International Dental Journal (2008) 58, 139-145

Guidelines for occlusion strategy

in implant-borne prostheses.
A review
Benito Rilo, Jos Luis da Silva, Mara Jess Mora and Urbano Santana
Santiago de Compostela, Spain.
Medium- or long-term failure of endosseous dental implants after osseointegration, when
it has occurred, has been associated in the great majority of cases with occlusal overload.
Overload depends ultimately on the number and location of occlusal contacts, which to a
great extent are under the clinicians control. Much of our current understanding of occlusal
contacts in this context is based on concepts derived from non-implant-borne prosthetics
and has not been rigorously tested. The present article reviews occlussal contact designs
and offers occlusion strategy guidelines for the main types of implant-borne prostheses.
Key words: Endosseous dental implants, overload, failure, implant-borne prosthetics

Osseointegration has been one of the most important

therapeutic advances in recent years, greatly facilitating
the placement of single or multiple prostheses. The
medium- and long-term results obtained to date are very
promising, and there is a continuing effort to improve
these techniques through the development of different
types of implant with modications of surface area,
surface texture, morphology, etc. Nevertheless, there
remains a small risk of implant failure, and these failures
can be divided into two major groups: early failures
closely related to the surgical procedure and late failures
manifesting after osseointegration has occurred.
Late failure of osseointegration may occur for several reasons such as host resistance, plaque build-up
and occlusal overload1,2. Some of these problems (such
as plaque build-up) are readily resolved, while others
(such as occlusal overload) are more complex. There
is an extensive literature supporting the view that occlusal overload may provoke peri-implant bone loss3-9
and eventually osseointegration failure. However, some
authors have argued that bone loss and osseointegration
failure are principally due to biological causes20, notably
infection, and that there is no rm evidence to support
a negative effect of prolonged periods of non-axial
loading on implant osseointegration11,12. Certainly, the
relative importance of mechanical and microbial factors
in determining the time-course of bone loss around
implants remains to be properly resolved13. What ap 2008 FDI/World Dental Press
0020-6539/08/03139-07

pears clear is that occlusal overload may at least cause

mechanical complications14-18 such as fracture of the
ceramic, decementation of the prosthesis and loss of
abutment retention.
Various factors and situations that can give rise to occlusal overloading have been reported16, including excessive crown-to-implant length ratio19, over-sized occlusal
surfaces20, unfavourable direction of axial forces21,22,
and cantilever effects23,25. Undoubtedly all these factors
may cause occlusal overloading, whether acting alone at
high intensity or together at lower intensities; however,
all act via a single route, i.e. via occlusal contacts. Thus
any damage due to occlusal overloading will be highly
dependent on the number and location of occlusal
contacts. Both variables can of course be controlled by
the dentist; in other words, our occlusion strategy and
occlusal adjustments will have a major inuence on the
risk of occlusal overloading, both in normal patients and
in patients showing parafunctional behaviours (bruxism,
clenching, etc.) that worsen prognosis8,15,19,26.
It would be of interest to have broad guidelines on
the optimal number and location of occlusal contacts
for each type of implant-borne prosthesis, though of
course adjustable in view of the specic characteristics
of each individual patient. As a rst approximation we
would suggest that patients can be divided into two
major groups. First, we have patients with many teeth
and few implants; in such cases, occlusion should be
doi:10.1922/IDJ_1893Rilo07

140

designed so that the teeth bear the full occlusal load,

and transmit mainly lateral loads to the implants. In
these cases there is no need to modify the pre-existing
occlusion, unless there are symptoms of dysfunction
requiring modication27. Thus restoration aims to be
in harmony with existing mandibular relations; in other
words, the restoration will be designed such that the
occlusal contacts of the other teeth are unaffected28,29.
Second, at the other end of the spectrum we have patients with many implants and few teeth, or no teeth;
in these patients the occlusion will be designed such
that the implants receive all the load. In such cases a
reorganisational approach is appropriate30, since the new
restorations will lead to different occlusal patterns that
need to be anticipated before rehabilitation is started.
To develop practically useful guidelines it is important to consider dentition status in greater detail, and
to consider the type of prosthesis to be tted. As far
as we are aware, there have been few previous reports
aimed at offering dentists recommendations on occlusal
considerations in implant rehabilitations1,16. We reviewed
occlusal contact designs in implant rehabilitations,
considering type of implant/prosthesis and dentition
status (Table 1).
It is important to distinguish between contacts in
static occlusion (when the mandible is closed and stationary) and dynamic occlusion (when the maxilla is
moving in relation to the mandible). In static occlusion,
the ideal occlusion paradigm is generally accepted,
for all implant/prosthesis types, as for tooth-tooth

occlusion31,32. In other words, the clinician aims for

the maximum intercuspation position to coincide with
centric relation, with the mandible free to move slightly
forwards from this position in the sagittal and horizontal
planes (i.e. freedom in centric occlusion). In lateral excursion movements, occlusion goals will be more varied,
and will be discussed below.
Single-tooth implants

With this type of implant, the aim should be to ensure

that occlusal loads are directed as much as possible along
the longitudinal axis of the implant, since bone height
and/or width are often insufcient for placement of the
implant in the most appropriate position. In addition,
it is important to ensure that loads are small33 and to
this end if there is a tooth contact of light or medium
intensity in maximum intercuspation position, a clearance of 30m should be left between the occlusal face
of the implant and the opposing arch34. This clearance
aims to compensate for the different biomechanics of
the tooth and the implant35,36 and to avoid overloading
of the implant, since under heavy loads the tooth may
intrude into the alveolus, whereas the implant-borne
prosthesis will not intrude into the bone. Failure to leave
this occlusal clearance will expose the prosthesis to excessive loads, and unfortunately the patient will typically
not be aware of the overloading due to the absence of
periodontal ligament and limited tactile sensitivity in the
bone implants alveolus37-39. The aim is thus to ensure

Table 1 Occlusal guidelines for the major categories of implant-supported prosthesis

Dentition status

Prostheses type

Occlusal contacts
Maximum Intercuspidation Position
Light intensity

Maximum intensity

Excursive Movements

Partially edentulous
Single missing tooth

Single-tooth implant

Clearance 30m

Contact

No contact

Partially edentulous with distal

tooth abutment

Fixed prosthesis

Clearance 30m

Contact

No contact

Canine present

Fixed prosthesis

Clearance 30m

Contact

Canine guidance

Canine absent

Fixed prosthesis

Clearance 30m

Contact

Group function

Bilateral free-end

Fixed prosthesis

Contact

Contact

Group function

Anterior partially edentulous

Fixed prosthesis

Clearance 30m

Clearance 30m

Contact protrusion only

Partially edentulous with distal

implant abutment

Implant/tooth-supported prostheses

Clearance 30-50m

Contact

No contact

Fixed prosthesis

Contact

Contact

Mutually protected
Occlusal balance

Overdenture

Contact

Contact

Occlusal balance

Unilateral free-end

Completely edentulous

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that the implant is not subjected to load during light or

moderate dental contact, and that during high-intensity
contacts the implant and the teeth contact simultaneously (Figure 1). In protrusive and lateral movements the
occlusal face of the implant should not be loaded, in
order to minimise the transverse forces that can act on
implants of this type; researchers using nite-element
models have indicated that non-axial horizontal forces
in particular give rise to high stresses around the neck
of the implant40. Minimisation of transverse forces can
be achieved by performing selective adjustments on
contacts marked on articulator paper, so that only the
natural teeth (not the implant) participate in occlusal
guidance. In addition, it may also be of interest to reduce the size of the occlusal face and/or the inclination
of cusp slopes in the denture41-43.
Fixed partial dentures

Occlusion goals for dentures of this type will vary

depending on location (anterior or posterior) and on
whether it has a uni- or bilateral free end. In what follows we discuss the different situations as grouped by
Kennedy classes, in order of decreasing number of
natural teeth.
Kennedy Class III

As with single-tooth implants, natural teeth located

anterior or posterior to the edentulous space will allow
clearance of 30m between the occlusal surface of the
implants and the opposing teeth during light- or moderate-intensity contacts. Loading should be as axial as possible, and there should not be contacts during protrusion

or lateral excursions32. Anterior or canine guidance may

minimise the potential destructive stresses on posterior
implants and it has been suggested that working-side
contacts should be placed as far anterior as possible to
minimise leverage34.
Kennedy Class II (unilateral free end)

Achieving an axial direction of loading tends to be more

difcult due to bone resorption processes. A clearance
of 30m should be left in low- to moderate-intensity
occlusion, so that the natural teeth can intrude and so
that there are contacts with both teeth and implants
during maximum-intensity occlusion, thus distributing
the loading more evenly. Contacts during protrusive
movements should be avoided. In the case of laterality
movements the appropriate response will depend on
type of guidance. If a canine is present (i.e. unilateral
free end with absence of premolars and molars), canine
guidance needs to be established, disoccluding the prosthesis during working and balancing movements44. If no
canine is present, it is necessary to establish group function, aiming to achieve the maximum contact possible
during working movements, with the aim of distributing the load over all the implants (Figure 2). Splinting
implant crowns may also be benecial, with the aims
of favourably distributing implant loadings, minimising
the transfer of horizontal loads to the bone-implant
interface, and increasing the bone surface45.
Kennedy Class I (bilateral free ends)

In this case if we leave a clearance between the teeth and

the implants in low-intensity occlusion it is very possible

Figure 1. Single-tooth implant. Teeth-implant contacts:

a) During light or moderate intensity. b) During high-intensity.
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142

Figure 2. Partially edentulous, unilateral free-end.

a) Canine present. Canine guidance.
b) Canine absent. Group function.

that this will overload the natural front teeth. Thus the
approach should be similar to mutually protected occlusion: contacts should be established on the implant
in low- and medium-intensity occlusion at maximum
intercuspation position, and the incisors should be left
without contact or with only slight contact. There is one
controversial point: if canines are present, these will
contact with their antagonists in maximum in the intercuspation position and the protrusion movement will be
guided by the natural teeth without involvement of the
implants. In lateral movements, if canines are present
we can opt for canine guidance; if they are not present
or are periodontally compromised, group function can
be established on the implant prosthesis33.
Kennedy Class IV

This is a bridge in the anterior sector, so that the opposite considerations apply. There should be no contacts
in the anterior sector in maximum intercuspation and
the loads should be borne by the posterior sectors of
the natural dentition. If an implant is located in the canine position the clinician will have to decide whether it
participates or not in the corresponding working movement during lateral movements. If the natural teeth have
good support, either canine guidance or group function
may be appropriate; occasionally, it may be advisable to
allow canine guidance to be established over an isolated
implant. The protrusive movement should be guided by
the anterior sector, independently of whether the loads
will be borne only by the implants (thus the planning
stage should include the number and length of implants
necessary), or whether they can be borne by both teeth
and implants. As a general rule, the posterior teeth
should be disoccluded for at least two incisive contacts
on each side of the midline46.
International Dental Journal (2008) Vol. 58/No.3

Full-arch fixed dentures

Two types of occlusal scheme can be considered for

this type of prosthesis: mutually protected occlusion
and occlusal balance.
Mutually protected occlusion47,48 is the most widely
used approach, especially when the opposing arch is of
natural teeth. This approach is based on concepts derived from the gnathological school and thus the posterior sector receives loads in maximum intercuspation
while a slight clearance is maintained in the anterior sector. In contrast, in the anterolateral sector the implants
in the incisor and canine positions should disocclude
the posterior sectors during lateral movements both on
the working and balancing side (it is not recommended
that all load should be borne only by the implant in the
canine position).
Occlusal balance49,50 (very useful when both arches
have been rehabilitated) is a concept derived from the
complete denture that aims to balance the action of
the muscles on both sides simultaneously, and thus to
balance forces and stress on the two sides of the dental
arch. This approach can be dened as a condition in
which there are simultaneous contacts of opposing
teeth or tooth analogues on both sides of the opposing
dental arches during eccentric movements within the
functional range51. The number of contacts is maximal
in maximum intercuspation and during lateral excursions
there are simultaneous working and balancing contacts
(Figure 3). Although the major disadvantages of this approach are evident (greater technical complexity, more
time-consuming), it appears to be the best approach
in terms of stability and even distribution of loadings
among implants. For natural teeth, a drawback of this
type of occlusion is uncertainty about the position of
the teeth, and thus of contacts, over time;31 however,
this is not a problem with prostheses permanently anchored with implants.

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Implant-retained overdentures

Despite occasional reports to the contrary, occlusal

balance seems to be the most advisable approach when
rehabilitation is of the two arches. This may be more
complex to perform when the opposing arch bears
natural teeth due to the difculty of obtaining all lateral contacts. In such cases simultaneous balancing and
working contacts for some if not all teeth should be
sufcient for stabilisation of the prosthesis in biome-

chanical terms: a contact on the balancing side, together

with one or various contacts on the working side may
imply a reduction in mandibular leverage52. In cases of
pronounced resorption of the upper maxillary bone lingualised occlusion has been proposed33,53 with contacts
established only between the upper palatal cusps and
the mandibular central fossae leaving a slight clearance
between the buccal cusps; this approach makes the implant loadings more axial, and simplies the procedure.
Another option in cases of extreme maxillary resorption
is to establish posterior crossbite, thus achieving more
axial implant loading.
Implant/tooth-supported prostheses

Figure 3. Occlusal balance. Simultaneous working and

balancing contacts during lateral excursion.

This is the most controversial type of implant-prosthesis. It is generally accepted that it is not an ideal situation,
due to the different biomechanical behaviours of tooth
and implant, so that the use of some sort of stressbreaker has been recommended such as an interlock or
a telescopic crown54-56. Despite this, follow-up studies
have indicated good results and biomechanical studies
have not observed stress gradients even when stressbreakers are not used, and independently of whether
rigid or non-rigid connectors are used57-62. Given that
the normal location for this type of prosthesis is in the
posterior sector with one or various implants distal, and
the supporting tooth mesial, and that there have been no
detailed scientic studies of occlusion strategy for this
type of prosthesis, we suggest the following guidelines:
leave a clearance of about 30-50m between the occusal
face of the implant and the opposing arch with the aim
of reducing the moment of the force produced at the

Figure 4. Implant/tooth-supported prostheses. Teeth-implant contacts:

a) During light or moderate intensity. b) During high-intensity.
Rilo et al.: Guidelines for implant-borne prostheses

144

start of the contact. If the contact is on tooth mesially

and implant distally and the opposing arch is similar,
due to very rapid intrusion of the tooth even under
very light loads (1N may provoke a tooth displacement
of 10m), the situation is analogous to that of an implant-supported prosthesis with cantilever, which may
lead to overloading of the implant. With the separation
proposed the tooth intrudes into, and reaches its apical
most position in, the alveolus; the loads are then distributed between tooth and implant and the prosthesis
functions with two xed abutments (Figure 4). The
supporting tooth should have excellent bone support.
Rotational movements should be avoided, and there
should be no lateral contacts. Under these conditions
occlusal overloading is not expected.
Conclusions

This article has presented occlusal guidelines for the

major categories of implant-supported prosthesis with
the aim of reducing the risk of occlusal overload. There
is widespread consensus about the pathogenic effects
of occlusal overload on peri-implant bone resorption,
and thus on osseointegration. However, solid information is not currently available about how loadings differ
between the different types of prosthesis, and how loadings can be modied by adjustment of occlusal contacts.
This lack of solid scientic evidence is particularly acute
for certain types of prosthesis, such as bilateral free-end
prostheses and implant/tooth-supported prostheses.
Much of the information available is derived from
occlusal concepts for non-implant-supported dental
prostheses and in general, discussions about occlusions
are based on personal experience rather than on scientic studies63. The clinician must thus be very careful
when establishing dental contacts and planning the
most appropriate occlusal scheme for each particular
case. The guidelines presented here may be useful to
this end.

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Correspondence to: Dr Benito Rilo, Prosthodontics Department,

Faculty of Medicine and Odontology, Santiago de Compost-
ela University, 15705 Santiago de Compostela. Spain. Email:
benitorilop@yahoo.es

Rilo et al.: Guidelines for implant-borne prostheses