Keterkaitan antara Bedah Mulult

dan Oklusi
PPDGS Bedah Mulut 2019
Introduction
• Oral rehabilitation impacts on general health
• Implications of particular importance include:
1. occlusion and function have implications for general
health through diet and nutrition
2. the psychological framework within which oral
rehabilitation is delivered has important psychosocial
impacts that include improved appearance of teeth and
face
3. the presence of sleep apnoea influences the risk of
cardiovascular disease and increased oropharyngeal space
can assist in management
 Tooth and periodontal feedback with
function
• Teeth has important function in the
sensorimotor control of jaw function
• These specific features of teeth are closely
linked with periodontal sensitivity, and a
recent review suggests an integrated role of
the pulp–dentine–enamel complex
• Cells that contributte in the pulp-dentine-
enamel complex for sensory function 
odontoblast with structural support from
glial cells.
• periodontal mechanoreceptors provide
afferent information to the brain stem, which
signals changing vertical and horizontal forces
on teeth.
• There are distinct differences between load
thresholds for anterior and posterior teeth –
anterior teeth are most sensitive to forces <1
N and posterior teeth to forces <4 N
• a specific occlusal design for rehabilitation of
natural teeth with fixed dental prostheses can
therefore be proposed:
– canine guidance is desirable,
– complex posterior occlusal form is not requirred
for posterior tooth reconstructions.
– require appropriate occlusal vertical dimension
and occlusal plane orientation as well as a stable
cusp – fossa design
Bahan Tomo
 Loading and Bone Remodelling

Bone quality, volume and site are pivotal for long-term clinical
success

Clinical data indicate that dental implants placed in bone with

lower density have a higher risk of failure and this supports the
significance of bone site for osseointegration

Mandibular bone has proven to be more successful than

maxillary bone
 Bone Remodelling
Bone Remodelling : Process where bone changes its internal
microstructure and external morphology, size and shape to adapt to
changed loading conditions

Bone remodelling involves apposition and deposition, and mechanical

stress may have both positive and negative

Mechanical stress induces strain. Strain is dependent on the

mechanical properties inherent in the structure so that the applied
force may affect various bone tissues differently – a similar stress evokes
different levels of strain in bone with different elastic properties
 Controlled increases in
occlusal load on Creased occlusal
implant crowns with load for up to 4
and without premature weeks (-)
contacts (+)

Premature
Excessive loading contacts >180 lm
(-) Bone (+)
remodelling
or Bone loss.
 Optimal functional strain

• An optimal functional strain at low frequency stimulation

(3 Hz based on De Smet et al. ), is required to ensure that
bone remodelling, with increased bone volume and
density, occurs to maintain osseointegration and implant
stability.
• In clinical application, guidelines proposed by Albrektsson
et al., stable marginal bone levels as a criterion for
successful implant outcomes, where vertical bone loss
should not exceed 0-2 mm annually after the first year
and that this was greater in the first year
 LOADING TIME
Convention Immediate
al Early
Immediate loading is
3–4 months in Delayed Early loading is considered to be
the mandible earlier than the loading with
and 6–8 months conventional 3– provisional
in the maxilla 6 months restorations within
48 h our of implant
surgery
• with implant supported partial fixed dental
prostheses, it is recommended that :
there are minimal cuspal contacts in intercuspal position
(ICP) (with shim clearance between supporting cusps),
which will develop as firm contacts (which hold shim) as
chewing forces increase with function and parafunction
and

an absence of contacts in eccentric movements, during the

immediate healing after implant placement.
a biomechanical assessment designed to
reduce the risk of overload includes:
(i) implant number, their location and angulation,

(ii) expected leverage induced by the superstructure and possible force generation,

(iii) the specifics of bone support and

(iv) occlusal design and occlusal contact pattern. The latter may also affect outcomes, and reducing stress
from occlusal loading, particularly with immediate or early loading, is considered significant to minimise
risk profile.
 Occlusion & Bone Remodelling
• Optimum restoration design is considered important for
bone remodelling and to minimise healing time
• Occlusal design (Occlusal form and cusp contact) may impact
on bone strains around implants with occlusal loading, which
influence the magnitude and direction of masticatory forces
directed on implants and surrounding bone.
• ‘mild overload’ (1500–3000 microstrains) → bone apposition
• Inadequate mechanical load transfer → reduce bone
engagement → bone resorption
Laboratory-based FEA study evaluated
occlusal designs on bone remodelling
• Investigated different cusp
inclinations (0°, 10° and 30°)
• Loading locations (central fossa, 1
and 2 mm offsets horizontally) on
the biomechanical response
• FEA data confirmed load
concentration at the coronal bone
around the upper section of the
implant where bone loss is the
most common in clinical situations.
 FEA (Finite Element Analysis)

• Finite element model of implant-

supported single pre-molar crown
within the simulated jaw bone
• Load concentration increased
with steeper cuspal inclination
and broader occlusal table and
decreased with central fossa
loading and narrower occlusal
table size
 Occlusal table size

(i) 30° cusp inclination and 6 mm occlusal table width

(ii) 30° cusp inclination and 4 mm occlusal table width
(iii) 10° cusp inclination and 6 mm occlusal table width
(iv) 10° cusp inclination and 4 mm occlusal table width
 Stress distribution with vertical loading in
central fossa

With central fossa threading, a symmetrical pattern was

observed with no stress concentration along the implant
Typical patterns of von Mises stresses in the four occlusal designs
and modelled implants.

Large stresses were concentrated at the

implant thread tips, and maximum stresses
were located asymmetrically on the buccal
 Important !!!

• Increased cusp inclination → stronger bone

engagement, it also increased normal and shear
stress magnitude → potential to damage bone–
implant contact → induce micromotion clinically
• Alternatively, a lower cuspal inclination → a slower
rate of bone engagement and a longer healing period
• Optimal design of implant superstructures should
maximise bone density and bone remodelling,
reduce healing time and increase bone–implant
contact
 OSSEOPERC
EPTION
Modulation of Complex
Central neural
occlusal loads feedback
plastic changes
occurs by mechanism

Peripheral
feedback
Mucosal PERIODONTAL Joint
Mechanorecept MECHANORECE Mechanorecept
or PTOR or
Muscle Muscle
Mechanorecept Mechanorecept
or
 Bone Cell processes
• Osseoperception allows the restoration of function in
implant - restored situations
• The three-dimensional network of bone cell processes :
– Viscoelastic system allow the varying loading of chewing
responses collagen network to the trabecular structure &
evoking bone cells
– Interconnecting with neighbouring bone cells allows the effects
of loading at the implant interface to be transduced or
‘perceived’ through fluid flow along cellular connection
– Chemical mediators (cytokines) also evoke bone cell responses
in a complex physio-chemical process
 SOMATOSENSORY INFORMATION IN THE
CONTROL OF JAW MOVEMENT DURING CHEWING

• Somatosensory information plays a critical

role in the generation and control of jaw
movements during chewing

• Movements and forces during chewing 

encoded in the frequency and duration of
activation along trigeminal afferent pathways
 Intra oral changes  lead to a change in the
somatosensory input available to the higher
cortical regions and lead to focussing thalamic
receptive fields of neurons processing oro-facial
input.

The corticothalamic pathways may

selectively enhance those particular
somatosensory pathways that are of
greatest need for the movement
PLASTICITY AND ADAPTIBILITY OF THE JAW
MOTOR SYSTEM

• Sensorimotor central control systems are

capable of remarkable change and
adaptation in response to learning motor
skills, and these neuroplastic changes
appear essential for learning new motor
skills
• Recent evidence indicates that significant neuroplastic changes also
occur in the face M1, in association with alterations to tooth form
or following tongue-task training and following tooth extractions

• The evidence for remarkable neuroplasticity within motor cortical

regions may underlie the adaptations that individuals undergo in
response to changes in occlusal form and dental status

• The degree of adaptability is likely to vary from person to person,

and it is therefore not possible to predict the individuals who will
be able to accommodate to particular changes in their occlusal
scheme
 LACK OF NEUROPHYSIOLOGICAL EVIDENCE
SUPPORTING PARTICULAR OCCLUSAL SCHEMES
• During locomotion, flat surface is more readily
negotiated than a rough surface.

• Particular occlusal schemes are desirable to

optimise function  bilaterally stable retruded or
intercuspal position vs unstable contacts

• Periodontal mechanoreseptor are important in the

recalibration of the muscle spindle afferent system
 SOMATOSENSORY INFORMATION PLAYS A
CRITICAL ROLE IN THE CONTROL OF ALL JAW
MOVEMENTS AND IS USED BY THE JAW MOTOR
SYSTEM IN LEARNING MOTOR TASK AND
ADAPTING TO CHANGES IN THE OCCLUSION

RELATIVELY MINOR CHANGES, SUCH AS

VARIATIONS IN OCCLUSAL SCHEME DESIGN,
APPEAR TO BE ACCOMMODATED BY THE
NEUPLASTICITY OF THE CENTRAL MOTOR
CONTROL SYSTEM. THE NEUROPLASTICITY
PROVIDES A BASIS FOR THE OBSERVATION
THAT DIFFERENT OCCLUSAL SCHEME
DESIGN
 THERE IS NO NEUROPHYSIOLOGICAL
EVIDENCE THAT ANY PARTICULAR
OCCLUSAL DESIGN IS BETTER THAN ANY
OTHER, AND THE NERVOUS SYSTEM
APPEARS REMARKABLY ADAPTABLE OR
PLASTIC TO THE DEMANDS PLACED ON IT
BY CHANGES ASSOCIATED WITH DENTAL
TREATMENT