The Journal of Craniofacial Surgery & Volume 23, Number 5, September 2012
even with difficult rehabilitations or in the presence of parafunction
Influence of Loading and
Use of Occlusal Splint in
Implant-Supported
Fixed Prostheses
Fabı́ola Marchezini Teixeira, MSc,*
Cristiane Aparecida de Assis Claro, PhD,*
Ana Christina Claro Neves, PhD,*
Sigmar de Mello Rode, PhD,Þ
Laı́s Regiane da Silva-Concı́lio, PhD*
Abstract: The aim of the study was to assess the tensions generated
in the long axis of the implants and the interimplants in the cervical,
middle, and apical regions when subjected to different loads with or
without interposition of the flat occlusal plane splint. A photoelastic
model was made with 2 external hexagon implants located in the
space corresponding to the second premolar and molar inferiors. A
screw-retained metal superstructure was installed on the implants
with a torque of 20 NIcm, and the set (photoelastic model with
superstructure) were positioned in the circular polariscope in the
dark-field configuration to observe the distribution of isochromatic
fringes around the implants and interimplant areas. Photographic
records were obtained before the application of the occlusal load
with the following loading conditions: 300, 600, and 900 N, with
and without interposition of the occlusal plane splint. The decrease
in stress with the application of the flat occlusal plane splint became
more evident after the application of the 600-N load. Generally, the
major stress magnitude occurred in the cervical region for inter-
implant areas and in the apical region around implants. Use of oc-
clusal splint in the loading of 300, 600, and 900 N reduced tension
33.22%, 66.66%, and 73.33%, respectively, in the samples. It can
be concluded that the interposition of the occlusal plane splint
caused a reduction in tension resulting from the simulation of oc-
clusal overload.
Key Words: Dental implant, fixed partial dentures, bruxism,
photoelastic stress analysis
S ince the beginning of implantology in 1952 with Branemark
et al,1 who defined osseointegration as a direct connection be-
tween the structural and functional organized vital bone and the
surface of a titanium implant able to receive functional loading, the
success of this type of treatment has produced promising results,
From the *Graduate Program in Dentistry, Department of Prosthodontics,
University of Taubaté, São Paulo, Brazil; and †Department of Dental
Materials, São José dos Campos Dental College, University of State São
Paulo, São Paulo, Brazil.
Received April 4, 2012.
Accepted for publication April 14, 2012.
Address correspondence and reprint requests to Laı́s Regiane da
Silva-Concı́lio, PhD, Expedicionário Ernesto Pereira St, 110, Centro,
Taubaté, São Paulo, Brazil 12020-330; E-mail: regiane1@yahoo.com
The authors report no conflicts of interest.
Copyright * 2012 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e31825aad82
* 2012 Mutaz B. Habal, MD
Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
(intervening with the use of the occlusal splint).2
An important prerequisite for the longevity of dental implants is
the occlusal pattern because in examining this phenomenon in nat-
ural dentition, the periodontal ligament behaves very differently
from the pillars of dental implants.3 When subjected to occlusal
loads, natural teeth can move around 100 Km owing to the resilience
allowed by the periodontal ligament fibers, unlike what occurs in
implants, because they are tightly integrated with bone tissue, with
an absence of periodontal fibers.4
Some biomechanical factors that can change the dynamics of
transmission loads for the implant are bruxism or dental clench-
ing,5,6 which consists of grinding or clenching the teeth, producing
sounds that can be observed while the person is awake or sleeping. It
is a very common condition in the general population; about 85% to
90% of people report episodes of grinding or clenching their teeth at
some point in their life.7 Biomechanical factors associated with an
overload of the implant in the region are often cited as predisposing
the area to marginal bone loss and bacterial infection, with values
higher than what is clinically acceptable.8Y10
When the parafunctional habit is diagnosed, use of the occlusal
splint is suggested,11 as it aims to reduce and modulate muscle
hyperactivity, protect teeth and their supporting structures, provide
muscular comfort,12,13 and decrease occlusal wear.
Photoelastic analysis has been widely used in dentistry to study
stress distribution around natural teeth, the abutment teeth of re-
movable partial dentures and fixed partial dentures (FPD),14,15 and
the area around osseointegrated implants, among other factors.16
Several studies have shown that the pattern of stress distribution in
the photoelastic model is very close to that of the real structure.17,18
Because the similarity between the location and pattern of stress
produced between them and,19 by direct observation of the stress
distribution in structures, is based on the ability of certain trans-
parent materials to expose the color patterns called isochromatic
fringes when they are subjected to stress during the polarized
light.20,21
Thus, this study aimed to evaluate the tensions generated on
implants by metallic FPD with simulated occlusions of a normal
vertical load and vertical overload. It also evaluated the influence of
the use of a flat occlusal plane splint (FOPS) with different inten-
sities of vertical loading.
The hypothesis of this study was that the interposition of the
FOPS could positively influence the distribution of stresses on the
implant, mainly at the highest intensity of axial loading.
MATERIALS AND METHODS
One block of photoelastic resin, 75  30  12 mm, was made with 2
external hexagon implants (4.0  13 mm, Titamax Ti; Neodent,
Curitiba, Paraná, Brazil) and placed in the area corresponding to the
second premolar and first molar lower regions. The photoelastic
resin (Araldite XGY; Huntsman, Everberg, Belgium) was manipu-
lated in accordance with the manufacturer’s instructions, submitted
to a vacuum (650 mm Hg) for 30 minutes, and set aside for 24 hours
to complete the resin polymerization.
Intermediate abutments (Neodent) were screwed into the
implants, and the conventional technique was used to fabricate FPD
FIGURE 1. Photoelastic model with FPD and plane occlusal splint.
e477
Brief Clinical Studies The Journal of Craniofacial Surgery
FIGURE 2. Sequence of colors and corresponding fringe orders recommended
by ASTM (modified by authors with values of 5Y7 fringe orders).
using a Ni-Cr alloy. The FPD was screwed into the implants in the
photoelastic model (Fig. 1).
The flat occlusal plane splint was used to simulate the clinical es-
tablishment of an occlusal condition that was made more favorable by
stabilizing the mandibular movements.12,13 The splint was made from
colorless acrylic resin polymerized by the conventional heat-curing
method. It was 2 mm thick, extending to the middle third of the
buccal and the lingual of the FPD (Fig. 1).
Before the photoelastic analysis, the model was submitted to a
thermal treatment in a stove at 50- C for 10 minutes to eliminate any
residual stresses.22,23 During the testing, the photoelastic model was
immersed in mineral oil to increase translucency and improve ob-
servation of the results.16
The model was positioned in a circular polariscope, and vertical
loads of 300, 600, and 900 N were applied on the occlusal surface of
the prostheses, with or without interposition of FOPS, using a
Universal Testing Machine (Versat 2000; Panambra, São Paulo,
Brazil) that was programed to transmit the vertical load.
The resulting stress on the areas of the photoelastic model was
photographed by a digital camera (Nikon D70; Nikon Corp, Mel-
ville, NY) and visualized using graphic software (Adobe Photoshop;
Adobe Systems Incorporated, San Jose, CA) so it could be analyzed.
The photographic records of the samples were evaluated by 2 cali-
brated observers who assessed the stress direction and intensity
according to the qualitative analysis of French et al,24 who estab-
lished that the higher the number of fringes, the greater the stress,
and the closer the fringes, the greater the stress concentration.
For establishing the sequence of colors produced in a polari-
scope with white light in a dark-field configuration, a table recom-
mended by ASTM D4093-95 (American Society for Testing and
Materials) was used.25 It was modified by adding the values of 5 to
7 fringe orders to enable the numbering of regions that exceed the
order 4 (Fig. 2).
To standardize the assessment points of the tension analysis,
15 points based on the profile drawing of the implant were pre-
established. These predetermined points for reading the fringe
orders were named as follows: CM (cervical mesial), CD (cer-
vical distal), MM (medial mesial), MD (medial distal), AM
(apical mesial), AD (apical distal), C (cervical), M (medium), and
A (apical) (Fig. 3).
FIGURE 3. Schematic illustration of the predetermined points of analysis.
e478
Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
& Volume 23, Number 5, September 2012
RESULTS
Figure 4 illustrates the stress distribution obtained in the photoelastic
model with loads of 300, 600, and 900 N with or without the in-
terposition of FOPS.
The stresses formed in the photoelastic model in different values
of loading increased in some cases and decreased in others, and
sometimes remained the same. Table 1 shows these percentage
changes in a qualitative analysis of the fringe orders; they resulted in
different values of loading when the values were compared, with
or without interposition of the FOPS. In the AM regions (second
premolar), the middle, apical (interimplants), CM, and MD (second
molar), the FOPS reduced the magnitude of tension in the 3 ap-
plied loads. However, in the AM and CD regions of the second
molar, the FOPS increased the magnitude of the tension in the 3
applied loads. The reduction in stress intensity after interposition
of the plane occlusal splint became more evident after the ap-
plication of a 600-N load.
Overall, regardless of region or location of the implant, stress
intensity was reduced from 57.77%, increased from 24.44%, and
remained equal at 17.77%, considering the total cases analyzed after
interposition of FOPS (Fig. 5).
Evaluating the percentage of variations in the intensity of tension
after the interposition of the FOPS according with various loads
(300, 600, and 900 N), the application of a 300-N load registered a
reduction of 33.22%, an increase of 26.66%, and an equality of 40%
in the stress intensity. With the application of a 600-N load, stress
intensity was reduced by 66.66%, increased by 20%, and remained
equal at 13.33%. With the application of a 900-N load, the stress
intensity was reduced by 73.33% and increased by 26.66% (Fig. 5).
In the 3 types of loading studied, there was a reduction in the stress
magnitude after interposition of FOPS.
DISCUSSION
Bruxism is generally considered a contraindication for dental
implants, although the evidence for this is usually based on clinical
experience only.5 However, there is still a small portion of literature
evaluating the relation of possible cause and effect between bruxism
and implant failure, and the treatment of choice in this matter. This is
not only because of the wide variation in the literature in both
technical and biologic aspects of the study material but also because
of the correlation between clinical and laboratory findings.
FIGURE 4. Photoelastic model after load application (300, 600, and 900 N)
evaluated in regions with (A, C, E) or without (B, D, F) interposition of the plane
occlusal spli
* 2012 Mutaz B. Habal, MD
The Journal of Craniofacial Surgery & Volume 23, Number 5, September 2012 Brief Clinical Studies

TABLE 1. Fringe Orders and Percentage of Alterations Resulting From the Application of Different Loads (N) in the Regions Evaluated With or Without Interposition of
the Plane Occlusal Splint

300 N 600 N 900 N

Without With Without With Without With

Implants Region Splint Splint % Change Splint Splint % Change Splint Splint % Change
Second premolar CM 2.00 2.00 0 2.67 2.00 ,25.10 3.10 2.00 ,35.49
CD 3.00 3.00 0 4.00 3.00 ,25 5.00 3.00 ,40
MM 2.33 3.00 j22.34 4.00 2.67 ,33.25 5.00 3.10 ,38
MD 1.81 1.81 0 1.81 1.81 0 2.50 1.81 ,27.60
AM 4.13 4.00 ,3.15 6.00 5.00 ,16.67 7.00 6.00 ,14.29
AD 3.60 4.00 j0 4.13 4.13 0 5.00 6.00 j16.67
Interimplants C 3.00 3.00 0 3.10 1.81 ,41.62 4.00 1.81 ,54.75
M 1.06 0.28 ,73.59 1.38 0.28 ,79.72 1.81 0.45 ,75.14
A 0.79 0 ,26.58 1.00 0.60 ,40 1.06 0.90 ,15.10
Second molar CM 3.60 3.00 ,16.67 4.00 2.00 ,50 4.00 2.00 ,50
CD 2.00 3.00 j33.34 3.00 4.00 j25 3.00 4.00 j25
MM 3.00 3.00 0 3.00 2.00 ,33.34 3.10 2.33 ,24.86
MD 2.33 2.00 ,14.17 2.50 2.33 ,6.8 2.67 2.33 ,12.74
AM 2.33 3.00 j22.34 2.67 3.60 j25.84 2.67 5.00 j46.60
AD 3.00 3.00 0 3.60 4.00 j10 4.00 5.00 j20

Photoelastic analysis is a widely used method to evaluate tension
owing to its correlation between the data and the clinical find-
ings.22,23,26 One of its main advantages is its visualization of the
internal tensions within bodiesVvisualizations that can be measured
and photographed.
It is known that torque application on the intermediate abutment
screws and FDP screws (20 NIcm each) by itself produces stress on
the model without the application of an axial load, so heat treat-
ment of the model has previously been used to eliminate residual
stress.22,23
Within the limitations of a clinical simulation with parafunctional
situations, there are several resulting from the force vectors that
focus on the occlusal surface. This study used axial loads because
Deines et al14 and Canay et al27 agree that this force is more relevant
to clinical conditions and thus more conducive to an analysis of this
type of loading direction.
The values used were 300,26,28 60029 to simulate normal loads,
and 900 N2 to simulate an overload. The results show that, as the
applied load was increased for both models with and without the
FOPS, the number of fringe orders observed was generally greater;
this is an expected condition because when a load is increased, there
is a greater stress concentration.
This study proposed to evaluate the influence of an occlusal
splint on reducing the stress concentration in peri-implant regions.
The results show that the interposition of the FOPS promoted stress
distribution, generally reducing the stress magnitude around
57.77%. It is even more efficient in cases of higher load application;
there was a reduction of 66.66% in cases with 600 N and 73.33% in
cases with 900 N. These results support the use of occlusal splints as
part of rehabilitative treatment.5,11 Their use in cases of clenching
and bruxism in patients with prostheses on implants reduces the
effects of this habit (such as occlusal wear); protects teeth, restora-
tions, and prostheses;5,13 and preserves bone integrity and conse-
quently osseointegration, in addition to reducing and modulating
muscle hyperactivity, providing a more comfortable jaw position,
favoring occlusion and patient comfort, and maintaining the integ-
rity of the rehabilitation treatment.5 This is the situation where the
stress concentration becomes more homogeneous, so the hypothesis
suggested by this study is true.
Future studies that test different loads and loading directions will
be important to elucidate the problems involved in the issues of
parafunction and osseointegration. Such studies will also allow for
comparison of results because there is still a limited number of
studies’ evaluating such situations.
CONCLUSIONS
On the basis the methodology used, the results demonstrated that the
higher stress magnitude occurred in the cervical region of the
interimplant areas and the apical region around implants, with or
without FOPS. And that the interposition of FOPS was effective
because the reduction in stress intensity and more homogeneous
distribution became more evident with an increasing load, especially
with 600- and 900-N loads.

FIGURE 5. Percentages of stress distribution (fringe orders) resulting from the
application of loads (total, 300, 600, and 900 N) after the interposition of plane
occlusal splint.
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5. Lobbezoo F, Brouwers JEIG, Cune MS, et al. Dental implants in patients
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& Volume 23, Number 5, September 2012
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Giant Cranial Osteoma:
Successful Staged Excision of the
Largest Reported
Kenneth L. Fan, MD,*Þ Kiu Ghadjar, MS,* Joyce T. Yuan, BA,*
Jorge Lazaref, MD,þ Libby Wilson, MD,*
James P. Bradley, MD*
Abstract: Craniofacial osteomas are benign, slow-growing neo-
plasms of the craniofacial region that are usually asymptomatic.
Uncommonly, giant craniofacial osteomas may be symptomatic and
cause serious morbidity including ophthalmologic problems, cere-
bral compression, pneumocephalus, and seizures. We present a case
of a 15-year-old Asian adolescent girl with a giant cranial osteoma
(17.5  13.2  5 cm: significantly larger than previously reported).
She also had multiple other synchronous giant osteomas of the face
causing facial asymmetry. These osteomas were resected in a multiple-
staged approach with a good aesthetic and functional outcome.
Key Words: Osteoma, osteoma excision, cranial osteoma, genetic
osteoma, largest osteoma
C ranial osteomas are progressively enlarging benign mesenchy-
mal osteoblastic tumors unique to the medullary bones of the
craniofacial complex.1 Characterized by slow progressive growth,
osteomas exhibit well-defined margins against adjoining bone.
Three general types occur: (1) central osteomas originating from the
endosteum, (2) peripheral osteomas developing from the periosteum,
or (3) extraskeletal soft tissue osteomas occurring within muscle.2,3
Histologically, they can resemble compact or cancellous bone.
In origin, endosteal osteomas are centrally derived within the
medullary bone. Further classification can be made anatomicallyV
intraparenchymal, dural, skull base, or skull vaultVeach correspond-
ing with specific frequency and symptoms.4 The etiology of osteoma
formation is unclear but has been attributed to trauma, infection,
or congenital abnormalities.5,6 Multiple osteomas have been closely
associated with Gardner syndrome.3,7 Because osteomas precede de-
velopment of gastrointestinal malignancy, diagnosis is paramount.
The predicted incidence is 0.43%, with 80% affecting frontal
or frontoethmoidal sinus only.8 However, the true prevalence of
From the *Division of Plastic and Reconstructive Surgery, David Geffen
School of Medicine at UCLA, Los Angeles, California; †University of
Miami, Miller School of Medicine, Miami, Florida; and ‡Division of
Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles,
California.
Received March 1, 2012.
Accepted for publication April 14, 2012.
Address correspondence and reprint requests to James P. Bradley, MD,
Division of Plastic and Reconstructive Surgery, David Geffen School
of Medicine, University of California, Los Angeles, 200 UCLA
Medical Plaza, Suite 465, Los Angeles, CA 90095; E-mail:
Bradley.research@gmail.com
The authors report no conflicts of interest.
Copyright * 2012 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0b013e31825aaeea
* 2012 Mutaz B. Habal, MD