INTRODUCTION

The ideal goal of modern dentistry is to restore the patient to normal contour, function, comfort, esthetics, speech, and health. Osseo integration has been one of the most important therapeutic advances in recent years, greatly

facilitating the placement of single or multiple prosthesis. Planning and executing optimal occlusion schemes is an integral part of implant supported prosthesis. Due to lack of the periodontal ligament, osseointegrated implants, unlike natural teeth, react biomechanically in a different fashion to occlusal force. It is therefore believed that dental implants may be more prone to occlusal overloading, which is often regarded as one of the potential causes for peri-implant bone loss and failure of the implant prosthesis. Overload depends ultimately on the number and location of occlusal contacts, which to a great extent are under the clinicians control. This seminar reviews occlusal contact designs and offers occlusion strategy guidelines for the different types of implant supported prostheses.

DIFFERENCE BETWEEN NATURAL TEETH AND IMPLANTS

The biophysiologic differences between a natural tooth and endosseous dental implant are well known, but potential bio-mechanical characteristics derived from the differences remain controversial (Rangert et al. 1991; Cho & Chee 1992; Lundgren & Laurell 1994; Schulte 1995; Glantz & Nilner 1998). Differences between teeth

and dental implants are summarized in Table.

The fundamental, inherent difference between the tooth and implant is that an endosseous implant is in direct contact with the bone while a natural tooth is suspended by PDL. The mean values of axial

displacement of teeth in the socket are 25-100 mm, whereas the range of motion of osseointegrated dental implants has been reported approximately 3-5 mm (Sekine et al. 1986; Schulte 1995). PDL is functionally oriented toward an axial load, which leads to the physiologicalfunctional adjustment of occlusal stress along the axis of the tooth and periodontal-functional adaptability to changing
2

stress conditions (Lindhe & Karring 1998). Furthermore, the tooth mobility from PDL can provide adaptability to jaw skeletal deformation or torsion in natural teeth (Schulte 1995). However, dental implants do not possess those advantages due to the lack of PDL.

Upon load, the movement of a natural tooth begins with the initial phase of periodontal compliance that is primarily secondary non-linear and complex, followed by the the

movement

phase

occurring

with

engagement of the alveolar bone (Sekine et al. 1986). In contrast, a loaded implant initially deflects in a linear and elastic pattern, and the movement of the implant under load is dependent on elastic deformation of the bone. Under load, the compressibility and deformability of PDL in natural teeth can make differences in force adaptation compared with osseointegrated implants. To

accommodate the disadvantageous kinetics associated with dental implants, gradient loading was suggested (Misch 1993; Schulte 1995). A natural tooth moves rapidly 56-108 mm and rotates at the apical third of the root upon a lateral load (Parfitt 1960), and the lateral force on the tooth is
3

diminished immediately from the crest of bone along the root (Hillam 1973). On the other hand, the

movement of an implant occurs gradually, reaching up to about 10-50 mm under a similar lateral load. In addition, there is concentration of greater forces at the crest of surrounding bone of dental implants without any rotation of implants (Sekine et al. 1986). Richter (1998) also reported that a transverse resulted in load the and clenching at centric

contacts

highest stress in the crestal

bone. The studies suggested that the implant sustains a higher proportion of loads concentrated on the crest of surrounding bone.

In natural teeth, PDL has neurophysiological receptor functions, which transmit information of nerve ends with corresponding reflex control to the central nervous system. The presence or absence of the PDL functions makes a remarkable difference in detecting early phase of occlusal force between teeth and implants (Schulte 1995). Jacobs & van Steenberghe (1993) evaluated occlusal awareness by use of the perception of an occlusal

interference. They found that interference perceptions of natural teeth and implants with opposing teeth were
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approximately 20 and 48 mm, respectively. In another study (MericskeStern et al. 1995), oral tactile sensibility was measured by testing steel foils. The detection threshold of minimal pressure was significantly higher on implants than on natural teeth (3.2 vs. 2.6 foils). Similar findings were also reported by Hammerle et al. (1995) in which the mean threshold value of tactile perception for implants (100.6 g) was 8.75 times higher than that of natural teeth (1-1.5 g). From the results of the above studies, it can be speculated that osseointegrated implants without periodontal receptors would be more susceptible to occlusal overloading because the load sharing ability, adaptation to occlusal force and mechanoperception are significantly reduced in dental implants.

TOOTH
Connection Periodontal ligament (PDL)

IMPLANT
osseointegration (Brnemark et al. 1977), functional ankylosis (Schroeder et al. 1976)

Proprioception

Periodontal mechanoreceptors

Osseoperception

Tactile sensitivity (Mericske-Stern et al 1995) Axial mobility (Sekine et al. 1986; Schulte 1995) Movement phases (Sekine et al. 1986)

High

Low

25-100 mm

3-5 mm

Two phases Primary: non-linear and complex Secondary: linear and elastic

One phase Linear and elastic

Movement patterns (Schulte 1995)

Primary: immediate movement Secondary: gradual movement

Gradual movement

Fulcrum to lateral force

Apical third of root (Parfitt 1960)

Crestal bone (Sekine et al. 1986) Stress concentration at crestal bone (Sekine et al. 1986) Screw loosening or fracture, abutment or prosthesis
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Load-bearing characteristics

Shock absorbing function Stress distribution

Signs of overloading

PDL thickening, mobility,

wear facets, fremitus, pain

fracture, bone loss, implant fracture (Zarb & Schmitt 1990)

WHAT IS OCCLUSION ?

GPT-8 : The static relationship between the incising or masticating surfaces of the maxillary or mandibular teeth or tooth analogues.

ASH AND RAMFJORD : The term occlusion often denotes a static, morphologic tooth contact relationship.
Implant occlusion is basically derived from complete denture occlusion and fixed partial denture occlusion before getting into implant occlusion let us see the various types of occlusal schemes in complete dentures and fixed partial dentures.
7

Occlusal concepts in complete dentures: 1. Anatomic

Balanced

Non-balanced 2. Semi anatomic

Balanced

Non-balanced 3. Non anatomic

4. Lingualised

Balanced

Non balanced 5. Neutron centric

Occlusal concepts in fixed partial dentures: 1. Canine guided occlusion 2. Group function/ unilateral balanced occlusal concept. 3. Mutually protected occlusion

CANINE GUIDED OCCLUSION :

According to GPT-8 it is defined as A form of mutually protected articulation in which the vertical and horizontal overlaps of the canine teeth disengage the posterior teeth in the excursive movements of the mandible.

Later in 1958 DAmico presented a new concept for the function of human mastication. In the summary he stated, The canine teeth serve to guide the mandible during eccentric movements. The upper canine teeth when in functional contact with the lower canines and first premolars, determine both lateral and protrusive movements of the mandible. Also, this functional relation opens the vertical relation, thus preventing any force to be applied to the opposing incisors, premolars and molars which would be at an angle to their long axis.
9

The canines, due to their crown-root ratio, strategic location away from the fulcrum, and stress-breaking capabilities, were the most likely candidates for this function. Hence the term canine disclusion was formulated. It acted as natures stressbreakers to protect the periodontium and supporting structures from lateral stress during eccentric movements. Upon functional contact by the canines, the periodontal proprioceptive impulses are transmitted to the mesencephalic root of the fifth cranial nerve, which altered the motor impulses to the musculature. The resultant involuntary reaction relaxed the muscles and thus decreased the adverse effects of the lateral force to the periodontium. Advantages i. ii. Patient tolerance Ease of construction

Disadvantages i. Cannot be given when anterior teeth are periodontally weak. ii. Class II and Class III situations, where the mandible is not guided by anterior teeth.
10

iii.

In cross bite situations cannot be used.

GROUP FUNCTION/ UNILATERAL BALANCED OCCLUSAL CONCEPT. According to GPT-8 it is defined as multiple contact relations between the maxillary and mandibular teeth in lateral movements on the working side whereby simultaneous contact of several teeth acts as a group to distribute occlusal forces. It is based on the concept of Schuyler and is widely accepted during restorative dental procedures . It eliminates

tooth contact on the balancing side which would be destructive. Group function on the working side distributes occlusal load.

The group function philosophy appears to be one of physiologic wear. Schuyler and other advocates of group function viewed occlusal wear as a compensatory adaptive change that distributed stress to create a normal functional relationship. Several authors have suggested that occlusal wear was natural and beneficial.

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Advantages i. Maintenance of occlusion i.e. saves the centric holding cusps from excessive wear ii. iii. Used in complete mouth occlusal rehabilitation Functionally generated path described by Meyer is used for producing restorations in unilateral balanced occlusion. MUTUALLY PROTECTED OCCLUSION

i.

Cusps of posterior teeth should be integrated to close in centric occlusion with the mandible in centric jaw relation.

ii. iii. iv.

In lateral excursions, only opposing canines contact. In protrusion, only anterior teeth contact. Mutual protection was defined as cusps of posterior teeth contacting in centric occlusion to protect the anterior teeth, while the contacts of the anterior teeth in incisive position protect the cusp tips of the posterior teeth.

LINGUALISED OCCLUSION:

Introduced by Alfred gysi in 1927. He designed and patented cross bite posterior teeth in 1927. Each maxillary tooth featured a single, linear cusp that fit into a shallow mandibular depression. These teeth were reasonably esthetic,
12

easy to arrange, and encouraged vertical force transmission via their mortar-pestle occlusal anatomy.

REVERSE LINGUALISED OCCLUSION :

Introduced by French in 1935, in which mandibular lingual cusp engages the shallow mandibular fossa.

In 1941 payne modified the lingual concepts via judicious recontouring of 30 th teeth. The maxillary lingual cusps maintained contact with the mandibular teeth in eccentric movements. In contrast, the maxillary buccal cusps did not contact the opposing teeth during mandibular movements. This arrangement provided distinct advantages. Three of these were particularly noteworthy.

i. Lingualized occlusion yielded cross-arch balance. This resulted in improved denture stability and enhanced patient comfort. ii. Lateral forces were reduced because maxillary lingual cusps provided the sole contact with mandibular posterior teeth. As a result, potentially damaging lateral forces were minimized.
13

iii. Vertical forces could be centered upon the mandibular residual ridges. The application of vertical forces was considered advantageous for denture stability and

maintenance of the supporting hard and soft tissues.

Kopp in 1990, introduced this lingualized occlusal scheme in implant supported overdentures and achieved better results than the conventional balanced occlusion.34

Reitz in 1994, introduced lingualized occlusion in single to multiple endosseous implant restoration. The advantages of this occlusion are that the penetration of the bolus of the food is accomplished with less occlusal force and that the opposing incline surfaces of the tooth provide bucco-lingual stability and eliminate the potential for lateral interferences in excursive movements. Mono plane occlusion Cuspless teeth set on a flat plane with 1.5- 2 mm overjet No cusp to fossa relationship No anterior contacts present in centric position No overbite
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Monoplane Occlusion How Stability is Improved Elimination of cusps Lateral forces reduced, improving stability Simplifies denture tooth arrangement

Ensure Teeth Set Over Ridge Minimize tilting/tipping Maximize stability minimize contacts on buccal of flat cusps Monoplane Occlusion Functional, but unesthetic Not balanced - flat Zero degree teeth can be balanced if condylarinclinations are shallow Monoplane Occlussion - When? Jaw size discrepancies, malocclusions cross-bite, Cl II, III Minimal ridge reduces horizontal forces implants help Uncoordinated jaw movements

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IDEAL OCCLUSION:

Ideal

occlusion

is

an

occlusion

compatible

with

the

stomatognathic system providing efficient mastication and good esthetics without creating physiologic abnormalities. Dawson (1974) also described five concepts

important concepts important for an ideal occlusion:

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

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IMPLANT PROTECTED OCCLUSION

(Misch & Bidez 1994). This concept is designed to reduce occlusal force on implant prostheses and thus to protect implants. For this, several modifications from

conventional occlusal concepts have been proposed, which include providing load sharing occlusal contacts,

modifications of the occlusal table and anatomy, correction of load direction, increasing of implant surface areas, and elimination or reduction of occlusal contacts in implants with unfavorable biomechanics. Also, occlusal morphology guiding occlusal force to the apical direction, utilization of cross-bite occlusion, a narrowed occlusal table, reduced cusp inclination, and a reduced length of cantilever in mesio-distal and bucco-lingual dimension have all been

suggested as factors to consider when establishing implant occlusion (Chapman 1989; Hobo et al. 1989; Lundgren & Laurell 1994; Misch & Bidez 1994; Misch 1999a).

17

Basic principles of implant occlusion may include (1) bilateral stability in centric (habitual) occlusion, (2) evenly distributed occlusal contacts and force, (3) no interferences between retruded position and centric (habitual) position, (4) wide freedom in centric (habitual) occlusion, (5) anterior guidance whenever possible, and (6) smooth, even, lateral excursive movements without working/non-working interferences. Along with evenly distributed occlusal contacts, bilateral occlusal stability provides stability of the masticatory system and a proper force distribution (Beyron 1969). This can reduce the possibility of premature contacts and decrease force concentration on individual implants. In addition, wide freedom in centric can accomplish more favorable vertical lines of force and thus minimize premature contacts during function. Weinberg (1998)

recommended continuous 1.5 mm flat fossa area for wide freedom in centric in the prosthesis based on his clinical experience. In addition,

Gibbs et al. (1981) found that anterior or canine guidance decreased chewing force compared with posterior guidance.
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Quirynen

et al. (1992) reported that lack of anterior

contacts in an implant-supported cross-arch bridge created excessive marginal bone loss in posterior implants. The

anterior or canine guidance could minimize potentially destructive forces in posterior implants. In addition to the advantage of the anterior guidance, smooth and even

lateral working contacts without cantilever contacts in the posterior region may be preferred to provide proper force distribution and to protect the anterior region that

(Chapman 1989; Engelman 1996). It was suggested working side

contacts should be placed as anteriorly as

possible to minimize the bending moment (Lundgren & Laurell 1994). Hobkirk evaluated & Brouziotou-Davas patterns (1996)

masticatoryforce

of two occlusal

schemes (balanced occlusion and group-function occlusion) with various

foods in mandibular implant-supported prostheses. The mean peak masticatory force and load rate were lowest

when eating bread and highest when chewing nuts, and the values of the mean peak masticatory force and load rate were lower with balanced group function occlusion occlusion upon compared with

chewing

nuts and

carrots. The study suggested that balanced occlusion might

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be more protective than group-function occlusion. However, Wennerberg et al. (2001) occlusal factors in mandibular observed that

implant-supported

prostheses opposing complete dentures did not influence patient satisfaction and treatment outcomes. It is implied that occlusal schemes may be less crucial factors of implant overloading than the

number and position of occlusal contacts on implant prostheses.

Developing tooth morphology to induce axial loading is an important factor to consider when constructing implant prostheses. The axial loading on thread-type implants can be distributed well along the implant-bone interface, and the cortical bone can resist the compressive stress favorably (Reilly & Burstein 1975; Misch 1993; Rangert et al. 1997). A flat area

around centric contacts can direct the occlusal force in an apical direction. Weinberg (1998) claimed that cusp inclination is one

of the most significant factors in the production of bending moment. The reduction of cusp inclination can decrease the resultant bending moment with a lever-arm reduction
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and improvement of axial loading force. Kaukinen et al. (1996) investigated the difference of force transmission between 331 and 01 cusps. The mean initial breakage force of the 331 cusped specimens was 3.846 kg while the corresponding value of the 01 cuspless occlusal design specimens was 1.938 kg. This result suggests that the cusp inclination affected the magnitude of forces transmitted to implant prostheses. In summary, a reduced cusp

inclination, shallow occlusal anatomy, and wide grooves and fossae could be beneficial for implant prostheses.

The

diameter

and

distribution

of

implants and

harmonization to natural teeth are important factors to consider when deciding the size of an occlusal table.

Typically 30-40% reduction of occlusal table in a molar region has been suggested, but any than the dimension larger

implant diameter can create cantilever effects bending moments in single implant

and eventual

prosthesis (Misch 1993; Rangert et al. 1997). A narrow occlusal table reduces the chance of offset loading and increases axial loading, which eventually can decrease the bending moment (Rangert et al. 1997; Misch 1999a). Misch (1999a) described that a narrow occlusal table also improves
21

oral hygiene and reduces risks of porcelain

fracture.

He

further described that the posterior maxillary region with buccal bone resorption may enforce palatal placement of implants compared with the position of natural teeth. Normal occlusal contour on the palatally placed implant may create a significant poor buccal cantilever in a

biomechanically

environment (heavy bite, poor

bone, and poor crown/implant ratio). In this case, the utilization of cross-bite occlusion can avoid the buccal cantilever and increase the axial loading (Misch 1993; Weinberg 1998). Force distribution between implants and natural teeth in a partially edentulous region can be accomplished with serial and gradient occlusal adjustments (Lundgren & Laurell 1994). Due to the non-significant mobility during initial tooth movement (3-5 mm), implants may absorb all heavy biting force because natural teeth can be intruded (25-50 mm) easily with any occlusal force. Misch (1993, 1999a) proposed that occlusal adjustments could be performed by the elimination of mobility

difference between implants and teeth under heavy bites. This approach may evenly distribute loads between

implants and teeth. Over the years, natural teeth have positional changes in vertical and mesial direction while
22

implants do not change their positions. In addition, enamel on the tooth wears more than porcelain on implant restorations. The positional changes of teeth may intensify the occlusal stress on implants. In order to prevent the potential overloading on implants from the positional

changes, re-evaluation and periodic occlusal adjustments are imperative (Dario 1995; Rangert et al. 1997; Misch 1999a).

OCCLUSAL CONTACT POSITION AND NUMBER:

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

The number of occlusal contacts in an occlusal scheme varies. According to P.K.Thomas occlusal theories ideal occlusal contact should be a tripod contact on each occluding cusp, marginal ridge and in the central fossa with 18-15 individual
23

occlusal contacts on a mandibular and maxillary molar, respectively.

Occlusal contact position determines the direction of force, especially during parafunction. An occlusal contact on a buccal cusp may be an offset load when the implant is under the central fossa and the buccal cusp is cantilevered from the implant body. The angled buccal cusp will introduce an angled load to the implant body. The marginal ridge is also a cantilever load because the implant is not under the marginal ridge but may be several millimeters away.

When the mesio-distal dimension of the crown exceeds the bucco-lingual dimension, the marginal ridge contact may be the most damaging. The laboratory creates the porcelain marginal ridge completely unsupported by metal substructure. The moment forces exerted on marginal ridge, it contribute forces that increase abutment screw loosening. Hence marginal contacts on implant crowns should be avoided whenever possible.

A posterior screw retained restoration often requires cantilevered occlusal contacts. The occlusal screw hole is rarely loaded because the obturation material wears or fractures easily.
24

Hence occlusal contacts are not directed over the top of the implant but are offset several millimeters away.

The number of occlusal contacts found on natural posterior teeth of individuals never restored or equilibrated by a prosthodontist and with no occlusal related pathologic condition has been observed to an average of only 2.2 [range of 1-3] contacts. If the opposing natural tooth had an occlusal restoration, then the occlusal contact number can be reduced to an average of 1.6.

The number of occlusal contacts apparently may be reduced to two contacting areas without consequence. Hence having these occlusal contacts with minimum offset to the implant body is rational. The central fossa is the logical primary occlusal contact position.

Possible overloading factors: 1. Cantilever A large cantilever of an implant prosthesis can generate overloading , possibly resulting in peri - implant bone loss and prosthetic failures (Lindquist et al. 1988; Quirynen et al. 1992; Shackleton et al. 1994). Duyck et
25

al. (2000) reported that the loading position on xed full arch implant supported prostheses could affect the resulting force on each of supporting implants . When a biting force was applied to t he distal cantilever , the highest axial forces and bending moments were recorded on the distal implants , which were more pronounced in the prostheses supported by only three implants as compared with prostheses with ve or six implants . Overextended cantileve 4 15 mm in the m andible (Shackleton et al. 1994) 4 1012 mm in the maxilla (Rangert et al. 1989; Taylor 1991

Cantilevers are force magnifiers. Moment or torque = Force X moment arm. Types of cantilevers : 1. Mesio distal cantilevers. (additional pontics) 2. Bucco lingual cantilever. (wider occlusal table) 3. Crown height space.(CHS)

26

 In fixed prostheses normal crown height space is 9 to 12mm. In removable prostheses is 12 to 15mm. Increased crown height space is acts as a vertical cantilever. For every 1 mm increase in height, the amount of force also increased 20 percent.

2.

Parafunctional habits / heavy bite force

1. Number of implants should be increased. 2. Longer and wider the implants should be placed. 3. Healing time should be prolonged. Delayed

loading is better than early loading. 4. Usage of Occlusal guards reduce the amount of force drastically. 5. Anterior teeth may be modified to recreate the proper incisal guidance and avoid posterior

interferences during excursions.

27

3.

Excessive premature contacts

Loss of osseointegration and excessive marginal bone loss from excessive lateral load provided with premature occlusal contacts were demonstrated in several animal studies (Isidor 1996, 1997; Miyata et al.2000). In nonhuman primate studies, it was observed that five out of eight implants lost osseointegration due to excessive occlusal overloading (Isidor 1996, 1997). after 4.5-15.5 months of loading

Among the three remaining implants, one showed severe crestal bone loss and the other two showed the highest bone implant contact and density. The results

suggested that implant loading might have significantly affected the responses of peri implant osseous structures. However, it should be noted that the loss of

osseointegration observed might have been attributed to the unrealistically high-occlusal overload used in the study. Similar studies were performed in monkeys with different heights of hyperocclusion, 100, 180, and 250 mm (Miyata et al. 1998, 2000). After 4 weeks of loading, bone loss was
28

observed in 180 and 250 mm group, not in the 100 mm group. The results of these studies suggested that there would be a critical height of premature occlusal contacts on implant prostheses for crestal bone loss. Hoshaw et al. (1994) applied an excessive controlled cyclic load (330 N/s, 500 cycles, 5 days) on implants in canine tibia. Significant bone resorption and less mineralized bone percentage were observed in loading group compared with non-loading group.

Another study demonstrated that excessive dynamic loading (73.5 N cm bending moment and total 2520

cycles for 2weeks) on implants placed in rabbit tibia caused crater-like bone defects lateral to implants (Duyck et al. 2001). Contradictory to the findings from the above studies, some studies have demonstrated that overloading did not increase marginal bone loss (Asikainen et al. 1997; Hurzeler et al. 1998). The difference observed between the studies may be attributed to different magnitude and duration of applied force. Also, it should be noted that direct application of the findings from the animal studies to humans requires caution. Nonetheless, it can be

speculated that occlusal overload may act as one of

29

the factors causing marginal bone loss and implant failure.

Bone quality has been considered the most critical factor for implant success at both surgical and functional stages, and it is therefore suggested that occlusal overload in poor-quality bone can be a clinical concern for implant longevity (Lekholm & Zarb 1985; Misch 1990a). In human studies, higher failures of implants were observed in bone with poor quality (Engquist et al.1988; Jaffin & Berman 1991; Becktor et al. 2002). Jaffin & Berman (1991) reported that 35% of implants placed in poor bone quality (i.e. posterior maxilla) failed at the second-stage surgery. However, it should be noted that all of the implants evaluated were Branemark implants with a smooth pure titanium surface, which is considered less favorable for poor quality bone (Cochran 1999). Some studies reported that higher implant failures in maxillary over dentures were attributed to poor bone quality of the maxilla (Engquist et al. 1988; Quirynen et al. 1992; Hutton et al. 1995). In addition to poor bone quality, unfavorable load direction may have

contributed to higher failure rates in the maxilla (Jemt & Lekholm 1995; Blomqvist et al. 1996; Raghoebar et al. 2001; Becktor et al. 2002). Esposito et al. (1997) found that
30

late failure of implants did not show any infectious factor in histological evaluation. The combination of poor bone quality and overload was considered to be the leading cause for the late implant failure.

4. 5. 6. 7.

Large occlusal table. Steep cuspal inclination. Poor bone density /quality. Inadequate number of implants.

CLINICAL APPLICATIONS

Occlusion on full-arch fixed prostheses For

full-arch

fixed implant prostheses, bilateral balanced occlusion has been successfully utilized for an opposing complete denture, while group-function occlusion has been widely adopted for opposing natural dentition. Mutually protected occlusion with a shallow anterior guidance was also recommended for opposing natural dentition (Chapman 1989; Hobo et al.1989; Wismeijer et al. 1995). Bilateral and anteriorposterior simultaneous contacts in centric relation and MIP should be obtained to evenly distribute occlusal force
31

during excursions

regardless of the

occlusal

scheme &

(Chapman 1989; Quirynen et al. 1992; Lundgren Laurell 1994). excursive occlusal In addition, smooth, even,

lateral

movements

without

working/non-working should be obtained

contacts on cantilever

(Lundgren & Laurell 1994; Engelman 1996). For occlusal contacts, wide freedom (1-1.5 mm) in centric relation and MIP can accomplish more favorable vertical lines of force and thus minimize premature contacts during

function (Beyron 1969; Weinberg 1998). Also, anteriorly placed posterior working contacts were advocated to avoid

overloading (Hobo et al. 1989; Taylor 1991).

When a cantilever is utilized in a full-arch fixed implant prosthesis, infraocclusion (100 mm) on a cantilever unit was suggested to reduce fatigue and technical failure of the prosthesis (Lundgren et al. 1989; Falk et al. 1990). Implant prostheses with less than 15 mm cantilever in the mandible demonstrated significantly better survival rates than those with longer than 15 mm cantilever (Shackleton et al. 1994). On the other hand, less than 10-12 mm cantilever was recommended in the maxilla due to unfavorable bone quality and unfavorable force direction compared with the mandible (Rangert et al. 1989;
32

Taylor 1991; Rodriguez et al. 1994). Wie (1995) found that canine guidance occlusion increased a potential risk of screw joint failure at the canine site due to stress concentration the area. on

Occlusion

on

overdenturesFor

the

occlusion

on

overdentures, it has been suggested to use bilateral balanced occlusion with lingualized occlusion on a normal ridge. On the other hand, monoplane occlusion was recommended for a severely resorbed ridge (Lang & Razzoog 1992; Wismeijer et al. 1995; MericskeStern et al. 2000). Although there has been consensus that

bilateral balance occlusion can provide better stability of over dentures (Engelman 1996), there are no clinical

studies which demonstrate the advantages of bilateral balanced occlusion for overdenture occlusion compared with other occlusal schemes. Recently, Peroz et al.

(2003) performed a randomized, clinical trial comparing two occlusal schemes, balanced occlusion and canine guidance, in 22 patients with conventional complete dentures. The results of the assessment using a visual analog scale revealed that canine guidance was comparable to
33

balanced

occlusion

in

denture

retention,

esthetic

appearance, and chewing ability.

Occlusion

on

posterior

fixed

prostheses.

Anterior

guidance in excursions and initial occlusal contact on natural dentition will reduce the potential lateral force on osseointegrated implants. Group-function occlusion should be utilized only when anterior teeth are periodontally compromised (Chapman 1989; Hobo et al. 1989; Misch & Bidez 1994). During lateral excursions, working and nonworking interferences should be avoided in posterior

restorations (Lundgren & Laurell 1994). Moreover, reduced inclination of cusps, centrally oriented contacts with a 1-1.5 mm flat area, a narrowed occlusal table, and elimination of cantilevers have been proposed as key factors to control bend overload in posterior restorations (Weinberg 1998; Curtis et al. 2000). In a recent in vivo study, it was reported that narrowing the buccolingual width of

the occlusal surface by 30% and chewing soft food significantly reduced bending moments on the posterior three-unit fixed prosthesis (Morneburg & Proschel 2003). The study also suggested that soft diet and reduction of the buccolingual, occlusal surface need to be considered in
34

unfavorable

loading

conditions, such as immediate

loading, initial healing phase, and/or poor bone quality.

Wennerberg

&

Jemt

(1999)

described that

additional implants in the maxilla could provide tripodism to reduce overloading and clinical complications. Also, axial positioning and reduced distance between posterior

implants are important factors to decrease overloading (Belser et al. 2000).

The utilization of cross-bite occlusion with palatally placed posterior maxillary implants can reduce the

buccal cantilever and improve the axial loading (Misch 1993; Weinberg 1998). If the number, position, and axis of implants are questionable, natural tooth connection with a rigid attachment can be considered to provide additional support to implants (Rangert et al. 1991; Belser et al.

2000; Naert et al. 2001).

Occlusion on single implant prosthesis. The occlusion in a single implant should be designed to minimize occlusal force on to the implant and to maximize force distribution to adjacent natural teeth (Misch 1993; Lundgren & Laurell 1994;
35

Engelman

1996).

To accomplish these objects, any anterior and lateral guidance should be obtained in natural dentition. In addition, working and non-working contacts should be avoided in a single restoration (Engelman 1996). Light contacts at heavy bite and no contact at light bite in MIP are considered a reasonable approach to distribute the occlusal force on teeth and implants (Lundgren & Laurell 1994). Like posterior fixed prostheses, reduced inclination of cusps, centrally oriented contacts with a 1-1.5 mm flat area, and a narrowed occlusal table can be utilized for the posterior single tooth implant restoration (Weinberg 1998; Curtis et al.2000). Wennerberg & Jemt (1999) claimed that centrally oriented occlusal contacts in single molar

implants were critical to reduce

bending

moments

attributable to mechanical problems and implant fractures. Increased proximal contacts in the posterior region may provide additional stability of restorations (Misch 1999b). Two implants for a single molar have been utilized and demonstrated less screw loosening and higher success rates (Balshi et al. 1996).

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However, the placement of two implants in a limited space is a challenging procedure, and difficulty in oral hygiene and prosthetic fabrication may develop. Instead of two implants in a single molar area, a wide-diameter implant with proper position and axis in a molar area could be a better option difficulties and to to reduce surgical and prosthetic

improve

oral hygiene and loading

condition (Becker & Becker 1995; Chang et al. 2002). The occlusal guidelines in various clinical situations are

summarized in Table.

Potential complications and solutions Implant overloading attributes clinical complications such as screw loosening, screw fractures, fractures of veneering materials, prosthesis fractures, continuing marginal bone loss below the first

thread along the implant, implant fractures, and implant loss (Zarb & Schmitt 1990; Jemt & Lekholm Wennerberg & Jemt 1993;

1999; Schwarz 2000). These

complications can be prevented by application of sound biomechanical principles such as passive fit of the the

prosthesis, reducing cantilever length, narrowing bucco-lingual/mesio-distal.

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CLINICAL SITUATIONS
Full-arch fixed prosthesis

OCCLUSAL PRINCIPLES
Bilateral balanced occlusion with opposing complete denture Group function occlusion or mutually protected occlusion with shallow anterior guidance when opposing natural dentition No working and balancing contact on cantilever Infraocclusion in cantilever segment (100 mm) Freedom in centric (1-1.5 mm)

Overdenture

Bilateral balanced occlusion using lingulized occlusion Monoplane occlusion on a severely resorbed ridge

Posterior fixed prosthesis

Anterior guidance with natural dentition Group function occlusion with compromised canines Centered contacts, narrow occlusal tables, flat cusps, minimized cantilever Cross bite posterior occlusion when necessary

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Natural tooth connection with rigid attachment when compromised support Single implant prosthesis Anterior or lateral guidance with natural dentition Light contact at heavy bite and no contact at light bite Centered contacts (1-1.5 mm flat area) No offset contacts Increased proximal contact Poor quality of bone/Grafted bone Longer healing time Progressive loading by staging diet and occlusal contacts/materials

IMPLANT SUPPORTED OVER DENTURE

Edentulous classification

Type of prosthesis

Optimal Occlusal Scheme

Edentulous

a)for normal ridges

Bilateral Balanced with lingualized occlusion

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 At least three point balance on lateral and protrusive excursion. Increase vertical dimension and alter plane relation to allow for vertical space for attachment housings and metal framework space if necessary. Decrease vertical dimension if interarch distance is excessive and poses a biomechanical risk. Keep attachment height minimal to avoid unfavorable torquing moments on implants. Horizontal axis of rotation of the denture base round anterior attachments is purported to reduce distal cantilever effect on loading of distal denture saddles. This and a lack of indirect retention causes distal denture displacement on anterior closure increasing need for protrusive balance. With anterior and posterior implant supported attachments, enhanced retention and resistance reduces the need for balance to prevent distal base displacement.

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41

LOADING PROTOCOL:

2008 ITI consensus

1. Immediate loading A restoration is placed in occlusion with the opposing dentition within 48 hours of implant placement.

2. Early loading A restoration in contact with the opposing dentition and placed at least 48 hours after implant placement but not later than 3 months afterward.

3. Delay loading The prosthesis is attached in a second procedure that take place some time later than the conventional healing period of 3 to 6 months.

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1.

Occlusal form

In many studied conducted of the effect of occlusal form on the loading and efficiency of implants, they have concluded saying that anatomic cusp are very efficient in grinding food but it produces angled load on the implant. Hence Jamie in 1996 said that instead of having a sharp cusp give a shallow occlusal anatomy and flat occlusal table at the point were the opposing cusps contacts. This act as long centric as well as it increases the efficiency of occlusion. According to kaukinen 1996, 33degree cusps breakdown food better than zero degree cusps but in a long usage zero degree is preferred by patients.

Weinberg in 1995 in a study said that every 10degree increase in cuspal inclination, there was 30% increase in loading to the implant. The matiscatory efficiency was seen in 20 degree teeth.

In

full

arch

prosthesis

or

implant

supported

prosthesis, the anterior guidance should be shallow not steep because every 10 degree change in angle of posteriors there is an increase force in anterior tooth. If the anterior teeth are also prosthesis or periodontal
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compromised then they should be splinted.

Since the proprioception is absent in implants patient tends to overload the implant, so a 20 degree cusp is preferred over flat cusp.

2.

Material of choice for occlusal table

ESTHETICS IMPACT FORCE CHEWING EFFICIENCY FRACTURE WEAR INTERARCH SPACE ACCURACY

PORCELAIN + + + -

GOLD + + + + + +

RESIN + + -

3.

How to check the final implant occlusion?

The final procedure by which dentists can analyses the force falling on the prosthesis is by using disclosing materials or T-scan technology. Using these dentists can locate the point of favorable and unfavorable contact so
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he/she can eliminate the unfavorable once. Articulating papers for implants 1. 16 2. 12 3. 8 : : : Gnatho-film/soft also ultra called thin

occlusal shimstock articulating

film film film

(red/blue/green/black)

(red/blue/green/black)

(red/blue/green/black) In which 8 is used of fixed implant prosthesis and 12 and 16 are used for removable implant prosthesis. We have articulating papers till 200 then why are we using the thinnest of all ? this depends to the load bearable by the prosthesis. Force bearable by tooth to tooth prosthesis = 58 m. Force bearable by tooth to implant prosthesis = almost 28 m. Force bearable by implant to implant prosthesis = almost 0 m.

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So to reduce the force to the minimum on the implant the thinnest articulating paper is used. Thing to be noted here is that the implant has no proprioception so the patient tends to over load when you ask him to bite. Hence the patient should be asked to close the mouth, not to bite. Procedure: Light force and thin articulating paper are first used to evaluate centric relation of the occlusal contacts. Then light force and thin articulating paper are used to ensure that no implant crown contact occurs during the initial lateral movement, if heavier forces are present during excursions it is balanced to provide similar occlusal contacts on both anterior implants and natural teeth. The primary aim is that occlusal force should be directed along the long axis of the implant body and not at an angle or following an angled abutment post. The occlusion should be rechecked after

cementation of the prosthesis. The articulating paper has a lot of disadvantage which are overcome by using T.scan
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4.

T-scan

The ultra-thin, reusable sensor, shaped to fit the dental arch, inserts into the sensor handle, which connects into the USB port of your existing PC, making it easy to move from one operatory to another. Evaluating occlusal forces is as simple as having a patient bite down on the sensor while the computer analyzes and displays timing and force data in vivid, full-color 3-D or 2-D graphics.

The ability to measure force over time makes the TScan an indispensable tool for appraising the sequential relationships of a mandibular excursion. You can view, on screen, a patient sliding from MIP or CR position into a lateral excursion. This is instrumental in locating occlusal interferences, determining the relative force on each interference , and evaluating the potential for trauma caused by the occlusal interferences.

With articulation paper marks, there is no scientific correlation between the depth of the color and the mark, its surface area, amount of force , or the contact timing
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sequence that results as that paper mark is made. The Tscan III Occlusal Analysis system quickly and precisely determines the amount of force within a given paper mark. The software graphically displays both forceful and time premature contacts to the user for predictable occlusal contraol during adjustment procedure.

In new research undertaken at the university of Alberta by Carey JP, Craig M, Kerstein RB, and Radke J, the following conclusion is drawn : No direct relationship between paper mark area and applied load could be found. When selecting teeth to adjust, an operator should not assume the size of the paper markings can accurately describing the markings occlusal contact force content. According to Jason p. Carey , only 21% of the marks correlated to the applied occlusal load, while 79% of the marks did not describe the applied load that imprinted the marks to the casts.

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ADVANTAGES: Improve clinical results. Differentiate your practice. Expand your practice in a wide range of applications. Take back control, no longer rely on patient feel. Determine premature contacts. Minimize destructive forces. Provide instant documentation for fee-for-service approach and/or insurance claims. Use as a patient education tool to enhance comfort and increase case acceptance. Save time by preventing remakes. 5. What are the other means of reducing force on an implant? Angle of the implant. Design of the prosthesis. Splinting of the implants. Staggering of implants. Number of implants 6. Roll of dentist.

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SUMMARY

50

REFERENCES.
1. 2. Dental implant prosthetics, Carl E. Misch DDS, MDS. Contemporary implant dentistry, 3RD EDITION, Carl E. MISH, 3. HT Shillingburg, Fundamentals of Fixed Prosthodontics, 3rd Edition Fundamentals of Occlusion. 4. Dawson PE Evaluation, Diagnosis and treatment of occlusion problems: A textbook of Occlusion. @nd Edition St. Louis, C.V Mosby Co. 1978. 5. Occlusal considerations in implant therapy : clinical guidelines with biomechanical rationale, 2004, 16, 26-35. 6. Occlusion and occlusal considerations in implantology, 2010,125-130. 7. Implant occlusion: biochemical considerations for implant-supported prostheses, J Dent Sci 2008 vol3 no.2.
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8.

Occlusion in implant dentistry: A review of the literature of prosthetic determinants and current concepts, Australian dental journal, 2008, s60-s68.

9.

Dental occlusion : modern concepts and their application in implant prosthodontics, Odontology 2009, 97 ; 8-17

10. The influence of functional forces on the biomechanics of implant-supported prostheses- a review. Journal of dentistry 2002 ; 271:282. 11. Strain of implants depending on occlusion types in mandibular implant-supported fixed prostheses, Journal of prosthodont 2011; 3 : 1-9. 12. Lingualized occlusion revisited, (jpd2010;104:342346), J Prosthet Dent 2010; 104:342-346. 13. Group function or canine protection, J Prosthet Dent 2004; 91:404-8. 14. Occlusion: Reflections on science and clinical reality, Journal of Prosthetic Dentistry 2003; 90: 373-84.
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