SHERIDAN ET AL
The Role of Occlusion in Implant Therapy:
A Comprehensive Updated Review
Rachel A. Sheridan, DDS, MS,* Ann M. Decker, DMD,* Alexandra B. Plonka, DDS,*
and Hom-Lay Wang, DDS, MSD, PhD†
lthough occlusion and occlusal
A trauma on natural teeth have
been studied extensively, there
is limited literature regarding implant
occlusion. The biophysiologic differ-
ences between a tooth and an implant
make application of the occlusion
literature for natural teeth to endo-
sseous dental implants nearly
impossible. Additionally, several
challenges exist in studying implant
occlusion, including its feasibility
and the ethics of studying occlusion
in human clinical studies. Thus, the
majority of the available information
regarding implant occlusion relies on
the principles of engineering and
mechanics to understand implant
occlusion. The purpose of this sys-
tematic literature review was to
describe the way occlusal forces
may impact dental implants and their
surrounding bone, to describe occlu-
sal overload on implants and possible
resulting complications, and to pro-
vide clinical recommendations for
implant occlusion.
*Graduate Student in Periodontics, Department of Periodontics
and Oral Medicine, University of Michigan School of Dentistry,
Ann Arbor, MI.
†Professor and Director of Graduate Periodontics, Department
of Periodontics and Oral Medicine, University of Michigan School
of Dentistry, Ann Arbor, MI.
Reprint requests and correspondence to:
Hom-Lay Wang, DDS, MSD, PhD, Department of
Periodontics and Oral Medicine, University of
Michigan School of Dentistry, 1011 North University
Avenue, Ann Arbor, MI 48109-1078, Phone: (734)
763-3325, Fax: (734) 936-0374, E-mail: homlay@
umich.edu
ISSN 1056-6163/16/02506-829
Implant Dentistry
Volume 25  Number 6
Copyright © 2016 Wolters Kluwer Health, Inc. All rights
reserved.
DOI: 10.1097/ID.0000000000000488
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
IMPLANT DENTISTRY / VOLUME 25, NUMBER 6 2016
Purpose: Occlusal overload may
cause implant biomechanical failures,
marginal bone loss, or even complete
loss of osseointegration. Thus, it is
important for clinicians to understand
the role of occlusion in implant long-
term stability. This systematic review
updates the understanding of occlusion
on dental implants, the impact on the
surrounding peri-implant tissues, and
the effects of occlusal overload on
implants. Additionally, recommenda-
tions of occlusal scheme for implant
prostheses and designs were formu-
lated.
Materials and Methods: Two
reviewers completed a literature
search using the PubMed database
and a manual search of relevant
journals. Relevant articles from Jan-
uary 1950 to September 20, 2015
published in the English language
were considered.
Results: Recommendations for
implant occlusion are lacking in
the literature. Despite this, implant
MATERIALS AND METHODS
A literature search was completed
using the PubMed database to create
a systematic literature review that up-
dates the understanding of occlusion on
dental implants, the impact on the
surrounding peri-implant tissues, and
the effects of occlusal overload on
implants. Additionally, information
from the literature was used for the
development of recommendations for
occlusal schemes for various implant
829
occlusion should be carefully ad-
dressed.
Conclusion: Recommendations
for occlusal schemes for single
implants or fixed partial denture
supported by implants include
a mutually protected occlusion with
anterior guidance and evenly dis-
tributed contacts with wide freedom
in centric relation. Suggestions to
reduce occlusal overload include
reducing cantilevers, increasing
the number of implants, increasing
contact points, monitoring for
parafunctional habits, narrowing
the occlusal table, decreasing cus-
pal inclines, and using progressive
loading in patients with poor bone
quality. Protecting the implant
and surrounding peri-implant bone
requires an understanding of how
occlusion plays a role in influenc-
ing long-term implant stability.
(Implant Dent 2016;25:829–838)
Key Words: dental implant, implant
occlusion, occlusal overload
prostheses and designs. Two reviewers
(R.S. and A.D.) searched the PubMed
database manually using the terms “den-
tal” and “occlusion” and several search
terms and pairs of search terms, includ-
ing, but not limited to, the words
“implant occlusion,” “implant biome-
chanics,” “occlusal scheme,” and “occlu-
sal overload.” In addition, a manual
search of the following journals was con-
ducted: The International Journal of Or-
al & Maxillofacial Implants, Clinical
830 ROLE OF OCCLUSION IN IMPLANT
Oral Implants Research, and Implant
Dentistry. Relevant articles from January
1950 to September 20, 2015 were con-
sidered under the condition that they
were published in the English language.
Figure 1 represents the selection process
for articles included in this article.1
Tooth and Implant Responses to
Occlusal Forces
Biophysiologic differences between the
natural tooth and endosseous implant.
An understanding of contrasting bio-
physiology of natural teeth and endo-
sseous dental implants is necessary to
understand how occlusal forces may
impact each differently (Table 1). The
most fundamental difference is their
attachment or connection to the alveo-
lus. Natural teeth are suspended in the
socket and connected to the alveolar
bone by the periodontal ligament
(PDL), whereas an endosseous implant
is directly connected to the bone
Fig. 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow-
chart: this flowchart describes the selection process for articles included in the manuscript.
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
THERAPY
through osseointegration (so-called
functional ankylosis).5 This difference
has several implications regarding biol-
ogy as well as the biomechanics of
occlusion.
The PDL functions as a shock
absorber for the tooth.12 In addition,
mechanoreceptors within the PDL send
information to the central nervous sys-
tem, allowing the detection of occlusal
loads. An implant, which lacks the
PDL, has shown less tactile sensibility
and occlusal awareness.4,13 Hammerle
et al4 showed that the natural teeth had
an 8.75 times higher mean threshold for
tactile sensibility than implants. Thus,
occlusal overload is more likely to be
detected in natural teeth, not implants,
and to elicit a protective reflex to
decrease the load.
Due to the presence of the PDL,
a natural tooth has increased physio-
logic mobility under occlusal forces. A
natural tooth can be displaced 25 to
100 mm in the axial direction and 56 to
SHERIDAN ET AL
150 mm horizontally.8 When occlusal
loads are applied, the stress distribution
diminishes along the root in the apical
direction.8,9 The fulcrum of movement
occurs at the apical third of the root and
the tooth can respond to movement by
rotation of the root.2,9 The dental implant
is connected directly to the bone, elimi-
nating space for physiologic movement.
In contrast to a tooth, an implant can only
be displaced 3 to 5 mm in an axial direc-
tion and 10 to 50 mm horizontally.8,12
Thus, while a tooth may adapt to move-
ment through intrusion or slight rotation,
the dental implant-bone interface may
absorb all of the forces. Although forces
are evenly distributed along the natural
tooth, the forces are concentrated at the
crestal bone level surround the implant.8
This process will be described in a later
section, titled “Complications That May
Be Related To Occlusal Overload.”
Differences between the natural
teeth and implants also affect how occlu-
sal forces impact the surrounding bone.
For example, implants lack a fibrous
attachment, and fibers around the
implant are oriented parallel to the
implant body. Contrarily, the fibers of
the PDL are perpendicular to the root and
are oriented to oppose an axial load.14
This is vital for the health of the tooth
because vertically directed physiologic
occlusal loads to not induce mobility,
as lateral occlusal loads can.15,16 Without
fibers oriented in toward to an axial load,
an implant is more likely to be suscepti-
ble to lateral forces which create bending
moments.6,17
The movement phases between the
natural teeth and implants differ as well,
impacting the response to occlusal
loads of the surrounding bone.8 In a nat-
ural tooth, tooth movement is not linear.
It begins with an initial phase, where the
tooth moves within the boundaries of
the PDL.7,18 Continued force involves
the secondary phase, which involves
elastic deformation of the alveolar
bone. An implant lacks the initial, adap-
tive phase of movement. The implant
moves in a linear and elastic fashion.
Mechanical loading on bone sur-
rounding the tooth versus peri-
implant bone. Wolff’s law introduced
the idea that bones are capable of adapt-
ing to mechanical stress.19 Frost20,21
SHERIDAN ET AL IMPLANT DENTISTRY / VOLUME 25, NUMBER 6 2016 831

Table 1. Tooth and Implant Comparison 6600 microstrain; however, net bone loss
occurred after a threshold of 6700 micro-
Characteristic Tooth Implant strain. A normal level of occlusion, how-
Attachment Periodontal ligament Osseointegration, functional ever, is associated with adaptive, bone
ankylosis, no fibrous remodeling,29 increased bone-to-implant
attachment1 contact,25 and enhanced osseointegra-
Fiber orientation Perpendicular Parallel2 (except laser tion.31 Bone response appears to differ
microetched surface)3 based on the type of loading studied:
Proprioception Mechanoreceptors in the PDL Osseoperception for tactile static loads lead to anabolic reactions,
sensibility whereas cyclic loads show bone resorp-
Axial mobility 25–100 mm axially4 3–5 mm vertically4,5 tion at the crestal portion of implants.22
Horizontal 56–150 mm vertically in 10–50 mm in the buccolingual Similar to biophysiologic differ-
Mobility buccolingual direction4 direction4,5 ences between teeth and implants trans-
Response to Rotates at apical third of the Concentration of greater forces
lating to different responses of their
lateral load root, force diminished at the crest of the
surrounding bone to occlusal loads,
immediately from crest of surrounding bone of
bone along root implants, no rotation of the
their physical properties influence bio-
implant, higher load
mechanical responses. The modulus of
concentrated at the crest elasticity describes stiffness or resis-
Movement Nonlinear, 2 phases Linear, lacks initial phase, tance to elastic deformity and is deter-
phases secondary/elastic phase mined by both stress and strain.32 When
only6,7 stress is plotted against strain, the slope
Initial: vertical within PDL of the curve determines the modulus of
boundaries elasticity. According to engineering
Secondary: elastic deformation principles, when the modulus of elastic-
of alveolar bone6,7 ity between 2 substances differs and one
Fulcrum to lateral Apical third of root8,9 Crestal bone level is loaded, stress is exerted where the
force first 2 materials come into contact.10,11
Load-bearing Shock-absorbing function, No shock absorption, stress The modulus of elasticity of a tooth is
characteristics stress distribution5 concentration at crestal very similar to the cortical bone.11 Thus,
bone4 when a tooth is loaded, it will not create
Modulus of Similar to the cortical bone10 5–10 times of the cortical a large amount of stress at the crest
elasticity bone11 interface. The modulus of elasticity of
This table highlights differences between the characteristics of the natural tooth and of dental implants. a titanium implant, on the other hand, is
5 to 10 times greater than the cortical
further elaborated on this concept; he is balanced by repair and the deposition bone.33 This supports the theory that
showed that the bone adaptation can of new bone. However, continuing to crestal or marginal bone loss may occur
occur in the form of anabolic or cata- increase the level of strain can lead to in the presence of occlusal overload.
bolic responses, depending on the bone resorption and, eventually, to bone
amount of mechanical force applied. fracture. Occlusal Overload
Frost’s Mechanostat model uses Frost created his Mechanostat Generally, both natural teeth and
the concepts of stress and strain. In this model based on the tibia, a long bone. dental implants should be in physio-
model of bone, stress is the mechanical Properties of the alveolar bone differ logic occlusion, which is described as
force on the bone over a given area and from this bone. Thus, the exact micro- “occlusion in harmony with the func-
creates strain.22 Strain describes the strain levels of the Mechanostat theory tions of the masticatory system.”34 If
deformation of the bone, specifically, do not apply to the alveolar bone; the occlusal scheme is not harmonious
its change in length over its original however, the concept may be applica- on natural teeth, occlusal trauma may
length. Although the amount of stress ble. This would suggest that some level occur. This may result in an adaptive
invariably impacts the amount of strain, of occlusal loading is required to avoid response, such as thickened lamina
the degree to which deformation occurs disuse atrophy, that a range of occlusal dura or occlusal wear, or a traumatic
is determined by inherent properties of load leads to healthy remodeling and response, including mobility or a wid-
the bone.17 Frost22 describes strain in that a threshold exists in which heavy ened PDL.35 In the context of implant
units of microstrain; 1000 microstrain occlusal forces can trigger bone occlusion, the appropriate term is occlu-
is equivalent to 0.1% bone deformation. resorption. sal overload. Occlusal overloading is
According to Frost,20,21 low Some evidence supports the appli- the application of force to an implant,
amounts of strain lead to catabolic bone cation of Frost’s model to peri-implant through either normal function or par-
reactions or disuse atrophy. However, bone.22–29 Melsen and Lang30 showed afunctional habits, which leads to struc-
some strain is required for bone remod- that bone apposition occurred around im- tural or biological damage.36 Occlusal
eling. In this “steady state,” bone damage plants in monkeys at levels of 3400 to overloading relates to damage to the

Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
832 ROLE OF OCCLUSION IN IMPLANT
prosthesis, abutment, implant structure,
or the surrounding alveolar bone.
Although consensus exists on the
general definition of occlusal overload,
modifications of how the term “occlusal
overload” is used in the literature vary
widely. Some have stated that using the
term overload for a dental implant is
appropriate only when an implant is fail-
ing or has failed.37 Applying Frost’s Me-
chanostat model, occlusal overload
would refer to the level of microstrain
that corresponds with a catabolic bone
response. Melsen and Lang30 quantified
this level of microstrain using dental im-
plants in a dog model. Beyond 6700 mi-
crostrain, bone resorption occurred.30
Research Challenges
The study of occlusal overload and
interpretation of literature on the subject
is difficult for several reasons. Occlusal
forces, like all forces, can be described in
the following 4 subjects: magnitude,
duration, distribution, and direction.17
Studies such as Frost’s take into account
only 1 variable, magnitude.38 Addition-
ally, while the occlusal load can be mea-
sured at the prosthesis or abutment level,
mechanical measurements cannot be ob-
tained from the bone-implant interface.38
Additional considerations such as con-
founders and risk of bias complicate the
study of occlusal overload. Lastly, for
obvious ethical reasons, clinical trials
applying occlusal overload are unethical
in humans. For this reason, occlusal
overload on implants remains controver-
sial.38–42 Despite this, occlusal overload
has suspected associations with many
implant complications, both biological
and biomechanical. In fact, occlusal
overload and peri-implantitis have been
described as the 2 most common reasons
for late (post-osseointegration) implant
failure.42–45
Complications That May Be Related to
Occlusal Overload
Occlusal overload has been sus-
pected to be one of the contributing
factors for marginal bone loss. Theo-
retically, this is possible. As previously
mentioned, the stress distribution of an
implant occurs at the crestal bone
level.12 The difference in the modulus
elasticity of bone compared with that of
the titanium implant implies that forces
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
THERAPY
are directed at the first area of contact, at
the crestal bone.11 Microfractures in this
area could in turn produce marginal
bone loss. Varied results in the available
literature have been described, ranging
from a possible association, a possible
relationship dependent on other factors,
to no probable association.23,24,43
Kozlovsky et al46 found that
dynamic occlusal overload created mar-
ginal bone loss, however, the extent was
determined by the presence of inflam-
mation. Without inflammation, the
bone resorption did not occur below
the implant neck. The presence of
plaque-induced inflammation led to
significantly greater bone loss, to the
level of the implant threads. Some the-
orize that, if occlusal overload is indeed
associated with marginal bone loss, the
micromovements could lead to the
development of peri-implantitis.47
Similar controversy surrounds
a possible association between occlusal
overload and the loss of osseointegra-
tion.29,48–50 The mixed results can be
attributed to the complicated nature of
studying occlusal overload, discussed
previously. Differences in study design
also challenge interpretation.
Occlusal overload has been re-
garded as a major cause of biomechan-
ical complications,31 including screw
loosening, prosthesis failure, and the
fracture of screws, veneering material,
or the implant.41,51–55 This is significant
because these complications can be
costly, time consuming, and some com-
plications, such as implant fixture frac-
ture, can lead to implant failure.31
Factors That May Cause
Occlusal Overload
Recognizing factors that may
cause occlusal overload is useful to
prevent occlusal overload and sus-
pected, related complications. Such
factors include: large cantilevers, par-
afunctional habits/bruxism, steep cusp
inclines, poor distribution of force (eg,
limited contacts), interferences, and
poor-quality bone.18,43
Recommendations for Physiological
Implant Occlusion
Implant occlusion should aim to
create a physiological, harmonious
occlusion, to avoid occlusal overload,
SHERIDAN ET AL
and to prevent unnecessary implant
complications. As previously men-
tioned, occlusal forces, like all forces,
can be described in 4 ways: magni-
tude, duration, distribution, and
direction.17 Many of the goals of
implant occlusion are based on these
4 factors.
In considering the direction of the
occlusal forces, it is recommended to
reduce shear (unaligned) forces and to
aim for compressive (aligned) forces.
In doing so, occlusion should create
axial forces, rather than lateral or
horizontal forces. Bone is stronger
under compressive forces than shear
forces.11,56 Nonaxial loading causes
higher stress and tension around the
crestal bone.22,57–59 In fact, Rangert
et al60 found that a deviation of 15 de-
grees in a buccolingual direction con-
tributed to occlusal overloading. Thus,
aiming forces in an axial direction and
reducing shear forces will protect the
supporting, peri-implant bone.
If a buccolingual deviation of 15
degrees can contribute to occlusal over-
load, it is interesting to consider if the
deviation of the implant that may be
presented in All-on-Four cases may
lead to occlusal overload. The All-on-
Four concept allows for 20 to 30
degrees of deviation in the mandible
or up to 45 degrees of deviation on the
maxilla.61,62 This does not specifically
refer to the buccolingual direction and
could relate to mesiodistal deviation.
This may also be important to factor
into a treatment-planning decision,
considering that Browaeys et al63 found
marginal bone in 49.2% of patients
with All-on-Four implants with a 20-
to 30-degree deviation. Ramiglia
et al64 also found an association
between implant inclination and bone
loss: buccal bone loss was associated
with lingual and distal inclination on
the mandible. The authors also found
the ideal angle of insertion to be 79.1
degrees, suggesting that approximately
20 degrees of deviation is acceptable.
Although other studies comparing
tilted implants to upright implants have
not reported significant differences in
marginal bone loss, these studies did
not consider buccal bone loss and did
not use 3-dimensional radiographic
analysis.65,66
SHERIDAN ET AL
Recommended Implant Occlusal
Scheme for Single Implants and Fixed
Partial Dentures Supported by Implants
A modified version of the mutually
protected occlusal scheme leads to
a harmonious implant occlusion
(Table 2). The force distribution should
be equal bilaterally and maximized on
adjacent teeth.31,67–69 Light to medium
occlusal contact in maximum intercus-
pation is recommended for the adjacent,
natural teeth, with lighter contact or
clearance between the occlusal face
and opposing tooth.68,70 This is because
the implant does not have a PDL sup-
port and does not have the vertical,
physiologic mobility within the socket
that a natural tooth has.
Anterior guidance is recommen-
ded in lateral and protrusive excur-
sions. In lateral excursions, posterior
teeth should avoid heavy forces in the
lateral direction by discluding.18,71,72
Avoiding working and nonworking
contacts on implant restorations is vital
to reduce shear forces in a nonaxial
direction.69,73 Premature contacts pre-
dispose implants to occlusal over-
load.18 Wide freedom (1–1.5 mm) for
maximum intercuspation and centric
relation are recommended to prevent
premature contacts.74,75
Table 2. Recommended Occlusal
Scheme for Single Implants and Fixed
Partial Dentures Supported by Implants
Implant Occlusion: Recommended
Occlusal Scheme
Mutually protected occlusion
Anterior guidance
Canine guidance in lateral excursion
with posterior disclusion
Anterior guidance in protrusion
Evenly distributed contacts
Light to medium contact on natural
teeth in maximum intercuspation
(MIP)
Lighter contact or clearance on
implant restoration in (MIP)
No working or nonworking contacts on
implant restoration
Crossbite for palatally positioned
implants
Wide freedom in centric relation and
MIP
Based on available literature, the recommended occlusal
scheme for single implants and fixed partial dentures supported
by dental implants are summarized. These recommendations
specifically pertain to occlusal scheme.
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
IMPLANT DENTISTRY / VOLUME 25, NUMBER 6 2016
There are clinical scenarios that
require modified occlusion for excur-
sive movements. If the canine has been
replaced with an implant restoration, it
should not be subjected to heavy lateral,
shear forces.31 Recall that bone is weak-
er under shear forces than compressive
forces and that shear forces lead to high-
er stress and tension around the crestal
bone.11,22,56–59 Thus, occlusal forces
should be aimed to be compressive,
aligned, and axially directed.
Similarly, periodontally compro-
mised anteriors or an anterior bridge in
a Kennedy class IV patient should not
be subjected to heavy anterior protru-
sion.70,76–78 In this situation, group
function should be used. If an implant
was placed in a palatal position (due to
limited buccal bone), the implant is
likely to undergo shear forces with
occlusion. Here, Misch et al79 advise
placing the teeth in crossbite to avoid
nonaxial loading.
Prosthesis Design
An understanding of how prosthesis
design impacts the dental implant and
surrounding bone is imperative for
a physiologic and harmonious implant
occlusion. Large cantilevers function as
a lever arm, placing stress on the adja-
cent abutment. Large cantilevers have
been associated with the production of
shear forces,18 bone loss, and prosthetic
failure.48,80 Shackleton et al81 found that
prosthesis failure was more common in
cantilevers .15 mm in length. A sys-
tematic review and meta-analysis by
Torrecillas-Martinex et al82 found
that minor complications, such as abut-
ment screw loosening, were more com-
mon with cantilevered restorations than
with noncantilevered restorations. Sev-
eral authors speculate that prosthetic
complications of cantilevered restora-
tions are associated with nonaxial
forces.60,83
A prosthetically driven implant
placement will reduce shear forces
and a cantilever effect on each implant.
The use of a surgical guide is recom-
mended for implant placement, when-
ever possible. Additional ways to
eliminate shear forces include increas-
ing the number of implants, maintain-
ing an adequate crown height space
(15 mm or more could create more
833
microstrain),84 reducing the crown-to-
implant ratio, minimizing vertical over-
lap,71 and obtaining a passive pros-
thetic fit.31
The anatomy of the implant crown
can largely impact the direction, mag-
nitude, and distribution of force that
may be imposed on the tooth. Factors
include the inclination of cusps, the size
of the occlusal table, and the number of
contact points with the opposing tooth.
Finite element analysis has shown that
high cuspal inclination increases the
magnitude of forces on the tooth85 and
that an increase of 10 degrees of cuspal
inclination increases the bending
moment by 30%.86 Opting for a reduced
cuspal inclination protects the tooth
from shear forces while decreasing
force magnitude.40,70,87–89 A narrow
occlusal table ensures that forces will
be directed axially,80,90 prevents canti-
lever effects and bending moments,67,90
and reduces the magnitude of forces.91
In 1 study, narrowing the occlusal table
by 30% reduced the magnitude of lat-
eral forces by almost 50%.91 The most
vital anatomical consideration for con-
trolling the distribution of forces is the
number of contact points on the implant
crown. Posterior teeth do not have the
same level of proprioceptive inhibition
that anterior teeth have and thus can be
subjected to unprotected force gener-
ated by the masticatory muscles.4,17,41
For this reason, increasing the distribu-
tion of force by including multiple con-
tact points on multiple teeth is vital to
protect the posterior occlusion. Studies
have shown that there is increased stress
on the bone when a dental implant has 1
contact point versus multiple contact
points.92 Additionally, contact points
should be centered on the crown to
avoid cantilevers and bending
moments.54
Patient Considerations
Individual patient considerations
influence implant occlusion. For exam-
ple, parafunctional habits or bruxism
impact implant planning, restoration,
and maintenance. Bruxism is associated
with occlusal overload,93 marginal bone
loss,48,80 mechanical problems,48,60,94
and implant technical and biological fail-
ure.48,95–99 In a Zhou et al99 meta-
analysis, the odds ratio of implant failure
834 ROLE OF OCCLUSION IN IMPLANT
for bruxers versus nonbruxers was 3.83.
The prosthetic design is the key in
bruxers, from correct implant placement
to anatomical considerations so shear
forces can be reduced. Additionally,
because bruxers experience more com-
plications and failures, frequent follow-
up is advised. If parafunctional habits
include nocturnal bruxing, an occlusal
nightguard should be fabricated.
The patient’s bone quality influen-
ces implant occlusion decisions. Le-
kholm and Zarb100 categorized bone
into 4 types, depending on the amount
of cortical and trabecular bone present.
Type 1 bone is the densest, made
entirely of the cortical bone. Type 4
bone describes bone that is mostly tra-
becular, surrounded only by a thin cor-
tical layer. This has an impact on
implant occlusion because the differing
modulus of elasticity between dense,
cortical bone and low density, trabecu-
lar bone.17 When substances have dif-
fering modulus of elasticity and one is
loaded, stress will be placed where the
substances meet. There is a larger dif-
ference in elasticity between titanium
and trabecular bone than between tita-
nium and cortical bone. Placing an
implant in low bone density leads to
higher levels of pure titanium implant
failure.22 Jaffin and Berman101 found
that 35% of pure titanium implants
placed into type IV bone had failed after
5 years but only 3% of implants placed
into types I to III bone had failed.
Goodacre et al51 analyzed 7 studies that
compared implants placed into different
bone types, including the Jaffin and
Berman101 study. The results of these
7 studies showed implant loss in 16%
of implants placed into type IV bone,
compared with only 4% lost when
placed in types I to III.51 One possible
solution is to use progressive loading of
the implant or roughened the implant
surface. This allows extended healing
time and may increase bone density
and reduce crestal bone loss.102,103 A
roughened implant surface could
shorten the time need for the osseointe-
gration therefore minimize the chance
of premature loading. Turkyilmaz
et al104 found that computed tomogra-
phy (CT) imaging could be used to
determine the bone type before implant
surgery. Thus, obtaining a CT image
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
THERAPY SHERIDAN ET AL
may help determine whether or not implants.119–121 Thus, the authors do not
bone quality will help avoid, or pro- feel there is enough evidence to recom-
mote, occlusal overload and possible mending splinting to reduce the risk
implant failure. occlusal overload.
The aforementioned recommenda-
Implant Design tions can aid in creating an implant
Implant design may have an impact occlusion that protects the implant,
on how the surrounding bone reacts to implant restoration, and natural denti-
occlusal forces. Screw-type implants tion (Table 3). In some situations,
have been shown to have higher bone implant occlusion may be compro-
to implant contact, thus, support, when mised, for various reasons. However,
compared cylindrical implants.105 A monitoring occlusion is the clinician’s
tapered implant design aids in reducing responsibility. Occlusal changes can be
shear forces more than a parallel expected and the possible consequen-
implant design.106–108 Regarding diam- ces of occlusal overload make periodic
eter, wider implants resist stress more evaluations imperative.41,67,79,88,122 Nat-
than those with narrow diameter;109– ural teeth tend to wear more than restor-
111
however, length is not as great a con- ative materials, such as the implant
sideration.111 A smooth collar is not rec- crown.18 Thus, to avoid high occlusion
ommended because it may increase on an implant restoration, occlusal ad-
shear forces; microthreads generate less justments may be necessary. Maintain-
shear force.112 Bone to implant contact ing good force distribution and
is also increased by using square direction will help maintain the longev-
threads, an increased thread depth, ity of the implant.68
increased thread pitch, and with coated
implants (as compared with machined
implants.).31,113–116 Although some the- CONCLUSIONS
orize that splinting implants could dis- Due to the challenges of studying
tribute the amount of stress and strain implant occlusion, particularly occlusal
placed on implants,117,118 studies have overload, minimal data is available.
not shown splinting to decrease sur- Although literature exists regarding
vival or bone loss in traditional or short the natural tooth and occlusion, the
Table 3. Implant Occlusion Recommendations for Single Implants and Fixed Partial
Dentures Supported by Implants: Based on Available Literature, Recommendations
for Single Implants and Fixed Partial Dentures Supported by Dental Implants Are
Summarized
Implant Occlusion Recommendations
Select a mutually protected occlusal scheme with anterior guidance in excursions
Reduce cantilever prosthesis and cantilever forces on implant crowns
Create an even force distribution
Increase the number of implants
Increase the number of contact points
Less contact on implant than adjacent natural teeth
Reduce shear, lateral forces on the tooth
Monitor parafunctional habits or bruxism
Maintain adequate crown height space
Reduce the crown to implant ratio
Minimize vertical overlap
Obtain passive fit of prosthesis
Narrow the size of the occlusal table
Decrease cuspal inclines
Center the contact points on the implant crown
Use progressive loading in patients with poor bone quality (type IV)
Consider implant designs that increase bone to implant contact
Monitor patient occlusion and provide serial adjustments
These recommendations pertain to occlusal scheme, implant design, and prosthesis design and provide a comprehensive summary
of guidelines to avoid occlusal overload.
SHERIDAN ET AL
differences between the natural tooth
and the dental implant alter the way that
occlusal forces impact the bone sur-
rounding them. The PDL of the tooth
provides protection against occlusal
force, whereas a dental implant lacks
the proprioception and support of the
PDL. At this time, the application of
engineering and mechanical theory is
crucial in understanding how implant
design, implant placement, and prosthe-
sis design impact implant occlusion.
Considering the 4 characteristics of
occlusal force (direction, magnitude,
duration, and distribution) are important
for placing and restoring an implant that
will be harmonious with the adjacent
natural dentition. This requires coordi-
nation from the clinician placing the
implant and the clinician restoring the
implant. If implant occlusion is not
harmonious, it is possible that the
implant can experience occlusal over-
load. Currently, this topic is highly
debated, from the definition of the term
to the possible complications that may
result. At this time, several observations
noted that occlusal overload may cause
complications ranging from biomechan-
ical failures to marginal bone loss or
complete loss of osseointegration. Thus,
it is vital for the clinician to keep implant
occlusion in mind when placing or
restoring an implant to protect the
implant and surrounding peri-implant
bone.
DISCLOSURE
The authors claim to have no
financial interest, either directly or
indirectly, in the products or informa-
tion listed in the paper.
ACKNOWLEDGMENTS
The authors acknowledge and thank
Dr William Carroll for his contributions
to this article.
REFERENCES
1. Moher D, Liberato A, Tetzlaff J, et al.
Preferred reporting items for systematic re-
views and meta-analyses: The PRISMA
statement. J Clin Epidemiol. 2009;62:
1006–1012.
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
IMPLANT DENTISTRY / VOLUME 25, NUMBER 6 2016
2. Parfitt GJ. Measurement of the
physiological mobility of individual teeth in
an axial. J Dent Res. 1960;39:608–618.
3. Nevins M, Gobbato L, Lee HJ, et al.
Maintaining interimplant crestal bone
height via a combined platform-switched,
laser-lok implant/abutment system: A
proof-of-principle canine study. Int J Peri-
odontics Restorative Dent. 2012;33:261–
267.
4. Hämmerle CHF, Wagner D, Brägger
U, et al. Threshold of tactile sensitivity per-
ceived with dental endosseous implants
and natural teeth. Clin Oral Implants Res.
1995;6:83–90.
5. Buser D, Ruskin J, Higginbottom F,
et al. Osseointegration of titanium implants
in bone regenerated in membrane-
protected defects: A histologic study in
the canine mandible. Int J Oral Maxillofac
Implants. 1995;10:666–681.
6. Rangert BO, Jemt T, Jörneus L.
Forces and moments on Brånemark im-
plants. Int J Oral Maxillofac Implants.
1988;4:241–247.
7. Kurashima K. Viscoelastic proper-
ties of periodontal tissue. Bull Tokyo Med
Dent Univ. 1965;12:240.
8. Sekine H, Komiyama Y, Hotta H,
et al. Mobility characteristics and tactile
sensitivity of osseointegrated fixture-
supporting systems. In: van Steenberghe
D, ed. Tissue Integration in Oral Maxillofa-
cial Reconstruction. Amsterdam, the Neth-
erlands: Excerpta Medica; 1996:326–332.
9. Hillam DG. Stresses in the periodon-
tal ligament. J Periodontal Res. 1973;8:
51–56.
10. Baumeister T, Avallone EA. Marks
Standard Handbook of Mechanical Engi-
neers. New York: McGraw-Hill; 1978;
378–382.
11. Misch CE, Suzuki JB, Misch-
Dietsh FM, et al. A positive correlation
between occlusal trauma and peri-
implant bone loss: Literature support.
Implant Dent. 2005;14:108–116.
12. Schulte W. Implants and the perio-
dontium. Int Dent J. 1995;45:16–26.
13. Jacobs R, van Steenberghe D.
Comparison between implant-supported
prostheses and teeth regarding passive
threshold level. Int J Oral Maxillofac Im-
plants. 1993;8:549–554.
14. Lindh J, Karring T. Anatomy of pe-
riodontium. In: Lindhe J, Karring T, Lang
NP, eds. Clinical Periodontology and
Implant Dentistry. Copenhagen, Denmark:
Munksgaaard; 1998:45–49.
15. Breitner C. Alteration of occlusal
relations induced by experimental proce-
dure. Am J Orthod Oral Surg. 1943;29:
277–289.
16. Beyron HL. Characteristics of func-
tionally optimal occlusion and principles of
835
occlusal rehabilitation. J Am Dent Assoc.
1954;48:648–656.
17. Michalakis KX, Calvani P, Hirayama
H. Biomechanical considerations on
tooth-implant supported fixed partial
dentures. J Dent Biomech. 2012;3:
1758736012462025.
18. Kim Y, Oh TJ, Misch CE, et al.
Occlusal considerations in implant therapy:
Clinical guidelines with biomechanical
rationale. Clin Oral Implants Res. 2005;
16:26–35.
19. Wolff JD. Das Gesetz der Transfor-
mation der Knochen. Berlin, Germany:
Verlag von August Hirschwald; 1892.
20. Frost HM. Perspectives: bone’s
mechanical usage windows. Bone Miner.
1992;19:257–271.
21. Frost HMA 2003 update of bone
physiology and Wolff’s Law for clinicians.
Angle Orthod. 2004;74:3–15.
22. Isidor F. Influence of forces on peri-
implant bone. Clin Oral Implants Res.
2006;17(suppl 2):8–18.
23. Chang M, Chronopoulos V,
Mattheos N. Impact of excessive occlusal
load on successfully-osseointegrated dental
implants: A literature review. J Investig Clin
Dent. 2013;4:142–150.
24. Chambrone L, Chambrone LA, Lima
LA. Effects of occlusal overload on peri-
implant tissue health: A systematic review
of animal-model studies. J Periodontol.
2010;81:1367–1378.
25. Berglundh T, Abrahamsson I,
Lindhe J. Bone reactions to longstanding
functional load at implants: An experimen-
tal study in dogs. J Clin Periodontol. 2005;
32:925–932.
26. Piattelli A, Corigliano M, Scarano A,
et al. Immediate loading of titanium
plasma-sprayed implants: An histologic
analysis in monkeys. J Periodontol. 1998;
69:321–327.
27. Piattelli A, Corigliano M, Scarano A,
et al. Bone reactions to early occlusal load-
ing of two-stage titanium plasma-sprayed
implants: A pilot study in monkeys. Int J
Periodontics Restorative Dent. 1997;17:
162–169.
28. Piattelli A, Ruggeri A, Franchi M,
et al. A histologic and histomorphometric
study of bone reactions to unloaded and
loaded non- submerged single implants in
monkeys: A pilot study. J Oral Implantol.
1993;19:314–320.
29. Heitz-Mayfield LJ, Schmid B,
Weigel C, et al. Does excessive occlusal
load affect osseointegration? An experi-
mental study in the dog. Clin Oral Implants
Res. 2004;15:259–268.
30. Melsen B, Lang NP. Biological re-
actions of alveolar bone to orthodontic
loading of oral implants. Clin Oral Implants
Res. 2001;12:144–152.
836 ROLE OF OCCLUSION IN IMPLANT
31. Fu JH, Hsu YT, Wang HL. Identify-
ing occlusal overload and how to deal with
it to avoid marginal bone loss around im-
plants. Eur J Oral Implantol. 2012;(5
suppl):S91–S103.
32. Bidez MW, Misch CE. Issues in
bone mechanics related to oral implants.
Implant Dent. 1992;1:289–294.
33. Lemons JE, Phillips RW. Biomate-
rials for dental implants. In: Misch CE, ed.
Contemporary Implant Dentistry. St Louis,
MO: Mosby; 1993:262.
34. American Academy of Periodontol-
ogy. Glossary of Periodontal Terms. Chi-
cago, IL: American Academy of
Periodontology; 2001:35.
35. Jin LJ, Cao CF. Clinical diagnosis
of trauma from occlusion and its relation
with severity of periodontitis. J Clin Peri-
odontal. 1992;19:92–97.
36. Hjørting-Hansen E, Laney WR,
Broggini N, et al. Glossary of Oral and
Maxillofacial Implants. Berlin, Germany:
Quintessence Publishing Ltd.; 2007.
37. el Askary AS, Meffert RM, Griffin T.
Why do dental implants fail? Part I. Implant
Dent. 1999;8:173–185.
38. Duyck J, Vandamme K. The effect
of loading on peri-implant bone: A critical
review of the literature. J Oral Rehabil.
2014;41:783–794.
39. Hublin C, Kaprio J, Partinen M,
et al. Parasomnias: Co-occurrence and
genetics. Psychiatr Genet. 2001;11:65–70.
40. Millwood J, Fiske J. Lip-biting in
patients with profound neuro-disability.
Dent Update. 2001;28:105–108.
41. Lobbezoo F, van der Zaag J,
Naeije M. Bruxism: Its multiple causes
and its effects on dental implants–an up-
dated review. J Oral Rehabil. 2006;33:
293–300.
42. Lobbezoo F, Brouwers JEIG, Cune
MS, et al. Dental implants in patients with
bruxing habits. J Oral Rehabil. 2006;33:
152–159.
43. Naert I, Duyck J, Vandamme K.
Occlusal overload and bone/implant loss.
Clin Oral Implants Res. 2012;23(suppl 6):
95–107.
44. Esposito M, Hirsch JM, Lekholm
U, et al. Biological factors contributing to
failures of osseointegrated oral implants.
(I). Success criteria and epidemiology.
Eur J Oral Sci. 1998;106:527–551.
45. Esposito M, Hirsch JM, Lekholm
U, et al. Biological factors contributing to
failures of osseointegrated oral implants.
(II). Etiopathogenesis. Eur J Oral Sci.
1998;106:721–764.
46. Kozlovsky A, Tal H, Laufer BZ,
et al. Impact of implant overloading on
the peri-implant bone in inflamed and
non-inflamed peri-implant mucosa. Clin
Oral Implants Res. 2007;18:601–610.
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
THERAPY
47. Wennerberg A, Albrektsson T.
Current challenges in successful rehabilita-
tion with oral implants. J Oral Rehabil.
2011;38:286–294.
48. Quirynen M, Naert I, Van
Steenberghe D. Fixture design and over-
load influence marginal bone loss and
future success in the Brånemark system.
Clin Oral Implants Res. 1992;3:104–111.
49. Fugazzotto PA. A comparison of
the success of root resected molars and
molar position implants in function in
a private practice: Results of up to
15-plus years. J Periodontol. 2001;72:
1113–1123.
50. Miyata T, Kobayashi Y, Araki H,
et al. The influence of controlled occlusal
overload on peri-implant tissue: A histo-
logic study in monkeys. Int J Oral Maxillo-
fac Implants. 1998;13:677–683.
51. Goodacre CJ, Bernal G,
Rungcharassaeng K, et al. Clinical compli-
cations with implants and implant prosthe-
ses. J Prosthet Dent. 2003;90:121–132.
52. Zarb GA, Schmitt A. The longitudi-
nal clinical effectiveness of osseointe-
grated dental implants: The Toronto
study. Part III: problems and complications
encountered. J Prosthet Dent. 1990;64:
185–194.
53. Jemt T, Leckholm U. Oral implant
treatment in posterior partially edentulous
jaws: A 5- year follow-up report. Int J Oral
Maxillofac Implants. 1993;8:635–640.
54. Wennerberg A, Jemt T. Complica-
tions in partially edentulous implant pa-
tients: a 5-Year retrospective follow-up
study of 133 patients supplied with unilat-
eral maxillary prostheses. Clin Implant Dent
Relat Res. 1999;1:49–56.
55. Schwarz MS. Mechanical compli-
cations of dental implants. Clin Oral Im-
plants Res. 2000;11(suppl 1):156–158.
56. Hoshaw SJ. Mechanical loading of
Brånemark implants affects interfacial
bone modeling and remodeling. Int J Oral
Maxillofac Implants. 1994;9:345–360.
57. Papavasiliou G, Kamposiora P,
Bayne SC, et al. Three-dimensional finite
element analysis of stress-distribution
around single tooth implants as a function
of bony support, prosthesis type, and
loading during function. J Prosthet Dent.
1996;76:633–640.
58. Kitamura E, Stegaroiu R, Nomura
S, et al. Influence of marginal bone resorp-
tion on stress around an implantdA three-
dimensional finite element analysis. J Oral
Rehabil. 2005;32:279–286.
59. See SJ, Tan EK. Severe
amphetamine-induced bruxism: Treatment
with botulinum toxin. Acta Neurol Scand.
2003;107:161–163.
60. Rangert B, Krogh PH, Langer B,
et al. Bending overload and implant frac-
ture: A retrospective clinical analysis. Int
SHERIDAN ET AL
J Oral Maxillofac Implants. 1995;10:
326–334.
61. Maló P, Rangert B, Nobre M. “All-
on-Four” immediate-function concept with
Brånemark SystemÒ implants for com-
pletely edentulous mandibles: a retrospec-
tive clinical study. Clin Implant Dent Relat
Res. 2003;5:2–9.
62. Maló P, de Araújo Nobre M, Lopes
A, et al. “All-on-4” immediate-function con-
cept for completely edentulous maxillae:
a clinical report on the medium (3 years)
and long-term (5 years) outcomes. Clin
Implant Dent Relat Res. 2012;14(suppl
1):e139–e150.
63. Browaeys H, Dierens M,
Ruyffelaert C, et al. Ongoing crestal bone
loss around implants subjected to
computer-guided flapless surgery and
immediate loading using the all-on-4 con-
cept. Clin Implant Dent Relat Res. 2015;
17:831–843.
64. Ramaglia L, Toti P, Sbordone C,
et al. Implant angulation: 2-year retrospec-
tive analysis on the influence of dental
implant angle insertion on marginal bone
resorption in maxillary and mandibular
osseous onlay grafts. Clin Oral Investig.
2015;19:769–779.
65. Ata-Ali J, Peñarrocha-Oltra D,
Candel-Marti E, et al. Oral rehabilitation
with tilted dental implants: A metaanaly-
sis. Med Oral Patol Oral Cir Bucal. 2012;
17:e582.
66. Menini M, Signori A, Tealdo T, et al.
Tilted implants in the immediate loading
rehabilitation of the maxilla a systematic
review. J Dent Res. 2012;91:821–827.
67. Misch CE. Occlusal considerations
for implant supported prostheses. Con-
temp Implant Dentistry. 1993:705–733.
68. Lundgren D, Laurell L. Biomechan-
ical aspects of fixed bridgework supported
by natural teeth and endosseous implants.
Periodontol 2000. 1994;4:23–40.
69. Engelman MJ, Craig JA. Clinical
decision making and treatment planning
in osseointegration. Implant Dent. 1997;
6:68.
70. Rilo B, Silva JL, Mora MJ, et al.
Guidelines for occlusion strategy in
implant-borne prostheses. A review. Int
Dent J. 2008;58:139–145.
71. Gross MD. Occlusion in implant
dentistry. A review of the literature of pros-
thetic determinants and current concepts.
Aus Dent J. 2008;53(suppl 1):S60–S68.
72. D’Amico A. The canine teeth.
J South Calif Dent Assoc. 1958;26:4–7.
73. O’Mahony A, Bowles Q, Woolsey
G, et al. Stress distribution in the single-
unit osseointegrated dental implant: Finite
element analyses of axial and off-axial
loading. Implant Dent. 2000;9:207–218.
74. Beyron HL. Optimal occlusion.
Dent Clin North Am. 1969;13:537–554.
SHERIDAN ET AL
75. Weinberg LA. Reduction of implant
loading with therapeutic biomechanics.
Implant Dent. 1998;7:277–285.
76. Chapman RJ. Principles of occlu-
sion for implant prostheses: Guidelines
for position, timing, and force of occlusal
contacts. Quintessence Int. 1989;20:
473–480.
77. Hobo S, Ichida E, Garcia LT. Os-
seointegration and Occlusal Rehabilitation.
Berlin, Germany: Quintessence Pub Co.;
1989:260.
78. Misch C, Bidez MW. Implant-pro-
tected occlusion: A biomechanical ratio-
nale. Compendium. 1994;15:1330–1332.
79. Misch CE. Occlusal considerations
for implant supported prostheses. In: Misch
CE, ed. Contemporary Implant Dentistry.
St. Louis, MO: Mosby; 1999:609–628.
80. Lindquist LW, Rockerl B, Carlsson
GE. Bone resorption around fixtures in
edentulous patients treated with mandibu-
lar fixed tissue-integrated prostheses.
J Prosthet Dent. 1988;59:59–63.
81. Shackleton JL, Carr L, Slabbert
JCG, et al. Survival of fixed implant-
supported prostheses related to cantilever
lengths. J Prosthet Dent. 1994;71:23–26.
82. Torrecillas-Martinez L, Monje A, Lin
GH, et al. Effect of cantilever for implant-
supported prostheses upon marginal bone
loss and prosthetic complications: Sys-
tematic review and meta-analysis. Int J
Oral Maxillofac Implants. 2014;29:1315–
1321.
83. Sertgoz A, Guvener S. Finite ele-
ment analysis of the effect of cantilever
and implant length on stress distribution
in an implant-supported fixed prosthesis.
J Prosthet Dent. 1996;76:165–169.
84. Nissan J, Ghelfan O, Gross O,
et al. The effect of crown/implant ratio
and crown height space on stress distribu-
tion in unsplinted implant supporting resto-
rations. J Oral Maxillofac Surg. 2011;69:
1934–1939.
85. Rungsiyakull C, Rungsiyakull P, Li Q,
et al. Effects of occlusal inclination and load-
ing on mandibular bone remodeling: A finite
element study. Int J Oral Maxillofac Implants.
2011;26:527–537.
86. Weinberg LA. Therapeutic biome-
chanics concepts and clinical procedures
to reduce implant loading. Part I. J Oral
Implantol. 2001;27:293–301.
87. Pidcock FS, Wise JM, Christensen
JR. Treatment of severe post-traumatic
bruxism with botulinum toxin-a: Case
report. J Oral Maxillofac Surg. 2002;60:
115–117.
88. Tan EK, Chan LL, Chang HM.
Severe bruxism following basal ganglia in-
farcts: Insights into pathophysiology.
J Neurol Sci. 2004;217:229–232.
89. Curtis DA, Sharma A, Finzen FC,
et al. Occlusal considerations for implant
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
IMPLANT DENTISTRY / VOLUME 25, NUMBER 6 2016
restorations in the partially edentulous
patient. J Calif Dent Assoc. 2000;28:
771–779.
90. Rangert BR, Sullivan RM, Jemt
TM. Load factor control for implants in
the posterior partially edentulous segment.
Int J Oral Maxillofac Implants. 1997;12:
360–370.
91. Morneburg TR, Pröschel PA. In
vivo forces on implants influenced by
occlusal scheme and food consistency.
Int J Prosthodont. 2003;16:481–486.
92. Eskitascioglu G, Usumez A,
Sevimay M, et al. The influence of occlusal
loading location on stresses transferred to
implant-supported prostheses and sup-
porting bone: A three-dimensional finite
element study. J Prosthet Dent. 2004;91:
144–150.
93. Naert I, Quirynen M, van
Steenberghe D, et al. A six-year prostho-
dontic study of 509 consecutively inserted
implants for the treatment of partial
edentulism. J Prosthet Dent. 1992;67:
236–245.
94. Falk H, Laurell L, Lundgren D.
Occlusal interferences and cantilever joint
stress in implant-supported prostheses
occluding with complete dentures. Int J
Oral Maxillofac Implants. 1990;5:70–77.
95. Duyck J, Naert IE, Van Oosterwyck
H, et al. Biomechanics of oral implants: A
review of the literature. Technol Health
Care. 1997;5:253–273.
96. Duyck J, Naert I. Failure of oral im-
plants: Etiology, symptoms and influencing
factors. Clin Oral Investig. 1998;2:102–
114.
97. van Steenberghe D, Naert I,
Jacobs R, et al. Influence of inflammatory
reactions vs. occlusal loading on peri-
implant marginal bone level. Adv Dent
Res. 1999;13:130–135.
98. Oh TJ, Yoon J, Misch CE, et al.
The causes of early implant bone loss:
Myth or science? J Periodontol. 2002;73:
322–333.
99. Zhou Y, Gao J, Luo L, et al. Does
bruxism contribute to dental implant Fail-
ure? A systematic review and meta-analy-
sis. Clin Implant Dent Relat Res. 2015
[epub ahead of print].
100. Lekholm U, Zarb G. Patient selec-
tion and preparation. In: Brånemark P-I,
Zarb GA, Albrekstsson T, eds. Tissue-Inte-
grated Prosthesis: Osseointegration in
Clinical Dentistry. Chicago, IL: Quintes-
sence; 1985:199–209.
101. Jaffin RA, Berman CL. The
excessive loss of Brånemark fixtures in
type IV bone: a 5-Year analysis. J Perio-
dontol. 1991;62:2–4.
102. Misch CE. Progressive bone
loading. Pract Periodontics Aesthet Dent.
1995;7:25–29.
837
103. Appleton RS, Nummikoski PV,
Pigno MA, et al. Peri-implant bone
changes in response to progressive osse-
ous loading. J Dent Res. 1997;76:412.
104. Turkyilmaz I, Sennerby L,
McGlumphy EA, et al. Biomechanical as-
pects of primary implant stability: A human
cadaver study. Clin Implant Dent Relat
Res. 2009;11:113–119.
105. Watzak G, Zechner W, Ulm C,
et al. Histologic and histomorphometric
analysis of three types of dental implants
following 18 months of occlusal loading: A
preliminary study in baboons. Clin Oral Im-
plants Res. 2005;16:408–416.
106. Steigenga JT, Al-Shammari KF,
Nociti FH, et al. Dental implant design
and its relationship to long-term implant
success. Implant Dent. 2003;12:
306–317.
107. Huang HL, Chang CH, Hsu JT,
et al. Comparison of implant body de-
signs and threaded designs of dental im-
plants: A 3-dimensional finite element
analysis. Int J Oral Maxillofac Implants.
2007;22:551–562.
108. das Neves FD, Fones D,
Bernardes SR, et al. Short implantsdan
analysis of longitudinal studies. Int J Oral
Maxillofac Implants. 2005;21:86–93.
109. Guan H, Van Staden R, Loo YC,
et al. Influence of bone and dental
implant parameters on stress distribu-
tion in the mandible: A finite element
study. Int J Oral Maxillofac Implants.
2008;24:866–876.
110. Guan H, van Staden R, Loo YC,
et al. Evaluation of multiple implant-bone
parameters on stress characteristics in
the mandible under traumatic loading con-
ditions. Int J Oral Maxillofac Implants.
2010;25:461–472.
111. Anitua E, Tapia R, Luzuriaga F,
et al. Influence of implant length, diam-
eter, and geometry on stress distribu-
tion: A finite element analysis. Int J
Periodontics Restorative Dent. 2010;
30:89–95.
112. Shin YK, Han CH, Heo SJ, et al.
Radiographic evaluation of marginal bone
level around implants with different neck
designs after 1 year. Int J Oral Maxillofac
Implants. 2006;21:789–794.
113. Abuhussein H, Pagni G, Rebaudi
A, et al. The effect of thread pattern upon
implant osseointegration. Clin Oral Im-
plants Res. 2010;21:129–136.
114. Chung SH, Heo SJ, Koak JY,
et al. Effects of implant geometry and sur-
face treatment on osseointegration after
functional loading: A dog study. J Oral Re-
habil. 2008;35:229–236.
115. Motoyoshi M, Yano S, Tsuruoka
T, et al. Biomechanical effect of abut-
ment on stability of orthodontic mini-
838 ROLE OF OCCLUSION IN IMPLANT
implant. Clin Oral Implants Res. 2005;16:
480–485.
116. Gotfredsen K, Berglundh T,
Lindhe J. Bone reactions adjacent to tita-
nium implants with different surface char-
acteristics subjected to static load. A study
in the dog (II). Clin Oral Implants Res.
2001;12:196–201.
117. Yilmaz B, Seidt JD, McGlumphy
EA, et al. Comparison of strains for
splinted and non-splinted screw-retained
prostheses on short implants. Int J Oral
Maxillofac Implants. 2011;26:1176–1182.
Copyright Ó 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
THERAPY
118. Guichet DL, Yoshinobu D,
Caputo AA. Effect of splinting and inter-
proximal contact tightness on load transfer
by implant restorations. J Prosthet Dent.
2002;87:528–535.
119. Lindh T, Gunne J, Tillberg A, et al.
A meta-analysis of implants in partial
edentulism. Clin Oral Implants Res. 1998;
9:80–90.
120. Naert I, Koutsikakis G, Quirynen M,
et al. Biologic outcome of implant-
supported restorations in the treatment of
partial edentulism. Part 2: a longitudinal
SHERIDAN ET AL
radiographic study. Clin Oral Implants Res.
2002;13:390–395.
121. Mendonca JA, Francischone CE,
Mendes Senna P, et al. A retrospective
evaluation of the survival rates of splinted
and non-splinted short dental implants in
posterior partially edentulous jaws.
J Periodontal. 2014;85:787–794.
122. Dario LJ. How occlusal forces
change in implant patients: A clinical
research report. J Dent Am Assoc. 1994;
126:1130–1133.