Occlusal consideration in

implant prosthesis
Presented by: Dr Farha Naz pg 3rd
year
CONTENT
 introduction
• Determining an occlusal scheme for the restoration of implants requires
careful consideration.

• Occlusal overload is often regarded as one of the main causes of peri-

implant bone loss and implant prosthesis failure because it can cause
crestal bone loss, thus increasing the anaerobic sulcus depth and peri-
implant disease states.

• It can be rightly said that occlusion is a determining factor for implant

success.

• The choice of occlusal scheme for implant-supported prosthesis is broad

and often controversial.

• Almost all concepts are based on those developed with natural dentition
and are transposed to implant support systems with a few modifications.
 Biomechanical difference
between implant and tooth
TMU.J.DENT vol.4;3july
sept2017
 Occlusal scehme
• Bilateral occlusion
• Monoplane occlusion
• Neutro centric occlusion
• Linear occlusion
• Unilateral occlusion
• Mutually protected occlusion
• Canine guided occlusion
• Group function
• Long centric occlusion
• Implant protected occlusion
 IMPLANT PROTECTED
OCCLUSION
 The issue of such differences between natural teeth and implants
lead to the establishment of implant-protected occlusion (IPO), the
credit for which goes to Dr. Carl Misch and Dr. MW Bidez.
 It is also called medially positioned lingulalized occlusion, and it
stems from the change in relation of the edentulous maxillary ridge
to the mandibular ridge due to resorption of edentulous ridges in a
medial direction.
 As a result, a few unique concepts are associated with implant-
supported prosthesis and these constitute the guidelines for IPO.

 There are 14 considerations for following the IPO scheme that

should be judiciously implemented before restoration. They are as
follows:
Elimination of premature occlusal contacts
: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.
• It has been speculated that occlusal load from
excessive lateral loads arising from premature
contact may cause bone loss and implant failure.
• Prior to the evaluation of occlusion on
implant reconstruction, the occlusion should
be evaluated and all occlusal prematurities
should be eliminated during maximum
intercuspation and centric relation.
• While restoring an implant, a thin, articulating
paper is used (<25 µm) for the initial implant
occlusion adjustment in centric occlusion
under light tapping forces.
• The implant prosthesis should barely make
contact, and the surrounding teeth in the arch
should exhibit greater initial contact.
• The implant crown should exhibit light axial
contact. .
• Once equilibration under light occlusal force is
completed, the occlusion is refined under
heavy occlusal contact.
Provision of adequate surface area to
sustain load transmitted to the
prosthesis : Increased load can be
compensated for by increasing the implant
width; reducing crown height; ridge
augmentation if necessary; increasing the
number of implants; or splinting the
prosthesis.
Controlling the occlusal table width:
• The width of the occlusal table is directly related
to the width of the implant body.

• The wider the occlusal table, the greater the

force developed to penetrate a bolus of food.

• As a result, in the nonaesthetic regions the width

of the occlusal table must be reduced in
comparison to a natural tooth.
Mutually protected articulation:
• It must be kept in mind that the anterior guidance of the implant
prosthesis with anterior implants should be as shallow as practicable.

• The steeper the anterior guidance, the greater are the anticipated forces
on anterior implants.

• In case of a single tooth implant replacing a canine, no occlusal contact

is recommended on the implant crown during excursion to the opposite
side.

• The rationale of mutually protected occlusion is that the forces are

distributed to segments of the jaws with an overall decrease in force
magnitudes.

• It must also be kept in mind that if anterior implants must disocclude

the posterior teeth, two or more implants splinted together should help
dissipate lateral forces whenever possible.
Implant body orientation and influence
of load direction : Whether the occlusal
load is applied to an angled implant body or an
angled load is applied to an implant body
perpendicular to occlusal plane, the
biomechanical risk increases
This is attributed to the anisotropic nature of
the bone, resulting in separation of the load to
compressive, shear, and tensile stresses.
• Crown cusp angle : It is important to control this, as the
angle of force to the implant body may be influenced by
cusp inclination, which in turn will increase crestal bone
stress.

• The occlusal contact over an implant crown should,

therefore, ideally be on a flat surface perpendicular to the
implant body.

• This positioning is accomplished by increasing the width of

the central groove. to 2-3 mm in posterior implant crowns,
which are positioned over the center of the implant
abutment.
 Cantilevers and IPO : Cantilevers are class-1 levers, which
increase the amount of stress on implants.

• Twice the load applied at the cantilever will act on the abutment
farthest from the cantilever, and the load on the abutment closest
to cantilever is the sum of the other two components.
• Cantilevers also add to noxious stresses (force on a cantilever is
compressive, while force on a distal abutment is tensile).The force
and the length of the cantilever are directly proportional to the
force on the implant.

• For a system with 4-6 implants, the following cantilever lengths are
recommended: Maxillary anteriors-10 mm; maxillary posteriors-15
mm; mandibular posteriors-20 mm.

• In general the goal should be to reduce the length and hence the
force on the cantilever. In addition, a gradient type of occlusal
contact force along the length of cantilever may be beneficial.
Crown height and IPO: An increased crown
height acts as a vertical cantilever, magnifying the
stress at the implant-bone interface.
• It also leads to angled load with a greater lateral
component of force.
• It is important to note that crown height is
determined at the time of diagnosis and that all
methods of either reducing the load or reducing
the crown-implant ratio should be applied before
restoration.
 Occlusal contact position: The ideal occlusal contact is over the
implant body. This contact leads to the axial loading of implants.
 A posterior implant is hence placed under the central fossa of the
implant crown.

 A buccal cusp contact is an offset or cantilever load. A marginal

ridge contact is also a cantilever load, as the marginal ridge may also
be several millimeters away from the implant body.

 In fact, the marginal ridge contact may be more damaging than the
buccal offset, as the mesio-distal dimension of the crown often
exceeds the buccolingual dimension.

 Moreover, the moment of force on the marginal ridge may

contribute to forces that increase abutment screw loosening. Thus,
the ideal primary occlusal contact should reside within the
diameter of the implant within the central fossa.

 The secondary occlusal contact should remain within 1 mm of the

periphery of the implants to decrease the moment loads.
• Implant crown contour :
Due to ridge resorption, the direction of the remaining ridge shifts lingually
and the implant body is most often not under the buccal cusp tip position
of natural teeth.

• In fact, it may be either under or near the central fossa or more lingual
under the lingual cusp of a natural tooth, depending on the resulting
position of the remaining ridge due to resorption.

• Hence, making the buccal contour the same as the original, natural tooth
will lead to buccal offset load to the implant.

• All attempts should be made to provide a narrow occlusal table with

reduced buccal contour, facilitating daily home care, improving axial loading,
and reducing the risk of porcelain fracture.
• In Division B-Division D bone, the implant position is
often lingual to the position of the natural tooth.
• Care has to be taken in case of mandibular posterior
implants regarding the limitation imposed by the
submandibular fossa.
• In case of excessive medial positioning of the implant, it
may be necessary to use angulated abutment and a
straight lingual profile.

• Maxillary posterior implants in division B-D bones may

often require restoration in crossbite .

• In case of Division C and D bone, all attempts must be

made to perform a bone
• Design of the prosthesis should favor the
weakest arch : Usually the maxilla is the weaker
of the two arches, predominantly due to less
dense bone.
• From a biomechanical perspective, an implant-
restored premaxilla is often the weakest section
compared with the other regions of the mouth.
• Compromised anatomical conditions include
narrow ridges and the need for narrow implants,
the use of facial cantilevers, oblique centric
contacts, lateral forces in excursion, reduced
bone density, the absence of a thick cortical plate
at the crest, and accelerated bone loss in the
incisor region often resulting in instability when
placing central and lateral incisor implants
without substantial augmentation procedures.
• In the anterior premaxilla, 15% higher maximum
bone strain for a straight abutment has been
predicted compared to an angled abutment.
• It has been suggested that, when restoring
implants in the anterior maxilla, the use of an
angled abutment, compared to a straight
abutment, may decrease the strain on the bone. In
fact, it has been recommended to increase the
number and the diameter of implants and provide
splinting when force factors are great.
• Occlusal material : The selection of occlusal
materials depends on the opposing dentition,
the remaining dentition, and the quadrant to
be restored.
• The selection is usually made from among
porcelain, zirconia, metal, and resin-based
materials.
Parafunctional activity : 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.
• According to them, shorter cantilevers, proper
location of the fixtures along the arch, a
maximum fixture length, and night-guard
protection should be prerequisites to avoid
parafunctional habits or the overloading of
implants in these patients.
 Timing of loading Implant: loading can be either
delayed (submerged), progressive bone loading or
immediate bone loading.
 Bone density is the key determinant in deciding the amount
of time between implant placement and prosthesis
restoration.
 Progressive bone loading is specifically indicated for less
dense bones. Progressive bone loading allows a
“development time” for load-bearing bone and allows bone
adaptability to loading via the gradual increase in loading.
 The concept is based on incorporating time intervals (3-6
months).
 Occlusal guidelines for different clinical
situations : Clin. Oral Impl. Res. 16, 2005 / 26–35
• OCCLUSALADJUSTMENT IN IMPLANT-
SUPPORTED PROSTHESIS
• This consists of modifying tooth anatomy
to obtain a good occlusion.
• Occlusal adjustments must be performed
in the upper and lower arch jointly at the
same time and on both sides.
• All of the following adjustments can be
done when checking a case prior to
laboratory work or once it is placed in mouth
or in finished cases to readjust occlusion.
• Technique – Double colored thin
articulating paper or black marking ribbon and
the patient close from CR to MI several times.

• Mandible : In normal occlusion (Class 1)

the distal lower inclines and the mesial upper
inclines contact in condylar centric relation
• Eliminating interferences: (Non
physiological contacts that appear in anterior
and posterior teeth in lateral and protrusive
excursions)
• Using red ribbon have the patient go
through working, nonworking and protrusive
movements.
• Next place black ribbon and have the
patient close to MI.
• Eliminate all red marking except the guide
marks of anterior disclusion.
• To adjust, we should follow these steps:
• Cusp distal incline

• Active-cusp outer inclines

• Inner inclines
Cusp distal
incline
 conclusion
• Occlusion has been an important variable in the
success or failure of most
• prosthodontic reconstruction.
• With natural teeth, a certain degree of
flexibility permits compensation for
• occlusal irregularity. But “Implants Cannot Bail
Out Our Faulty Occlusion”…
• Therefore occlusion must be more rigorously
evaluated with implant supported
• prosthesis
 bibliography
1. Dental implant prosthetics – Misch
2. Implant supported prosthessis: occlusion, clinical cases, laboratory
procedures - Vicente Lopez
3. Osseointegration and oral rehabilitation – Hobo
4. Surgical and Prosthetic techniques for dental implant –
Ismail,Fagan,Meffert
5. Clinical decision making and treatment plannning in
osseointegration.Engleman MJ.
6. Implants in dentistry. Black. Kent , Guerra.
7. Indication for splinting implant restorations. J oral maxillofc surg. 63;
1642;2005.
8. Guidelines for occlusal strategy in implant borne prosthesis. Idj 2008, 58
9. Factors to consider in selecting an occlusal concept for pts with
implants in edentulous mandible. JPD 1995; 74; 380