651

The Association Between Occlusal Status and the

Soft and Hard Tissue Conditions Around
Single-Unit Dental Implants

Carmen V. Graves, DDS, MSc, MS1 Dental occlusion plays a central role
Steve K. Harrel, DDS, MS2 in clinical dentistry and is essential
Martha E. Nunn, DDS, PhD3/Jorge A. Gonzalez, DDS, MS4 for normal physiologic function.1
Elias D. Kontogiorgos, DDS, PhD5 Harrel and Nunn found that pre-
David G. Kerns, DMD, MS2/Jeffrey A. Rossmann, DDS, MS2 mature occlusal contacts in centric
relation, posterior protrusive con-
The occlusal status of single-unit dental implants were evaluated using tacts, and balancing contacts were
traditional and computerized methods. The type of occlusal contact in maximum all associated with significantly
intercuspation and the presence of occlusal contacts on the implant during deeper periodontal probing depths
eccentric movements were recorded. A digital sensor was used for computerized
in teeth.2,3 It is unknown if occlusion
analysis of occlusion. Forty-four patients with 74 implants were included. Twenty-
nine implants (39%) presented with “heavy” occlusal contacts, 40 implants plays a role in inflammation of the
(54.1%) presented with “light” contacts, and 5 implants (6.8%) presented with soft tissue and loss of hard tissues
“no contact.” No statistically significant association was found between the surrounding an implant.
occlusal status and any of the soft and hard tissue condition variables (P > .05). Studies at the animal level show
Int J Periodontics Restorative Dent 2019;39:651–656. doi: 10.11607/prd.4184 conflicting results. Isidor4 reported
in a monkey study that excessive
occlusal loading on dental implants
could cause loss of osseointegra-
tion. Similarly, in monkeys, Miyata
et al5 suggested that the presence
of 180 µm of excessive height of the
prosthesis is associated with peri-
implant bone breakdown. However,
other animal studies do not support
the role of occlusion in peri-implant
Department of Periodontics, University of Illinois at Chicago College of Dentistry;
1 deterioration. Kozlovsky et al6 con-
Private Practice, Chicago, Illinois, USA. cluded in a canine study that over-
2Department of Periodontics, Texas A&M College of Dentistry, Dallas, Texas, USA.

3Center for Oral Health Research, Creighton University School of Dentistry,

load, mimicked by supra-occlusal
Omaha, Nebraska, USA. contacts acting on an uninflamed
4Center for Maxillofacial Prosthodontics, Texas A&M College of Dentistry, peri-implant environment, did not
Dallas, Texas, USA. negatively affect osseointegration
5Department of Restorative Sciences, Texas A&M College of Dentistry,
and was associated with improved
Dallas, Texas, USA.
tissue and bone response.
Correspondence to: Dr Carmen V. Graves, Department of Periodontics, There are few human studies on
University of Illinois at Chicago College of Dentistry, 801 S. Paulina St. RM.458 MC 859, the effects of occlusion on implants.
Chicago, IL 60612, USA. Fax: 312-996-0943.
Email: cgraves6@uic.edu, perio@cvgdental.com
In a case series, Quirynen et al7 eval-
uated occlusal overload in patients
Submitted November 11, 2018; accepted March 10, 2019.
©2019 by Quintessence Publishing Co Inc. with fixed full prostheses and found

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652
Fig 1 Presence of balancing contact.
that failing or failed implants were
observed when there was parafunc-
tional activity or a lack of anterior
contact. Other authors have devel-
oped concepts based on their clini-
cal experience and have presented
extensive reviews on this topic.
Misch and Bidez8 describe “implant-
protected occlusion” guidelines.
Naert et al9 reviewed the effect of
occlusal load in peri-implant bone
and highlighted the challenges faced
when studying this topic. Similarly, a
review by Kim et al10 states “there is
no evidence-based implant-specific
concept of occlusion. Future studies
in this area are needed to clarify the
relationship between occlusion and
implant success.”
The aim of the present study
was to evaluate the association
between the occlusal status and
the soft and hard tissue condition
around single-unit dental implants.
Materials and Methods
This cross-sectional study was con-
ducted at the Texas A&M College of
Dentistry in Dallas, Texas, and com-
plied with institutional review board
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regulations and the Helsinki accords
(IRB #2014-0471-BCD-FB). The in-
clusion criteria consisted of patients
who had received at least one den-
tal implant that was restored with a
single-unit crown and had been in
function for at least 1 year. Implants
with interim crowns were excluded.
Patients that fulfilled these criteria
signed an informed consent docu-
ment and underwent a clinical and
radiographic evaluation.
The occlusal evaluation in-
cluded recording the type of oc-
clusal contact during maximum
intercuspation (MI). Using articu-
lating silk ribbon, the contacts on
the implant-supported crown were
classified as “heavy,” “light,” or “no
contact.” In addition, the presence
or absence of occlusal contacts on
the implant during working, balanc-
ing, and protrusive movements was
recorded (Fig 1). The computerized
analysis of occlusion was complet-
ed using a commercially available
device (T-Scan, Tekscan), and the
computer-generated variables were
calculated. The implant mean rela-
tive Maximum Bite Force (rMBF),
which is a number from 0% to 100%
that represents the relative amount
of force received by the implant
when compared to the entire den-
tition, was calculated (Fig 2). From
the digital recordings, implant peak
force was also calculated, which is a
computer-generated ordinal color-
coded variable that was assigned a
numeric value from 0 to 6 according
to the force exerted on the implant.
Dark blue = 1, which represents very
low force; and pink = 6, which rep-
resents very high force. Disclusion
time, which is the amount of time
it takes for the teeth and implant to
separate, was also recorded. The
disclusion times during working,
balancing, and protrusive move-
ments were recorded and calculat-
ed for each implant.
To evaluate tissue condition
around the dental implant, the fol-
lowing parameters were recorded:
implant mobility (Y/N), suppuration
(Y/N), pain upon vertical percussion
(Y/N), bleeding on probing (BOP)
(Y/N), and the deepest implant
probing depth (PD) (mm) using a
plastic UNC-15 probe (Hu-Friedy).
All clinical measurements were per-
formed by a single calibrated exam-
iner (C.V.G.). Periapical and vertical
bitewing radiographs were taken
with a digital radiograph machine
(ProStyle, Planmeca) using a stan-
dardized film holder. The crestal
bone level, defined as the distance
from the implant platform to the
first implant-to-bone contact, was
measured in millimeters on both
the distal and mesial aspects of
the dental implant. All radiographic
measurements were performed
twice. The amount of bone loss was
calculated by subtracting the initial
crestal bone level (measured in the
baseline radiograph taken at the
time of implant placement or crown
delivery) from the crestal bone level
measured at the time of the study
evaluation. Baseline radiographs
were performed at various treat-
ment locations using multiple differ-
ent techniques and were therefore
not standardized.
An implant was classified as
having “peri-mucositis” when it
presented with gingival inflamma-
tion, BOP, and had no bone loss.11
 653

11 21
12 22

13 1.4% 2.6 23
1.6% 1.7%
15 2.7% 6.3%
25
8.2% 7.9%
16 I-26
9.4% 9.4%

17 27
19.4% 28.8%

Right 43.3% 56.7% Left

Fig 2 Computer view of T-Scan recordings. In this example, an implant is placed at tooth site 26 (marked as I-26; FDI system) and presents
with an rMBF of 9.4%, with a peak force that reaches a light blue color (low force). In contrast, the tooth at site 27 presents with an rMBF
of 28.8% and a peak force that reaches a pink color (very high force).

An implant was classified as having
“peri-implantitis” when it presented
with the following conditions: pres-
ence of BOP, PD ≥ 5 mm, and bone
loss ≥ 2 mm.11,12 Implants were con-
sidered healthy if neither of these
conditions were present.
The following confounding vari-
ables were included in the analy-
sis: age, gender, smoking status,
diabetic status, bruxism, platform
switch, use of an occlusal guard, ver-
tical offset, type of restoration, and
restorative clinician experience. A
statistical power analysis to deter-
mine the sample size was calculat-
ed using a statistical power of 80%
and a statistical significance of 5%
(α = .05). In order to find a correla-
tion of 0.4, the required sample size
was 44 patients. Data analysis was
completed using statistical software
systems (Microsoft Excel 2015; IBM
SPSS Statistics 23).
Results
Forty-four patients with a total of
74 implants were included in this
study, from July 2014 to Septem-
ber 2015. Descriptive statistics are
presented in Appendix Table 1 (see
Appendices in the online version of
this article at www.quintpub.com/
journals). The mean patient age was
63.8 (± 12.8) years, with a range of
31 to 79 years. Twenty-seven pa-
tients were females (61.4%), and 17
patients were males (38.6%). Two
patients reported being smokers
(4.5%), and 4 patients reported hav-
ing diabetes (9.1%). The mean time
from crown placement was 56.7 (±
12.0) months with a range of 12 to
132 months. Thirty implants (40.5%)
presented with horizontal offset
(platform switch), whereas 44 im-
plants (59.5%) did not. Also, it was
observed that 5 implants (6.8%)
were “tissue level” and 69 implants
(93.2%) were “bone level.” Most of
the restorations were screw-retained
(64 implants, 86.5%), while only 10
implants (13.5%) received cement-
ed restorations. Sixty-four implants
(86.5%) were restored by prosth-
odontists at the Center for Maxillo-
facial Prosthesis at the Texas A&M
College of Dentistry, and all restora-
tions in this group were fabricated
in the same lab. The remaining 10
implants (13.5%) were restored in
the undergraduate implant clinic of
Texas A&M College of Dentistry by
multiple students.
A total of 42 implants (56.8%)
presented with peri-mucositis. Three
implants presented with peri-im-
plantitis (4.1%); this low number was
inadequate for statistical analysis
and thus this variable was excluded
from the current statistical analysis.
The mean deepest implant PD was

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654
3.68 ± 1.17 mm with a range of 1 to
7 mm. The mean radiographic bone
loss was –0.17 ± 0.84 mm, ranging
from –3.43 to 1.40. A negative value
indicates bone loss, whereas a posi-
tive value indicates bone gain. No
implant presented with suppura-
tion, mobility, or pain upon vertical
percussion.
The occlusal status character-
istics are presented in Appendix
Table 2. The type of occlusal con-
tact during MI, as detected with silk
ribbon, was “heavy” in 29 implants
(39.2%) and “light” in 40 implants
(54.1%), and “no contact” was pres-
ent in 5 implants (6.8%). Twenty
implants presented with working
contact (27.0%), 4 presented with
balancing contact (5.4%), and 7
presented with protrusive contact
(9.5%). Five patients (11.4%) report-
ed a history of bruxism and using
an occlusal guard, while 15 (34.1%)
patients reported a history of brux-
ism but were not using an occlusal
guard. Twenty-four patients (54.5%)
reported not having bruxism.
The computerized occlusal vari-
ables presented the following de-
scriptive statistics (Appendix Table 3).
The mean rMBF on the implant was
10.9% ± 11.0% (range: 0% to 56.1%),
meaning that at least one implant
did not receive any force whatso-
ever (0%) during MBF and one im-
plant received 56.1% of force during
MBF. The mean implant disclusion
time was 1.11 ± 1.01 seconds when
the patient was asked to move their
jaw towards the working side, 0.66 ±
0.84 seconds when the patient was
asked to move their jaw towards the
balancing side, and 0.46 ± 0.62 sec-
onds in protrusive movement.
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When analyzing the deepest
implant PD (Appendix Table 4a) and
radiographic bone loss (Appendix
Table 4b) with the traditional occlu-
sal variables and computerized oc-
clusal variables (Appendix Table 5),
the statistical analysis using gener-
alized estimating equation models
did not reveal any statistically sig-
nificant association among the vari-
ables (P > .05).
When analyzing the occlusal
variables with the peri-mucositis sta-
tus (Appendix Tables 6 and 7), the
statistical analysis using Rao-Scott
chi-square test to adjust for clus-
tering showed that none of the oc-
clusion variables had a statistically
significant association with the peri-
mucositis condition (P > .05), with
the exception of protrusive contact
(P = .023).
When relevant possible con-
founding variables were included in
the statistical analysis—such as age,
gender, smoking status, diabetic
status, bruxism, platform switching,
vertical offset, type of restoration,
usage of an occlusal guard, and
clinician experience—only one sta-
tistically significant association was
found between protrusive contact
and radiographic bone loss (P = .042)
when adjusting for age and gender
(Appendix Table 8). Implants that
presented with protrusive contacts
had a statistically significant asso-
ciation with bone gain (0.46 mm),
whereas implants that lacked a pro-
trusive contact were associated with
bone loss (–0.18 mm). However, this
statistically significant association
may lack clinical significance, as it
represents a difference of less than
1 mm from one group to the other.
Discussion
In this cross-sectional clinical study,
we did not find a clinically significant
association between the occlusal
variables and any of the soft and hard
tissue–condition variables included
in this study. While the influence of
occlusion on the development of
peri-implant disease remains plausi-
ble from a biomechanical and bone
physiology standpoint,13–15 the data
from the present study do not sup-
port this at a clinical level.
Because a prospective study that
induced occlusal stress in humans
would be unethical, cross-sectional
studies are the only reasonable meth-
od to evaluate the possible associa-
tion between occlusal status and the
soft and hard tissue conditions in a
human clinical setting. The authors
could not find any previously pub-
lished articles on this topic that de-
scribed the occlusal contact scheme
found on implants in the general
population. In the present study, the
authors found that the sample had
diverse occlusal schemes: some
implants presented with heavy oc-
clusion while others had no occlusal
contact. Having this wide variability in
occlusal status in the sample allowed
for the possibility of finding an asso-
ciation with any of the hard and soft
tissue–condition implant variables.
However, when the statistical analy-
sis was completed, the authors did
not find any statistically significant
association that had a clinical signifi-
cance between the variables.
In the present sample, the
authors found that only three im-
plants (4.1%) presented with peri-
implantitis. Peri-mucositis was

present in 42 implants (56.8%),
which is higher compared to the
peri-mucositis prevalence of 48%
that was previously reported.16
However, because peri-implant mu-
cositis is reversible with early inter-
vention,17 it is quite possible that its
prevalence could be underreported
in the previously reported studies.
The reversible nature of peri-mu-
cositis could explain the difference
between the prevalence reported
among studies.
The mean radiographic bone
loss found in the present sample was
–0.18 ± 0.83 mm, which is compat-
ible with implant health and normal
bone remodeling. Very few im-
plants presented with pronounced
radiographic bone loss (maximum:
–3.43 mm). A few implants pre-
sented with crestal bone gain (up
to 1.40 mm). Based on these obser-
vations, the sample was comprised
mainly of nonfailing implants. It is
important to conduct additional
studies in this topic with a larger
sample to supplement these results.
The authors previously pub-
lished a comprehensive review
of the published literature on this
topic18 and found no comparable
studies with which to compare the
present results. To the authors’
knowledge, this is the first human
cross-sectional study that evaluated
the occlusal status using both tradi-
tional and computerized methods
and analyzed it in relation to the soft
and hard tissue conditions around
dental implants. In the present
analysis, the authors included rel-
evant confounding variables, such
as age, gender, smoking status,
diabetic status, bruxism, use of an
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occlusal guard, platform switch, ver-
tical offset, and type of restoration.
It is probable that peri-implant
diseases are multifactorial. Previ-
ous studies have shown an associa-
tion with multiple factors, such as
plaque,19 history of periodontal dis-
ease,20 smoking,21 and diabetes.21
The present study did not find an
association between occlusal status
and the condition of soft and hard
tissues, even when controlling for
relevant confounding variables.
Conclusions
Within the limitations of the present
study, the occlusal status of single-
unit dental implants is not associ-
ated with the soft and hard tissue
conditions around nonfailing single
implants.
Acknowledgments
The authors would like to thank Dr Rob-
ert Kerstein, for sharing his experience on
the usage of the T-Scan device, as well as
Tekscan (Boston, Massachusetts, USA), for
providing the T-Scan device, sensors, and
training. The authors report no conflicts of
interest. The study was completed using
funds from the Graduate Fund of the Texas
A&M College of Dentistry.
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 656a

Appendices

Appendix Table 1 Descriptive Statistics Appendix Table 2 Occlusal Status

Patient characteristics (n = 44 patients) Occlusal characteristics n (%)
Age (y) Type of contact during MI
Mean (± SD) 63.8 (± 12.8) Heavy 29 (39.2)
Median 66 Light 40 (54.1)
Range 31 to 79 No contact 5 (6.8)
Gender Working contact
Female 27 (61.4%) Yes 20 (27.0)
Male 17 (38.6%) No 54 (73.0)
Smoking status Balancing contact
Smoker 2 (4.5%) Yes 4 (5.4)
Nonsmoker 42 (95.5%) No 70 (94.6)
Diabetes Protrusive contact
Yes 4 (9.1%) Yes 7 (9.5)
No 40 (90.9%) No 67 (90.5)
Implant characteristics (n = 74 implants) Bruxism
Bruxer with OG 5 (11.4)
Time from restoration (mo)
Bruxer without OG 15 (34.1)
Mean (± SD) 56.7 (± 12.0)
Nonbruxer 24 (54.5)
Median 60
Range 12 to 132 MI = maximum intercuspation; OG = occlusal guard.

Horizontal offset (platform switch)

Yes 30 (40.5%)
No 44 (59.5%)
Vertical offset (level)
Tissue level implant 5 (6.8%)
Appendix Table 3 Occlusal Status of
Bone level implant 69 (93.2%) Computerized
Occlusal Variables
Type of restoration
Screw-retained 64 (86.5%) Mean (± SD) Median Range
Cemented 10 (13.5%)
Implant rMBF, % 10.9 (11.0) 7.5 0 to 56.1
Clinician placing crown
Student 10 (13.5%) Implant disclusion time, s
Prosthodontists 64 (86.5%) Working 1.11 (1.01) 0.87 0 to 4.33
Peri-mucositis Balancing 0.66 (0.84) 0.41 0 to 3.78
Yes 42 (56.8%) Protrusive 0.46 (0.62) 0.26 0 to 3.88
No 32 (43.2%)
Implant peak force, range 0–6
Peri-implantitis
Yes 3 (4.1%) Closure 3.10 (2.04) 3 0 to 6
No 71 (95.9%) Working 2.04 (± 1.58) 2 0 to 6
Balancing 1.59 (± 1.31) 1 0 to 6
Deepest probing depth (mm) Protrusive 1.76 (± 1.36) 1 0 to 6
Mean (± SD) 3.68 (± 1.17)
Range 1 to 7 SD = standard deviation; rMBF = relative maximum bite force.

Radiographic bone loss (mm)

Mean (± SD) –0.17 (± 0.84)
Range –3.43 to 1.40
SD = standard deviation.

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656b

Appendix Table 4a Statistical Analysis of Deepest Implant PD (mm) with

Traditional Occlusal Variables
Occlusal variable n LSM (± SE), mm Median, mm Range, mm P
Type of contact MI
No contact 5 4.00 (± 0.65) 4 2 to 7 .719
Light contact 40 3.75 (± 0.21) 4 1 to 6
Heavy contact 29 3.53 (± 0.20) 4 2 to 5
Working contact
Yes 20 3.85 (± 0.18) 4 3 to 5 .362
No 54 3.62 (± 0.19) 4 1 to 7
Balancing contact
Yes 4 4.32 (± 0.69) 4.5 2 to 6 .368
No 70 3.64 (± 0.16) 4 1 to 7
Protrusive contact
Yes 7 3.24 (± 0.38) 3 2 to 5 .250
No 67 3.73 (± 0.16) 4 1 to 7
Bruxism
Yes (No OG) 26 3.66 (± 0.28) 4 2 to 6 .865
Yes (OG) 5 3.80 (± 0.18) 4 3 to 4
No 43 3.67 (± 0.22) 4 1 to 7
Clinician placing crown
Prosthodontist 64 3.66 (± 0.17) 4 1 to 7 .785
Student 10 3.76 (± 0.34) 4 2 to 6
PD = probing depth; LSMs = least-squares means; SE = standard error; MI = maximum intercuspation;
OG = occlusal guard.
Generalized estimating equation (GEE) models regression, with LSM obtained from the regression.
No statistically significant association was found of any of the traditional occlusal variables with deepest implant PD.

Appendix Table 4b Statistical Analysis of Radiographic Bone Loss (mm) with

Traditional Occlusal Variables
Occlusal variable n LSM (± SE), mm Median, mm Range, mm P
Type of contact MI
No contact 5 –0.64 (± 0.34) –0.25 –2.07 to –0.01 .470
Light contact 40 –0.14 (± 0.14) –0.03 –3.43 to 1.29
Heavy contact 29 –0.13 (± 0.14) –0.02 –1.66 to 1.40
Working contact
Yes 20 –0.39 (± 0.23) –0.27 –3.43 to 0.90 .248
No 54 –0.08 (± 0.10) –0.03 –2.07 to 1.40
Balancing contact
Yes 4 0.55 (± 0.35) 0.77 –0.52 to 1.38 .140
No 70 –0.20 (± 0.10) –0.09 –3.43 to 1.40
Protrusive contact
Yes 7 0.28 (± 0.23) 0.06 –0.58 to 1.38 .103
No 67 –0.21 (± 0.11) –0.13 –3.43 to 1.40
Bruxism
Yes (No OG) 26 –0.21 (± 0.22) –0.17 –3.43 to 1.40 .922
Yes (OG) 5 –0.23 (± 0.26) 0 –1.15 to 0.58
No 43 –0.13 (± 0.12) –0.02 –2.07 to 1.38
Clinician placing crown
Prosthodontist 64 –0.13 (± 0.12) –0.03 –3.43 to 1.40 .296
Student 10 –0.35 (± 0.16) –0.48 –1.15 to 0.58
LSMs = least-squares means; SE = standard error; MI = maximum intercuspation; OG = occlusal guard.
Generalized estimating equation (GEE) models regression, with LSM obtained from the regression.
No statistically significant association was found of any of the traditional occlusal variables with radiographic bone loss.

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Appendix Table 5a Statistical Analysis of Appendix Table 5b Statistical Analysis ofRadio-

Deepest Implant PD with graphic Bone Loss with
Computerized Computerized
Occlusal Variables Occlusal Variables
Computerized occlusal variable Spearman rho Pa Computerized occlusal variable Spearman rho Pa
Implant rMBF 0.289 .060 Implant rMBF 0.114 .468
Implant disclusion time Implant disclusion time
Working –0.025 .876 Working 0.249 .116
Balancing –0.024 .881 Balancing 0.115 .469
Protrusive –0.239 .122 Protrusive 0.015 .926
Implant peak force Implant peak force
Closure 0.086 .589 Closure –0.046 .771
Working 0.074 .643 Working –0.054 .734
Balancing 0.089 .575 Balancing –0.021 .894
Protrusive 0.095 .549 Protrusive –0.029 .855
PD = probing depth; rMBF = relative maximum bite force. rMBF = relative maximum bite force.
No statistically significant association was found of any of the No statistically significant association was found of any of the
computerized occlusal variables with implant deepest PD. computerized occlusal variables with radiographic bone loss.
a
Spearman correlation using patient-level means. a
Spearman correlation using patient-level means.

Appendix Table 6 Statistical Analysis Between Appendix Table 7 Statistical Analysis Between
Peri-mucositis and Traditional Peri-mucositis and
Occlusal Variables Computerized
Occlusal Variables
Perimucositis
n (%) Perimucositis
Occlusal variable Yes No Pa Mean (± SE)
Type of contact MI Occlusal variable Yes No P
No contact 3 (7.1) 2 (6.3) .728 rMBF (%) 12.8 (± 1.88) 8.4 (± 1.59) .067
Light contact 21 (50.0) 19 (59.4)
Heavy contact 18 (42.9) 11 (34.4) Implant disclusion time, s
Working contact Working 1.29 (± 0.21) 0.94 (± 0.13) .145
Yes 11 (26.2) 9 (28.1) .876 Balancing 0.55 (± 0.14) 0.78 (± 0.14) .157
No 31 (73.8) 23 (71.9) Protrusive 0.38 (± 0.07) 0.56 (± 0.14) .227
Balancing contact Implant peak force, range 0–6
Yes 2 (4.8) 2 (6.3) .786 Closure 3.33 (± 0.29) 2.94 (± 0.41) .412
No 40 (95.2) 30 (93.8) Working 2.27 (± 0.24) 2.11 (± 0.26) .542
Protrusive contact Balancing 1.68 (± 0.22) 1.46 (± 0.21) .491
Yes 1 (2.4) 6 (18.8) .023* Protrusive 1.95 (± 0.23) 1.68 (± 0.22) .304
No 41 (97.6) 26 (81.3) rMBF = relative maximum bite force; SE = standard error.
No statistically significant association was found between
Bruxism peri-mucositis and computerized occlusal variables.
Yes (No OG) 14 (33.3) 12 (37.5) .554
Yes (OG) 4 (9.5) 1 (3.1)
No 24 (57.1) 19 (59.3)
Clinician placing crown
Prosthodontist 35 (83.3) 29 (90.6) .385
Student 7 (16.7) 3 (9.4)
MI = maximal intercuspidation; OG = occlusal guard.
aRao-Scott chi-squared test.

*Statistically significant correlation.

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Appendix Table 8 Statistical Analysis of Radiographic Bone Loss (mm) by

Occlusal Variables with Adjustment for Age and Gender
Occlusal variable n LSM (± SE), mm 95% CI, mm P
Type of contact MI
No contact 5 –0.66 (± 0.32) –1.28 to –0.03 .353
Light contact 40 –0.10 (± 0.13) –0.36 to 0.16
Heavy contact 29 –0.05 (± 0.13) –0.30 to 0.20
Working contact
Yes 20 –0.40 (± 0.19) –0.77 to –0.03 .149
No 54 –0.02 (± 0.11) –0.22 to 0.19
Balancing contact
Yes 4 0.71 (± 0.34) 0.04 to 1.37 .103
No 70 –0.17 (± 0.09) –0.35 to 0.01
Protrusive contact
Yes 7 0.46 (± 0.20) 0.06 to 0.86 .042*
No 67 –0.18 (± 0.09) –0.36 to 0.01
Bruxism
Yes (No OG) 26 –0.19 (± 0.19) –0.55 to 0.18 .782
Yes (OG) 5 –0.22 (± 0.23) –0.66 to 0.23
No 43 –0.07 (± 0.11) –0.29 to 0.16
Clinician placing crown
Prosthodontist 64 –0.08 (± 0.10) –0.28 to 0.12 .148
Student 10 –0.34 (± 0.14) –0.61 to –0.08
LSMs = least-squares means; SE = standard error; CI = confidence interval;
MI = maximum intercuspation; OG = occlusal guard.
Generalized estimating equation (GEE) models regression, with LSM obtained from the regression.
*A statistically significant association was found between protrusive contact and radiographic bone loss when
adjusting for age and gender. Implants that presented with protrusive contact were associated with bone gain
(0.46 mm), while implants lacking a protrusive contact were associated with bone loss (–0.18 mm).

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