Australian Dental Journal 2008; 53:(1 Suppl): S60–S68

doi: 10.1111/j.1834-7819.2008.00043.x

Occlusion in implant dentistry. A review of the literature

of prosthetic determinants and current concepts
MD Gross*
*Department of Oral Rehabilitation, Tel Aviv School of Dental Medicine, Tel Aviv University, Israel.

ABSTRACT
Today the clinician is faced with widely varying concepts regarding the number, location, distribution and inclination of
implants required to support the functional and parafunctional demands of occlusal loading. Primary clinical dilemmas of
planning for maximal or minimal numbers of implants, their axial inclination, lengths and required volume and quality
of supporting bone remain largely unanswered by adequate clinical outcome research. Planning and executing optimal
occlusion schemes is an integral part of implant supported restorations. In its wider sense this includes considerations of
multiple inter-relating factors of ensuring adequate bone support, implant location number, length, distribution and
inclination, splinting, vertical dimension aesthetics, static and dynamic occlusal schemes and more.
Current concepts and research on occlusal loading and overloading are reviewed together with clinical outcome and
biomechanical studies and their clinical relevance discussed. A comparison between teeth and implants regarding their
proprioceptive properties and mechanisms of supporting functional and parafunctional loading is made and clinical
applications made regarding current concepts in restoring the partially edentulous dentition. The relevance of occlusal
traumatism and fatigue microdamage alone or in combination with periodontal or peri-implant inflammation is reviewed
and applied to clinical considerations regarding splinting of adjacent implants and teeth, posterior support and eccentric
guidance schemes.
Occlusal restoration of the natural dentition has classically been divided into considerations of planning for sufficient
posterior support, occlusal vertical dimension and eccentric guidance to provide comfort and aesthetics. Mutual protection
and anterior disclusion have come to be considered as acceptable therapeutic modalities. These concepts have been
transferred to the restoration of implant-supported restoration largely by default. However, in light of differences in the
supporting mechanisms of implants and teeth many questions remain unanswered regarding the suitability of these
modalities for implant supported restorations. These will be discussed and an attempt made to provide some current clinical
axioms based where possible on the best available evidence.
Key words: Implant occlusion, implants, dental occlusion, treatment planning.
Abbreviations and acronyms: FPD = fixed partial denture; ICD = individual clinical determinant; MI = maximum intercuspation; OVD =
occlusal vertical dimension; PDL = periodontal ligament; RCT = randomized controlled trials; TMD = temporomandibular disorder.

In many cases clinicians appear to be applying

INTRODUCTION
The intended function of implant-supported restora-
tions is to restore missing teeth and lost elements of the
dentition, to maintain or restore form, function and
aesthetics and to optimize the longevity of the restored
or remaining dentition. Implants and their bony
housing need to be planned and placed to support the
functional and parafunctional demands of occlusal
loading. Occlusal restorative concepts that have
evolved through complete denture and fixed tooth-
supported reconstruction are having to be rethought
with the continuing development and advances in
implant dentistry.
S60
paradigms transferred from occlusion in the natural
dentition, basing treatments on continued empirical
decisions in treatment planning and often appear to
be experimenting with treatment. Recent concepts of
replacing whole arches on four or three implants,
angulating implants and supporting occlusal loads on
bone substitutes are challenging former paradigms
and the clinician is often in a quandary as to what is
the most appropriate implant distribution, angulation
and position, particularly if an evidence-based
approach is considered to be the goal. In terms of
evidence-based treatment planning and treatment,
clinicians are sorely lacking in sufficient evidence at
ª 2008 Australian Dental Association

many levels and remain with more questions than
answers.
A preliminary consideration of the natural anatomy
of the dentition, occlusion and alveolar support mech-
anisms is helpful to provide a perspective for planning
and future function of implant supported restorations
designed to replace missing elements of the dentition
and alveolar housing.
Principles of occlusion
Evolution of the dentition
The human dentition appears to have evolved via
omnivorous apes and various generations of hominids
over a period of six million years. The molars of apes
and hominids have not changed significantly. Canines
no longer used for killing prey, have become smaller,
while the incisors have remained similar in shape.
Force distribution to the facial skeleton
Posterior teeth crush and prepare food on mastication
for digestion and stabilize the mandible for swallow-
ing. The skull is designed with posterior intercuspa-
tion providing posterior occlusal support, with max-
imum force application at the zygomatic base above
the first and second molars. In the maxilla, sinus and
nasal cavities are located directly above the apices of
the teeth with the forces of occlusion distributed
peripherally along the facial aspect of the maxilla and
premaxilla by in-plane loading. The teeth in the
mandible are supported by periodontal tissues in
alveolar bone surrounded by thicker mandibular
cortices. All maxillary and mandibular teeth except
for posterior mandible, generally have very thin
buccal plates. Posterior areas of maximal loading
tend to be more trabeculated than the anterior,
particularly in the mandible. The anterior teeth are
used for incision and food preparation with ver-
tical and horizontal overlap varying between Class I,
II and III relations in a wide range of normal
distribution.
Implant challenge to adaptation
Restoring the dentition with titanium screw-shaped
implants in the residual alveolar bone supporting fixed
partial dentures (FPDs) has significantly challenged the
adaptive potential of this complex system. Anterior
splinted FPDs with distal cantilevers, implants in
augmented sinuses, and multiple permutations of
possible implant length, diameter, distribution, inclina-
tion and pontic options, are all additional challenges
to the adaptive potential of the individual case, and to
the diagnostic and prognostic abilities of the clinician
ª 2008 Australian Dental Association
Occlusion in implant dentistry
faced with these multiple options, which are often not
supported by adequate scientific research.
Principal components of the occlusion and their
interaction
The occlusion may be viewed as consisting of three
basic elements: posterior support, occlusal vertical
dimension (OVD) and eccentric or anterior guidance.
Posterior support
Posterior teeth provide the posterior occlusal support
that bears the often considerable forces of mastication,
swallowing and occlusal parafunction, and maintains
the occlusal vertical dimension.
Eccentric guidance
The eccentric guidance is the dynamic contact relation
of the teeth as they slide voluntarily from maximum
intercuspation (MI) to edge to edge relations in all
excursions. This also guides reflex masticatory cycles
into maximum intercuspation MI and is the site on
which eccentric occlusal parafunction occurs.
Parafunction
Eccentric occlusal parafunction may generate extremely
high and potentially destructive loads, sufficient to wear
down the teeth, fracture crowns and roots, decement
or break FPDs, dislodge or break abutment screws,
fracture porcelain or superstructures, traumatize sup-
porting bone and break implants. Considerations for
planning need to focus on minimizing the poten-
tial destructive effects of this destructive behavioural
phenomenon about which we know very little.
Anterior guidance
The degree of vertical and horizontal overlap deter-
mines whether the anterior teeth disclude the posteriors
in protrusion and whether the working side discludes
the non-working side in lateral and lateroprotrusive
excursions. When the anterior teeth disclude the
posterior teeth in all excursions, this has been termed
‘‘anterior disclusion’’ and ‘‘mutual protection’’. Mutual
protection is described as the molars protecting the
anteriors in MI and the anterior teeth protecting the
posteriors in excursions.
Mutual protection
There is no phylogenetic evidence that this is a
consequence of evolutionary specialization. Canines
were for killing prey and incisors for tearing meat or
S61
MD Gross
peeling fruit, and not for protecting molar teeth during
occlusal parafunction. Neither does there appear to be
any convincing evidence that Class II Division I, Class
III and other dentitions lacking anterior disclusion,
have higher morbidity or greater incidence of temporo-
mandibular disorder (TMD), occlusal parafunction or
tooth loss. This is relevant in planning implant-
supported occlusions and the interaction of posterior
and anterior teeth and implants.
Mutual protection and anterior disclusion
Mutual protection and anterior disclusion are pur-
ported to be desirable restorative occlusal schemes in
tooth-supported fixed prosthodontics. Neuromuscular
protective mechanisms and the mechanical advantage
of a Class III lever are claimed to reduce occlusal
loading, parafunction and TMDs. Applying these same
principles to implants is problematic. Implants are more
often than not supported buccally by thin buccal plates
that do not have periodontal receptors and may be
susceptible to cervical bone loss with occlusal overload.
Considerations will vary between mixed tooth and
implant-supported dentitions and between totally
implant-supported fixed restorations. In mixed tooth
and implant-supported dentitions, decisions need to be
made whether teeth disclude implants, or whether
implants or teeth and implants support excursive
guidance, and whether restorations are independent
or splinted. Local biomechanical considerations may
outweigh the purported theoretical benefits of neuro-
muscular protection of anterior disclusion and mutual
protection. Considerations of disclusion are complicated
by full-arch splinting whereby anterior and posterior
segments are no longer independent elements but part of
a rigid structure with different biomechanical properties.
Interacting prosthetic determinants
Interaction of the various determinants of occlusion
will also affect planning of implant location, dimen-
sions, inclination, support and occlusal design. Aes-
thetic tooth display at rest and smiling determines the
length of the maxillary crowns. Vertical dimension
determines the interarch distance, crown ⁄ implant ratio
and crown height space.1 Skeletal and residual antero-
posterior and bucco-lingual ridge relations determine
the degree of implant inclination, off-axis loading or
need for bone augmentation. Planning of implant
dimensions, distribution, inclination, support, super-
structure design and occlusal schemes should therefore
consider these various interactions. These requirements
are case-specific, and should be designed to provide
adequate posterior support at an appropriate occlusal
vertical dimension with an eccentric guidance that
optimally distributes the potentially destructive effects
S62
of excursive occlusal parafunction. The appropriate use
of diagnostic preparations, radiographic and surgical
guides, provisional restorations, and cross-mounting
restorative and surgical modalities can aid in facilitat-
ing this challenging clinical task.
Occlusal force distribution – teeth versus implants
Teeth are suspended in the alveolus with periodontal
tissues; may be displaced 25–100 lm vertically and
56–108 lm buccolingually and maintain the alveolus in
response to customary functional loading. Excessive
load causes trauma at the compression site with
subsequent repair and widening of the periodontal
ligament (PDL). Teeth with normal support respond to
jiggling forces from occlusal overload with resorption,
repair, widened periodontal space and increased mobil-
ity; in the absence of periodontal inflammation there is
no apical loss of attachment. This is a reversible process.
However, the combination of a traumatic lesion with
periodontitis, causes increased irreversible bone loss.
Implants are more rigidly attached to the bone and
may be displaced 3–5 lm vertically and 10–50 lm
laterally.2 The integrity of the interface is maintained in
a steady state by bone ‘‘remodelling’’ as a continuous
process of microtrauma and repair.3 Implants lack the
adaptive facility of teeth to develop reversible increased
mobility when loaded. Current concepts are mixed
regarding the peri-implant response to occlusal over-
load. A phenomenon of fatigue microtrauma has been
proposed as the process of cervical and progressive
bone loss as bone ‘‘modelling’’ due to excessive occlusal
load. When the rate of fatigue microdamage exceeds
the reparative rate, cervical bone is irreversibly lost.
Dynamic cyclic loading of dog and rabbit tibiae have
shown cervical bone loss similar to saucerized cervical
bone loss in the clinical situation.3,4
Occlusal overload with restorations in extreme
superocclusion showed complete loss of integration in
baboons,5 while smaller amounts of supraocclusion
showed no bone loss.6 Static loading models with
springs between adjacent implants showed no evidence
of marginal bone loss at test or control sites with higher
bone density and mineralized bone-to-implant contact
adjacent to the loaded implants interpreted to be the
result of adaptive remodelling to the applied force.7 One
study in monkeys with repetitive mechanical trauma
showed no histological effect on ligature-induced peri-
implant bone loss either in healthy or diseased implant
sites after four months.8 In a recent beagle dog model,
ligature-induced peri-implantitis with occlusal overload
caused more marginal bone loss than peri-implantitis
alone. In the presence of plaque-induced peri-implant
inflammation overloading aggravated plaque-induced
bone resorption, and increased bone loss on the buccal
and lingual sides of the implant.9 Osseoperception and
ª 2008 Australian Dental Association

the presence of mechanoreceptors at the bone-implant
interface have recently been shown, supporting the
hypothesis for the presence of sensory feedback from
loaded implants.10
Biomechanical studies
Several physical and mathematical modalities are used
to simulate occlusal loading. These include 2- and 3-D
photoelastic models, strain gauge analysis and 2- and
3-D finite element analysis. While each has inherent
advantages and weaknesses they essentially demon-
strate points or areas of relative stress concentration in
modelled superstructures, implants and supporting
structures. Some quantify the degree of strain and
relate these to calculated values of fatigue overload in
bone deformation models. Some correlation is seen
with animal and clinical outcomes as they all show an
increased amount of cervical stress concentration with
increased degree of load, off-axis inclination and
bending moments. While not being directly applicable
they have value in indicating relative degrees of
biomechanical risk for differing loading situations.11
Splinting
The question of splinting is relevant to a discussion of
occlusion. Tooth connection particularly of mobile
teeth has been considered advantageous in increasing
the collective resistance of the splinted superstructure to
lateral forces, which may be further enhanced by non-
collinear or cross-arch splinting. This concept is chal-
lenged in various ways when considering splinting teeth
to implants or splinting adjacent implants. Connection
of teeth and implants has been confounded by the
potential overload of the implant due to differential
resiliency, by the problem of retrievability of a rigid
connection, and the potential tooth abutment intrusion
with a non-rigid connection. Implant connection par-
ticularly with unfavourable crown ⁄ implant ratio has
been linked with increased torque loads and bending
moments to the implant, abutment, crown and support-
ing bone. Mandibular flexure and retrievability for
repairing damaged superstructures are considered when
deciding on full-arch or segmental splinted units.12 In a
systematic review of tooth to implant connections,
intrusion of the abutment teeth occurred on non-rigid
connection in 5.2 per cent of cases. Implant failures
(mobility or fractures) occurred (3.4 per cent) in five
years and 15.6 per cent after 10 years. Abutment teeth
were lost (3.2 per cent) after five years and 10.6 per cent
after 10 years. The survival rate of tooth and implant-
connected FPD was 94.1 per cent after five years and
77.8 per cent at 10 years. The conclusions were that the
freestanding solution is the primary option of choice.
To avoid intrusion of abutment teeth, the connection,
ª 2008 Australian Dental Association
Occlusion in implant dentistry
if made, should be rigid.13 In another review compar-
ing implant success for implant versus implant-tooth
supported FPDs the success rate was higher for implant
support alone with 97 per cent for implant support, and
89 per cent respectively with no statistical difference for
implant-tooth-supported FPDs.14
Some authors advocated separation of mandibular
superstructures in the midline and cite mandibular
flexure as a potential source of distal implant morbidity
in full-arch restorations. However, many outcome
studies reporting high success rates have not identi-
fied this factor or failed implants as a consideration in
bone loss.
Considerations for replacing posterior teeth with
implant-supported fixed partial dentures
Reduced posterior support
When the posterior teeth become progressively lost, this
situation may be restored with tooth-supported FPDs,
or may continue to function with occluding premolars
as a shortened dental arch. When the supporting bone
is inadequate or abutment span too large, additional
implant-supported units may be considered necessary.
Loss of posterior support: multiple restorative
permutations
With loss of all molars and premolars, the restora-
tive options available allow multiple permutations of
implant arrangements, lengths, angulations and super-
structure designs. Residual ridge height, bone density,
maxillary sinus morphology and inferior alveolar nerve
relations are significant determining factors. Options
range from minimal single premolar implants or a
single premolar implant connected to the adjacent
natural canine, to increasing combinations of 2, 3, or 4
posterior implants. These may be adjacent, connected
or single, or may be spaced for interposed pontics or for
inclusion of distal or mesial cantilevers. Sinus augmen-
tation, horizontal and vertical ridge augmentation
further extends the range of clinical options. Bio-
mechanical considerations arise with axial or non-axial
implant inclination and crown-implant ratio. Changing
paradigms obviate the need to provide molar support
solely to avoid overload of the temporomandibular
joints with the emerging acknowledgement of the
shortened dental arch.
The clinician is constantly faced with the dilemma
of which of these multiple options to apply and must
rely on the best available evidence at the time. Since
many of these modalities are not isolated in clinical
trials, this evidence is sadly lacking. Clinical decision-
making must, as a result, be made more subjectively,
taking into account patient health age, psychosocial
S63
MD Gross
behavioural and socio-economic factors, and necessar-
ily incorporate the cognitive and personal biases,
education and experience of the individual clinician.
Number of implants
Studies of clinical outcome generally do not isolate the
prosthetic and abutment variables. So while high
partially edentulous FPD success rates of 95 per cent
at 10 years are reported, the abutment distribution,
number, length and diameter are not specified.14,15 One
split-mouth study restoring mandibular Kennedy Class
I cases compared posterior rigid short-span tooth to
implant connected FPDs, with contralateral lone stand-
ing FPDs on two implants. Cumulative success rates at
10 years were 88.4 per cent for the tooth-implant FPDs
with no outcome difference compared with the contra-
lateral implant-supported FPDs. Sixty-nine implants
were used at the outset.16 Another study showed no
difference between 2 and 3 implants at five years. A
systematic review of posterior restored quadrants with
sinus augmentations reviewed 39 ⁄ 252 articles (3 RCTs)
with 6913 implants in 2046 subjects. They showed
overall implant survival rates of 92 per cent in the 39
articles where 96 per cent were roughened surfaces and
86 per cent were machined surfaces.17
Outcome results of posterior mandibular short-wide
implants vary between studies ranging from 67–100 per
cent. Co-variables of surgical technique, implant sur-
face, bone volume and density, may obscure the effect
of implant length and diameter. Studies after 1997
taking into account bone density and surface finish with
microtexture versus machined co-variables, report
comparable survival rates for short and standard length
implants. The co-variable of implant surface from
machined to microtexture significantly improved short
and wide implant prognosis.18
Thus comparable success rates are shown for mini-
mal and maximal options. Clinical decision-making
will need to be guided by case-specific patient factors
including psychosocial and socio-economic or subjec-
tive, such as individual patient preference regarding
chewing efficiency, aesthetics and comfort. Prosthe-
tic combinations with insufficient clinical outcome
research include situations with a single maxillary
distal implant connected to a natural canine or anterior
FPDs, long-span posterior implant-supported restor-
ations, implants as pier abutments in an FPD with
peripheral natural tooth abutments, excessive crown
implant ratio >1:1, extreme off-axis angulations >30
and varying bone factors.
Occlusal vertical dimension (OVD) considerations
Lost posterior support may result in posterior over-
closure and loss of occlusal vertical dimension of
S64
occlusion. Restoration of posterior teeth may necessi-
tate increasing OVD to increase posterior inter-ridge
distance, increasing vertical crown space for prosthetic
convenience and enhanced aesthetics. Alternatively,
with severe vertical bone loss, excessive inter-ridge
distance and unfavourable crown ⁄ implant ratio, con-
siderations may be directed to decreasing the OVD with
appropriate consideration of the reduced tooth display
for aesthetics. When skeletal and aesthetic determinants
predicate a severe anterior vertical overlap, the need to
increase the occlusal vertical dimension and flatten
excursive guiding inclines may be considered to reduce
lateral loading vectors and should be weighed against
the potential for an increased crown ⁄ implant ratio and
the additional restorative commitment of restoring an
entire dental arch.
Excursive guidance
Considerations for excursive guidance vary between
mixed partially edentulous and fully edentulous im-
plant supported modalities. In partially edentulous
situations when anterior teeth remain with good bone
support they may be used to disclude posterior implants
in protrusion. Strong healthy canines or incisors can
guide lateral movement discluding posterior implants
and separating non-working contact conforming to
tested tooth-supported conventional paradigms. When
anterior implants are required to bear the protrusive
excursive contact, questions arise as to how many
implants are necessary, which lengths and diameters are
indicated, how off-axis the implants may be inclined,
and whether buccal bone augmentation is necessary.
Similar considerations apply for lateral guidance when
posterior implants must be employed for working
guidance in the absence of suitable natural tooth
guidance.
Decisions must be made on whether to distribute
lateral load over all working-side contact in group
function, how far distally the group function should
extend or where the traditional paradigm of anterior
guidance be considered.
Insufficient outcome studies are available to help
with these decisions. Here too most outcome studies fail
to isolate the relevant clinical parameters. Many clinical
technique articles refer to aesthetic factors in anterior
implant-supported restorations. Biomechanical studies
show that off-axis loading and increased vertical
overlap increases the facial loading vectors with
increased cervical and facial stress concentrations.
Other clinical studies show the presence of facial
cratering together with interproximal bone loss.
It is not clear whether the purported neuromuscular
benefit ascribed to anterior disclusion and mutual
protection in the natural dentition applies to anterior
implant-supported protrusive guidance. Although an
ª 2008 Australian Dental Association

osseoperceptive mechanism is recognized, its contribu-
tion to an anterior neuromuscular protective function is
unknown. In addition, the thin buccal bone support
and different implant-bone interface connection and
loading response, compared with the natural PDL,
makes the concept of protrusive disclusion as a
protective element for posterior teeth or implants
dubious. This uncertainty applies also for canine
guidance where buccal bone covering implants in the
maxillary canine region would not appear to have the
same biomechanical and sensory properties as with
natural canines. When aesthetic and skeletal factors
predicate, guidance on anterior implant-supported
restorations may be unavoidable.
In these cases multiple contact distribution, maximal
implant length optimized bone resistance and splinting
of adjacent implants should be considered to reduce
potential morbidity. The Class III lever action of
mandibular closure may play a role in reducing loading
but each case would need to be planned according
to individual clinical determinants (ICDs). It is often
difficult to choose between a mild implant-supported
anterior disclusion or a flat protrusive guidance with
simultaneous posterior contacts. Adhering to tradi-
tional paradigms with a mild disclusion is tempting,
however there is no evidence to support either
approach, or many of the other clinical dilemmas
outlined above.
In Class II Division I or Class III skeletal relations,
the protrusive and working guidance would benefit
from flattened guiding inclines with optimal distri-
bution of excursive load on as many abutments as
possible, with smooth even guiding contacts to mini-
mize unfavourable biomechanical risk.
Bruxism should be diagnosed and addressed as a
complicating and additional risk factor. The use of a
full-arch night splint may be beneficial in reducing
potential overload from nocturnal parafunction. In
spite of the fact that some reviews show that bruxism
has not been causally linked to supporting bone
morbidity, its potential for creating complication in
the superstructure and implant stack are very real.
Thus common sense tempered with psychosocial and
socio-economic patient factors must be the guiding
determinants for decision making in treatment planning
and occlusal design at present.
Evidence and history of occlusal parafunction is a
significant factor in the planning of excursive guidance
and the creation of an occlusal scheme with abutment
and bone support optimally designed to minimize the
potentially destructive forces of bruxism. Flattening
guiding inclines, increasing implant numbers and bone
support, reducing occlusal vertical dimension to
decrease crown-root ratio and minimizing porcelain
occlusal surfaces without excessively compromising
tooth display should be considered.
ª 2008 Australian Dental Association
Occlusion in implant dentistry
Table 1. Single tooth implant-supported restoration –
optimal criteria and current paradigms
Single tooth implant-supported restorations – posterior
Axial posterior inclination at right angle to the occlusal plane is still
the optimal paradigm (>30 controversial)
Length ‡ 10 mm
Diameter ‡ 3.75 mm
Centred contacts (point centric or freedom in centric 1–1.5 mm)
Narrow occlusal table
Flat cusps
Minimal cantilever
No CR-MI slide (RC-IC syn. old), working, non-working or
protrusive interferences
Avoid creation of excursive guidance on single implant restorations.
Table 2. Posterior fixed implant-supported restoration
clinical guidelines, current paradigms considerations
and controversies. Considerations governed by
case-specific individual clinical determinants
Posterior fixed implant-supported restoration
Axial implant inclination at right angles to the occlusal plane when
possible.
Mesio-distal inclination and bucco-lingual angulation >30 is still
controversial.
Inter-implant distance to be not less than 3 mm.
Number of implants may vary between 1–4 per quadrant. (The
greater the number the smaller the biomechanical risk.)
Splinting of adjacent implants is current practice (unconnected
adjacent implants is still controversial).
Lone-standing self-supporting implant segment is preferable.
Crown ⁄ implant ratio >1:1 is biomechanically unfavourable.
Rigid connection to adjacent teeth is less preferable but acceptable
in small spans (risk of tooth abutment intrusion on non-rigid
connection).
Diameter ‡ 3.75 mm (smaller diameters increased risk factor).
Length ‡ 10 mm (smaller wider implants at increased risk).
Centred contacts in maximum intercuspation MI (point contact or
freedom-in-centric).
Restore in centric relation or established intercuspal relation
according to conventional tooth-supported paradigms.
Full-arch simultaneous contact (infra-occlusion of implant
restorations in relation to teeth is controversial).
Narrow occlusal table when possible.
Steep cusps increase biomechanical risk and bending moments.
Use bucco-lingual cross bite when necessary.
Avoid cantilevers when possible (the greater the bucco-lingual,
mesial or distal cantilever the greater the risk).
Mesial cantilever is biomechanically more favourable than a distal
cantilever.
Infra-occlusion on cantilevered section reduces biomechanical risk.
Excursive guidance on well-supported anterior natural teeth
discluding posterior implant supported segment when possible.
Single excursive contact on implant-supported restoration places
restoration, implant-abutment-crown and supporting bone at
greater risk (avoid posterior interferences).
When working group function on posterior implant supported
segment is selected, flattened cusps and smooth even contacts in
group function are desirable to reduce biomechanical risk.
Working guidance should separate non-working contact.
Working guidance should be supported by optimal abutment
buccal bone dimension to maximize lateral resistance and reduce
biomechanical risk.
Sufficient metal support for porcelain should be established.
Use of full-arch night splint is recommended particularly if bruxism
is diagnosed or suspected.
S65
MD Gross

occlusal scheme design. Their interaction must be

Fully edentulous considerations
Original ‘‘ad modum Brånemark’’ designs with inter-
foraminal mandibular implant distribution and
premaxillary maxillary distribution with distal canti-
levers showed high long-term success rates and often
mimicked the shortened dental arch. Extended
options for sinus augmentation and increased number
of posterior implants allow more posterior abutments
with the anterior segment supported with anterior
canine to canine pontics. This facilitates greater
aesthetic control but may create an extended anterior
cantilever. Alternative options of 4, 5, 6, 8 or 10
implants per arch are advocated and create treatment
planning dilemmas between minimal and maximal
options.19
Decision making for treatment planning must be
based on psychosocial, psychophysiological and eco-
nomic patient-specific factors and governed by patient-
informed preferences for the available options. To this
effect the urgent need for high level long-term outcome
studies for appropriate evidence-based planning and
determination of prognosis, has never been more
pressing.
In fully edentulous planning, the interaction of
skeletal relations, residual ridge relations, vertical
dimension, supporting anatomy, interarch distance
and aesthetic factors of occlusal plane orientation,
tooth display and lip support are significant determi-
nants for planning implant positioning, support and
established in advance with the appropriate application
of diagnostic preparations to facilitate radiographic and
surgical guides. Each case must be planned in accor-
dance with its own particular combination of individual
clinical determinants.
The guiding treatment objectives must be those
outlined as the guiding parameters for prosthodontics
as restoring and maintaining, health, form, function,
comfort and aesthetics. The guiding principles of
occlusal restoration should be to create an appropriate
posterior occlusion to support forces of mastication,
swallowing and occlusal parafunction, at an optimum
occlusal vertical dimension, with excursive guidance
which is appropriate to the planned supporting base of
integrated dental implants.
Best available evidence (BAE) – hierarchy of
evidence
The aspiration and need for studies to provide the
necessary evidence to answer the many clinical ques-
tions outlined above is clear. It is becoming more and
more difficult to keep up with the ever growing
published implant-related literature.
Hierarchy of evidence
Since clinical evidence is highly varied in scientific
validity and clinical applicability, a hierarchy of

Table 3. Anterior fixed implant-supported restoration clinical guidelines, current paradigms considerations and
controversies. Considerations governed by case-specific individual clinical determinants
Anterior fixed implant-supported prosthesis

Minimal buccal bone of 2 mm thickness.

Augmentation of buccal bone would appear to improve biomechanical resistance to facial loading but indications are as yet undefined
(biomechanical durability and longevity of buccally augmented bone unproven).
Lengths > 10 mm.
Diameters < 3.75 mm sometimes unavoidable but at greater risk of interface component fracture.
Crown ⁄ implant ratio >1:1 becomes biomechanically unfavourable with increased risk. No absolute criteria for contraindication based on
clinical outcome data.
Splinting adjacent anterior units is currently accepted paradigm.
The suitability of wider implants with less buccal bone thickness but greater bone-implant surface area as opposed to less wide implants
with greater buccal bone volume and lateral resistance is still under debate.
Number of implants 2–6 (depends on bone dimensions width of arch and aesthetic factors. No evidence-base to define minimum acceptable
number and dimensions).
Vertical and horizontal overlap (overbite, overjet syn. old) – flatten or round-out protrusive and working guiding inclines to reduce lateral
forces when possible (within limitation imposed by skeletal relations and aesthetic factors of tooth display and lip support).
Contact in MI simultaneous with remaining posterior quadrants, skeletal and relations permitting (anterior MI contact in infraocclusion not
substantiated).
Selective excursive guidance – chose protrusive and working guidance according to the best biomechanical abutment distribution.
Skeletal Class II Div I: mild retrognathia – flat lingual incisal platform within phonetic and comfort limitations. Severe retrognathia – protrusive
guidance on mesial maxillary premolar inclines.
Skeletal Class II Div II (increased vertical overlap, deep bite syn.old.) increased biomechanical risk when unavoidable. Raising OVD to flatten
anterior guidance requires full-arch restoration at an increased iatrogenic biological risk and economic burden.
Skeletal Class III flat protrusive guidance – mild anterior disclusion to slightly disclude posterior teeth or combine premolar protrusive contact
according to case-specific clinical determinants.
Conventional paradigms of protrusive anterior guidance separating posterior tooth contact for mutual protection are challenged. Stronger
elements should bear the excursive guidance separating weaker elements when appropriate.
Use of full arch night splint is strongly recommended particularly if bruxism is diagnosed or suspected.

S66 ª 2008 Australian Dental Association

 Occlusion in implant dentistry

evidence categorizing validity has been presented.

Prospective randomized controlled clinical trials (RCTs)
give the highest levels of evidence followed by retro-
spective case series, animal studies, biomechanical
studies, opinion-based reviews and case reports.
Review papers
Review papers are published to assimilate this ever
changing knowledge base.
Systematic reviews
The highest level of review paper is the systematic
review in which meta-analysis is used in assessing
outcome studies including only prospective RCTs of the
most stringent scientific rigour. The problem is that so
few publications of this nature are available that the
conclusions are often limited and of minor clinical
usefulness. In many cases the available retrospective
case series are reviewed.

Table 4. Fully edentulous fixed implant supported restoration clinical guidelines, current paradigms considerations
and controversies. Considerations governed by case specific individual clinical determinants
Fully edentulous – fixed prosthesis

Number of implants per jaw is controversial

Maxilla: 6–8 implants acceptable, 4 implants controversial, 10 and more might be considered as over treatment?
Mandible: 5–8 implants acceptable, 3–4 implants controversial, 10 and more might be considered as over treatment?
Angulation: conventional paradigms of axial inclination at right angles to plane of occlusion.
>30 inclination controversial. Potential support and biomechanical difference between mesio-distal and bucco-lingual inclinations.
Occlusal vertical dimension initially determined according to conventional complete denture paradigms. These may need to be modified by
individual clinical determinants of aesthetic display at rest and smiling, occlusal plane display, lip support, interarch distance, inter-ridge
relations crown height space and crown to implant ratio.
Cantilevers: distal cantilevers of 1 premolar unit, safe >1 premolar unit is controversial. Compressive resistance to load is provided by the two
implants adjacent to the cantilever further implants do not participate in load distribution.
Mesial cantilevered anterior segment is biomechanically potentially unfavourable when extended significantly anterior to the most mesial
of the posterior supporting implants.
Splinting cross-arch versus segmental. Conventional paradigms consider cross-arch splinting to provide composite resistance for supporting
structures to lateral vectors of functional and parafunctional loading. A strain gauge study shows no difference between cross-arch and
segmental splinting for both fixed and removable superstructure. Splinting increases bending moments (still controversial).
Crown ⁄ implant ratio >1:1 increased biomechanical risk.
Minimize vertical overlap and flatten guiding cusp inclines.
Occlusal schemes dependent on case specific individual clinical determinants ICDs (skeletal relation, implant distribution, occlusal vertical
dimension, posterior support, interarch distance, crown implant ratio, segmental inclinations, aesthetic occlusal plane orientations, tooth
exposure, lip support etc.).
Protrusive guidance should be as flat as possible according to the individual clinical determinants. Anterior disclusion or flat protrusive group
function will depend on ICDs.
Working guidance as group function with optimal load distribution and flattened guiding inclines should separate non-working contact.
Insufficient evidence available regarding the appropriateness of simultaneous working and non-working lateral guidance.

Table 5. Fully edentulous removable overdenture clinical guidelines, current paradigms considerations and
controversies
Implant-retained overdentures

Use conventional complete denture paradigms for aesthetics, occlusal planes, occlusal vertical dimension, centric relation intercuspation and
bilateral balanced occlusion
Plan support to be combined tissue and implant supported or tissue supported and implant retained integrating support factors into occlusal
loading scheme.
Connected implants with bar versus single stud attachments is controversial particularly in the maxilla. Bar retained components are implant
supported. Stud retained segments may be made tissue supported with suitable relief.
Balanced occlusion is advocated to avoid denture base displacement in the final gliding occlusal phase of mastication following bolus reduction.
(If attachments prevent denture base displacement the need to achieve full balance may be amended appropriately.)
Lingualized occlusion may be considered to facilitate bilateral balance.
For a single complete overdenture opposing the natural dentition, balance can be technically difficult to achieve. Attempt to achieve at least
three point balance on lateral and protrusive excursion.
Increase vertical dimension and alter plane relation to allow for vertical space for attachment housings and metal framework space if
necessary.
Decrease vertical dimension if interarch distance is excessive and poses a biomecnahical risk.
Keep attachment height minimal to avoid unfavourable torqueing moments on implants.
Horizontal axis of rotation of the denture base round anterior attachments is purported to reduce distal cantilever effect on loading of distal
denture saddles. This and a lack of indirect retention causes distal denture displacement on anterior closure increasing need for protrusive
balance
With anterior and posterior implant supported attachments, enhanced retention and resistance reduces the need for balance to prevent distal
base displacement.

ª 2008 Australian Dental Association S67

MD Gross
General review
The general review paper, of which this paper is an
example, provides an overview choosing selective
examples of studies of various categories and discussing
their clinical applicability and relevance.20 The weak-
ness is that such reviews tend to incorporate the
opinions and bias of the reviewer which, while being
appropriate, may vary between reviewers; a fact that
should be borne in mind. Such general reviews may
incorporate clinical guidelines as axioms, paradigms,
concepts and current practice that are highly practical
but are in many cases not evidence-based due to lack of
available evidence.
Clinical axioms and current paradigms
Clinical factors and determinants relevant to planning
and fabrication of posterior, anterior and fully eden-
tulous implant-supported fixed restorations are shown
in Tables 1–5. Restorations should be planned in
advance on an articulator with a diagnostic set up,
and radiographic and surgical guides used when
necessary. Computerized guidance systems may en-
hance planning and surgical accuracy particularly with
unfavourable ridge and anatomical relations. Clinical
outcome studies in most instances do not isolate many
of the prosthetic details listed in Tables 1–5, so at
present, and until further research is available, clinical
guidelines need to be based on biomechanical prin-
ciples and the state-of-the-art of current therapeutic
paradigms.
REFERENCES
1. Misch CE, Goodacre CJ, Finlay JM, et al. Consensus conference
panel report: crown-height space guidelines or implant dentistry –
Part 2. Implant Dent 2006;15:113–121.
2. Kim Y, Oh T-J, Misch CE, Wang H-L. Occlusal considerations in
implant therapy: clinical guidelines with biomechanical rationale.
Clin Oral Implants Res 2005;16:26–35.
3. Hoshaw SJ, Brunski JB, Cochran GVB. Mechanical loading of
Brånemark implants affects interfacial bone modelling and
remodelling. Int J Oral Maxillofac Implants 1994;9:345–
360.
4. Duyck J, Naert I, Van Oosterwyck H, et al. The influence of static
and dynamic loading on marginal bone reactions around osseo-
integrated implants: an animal experimental study. Clin Oral
Implants Res 2001;12:207–218.
5. Isidor F. Influence of forces on peri-implant bone. Clin Oral
Implants Res 2006;17(Suppl 2):8–18.
6. Miyata T, Kobayashi Y, Araki H, Ohto T, Shin K. The influence
of controlled occlusal overload on peri-implant tissue. Part 3: a
histologic study in monkeys. Int J Oral Maxillofac Implants
2000;15:425–431.
S68
7. Gotfredsen K, Berglundh T, Lindhe J. Bone reactions at implants
subjected to experimental peri-implantitis and static load. A study
in the dog. J Clin Periodontol 2002;29:144–151.
8. Hurzeler MB, Quinones CR, Kohal RJ, et al. Changes in peri-
implant tissues subjected to orthodontic forces and ligature
breakdown in monkeys. J Peridontol 1998;69:396–404.
9. Kozlovsky A, Tal H, Laufer B-Z, et al. Impact of implant over-
loading on the peri-implant bone in inflamed and non-inflamed
peri-implant mucosa. Clin Oral Implants Res 2007;18:601–
610.
10. Wada S, Kojo T, Wang Y-H, et al. Effect of loading on the
development of nerve fibres around oral implants in the dog
mandible. Clin Oral Implants Res 2001;12:219–224.
11. Sahin S, Cehreli MC, Yalcın E. The influence of functional forces
on the biomechanics of implant-supported prostheses—a review.
J Dent 2002;30:271–282.
12. Miyamoto Y, Fujisawa K, Takechi M, et al. Effect of the addi-
tional installation of implants in the posterior region on
the prognosis of treatment in the edentulous mandibular jaw.
Clin Oral Implants Res 2003;14:727–733.
13. Lang NP, Pjetursson BE, Tan K, Bragger U, Egger M, Zwahlen
M. A systematic review of the survival and complication rates of
fixed partial dentures (FPDs) after an observation period of at
least 5 years. II. Combined tooth–implant-supported FPDs. Clin
Oral Implants Res 2004;15:643–653.
14. Weber H-P, Sukotjo C. Does the type of Implant prosthesis affect
outcomes in the partially edentulous patient? Int J Oral Max-
illofac Implants 2007;22(Suppl):140–172.
15. Pjetursson BE, Tan K, Lang NP, Bragger U, Egger M, Zwahlen
M. A systematic review of the survival and complication rates of
fixed partial dentures (FPDs) after an observation period of at
least 5 years. I. Implant supported FPDs. Clin Oral Implants Res
2004;15:625–642.
16. Gunne J, Rangert B, Glantz P-O, Svensson A. Functional loads on
freestanding and connected implants in three-unit mandibular
prostheses opposing complete dentures: an in vivo study. Int J
Oral Maxillofac Implants 1997;12:335–341.
17. Del Fabbro M, Testori T, Francetti L, Weinstein R. Systematic
review of survival rates for implants placed in the grafted maxillary
sinus. Int J Periodontics Restorative Dent 2004;24:565–577.
18. Renouard F, Nisand D. Impact of implant length and diameter
on survival rates. Clin Oral Implants Res 2006;17(Suppl 2):35–
51.
19. Brånemark P-I, Svensson B, van Steenberghe D. Ten-year survival
rates of fixed prostheses on four or six implants ad modum
Brånemark in full edentulism. Clin Oral Implants Res
1995;6:227–231.
20. Taylor TD, Wiens J, Carr A. Evidence-based considerations for
removable prosthodontic and dental implant occlusion: a litera-
ture review. J Prosthet Dent 2005;94:555–560.
Address for correspondence:
Professor Martin D Gross
Head of Graduate Prosthodontics
Department of Oral Rehabilitation
Tel Aviv School of Dental Medicine
Tel Aviv University
Israel
Email: grossmd@post.tau.ac.il
ª 2008 Australian Dental Association