixed full arches implants)
Waldenburg, (1.1%), overdentures
Switzerland) (27.5%). Bruxers received
1 implant per rehabilitated
unit without, however, any
further extra-attention like
night guards/opposing
dentition: NM
Ibañez et al14 Patients were considered Acid etched (Osseotire; Maxilla, mandible/fixed full- Flapless approach in 10
bruxers when they 3i Innovations, Palm arch prostheses/opposing patients, 62 implants
presented with teeth Beach Gardens, FL) dentition: natural teeth and in smokers
grinding or/and clenching, fixed prostheses (n ¼ 19),
in combination with other complete removable
symptoms like a sore or denture (n ¼ 14), fixed full-
painful jaw, headache, arch implant-supported
earache, anxiety, stress prostheses (n ¼ 16)
and tension, and eating
disorders

(continued on next page)

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 510 BRUXISM AND DENTAL IMPLANTS
CHRCANOVIC ET AL

Table 2. (Continued)
Region/Prosthetic
Implant Surface Rehabilitation/Opposing
Study Bruxism Definitions Modification (Brand) Dentition Observations
15
Bischof et al NM Sandblasted and acid Maxilla, mandible/single Only in the posterior
etched (SLA, ITI; crowns (n ¼ 157), fixed region, simultaneous
Straumann) partial prostheses (n ¼ bone augmentation
80). In bruxing patients, (37 implants), sinus
metallic occlusal surfaces grafting (3 implants),
were proposed but not insertion in fresh
always accepted. Special extraction sockets (3
care was taken to implants), smokers (53
reinforce the metallic implants). Bruxers
framework and to flatten received 1 implant per
the occlusal surfaces/ rehabilitated unit; in
opposing dentition: NM case of multiple
implant rehabilitation,
these patients were
encouraged to wear
night guards to avoid
prosthetic
complications
Siebers et al16 NM Sandblasted and acid Maxilla, mandible/single No grafted patients, 46
etched (Camlog crowns, fixed partial implants placed in
Rootline and Screw prostheses/opposing fresh extraction
Line; Camlog dentition: NM sockets, 15 smokers
Biotechnologies,
Basel, Switzerland),
acid etched
(Osseotite; Biomet 3i),
blasted with HA and
calcium phosphate
(Restore RBM;
Lifecore Biomedical,
Chaska, MN)
Maló et al17 Classified in absent or Sandblasted and acid Maxilla/fixed full-arch Insertion in fresh
present, and diagnosed etched (MkII, MkIII, prostheses/opposing extraction sockets (31
by evaluating the degree MkIV, Nobelspeedy; dentition: implant- patients, 45 implants).
of tooth wear vs the Nobel Biocare AB) supported prostheses There were patients
patient’s age or the (104 patients), natural who were smokers,
degree of prosthesis wear teeth (56 patients), but the exact number
vs the prosthesis time in a combination of both (55 was not informed
function and by asking patients) and removable
the patient prostheses (6 patients)
Ji et al18 NM Sandblasted and acid Maxilla, mandible/fixed full- 8 smokers, 1 diabetic
etched (Xive; Dentsply arch prostheses/opposing patient
Friadent, Mannhein, dentition: NM
Germany; n ¼ 10),
oxidized (TiUnite;
Nobel Biocare AB; n ¼
233), HA coated
(Steri-Oss Hex-Loc;
Nobel Biocare AB;
Tapered Screw-Vent;
Zimmer Dental,
Carlsbad, CA; n ¼ 54)

(continued on next page)

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 IMPLANT DENTISTRY / VOLUME 24, NUMBER 5 2015 511

Table 2. (Continued)
Region/Prosthetic
Implant Surface Rehabilitation/Opposing
Study Bruxism Definitions Modification (Brand) Dentition Observations
19
Schneider et al NM Sandblasted and acid Maxilla, mandible/single Only in the posterior
etched (Brånemark; crowns/opposing region, 31 smokers,
Nobel Biocare AB; n ¼ dentition: natural dentition 14 patients with
76; SLA, ITI; or tooth-supported fixed a history of
Straumann; n ¼ 24) prostheses (54 patients), periodontitis, GBR (46
implant-supported fixed implants), sinus lifting
prostheses (9 patients), (12 implants)
removable denture (4
patients), not evaluated (3
patients)
GBR indicates guided bone regeneration; HA, hydroxyapatite; NM, not mentioned; TPS, titanium plasma-sprayed.

score represents the highest quality,
where 6 or more points were considered
high quality.
Data Extraction and Meta-Analysis
From the studies included in the
final analysis, the following data were
extracted (when available): year of
publication, study design, unicenter or
multicenter study, number of patients,
patients’ age, follow-up, days of antibi-
otic prophylaxis, mouth rinse, implant
healing period, failed and placed im-
plants, postoperative infection, mar-
ginal bone loss, bruxism definitions,
implant surface modification, jaws
receiving implants (maxilla and/or
mandible), type of prosthetic rehabilita-
tion, and opposing dentition. Contact
with authors for providing missing data
was performed.
Implant failure and postoperative
infection were the dichotomous out-
comes measures evaluated. Weighted
mean differences were used to con-
struct forest plots of marginal bone
loss, a continuous outcome. The sta-
tistical unit for “implant failure” and
“marginal bone loss” was the implant
and for “postoperative infection” was
the patient. Whenever outcomes of
interest were not clearly stated, the data
were not used for analysis. The I2 sta-
tistic was used to express the percent-
age of the total variation across studies
due to heterogeneity with 25% corre-
sponding to low heterogeneity, 50% to
moderate, and 75% to high. The
inverse variance method was used for
random-effects or fixed-effects model.
Where statistically significant (P ,
0.10) heterogeneity is detected, a ran-
dom-effects model was used to assess
the significance of treatment effects.
Where no statistically significant het-
erogeneity is found, analysis was per-
formed using a fixed-effects model.9
The estimates of relative effect for
dichotomous outcomes were ex-
pressed in risk ratio (RR) and in mean
difference in millimeters for continu-
ous outcomes both with a 95% confi-
dence interval (CI). Only if there were
studies with similar comparisons re-
porting the same outcome measures,
meta-analysis was to be attempted. In
the case where no events (or all events)
are observed in both groups, the study
provides no information about relative
probability of the event and is automat-
ically omitted from the meta-analysis.
In this (these) case(s), the term “not
estimable” is shown under the column
of RR of the forest plot table. The soft-
ware used here automatically checks
for problematic zero counts, and adds
a fixed value of 0.5 to all cells of study
results tables where the problems
occur.
A funnel plot (plot of effect size vs
SE) was planned to be drawn. Asym-
metry of the funnel plot may indicate
publication bias and other biases
related to sample size although the
asymmetry may also represent a true
relationship between trial size and
effect size.
The data were analyzed using the
statistical software Review Manager
(version 5.3.3; The Nordic Cochrane
Center, The Cochrane Collaboration,
Copenhagen, Denmark, 2014).
RESULTS
Literature Search
The study selection process is sum-
marized in Figure 1. The search strategy
resulted in 840 articles. The combina-
tions of terms used in the literature
search of different databases resulted
in a number of 292 duplicates. The 3
reviewers independently screened the
abstracts for those articles related to
the focus question. The initial screening
of titles and abstracts resulted in 548
full-text articles; 491 were excluded
for not being related to the topic. Addi-
tional hand-searching of the reference
lists of studies not excluded so far
yielded 7 additional articles. The full-
text reports of the remaining 64 articles
led to the exclusion of 54 because they
did not meet the inclusion criteria (18
reviews, 16 did not inform of the num-
ber of implants inserted and/or lost per
group, 7 case reports, 6 not evaluating
implant failures, 5 animal studies, and 2
evaluating failed implants only). Thus,
a total of 10 publications were included
in the review.
Description of the Studies
Detailed data of the 10 included
studies are listed in Tables 1 and 2. Two
controlled clinical trials (CCT),13,16 3
prospective noncontrolled studies,11,12,14
and 5 retrospective analyses10,15,17–19
were included in the meta-analysis.
The 2 CCTs here included were not

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 512 BRUXISM AND DENTAL IMPLANTS
CHRCANOVIC ET AL

controlled for the condition bruxism but

The NOS calculates the study quality on the basis of 3 major components: selection, comparability, and outcome for cohort studies. A maximum of 9 stars/points can be given to a study, and this score represents the highest quality, where 6 or more points are
Total (9/9)
for the implant surface treatment13 and

5/9
5/9
3/9

6/9
5/9
6/9
5/9
5/9
3/9
5/9
for the occlusal loading.16
One study11 had a follow-up of on-
ly 12 months after loading. All studies

Adequacy of
had available data of the patients’ age,

Follow-up
and only one10 included non-adult pa-

★
0

0
0
0
0
tients. Some patients in 8 studies12–19
were smokers. In 4 studies,13,15–17 some
implants were inserted in fresh extrac-
tion sockets. In 4 studies,12,14,17,18
Outcome

Follow-up

Enough*

the patients were rehabilitated with

Long

fixed full-arch prostheses only, and in

★

★
★
★

★
0
0

0
another one,19 single crowns only.
Patients were submitted to grafting pro-
Assessment
of Outcome

cedures at the implant site in 3 stud-

ies.11,15,19 One study10 included only
★

★
0
0
0

0
0

0
0
edentulous patients, and other 215,19 in-
serted implants only in the posterior seg-
ments. Some implants were submitted to
immediate loading in 2 studies11,12 and
Outcome of Comparability of Cohorts

Additional
Factor

exclusively in 3 studies.14,17,18 In the

0
0
0

0
0
0
0
0
0
0
Comparability

other 5 studies,10,13,15,16,19 the implant

healing time before loading ranged from
2.3 to 12 months. Implants were inserted
exclusively in maxillae in one study17
Factor

and in mandibles in another one.12 Five

Main

0
0
0

0
0
0
0
0
0
0

studies10,12,14,17,19 provided information

about the dentition opposed to the im-
plants being evaluated.
Interest Not
Ascertainment Present at
the Start

Eight studies10–13,15,16,18,19 did not

★
★
★

★
★
★
★
★
★
★

report the adopted criteria to classify

a patient as having bruxing habits. Only
one study15 informed that the patients
with bruxing habits were encouraged
of Exposure

to wear night guards. None of the 10

★
★
★

★
★
★
★
★
★
★

studies provided information about

*Five years of follow-up was chosen to be enough for the outcome “implant failure” to occur.

postoperative infection. Six stud-

ies10,12,15,17–19 provided information
Table 3. Quality Assessment of the Studies by the NOS

about marginal bone loss, but in none

Selection

Selection of

of them, there was a distinction between

External
Control

bruxers and non-bruxers.

★
★
★

★
★
★
★
★
★
★

The 10 included studies reported

a total of 760 dental implants inserted
in bruxers (49 failures; 6.45%) and
Representativeness of
the Exposed Cohort

2989 implants in non-bruxers (109

failures; 3.65%). Implants from the
Nobel Biocare AB (Göteborg, Sweden)
★

★
★

were the most commonly used in

0

0
0
0

6 studies10–12,17–19 but not exclusively

in 2 studies.18,19 One study16 informed
whether there was a statistically
significant difference or not in the
considered high quality.
Glauser et al11

Bischof et al15
Siebers et al16
Ibañez et al14

implant failure rates. There were no

Naert et al10

Nedir et al13

Maló et al17
Engstrand

Schneider

implant failures in one study.14 Four

et al12

et al19
Ji et al18

studies11,14,15,17 provided information

Study

about the use of prophylactic antibiotics.

Two studies11,14 provided information

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Fig. 2. Forest plot for the event “implant failure.” The insertion of dental implants in patients
being diagnosed as bruxers affected the implant failure rates.
about the use of chlorhexidine mouth
rinse by the patients.
Quality Assessment
Two studies were of high quality, 6
of moderate quality, and 2 of low quality.
The scores are summarized in Table 3.
Meta-Analysis
In this study, a random-effects
model was used to evaluate the outcome
“implant failure” because statistically
significant heterogeneity was found
(P ¼ 0.0007; I2 ¼ 70%). The insertion
of dental implants in patients being
diagnosed as bruxers affected the
implant failure rates (P ¼ 0.002;
Fig. 3. Funnel plot for the studies reporting the outcome event “implant failure” (RR, risk ratio).
There is asymmetry, indicating the possible presence of publication bias.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
IMPLANT DENTISTRY / VOLUME 24, NUMBER 5 2015
Fig. 2) with a RR of 2.93 (95% CI,
1.48–5.81). Thus, the relative risk
reduction (RRR) was −193%. Being
RRR negative, the insertion of implants
in bruxers increases the risk of implant
failure by 193% in comparison with
non-bruxers. Due to lack of informa-
tion, meta-analyses for the outcomes
“postoperative infection” and “mar-
ginal bone loss” were not possible.
Publication Bias
The funnel plot (Fig. 3) showed
asymmetry when the studies reporting
the outcome “implant failure” were
analyzed, indicating the possible pres-
ence of publication bias.
513
DISCUSSION
Bruxism has been suggested to
cause excessive occlusal load of dental
implants and their suprastructures, ulti-
mately resulting in bone loss around the
implants or even in implant failure,5
although some of the articles here
included did not provide clear conclu-
sions on the issue13,14,18 or did not sup-
port bruxism as a causative effect of
dental implant failures.16 The present
meta-analysis found a statistically sig-
nificant difference when comparing
dental implant failures in bruxers and
non-bruxers. However, the included
studies have some limitations, thus
being not possible to suggest that
the insertion of dental implants in
bruxers affects the implant failure rates.
Although this cause-effect relationship
still needs to be confirmed with appro-
priately designed studies, it worth re-
minding that a high and unpredictable
or uncontrolled loading of the implant
could lead to micromotions above the
critical limit, resulting in fibrous encap-
sulation of the implant instead of os-
seointegration.20 It is also important to
stress that the periodontal ligament of
natural teeth provides the central nerve
system with feedback for sensory per-
ception and motor control.21 Proprio-
ception around dental implants is
limited because of the absence of a peri-
odontal ligament, causing lower tactile
sensitivity. Consequently, the proprio-
ceptive feedback mechanisms to the
jaw-closing muscles are limited as well.
In addition, the perception of forces is
limited in implant patients.22 It is, there-
fore, not unlikely that forces that are
applied to implants during bruxism are
even larger than those exerted during
mastication,5 making them more prone
to occlusal overload and possible sub-
sequent failure.21 Chewing is supposed
to be a physiological load for dental im-
plants; bruxism, an overload.5
Although there was no information
regarding marginal bone loss compar-
ing bruxers and non-bruxers to perform
a meta-analysis, some comments on the
subject will be made. Contrary to early
failures, late biological failures are
characterized by pathological bone loss
after full osseointegration was obtained
at an earlier stage. Late biological
 514 BRUXISM AND DENTAL IMPLANTS
implant failures are, among other rea-
sons, associated with overload.5 Occlu-
sal overloading has been suggested to
cause periimplant marginal bone loss
and constitutes a high risk for early
implant failure.23 Natural teeth have
a lower detection threshold of minimal
pressure compared with implants, but
stresses are distributed evenly around
them, whereas stresses around implants
tend to concentrate at the crestal bone
region instead of distributing them-
selves evenly.24 In case of overload,
equilibrium between bone resorption
and deposition is being disturbed,
thereby causing fatigue-related micro-
fractures at, and around, the bone-
implant interface.25
In a clinical human study, Lind-
quist et al26 showed that parafunctional
activity, such as bruxism reported as
tooth clenching and occlusal wear on
the prosthesis, led to increased bone
loss around Brånemark implants. Ani-
mal studies also evaluated the relation-
ship between implant occlusal overload
and marginal bone loss. Miyata et al27
investigated the relationship between
occlusal overload and periimplant tis-
sue and suggested that there is a possi-
bility of bone resorption around the
implants caused by excess occlusal
trauma, even when there is no inflam-
mation in the periimplant tissue. Duyck
et al28 showed that dynamic overload
generated by the grinding of teeth re-
sulted in severe angular bone loss. In
a recent review,29 the authors pointed
out that animal experimental studies
indeed suggested the potential detri-
mental effect of excessive mechanical
load on periimplant bone although ran-
domized or CCTs of treatment interven-
tions of oral implants designed to study
overload are lacking. The authors also
observed that the level of evidence
of the studies on bone response to
implant loading is weak and does not
indicate that overload can lead to peri-
implant bone loss, except in case of
inflammation. Thus, the subject is still
controversial.
It is important to say that there is
still a lack of agreement about the
definition of bruxism, which makes it
sometimes difficult to unequivocally
interpret the available evidence.5 The
clinical features for diagnosis of
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

CHRCANOVIC ET AL
bruxism include complaint of jaw mus-
cle discomfort, fatigue, stiffness, and/or
occasional headaches, the presence of
tooth wear, tooth sensitivity, muscle
hypertrophy, temporomandibular joint
clicking or jaw lock, and tongue inden-
tation. The clinical diagnosis of brux-
ism is based on orofacial examination
and is usually supported by patient his-
tory, self-reports, or parental/partner re-
ports. Considering that many sleep
bruxism patients are not aware of grind-
ing if they slept alone or with a partner
who sleeps deeply30 and that the overall
prevalence of daytime clenching aware-
ness has been reported by approxi-
mately 20% of the adult population,31
this may misguide the clinician to the
correct clinical diagnosis.30 Polysom-
nographic analysis has been proposed
for a more accurate diagnosis,2
although the process of diagnosing
sleep bruxism by means of polysom-
nography is considered to be compli-
cated by some authors.32 Thus, there
seems to be a need to establish more
accurate and objective methodology
for detecting bruxism.2 Most of the
studies10–13,15,16,18,19 here included did
not even report the adopted criteria to
classify a patient as having bruxing hab-
its, that is, the mode of bruxism deter-
mination is not given at all. Without
a definitive diagnosis of bruxism hav-
ing been established, it is acknowl-
edged that some of the outcomes
illustrated in some of the clinical cases
may be due to such load-increasing or
material-related factors, rather than to
bruxism per se.32 Therefore, the possi-
ble cause-effect relationship between
bruxism and implant failure do not yield
consistent and specific outcomes. This
is partly because of the large variation in
the literature in terms of both the tech-
nical aspects and the biological aspects
of the study material.5
The use of grafting procedures in
some studies11,15 is a confounding fac-
tor as well as the presence of smokers
among the patients,12–19 the insertion of
some implants in fresh extraction sock-
ets,13,15–17 the insertion of implants in
different locations, different healing pe-
riods, and different prosthetic configu-
rations, including splinting of the
implants, which allows a more even dis-
tribution of the occlusal forces, thereby
reducing stresses at the bone-implant
interface.33 In only 1 study,15 the pa-
tients with bruxing habits were encour-
aged to wear night guards. A hard
stabilization splint for nightly use (night
guard) contributes to optimally distrib-
uting, and vertically redirecting, the
forces that go with nocturnal teeth
grinding and clenching.2 Moreover, it
is known that the surface properties of
dental implants such as topography and
chemistry are relevant for the osseoin-
tegration process influencing ionic
interaction, protein adsorption, and cel-
lular activity at the surface.34 The stud-
ies here included made use of implants
with different brands and surface treat-
ments. Titanium with different surface
modifications shows a wide range of
chemical, physical properties, and sur-
face topographies or morphologies, de-
pending on how they are prepared and
handled,35–37 and it is not clear whether,
in general, one surface modification is
better than another.34 It is also important
to comment that when overload occurs,
the level of stress concentration at the
implant-bone interface depends on sev-
eral factors related to load transfer, such
as the direction of the functional loads,
the resiliency properties of the implant
and alveolar bone, the implant macro-
geometry and microgeometry, and the
quality of the bone support,38 and it was
impossible to control these variables in
the included studies.
The results of this study have to be
interpreted with caution because of its
limitations. First of all, all confounding
factors may have affected the long-term
outcomes and not just the fact that
implants were placed in patients who
were diagnosed with bruxism or not,
and the impact of these variables on the
implant survival rate, postoperative
infection, and marginal bone loss is
difficult to estimate if these factors are
not identified separately between the 2
different procedures to perform a meta-
regression analysis. The lack of control
of the confounding factors limited the
potential to draw robust conclusions.
Second, most of the included studies
had a retrospective design, and the
nature of a retrospective study inher-
ently results in flaws. These problems
were manifested by the gaps in infor-
mation and incomplete records.

Furthermore, all data rely on the accu-
racy of the original examination and
documentation. Items may have been
excluded in the initial examination or
not recorded in the medical chart.39–41
Moreover, in a criterion for a valid
cause-effect relationship to be estab-
lished, the suggested cause, which
would be bruxism, should precede the
effect, that is, implant failure. In that
case, a prospective approach with mul-
tiple evaluations of the study sample is
required, because it is not possible to
establish the order of events retrospec-
tively.5 Third, much of the research in
the field is limited by small cohort size.
Fourth, the criteria for the diagnosis of
bruxism were seldom reported by the
included studies, which probably re-
sulted in a poor homogeneity of the
study group. Fifth, all included studies
are characterized by a low level of spec-
ificity, where the assessment of bruxism
as a complicating factor for dental im-
plants was seldom the main focus of the
investigation.
Unfortunately, most of the avail-
able data regarding bruxism as a risk
factor in implant dentistry are extracted
from case series. Because of conflicting
data from studies with small sample
sizes or case series, groups that were not
completely comparable at baseline in
some studies or studies involving mul-
tiple surgeons, clinicians are unable to
provide concrete answers to questions
posed by patients seeking dental
implant treatment. The presented re-
sults do not reflect a high level of
scientific evidence and may need mod-
ification when new research results
appear. For a more definite conclusion,
the authors of this study believe that
future controlled studies with a larger
number of patients in the bruxism group
(most studies included far fewer
bruxers than non-bruxers patients) are
required to determine the real effect of
the condition on the dental implant
outcome.
CONCLUSIONS
The results of this study cannot
suggest that the insertion of dental
implants in bruxers affects the implant
failure rates, due to a limited number of
published studies, all characterized by
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
IMPLANT DENTISTRY / VOLUME 24, NUMBER 5 2015
a low level of specificity, and most of
them dealing with a limited number of
cases without a control group. There-
fore, the real effect of bruxing habits on
the osseointegration and survival of
endosteal dental implants is still not
well established.
DISCLOSURE
This work was supported by CNPq,
Conselho Nacional de Desenvolvimen-
to Científico e Tecnológico, Brazil. The
authors claim to have no financial inter-
est, either directly or indirectly, in the
products or information listed in the
article.
ACKNOWLEDGMENTS
The authors would like to thank
Dr. Miguel de Araújo Nobre for hav-
ing sent us his article, Dr. Derk Sieb-
ers, Dr. Devorah Schwartz-Arad, Dr.
Miguel de Araújo Nobre, and Dr.
David Schneider, who provided us
some missing information about their
studies, and Dr. Monica Wahlström,
Dr. Karin Wannfors, Dr. Giuseppe
Luongo, Dr. Francesco Guido Manga-
no, and Dr. Anders Ekfeldt, who
replied our e-mail, although it was
not possible for them to provide the
missing information requested.
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