Journal of Investigative and Clinical Dentistry (2013), 4, 142–150

REVIEW ARTICLE
Implant Dentistry

Impact of excessive occlusal load on successfully-

osseointegrated dental implants: a literature review
Michael Chang1, Vasileios Chronopoulos1,2 & Nikos Mattheos3
1 School of Dentistry and Oral Health, Griffith University, Gold Coast, Qld, Australia
2 Department of Prosthodontics, Faculty of Dentistry, University of Athens, Athens, Greece
3 Department of Oral Rehabilitation, Faculty of Dentistry, The University of Hong Kong, Hong Kong, SAR-PR, China

Keywords
bone remodeling, bone resorption, dental
implant, occlusal loading, overload.
Correspondence
Associate Professor Nikos Mattheos, Prince
Philip Dental Hospital, Faculty of Dentistry,
The University of Hong Kong, 34 Hospital
Road, Sai Ying Pun, Hong Kong, China.
Tel: +852-2859-0411
Email: nikos@mattheos.net
Received 4 October 2012; accepted 15
December 2012.
doi: 10.1111/jicd.12036
Abstract
The aim of the present study was to review the available evidence on the
response of the peri-implant bone when subjected to excessive occlusal forces.
The search strategy included papers published in English in the Medline data-
base and the Wiley Online Library from January 1991 to December 2011.
Experimental or review papers reporting the conditions of the peri-implant
bone of dental implants submitted to excessive occlusal loading in the presence
of a controlled oral hygiene regime were eligible for inclusion. The knowledge
regarding the response of the peri-implant bone when the dental implant is
excessively loaded is limited, and the level of evidence is poor. With animal
experimental studies showing conflicting results, it is unclear whether occlusal
overload might cause marginal bone loss or total loss of osseointegration to
already osseointegrated dental implants when the applied load exceeds the bio-
logically-acceptable limit. This biological limit is also unknown. Furthermore,
higher remodeling activity of the peri-implant bone is found around implants
subjected to high loading forces.

load is adequately distributed.6 However, there have been

Introduction
Dental implants are a popular treatment modality in
restoring missing teeth. They have been shown to achieve
long-term high success and survival rates of over 90%.1
Titanium implants osseointegrate with the alveolar bone
through a process of tissue formation and remodeling.
Once osseointegrated, they are maintained by dynamic
tissue modeling and remodeling processes. Despite the
reported high success rate, complications and failures do
occur.2 One of the most controversial topics in implant
failure is occlusal overload.
Mechanical stress on dental implants can cause positive
or negative consequences for bone tissue.3 A certain level
of mechanical load is required for normal bone remodel-
ing,4 but when this load exceeds the biological load-bear-
ing capacity of the alveolar bone, it could cause tissue
damage, including loss of osseointegration.4 If this hap-
pens, the implant is considered overloaded.5
Under normal functional load, the osseointegration is
enhanced around the dental implant when the occlusal
studies suggesting that marginal bone loss or complete
loss of osseointegration can occur when a successfully-
osseointegrated oral implant is placed under excessive
loading conditions.7–11 Most of the suggestions are, how-
ever, speculative in nature, due to the difficulty in quanti-
fying the magnitude and direction of natural or
physiological occlusal forces, as opposed to what is
defined as excessive.12 Thus, the impact of excessive load-
ing on dental implants, and whether this could cause or
contribute to marginal bone loss or loss of osseointegra-
tion, continues to be a point of controversy.
One animal experimental study provided evidence of
the loss of osseointegration along the entire surface of the
dental implant when the implant was subjected to exces-
sive occlusal load,13 while another animal experiment
provided evidence of marginal bone remodeling when the
implant was excessively loaded, without leading to
implant loss.14 Controversially, more recent animal exper-
iments did not show loss of bone or osseointegration
when the implants were subjected to excessive force.15,16

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M. Chang et al.
Instead, these studies showed increased bone-to-implant
contact (BIC) percentage and/or increased surrounding
bone density when the implants were under excessive
occlusal forces.
It is important to define the damaging threshold of
occlusal forces transferred to the bone through dental
implants, as well as to understand how the peri-implant
bone responds to excessive load. This knowledge would
enable clinicians to make evidence-based decisions when
planning treatment for dental implants in patients with
possible excessive biting force, abnormal occlusion, exces-
sive reconstructions, or parafunctional habits. It would
also allow a better understanding of the true nature of
complications and the cause for failures of dental
implants.
Influence of mechanical load on bone tissue
Bones are capable of withstanding functional load to a
certain extent, without breaking or causing pain. This
threshold depends on the bone volume, architecture, and
the ability of the calcified tissue to remodel in response to
function.17
Frost proposed that bone response depends on a com-
plicated interaction of strain magnitude and time.4,17
Strain, that is, deformation of the bone, is defined as the
relative change in the length of the bone, and is often
expressed in microstrains, where 1000 microstrains corre-
spond to a deformation of 0.1%. The amount of strain is
directly correlated to the stress applied to the bone; for
example, occlusal loading, but it is also dependent on the
mechanical properties of the bone.
Frost’s theory suggests that bone can act like a
mechanostat, in that it brings about a biomechanical
adaptation, corresponding to the external loading condi-
tion. The theory proposed four microstrain zones, which
correlated to a mechanical adaptation: (a) disuse atrophy;
(b) steady state; (c) physiological overload; and (d) path-
ological loading.
Figure 1 shows the summary of Frost’s mechanostat
theory, which is applied to the long bones in response to
static loading. It is important to note that this is different
to the cyclic impact, as seen in the mastication, but it is
reasonable to assume that a similar principle applies to
the mandible and the maxilla with different threshold
values. At both ends of this graph, disuse atrophy and
pathological loading zones are proposed to lead to loss of
bone volume, whereas the steady-state zone and physio-
logical overload zone promote bone modeling and
remodeling, respectively. In the long bone, when the peak
strain magnitude falls below 50–200 microstrains, disused
atrophy is believed to occur, and when the peak loading
levels are greater than 3500 microstains, pathological bone
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Successful osseointegrated dental implants
Figure 1. Frost’s mechanostat theory.
resorption begins. Peak load levels greater than 25,000
microstrains lead to rapid catastrophic fracture.
The peak loading strains between 200 and 2500 micro-
strains are considered as the steady-state zone, where
most of the remodeling of woven bone-to-lamellar bone
occurs. Between 2500 and 3500 microstrains of mechani-
cal fatigue damage occurs, but bone modeling normally
repairs the damage by depositing new bone, which is
comprised mainly of woven bone. It is probable that bone
mass will continue to increase until the bony interface
accommodates these changes and the load strain values
decreases back to the steady-state zone.
It is reasonable to assume that with different bone
types and composition, the thresholds of destructive
strain values will be different for each individual, while
age and sex might play a significant role in this diversity.
Even within the same individual, structural differences
might imply different strains in response to forces; for
example, the posterior maxilla would present with higher
strain values than the posterior mandible when the same
amount of stress is applied on the alveolar bone due to
different bone structure.
It is important to note that it is not the actual load
that is measured, but the effect of the load on the bone.12
According to Frost, 1–2 MPa is equivalent to 50–100
microstrains in the cortical lamellar bone in healthy
young adult mammals, and 60 MPa is 3000 microstrains;
120 MPa equates to 25,000 microstrains, which is the
level for sudden fractures.
Is Frost’s theory on long bone applicable to alveolar
bone and implants?
Many experimental studies have been conducted and have
demonstrated that an increase in load induces the remod-
eling process, and thus, increases the bone density around
the oral implants.6,18–21 Although it has been very difficult
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Successful osseointegrated dental implants
to calculate clear values corresponding to the Frost zones
when studying the maxilla and mandible, it is reasonable
to expect that Frost’s mechanostat theory can be trans-
ferred and applied to dental implants placed in the alveo-
lar bone. This evidence is discussed later in this review
paper.
Aims
The aim of the present study is to review the available lit-
erature on the impact of occlusal load on the
peri-implant bone. The review will, in particular, focus
on literature investigating the impact of occlusal load on
the potential loss of osseointegration (type and pattern),
and also parameters, such as mineralized BIC and bone
density around oral implants.
Material and methods
Search strategy
A modified search based on the terms used by Chamb-
rone et al.22 was used for a Medline (via Pubmed) and
Wiley Online Library search. Human and animal experi-
mental studies were primarily targeted, but retrospective
studies, cross-sectional studies, and case reports were also
144
M. Chang et al.
examined. The search terms used were: dental implant
OR dental AND implant OR osseointegration AND
occlusal load OR overload* OR excessive loading OR
forces AND bone remodeling OR bone response OR bone
loss OR bone defect OR implant failure.
Papers published in English from January 1991 to
December 2012 were identified. Studies reporting on the
response of the peri-implant bone when the osseointegrat-
ed dental implant is subjected to excessive load force
under a controlled oral hygiene regime were eligible for
inclusion.
Results
A total of 522 potentially-relevant publications were
found from both databases; 503 articles were excluded
based on the title and abstract, leaving 19 articles for full-
text screening. After reading the full text of these 19 arti-
cles, another five articles were excluded, leaving 14 articles
for inclusion (Figure 2).
Load and loss of osseointegration
For many years, overloading dental implants was consid-
ered a reason for implant failure or marginal bone loss
after successful bone-to-implant osseointegration.8
Figure 2. Flowchart of the screening process
of the articles searched from the Medline
database and the Wiley Online Library.
ª 2013 Wiley Publishing Asia Pty Ltd
M. Chang et al.
However, this theory is mainly speculative in nature, and
the evidence is significantly lacking. Furthermore, it is dif-
ficult to discover the possible relationship between occlu-
sal overload and implant failure, due to the challenge to
clinically quantify the magnitude and direction of natu-
rally-occurring occlusal forces. There are both clini-
cal11,23,24 and experimental studies8,13,25,26 suggesting that
occlusal overload might have a role in the loss of osseoin-
tegration. However, other experimental studies have
demonstrated contradicting results. Table 1 shows the
summary of reviewed animal and clinical studies.
Animal studies
Isidor13,25,26 published a series of experimental studies
using four monkeys to compare the breakdown of bone
around oral implants following excessive occlusal load or
plaque accumulation. Five self-tapping implants were
placed in the mandible, two in the lateral segments, and
one in the frontal area. In the lateral segment, one fixture
was machined surfaced, and the other had a titanium
dioxide surface. One of the lateral segment implants was
restored in supra-occlusion with fixed prosthesis against
splinted maxillary molar and premolar teeth. After
18 months of loading, the result showed that six out of
eight loaded implants lost osseointegration. Two of these
implants were lost and unscrewed out of the jaw during
demounting of the prosthesis after 4.5 and 5.5 months’
post-loading. The remaining four implants showed clini-
cal mobility, but with little or no marginal bone loss. All
mobile implants presented with a surrounding radiolu-
cency. Histological evaluation showed that two of the
loaded implants in one monkey completely lost osseointe-
gration, with fibrous tissue surrounding the implants.
Two implants in another monkey showed only osseointe-
gration at the apical half.The excessively-loaded implants
in the fourth monkey did not lose osseointegration and
did not show clinical mobility. It was concluded that
occlusal overload can be the main factor for an already
osseointegrated implant to lose osseointegration.13,25,26
This was attributed to fatigue microfractures in the bone
exceeding the repair potential, as described in Frost’s
mechanostat theory.
These results were not confirmed by Miyata et al.27,
who also conducted an experimental study using monkeys
(Macaca fascicularis), and found no marginal bone loss
or loss of osseointegration with non-inflamed dental
implants. The study involved five monkeys, with two
implants placed in each monkey. After 3 months of
osseointegration, occlusal overload was achieved through
superstructures that were in over-occlusion by approxi-
mately 100 lM mounted on the implants, and a trau-
matic occlusal force was experimentally delivered to its
implant from the lingual to the buccal side. Plaque
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Successful osseointegrated dental implants
control was performed throughout the experimental pro-
cedure. The monkeys received an excessive occlusal force
for 1–4 weeks, and were then immediately killed. The
results showed that the implants remained firmly inte-
grated with the bone, and no marginal bone loss was
found.
A follow-up study was conducted by the same group,
who experimented on different levels of superstructure
heights (100, 180, and 250 lM) using the same breed of
monkeys.28 Four monkeys were subjected to occlusal
trauma for 4 weeks, and were then immediately killed.
The results showed increased probing peri-implant sulcus
depth in the 180- and 250-lM excess occlusal height
models. This was also in agreement with radiographic
evaluations. There was no difference found between the
control and the 100-lM height test group. Both 180- and
250-lM height test groups showed bone resorption. In
particular, the 250-lM height group demonstrated bone
resorption to almost half of the implant length. The
authors concluded that there is a possibility of bone
resorption around dental implants under excessive load-
ing force. According to this experimental study, increased
bone resorption occurred with an excess occlusal height
of 180 lM or higher.
However, a later experimental study using Labrador
dogs showed no marginal bone loss or loss of osseointe-
gration due to excessive occlusal forces.15 The experiment
included six Labrador dogs. Each dog’s bilateral mandibu-
lar premolar and molar teeth were removed. After
3 months of healing, two titanium plasma-sprayed (TPS)
and two sandblast, large-grit, acid-etched implants were
placed in each side of the mandible in each dog. Follow-
ing 6 months of healing, occlusal overload was created by
constructing crowns in the supra-occlusal position in the
test sites, one side of the mandible, whereas the controlled
site implants were not loaded. Thorough plaque control
was performed throughout the experimental period. After
8 months of loading, the mean probing depth, and also
the radiographic distance from the implant shoulder to
the marginal bone level, did not differ significantly
between the occlusal overloaded implants and unloaded
controls. Histology revealed that mineralized bone in con-
tact with the control and the test implant surfaces was
not statistically different, 72.6% and 73.9%, respectively.
Similar findings were made by Kozlovsky, who per-
formed experimental studies using Beagle dogs and found
no loss osseointegration or marginal bone loss with non-
inflamed, occlusally-overloaded dental implants.16 In their
study, four Beagle dogs were used with four screw-shaped
machined implants placed bilaterally in the mandible of
each dog. Prosthetic abutments were placed either in
supra-occlusion (loaded) or infra-occlusion (unloaded),
in contact with the opposing teeth. Cotton floss ligatures
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Successful osseointegrated dental implants
Table 1. Summary of the included studies for review
Study Study type
Miyata et al.27 Retrospective study:
animal experiment
Miyata et al.28 Retrospective study:
animal experiment
Gotfredsen et al.18 Retrospective study:
animal experiment
Gotfredsen et al.19 Retrospective study:
animal experiment
Gotfredsen et al.20 Retrospective study:
animal experiment
Duyck et al.14 Retrospective study:
animal experiment
Isidor13,25,26 Retrospective study:
animal experiment
Miyamoto et al.21 Retrospective study:
animal experiment
146
Sample Material/Method
Five monkeys (Macaca Dynamic loading at excess
fascicularis) height of 100 lM (loading
period: 1–4 weeks): 1
control and 4 test; control
oral hygiene
Four monkeys (Macaca Dynamic loading at excess
fascicularis) height of 100, 180, and
250 lM (loading period:
4 weeks): 1 control and 3
test; control oral hygiene
Three Beagle dogs Static loading (loading
period: 24 weeks); 8 TPS
implants in each dog; split-
mouth design
Three Labrador dogs Static loading (loading
period: 24 weeks); 2 TPS
and 2 machined implants in
each dog’s bilateral
mandible; split-mouth
design
Three Beagle dogs Static loading (loading
period: 10 & 46 weeks); 6
TPS implants in each dog;
split-mouth design
10 adult New Zealand Dynamic and static loading
black rabbits (loading period: 14 days); 3
Noble Biocare implants (1
dynamic loaded, 1 static
loaded, & 1 control) placed
in tibiae
Four monkeys Dynamic lateral loading
(loading period: 18 months);
5 Astra (machined & TiO2)
in each dog; split-mouth
design
12 Beagle dogs Static load with excess height
of 250 lM (loading period:
4 & 12 weeks); 3 Noble
Biocare (machined surface)
in each dog; 3 test groups
(control, 4- & 12-week
loading)
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M. Chang et al.
Results
No loss of osseointegration in
loaded implants
No difference between
control and 100-lM groups.
Marginal bone loss evident
at height ≥180 and 250 lM
No bone loss found around
loaded implants. Bone
density and mineralized BIC
percentage were higher
adjacent to the loaded
implants compared to
control implants
No bone loss found around
loaded implants. Bone
density and mineralized BIC
percentage were slightly
higher adjacent to the TPS
implants compared to
machined implants
No bone loss found. Similar
proportion of bone density
and degree of BIC between
10-week loading and
46-week loading group.
Higher proportion of
fluorochromes in 10-week
group than 46-week group
Marginal crater bone loss
evident in dynamic-loading
group. Decreased marginal
bone density on tension side
of dynamic-loaded implants,
but not statistically
significant
6/8 loaded implants lost
osseointegration with little
or no marginal bone loss; 2
implants lost due to
complete loss of
osseointegration; remaining
4 had significant clinical
mobility
Marginal bone loss
statistically-significantly
greater in 12-week loading
group than 4-week loading
group. Higher amount of
fluorescence label found in
4 week loading group than
12-week loading groups
M. Chang et al. Successful osseointegrated dental implants

Table 1. (Continued)

Study Study type Sample Material/Method Results

Heitz-Mayfield et al.15 Retrospective study: Six Labrador dogs Dynamic loading (loading
animal experiment period: 8 months); 4 TPS
and 4 SLA implants in the
mandible of each dog; split-
mouth design
Kozlovsky et al.16 Retrospective study: Four Beagle dogs Dynamical loading (Loading
animal experiment period: 12 months); four
implants (machined
surfaced) placed bilaterally
in the mandible in each
dog; split-mouth design
Mattheos et al.24 Clinical case report Two patients Two cases of loss of
osseointegration are
documented with single
implants in the posterior
maxilla (tooth 16 & 26).
Implant mobility in both
case, with absence of
plaque-induced
inflammation
Fugazzotto23 Case series: results of up 1472 molar implants Retrospective analysis of
to 15+ years were evaluated treated private patients by
examining active and
inactive patient charts
Tawil11 Clinical case report One patient Single case of loss of
marginal bone after implant
loaded with unstable
prosthesis
No statistically-significant
difference in bone height in
relation to the total length
of the implant percentage
between control and test
implants. No significant
difference in mineralized
bone density between
control (72.6%) and test
(73.9%) group
Loaded uninflamed group
showed mild crestal bone
resorption, but not apical to
the implant neck, and also
increased in BIC percentage
Implant mobility and loss of
osseointegration on implant
16 and 26 position, due to
implant rotation after 6 and
15 months’ loading,
respectively
8/11 implants failed within 0
–3 years of function due to
presence of detectable
parafunctions
Marginal bone loss after
placement of unstable
prosthesis for 6 months

BIC, bone-to-implant contact; SLA, sandblast, large grit, acid etched; TPS, titanium plasma sprayed.

were used unilaterally around the abutments to accumulate
plaque. The implants were divided into: (a) loaded non-
inflamed; (b) unloaded non-inflamed; (c) loaded inflamed;
and (d) unloaded inflamed. After 12 months, all of the
dogs were killed. The results showed no change in the clin-
ical parameter in both loaded and unloaded non-inflamed
groups (a,b). Loaded non-inflamed groups showed an
increase in the percentage of total BIC, with a slight
increase in crestal bone resorption, but not apically to the
implant neck. The authors concluded that overloading
implants in dogs at the absence of inflammation increased
the BIC percentage, with no marginal bone resorption.
The differences in the outcome of these experimental
studies can be attributed to confounding factors, such as
different experimental design, differences in definition
and cause of occlusal overload, and also in differences
in bone quality. The occlusal overload designed in the
experimental studies above was achieved by creating pre-
mature contacts of the dental prosthesis, but there was
no consistent experimental model or design of the pros-
thesis height and characteristics. In addition, due to the
fact that dogs are unable to perform lateral movements
like humans, lateral forces applied on the implant pros-
thesis could only be artificially created by inclined cusps
of different types, which were not consistently employed
in these studies. It is consequently difficult to measure
the amount and direction of forces applied through
these premature contacts. Both Isidor and Miyata
created a lateral displacement on the supra-occluding
prosthesis, whereas Heitz-Mayfield et al. created prema-
ture contacts in centric occlusion.13,15,25–27 In addition,
in Isidor’s experiment, the bone density apical to the
most coronal bone in direct contact to the implant was
an average of 55% for the excessive loaded implants,
compared to a mean average of 73.9–81.8% (bone
implant interface, and 1 mm lateral to the implant sur-

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Successful osseointegrated dental implants
face) for the loaded implants in Heitz-Mayfield et al.’s
study.15,26 One of the major weaknesses is that different
studies used different modes and protocols of oral
hygiene, which were not of the same intensity, and
could not always safely exclude the presence of peri-
implant tissue inflammation.
From these experiments, it cannot be safely concluded
whether excessive loading force on dental implants can
cause loss of osseointegration when the loading force
exceeds the biological adaptable threshold.13,15,16,25–28
While early studies on monkeys have indicated a plausible
link between occlusion and loss of osseointegration, later
studies on monkeys and dogs have failed to replicate
these findings. The experimental model, as well as the
level of oral hygiene and the complete prevention or not
of plaque-induced inflammation, might be a critical con-
founding factor here.
Human studies
Due to the absence of experimental studies, conclusions
are limited to case reports and cohort studies, usually
retrospective, which often attribute failures retrospectively
to “overloading” on a subjective basis.
Recently, Mattheos et al.24 presented a case report docu-
menting two cases where loss of osseointegration without
loss of marginal bone occurred several months after suc-
cessfully loading the dental implants, possibly as a result of
excessive loading. In both cases, when the occlusal load was
removed, the implants clinically re-osseointegrated within
6–8 months.
In another case report, Tawil11 noted that the placement
of an unstable removable prosthesis on three osseointegrat-
ed implants, which had been stable for 9 years, caused
noticeable marginal bone loss after 6 months. In contrast
to the previous two cases,24 no clinical mobility was noted;
instead, marginal bone loss around the machine-surfaced
implants was found after placement of the unstable over-
denture. Tawil11 believed that the marginal bone loss could
only be explained from occlusal overload due to the well-
documented, long-term stability of the bone level and
absence of pathological changes in the marginal soft tissues.
However, no record of periodontal pocket depth or bleed-
ing-on-probing index was reported.
In a case series, Fugazzotto23 found that eight out of 11
implants failed in the second molar region, with the pres-
ence of a detectable parafunction habit, indirectly suggest-
ing the occlusal excessive loading as a damaging factor.
Furthermore, Isidor published a review paper on the
influence of forces on peri-implant bone,and concluded
that there was an association between late implant failure
and parafunction based on studies by Balshi et al., Balshi
and Wolfinger, Ekfeldt et al., and Quirynen et al.8,12,29–31
However, none of those studies presented any solid exper-
148
M. Chang et al.
imental evidence for the role of excessive load, and were
merely retrospectively attributing implant failures to
“overloading”, mainly through subjective criteria. Many
of these studies indirectly hinted overload by retrospec-
tively attributing failures to Bruxism. The definitions of
parafunction were, however, expressing the subjective
opinions of clinicians.31
Load and mineralized BIC and bone density around oral
implants
Animal studies
When the dental implant is first loaded after successful
osseointegration, the surrounding bone, at large composed
of woven bone, will gradually remodel into lamellar bon,
and achieve its highest degree of organization and
mechanical properties after 1.5 years.32 Occlusal overload
of dental implants has resulted in increases in bone density
and mineralized BIC in some experimental studies.18–21
In a series of experimental studies Gotfredsen et al.
found that implants subjected to static lateral load present
with an increase in the surrounding bone density and the
percentage of mineralized BIC, compared to non-loaded
implants.18–20 Miyamoto et al.21 also found increased
remodeling activity in the inner thread of the static
loaded implants. In contrast, Heitz-Mayfield et al.15 did
not find a statistically significant-difference between
dynamic loaded and control implants at the bone–
implant interface and 1-mm distant from the implant
surface.
Both Gotfredsen et al. and Miyamoto et al. experi-
mented with static load on dental implants, but Gotfred-
sen et al. used lateral expansion force, whereas Miyamoto
et al. used vertical forces.18,21
Gotfredsen et al.’s18 experiment involved three Beagle
dogs, with eight TPS dental implants placed in each dog.
The implants were placed bilaterally in the mandibular sec-
ond, third, and fourth premolar sites. After 12 weeks of
uneventful healing, crowns connected in pairs were screwed
onto the implants. The crowns were loaded laterally
through an expansion screw, and were not in contact with
the opposing teeth in the maxilla. After 24 weeks of load-
ing, no evidence of marginal bone loss was found. The bone
density and mineralized BIC percentage were higher adja-
cent to the loaded implants, compared to the control
implants. In a subsequent study, Godfredsen et al.19 found
that lateral static expansion force resulted in structural
adaptation of the peri-implant bone. In addition, a rough
implant-surfaced texture showed a higher percentage of
mineralized BIC and bone density compared to machine-
surfaced implants.19
Miyamoto et al.21 used 12 adult Beagle dogs and
divided them equally into control, 4-week loading, and
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M. Chang et al. Successful osseointegrated dental implants

12-week loading groups. Each dog received three
machined Br anemark implants in the premolars region
on the right side of the mandible. The opposing maxillary
premolars were removed in order to control the amount
of overload. The superstructures were attached 12 and
20 weeks after implant placement in the 12-week and 4-
week loading groups, respectively. The implants in the
control group were not loaded. Fluorescence dye was
injected to monitor the remodeling process. Overload was
created with a submerging load of 250 lM onto the
implant. A higher level of fluorescence label was found in
the 4-week loading group compared to the 12-week load-
ing group. This indicates that the remodeling process was
greater in the 4-week loading group than the 12-week
loading group. The marginal bone loss was found statisti-
cally significantly greater in the 12-week loading group
than the 4-week loading group. Similar results were found
in Gotfredsen et al.’s20 study, in which the proportion of
fluorochromes was higher at sites subjected to 10 weeks
of loading than 46 weeks of loading. Extrapolating from
Frost’s mechanostat theory, loading force beyond the nor-
mal load and within the biological acceptable range might
promote bone formation and lead to an increase in bone
mass. Thus, it is appropriate to consider that the 12-week
loading group has lower remodeling activity due to the
changes in the bony structure.
From these experimental studies, it is clear that the sta-
tic load on the dental implant can increase the remodel-
ing activity of the peri-implant bone. Furthermore, the
percentage of mineralized BIC is greater with a rough
implant-surface texture compared to machine-surfaced
implants.19
Conclusions
It is difficult to clinically quantify the magnitude and
direction of naturally-occurring occlusal forces,12 which
makes the definition of excessive forces or “overload” elu-
sive at present. It is also very likely that the alveolar bone
will demonstrate a different degree of tolerance depending
on the individual, the location, and other anatomic and
physiological parameters. It is consequently very difficult
for clinical studies to demonstrate a possible correlation
between occlusal overload and implant failures. Therefore,
the majority of our direct evidence at present is gathered
from animal experimental studies and human case
reports. At this stage, no randomized control trials or
meta-analyses are available.
Based on the limited and often conflicting evidence
available, the following conclusions were drawn in this
review:
(a) the principles of Frost’s mechanostat theory on
destructive mechanic forces should also be applicable
to dental implants placed in the alveolar jaw. How-
ever, it remains unclear how the strain thresholds
identified on long skeletal bones would correlate to
the alveolar bone;
(b) complete loss of osseointegration or marginal bone
loss has been shown in few animal studies, but the
majority of more recent animal studies have not
replicated these findings;
(c) animal studies have consistently shown that func-
tional occlusal load applied on the dental implants
increases the remodeling activity around the peri-
implant bone tissue, which can increase the mineral-
ized BIC and bone density;
(d) total loss of osseointegration appears possible with
an already osseointegrated dental implant, when the
applied force exceeds the biological adaptable limit,
but this has been very rarely documented. This
threshold is currently unknown. Bone density/quality
is a significant influencing factor;
(e) re-osseointegration appears possible once the occlusal
load is removed; provided that the peri-implant tis-
sues are free of inflammation, the marginal soft tissue
seal is not compromised and the duration and the
intensity of the applied load have not overwhelmed
the repair potential of the bone;
(f) marginal bone loss as a result of excessive occlusal
forces has been repeatedly reported in the literature
concerning human patients, mainly when retrospec-
tively examining implant failures. Whether occlusal
loading has been a reason for this failure or other
causes are to be considered, such as plaque-induced
peri-implant inflammation, remains unclear, as these
reports could not account for the plaque and condi-
tions of the peri-implant soft tissues.

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