Discussion

Introduction

All the advances in medical sciences have led to people living longer
today. Increased life expectancy and increased expectations from life
have propelled dental profession like never before. There is a desire to
live life to the fullest. Thus today in the clinical practice, there are more
number of patients who care for their general and dental health in order to
eat better, look better, feel better.

Rehabilitation of missing teeth with prosthesis has undergone a series of

changes over the years.various treatment options considered for missing
teeth are complete dentures, removable partial dentures, fixed partial
dentures and overdentures. The quest for replacements as close to
natural teeth as possible resulted in the development of implants 1,2.

The introduction of osteointegrated implants in the nearly 1980s' all the

way in which partially and fully edentulous patients are treated
prostheticaily. Dentures are more stable with attachments on the implants,
and implants can act along with the natural dentition as abutments' or can
stand alone to support fixed prostheses10

presently, implant restorations are considered to be the most ideal

restorative option available. Implants provide with advantages such as
maintenance of bone, restoration and maintenance of occlusal vertical
dimension, maintenance of facial aesthetics, improved esthetics, improved
phonetics, improved occlusion, improvement or allowance for regaining of
oral proprioception, improved stability and retention of removable
prostheses, improved psychological health and elimination of the need to
alter adjacent teeth2,3,4

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Gradually, with the increase in the number of implant cases, an

increased number of failure rates were also reported. An increase in
failed implants led to an introspection of the various reasons for the
same3,5,6. Studies proved that occlusal load was one Of the primary
contributing factors. This resulted in the concept of a restoration driven
implant, rather than an implant driven restoration 7,8,9.

Clinical success and longevity of implant supported prosthesis

depends upon number,position and design of implants .designing the
occlusal load to the implants and underlying bone after achieving the
rigid fixation is an important factors for long term success of
prosthesis11.after achievement of rigid fixation with proper crestal bone
contour and gingival health, the mechanical stress or strain beyond the
physical limits of hard tissues has been suggested as the primary cause
of initial and long-term bone loss around implants. 12

After successful surgical and prosthetic rehabilitation with a passive

prosthesis, noxious stresses and loads applied to the implant and
surrounding tissues result primarily from occlusal contacts. Complications
(prosthetic or bony support) reported in follow-up studies underline
occlusion as a determining factor for success or failure 16,17

The success of any prosthetic design depends on proper management of

the occlusion. The clinical variables influencing occlusal stability must be
determined and considered in the design of the final prosthesis 13. Due to
lack of the periodontal ligament, osseointegrated implants, unlike natural

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teeth, react biomechanically in a different fashion to occlusal force. It is

therefore believed that dental implants may be more prone to occlusal
overloading . Occlusal overload and its relationship to implant overload
and failure is a well-accepted phenomenon. Dental implants - occlusal
overloading, regarded as one of the potential causes for peri-implant
bone loss and failure of the implant/implant prosthesis 14. It can cause
mechanical and clinical complications on dental implants and implant
prostheses such as screw loosening, screw fracture, fracture of veneering
material, prosthesis fracture, and continual marginal bone loss, implant
fracture and even implant loss15. It may also damage the implant and
superstructure and lead to loss of osseointegration . Occlusal overload as
a factor related to crestal bone loss without leading directly to failure is
more controversial. Some have the impression that if occlusal overload
can cause crestal bone loss, the condition should continue until the
implant fails15. The issue of occlusal overload and its relationship to crestal
bone loss has been well established by misch and others. Animal studies,
clinical reports, biomechanical evaluation, bone physiology, and bone
research support the concept that noxious stresses can cause crestal
bone loss14.
The local occlusal considerations in implant dentistry include the
transosteal forces, bone biomechanics, basic biomechanics, differences in
natural teeth and implants, muscles of mastication and occlusal force, and
boneresorption. The incorporation of all these factors lead to an occlusal
scheme (ipo)12.
The quality of bone, type of implant, type of prosthesis and patient factors
all play important roles in the selection of an occlusal scheme 18. The
choice of an occlusal scheme for implant-supported prosthesis is broad
and often controversial. A proper occlusal scheme is a primary requisite

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for long-term survival, especially when parafunction or marginal

foundations are present. A poor occlusal scheme both increases the
magnitude of loads and intensifies mechanical stresses (and strain) at the
crest of the bone. Most occlusal concepts and ideas have been designed
for natural teeth and are applied to implants without any modification and
as osseointegrated implants lack specific defence mechanisms, poorly
restored occlusion on osseointegrated implants can result in deleterious
effects to the prosthesis and supporting alveolar bone 18. According to
gartner et al19, occlusal concepts developed from the natural dentition can
be transposed to implant support systems without further modifications,
because mandibular movement, velocity, and chewing patterns are the
same for patients with natural teeth and implants. During maximal
occluding force, the electromyograms showed that the implant patient
group activated similar working and nonworking muscles as patients with
natural dentition.

Biomechanical parameters are excellent indicators of the increased

risk because they are objective and can be measured. The dentist can
determine which condition presents greater risk and by how much the risk
is increased. If a clinical condition is likely to increase biomechanical
stresses, dentists should implement occlusal mechanisms to decrease
the stresses and develop an occlusal scheme that minimizes risk factors
and allows the restoration to function in harmony with the rest of the
stomatognathic system. This is what we call implant-protected occlusion.

The objectives of implant occlusion are to minimize overload on the

bone-implant interface and implant prosthesis, to maintain implant load
within the physiologic limits of individualized occlusion, and finally to

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provide long-term stability of implants and implant prostheses. To

accomplish these objectives, increased support area, improved force
direction, and reduced force magnification are indispensable factors in
implant occlusion. In addition, systematic individualized treatment plans
and precise surgical/prosthodontic procedures based on biomechanical
principles are prerequisites for optimal implant occlusion 14,151,9.

The restoring dentist has specific responsibilities to minimize overload to

the bone-to-implant interface.these include a proper diagnosis leading to a
treatment plan providing adequate support, based on the
patient’sindividual force factors; a passive prosthesis of adequate
retention and progressive loading to improve the amount and density of
the adjacent bone and further reduce the risk of stress beyond physiologic
limits. The final element is the development of an occlusal scheme that
minimizes risk factors and allows the restoration to function in harmony
with the rest of the stomatognathic system 19

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TERMINOLOGIES AND DEFINITIONS

( Glossary of prosthodontic terms – edition 8 )

A precise, consistent terminology is fundamental to our ability to

communicate. Proper terminology makes it possible to introduce a
touch of philosophy in every aspect of a discussion.

Gnathology- is the science that treats the biologics of the masticating

mechanisms; that is, the morphology, anatomy, histology, physiology,
pathology and the therapeutics of the oral organ, especially the jaws and
teeth and the vital relations of the organ to the rest of the body.

Occlusion :

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

2. The static relationship between the incising or masticating surfaces of
the maxillary or mandibular teeth or tooth analogues.
Centric relation - the most retruded relation of the mandible to the
maxillae when the condyles are in the most posterior unstrained position
in the glenoid fossae from which lateral movement can be made at any
given degree of jaw separation.

Centric occlusion - the occlusion of opposing teeth when the mandible

is in centric relation. This may or may not coincide with the maximal
intercuspal position.

Balanced occlusion- the bilateral, simultaneous, anterior, and posterior

occlusal contact of teeth in centric and eccentric positions.

Mutually protected occlusion- an occlusal scheme in which the posterior

teeth prevent excessive contact of the anterior teeth in maximum

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intercuspation, and the anterior teeth disengage the posterior teeth in all
mandibular excursive movements. Alternatively, an occlusal scheme in
which the anterior teeth disengage the posterior teeth in all mandibular
excursive movements, and the posterior teeth prevent excessive contact
of the anterior teeth in maximum intercuspation.

Canine protected occlusion - a form of mutually protected articulation in

which the vertical and horizontal overlap of the canine teeth disengage the
posterior teeth in the excursive movements of the mandible

Centric slide: the movement of the mandible while in centric relation,

from the initial occlusal contact into maximum intercuspation

Centric stop - opposing cuspal/fossae contacts that maintain the

occlusal vertical dimension between the opposing arches.

Eccentric relation - any eccentric relationship position of the mandible

relative to the maxilla, whether conditioned or learned by habit, which will
bring the teeth into contact.

Maximum intercuspation- the complete intercuspation of the opposing

teeth independent of condylar position, sometimes referred to as the best
fit of the teeth regardless of the condylar position.

Disclusion: separation of opposing teeth during eccentric movements of

the mandible.

.Working side- the side toward which the mandible moves in a lateral
excursion.

Non working side/ balancing side- the side of the mandible that moves
toward the median line in a lateral excursion.

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Trauma from occlusion: trauma to the periodontium from functional or

parafunctional forces causing damage to the attachment apparatus of th
periodontium by exceeding its adaptive and reparative capacities. It may
be self-limiting or progressive.

Occlusal contacts - 1: The touching of opposing teeth on elevation of the

mandible.

2: Any contact relation of opposing teeth.

Long centric - the range of tooth contacts in maximum intercuspation

also called as intercuspal contact area ( freedom in centric) (intercuspal
contact: the contact between the cusps of opposing teeth)

Deflective occlusal contact : a contact that displaces a tooth, diverts the

mandible from its intended movement.

Anterior guidance: anterior guidance refers to the dynamic relationship of

the lower anterior teeth against the lingual contours of the maxillary
anterior teeth incentric, long centric and in their protrusive,
lateroprotrusive, and lateral excursions. Along with centric relation and
vertical dimension, anterior guidance must be regarded as the most
important factor in reconstructing the stomatognathic system.

Deprogrammer: various types of devices or materials used to alter the

proprioceptive mechanism during mandibular closure.

Functional occlusion : the contacts of the maxillary and mandibular teeth

during mastication and deglutition.

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Functional record: a record of lateral and protrusive movements of the

mandible made on the surfaces of an occlusion rim or other recording
surface

Functionally generated path: a registration of the paths of movement of

the occlusal surfaces of teeth or occlusion rims of one dental arch in
plastic or other media attached to the teeth or occlusal rims of the
opposing arch

Infraocclusion : malocclusion in which the occluding surfaces of teeth are

below the normal plane of occlusion.

Occlusal disharmony: a phenomenon in which contacts of opposing

occlusal surfaces are not in harmony with other tooth contacts and/or the
anatomic and physiologic components of the craniomandibular complex.

Occlusal interference : any tooth contact that inhibits the remaining

occluding surfaces from achieving stable and harmonious contacts.

Occlusal plane : the average plane established by the incisal and

occlusal surfaces of the teeth. Generally, it is not a plane but represents
the planar mean of the curvature of these surfaces.

Occlusal prematurity: any contact of opposing teeth that occurs before

the planned intercuspation.

Working side contacts: contacts of teeth made on the side of the

articulation toward which the mandible is moved during working
movements.

Occlusal device: any removable artificial occlusal surface used for

diagnosis or therapy affecting the relationship of the mandible to the

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maxillae. It may be used for occlusal stabilization, for treatment of

temporomandibular disorders, or to prevent wear of the dentition.

Implant prosthodontics: it is the branch of implant dentistry concerned

with the restorative phase following implant placement and the overall
treatment plan component before the placement of implants.

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Occlusion has been described as the most important subject in all the
disciplines of dentistry,and for good reason,because the way the teeth
come together,and function together,is as important to most of us now as
it was to our ancestors,who lived on diets much more difficult to cope
with.when as dentists,we are faced the problem of replacing occlusion
surfaces,either by restorations in natural teeth,or replacement of some or
all of the teeth,then a thorough knowledge of the way teeth come together
and function together and function together,is essential.

What is occlusion ?
The original definition of occlusion was the act or process of occluding,
from the latin occludere “to shutnupor close up”

Acc. to GPT 8, occlusion is defined as any contact between the incising

or masticating surface of the maxillary or mandibular teeth. Ideal occlusion
provides function, which is efficient mastication and good esthetics without
creating physiologic abnormalities1.

Acc. To Ramfjord & Ash, occlusion=contact between teeth

“multifactorial functional relationship between the teeth & other
components of the masticatorysystem as well as with other areas of the
head & neck that directly or indirectly relate to function, parafunction or
dysfunction of the masticatory system.”

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COMPONENTS OF OCCLUSION

The components of occlusion as interpreted by prosthodontists are :

1. The temporomandibular joint

2. The muscle
3. The teeth

1 . Te mp o ro ma n d i b u l a r j o i n t 8 (f i g 1 )

Temporomandibular joint is the most important guiding factor of occlusion.

It is one of the two connections between the upper and lower jaw, which
are not changed by the loss of the teeth. It is the component of occlusion
which is not in the control of the dentist, but which must be accepted by
dentist, as it exists in the patient's head.

The temporomandibular joint is a diarticular ginglymo-arthrodial joint

between the mandible and the skull. The female part of the joint consists
on the bony glenoid fossa with its investments and the male part of the
joint is the bony condyle with its investments. Interposed between these
parts is the meniscus and two synovial sacs.

The glenoid fossa is concave upward. Its deepest part is a thin layer of
compact bone without a fibro cartilaginous covering. This would indicate
the pressure is not normally applied against it. The anterior part of the
glenoid fossa consists of cancellous bone which is covered by a cortical
plate and a fibro cartilaginous covering. This would indicate that pressures
are normally exerted against it in certain jaw positions. The posterior part
of the glenoid fossa consists of thin plates of compact bone without a

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fibro cartilaginous covering. The petro tympanic fissure is located

between these thin plates of bone. This part of the glenoid fossa
contains part of the capsular ligament and areolar tissue. Hence
pressure should not be applied distally against this part of the fossa.

The articular meniscus is a fibrocartilagnious disc which is placed between

the condyle and the glenoid fossa. This is a synovial cavity or sac above it
and another below it. These structures are found where pressures are
applied.

The condyle is of cancellous bony structure with a compact outer layer

which is covered above with a layer of fibro cartilage. The structure of the
condyle permits it to withstand upward stresses. In normal conditions
pressures are applied through the condyle to the glenoid fossa only
when the mandible is protruded from its rest position in centric relations.

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fig 1. Sagittal view of temporomandibular joint

Movements in the temporomandibular joint:

The movements in the temporomandibular joint are many and varied. They
may occur below the meniscus, or above the meniscus, or in both parts of
the joint simultaneously. Most prosthodontists believe that the
movements in the lower part of the joint are limited to rotations either in
the vertical or horizontal plane or in combinations of these. The other
movements are believed to occur in the upper part of the joint. The
movement which occurs in the joint when the mandible is carried

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forward in protrusion is in a downward and forward direction. The

condyle and meniscus are guided downward by the articulating eminence
of the glenoid fossa. The angle of this glide may vary from patient to
patient and from side to side of the same patient. The position of the
articular disc in relation to the condyle during this movement may alter the
angle of the movement from that indicated by the bony structure. This is
due to the variation in the thickness of the meniscus in its different parts.

The movement that occurs in the temporomandibular joint on the working

side (the side toward which the mandible is moved ) is one of rotation;
chiefly in a horizontal plane, but modified by the vertical opening produced
by the height of the cusps and by the downward and forward movement
of the balancing side condyle. This movement is believed to occur in the
lower part of the joint.

Simultaneously, in some mouths and with wide variations in direction and

magnitude the mandible slides laterally (the bennett movement). This
slide is thought to be due to the angle at which the external pterygoid
muscle on the balancing side is placed in relation to the condyle. This
movement occurs in the upper part of the joint. It may be in the
horizontal plane or it may be slightly upward, downward or backward,
depending upon the shape of the glenoid fossa on the working side and
the relation of the condyle to the disc during the movement.

The movement that occurs in the temporomandibular joint on the

balancing side (the side opposite the working side) is partly rotary
(opening) and partly gliding forward downward and medially. This is the
most obvious deviation from a simple hinge and forward movement of the
condyle. It is readily measurable and is given considerable attention in

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most denture techniques in use today. It occurs in both parts of the joint,
with the rotation occurring in the lower part and the gliding occurring in
the upper part of the joint. The direction of the glide is determined by the
shape of the glenoid fossa and its fibrocartilagnious covering, the relation
of the articular disc to the condyle, the magnitude of the lateral movement,
and the amount of lateral slide (bennett movement) of the mandible. It is of
extreme importance to the prosthodontist who is to develop a “balancing
contact” of teeth on the balancing side when the teeth on the working side
are in contact in lateral protrusive positions.

The movement in the temporomandibular joint which has provoked more

differences of interpretation than any other is that which occurs during the
opening of the mouth. The simplest and apparently the most logical of
these interpretations is that, for practical purposes of prosthodontics, a
simple rotary movement occurs in the lower part of the joint from the
vertical dimensions of occlusion during the opening of the mouth until the
vertical dimension of rest position is reached. Further opening involves a
forward and downward movement of the condyle and the meniscus in the
upper part of the joint along with further rotation in the lower part of the
joint. Closures beyond the vertical dimension of occlusion are apparently
simple rotations in the lower part of the joint but modified by the irregular
articulating surface of the condyle and by the soft tissues in the fossa.

2. Muscles:

The importance of the musculature of the mandible as it relates to

occlusion is becoming increasingly important to prosthodontists. The
muscles control position of the mandible which makes them an important

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component of occlusion in the static jaw relations as well as in its kinematic

relations.

The muscles that control and move the mandible may be considered in
three groups, these are the closing muscles (elevators) , the guiding
muscles, and the opening muscles (depressors) of the mandible. several
factors regarding these muscles must be recognized immediately.

1. Like all muscles, they act by contraction so they pull instead of

push.

2. The direction of their fibers at the time of contraction determines

the direction of their action.

3. The number of fibers contracting at a given time determines the

amount of force produced.

4. A tonic contraction of the different muscle fibers occurs even when

the muscle is at rest.
5. Wherever a muscle fiber contracts, it contracts to its maximum
capacity.

The closing muscles of the mandible are the masseter, the temporalis,
and the internal pterygoid. They are so listed because the directions of
most of their fibers are essentially vertical and their origin is superior to
their insertion on the mandible. They are the source of power for closing
the teeth into occlusion. The direction of the specific contracting fibers
within each of these muscles will determine the direction of the force
applied by those fibers. This direction can be altered by the relative
position of the mandible at the time the contraction occurs. For example,
when the mandible is in a right lateral position and the closing muscles

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contract the right internal pterygoid muscle will exert a force that is
directed more medially than if the mandible were centrally placed (in
centric position).

The external pterygoid muscles are the guiding muscles of the mandible.
They furnish the power for steering the mandible into a position, which is
most favorable for mastication of the food being chewed at the moment.
Their second function is to complete the masticatory cycle, in certain
situations, after the closing muscles have accomplished as much as
they can. The action of the external pterygoid muscles is to pull the
mandible forward if they both contract simultaneously, or to pull the
mandible laterally if they contract individually. They also pull the
meniscus forward with the condyle. Their origin is anterior and medial to
the condyle so the force they apply is in that direction.

The opening muscles of the mandible are those whose origins are below
the mandible. They are divided into two groups, the suprahyoid and the
infrahyoid muscles. The infrahyoid group serves to anchor the suprahyoid
group during their contraction. This anchorage can be at varying levels
according to the amount of contraction of the infra hyoid group. The
direction of the action of the supra hyoid group of muscles is downward
and backward.

The power potential of the opening muscles is much less than that of the
closing muscles because of the smaller number of muscle fibers involved.
However, there is a perfect balance of power between them when the
mandible is at rest at the vertical dimension of rest position. This requires
that the mandible be so positioned that both the opening and closing
muscles be established at the optimum length for the tonic contraction of

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rest. This “rest position” of the mandible requires that the guiding muscles,
also be in no more than tonic contraction. When these conditions are met ,
the mandible is in a centric relation to the maxilla at the vertical
dimension of rest position.

fig 2. Elevators and depressors of the mandible

It has been shown that the maximum effectiveness of the closing

muscles of mastication is at the jaw separation (vertical dimension) of
rest position, and that the power delivered by the closing muscles
decreases upon further closure or further opening of the jaw from rest
position. This may be open to some question as the tests were made on
the anatomic foundation of edentulous ridges. None of the registrations
of the closing power of these muscles equaled the registration of muscle
power with natural teeth.

The vertical dimension of rest position is an important factor in

prosthodontics but it is not a working registration. It is a guide to the
vertical dimension of occlusion which is the "working" registration

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necessary to prosthodontists. The casts of the jaws must be related to

each other in the vertical dimension of occlusion in order that teeth can
be arranged.

3. Teeth:

The third component of occlusion is the teeth themselves. The muscles of

mastication are not necessarily controlled by impulses arising from the
conscious level of the brain, but rather from sensory impulses emanating
from proprioceptive receptors found within the periodontal membranes of
the teeth. Natural teeth are moving and changing their positions daily. As
occlusal and proximal wear continues, deflective occlusal contacts and
irregularities develop, but if these are not too severe, daily adjustment
occurs. This adjustment cannot occur for gross irregularities, improperly
placed restorations, or certain malocclusions, and sensory impulses are
transmitted continually to the mesencephalic nucleus via the
proprioceptive fibers. Since this system seems to be protective in nature,
motor impulses direct the muscles of mastication to place the mandible
into a position in which there are less interferences. The position is one
in which the least number of impulses are elicited by the sensory
receptors.

An abnormal maxillomandibular relationship may be seen as a result of

interferences found in the occlusion of the teeth. When patients who
have developed a mandibular displacement or an eccentric occlusal
position become edentulous and lose the proprioceptive sensory
receptors that the periodontal structures afford, the muscles of
mastication can begin once more to function normally and the

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displacements are eliminated quickly. However, they may reappear if

improperly constructed dentures are inserted.

With loss of the teeth, the patient loses the contribution which the
proprioceptive mechanism of the periodontal structures of the teeth
affords. That is, the masticating muscles no longer receive directive
messages which dictate the path of closure of the mandible, and the
patient finds it difficult to relate the mandible in space. This loss of
mandibular perspective poses one of the most formidable problems to
the prosthodontist.

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CONCEPTS APPLIED TO NATURAL DENTITION:

Although early anatomists such as Andreas versalius and John hunter

described the static relationships of the natural dentition, these issues
were not directly addressed until the dentists began to evolve the
concepts related to the replacement of the natural dentition by artificial
complete dentures.

Development of concept of occlusion--three periods 64:

1. Fictional period (prior to 1900)

2. Hypothetical period (1900-1930)

3. Factual period (1930 to present)

FICTIONAL PERIOD (PRIOR TO 1900)

Each practitioners concepts of occlusion were vargue, at best. Terms such

“antagonism,” “meeting ,” and “gliding” of teeth .other relied on anatomic
descriptions of the morphology of the teeth as indivisual units.the creation
of a normal standard ,a typical relationship, a basis on which to compare
departures from the normal was lacking.

HYPOTHETICAL PERIOD(1900-1930)

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 Discussion

During this period concept was based on reasoning without assuming the
truth scientifically.this was the era of static concept.

Edward H. angle.in 1907 wrote “occlusion is the basis of science of

orthodontia. Th shapes of the cusps, crowns and roots and even the very
structural material of the teeth and attachments are all desined for the
purpose of making occlusion the one grand object.we shall design
occlusion as being the normal relations of the occlusal inclined planes of
the teeth when the jaws are angle describes the best example of
hypothesis- his “Key to occusion”.

Mattnew cryer and Calvin case

Cases concept of occlusion was static. They define occlusion as :

“Occlusion refers to the closure of one upon the other ;and normal dental
relation normal occlusion ,and typical occlusion refers to the standard
relation normal occlusion ,and typical occlusions refers to the standard
anatomical occlusion ;the world normal means “Acc. To the rule”, “that
which is in conformity with the nature law”.Case accepted Angle’s
hypothesis of constancy of first molar as strongly as be rejected the fiction
that “normal occlusion and normal fasical lines are inseparable”.

FACTUAL PERIOD:

In the era concept of occlusion was scientifically providient the truth was
realized.in 1930 broadment introduce an accurate technique of
roentgenographic cephlometry. The factual period was to become a
functional period.Planner of Vienna pointed out in 1930 that mere occlusal
contact of teeth was not enough .occlusion now meant the interdigitation
of teeth plus the status of controlling musculature and functional factors.In

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past 40 years or since 1930 , a third element of occlusion was received

more attention – the temporomandibular joint . Through the efforts of
many investigators the importance of the role of temporomandibular
articulation in relation to occlusion has been estabilished . There is an
intimate relationship between interdigitation of teeth , status of controlling
musculature and the integrity of TMJ. This relationship makes it
impossible to exclude any component in the development of present total
concept of occlusion.although there are considerable controversy exists
over the relationship of the condyle to the articular eminence and the
influence on occlusion.

Concept based on theories

Early concepts65:

Bonwill:

Prior to bonwill’s law, concepts of occlusion were based on the idea

of a single, centrally located static hinge. This was embodied in the simple
hinged articulators of the middle and late 19 th century. Bonwill analyzed
the mandible and described in terms of an equilateral triangle with 10cm
sides connecting both condyles and the mesio-incisal angles of the
mandibular central incisors.

His concept of geometric ideal was ‘ for the purpose of bringing into
contact the largest amount of grinding surface of the bicuspids and
molars, and , at the same time, to have the incisors all come into action

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during lateral movements’(1885). The resulting balanced occlusion would

be for equalizing the action of muscles on both sides simultaneously, and
getting the greatest amount of grinding surface at each movement which
helps to equalize the pressure and force on both sides or parts of the
dental arches.

Bonwill introduced equilateral anatomical articulator with 2

independent condylar elements. This instrument is considered the first
example of the application of mathematical principles to the problems of
occlusion (butler and zander, 1968). Bonwill’s instrument did not allow
provision for condylar inclination. Walker in 1893 recognised this and
designed an articulator with an adjustable condylar path mechanism and a
complex extaoral tracing device to record the inclination of this path for
each patient. This forerunner of later ‘gnathological’ concepts and
instrumentation gave impetus to the idea that the creation of a balanced
occlusion required the recording of the patient’s condylar inclination during
protrusion and lateral excursion.

AQ Ferdinand graf spee :

The concept of balanced occlusion itself is often credited to ferdinand graf

spee. He proposed that

1. The contacting occlusal surfaces of all natural mandibular teeth

glide against those of maxillary teeth.
2. These area of contact lie on the same cylindrical surface , and

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 Discussion

3. The horizontal axis of the cylinders curvature pass through the

middle of the medial surface of the orbit behind the medial surface
of the lacrimal duct.

Spee suggested that the occlusion functions like grinding millstones

and that the mandibular movement occurs in circular paths just as the
pendulum moves around an axis. The term curve of spee derives from his
observation that when viewed laterally, ‘the masticatory surfaces of the
molars are aligned in an downward convex curve along the upper jaw and
in an upward concave curve along the lower jaw’ (1890). He also believed
that a posterior continuation of this curvature would pass along the
anterior surface of the condyle, which also moves on a circular path with
the same length of radius on the occlusal surfaces of the molars, that is,
on the same cylindrical surface.

Spee concluded that, ‘ as forward and backward gliding of the mandible

takes place in a path of circular motion, such displacement can occur over
long distances without any need for the arches to separate from each
other. Thus, masticatory efficiency is guaranteed. A separation of occlusal
surface is only evitable in order to overcome the contact of strongly
protruding upper and lower canineds. But this can also be eliminated by
wear….this ought to be considered in construction of the dentures, not
only to enable better mastication but also in order to avoid lever effects
during chewing.

Thus, the balanced occlusion organization was born particularly for

complete denture occlusion.

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Edward Hartely Angle(1900)

Gave his famous classification- angle class i , ii, and iii in 1900.

Drawback: it deals with the static occlusal relationships in centric

occlusion. Thus angle’s concepts, although very valuable, did not directly
deal with the issues of balanced occlusion, mutual protected occlusion or
occlusal organization associated with eccentric positions of the mandible.

Christensen(1902)

He was the first to describe an intraoral method for recording a static

protrusive record to determine the condylar inclination, and he produced
an adjustable condylar guide articulator, the rational articulator, to promote
this technique. From his description came what ulf posselt coined
“christensen phenomenon”, or the posterior separation of the occlusal
rims that occur when the mandible moves from a centric to a protrusive
position.

Alfred Gysi(1910)

He criticized the continued use of the simple up and down hinge

articulator. He developed simpler methods to more accurately record the
pathway of the condyle as it translates anteriorly and inferiorly on the
articular eminence. Gysi built several new articulators and extraoral
tracings during this period.

He contended the condyle path does not form a straight as stated

by walker and christensen , but follows a curved line or a s-shaped curve.
He believed that mandibular movement is dependent on incisal as well as
condylar inclination. Also, these points of rotation are not fixed points but

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results from diverse contraction of the masticatory muscles, and happens

to coincide only now and then with the condyles.

George S Monsoon

Proposed spherical theory, which was based, on the concept hat the
mandibular teeth move over the occlusal surface of the maxillary teeth, as
over the external surface of a segment of an 8 inch sphere, and the radius
( or the common center) of the sphere is located in the region of crista
galli.Monsoon disregarded the bonwill horizontal excursion. However, he
adapted the 10cm equilateral triangle that formed the basis of bonwill
theory, and added it to the occlusal curvature- fixed central axis of rotation
concept of spee. His conclusion produced the 10-cm radius sphere, a
geometric embodiment of the function, form, and beauty of the masticatory
system.

According to monsoon, elongated teeth must be reduced in their

length and teeth that have been in excessive function built up to their
proper occlusion, bringing the occlusion of all teeth to conform to the
surface of the sphere having proper interlocking cusps to maintain them in
their alignment. The teeth are then ground into the full range of occlusion.

He did recognize two schools of thoughts for mandibular

movement. The first believes that the shape and movement of the
condyles govern the occlusion of the teeth, while the 2 nd contends that the
occlusion of the teeth is the dominant guiding factor, which determines the
shape and movements of the condyles in the glenoid fossa. Monsoon
followed the 2nd group as reflected in his articulators (maxillo-mandibular
instrument) – he utilized a single midline pivot 10cm above the occlusal
plane, and no condylar mechanism whatsoever.

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These divergent theoretical approaches to understand and reproduce

the mandibular movement shared one essential therapeutic objective: a
completely balanced occlusion for full denture prosthesis. Denture stability
was a paramount, and as a result the cross-arch, cross-tooth, and
protrusive elements of balance were accepted.

Cross arch balance: simultaneous contact of working and non-working

teeth.

Cross tooth balance: simultaneous contacting inclines of buccal-to-

buccal and lingual-to-lingual cusps of working side teeth.

Protrusive balance: provided simultaneously contacting inclines of both

anterior and posterior teeth during protrusion.

Rupert hall(1914)

To explain his theory of mandibular movement, hall envisioned that if two

equilateral triangles ( constructed on bonwill’s principles) were placed
back to back, they would share a common base that represented the
condylar axis. The vertex of the anterior triangle would be located at the
incisor point, and the posterior vertex would be located at the external
occipital protuberance.

Hall believed that an angle of 45 degrees would produce cusp of the

highest efficiency in mastication. In natural teeth this is found
predominantly in the maxillary first bicuspids. Hall chose the 45 degree
angle as the generating angle for the cone.

MODERN CONCEPTS

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Three occlusal concepts:

1.The Gnathological
2.The freedom-in-centric

3.European conceptual model

1.Gnathology:

History:
Dr. Beverly B. Mccollum is considered the "father of gnathology." Dr.
Harvey stallard, an orthodontist, proposed the word gnathology. It is
derived from "gnathos," meaning jaw and "ology," meaning study of, or
knowledge of.

In 1924, dr. Mccollum discovered the first positive method of locating the
hinge axis, a milestone in dental research. He founded the gnathological
society in 1926. Mccollum and the gnathological society's definition of
gnathology: gnathology is the science that treats the biologics of the
masticating mechanisms; that is, the morphology, anatomy, histology,
physiology, pathology and the therapeutics of the oral organ, especially
the jaws and teeth and the vital relations of the organ to the rest of the
body." mccollum and his associates developed their concept of occlusion
on what was considered the immutable and ideal nature of the relationship
between the condyle and the fossa, which in turn was responsible for
guiding the mandible in its correct relationship to the maxilla. They
believed that if an articulator could absolutely duplicate jaw relations and
condylar movement, it would be possible to make the teeth that occlude
ideally.

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Mccollum introduced the hinge axis locator, which could precisely

pinpoint the transverse axis of condylar rotation. He embraced the idea of
a completely balanced occlusion for the natural dentition that was totally
consistent with his notion of an idealized biomechanical mechanism.

The presumed objectives were:

1. To maintain idealized occlusal contact throughout all excursions,

coordinated in function with the stable condylar-fossa relationship, thereby
eliminating potential tooth interferences during the ideal condyle positions
and movements.

2. To distribute occlusal contacts among as many teeth as possible,

resulting in reduced loading to the individual teeth and curtailment of
periodontalbreakdown.

In 1927, Harvey Stallard recognized that the teeth dictate the arc of
closure and the occluded position of the mandible. If articulators were to
be used to reveal mal-occluded teeth, then "interocclusal records" would
be needed to mount the casts in the centric relation position.
Proprioceptors from the teeth were dictating to the muscles, and this
feedback had to be dealt with. Interocclusal registrations solved the
problem. Since these registrations were taken at a slightly opened
position, the hinge axis of the mandible must have been accurately
located. In 1930, Dr. Charles Stuart and Dr. Mccollum developed the first
semi-adjustable articulator called the mccollum gnathoscope.

By 1933, Stuart invented a frictionless jaw-writing device for recording

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mandibular movement with styli on plates outside the face. In 1934, with
the aid of Dr. Stuart, mccollum produced the first mandibular movement
recorder known as the mccollum gnathograph.

It differed from today's recorder in that it anteriorly had a sagittal plate with
a horizontal stylus. It would record the entire capacity of mandibular
movements. These movements were later described by posselt, as the
"envelope of motion."

Dr. Stuart and Dr. Stalard worked together to teach "organic occlusion."
they gave us the determinants of occlusal morphology and renewed an
interest in gnathological principals. Dr. Stuart often said that he had stolen
the wax-addition technique from everitt payne and the cusp-fossa
occlusion from the good lord to come up with organic occlusions. Peter k.
Thomas, who taught the principles of gnathology to study groups all over
the world, was considered the "Ambassador Of Excellent Dentistry."

The Philosophy of Arne G. Lauritzen

 Direction of occlusal stresses-long axis of teeth.

 Centric relation=centric occlusion
 (condyles in uppermost and rearmost position)
 Simultaneous occlusal loads fall on as great number of teeth.
 Optimal tooth-to –tooth occlusion should reach terminal hinge axis
intercuspation without interferences.
 Terminal hinge axis intercuspation should occur from an adequate
interocclusal freeway space.
 Lateral excursion may be free.

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 Canine guided occlusion.

 Group contact between upper and lower anterior teeth during
straight protrusive movement.

De Amico ‘s concept

His conclusions had a direct impact on the thinking of the dentists with
regard to concepts of occlusion. He developed the view that

1. The flattened edge-to-edge occlusion seen in aboriginal dentitions were

due to excessive attrition and are abnormal.

2. A lateral ruminating type of mandibular function in humans is not typical.

3. Steeply cusp teeth are entirely appropriate

4. The maxillary incisors and canines are meant to exhibit overbite so as

to disclude the posterior teeth during eccentric positions of mandible.

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De Amico particularly emphasized the maxillary canines having the

principal occlusal contact in lateral excursion and serving to guide the
closing movement of the mandible in the centric occlusion. This idea has
been termed canine protection.

Niles Guichet and Gnathology

Tried to explain the advantages of canine guidance by means of

biomechanics.

Optimal occlusion (1966)

• Canine guided occlusion- biomechanics

• Occlusion must be in harmony with the mandibular movements of
each patient.
• Introduced modification of gnathological extra oral device of graphic
registration called gnathograph to be used with a pantograph,
which were adjusted to denar articulator.
• In regard to vertical stresses, he incorporated the factors of an
interocclusal relationship in order to reduce them.
• In regard to horizontal stresses co=cr. This eliminates the horizontal
stress potential induced by patients when guiding their food in the
retrusive range of the centric contacts. There is horizontal
movement of the mandible from the maximal intercuspal position
and teeth are capable of standing that horizontal stress in function.
• He utilized d’ amicos findings -canines –withstands eight times

stresses than on the 2nd premolars.

• Bennet movement: lateral shift increases as occlusion becomes
tight.

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The vision of Transographic concept

Page H L being a layman conceived transographic theory.

Four principles:

1.Opening axis

2.Cranial plane

3.Bennett movement

4.Envelope of motion

1. Opening axis: 12º to 15º of rotation.

transverse hinge axis –reproducible.

2.Cranial planes: no translatory condyles, so no practical support for

horizontal plane.

3.Bennett movement: such a movement is because of mouth opening to 2

noncolinear axes, page did not concede to the existence of the bennett
side shift.

4. In the discussions conceding the envelope of motion, when one takes

the motions to a narrow functional terminal orbit, raised a great number of
questions in the oral rehabilitation.

Influence of physical Anthropology

Many anthropological studies had great influence over occlusal

concepts.Spee had emphasized the ruminant like grinding action of the

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human dentition, which strongly implied laterally directed excursive-

incursive shearing movements of the mandible.

Examination of the flattened edge-to-edge occlusion and reverse curve of

wilson found in aboriginal societies seemed to bear witness to the
importance of lateral component of the chewing cycle and to the maximum
shearing of multiple inclined planes- an idea seemingly compatible with
both the geometrical ideal and early gnathological concepts. In studies of
the dentitions of australian aborigines begg (1964) noted severe
interproximal and occlusal attrition and concluded that attritional process
produced the only anatomical correct occlusion.

Jones observed in humans mastication is from lateral to medial and is

unilateral, the teeth of opposite side being definitely not in contact.

Occlusal concepts of schuyler

Like many gnathologists Clyde H Schuyler believed in harmony between

centric relation and centric occlusion for natural dentition. He did not
impose a set of rigid standards on the occlusion that, if lacking, was
tantamount to pathology. This concept when applied to natural teeth was
called functionalism.

Schuyler observed that all principles of occlusion pertaining to full

denture prosthesis does not hold good for natural dentition. The term-
balanced occlusion is most applicable to restorations supported by soft
tissues. He believed there was a relationship between functioning occlusal
inclines and potential stress to the periodontium, and his occlusal
adjustment were to ameliorate these stresses. He suggested reducing the

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contact areas during maximum intercuspation and described a division of

labor between inclines, cusp tips and occluding surfaces of teeth.

He favoured point contacts opposite flat planes during lateral

excursions. In 1953, he stated, “in the natural dentition i fail to see the real
value of contacts on the non-functioning side, as they do not reduce the
application of stress being applied to the teeth on the working side, and
their contact may be a contributing factor to traumatic injury.”

His observation effectively signaled the end of balance as an acceptable

treatment approach to the dentulous patient. Schuyler also emphasizes
the importance of incisal guidance as the predominating factor
determining posterior occlusal morphology. Although the muscles and
tmj’s control the direction of movement of the mandible when the dentition
is out of occlusion.

When the opposing teeth of the natural dentition come into contact the
guiding planes of the teeth immediately assume almost complete control
of the direction and the extent of movement of the mandible. His concepts
thus included the importance of canine guidance and canine –protected
occlusion that was used for the desired relief of stress upon the balancing
inclines of posterior teeth.

Anterior guidance – purpose: permit a condylar motion without

restrictions along with the prevention of posterior contacts, during lateral
excursions

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2.Freedom in centric
According to schuyler,

Freedom in centric is a maxillomandibular position where maximum

intercuspation and centric relation coincide to a certain degree of freedom
for eccentric excursions without the influence of occlusal inclines. (figure)

Variation in centric relation recording – not a point – area in relation to

horizontal plane.

Concepts that form this large occlusion group, freedom–in–centric, dealt

initially with denture construction. Posselt was first to describe its
principles.

Supporters of functional occlusion developed the principles of this

philosophy.This concept basically deals with functional occlusion.
Functional occlusion takes into consideration fundamentals of
neurophysiological, psychological states, muscular functions, articular
mechanisms and biomechanical knowledge. Rationale of this concept

1. To adapt itself to all maxillomandibular relationship patterns.

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2. Fulfill the requirements of physiologic relations such as mandibular

guidance, occlusal stability, mastication and swallowing.

According to this concept,

Maximum intercuspation and centric relation are coincident but flat areas
on the depth of the fossae, on which opposing cusps occlude, will allow for
a certain degree of freedom in both centric and eccentric movements
without the guiding influences of occlusal inclines.

vertical dimension of occlusion in maximum intercuspation and centric

relation might be the same when all the interferences for closing in centric
relation are eliminated.

Stuart and stallard concept

Stallard and stuart: organic or organised occlusion.

They noted that balanced occlusion in reconstructed natural dentitions
leads to

1. Injudicious increase in occlusal vertical dimension to achieve balance.

2. Often led to instability of occlusion.
3. Frequently showed increased wear of teeth and restorations.
4. Provided poor group usage of teeth.
5. Extraordinary technical demands.
6. Esthetic character of the restored balanced occlusions, which often
required severe reduction of anterior overbite, was found to be far from
adequate.

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Thus, some parallel ideas evolved in the concepts of both the

gnathologists and the functionalists, and both groups came to speak of
the mutually protection concept of occlusion. This concept is based on
the premise that the teeth should act as a specialized groups so that in
centric or eccentric positions of the mandible certain teeth or groups of
teeth are best able to withstand the occlusal loads and, in doing so, will
protect other teeth or groups of teeth from unfavorable forces.
Beyron’s occlusal concepts

Based on functional convenience and avoidance of discomfort. An

optimal occlusion would be one that requires less muscular activity and is
harmony with the neuromuscular system and tmj guidance. Such
occlusion might not be considered as static entity and might not be
evaluated as having what he called ‘instantaneous occlusion’. Most
physiological inter-relationship between morphology and function might be
the most natural one. Beyron revealed that he majority of the subjects had
anteroposterior slide, in the mandibular central position, in the range of 0
to 2 mm. Only 10% of them presented a coincidence of co=cr. He also
advocated freedom in centric concept & canine guided occlusion.

Pankey mann philosophy

Monson’s sphere (occlusal line and plane) + meyer’s concepts of a

functionally generated path; some principles of occlusion and establishing
incisal guidance from schuyler.

Pankey mann philosophy – oral rehabilitation

Objectives: - optimal health, masticatory efficiency, comfort and esthetics

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Pankey mann schuyler concept (based on group function). Rationale

about this group function is that a certain quantity of lateral stress on the
posterior teeth might provide, during function and within a physiological
tolerance, the necessary periodontal stimulus and might even spread the
occlusal load to a certain number of teeth. The fundamental principles of
this philosophy are as follows:

 Stable and static contacts - greatest number of teeth

 Long centric – occlusal harmony with an anterior slide between
centric relation and maximum intercuspation (1mm) and a small
amount of lateral freedom for accommodation of the bennett
movement on the horizontal plane.
 Group function during lateral excursion (working side)
 Balancing side - no contacts
 Protrusion – immediate disocclusion

Dawson’s concept

 Peter dawson introduced bimanual technique for the manipulation

of the jaw in centric relation and for
recording the border movements according to modification of functionally
generated path technique. (in this colossal scheme, the maxillary teeth
carve out a path in the wax placed on the lower colossal table. This is
known as “functionally generated path”. Later, the wax containing this path
is replaced with cast gold or cobalt-chromium alloy).

 Group function during lateral excursion (working side)

 Balancing side - no contacts
 Protrusion – immediate disocclusion

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Theory of “nutcracker”

When establishing an ideal occlusion, he assumed that he anterior

guidance would have a key role. He defended the ideas that the anterior
teeth are more capable of supporting stresses than are the posteriors
because of the anteriors’ mechanical position in relation to the
fulcrum(TMJ) and force( masticatory muscles), and because of higher
density of bone surrounding the anteriors’ long roots, with a better crown
root ratio. Dawson presented his theory of nutcracker. The farther the nut
(anterior teeth) was from the fulcrum (condyles), the lesser would be the
force exerted on the nut. Making the nut as strong as possible by means
of a correct interdental contact would make the role of protection of the
anterior teeth better.

The condylar path is not supposed to dictate how the anterior guidance
works, and so there is no advantage or necessity in trying to make the
anterior guidance duplicate the condylar one. As a final consideration,
the condyle path dictate where the external limits of the mandibular
motion (envelope of motion) are and, in a free moving joint, the action
of the muscles is responsible for both their functions and dysfunctions.

Nutcracker theory

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European concept

 His theory is influenced from gysi’s philosophy.

“the normal or ideal occlusion proposed by gerber was one in which the
teeth would be in maximum intercuspation, with the condyles centered in
the articular surfaces in the median and uppermost position. Any deviation
related to this mandibular centralization constitutes a condylar
displacement.”

Dawson (1974) also described five concepts important concepts

important for an ideal occlusion1:
1. Stable stops on all the teeth when the condyles are in the most superior
posterior position (centric relation)
2.An anterior guidance that is in harmony with theborder movements of
the envelope of function.
3. Disclusion of all the posterior teeth in protrusive movements.
4. Disclusion of all the posterior teeth on the balancing side.
5. Non interference of all posterior teeth on the working side with either the
lateral anterior guidance or the border movements of the condyles.

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IMPLANT BIOMECHANICS

Dental implant is a prosthetic device made of alloplastic material(s)

implanted into the oral tissues beneath the mucosal or/and periosteal
layer, and on/or within the bone to provide retention and support for a
fixed or removable dental prosthesis; a substance that is placed into
or/and upon the jaw bone to support a fixed or removable dental
prosthesis.(Acc. To GPT 8)

. The primary function of an implant is to act as an abutment for prosthetic

device.The present surge in the use of implants was initiated by
Branemark (1952).

Biomechanics is one of the most important considerations affecting the

design of framework for an implant –borne prosthesis. In general, the
forces that participate in both the masticatory process and parafunction
must be considered in the design of the prosthesis. These considerations
act as determining factors of the device’s success or failure . If the
occlusal load exceeds the mechanical or biological load bearing capacity
of the implant causes either mechanical failure or failure in
osteointegration.

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WHAT ARE BIOMECHANICS?

GPT-8 It is the relationship between the biologic behavior of oral

structures and the physical influence of a dental restoration.

RATIONALE OF CONCEPT OF BIOMECHANICS

1. The loading (bite forces) exerted on the prosthesis.

2. The distribution of the applied forces to the implants and teeth

supporting the prosthesis.

3. The material, shape and size of the implant so that force on each
implant must be delivered safely to bony tissues .

4. The bone response to mechanical loads and the bone-implant

interface.

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BIOMECHANICS

BIOLOGICAL MECHANICAL

FORCES

• Forces may be described by magnitude, duration, direction, type,

and magnification factors.

• Forces acting on dental implants are referred to as vector

quantities; that is, they possess both magnitude and direction.

A force applied to a dental implant is rarely directed absolutely

longitudinally along a single axis.

In fact, forces are three dimensional with components directed

along one or more of the three clinical coordinate axes i.e. :-

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Fig;Forces are three dimensional,with components directed along

one or more or the clinical coordinate axes.

Components of Forces (Vector Resolution)

A single occlusal contact most commonly result in a three-dimensional

occlusal force. The process by which three-dimensional forces are broken
down into their component parts is referred to as vector resolution .

Types of Forces

Forces may be described as :-

1. Compressive forces attempt to push masses toward each other.

2. Tensile forces pull objects apart.

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3. Shear forces on implants cause sliding forces.

• Compressive forces tend to maintain the integrity of a bone-to-

implant interface, whereas tensile and shear forces tend to disrupt
such an interface.

• Shear forces are most destructive to implants and bone when

compared with other load modalities.

• Compressive forces, in general, are best accommodated by the

complete implant-prosthesis system.

The implant body design transmits the occlusal load to the bone.
Threaded or finned dental implants impart a combination of all three
force types at the interface under the action of a single occlusal
load.Cylindrical implants are at highest risk for harmful shear loads
under an occlusal load directed along the long axis of the implant
body. As a result, cylinder implants require a coating to manage the

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shear stress at the interface through a more uniform bone

attachment along the implant length.

• Compressive forces should typically be dominant in implant

prosthetic occlusion.

STRESS AND STRAIN

The manner in which a force is distributed over a surface is referred

to as mechanical stress. Thus stress is defined by the familiar
relation:

Stress = F/A

The magnitude of stress is dependent on two variables:-

1. force magnitude and

2. cross-sectional area over which the force is dissipated.

Force magnitude

The magnitude of the force may be decreased by reducing the significant

"magnifiers of force“ :- cantilever length, offset loads, and crown height.
Night guards to decrease nocturnal parafunction, occlusal materials that
decrease impact force, and overdentures rather than fixed prosthesis so
they may be removed at night are further examples of force reduction
strategies.

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Functional cross-sectional area is defined as that surface that

participates significantly in load bearing and stress dissipate

It may be optimized by :-

1. Increasing the number of implants for a given edentulous site,

and

2. Selecting an implant geometry that has been carefully designed to

maximize functional cross-sectional area.

STRAIN

Strain is defined as the change in length divided by the original length.

For tension and compression, strain expresses a lengthening and a

shortening of the body respectively. In shear, the shape change is
expressed in terms of a change in angle of one part of the body relative to
the other. The deformation and strain characteristics of the materials used
in implant dentistry may influence interfacial tissues, and clinical longevity.

. STRESS AND STRAIN RELATIONSHIP

A relationship is needed between the applied force (and stress) and

the subsequent deformation (and strain).

If any elastic body is experimentally subjected to an applied load, a

load-vs.-deformation curve may be generated.

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If the load values are divided by the surface area over which they
act and the change in the length by the original length, a classic
engineering stress-strain curve is produced

ORIENTATION AND DELIVERY OF FORCE

• The manner in which forces are applied to implant restorations

dictates the likelihood of system failure.

• If a force is applied some distance away from an implant or

prosthesis, bending or torsional failure may result from moment
loads.

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MOMENT LOADS

• The moment of a force about a point tends to produce rotation or

bending about that point.

• This imposed moment load is also referred to as a torque or

torsional load and may be quite destructive with respect to implant
systems.

100N

Fig :Moment Loads = force magnitude X moment arm

(perpendicular distance (moment arm )from the point of
interest to the line of action of the force).

2) CINICAL MOMENT ARMS

A total of six moments develop about the three clinical coordinate

axis i.e Mesio distal, vertical,Facio lingual.Clockwise and
counterwise rotations in three planes (transverse,faciolingual,and
mesiodistal).clockwise and 99999counterwise rotations of the

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implants,and/or restoration in each of thesethree planes,results

from six moment loads; lingual-transverse and

facial- transverse moments(in the transverse plane )’occlusal and

apical moments (in the mesodistal plane ),and facial and lingual
moments (in the faciolingual plane).

Moment loads tends to induce rotations in three planes.

Clockwise and counterwise rotations in these three planes

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result in six moments;lingual-

transverse,occlusal,apical,facialand lingual .

Such moment loads induce microrotations and stress

concentrations at the crest of the alveolar ridge of the implant-to-
tissue interface, which leads to crestal bone loss.

• Three clinical moment arms exist in implant dentistry :

A) OCCLUSAL HEIGHT
B) CANTILEVER LENGTH
C) OCCLUSAL WIDTH

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OCCLUSAL HEIGHT

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 Discussion

Occlusal height serves as the moment arm for force components directed
along the faciolingual axis as well as along the mesiodistal axis.

Occlusal height serves as moment arm for force components

directed along faciolingual axis .

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Occlusal height serves as moment arm for force components

directed along mesiodistal axis.

Moment of a force along the vertical axis is not affected by the

occlusal height because there is no effective moment arm. Offset
occlusal contacts or lateral loads can introduce significant moment
arms.

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CANTILEVER LENGTH

• Large moments may develop from vertical axis force

components in cantilever extensions or offset loads from
rigidly fixed implants.A lingual force component may also
induce a twisting moment about the implant neck axis if
applied through a cantilever length

LINGUAL FORCE COMPONENT ALSO INDUCE TWISTING MOMENT

ABOUT IMPLANT NECK IF APPLIED THROUGH THE CANTILEVER
LENGTH

C) OCCLUSAL WIDTH

Wide occlusal tables increase the moment arm for any offset occlusal
loads.Faciolingual tipping (rotation) can be significantly reduced by
narrowing the occlusal tables and/or adjusting the occlusion to provide
more centric contacts.

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 Discussion

So,to understand biomechanical problems of implant-supported

prostheses differences between natural tooth and implant biomechanics
should be considered.

Difference b/w natural tooth vs implant biomechanics

Compared with an implant, the support system of a natural tooth is

designed to reduce the forces distributed at the crestal bone through
several mechanisms. The periodontal membrane, biomechanical design,
elastic modulus of material, nerve and blood vessel complex, occlusal
material, and surrounding type of bone blend to decrease the risk of
occlusal overload. The fibrous tissue interface (periodontal ligament)
surrounding natural teeth acts as a viscoelastic shock absorber, serving to
decrease the magnitude of stress to the bone at the crest and to extend
the time during which the load is dissipated (thereby decreasing the
impulse of the force.)

Fig.3

Tooth versus implant biomechanics 10:

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 Discussion

Tooth Implant
1 periodontal membrane 1. Direct bone-implant
A. Shock absorber A. High implant force
B. Longer force duration (decrease B. Short force duration (increased
impulse of force) force impulse)
C. Distribution of force around tooth C. Force primarily to crest
D. Tooth mobility can be related to D. Implant is always rigid (mobility
force is failure)
E. Mobility dissipates lateral force E. The lateral force increases strain
bone.
F. Fremitus related to force. F. No fremitus
G. Radiographic changes related to G. Radiographic changes at crest
force-reversible (bone loss) - not reversible.
2. Biomechanical design 2. Implant design
A. Cross-section related to direction A. Round cross-section and
and amount of stress designed for surgery
B. Elastic modulus similar to bone B. Elastic modulus 5 to 10 times
that of cortical bone
C. Diameter related to force C. Diameter related to existing bone
magnitude

3. Sensory nerve complex in and 3. No sensory nerves

around tooth
A. Occlusal trauma induces A. No precursor sign of slight
hyperemia and leads to cold occlusal trauma
sensitivity
B. Proprioception (reduced B. Occlusal awareness of 2 to 5
maximum bite force) times less (higher maximum bite

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 Discussion

force functional)
C. Less functional bite force C. Functional bite force 4 times
higher
4. Occlusal material: enamel 4. Occlusal material: porcelain
(metal crown)
A. Enamel wear, stress lines, A. No early signs of force
abfraction, and pits
5. Surrounding bone is cortical 5. Surrounding bone is
trabecular (may be fine)
A. Resistant to change A. Conducive to change.

The presence of a periodontal membrane around natural teeth

significantly reduces the amount of stress transmitted to the bone,
especially at the crestal region. 12 the force transmitted is so complete that
a thin layer of cortical-like bone (cribriform plate) forms around the tooth.
Compared with a tooth, the direct bone interface with an implant is not as
resilient, so the energy imparted by an occlusal force is not dissipated
partially (the displacement of the periodontal membrane dissipates
energy) but rather transmits a higher-intensity force to the contiguous
bone. The crestal bone around dental implants may act as a fulcrum point
for lever action when a force (bending moment) is applied, indicating that
peri-implant tissues could be more susceptible to crestal bone loss by
applying force.32
The mobility of a natural tooth can increase with occlusal trauma.
This movement dissipates stresses and strains otherwise imposed on the
adjacent bone interface or the prosthetic components. After the occlusal
trauma is eliminated, the tooth can return to its original condition with

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 Discussion

respect to the magnitude of movement. Mobility of an implant also can

develop under occlusal trauma. However, after the offending element is
eliminated, an implant rarely returns to its original rigid condition. Instead,
its health is compromised, and failure is usually imminent. Clinical
evidence of occlusal trauma on teeth includes an overall increase in the
periodontal membrane thickness and an increased radiopacity and
thickness of the cribriform plate around the tooth, observed on
radiographs and not just localized at the crest. No generalized
radiographic signs are apparent around an implant under excess occlusal
force, except at the crestal region, which demonstrates bone loss but may
be misdiagnosed as preiimplant disease from bacteria. 32

A lateral force on a natural tooth is dissipated rapidly away from

the crest of bone toward the apex of the tooth. The healthy, natural tooth
moves almost immediately 56 to 108 m and pivots two thirds down
toward the tapered apex with a lateral load. This action minimizes crestal
loads to the bone. An implant does not exhibit a primary immediate
movement but a secondary movement 10 to 50 m under similar lateral
loads, which is related to the viscoelastic bone movement. In addition, this
action does not pivot (as a tooth) toward the apex but instead
concentrates greater force at the crest of the surrounding bone. Therefore
if an initial angled load (e.g., premature contact) of equal magnitude and
direction is placed on an implant and a natural tooth, the implant sustains
a higher proportion of the load that is not dissipated to the surrounding
structures11,32.

The width of almost every natural tooth is greater than the width of
the implant used to replace the tooth. The greater the width of a
transosteal structure (tooth or implant), the lesser the magnitude of stress

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transmitted to the surrounding bone. The cross-sectional shape of the

natural tooth at the crest is biomechanically optimized to resist lateral
(buccolingual) loads because of the bending fracture resistance (moment
of inertia) of the tooth and the direction of occlusal forces. Implants are
almost all round in cross section, which is less effective in resisting lateral
bending loads and consequent stress concentration in the crestal region in
the jaws. In addition, the size of the implant often is decided by the
existing bone volume rather than the amount and direction of force 11,32.

The elastic modulus of a tooth is closer to bone than any of the

currently available dental implant biomaterials. The greater the flexibility
difference between two materials (metal and bone or tooth and bone), the
greater the potential relative motion generated between the two surfaces
at the transosteal region 4. Hence under similar mechanical loading
conditions, implants generate greater stresses and strains at the crest of
bone compared with a tooth11,32.

The precursor signs of a premature contact or occlusal trauma on

natural teeth are usually reversible and include hyperemia and occlusal or
cold sensitivity13. The initial reversible signs and symptoms of trauma on
natural teeth do not occur with endosteal implant. Due to absence of soft
tissue interface between the implant body and bone the greatest portion of
the force is concentrated around the transosteal implant-bone region 4. The
magnitude of stress may cause bone microfractures, place the
surrounding bone in the pathologic loading zone causing bone loss 14, and
may lead to the mechanical failure of prosthetic or implant components.
Unlike the reversible signs and symptoms exhibited by natural teeth,
implant bone loss or unsecured restorations most often occur without any
warning signs. Implant occlusal sensitivity is uncommon and signifies

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 Discussion

more advanced complications. The loss of crest bone around the implant
is not reversible without surgical intervention and results in a decreased
implant support and increased sulcus depth around the abutment. 32

The natural teeth and their periodontal ligament provide proprioception

and early detection of occlusal loads and interferences. As a result, the
bite forces used in mastication or parafunction can be of less magnitude.
Hence the lack of proprioception can lead to a higher bite force on implant
patients. The proprioceptive information relayed by teeth and implants
also differs in quality. Teeth deliver a rapid, sharp pain sensation under
high pressure that triggers a protective mechanism. However, implants
deliver a slow, dull pain that triggers a delayed reaction, if any. 13

Teeth benefit from increased occlusal awareness compared with

implants. Jacobs and van steenberghe ,18, 24 evaluated occlusal awareness
by the perception of an interference 12. When teeth oppose each other, an
interference is perceived at approximately 20 m. An implant opposing a
natural tooth detects an interference at 48 m, therefore more than twice
as poor. As implant opposing an implant perceives the interference at 64
m, and when a tooth opposes an implant overdenture, the awareness is
108 m. (5 times poorer than teeth opposing each other). As a result,
premature occlusal contacts on teeth usually are associated with a
modification of the arc of closure and with decreased force before centric
occlusion or full interdigitation. In addition, the mandible may close in a
different position to avoid the premature contact and result in centric
occlusion different from centric relation occlusion. Unfortunately, because
of the decreased occusal awareness of implants, the premature contact
does not trigger such as adaptation. In addition, premature contacts are

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 Discussion

often on smaller areas of load and therefore result in greater stress (s =

f/a, where s is stress, f is force, and a is the area over which the force is
applied). The contacts are most often on inclines of posterior teeth, which
also generate an angled load of greater stress to the implant-bone
interface.32

The tooth can show clinical signs of increased stress such as

enamel wear facets, stress lines, lines of luder (in amalgam fillings),
cervical abfraction, and pits on the cusps of teeth. An implant crown rarely
showsclinical signs other than fatigue fracture. Prosthesis and abutment
fixation screws and implant bodies are also susceptible to fatigue fracture
and stress corrosion, resulting in significant increases in stress and higher
incidence of failure for the other implants in the associated prosthesis. 32

An implant handles stress poorly (capturing the stress at the crest

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

To summarize:-

Natural tooth versus implant characteristics under load 10:

Criterion Tooth Implant

Connection Pdl Function ankylosis
Impact force Decreased Increased
Mobility Variable None

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 Discussion

Anterior teeth more than

posterior teeth
Movement Shock breaker effect of pdl Stresses captured at
crest
Movement phases Two phases one phase One phase
(sekine et al. 1986) primary: linear and elastic
non-linear and complex linear
and elastic
Secondary: linear and elastic
Movement
Movement patterns Primary: immediate Gradual movement
movement gradual movement
(schulte 1995) secondary:
gradual movement
Apical Intrude quickly 28 m No initial movement
Lateral 56 to 108 m 5 to 10 m
Axial 25 to 100 m 3–5 mm
Diameter Large Small
Cross section Not round Round
Signs of hyperemia Yes No
Orthodontic movement Yes No
Fremitus Yes No
Radiographic changes Pdl thickening and cortical No
bone
Progressive loading Since childhood Shorter loading period
Wear Enamel wear facets, localized Minimal wear, screw
fatigue and stress fracture, loosening, stress, and
cervical abfraction, and pitting fracture of prosthetic

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 Discussion

on occlusal cusps components or implant

body
Tactile sensitivity High Low
Occlusal awareness High detection of premature Low; higher loads to
(proprioception) contacts premature occlusal
contacts
Proprioception Periodontal Osseoperception
mechanoreceptors
Fulcrum to lateral force Apical third of root (parfitt Crestal bone (sekine et
1960 al. 1986)
Load-bearing Shock absorbing function Stress concentration at
characteristics Stress distribution crestal bone (sekine et
al. 1986)

,6,7
Occlusal goals for implant prosthodontics

Because of the special conditions unique to implants, it is important to

develop an occlusion that places minimal stress on both the bone-implant
interface and the prosthesis. Continual stress from interfering occlusal
contacts that develop unnecessarily high occlusal loads must be
eliminated, and heavy occlusal forces developed on cantilevers or any

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 Discussion

other segment of the prosthesis should be equalized throughout the entire

prosthesis.
1) Bilateral simultaneous contact
2) No prematurities in retruded contact position (rcp)
3) Smooth, even, lateral excursive movements
with no interferences
4)Equal distribution of occlusal forces

Bilateral simultaneous contact is the accepted standard of an ideal

occlusion. It is the most important factor in the construction of occlusion
and is of particular importance for implant prostheses. In addition to the
potential for neuromuscular dysfunction that
Premature contacts can create,' occlusal force is increased when a high or
premature contact is present.'
Freedom from retruded contact position to intercuspal position (ip) has
long been advocated by dawson'" because contact in rcp during certain
functions does occur." however, it may also be necessary to create an
occlusion free from prematurities in ip.
Deflective contacts in ip may often be responsible for excessive force
development. Gibbs et al'' reported that the greatest forces during chewing
are exerted in the inter cuspal position.
If this position is unstable because bilateral simultaneou contact was not
properly established at the time of prothesis insertion, intolerably high
forcescould be exerted. Gibbs et al'have also indicated that chewing
forces are lower with anterior guidance factors, ie, canine guidance, than
with posterior guidance. Thus, potentially destructive forces can be
minimized by creating canine and anterior guidance wherever possible.

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 Discussion

In addition to the minimal goals stated above, ideal occlusion for implant
prosthesis should also include

1) Freedom from deflective contacts in icp

2) Anterior guidance whenever possible.

Rationale of occlusion for implant prosthesis

 To maximize occlusal function.

 To minimize harm to opposing and adjacent teeth.

 To minimize wear of occlusal surfaces.
 To minimize risk of fracture of the implant superstructure.
 To reduce the risk of fracture of the implant body and its
connecting components.
 To protect the implant host interface.

ANATOMICAL CONSIDERATIONS 32,62

I. Arch form :

It describes the configuration of the arch when viewed from the

occlusal aspect. It is the geometric shape of dental arch. The differences
in arch form, varying from square to ‘v’ shaped, affect the positions in

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 Discussion

which the implants can be placed. The resulting occlusion is affected by

the opposing arch form.

The visibility and resultant tooth arrangements are more

pronounced in the anterior aspects of the arch than in the posterior areas.
For example, in a narrow maxillary ‘v’ shaped arch. The amount of
available room for the mesiodistal placement of implants is considerable
less than in a broad square – shaped arch. For such a situation, the
position of implants in relation to the superimposed teeth may represent a
compromise position in that ideal incisal guidance is precluded because of
vertical overjet configuration. Additionally the placement of implants also
has a bearing on anteroposterior position of teeth which also influences
the incisal guidance owing to the amount of horizontal overjet.

In the posterior areas of discrepancy between the maxillary and

mandibular ridges may prevent the formulation of an ideal occlusion and a
cross bite type of occlusion may have to be developed. Cross bites are not
unusual when posterior maxillary or mandibular areas have had excessive
resorption.

ii. Inter arch distance and jaw relationship :

Interarch or inter-ridge distance may prevent the development of an

acceptable occlusal scheme. The space may be diminished owing to over
eruption of the teeth into an opposing edentulous space or malplaced
implants, or the space may be exaggerated because of the excessive
resorption of maxillary or mandibular bone before the placement of
implants.

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 Discussion

Decrease in the amount of space available may influence the type

of tooth form used. Thus tooth form dictates the type of occlusion
developed. An increase in the interarch space requires close attention to
lateral forces acting on the implants owing to the increased length of lever
arm that that results.

Significance that has been given to crown-to-root ratio of natural

teeth may be as important in projecting an implant to crown ratio.

In attempting to reduce the lateral forces on implants, modifications

to occlusal scheme must be made. Maintaining the correct interarch
distance in establishing the vertical dimension of occlusion and allowing
for a distinct rest position are essential.

When posterior alveolar bone resorbs in the mandible, the

remaining basal bone is in a more lateral position to the remaining
maxillary bone, requiring a cross bite relationship of teeth in that area.

In the anterior part of mandible, resorption results in the remaining

basal bone being more anterior to maxillary basal bone. This discrepancy
can be further aggravated by placement of mandibular implants in the
symphysis, which forces the setting of artificial mandibular dentition in a
further labial position. This anterior placement also influences the
development of anterior guidance and affects the occlusal scheme.

Similar resorptive processes occur in partially edentulous patients.

In the maxilla, for instance, the architecture resulting from these patterns
of resorption may result in implants being palatally placed to achieve
anchorage of implants in solid bone. This positioning of implants has a

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 Discussion

bearing on the type of occlusion developed for the individual patient as

well as on tongue placement and phonetics.

iii. Soft tissue attachments :

The health of the soft tissue is influenced by the occlusal scheme

that is developed. The maintenance of the soft tissues around the
supporting structures of a prosthesis has always occupied a central
position in the restorative procedures. Unless the soft tissues can be
maintained, long term survival of implants is in jeopardy.
Developing an occlusion that is non traumatic to the soft tissues by
designing an occlusal form that reduces the loading on the implants, is
complemented by proper contours to avoid traumatizing the surrounding
soft tissues, and ensures open embrasures to facilitate maintenance of the
soft tissues by the patient while adhering to strict aesthetic requirements.

An important aesthetic consideration in the anterior arch is the

emergence profile of the restoration. The challenge in this area is to
fabricate an aesthetic restoration that is acceptable in size, shape and
contours and capable of being maintained by the patient and that does not
place adverse stresses on the underlying implants.

iv. Orientation of the occlusal plane :

The orientation of occlusal plane depends on anterior placement of

teeth to ensure proper incisal guidance. Placement of posterior teeth is
done to ensure proper mastication.

For patient with implants, however, the amount of resorption of

residual alveolar ridges, the location of the available bone for implant

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 Discussion

placement, aesthetic considerations and biomechanical considerations

influences the development of an acceptable occlusal plane.

It should always be kept in mind that the arch in which implants are
placed usually becomes the dominant arch. That is, the opposing
edentulous arch now becomes the weaker arch. The plane of occlusion
must be developed to take this in the consideration when the opposing
arch has received an implant supported prosthesis. The arch without
implants subsequently becomes the arch that may have to be favored with
fine tuned, non-intefering occlusal patterns

. V. Mandibular movements :

Movements of the mandible that are out of the normal also

influence the development of the occlusal plane. Depending on patients
individual needs, existing dental condition and records obtained, Group
function or Cuspid disclusion may be used to achieve the goal of lateral
force dissipation

vi. Condylar guide angle and incisal guide angle :

Regardless of which occlusal philosophy followed the condylar angles

should be recorded so that occlusion developed is in harmony with the
angles.

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 Discussion

The incisal guide which is controlled by the clinician, plays a key

role in the proper placement of the anterior dentition. Cusp height, cusp
angulation and compensating curves are affected by these determinants
and affect the final aesthetic result.

Vii. Phonetics :

The position of teeth and the contour of palate relate to non-

intrusive placement of implants .in proper articulation the tongue must
contact these structures correctly to achieve favourble speech. Variations
in articulation required to produce certain sounds should be considered
when occlusal scheme is being developed.

The area of greatest difficulty is the maxillary arch. The relative

narrowing of the maxillary arch owing to bony resorption usually results in
the implants being placed in a palatal position in relation to natural
dentition resulting in crowding of tongue and improper articulation.

The contour of the palate may be adversely affected by implants

placed in the resorbed anterior maxilla. This results in implants being
placed distally in relation to the position of natural dentition. This steepens
the anterior palatal curve, crowding the tip of tongue and prevents proper
tongue placement during articulation.

Implant maintenance in a fixed-implant-borne prosthesis requires

that a space of varying dimensions be provided between the prosthesis at
the crest of ridge. This space in the maxillary arch presents a unique
problem in phonetics by disrupting normal articulation.

viii. Occlusal schemes :

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 Discussion

The goal of an occlusal scheme is to maintain the occlusal load that

has been transferred to implant body within physiologic limits of the
patient. The implant dentist can dissipate these forces by selecting the
proper implant size, number, and position, using stress – relieving
elements, increasing bone density by progressive loading, and selecting
the appropriate occlusal scheme.

. There are three accepted and recognized ideal occlusal schemes that
describe the manner in which the teeth should and should not contact in
various functional and excursive positions of the mandible. These include
Balanced occlusion, Mutually protected occlusion and Group
function occlusion1,2.

Balanced occlusion1
Defined as the simultaneous contacting of the maxillary and mandibular
teeth on the right and left and in the posterior and the anterior occlusal
areas in centric an acentric position developed to lessen or limit tipping or
rotating of the denture bases in relation to the supporting structures (gpt).
Balance occlusion is absent in natural dentition. In bilateral balanced
occlusion, all teeth comes into contact during excursion therefore it is
primarily used in complete denture fabrication .3balanced occlusion can be
further classified into 4 types:

1.1. Unilateral balanced occlusion

1.2 Bilateral balanced occlusion
1.3 Protrusive balanced occlusion
1.4 Lateral balanced occlusion

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 Discussion

fig.4 Balanced occlusion: all teeth contact during centric and eccentric
movements.1
Lucia described the limitations of balanced occlusion as follows10:

1. The cusp to fossa relationship exists only in part of the molar

contacts. The bicuspid cusps function in the opposing embrasures
making wedging and tooth drifting possible.
2. There are larger areas of tooth contact and broad occlusal
surfaces.
3. In “tight occlusion” slight changes produce a readily visible
discrepancy.
4. Errors in a full mouth balance are errors of commission or
omission.
5. When a restoration is fully balanced incision is frequently
difficult
6. In order to produce a full balance, it may be necessary to
increase the vertical dimension to a dangerous degree.

Centric position Protrusive Lateral position

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 Discussion

position
Occlusal Interarch Working Nonworking
contact relation
condition

 Point  One-  All  Lingual  Lingual

centric. tooth to maxillary inclines cusps of
two- and and of maxillary
 Anterior teeth. mandibul anterior teeth and
and Cusp-to- ar teeth teeth, buccal
posterior ridge contact. and cusps of
teeth relation. buccal mandibul
contact. and ar teeth
lingual make
cusps of contact.
posterior
teeth  Cross-
make arch
contact. balance.
 Cross-
tooth
balance.
Balanced occlusion

2. Group function occlusion

Group function occlusion is also known as unilateral balanced occlusion. It
is seen on the occlusal surface of teeth on one side, when they occlude

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 Discussion

simultaneously with a smooth uninterrupted glide. The group function on

working side distributes the occlusal load 1. Absence of contacts on non
working side prevents those teeth from being subjected to the destructive,
obliquely directed forces found on the non working side. This destruction
was first observed by schuyler in 1959 . A study reported by beyron et al
shows that, group function occlusion prevents the excessive wear of the
centric holding cusp thus helps in maintenance of occlusion 4.

fig:5 Group function occlusion: horizontal pressures during lateral

Movements are distributed to one half of the arch from central incisor
through molar on the working side1.

Group function occlusion:

Centric position Protrusive Lateral position

Occlusal Interarch position Working Nonworking
contact relation
condition
 Long  One-  Maxillary  Maxillary  No tooth
centric. tooth to incisors lingual contacts.
 Anterior two- guide the inclines

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 Discussion

teeth may teeth. mandible. of

or may Cusp-to-  Canines anterior
not ridge and and
contact. relation. posterior posterior
teeth buccal
disclude. cusps
guide the
mandible.

63
3. Canine protected occlusion
It is also known as mutually protected occlusion or organic occlusion.
During lateral or protrusive movements, maxillary and mandibular anterior
teeth, guides the mandible in such a way that, there is no posterior
occlusal contact. This leads to absence of frictional wear. This occlusion is
mutually protective because the posterior teeth protect the anterior teeth
at centric relation; the incisors protect the canine and posteriors in
protrusion while the canines protect the incisors and posterior teeth during
lateral movements 1. This is solely based on the canine as the key
element of occlusion avoiding heavy lateral pressures on posterior teeth 5.
-

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 Discussion

fig 6.mutually protected occlusion1

Advantages:

1. Esthetically, the arrangement most closely resembles the

patient's natural dentition.
2. Penetration of the bolus of food has been reported to be better
therefore requiring less occlusal force.
3. Opposing inclines provide bucco-lingual stability, preventing tongue
pressure from tilting a tooth buccolingually.

Disadvantages:

1. With the number of contacts on each tooth, previous patients

records are necessary to transfer to the articulator are only a
mechanical representation of mandibular movements, making precise
intra oral adjustments, necessary to prevent destructive aberrant occlusal
contacts.
2.Occlusal contacts on cuspal inclines during excursive
movements are more apt to occur because of the number of posterior
inclines present. If these inclines are not removed they present a

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 Discussion

destructive force transmitted to the bone fixture interface.adjusting

the inclines while maintaining even light forces on all posterior teeth is a
challenge.
3. Because of the number of contacts on each posterior tooth it is difficult
to evaluate bilateral simultaneous contact. The only method to evaluate
this is photo occlusion wafers, t scan.

Implications:
An occlusal scheme incorporating all the advantages mutually
protected occlusion without the disadvantage would include

(1)Centric occlusai forces directed vertically

(2) Anterior guidance
(3) No posterior interferencesin protrusive and excursive movements
(4)Ease of fabrication and verification of evenly distributed forces
(5) A vertical dimension of occlusion harmony with muscle-established
speaking space
(6) Esthetic qualities that please the patient
In the choice of occlusal scheme for each individual is dictated by the
nuances of the patients existing dentition. For this reason al thorough
treatment plan must be designed before oral rehabilitation to ensure
optimal results.

Mutuallly protected occlusion:

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 Discussion

Centric position Lateral position

Protrusive
position

Occlusal Interarch Working Nonworking

contact relation
condition

 Point  One-  Maxillary  Maxillary  No tooth

centric. tooth incisors canines contacts.
to one- guide the guide
tooth. the
mandible. mandible.

 Only  Cusp-to-
posterior fossa
teeth relation.
make
contact.
 Canines  It is
and permissa
posterior ble to
have
other
 Tripodis Teeth disclude. Anterior teeth
m.
Contact.

 Anterior

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 Discussion

teeth
have a
Space of 30  Mesial
microns. inclines of
Mandibular first  Posterior
premolar buccal teeth
disclude.
Cusps may
contact.

Lingualized occlusion63 :

It was advocated by gysi because of its ability to direct the forces

of mastication vertically onto the ridge. The occlusal scheme is based on
the use of the maxillary lingual cusp as the stamp cusp, which occludes
with a shallow mandibular central fossa. At no time is there contact of the
maxillary buccal cusp or mandibular lingual cusp. The effect creates a
mortar-and-pestle style of occlusion.

Advantages :

1) Mortar and pestle type style of interdigitation provides for effective

mastication of food. The steep maxillary cuspal inclination
decreases the need for unfavourable horizontal movement in
mastication.
2) Elimination of mandibular cusp tip function eliminates the potential
for lateral interferences in excursive movements.
3) A shorter maxillary buccal cusp eliminates its interference in
excursive movement.

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 Discussion

4) Limited number of occlusal contacts on each tooth makes the task

of establishing, even distribution of forces easier and more
attainable.
Disadvantages :

1) Lingualized occlusion is less natural in appearance than cusp to

fossa occlusion.
2) There is a possible reduction in masticatory efficiency.

Fig:7

The concept of occlusion suitable for osseointegrated prosthesis is

basically the same as gnathologic occlusion. In centric, all of the
posterior teeth should have contacts and anterior teeth should have a
clearance of 30 µm. If the entire arches are restored with
osseoinegrated prosthesis such as a fully bone anchored bridge, it will be
easier to establish such an occlusion. In mixed dentition, which is
composed of natural teeth and bridgework, it becomes more complicated
to obtain a good occlusion. The natural tooth sinks approximately 30 µm
during function. An osseointegrated bridge supported only by bone

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 Discussion

does not sink. Therefore it is necessary to adjust centric contacts of

the osseointegrated fixed bridge slightly more open than natural
teeth. Accordingly in centric, the osseointegrated bridge should not
contact with opposing teeth under the soft bite pressure. Under strong
bite pressure, the bridge should contact after the contact of all the
natural teeth intrudes approximately 30 µm. The osseointegrated bridge
begins to contact after all the natural posterior teeth contact. If the
osseointegrated bridge is adjusted to contact at soft bite pressure,
under hard bite pressure, all occlusal load will be borne only by the
bridge and will overload the bone structure.

In order to avoid the overloading of the occlusal surface, the

osseointegrated prosthesis should not have plane to plane contact.
Point contact, especially cusp to fossa tripodal contact is preferred.
During eccentric movement, in order to minimize horizontal loading the
concept of disclusion is recommended. Anterior segment of the
osseointegrated prosthesis should guide the mandible to produce
posterior disclusion.

Canine guided occlusion is not recommended because it generates

excessive occlusal forces into the single implant fixture which is placed
in the canine area. In order to distribute the stress over the entire fixture
anterior group function is recommended.

The ideal place to bear the horizontal load is the trapezoid area which is
surrounded by the osseointegrated implants. This area is formed by the
most mesially located fixture to the most distally located fixture and from
the farthest right side fixture to the farthest left side fixture. This rule can
be altered to the anterior extensions of the osseointegrated prosthesis

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for e.g, even if the anterior arch is located slightly more anterior than the
most anteriorly located fixture. The load applied by the mesial extension
is smaller because it is far away from the condyle. Therefore the load
transmitted to the fixture is not so destructive. On the contrary; if the
prosthesis is extended distally it is more destructive. Hence anterior
group function and posterior disclusion are recommended for
osseointegrated prostheses.

The specific amount of disclusion to be given is not clearly understood.

According to measurements of samples that have the ideal natural
dentition and are free of tmj symptoms, the amount of disclusion
observed at the mesiobuccal cusp tips of the mandibular first molars
while the condyle moves 3 mm from centric are as follows :

1. The average amount of disclusion in protrusion is 1.1 ± 0.6 mm

2. The amount of disclusion on the non-working side is 1.0 ± 0.6 mm
3. The amount of disclusion on the working side is 0.5 ± 0.3 mm

The quality of bone, type of implant, type of prosthesis and patient

factors allplay important roles in the selection of an occlusal scheme..
There is no one occlusal pattern for all individuals but an appropriate
pattern can be found based on the above criteria. Each patient must be
treated with an individualistic approach the guidelines for the choice of
restoration or type of occlusal scheme must be customized to allow for
longevity of the restoration in harmony with the health of the surrounding
dentoalveolar structures19..

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Implant overload

Due to lack of the periodontal ligament, osseointegrated implants,

unlike natural teeth, react biomechanically in a different fashion to occlusal
force. Dental implants are more prone to occlusal overloading, which is
often regarded as one of the potential causes for peri-implant bone loss
and failure of the implant/implant prosthesis it may also lead to lead to
implant failure, intermediate to late screw loosening (abutment or coping),
uncemented restoration, component fracture, porcelain fracture, and

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prosthesis fracture which are all related to stress conditions. Hence, it is

important to control implant occlusion within physiologic limit and thus
provide optimal implant load to ensure a long-term implant success.

Overloading factors for implant are8,11,2:

1. Over extended cantilever

2. Excessive premature contacts
3. Poor bone density
4. Steep cusp inclination
5. Large occlusal table
6. Inadequate number of implants .
7. Parafunctional activities

Cantilevers2
Cantilevers with less-favorable crown/implant ratios can increase the
possibility of overloading, possibly resulting in peri-implant bone loss and
prosthesis failure. In terms of cantilever length, aclinical study
demonstrated that long cantilevers (≥15 mm) induced more implant-
prostheses failures compared to cantilevers < 15 mm long. Duyck et
al.also reported that when a biting force was applied to a distal cantilever,
the highest axial forces and bending movements were recorded on the
distal implants, which were more pronounced in prostheses supported by
only 3 implants, compared to prostheses with 5 or 6 implants. The above
study indicated that a shorter cantilever length is more favorable for the
success of implant-supported prostheses, particularly for prostheses with
fewer implants.

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The occlusal contact position can determine the direction of force which
may result in overloading of supporting implants, especially during
parafunction. An occlusal contact on a buccal cusp which is cantilevered
from the implant body, angled buccal cusp, or marginal ridge contact may
also be damaging. After a period of time, the distribution of occlusal forces
changes so that there is greater force over the cantilever. Clinicians must
keep in mind the potential anterior, as well as posterior, cantilever that can
be created. Cantilevers can cause screw loosening and/or prosthetic
screw or abutment screw breakage and should be eliminated. Therefore,
periodic evaluation of occlusion is necessary.

Parafunctional activity2
Both the force intensity and parafunctional habits can have a
considerable negative effect on the stability of implant components. Many
studies have reported that parafunctional activities and improper
occlusaldesigns are correlated with implant bone loss and failures. Falk et
al. Proposed that the numbers and distribution of occlusal contacts had
major influences on the force distribution between a cantilevered segment
and the implant-supported area, especially with cantilevered units. Naert
et al. Reported that overloading from parafunctional habits such as
clenching or bruxism seemed to be the most probable cause of implant
failure and marginal bone loss. They suggested that shorter cantilevers,
proper location of the fixtures along the arch, a maximum fixture length,
and night-guard protection should be prerequisites to avoid parafunctions
or overloading of implants in these patients. Quirynen et al. Also reported
that excessive marginal bone loss and implant loss were found in patients
with a lack of anterior contacts, the presence of parafunctional activities,
and full-fixed implant-supported prostheses in both jaws. Rangert et al.

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Analyzed 39 fractured implant cases and found 35 (90%) of cases had

occurred in the posterior area while 30 (77%) of the prostheses were
supported by 1 or 2 implants with a cantilever associated with heavy
occlusal forces such as bruxism. They concluded that an in-line placement
of an implant, a cantilever, and bruxism or heavy occlusal forces may
increase risks of bending overloadwhen replacing missing posterior teeth
with 1 or 2 implants.

Premature contacts2
Premature contacts are defined as occlusal contacts that divert the
mandible from a normal path of closure, interfere with normal, smooth,
gliding mandibular movement, and/or deflect the position of the condyle,
teeth, or prosthesis. Several animal studies demonstrated that excessive
lateral forces from premature occlusal contact can cause excessive
marginal bone loss or even osseointegration failure. Isido reported that
excessive occlusal overloading can cause severe crestal bone resorption
and loss of osseointegration. Miyata et al.studied monkeys with different
heights of hyperocclusion, 100, 180, and 250 mm, under inflammatory and
non-inflammatory conditions. After 4 weeks of loading, bone loss was
observed in 180 and 250 mm group, not in the 100 mm group. Their
results suggested that there is a critical height of premature contact on
implant prostheses for crestal bone loss, especially under peri-implantitis.
Lateral premature occlusal loads to the implant crestal region are further
magnified when crown height is increased or when present on the
cantilevered portion of the prosthesis. Therefore we speculated that
occlusaloverload from excessive lateral forces may act as one of the
factors causing marginal bone loss and implant failure.

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Bone quality2
Bone quality has been considered themost critical factor for implant
success at both surgical and functional stages, and it is therefore
suggested that occlusal overload in poor-quality bone can be a clinical
concern for implant longevity (lekholm&zarb1985; misch 1990) in human
studies, higher rates of implant failure were reported in bone of poor
quality. Occlusal overload on poor-quality bone can be a crucial factor in
implant success and longevity at both the surgical and prosthetic stages.
Engquist et al. Reported that higher implant failures in maxillary
overdentures wereattributed to poor bone quality of the maxilla. Jaffin and
berman evaluated 90% of 1054 branemark implants placed in type i, ii,
and iii bone and 10% of fixtures placed in type iv bone and reported that
only 3% of fixtures in type i, ii, and iii bone were lost compared to 35% of
fixtures in type iv bone which failed during second-stage surgery. They
pointed out that the quality of bone was the greatest determinant of fixture
loss. In addition to poor bone quality, unfavorable force direction and
concentration may increase failurerates of implants. Becktor et al.
Evaluated the influence of mandibular dentition on maxillaryimplant failure
and suggested that efforts should be made to build up a favorable
occlusion with special attention to a broad distribution of occlusal contacts.
Esposito et al. Characterized the cellular composition of the soft tissues
surrounding consecutively retrieved late failures of branemark implants
and suggested that on-going infection was unlikely to be an etiological
factor in late failures of implants. They thought that the combination of
poor bone quality and overloading were the causes of late implant failure.

Occlusal table width2

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Typically, a 30%~40% reduction in the occlusal table in a molar region has

been suggested because any dimension larger than the implant diameter
can cause cantilever effects and eventual bendingmoments in single-
implant prostheses. A narrow occlusal table reduces the chance of offset
loading and increases axial loading, which eventually can decrease the
bending moment. Misch also described how a narrow occlusal table can
improve oral hygiene and reduce the risk of porcelain fracture. In addition,
the posterior maxillary region with buccal bone resorption may cause
palatal placement of implants compared with the position of natural teeth if
bone augmentation is not performed. A normal occlusal contour in these
conditions may create a buccal cantilever with a poor biomechanical
environment. We can use cross-bite occlusion in these conditions to avoid
the buccal cantilever and increase the axial loading.

Occlusal considerations

A proper occlusal scheme is a primary requisite for long-term survival,

especially when parafunction or a marginal foundation is present. A poor
occlusal scheme increases the magnitude of loads and intensifies
mechanical stress (and strain) at the crest of the bone. These factors
increase the frequency of complications of the prosthesis and bone sup-
port. Implant-protective occlusion (ipo) was presented previously as
medial positioned-lingualized occlusion and developed by carl e. Misch.
Early implant failure, early crestal bone loss, intermediate to late implant
failure, intermediate to late screw loosening (abutment or coping),
uncemented restorations, component fracture, porcelain fracture, and
prosthesis fracture are related to stress conditions . Bone loss may lead to
anaerobic sulcus depths and peri-implant disease states. This occlusal

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concept refers to an occlusal plane specifically designed for the

restoration of endosteal implants, providing an environment for
improved clinical longevity of implant and prosthesis.53

Factors influencing implant protected occlusion are:9

1. No premature occlusal contacts or interferences

2. Timing of occlusal contacts

3. Influence of surface area

4. Mutually protected articulation

5. Implant body angle to occlusal load

6. Cusp angle of crowns (cuspal inclination)

7. Cantilever or offset distance (horizontal offset)

8. Crown height (vertical offset)

9. Occlusal contact positions

10. Implant crown contour

11. Protect the weakest component

12..Occlusal materials

Premature occlusal contacts35 :

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Premature occlusal contacts results in localized lateral loading of the

opposing contacting crowns .because the surface area of a premature
contact is small,the magnititude of stress in the bone increases
proportionately i.e.. Stress=force/area.all the occlusal forceis applied to
one region rather than being shared by several abutments and /orteeth.in
addition ,the premature contact is often on an inclined plane,therefore
creating a greater horizontal component to the load and increasing
compressive and tensile crestal stresses.

The elimination of premature occlusal contacts is especially important

when habitual parafunction is present because both the duration and
magnitude of occlusal force are increased .the elimination of premature
contacts is more important than in natural teeth because the implant is
less mobile and often cannot effectively dissipate the forces.the premature
occlusal contact on tooth corresponds to less initial occlusal forces and
often modifies the closure of the mandible,resulting in centric relation
occlusion .

Timing of occlusal contacts2 :

. Unlike teeth, implants do not extrude, rotate, or migrate under occlusal

forces. As such, the restoring dentist may vary the intensity of the force
applied to an implant without causing the implant to change its position
readily in the bone. On the contrary, natural teeth do exhibit mesial drift,
and slight changes in occlusal position do occur over time. The proposed
occlusal adjustment does not encourage additional tooth movement
because regular occlusal contacts occur. The teeth opposing implants are

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not taken out of occlusion. Brief occlusal contacts on a daily basis

maintain the tooth in its original position (similar to the rest of the mouth).
In addition, because most teeth occlude with two teeth (with the exception
of the mandibular central incisor), the opposing teeth positions are even
more likely to remain the same.

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

direction under a 3-to-5-ib load, depending on the size, number, and
geometry of the roots and the time elapsed since the last load application.
Once the initial tooth movement occurs, the secondary tooth movement
reflects the property of the surrounding bone and is similar to the bone-
implant movement. The initial axial movement of an implant has no initial,
sudden movement. The implant may move from 3 to 5 m after additional
force causes the bone to move, with little correlation to the implant body
length.

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Fig:8 A tooth exhibits more vertical movement than an implant. This

results in higher occlusal load on an implant.

When teeth oppose each other, the combined intrusive movements of the
contacting elements may be 56 m (28 + 28 m). When a tooth opposes
an implant, the initial combined intrusive movement is only 28 m (28 + 0
m). When implant prostheses oppose each other, the biomechanical
mismatch between teeth in the rest of the mouth and implants further
increases. The total combined implant movement may remain at 0 m
compared with 56 m in the rest of the mouth, and contrary to the teeth
that move immediately, even with light loads, the implants only move
under a heavy occlusal load.therefore although the occlusal design in
occlusion may be ideal, premature occlusal contacts on the implants still
may occur because the teeth have a sudden initial movement away from
the occlusal force.

Because the initial difference in vertical movement of teeth and

implants in the same arch may be as much as 28 m, the initial occlusal
contacts should account for this difference, or the implant will sustain
greater loads than the adjacent teeth. The dentist evaluates the existing
occlusion before implant reconstruction, and ideally eliminates occlusal
prematurities on implants and teeth before the final evaluation of the
occlusion on the implant reconstruction. After this step, the dentist uses
thin articulating paper (less than 25 m thickness) for the initial implant

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occlusal adjustment in centric occlusion under a light tapping force. The

implant prosthesis should barely contact, and the surrounding teeth in the
arch should exhibit greater initial contacts. Only light axial occlusal
contacts should be present on the implant crown.

Fig9: Less initial contact on light tapping force

Once the equilibration with a light bite force is completed, the dentist
applies a heavier centric occlusal force. The contacts should remain axial
over the implant body and may be of similar intensity on the implant crown
and the adjacent teeth when under greater bite force because all the
elements react similar to the heavy occlusal load. Hence to harmonize the
occlusal forces between implants and teeth, the dentist uses a heavy bite
force occlusal adjustment because it depresses the natural teeth,
positioning them closer to the depressed implant position, and therefore
permits equal sharing of the load10.

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fig 10:Similar occlusal contacts on heavy biting force

I. Posterior teeth in one or both quadrants are implants, the same occlusal
timing is suggested. Under a light bite force, the contacts between the
anterior natural teeth are slightly heavier in centric occlusion. Under a
heavy bite force, in centric occlusion, similar contacts are created around
the arch.

(ii) Implant prostheses oppose each other in one quadrant, the heavy bite
force occlusal adjustment must account for a 56-m difference in vertical
movement between one posterior quadrant and the other. Hence the light
bite force occlusal adjustment should be performed with a full-arch-size
articulating paper, and the implant-implant section should barely contact,
whereas the tooth-tooth posterior section has more occlusal contact.
Under a heavy bite force in centric occlusion, similar occlusal contacts are
present on either side of the arch.

(iii) A complete arch implant-supported prosthesis on one arch opposing

complete natural teeth does not require a difference in a light and heavy

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bite force occlusal evaluation. Likewise, when implants support maxillary

and mandibular prostheses, a light and heavy bite force difference in
occlusal timing is not required.

One follows a similar equilibration scenario when anterior implants

and teeth are not connected and disocclude the posterior dentition during
mandibular excursions. The initial lateral movement of healthy anterior
teeth ranges from 68 to 108 m before secondary tooth movement, or 2 to
4 times more movement than their apical movement.

(iv) Anterior implant movements are not immediate and with heavier force
range from 10 to 50 m. Therefore anterior teeth exhibit greater apical and
lateral movements compared with implant. Because of the greater
discrepancies in lateral movement, the occlusal adjustment in this
direction is more critical to implant success and survival. The dentist first
uses light force and thin articulating paper (20 m; e.g., accufilm; parkell,
farmingdale, ny) to ensure that no implant crown contact occurs during the
initial occlusal or lateral movement of the teeth. Then the dentist uses a
heavier force during centric occlusion and excursions to develop similar
occlusal contacts on anterior implants and natural teeth.

. No occlusal scheme will prevent mesial drift and minor tooth

movement from occurring, however. An integral part of the ipo philosophy
is the regular evaluation and control of occlusal contacts at each regularly
scheduled hygiene appointment. This permits the correction of minor
variations occurring during long-term function and also helps prevent
porcelain fracture and other stress-related complications on the remainder
of the natural teeth.

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Influence of surface area

An important parameter in ipo is the adequate surface area to
sustain the load transmitted to the prosthesis therefore when an implant of
decreased surface area, subjected to increased load in magnitude,
direction or duration, the stress and strain in the interfacial tissue will
9
increase .mechanical stress, in its simplest form, can be defined as the
force magnitude divided by the cross-sectional area over which that force
is applied14. The forces that are delivered to the implant must be able to be
capably sustained with minimum effect on the surrounding crestal bone.
Studies have shown that when implants of decreased surface area are
subjected to angled loads, the magnified stress and strain magnitudes in
the interfacial tissues can be minimized by placing an additional implant in
the region of concern. In cases where forces are increased in magnitude,
direction, or duration (parafunction) ridge augmentation, reduction in
crown height or increase in implant width or number may be useful in
compensating for the increased stresses. The type of prosthesis may also
be modified from a fixed prosthesis to a removable prosthesis while
incorporation of modifications such as increased soft tissue support to
relieve undue stresses19.
When implants of decreased surface are subject to angled or increased
loads, the magnified stress and strain magnitudes in the interfacial tissues
can be minimized by placing an additional implant in the region of
concern, which will reduce some of the complications. The implant crowns
are splinted together, so the surface area of support is increased ..
Thus when narrow-diameter implants are used in regions that receive
greater forces, additional splinted implants are indicated even more to
compensate for their narrow design and to help decrease and distribute
the load over a broader region. When force are increased in magnitude,

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direction, or duration (e.g., parafunction), ridge augmentation may be

required to improve implant placement, reduce crown height, and increase
implant width and number to compensate for the increased stress.
Wider-diameter root-form implants have a greater area of bone contact at
the crest than narrow implants (resulting from their increased
circumferential bone contact areas).
As a result, for a given occlusal load, the mechanical stress at the crest is
reduced with wider implants compared with narrow ones. Some authors
encourage the placement of implants in the posterior jaws to be staggered
to improve biomechanical resistance to loadsan important parameter in
ipo is the adequate surface area to sustain the load transmitted to the
Prosthesis.
.

Mutually protected articulation :

The most ideal occlusal concept advocated for implant supported

restorations is that of mutually protected articulation. The posterior and
anterior groups of teeth mutually protect each other. In protrusion, only the
18
anterior teeth are controlled by the incisal guidance and there is uniform
disocclusion seen in the posterior regionwhereas in centric occlusion there
is intercuspation of the posterior teeth and the anterior teeth are free of
any contact19.

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Fig:11 Mutually protected occlusion

When the natural canines are present, during excursions it allows the
teeth to distribute horizontal load and also the posterior tooth to
disocclude. This concept is known as canine guidance or mutually
protected articulation. However, there should be no contact on the
implant crown during excursion to the opposing side and also during
protrusion . The anterior guidance of implant prosthesis with anterior
implant should be shallow. This is because, the steeper the incisal
guidance the greater the force on the anterior implants 17. Weinberg et al
have reported a study stating, every 10- degree change in the angle of
disclusion, there is a 30 % difference in the load. For example, if the
incisal guidance is 20 degrees, 100 psi is put on the implant 9.

Implant body orientation and influence of load direction

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

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fig:12 Angled implants – more stress

There can be different impact on the bone and implant interface based on
the direction of the load applied even if it’s of same magnitude of force,
however implant is mainly designed for long axis load.. Two-dimensional
finite element analysis studya was reported by binderman in 1970
evaluated 50 endosteal implant designs and found that all designs
sustained lesser stress under a long-axis load 20. Stress contours were
concentrated primarily at the transosteal (crestal) region. An axial load
over the long axis of an implant body generates a greater proportion of
compressive stress than tension or shear forces.

whether the occlusal load is applied to an angled implant

body or an angled and is applied to an implant body perpendicular to the
occlusal plane, the results are similar. The biomechanical risk increases.
Any load applied at an angle may be separated into normal (compressive
and tensile) and shear forces. The greater the angle of load to the implant
long axis, the greater the compressive, tensile, and shear stresses 14 ,21-22,.

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Fig:13

For example, three-dimensional finite element analysis conducted by

mischce in 1989 demonstrates that a vertical load on an implant with 100%
bone contact may have compressive stress of 7,000 psi and almost no
tensile stress at the bone implant-crest interface. With a 45-degree load
on the same implant design, the compressive stress may increase to 14,000
psi and tensile stress to 4000 psi on the opposite side. Hence, the
compressive stresses are doubled and the tensile stress increase 1000-fold
with a 45 degree load21.

These stress contours resemble the pattern of early crestal bone loss on
implants. Therefore not only does the stress increase under angled loads,
but also it evolves into a more noxious shear component, which is
conducive to bone loss and has been shown to impair successful bone
regrowth 14,21-23.

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Bone mechanics and force direction :

The noxious effect of offset or angled loads to bone is exacerbated

further because of the anisotropy of bone. Anisotropy refers to the
character of bone, whereby its mechanical properties, including ultimate
strength, depend on the direction in which the bone is loaded. Cortical
bone of human long bones has been reported as strongest in
compression, 30% weaker in tension, and 65% weaker in shear 24.
Therefore ipo attempts to eliminate or reduce all shear loads to the
implant-to-bone interface. The greater the angle of the force, the greater-
the shear component. Because shear forces are increased with an angled
load to the implant body, an attempt is made to reduce the negative effect
of angled loads.

fig:13 Bone has the highest resistance to fracture under compressive

force hence, whenever possible compressive loads should be applied
on implants.

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fig:14 When an angled load is applied compressive stresses on the

opposite side and tensile and shear stresses on the same side
increase.

Forces applied at an angle to the bone further affect the physiologic limit
of compressive and tensile strengths of bone. The reported strength of
cortical bone decreases with an increasing angle of applied load 24. A force
applied at a 30-degree angle may decrease the bone strength limits by
10% under compression and 25% with tension. A 60-degree force reduces
the strength 30% under compression and 55% under tension. Therefore
not only does the crestal bone load increase around the implant with
angled forces, but also the amount of stress the bone may withstand (i.e.,
the ultimate strength) decreases. The greater the angle of load, the lower
the ultimate strength. The ipo attempts to eliminate lateral or angled loads
to an implant-supported prosthesis because the magnitude of the force
increases and the strength of the bone decreases.

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Cortical bone strength related to angle of load 24 :

Type Strength (mpa) Direction of load

Compression 193 Longitudinal
173 30 degrees of axis
133 60 degrees off axis
133 Transverse
Tension 133 Longitudinal
100 30 degrees off axis
60.5 60 degrees off axis
51 Transverse

The primary component of the occlusal force therefore should be

directed along the long axis of the implant body, not at an angle or
following an angled abutment post. Angled abutments should be used only
to improve the path of insertion of the prosthesis or improve the final
esthetic result. The angled abutment, which is loaded along the abutment
axis, transmits a significant moment load (i.e., tending to rotate or rock the
implant) to the implant crestal region and to the abutment screw
proportional to its angle of inclination.

Angles implants often requires an angled abutment. Angled

abutment are fabricated in two pieces and are weaker in design than a
one-piece post. Hence an angled implant body or angled load increase
the amount of crestal stresses around the implant body, transform a
greater percentage of the force to tensile and shear force, and reduce
bone strength in compression and tension. In contrast, the surrounding
implant body stress magnitude is least and the strength of bone is greatest

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under a load axial to the implant body. All three of these factors mandate
the reduction of angled forces.

Fig: 15 As the angle of the implant body load direction increases,

stresses to the entire crown implant bone-system increases.

When lateral or angled loads cannot be eliminated, a reduction in

the force magnitude or additional surface areas of implant support is
indicated to reduce the risk of bone loss or implant component fracture.
For example, if three adjacent implants are inserted with the first in the
long axis to the load, the second at 15 degrees, and the third at 30
degrees, the surgeon may decrease the overall risk by increasing the
diameter of the angled implants, selecting an implant design with greater
surface area, or adding an additional implant in the edentulous space next
to the most angled implant. The restoring dentist may reduce the overload
risk by splinting the implants, reduce the load on the second implant, and
further reduce the load on the third implant. All lateral loads especially
should be eliminated from the most angled implant.

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In the anterior maxilla, labial concavities may require that the

implant be angled away from the labial bone and the abutment toward the
facial crown contour. These implant bodies are more frequently loaded at
an angle, and an angled prosthetic abutment is required. As a results,
larger-diameter implants or a greater number of implants are indicated to
minimize the crestal bone stress on each abutment. Ridge augmentation
may be necessary before implant placement to improve implant placement
and facilitate the use of a wider-diameter implant, especially occlusion
aims at reducing the force of occlusal contacts, increasing implant
number, or increasing implant diameter for implant subjected to angled
loads.

Crown cusp angle :

The angle of force to the implant body may be influenced by the

cusp inclination. The natural dentition often has steep cuspal inclines, and
30 degree cusp angles have been restored in denture teeth and natural
tooth crowns. The greater cusp angles may incise food more easily and
efficiently, yet the occlusal contact along an angled cusp results in an
angled load to the crestal bone. The magnitude to the force is minimized
when the angled occlusal contact is not premature contact but instead is a
uniform load over several teeth or implants. However, the angled cusp
load does increase the resultant stress with no observable benefit. Hence
no advantage is gained but the risk is increased.

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Fg:16 Cusp angles modify direction of force

The occlusal contact over an implant crown therefore should be

ideally on a flat surface perpendicular to the implant body. This position
usually is accomplished by increasing the width of the central groove to 2
to 3 mm in posterior implant crowns, which are positioned over the middle
of the implant abutment. The opposing cusp is recontoured to occlude the
central fossa directly over the implant body.

Axial loading of the implant is especially critical when the intensity

of force or its duration increases (i.e., parafunction). Occlusal schemes
and crown occlusal anatomy should incorporate axial loads to implant
bodies and, when not applicable, should consider mechanisms to
decrease the noxious effect of lateral loads. Because horizontal or lateral
loads cause an increase in the amount of tension and shear forces at the
crest of the ridge, these loads must be reduced within the occlusal
scheme, especially in mechanical systems that increase the
biomechanical load.

Weinberg also claimed that cusp inclination is one of the most significant
factors in producing bending moments. Because the angle of force to the
implanted body may be influenced by cusp inclination, a reduction in cusp

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inclination can decrease the resultant bending moment with a lever-arm

reduction and improvement of the axial loading force. Therefore a reduced
cusp inclination, shallow occlusal anatomy, and wide grooves and fossae
may be beneficial when constructing implanted prostheses due to the axial
loading induced. It is especially critical when the intensity and duration of
The force increase31.

Cantilevers and implant-protective occlusion :

Cantilevers or crowns with less favorable crown-implant ratios also

increase the amount of stress to the implant. The primary vector of a
compressive force on a unilateral cantilever portion of a fixed partial
denture applies shear and tensile forces on the most distant abutment.
The magnitude of loads sustained by the implants is approximately
proportional to the length of the cantilevers and varies as a result of
implant number, spacing and location. 27-,29a clinical report by lundquist et
al.43 correlated long cantilevers with increased crestal bone loss 30. In
addition, cantilevers are known to cause more occurrence of prosthesis
component failure, in particular, failure of prosthesis retaining screws.

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Fig:17.A cantilever may be considered a class 1 lever. For example,

if two implants are 10 mm apart and are splinted with a cantilever
of 20 mm, the following mechanics result: the mechanical
advantage of the cantilever is 20 mm /10 mm, or 2. Therefore
whatever force is applied to the cantilever, a force twice as great
will be applied to the farthest abutment from the cantilever.

The force on the cantilever is a compressive force, whereas the force to

the distal abutment is a tensile force. The load on the abutment closest
to the cantilever (which acts as a fulcrum) is the sum of the other two
components and is compressive. Hence a 100-n force on the cantilever
equals a 200-n force on the distal abutment and a 300-n force on the
other abutment (the fulcrum). The greater the force on the cantilever, the
greater the forces on the implants. Hence parafunctional loads are
particularly dangerous for biomechanical overload. The greater the
length of the lever, the greater the mechanical advantage and the
greater the loads on the implants. The shorter the distance between the
implants, the greater the mechanical advantage and the greater the
force on the abutment.

The goal of ipo relative to cantilevers is to reduce the force on the

lever or pontic region compared with that over the implant abutments. In
addition, no lateral load is applied to the cantilever portion, and a gradient
of force type of load that gradually decreases the occlusal contact force
along the length of the cantilever may be beneficial.

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Crown height and implant-protective occlusion :

The implant crown height is often greater than the original natural
anatomical crown. Crown height with a lateral load may act as a vertical
cantilever and a magnifier of stress at the implant-to-bone interface. The
greater the crown height, the greater the resulting crestal moment with any
lateral component of force, including those forces that develop because of
an angled load14. Angled abutments loaded in the direction of the
abutment with an increase in crown height are subject to even greater
crestal moment loads because of the lateral load and the increased level
effect from the crown height.

fig:17

The angled load on an implant crown is at greater risk to the crestal bone
than the angled implant body because the crown height acts as a vertical
cantilever. Therefore whatever load is applied to the occlusal table (or

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 Discussion

cusp angle) is magnified by the crown height. For example, a 12-degree

angled load of 100 n on the implant crown results with a 21-n additional
load as a lateral force component. However, if the crown is 15 mm high,
the final load to the crest of bone is 21 n x 15 mm = 315 nmm moment
force. Therefore the noxious effects of a poorly selected cusp angle, an
angled implant body, or an angled load to the crown will be magnified by
the crown height measurement.

10. Occlusal contact positions :

The number of occlusal contacts in an occlusal scheme varies. For

example, peter k. Thomas32 occlusal theories suggest that there should be
a tripod contact on each occluding cusp (stamp cusp), on each marginal
ridge, and in the central fossa with 18 and 15 individual occlusal contacts
on a mandibular and maxillary molar, respectively. Other occlusal contact
schemes indicate the number of occlusal contacts for molars may be
reduced.

fig :18 Tripod contacts

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 Discussion

Occlusal contact position determines the direction of force,

especially during parafunction. An occlusal contact on a buccal cusp may
be an offset load when the implant is under the central fossa and the
buccal cusp is cantilevered from the implant body. The angled buccal cusp
also will introduce an angled load to the implant body. The marginal ridge
contact is also the cantilever load because the implant is not under the
marginal ridge but may be several millimeters away. Because the
mesiodistal dimension of the crown often exceeds the buccolingual
dimension, the marginal ridge contact may be the most damaging. In
addition, the laboratory creates an all-porcelain marginal ridge completely
unsupported by the metal substructure (further increasing the risk of
porcelain fracture). The moment forces on marginal ridges also may
contribute to forces that increase abutment screw loosening. Therefore
marginal ridge contacts on implant crowns should be avoided whenever
possible.

fig : 19 A buccal cusp contact is an offset or cantilever load. The

ideal occclusal contact is over the implant body.

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The central fossa of an implant crown should be 2 to 3 mm wide in

posterior teeth and parallel to the occlusal plane. The ideal implant body
position is usually directly under the central fossa and may be 1 to 2 mm
to the facial aspect (when bone is abundant) to be under the buccal cusp
of the mandible and to improve the esthetic emergence of maxillary
implant crowns. The ideal primary occlusal contacts therefore will reside
within the diameter of the implant, within the central fossa. Secondary
occlusal contacts should remain within 1 mm of the periphery of the
implant to decrease moment loads. Marginal ridge contacts should be
avoided.

Implant crown contour :

The maxillary dentate posterior ridge is positioned slightly more

facial than its mandibular counterpart. Once the maxillary teeth are lost,
the edentulous ridge resorbs in a medial direction as it evolves from
division a to b, division b to c, and division c to d. As a result, the maxillary
permucosal implant site gradually shifts toward the midline as the ridge
resorbs. Sinus grafts permit the placement of endosteal implants even in
previous division d ridges. However, because of resorption in width the
maxillary posterior implant permucosal site may even be palatal to the
opposing natural mandibular tooth. The posterior mandible also resorbs
lingually as the bone resorbs from division a to b. As a result, endosteal
implants are also more lingual than their natural tooth predecessors.
Although many of the occlusal concepts are similar for natural teeth and

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fixed implant restorations, several aspects remains unique to implant-

supported prostheses.

Fig :20 Transformation from Type A to Type D bone

after extraction

The implant body buccolingual dimension is smaller than the

natural tooth. The center of the implant most often is placed in the center
of the edentulous ridge. Because the rest of the ridge shifts lingually with
resorption, the implant body is most often not under the buccal cusp tips
but rather near the central fossa or even more lingual, under the lingual
cusp of the natural tooth. Most often the laboratory fabricates a
mandibular posterior implant crown fossa of the maxillary posterior tooth.
A buccal lingual cantilever is called an offset load, and the same principles
of class i levers apply. In other words, the greater the offset, the greater
the load to the implant. Offset loads create moment forces, which increase
compressive tensile and shear forces are the implant crest.

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A wide occlusal table favors offset contacts during mastication or

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

The posterior narrow occlusal table also facilitates daily home care.
The laboratory technician often attempts to fabricate occlusal facial and
lingual contour similar to that of natural teeth. This not only increases
offset loads but also often results in ridge laps or porcelain extension at
the facial gingival margin of the implant. As a result, home care in the
sulcular region of the implant is impaired by the overcontoured crown
design. On the contrary, a narrow occlusal table combined with a reduced
buccal contour (in the posterior mandible) facilitates daily care in a manner
similar to a tooth and improves axial loading.

The narrower occlusal contour also reduces the risk of porcelain

fracture. A facial profile similar to a natural tooth on the smaller-diameter
implant (e.g., 10-mm tooth versus 4 to 6-mm implant) results in
cantilevered restorative materials. The facial porcelain most often is not
supported by a metal substructure because the gingival region of the
crown is also porcelain. As a result, shear forces result on the buccal cusp
on the mandibular crown, or lingual cusp in the maxillary crow, and are
more likely to increase the risk of porcelain fracture. This risk is
compounded further by the higher impact force developed on implant
abutments compared with natural teeth.

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Posterior implant under central fossa Over contoured restoration

position

Cervical region hinders hygiene maintenance

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 Discussion

In summary, restorations mimicking the occlusal anatomy of natural

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

.12. Protection of weakest arch :

The weakest component philosophy is used when one opposing
segment has different factors of force or is more at risk of
complications than an opposing area, for example, the occlusal
concept in a maxillary completely edentulous area restored with a
complete denture opposing an implant supported restoration in the
mandible is determined by the maxilla because it is the weakest
area.

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The amount of force distributed to a system can be reduced by

stress- relieving components that may dramatically reduce impact
loads to the implant support. The soft tissue of the traditional
completely removable prosthesis opposing implant prosthesis is
displaced more than 2mm and is an efficient stress reducer. Lateral
loads do not result in as great a crestal load to the implants,
because the opposing prosthesis is not rigid. As a result the occlusal
concept may be designed to favor the complete removable denture,
which is the weakest arch. The most common implant treatment
which includes a traditional soft tissue supported complete denture is a
maxillary denture opposing a mandibular implant supported restoration
.the occlusal scheme for this condition raises the posterior plane of
occlusion ,uses a medial positioned lingualised occlusion and bilateral
balanced occlusion. Whether the mandibular restoration is fp-1, fp-2, fp-
3-, rp-4 or rp-5, the maxillary denture follows these guidelines. A bilateral
balanced occlusion ideally exhibits contacts in all teeth for centric and
eccentric occlusal movements. This is a popular occlusal scheme for
soft tissue supported removable prosthesis which improves maxillary
denture stability especially during parafunction. However, the
mandibular implant supported restoration may exert greater force on
the premaxilla under a maxillary denture, by the total elimination of
anterior contacts with the mandibular anterior teeth in centric occlusal
relation.

The weakest component philosophy applies to axial occlusal contacts

in the regions of the implant bodies, when cantilevers of offset loads are
present. Heavier contacts are applied over the implant bodies to reduce
the magnification of the compressive forces from the distal most

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cantilever and the tensile and shear forces on the most anterior implant
abutment. Reduced occlusal forces and absence of lateral contacts in
excursions are recommended on posterior cantilevers or anterior offset
pontics whenever possible. This reduces the moment forces on the
abutments and decreases the amount of crestal bone load on the
terminal implant abutments. If the implants for both the arches cannot
be loaded in an axial position, bone density, implant surface area and
prosthesis type determine the area to be protected. The maxillary
implants are most likely to be protected with the axial load in order to
follow the weakest component theory when there are cantilever pontics in
both the arches, they should oppose each other. If maxillary posterior
implants cantilever anterior teeth and mandibular anterior implants
cantilever posterior teeth, the occlusal scheme cannot reduce forces on
both the cantilevers. In this scenario, the weaker component is usually the
anterior maxilla, and reduced force in the region would be appropriate. It is
better for mandibular cantilever pontics to oppose maxillary implants
than the reverse situation. The weaker component occlusal concept
also applies to the anterior maxilla implant reconstruction. The implant
restored anterior maxilla is often the weakest section of all other implant
reconstructed or natural tooth regions in the mouth. Narrower implants,
facial cantilevers, oblique centric contacts, lateral or apex and the inability
to often place central or lateral incisor implants are all characteristics of
the maxilla which mandate special consideration when establishing
occlusal scheme. Augmentation procedures are indicated for fixed
restorations in the maxilla in order to place more and greater diameter
implants when greater forces are diagnosed in the implant candidate.

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Methods to help reduce force on maxillary anterior implants opposing a

fixed dentition or restoration include excursive forces distributed to at
least two splinted implants. As a result , anterior implants should be
placed in the canine-lateral or canine-central or canine and first premolar
for each anterior quadrant of the arch. Hence the position of canine is
very important when the anterior teeth are missing. When the canine
region cannot be used to place an implant, three implants often are
required in the anterior quadrant of each arch.

A first premolar and lateral implant may distribute the working lateral load,
and the lateral and central implant can be used for the protrusive
excursion.

Hence, a minimum of two anterior implants are most often required in

each excursion of a completely edentulous premaxilla, and three implants
may be required when there are additional forces (bruxism).

Since there are three excursive directions for the mandible, the complete
edentulous anterior maxilla often requires four implants. In this usage, one
of the implants in a lateral excursion may also be used for the protrusive
movement.

Full-arch fixed prostheses :

Fixed prostheses on natural teeth opposing fp-1 to rp-4 implant

restorations should follow mutually protected occlusal schemes whenever
possible. In protrusion, posterior contacts should be totally absent,
especially for cantilevered posterior units. The masticatory force
generated during lateral excursions is decreased in absence of posterior

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 Discussion

contacts. This assists in reducing the noxious effect of lateral forces on the
anterior implants. Two or more implants should share any lateral force,
and lateral excursions should occur as far forward as is practical and
should include the canine32.

Mandibular arch

The mandible exhibits a torsional movement primarily in a medial

and rotating and dorsoventral direction during opening and clenching. The
effect of mandibular bone movement are limited almost completely to the
regions posterior to the mental foramen in most individuals. As a result,
sufficient numbers of anterior implants with a sufficient anteroposterior
distance may often replace the mandibular teeth with a one-piece rigid
bilateral posterior cantilever as far as the first molar region with no
consequence related to flexure of the mandible. However, the posterior
cantilevers are still the weakest component of the system, and minimal
occlusal contact in the cantilevered regions and the total absence of
posterior. Lateral contacts during excursions are indicated when opposing
the natural dentition or a fixed restoration 32.

When implants are used in both mandibular posterior regions, they

should be independent from the implant placed in the contralateral region.
As a result, when posterior implants are placed in an edentulous mandible
instead of a cantilever, two to four implants support an independent
prosthesis on at least one side, depending on the length of the span,
density of bone magnitude of force, and direction and duration of load.
Seven to eight implants to support a complete implant prosthesis in two
separate units are suggested in the mandible for a fixed restoration
opposing a fixed prosthesis or natural teeth with moderate to severe
stress factors32.

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Fig:22 Panoramic radiograph illustrating a mandibu99lar fp-2

prosthesis.seven to eight implants to support implant prosthesis in
two separate units are suggested in mandible for a fixed restoration
opposing a fixed prosthesis or natural teeth with inadequate to
severe stress factors.

Maxillary arch

In the edentulous maxilla, full-arch prosthesis may be fabricated in one

section. However, the dentist usually places two rigid attachments distal to
the canine. This maintains the biomechanics of an arch, yet the prosthesis
may be removed in three sections to facilitate the management of
uncemented restoration or porcelain fracture. In addition, the anterior
lateral forces generated during excursions should not be distributed
directly to the posterior region by posterior lateral contact. 8 to 10
maxillary implants most often are required for a 12-unit fixed prosthesis
opposing a fixed addition on teeth or implants with moderate to severe
stress factors. Posterior implants are more critical in the maxilla to

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 Discussion

eliminate cantilevers and increase the anteroposterior implant distance,

which further decreases stress to the maxillary anterior implants 32.

Fig :23 panoramic radiograph illustrating maxillary fp-2

proshesis.eight to ten maxillary implants most often are required for
Twelve-unit fixed prosthesis opposing a fixed dentition on teeth
and/or implants with moderate to severe stress factors.

13. Occlusal materials :

The occlusal surface materials selected affect the transmission of

forces and the maintenance of occlusal contacts. 56 in addition, occlusal
material fracture is one of the most common complications for
restorations on natural teeth or implants. Therefore consideration of the
occlusal material for each individual restoration is wise. Occlusal
materials may be evaluated for,

i) Esthetics

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 Discussion

ii) Impact force

iii) Static load
iv) Chewing efficiency
v) Fracture
vi) Wear
vii) Interarch space requirement
viii) Accuracy of castings

Skalak explained, “a stiff prosthesis is preferable over a flexible one in the

superstructure which is supported by osseointegrated implants and will
distribute loads more effectively to the supporting abutments.

For implant-supported prostheses, it was originally strongly recommended

to use a shock-absorbing material such as acrylic resin on top of the
superstructure to protect the implant–bone interface.the three most
common groups of occlusal materials are porcelain, acrylic, metal. These
materials for fixed prosthesis on implants are reviewed with reference to
the above mentioned criteria. Based on biomechanical analyses, acrylic
resin denture teeth were therefore predominant during the developmental
years in a clinical study on five subjects using fixed prostheses with either
acrylic resin or porcelain occlusal surfaces, masticatory forces were
recorded while the subjects chewed various foods. No differences related
to tooth material could be detected in the load rates.60 in a study covering
6 years, the use of porcelain instead of composite resin as occlusal
material had no infl uence on the marginal bone height around the
implants. The most common complications of implant restorations have
\been related to fractures of the acrylic resin of the prostheses. Wear of
acrylic occlusal surfaces increased substantially with time, according to a

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 Discussion

15-year follow-up of fixed implant-supported prostheses in the edentulous

maxilla . In current clinical practice, porcelain has become the primary
occlusal material for single-tooth and partial fixed implant restorations.. In
removable types of implant supported prostheses, e.g., overdentures,
polymer teeth are the most common.57

Occlusal material characteristics :

Porcelain Gold Resin

Esthetics + - +
Impact force - + +
Static load + + +
Chewing efficiency + + -
Fracture - + -
Wear + + -
Interarch space - + -
Accuracy - + -

I) Esthetics

Esthetics is a primary concern for patients. The most esthetic material

available today is porcelain; acrylic acceptable for esthetics and metal is a

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 Discussion

poor choice when esthetics is the chief criteria. Porcelain fracture is

the second most common cause of prosthesis failure. Use of
porcelain is suggested when the prime consideration is esthetics.

fig :24 Metal occlusal surfaces on implant crowns have the poorest
esthetics. Porcelain is the most esthetic choice.

Ii) Forces

The hardness of a material is related to its ability to absorb stress

from impact loads. An all-porcelain occlusal surface exhibits
hardness 2.5 times greater than that of natural teeth. Acrylic resin
has a knoop hardness of 17 kg/mm2, and enamel has a 350
kg/mm2 hardness. A composite resin may exhibit a hardness of
85% that of enamel. Therefore impact loads are lowest with acrylic,
increase with composite and metal occlusals, are greater with
enamel, and further increase with porcelain. As a result use of resin was
originally suggested due to dampening effect.

The type of occlusal materials selected can affect the implant to

bone interface and components under such abnormal loading conditions.

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 Discussion

For bruxers, the impact force may be reduced by use of metal occlusal
materials.continued forces (e.g. with clenching) however are affected
minimally by the occlusal material a static or constant load on occlusal
material results in a similar amount of stress on the crestal bone,
regardless of occlusal material type. Hence clenchers do not have a
considerable amount of stress reduction when acrylic materials are used
on the occlusal surfaces instead of porcelain.

Fully bone-anchored prosthesis

Natural teeth

Complete dentures

fig: 25 The impact force to the occlusal material is least with

complete dentures supported by soft tissue and highest for
osteointegrated implant-supported prostheses.

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 Discussion

fig : 26 Impact force on implant bone interface is greater than natural

teeth. The picture represents reduced force with mobile tooth compared
with impulse of the force on a rigid structure.

iii) Chewing efficiency:

Fixed prosthesis exhibit an improved efficiency compared with

removable soft tissue borne prosthesis, regardless of the occlusal
material. Shultz compared the difference of acrylic, gold and
porcelain on identical dentures in two patients. Acrylic was 30% less
than porcelain or metal, whereas no difference was found between
gold and porcelain.

Iv) Wear

The definition of wear is the deterioration, change or loss of a surface

caused by use. Acrylic resin wears 7 to 30 times faster when opposing
gold, resin, enamel or polished porcelain, compared with gold
opposing gold, enamel or porcelain. Gold occlusal surfaces exhibit less
volume loss than any other combination of materials. Porcelain opposing
porcelain wears more than porcelain opposing gold or metal.

The wear rate of occlusal materials especially in partially edentulous

patients with un restored teeth , should be similar to enamel. In principle,
for the partially edentulous patient to have greater occlusal wear on

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 Discussion

implants, rather than less, would be preferable because the additional

forces placed on the teeth are better tolerated than on implant prosthesis.
As a result, total volume wear may favor porcelain opposing enamel for
the implant prosthesis opposing teeth in the partially edentulous patient
and metal opposing enamel in the other regions of the mouth that require
restoration of natural teeth.

For full arch implant supported prosthesis the metal occlusals may
be considered to minimize wear and prolong the accuracy of occlusal
schemes long term. Porcelain in esthetic regions opposing gold in the
non-esthetic areas or metal occlusals in both arches when parafunction or
marginal crown height space is present.

fig:27 Metal occlusals show the least wear. The implant crown
stays in a constant position as the material wears.

V) Material fracture

Acrylic or composite materials fracture more easily. The

Compressive strength of acrylic resin is 11,000 psi compared with
40,000 psi for enamel. Composite resin is 3 times stronger than
acrylic. Metal occlusals do not fracture easily, provide good wear

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 Discussion

resistance, and have minimum impact load compared with

porcelain.

Mechanical retention must be incorporated in the metal

superstructure with proper resistance to the forces of occlusion.
Posterior acrylic or composite facings often fracture because of the
inadequate yield and fatigue strengths compared with the bite force
developed under parafunction or on cantilevers for fixed restorations. Metal
occlusals are the safest to use and are suggested in non esthetic regions
or in the presence of parafunction.

Vi) Accuracy:

. Accuracy is most important in regions of long span and with a large

volume of material.

Vii) Inter arch space:

Acrylic restorations receive their strength from bulk and therefore

require greater inter arch space. Metal occlusals require the least
amount of space. In addition, when increased retention of cement
retained prosthesis is required, a longer abutment and greater retention
may be achieved with a metal occlusal. Porcelain is intermediate in
the interarch space requirement.

Hence when all the seven criteria are evaluated, metal is an excellent
occlusal material, with improved properties in accuracy, wear,
fracture resistance, abutment retention and good qualities for impact

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 Discussion

or static force. Esthetics is best satisfied with porcelain which also provides
better fracture resistance and retention as compared to acrylic.

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 Discussion

RECOMMENDED OCCLUSION FOR DIFFERENT TYPES

OF OSSEOINTEGRATED PROSTHESIS

Hobo s, classified osseointegrated prosthesis as follows 52 ,10 ,58

1. Fully bone anchored bridge

2. Over denture
3. Free standing bridge
a) Kennedy class i
b) Kennedy class ii
c) Kennedy class iii
d) Kennedy class iv
4 Bridge connected to natural teeth

5. Single tooth replacement

1.Occlusion for fully bone anchored prosthesis 2,10,11:

This is used for edentulous cases. It is very successful for the mandibular
arches because there are no anatomic limitations for placing fixtures
between the right and left mental foramen for full-arch fixed implant
prostheses,bilateral balanced occlusion has been successfully utilized for
an opposing complete denture, while group-function occlusion has been
widely adopted for opposing natural dentition. Mutually protected
occlusion with a shallow anterior guidance was also recommended for
opposing natural dentition (chapman 1989; hobo et al. 1989; wismeijer et
al. 1995). Bilateral and anterior–posterior simultaneous contacts in centric
relation and mip should beobtained to evenly distribute occlusal force

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 Discussion

during excursions regardless of the occlusal (chapman 1989; quirynen et

al. 1992; lundgren & laurell 1994). In addition, smooth, even, lateral
excursive movements without working/non-working occlusal contacts on
cantilever should be obtained (lundgren & laurell 1994; engelman 1996).
For occlusal contacts, widefreedom (1–1.5mm) in centric relation and mip
can accomplish more favorable vertical lines of force and thus minimize
premature contacts during function (beyron 1969; weinberg 1998). Also,
anteriorly placed working contacts were advocated to avoid posterior
overloading(hobo et al. 1989; taylor 1991). When a cantilever is utilized in
a full-arch fixed implant prosthesis, infraocclusion (100 mm) on a
cantilever unit was suggested to reduce fatigue and technical failure of the
prosthesis (lundgren et al. 1989; falk et al. 1990). Wie (1995) found that
canine guidance occlusion increased a potential risk of screw joint failure
at the canine site due to stress concentration on the area.
The fully bone anchored prosthesis is connected to supporting fixtures
through the transmucosal components, the abutments, either in the
maxilla or the mandible. (leung et. Al, 1983)

fig :27 Fully bone anchored prosthesis with six mandibular fixtures

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 Discussion

usually, four to seven fixtures are installed in this area and the prosthesis
is connected into these fixtures. Mandibular fully bone anchored bridges can
be extended to a maximum of 15-20mm posteriorly.

.. In centric, it is necessary to have a 30 µm clearance at the anterior

region and to have centric stops on posterior teeth. In order to eliminate
harmful horizontal stress, disclusion should be employed. To avoid the
localization of stress, anterior group function must be used. The anterior
guidance should be made slightly flatter than natural teeth to avoid
overstress of the fixture. This produces a smaller amount of disclusion10.
Recommended amounts of disclusion for fully bone anchored bridges are

Protrusive 1.0 mm

Non working side 0.8 mm

Working side 0.3 mm

2.Occlusion for Overdentures2,10,11

For the occlusion on overdentures, it has been suggested to use bilateral

balanced occlusion with lingualized occlusion on a normal ridge. On the
other hand, monoplane occlusion was recommended for a severely
resorbed ridge (lang & razzoog 1992; wismeijer et al. 1995; mericske-
stern et al. 2000). Although there has been consensus that bilateral
balance occlusion can provide better stability of overdentures (engelman
1996), there are no clinical studies which demonstrate the advantages of
bilateral balanced occlusion for overdenture occlusion compared with

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 Discussion

other occlusal schemes. Recently, peroz et al. (2003) performed a

randomized, clinical trial comparing two occlusal schemes, balanced
occlusion and canine guidance, in 22 patients with conventional complete
dentures. The results of the assessment using a visual analog scale
revealed that canine guidance was comparable to balanced occlusion in
denture retention, esthetic appearance, and chewing ability.
Overdentures are attached to supporting fixtures using various
connections or attachments which usually do not alter esthetic results.
(stalbad et al, 1985).

Fig :28 Schematic diagram of an overdenture supported by two

fixtures with bar and clip attachment

The overdenture design can be mainly mucosally supported, a

combined mucosa implant-supported, or an implant- supported
overdenture depending on the number and location of the implants.
In case of an full arch maxillary over denture and a mandibular

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 Discussion

fully bony anchored bridge, a small clearance in centric is

recommended in the anterior teeth, while posterior teeth contact
simultaneously. The amount of disclusion in protrusive, lateral working
and non-working side is 0 mm.

fig 29 Protrusive balance in implant supported overdenture patient

Fig:30 Bilateral balance is recommended for implant supported

overdentures.

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 Discussion

Protrusive 0mm

Nonworking side 0mm

Working side 0mm

3.Occlusion for free standing bridge 10:

Kennedy's class 1 - Bilateral edentulous case where both sides are

restored by osseointegrated bridges and they maintain the vertical
height. Careful consideration should be taken to determine the
amount of clearance given to the natural anterior dentition. The
clearance of anterior teeth should be smaller than the one given to
natural teeth. The amount of disclusion required for this case is the
same as in the natural dentition because anterior guidance is
provided by the natural dentition:

Protrusive 1.1 mm

Non working side 1.0 mm

Working side 0.5 mm

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Fig 31:kennedy’s class i and classii situation with implant

prostheses

Kennedy's class ii - Unilateral case. This situation is ideal for the

osseointegrated free standing bridge because the contra lateral side
of the arch will maintain the vertical height, while the other side is
restored by the osseointegrated bridge. It induces less stress to the
implant while it holds centric. In centric, the posterior osseointegrated
bridge should have 30 µm open contacts, while anterior teeth also
have 30 µm openings, and it begins to contact under strong bite
pressure. In the kennedy class ii situation because the anterior teeth are
natural they can bear the occlusal load safely. The amount of disclusion
suggested is the same as for natural dentition.

Protrusive 1.1 Mm
Non working side 1.0 Mm

Working side 0.5 Mm

0.5

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Kennedy’s class iii - Is also ideal for osseointegrated implants because

vertical height is maintained by natural teeth in centric, the osseointegrated
bridge contacts only under strong bite dentition. The amount of disclusion
suggested is the same as for natural dentition.

Protrusive 1.1 mm

Non-working side 1.0 mm

Working side 0.5 mm

Kennedy’s class iv - Requires an anterior free standing bridge, and it is

another indication for the osseointegrated bridge. In a case where 8 teeth
from 1st premolar to 1st premolar are missing, restoration with a regular
fixed bridge is contraindicated as it produces a fulcrum. If the teeth are
restored with a removable partial denture, it also produces a fulcrum
and introduces tremendous torque to the abutment teeth. However, this
case is easily restored with an osseointegrated bridge. Anterior eight
unit fixed bridges can be supported by four fixtures, without creating a
fulcrum.

Protrusive 1.0mm

Non working side 0.4mm

Working side 0mm

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fig 32: kennedy's' class iii and iv situations with implant prosthesis

Kennedys' class v - In this case posterior disclusion is guided by the

osseointegrated bridge. In order to minimize horizontal load group
function occlusion is preferred. During lateral movements, posterior
teeth on the working side can bear the horizontal load while the non-
working side is discluded. During protrusive movement, an
osseointegrated bridge will guide the mandible and produce posterior
disclusion. In order to minimize the load induced to the fixtures
during protrusive movement, anterior guidance should be flatter than
the natural dentition. The amount of disclusion suggested for this case
is as follows.

Protrusive 0.8 mm

Non-working side 0.4 mm

Working side 0.0.mm

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Because an anterior fixed bridge does not sink like natural teeth, the
clearance of anterior teeth must be greater than the one given to natural
anterior teeth (> 30 µm).

4. Bridge connected to natural teeth

fig 33 .Fixed partial denture supported by natural tooth and a fixture.

When single fixtures are used to restore the bridge, in order to prevent
loosening of the screw by the rotation of the bridge, the mesial end of
the bridges are connected to natural teeth. If the osseointegrated implant
prosthesis and natural teeth are connected rigidly, under the occlusal
loads, the implant receives the majority of the stress and is overloaded.
The female attachment (keyway) is placed on the distal end of the retainer
supported by the natural tooth; the key connected to the osseointegrated
bridge is engaged into keyway. Thus the natural tooth can be depressed
freely without interference of the osseointegrated bridge.

However, based on long term observation it was found that the

natural tooth is depressed permanently and a gap is produced between
the key and a keyway. The osseointegrated prosthesis with the key is

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extruded a visible amount and the retainer cemented to the natural tooth
is depressed. The reasons are not clear. Henry believes that this
phenomenon is caused when the key and keyway are made very
precisely. When the natural tooth is depressed the key and keyway are
sometimes locked, then the tooth is depressed permanently.

In order to avoid this phenomena, some suggested the use of telescopic

crown to connect the osseointegrated bridge. However, through a long-
term observation., it was found again that the natural tooth depressed
often, the cement connecting the outer crown to the inner crown was
broken down and washed out producing plaque accumulation. At present,
the use of a rigid connector between osseointegrated bridge is suggested
rather than a non rigid connector, this may result in ankylosis of the
abutment tooth, creating resorption of root or absorption of alveolar bone..
The connection to natural teeth is questionable and the freestanding
procedure is preferred.

2,10,11
5.Occlusion for single tooth replacement

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 Discussion

fig:33

The occlusion in a single implant should be designed to minimize occlusal

force onto the implant and to maximize force distribution to adjacent
natural teeth (misch 1993;lundgren&laurell 1994; engelman 1996).
To accomplish these objects, any anterior and lateral guidance should be
obtained in natural dentition. In addition, working and non-working
contacts should be avoided in a single restoration (engelman 1996). Light
Contacts at heavy bite and no contact at light bite in mip are considered a
reasonable approach to distribute the occlusal force onteeth and implants
(lundgren & laurell 1994)..like posterior fixed prostheses, reduced
inclination of cusps, centrally orientedcontacts with a 1–1.5mm flat
area,and a narrowed occlusal table can be utilized for the posterior single
tooth implant restoration (weinberg 1998; curtis et al.2000). Wennerberg &
jemt (1999) claimed that centrally oriented occlusal contacts in single
molar implants were critical to reduce bending moments attributable to
mechanical problems and implant fractures.increased proximal contacts in
the posterior region may provide additional stability of restorations (misch
1999). Two implants for a single molar have been utilized and

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 Discussion

demonstrated less screw loosening and higher success rates (balshi et al.
1996).
Occlusion required for this restoration is equal to the natural dentition in
centric for anterior-teeth. It must have clearance of 30 µm , for a premolar it
should contact only under heavy load.
During eccentric movement, the anterior restoration should contact
with opposing teeth in order to create anterior group function. This
eccentric contact is essential to prevent extrusion of opposing teeth.
Because the restoration does not contact in centric, contact during
eccentric movement is required. For premolars, the restorations must
disclude during eccentric movements and avoid lateral stress.

To summarize: the amount of disclusion at eccentric movements for

each occlusal scheme is mentioned below for each type of
osseointegrated prosthesis

Type of Protrusive Non Working Type of

prosthesis working side occlusion
side

Overdenture 0mm 0mm 0mm Balanced

Fully bone 1.0mm 0.8mm 0.3mm Mutually

anchored protected

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 Discussion

Anterior free 1.0mm 0.4mm 0mm Group

standing function

Posterior free 1.1mm 1.0mm 0.5mm Mutually

standing protected

. The amount of disclusion for osseointergated implants

prostheses.

LOADING OF IMPLANT

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Branemarks protocol : Final prosthesis after 3-6 months of initial healing

Delayed loading : 1 Stage

Loading 3 months after
2 Stage implant placement

Progressive loading : Provisional prosthesis brought progressively into

occlusion

Early loading : Between 2 wks – 3 months

Immediate loading : Within 2 weeks of implant placement loading is done

Functional : Temporary
restoration on the same Non-functional : Not in
day of surgery in occlusion
occlusion

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Bone density is the most critical factor in determining the amount of

healing time between first and second-stage surgery and the
59
appointments for prosthesis restoration. Jaffin and berman and friberg et
al.60 reported early implant failures of as great as35%, especially in cases
with poor bone quality, aftersuccessful surgical survival of implants.
Misch61 first proposed the concept of progressive bone loading during
prosthetic reconstruction to permit development time for load-bearing
bone at the bone-to-implant interface and provide bone with adaptability to
loading via a gradual increase in loading. Then he modified this concept
by incorporating time intervals (from 3 to 6 months), diet (avoid chewing
with a soft diet, then harder food), occlusion (gradually intensify the
occlusal contacts during prosthesis fabrication), prosthesis design, and
occlusal materials (from resin to metal to porcelain) for poor bone quality
conditions19,31 .the time interval between the two surgical appointments
depends on the type of bone (d1-d4) in which the implant is placed. The
diet of the patient is controlled from soft to semi-soft to hard in order tobe
able to control the amount of force being deliveredto the implant 19. The
occlusal material may be varied to load the bone-to-implant interface
gradually. During the initial steps, the implant has no occlusal material
over it. At subsequent appointments, the dentist uses acrylic as the
occlusal material, with the benefit of a lower implant force than metal or
porcelain. Either metal or porcelain can be used as the final occlusal
material. If para function or cantilever length cause concern relative to the
amount of force on the early implant-bone interface, the dentist may
extended the softer diet and acrylic restoration phase several months. The
dentist gradually intensifies the occlusal contacts during prosthesis
fabrication. No occlusal contacts are permitted during initial healing. The
first transitional prosthesis is left out of occlusion in partially edentulous

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patients. The occlusal contacts then are similar to those of the final
restoration for areas supported by implants. However, no occlusal contact
are made on cantilevers. The occlusal contacts of the final restoration
follow the implant-protective occlusion concepts56.

Progressive loading appointments for a cement-retained prosthesis

:
Step Procedure Diet Occlusal Occlusal contacts
material
1 Healing abutments Soft 0 0
preliminary impression

2 Transitional prosthesis i Soft Acrylic 1*;none

Final impression 2*; no cantilever

3 Transitional prosthesis ii Soft Acrylic 1 and 2*; contacts

only on implant; no
metal try-in; modify
contacts on

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 Discussion

transitional prosthesis i cantilevers/pontics;

occlusal table same
as final prosthesis

4 Final prosthesis Harder Metal or Occlusion follows

porcelain implant-protective
Adjust occlusion
occlusion guidelines;
narrow occlusal table

5 Final prosthesis Normal Metal or Same as above

porcelain
Final cementation

1*, Partially edentulous.

2*, Fully edentulous.

OCCLUSAL REGISTRATION FOR IMPLANTS

It is recommend that the casts for all partially dentate cases should be
mounted on a semi-adjustable articulator. This will require appropriate

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occlusal records and a face-bow transfer for mounting the maxillary cast.
Where there is an insufficient number of occluding teeth to permit
freehand location, then records suitable for mounting the casts in the
intercuspal position (tcp) will be needed. This usually requires a technique
that utilizes some form of occlusal platform to obtain an occlusal record at
the working vertical dimension of occlusion. This can be made so as to fit
the implants either directly or via abutments, in order to maximize the
accuracy of the record. For these reasons the occlusal jig should be made
in a relatively rigid material such as an acrylic resin, rather than wax,
which is not recommended . The 'registration device' is then secured intra-
orally on either the abutments or the implants, ensuring that it is carefully
adjusted to have no deflecting contacts with the opposing teeth. A fluid
interocclusal recording material is then placed between the opposing
teethand the occlusal jig to record the desired jaw relationship. Where this
is coincident with icp, then neither the jig nor a bulk of registration material
should intrude between the opposing natural teeth in this position.

ANALYZING DENTAL OCCLUSION FOR IMPLANTS

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 Discussion

Biomechanical elements associated with occlusion have been an

increasing focus of treatment planning and coordination among clinicians.
For many clinicians over the years, measuring dental occlusion forces has
been an inexact science, requiring pressure-revealing articulation paper,
waxes, and pastes. Dentists in many disciplineshave needed a method for
measuring simultaneous contact, biting time, and biting force.

No sound method is available for evaluating the function of

osseointegrated prosthesis. The patient can be asked about the quality of
function but it is difficult to assess individual judgement ( haraldson,
carlsson 1977).

A k-g diagnostic system was developed to evaluate the functional

mandibular movements such as mastication and swallowing. It is a
computerized movement analyzer which uses magnetic fields. It can be
used to analyze condylar positions and functional movement based on the
muscular conditions in conjunction with em ii electromyography.

The system has the following programs:

Photo 1: Free open and closure movement.

Photo 2: Custom open and closure movement and quick open and closure
movement

Photo 3: Rest position

Photo 4: Rest position after relaxation

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 Discussion

Photo 5: Myocentric and closure trajectory

Photo 6: Swolling movement and swolling position

Photo 7: Quick open and closure movement after relaxation

Photo 8: Masticatory movement

Photo 9- Electromyogram of rest position

Photo 10: Electromyogram of masticatory movement, rest mode.

Photo 1 1 : Electromyogram of intercuspation.

Photo 12: Electromyogram of masticatory movement, functional

mode

Apply the electrodes on the patients face and connect the preamplifier
for them . Attach the magnet of the k-6 to the midline of the mandible with
a special adhesive, then attach the sensor, array. Press the computer key to
recall for testing masticatory movement. The masticatory test is used to
evaluate mastication, in the sagittal plane and mandibular movement
trajectory in the frontal plane. Have the patient chew crackers or raisins to
analyze the limited movement for the frontal trace. When the occlusion is
satisfactory the masticatory strokes return to maximum intercuspation
within a 0.5 mm limit called the chopper type.

When the condylar path and anterior guidance are not well matched
the masticatory strokes are irregular called the grinder type. If the
masticatory stroke is the chopper type, stable contacts in maximum
intercuspation are considered satisfactory (graf, zander, 1963; scharer et

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 Discussion

al; 1967, gibbs et al, 1981) and muscular activity is stable within
physiological limits.

Calculate an electromyogram of intercuspation, when the

computer function key is activated, the patient occludes three times; the
data shows balance between muscle contractions. If the action potentials
for right and left masseter muscles are lower than right and left temporalis
muscle, maximum intercuspation position may be dislocated
posteriorly from normal position. This method can be useful for
obtaining objective data of function with osseointegrated prosthesis

Fig 35 use the k-6 diagnostic system with em-n for functional
evaluation

With current methods, bilateral simultaneous contact can be obtained

only with great difficulty because there is no quantitative method for
comparing the timing of tooth contacts bilaterally. The only available

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 Discussion

method of practically assessing force is through the useof photocclusion

wafers.'''this method, although quantitative, is time-consuming and
requires much training to interpret the biréfringent patterns produced by
the occlusal contacts. A recently developed computerized device (t-
scan,teksean corp) uses both time and force to quantify occlusal
contacts.

The t-scan, a system that quantifies occiusal contact timing and force,
accomplishes the fallowing goals ofImplant proslhodontic occlusion:
1. Bilateral simultaneous contact at the time of insertion
2. Smooth, even working contacts with no interfering
Contacts in rcp or ip
3. Equality of force of the fina! Contacts
4. Records of monitoring occiusal contacts over time
For bilateral simultaneous contact and force distribution

The t-scan is a computer with a color monitor that uses a sensor

technology to quantify the ocelusal contact data. The sensor is made of
two layers of 25-tm-mylar film printed with horizontal and vertical silver
traces lo form a grid pattern . A force ink between the silver traces allows
increased current fiow between the traces when pressure is applied. A
minimal current level is interpreted by the software as a contact. Because
a 70-ma current is cycling through the sensor every 0.01 seconds, the
time of any occlusal contact can be determined within a 0.01-second time
frame.'- the distance between the silver traces is 1.25 mm; therefore the
location of any occlusal contact registered will be within a radius of 0.67
mm. Software displays both the timing and force of the occlusal contacts
in two separate modes6.

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Fig:36

Time mode
The time mode immediately displays all the contacts and highlights the
first three contacts with their relative time values .

Force mode
When the patient closes on the sensor in the force mode, electrical
resistance decreases as occlusal pressure is applied. The resistance
change calibrated to display the lowest force level is approximately 100 g
at any one contactpoint; the upper limit of force discrimination at any one
point is 1.1 kg." the different levels of force are displayed on the three-
dimensional screen as variations in height of the columns, this visual
display provides information for appropriate placement of occlusally
generated forces relative to both the bone-implant interface and
prosthesis6.

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Fig: 37
Occlusal records
The computer also prints records using a thermal printer. Any screen
displayed on the monitor can be printed. This creates a history of the
patient's occlusion on the implant prosthesis for occlusal contact timing,
position, and force.

As early as 1989, tekscan’s original t-scan technology received clinical

tests to determine its accuracy in modeling the dental arch and in
measuring the area and direction of force change over time. A 2002 study
assessed the reproducibility of the t-scan ii system evaluations and results
for completedenture wearers, including 13 dentate subjects and 14
complete denture wearers.this study involved the t-scan ii system. The
study concluded that the t-scan ii provided acceptable reproducibility for
evaluating occlusal contacts of complete denture wearers.
A 2006 study also involved the t-scan ii system and focused on sleep
bruxism, attempting to evaluate the connection between occlusal factors

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and nocturnal parafunctional activities. Two groups (one with nocturnal

parafunctional activity ofmandible and a control group with no signs and
symptoms of bruxism) were both analyzed using the tscan ii system,
revealing statistically significant differences of force distribution between
the left and the right side of the arch for the bruxism group. The
differences of the center of occlusal force were not significant, but the
trajectory was longer in the bruxers. In addition, the significant difference
of center of force position in relation to the center of the elliptic fields was
not found in bruxers, but results revealed uneven distribution of the
occlusal forces, which caused excessive attrition and tooth mobility. The
study found a contributing correlation between occlusal factors and
bruxism.
The latest iteration of this technology is the t-scan iii: dental occlusal
analysis system,accompanied by version 5.0 icondriven software. The
hardware for the system, ahand-held device with a flat, ushaped pressure-
measuring device, which fits into the patient’s mouth between the upper
and lower teeth, produces measurements at a consistent rate of 100hz.
This sampling rate can be used to produce a frame-by-frame (equal to
0.01 seconds)t-scan movie, which produces, in turn, a consistent
datadisplay.
The t-scan iii connects to theusb port of a windows-based pc or laptop.
Noteworthy are the system’s vivid graphics, which enable the clinician to
see the balance or lack of balance in the patient’s bite pattern. The
printable data provide superb information for patient files. The output
displays the percentageforce per tooth and a two-dimensional arch view
that can be divided into quadrants.

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The t-scan iii has many applications in dentistry, including those crucial to
implant placement: fixed, prosthetics, general occlusion, implant
occlusion, implant prosthetics, and occlusal equilibration.
T-scan iii has a number of features that enable accurate measurement of
occlusive forces that are :
“center of force”
Which helps to indicate a balanced bite. T-scan canshow “force movies” to
indicate thebefore and after measurements, for example, of a patient
biting into an intercuspated position. The software uses an icon to indicate
the precise location of the balance of occlusion.
Adjustments can be made until the patient’s “center of force” icon centers
in the arch, showing a balance of occlusal forces.
“excursive force movies”
Which can be used to remove traumatic interferences. These results can
be used to load implants sequentially to preserve balanced occlusal
forces.

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