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Principles of occlusion in implant dentistry


Mahesh Verma, Aditi Nanda, Abhinav Sood

Department of Prosthodontics, Maulana Azad Institute of Dental Sciences, Delhi, India

ABSTRACT
Dental implants require different biomechanical considerations from natural teeth. Also, with one of the
criteria for long-term implant success being occlusion, it becomes imperative for the clinician to be well
versed with the different concepts when rehabilitating with an implant prosthesis. All endeavors must be
made to reduce the overload and noxious forces on implants during mandibular movements. The occlusal
rehabilitation schemes for implant-supported prostheses are derivatives of the occlusal scheme for natural
dentition. The implant-protected occlusion (IPO) scheme has been designed to ensure the longevity of both
prosthesis and implant. The article reviews the concepts of IPO and their applicability in different clinical
scenarios.

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DOI: 10.4103/2231-0754.172924
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Key words: Biomechanical, guidelines, implant, occlusal scheme, occlusion

INTRODUCTION
Determining an occlusal scheme for the restoration of
implants requires careful consideration. This stems from the
fact that after osseointegration, mechanical stresses beyond
the physical limits of hard tissues have been suggested as
the primary cause of initial and long-term bone loss around
implants.[1-4] 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.[5,6]
It can be rightly said that occlusion is a determining factor
for implant success in the long run.[7,8]
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. The probable reason for this practise is the
similarity (during mandibular movement) in the velocity ,
the pattern of movement and the operating muscles that
are used by patients with implants and those with natural
dentitions.[9] Moreover, it has been established that the
clinical success and longevity of implants can be achieved by
biomechanically controlled occlusion.[10] This implies that the
occlusion provided must follow sound mechanical principles,
Address for correspondence:
Dr. Mahesh Verma, Maulana Azad Institute of Dental Sciences,
Bhadur Shah Zafar Road, New Delhi - 110 002, India.
E-mail: maidsdp@gmail.com

direct forces predominantly along the long axis of the implant


body, and minimize off-centered forces. The same should be
aimed to impart and enhance biological stability.
However, there are a few innate differences between natural
teeth and implants, which need to be considered when
restoring implants. Natural teeth are associated with high
occlusal awareness (proprioception) of about 20 m. Occlusal
proprioception is low in implants. For instance, between a
tooth and an implant the proprioception is around 48 m;
between two implants it is around 64 m; and between a
tooth and an implant-supported overdenture it is around
108 m.[11-14] The lack of proprioception and the absence
of periodontal shock absorption are often associated with
increased impact force with an implant-supported prosthesis
than with a tooth-supported prosthesis.[15-18] Besides the
proprioception, the presence of periodontal ligament as
a shock absorber in a natural tooth brings about an apical
intrusion by about 28 m and lateral movement by around
50-108 m. In the case of a similar load acting on an implant,
no initial movement is seen and the delayed apical movement
observed is around 10-50 m. The same can be attributed to
the viscoelastic properties of bone. Also, such a load acting
on an implant is primarily concentrated on the crest of the
implant.[11,12]
In case of occlusal trauma, mobility can develop in a tooth as
well as in an implant. However, upon removal of the trauma,
mobility can be reduced or controlled with a natural tooth,
while no such response can be noted in an implant. In general

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the diameter of natural teeth is larger than the diameter


of implants. Also, the cross-section of implants is rounded
and the diameter is selected primarily according to bone
available, not according to the load that it is anticipated to
be subjected to. The cross-section of the root of a natural
tooth, on the other hand, varies according to the force it
has to withstand. For example, mandibular anterior teeth
have wider diameters faciolingually, mainly to resist forces
during protrusion. Likewise, the roots of canines are shaped
to withstand lateral loads and those of molars to withstand
axial loads.[5,12,19,20]
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.[2] 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.[1,2,12]
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.[21-24]
While restoring an implant, a thin, articulating paper is
used (<25 m) 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. This is
because a natural tooth exhibits greater vertical movement
than an implant. Once equilibration under light occlusal force
is completed, the occlusion is refined under heavy occlusal
contact. A tooth may not return to its original position for
several hours after the application of heavy occlusal force. As
a consequence, light occlusal forces on the adjacent natural
teeth are equilibrated first. The occlusal contact should
remain axial over the implant body and may be of similar
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intensity on the implant crown and adjacent teeth when


under greater bite force. This implies that all elements react
similarly to heavy occlusal loads. The harmonization under
light occlusal loads is followed by adjustment under heavy
occlusal load. The heavy occlusal load positions the natural
teeth closer to the depressed position of the implant, thereby
permitting equal sharing of the load between the implant
and the natural teeth. However, an important part of the
philosophy behind IPO is the regular evaluation of occlusal
contacts at regularly scheduled hygiene appointments so
that minor variations occurring during long-term functioning
help in preventing porcelain fracture and other stress-related
complications.[1,5,21]

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.[10,25]

Controlling the occlusal table width


The width of the occlusal table is directly related to the
width of the implant body.[1,2] The wider the occlusal table,
the greater the force developed to penetrate a bolus of food.
However, a restoration mimicking the occlusal anatomy of
natural teeth often results in offset load (increased stress),
increased risk of porcelain fracture, and difficulties in home
care (due to horizontal buccolingual offset/cantilever).[1,2,12]
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


This implies that during excursion the posterior teeth
are protected by the anterior guidance, whereas during
centric occlusion the anterior teeth have only light contact
and are protected by the posterior teeth.[26] 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.[27] 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.

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Verma, et al.: Occlusion in implantology

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. Anisotropy refers to the character
of bone whereby the mechanical properties depend on
the direction in which the bone is loaded. The greater
the angle of the load, the greater is the shear component
of the load. It must be borne in mind that cortical bone
is the strongest and most able to withstand compressive
forces. Its ability to withstand tensile and shear forces is
30% and 65% less, respectively, than its ability to withstand
compressive forces.[2-4]
Additionally, a force at a 30-degree angle decreases the bone
strength limit by 10% under compression and by 25% under
tension. The increase in the shear component of stresses
is by almost three times, which predisposes the bone to
increased crestal bone loss and impairs successful bone
growth. During loading, the primary component of occlusal
forces should be directed along the long axis of the implant
body. The three conditions where one can anticipate angled
loads are: Angled abutments, angled implant bodies, and
premature occlusal contact. Angled abutments are used to
improve the path of insertion of the prosthesis or to improve
the final aesthetic results. The implant body should be placed
perpendicular to the occlusal plane and along the primary
occlusal contact. Premature occlusal contacts result in the
localized lateral loading of opposing contacting crowns.
Because the surface area of a premature contact is small, the
magnitude of stress in bone increases. Also, the contact is
most often on an inclined plane; therefore, it increases the
horizontal component of load and increases the tensile crestal
stress. In general, whenever lateral/angled loads cannot be
eliminated, a reduction in force magnitude or additional
surface area of the implant surface is indicated to reduce
the risk of bone loss or of implant component fracture. Such
measures include increasing the diameter of angled implants,
selecting implant design with greater surface area, adding
an additional implant next to the most angled implant, and
splinting of implants.[2-4]

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. It may be necessary
to recontour the opposing cusp to occlude in the central
fossa over the implant body. If the implant crown mimics
the natural cusp angle, the premature contact will occur on
a cuspal incline and the resulting direction of load may be
30 degrees to the implant body.[1,27,28]

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).[1,2,12] 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.[29-32]

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.[29]

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. The marginal ridge contact is not an offset
load when located between implants splinted to one another,

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and is acceptable only under such circumstances. Moreover,


adjacent crowns should preferably be splinted in order to
decrease occlusal stresses to crestal bone and to reduce
screw loosening.[2]

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. Crown contour in Division A bone has been
described in the respective figures [Figures 1-3]. 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 [Figure 4]. In case of Division C
and D bone, all attempts must be made to perform a bone

Figure 1: maxillary natural tooth vs mandibular implant-supported prosthesis


in division a bone[2,3]

Figure 3: maxillary implant-supported prosthesis vs mandibular implant-supported


prosthesis in division a bone[2,3]

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augmentation procedure and create a condition as close as


possible to Division B bone.[33-35]

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.[1] 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

Figure 2: maxillary implant-supported prosthesis vs mandibular natural tooth


in division a bone[2,3]

Figure 4: maxillary implant-supported prosthesis vs mandibular natural tooth in


division b-d bone, might require cross-arch relation of teeth[2,3]

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restored. The selection is usually made from among porcelain,


zirconia, metal, and resin-based materials.[2,36]

Parafunctional activity
Many studies have reported that parafunctional activities
and improper occlusal designs are correlated with implant
bone loss and failures. Further, it has been proposed
that the numbers and distribution of occlusal contacts
had major influences on the distribution of force. Naert
et al.[5,31] 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.[1,36,37]
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), diet
(avoiding chewing with a soft diet, then progressing to harder
food), occlusion (gradually intensifying the occlusal contacts
during prosthesis fabrication), prosthesis design, and occlusal
materials (from resin to metal to porcelain) for poor bone
quality conditions.

Occlusal guidelines for different clinical situations


In case of a full-arch fixed prosthesis, if the opposing arch is
a complete denture, balanced occlusion is recommended.
Group function or mutually protected occlusion with
shallow anterior guidance is recommended when opposing
natural dentition or a full-arch fixed prosthesis. There
should be no working side and balancing contact on
the cantilever.[11,38-42] The infraocclusion of the cantilever
segment should be by 100m[43,44] and freedom in centric
should be 1-1.5 mm. In case of overdentures, bilateral
balanced occlusion with lingualized occlusion should
be used. In case of severely resorbed ridges, monoplane
occlusion should be used.[44,45]
If the posterior arch is rehabilitated with a fixed prosthesis,
contacts should be centered over the implant body,
and narrow occlusal tables, flat cusps with minimized
cantilever should be employed. Where necessary, the
posterior occlusion must be placed in crossbite. Anterior

guidance should be with the natural dentition, and group


function occlusion should be employed with compromised
canines.[46,47]
Guidelines for choice of reconstruction and occlusal
concept when rehabilitating the edentulous mandible
with oral implants have been suggested by QuirynenM
et al.[41] In case of the fully edentulous maxilla, whether the
mandibular rehabilitation is done on an overdenture
supported on two implants or on a mucosal-implantsupported overdenture (four implants with a bar
attachment), a balanced occlusal scheme (bilateral/
lingualized/monoplane) is recommended. In conditions
where a Kennedy class I partially edentulous condition
is present in the maxillary arch and mandibular mucosaimplant supported (four implants with a bar attachment)
or an implant-supported prosthesis is planned for the
mandibular arch, balanced occlusion is recommended.
In case of a maxillary arch presenting with Kennedy
classII condition, if a mucosal-implant-supported
prosthesis is planned for the mandibular arch, balanced
occlusion is recommended. If an implant-supported
prosthesis is advised for the mandibular arch, group
function or mutually protected occlusion is advised.
In case of Kennedys class I in maxillary arch that has
been restored with fixed denture prosthesis (FDP) or
with implants, and a mandibular implant-supported
prosthesis is advised, it is recommended to follow group
function or mutually protected occlusion. In cases where
the maxillary arch presents with Kennedys class III and
IV and implant-supported prosthesis is advised for the
mandible, group function or mutually protected occlusion
is recommended. Lastly, in case of the fully dentate
maxilla and implant-supported prosthesis, group function
or mutually protected occlusion is recommended.

CONCLUSION
A poor selection of occlusal scheme can lead to biological
and mechanical complications.[2-4] The various consequences
that can be encountered are implant failure, early crestal
bone loss, screw loosening, uncemented restorations,
component failure, porcelain fracture, prosthesis fracture,
and peri-implant disease.[1,11]. An IPO scheme addresses
several conditions to minimize overload on bone/implant
interfaces and implant prostheses, thus restricting implant
loads within physiological limits. The guidelines need to
be implemented in specific conditions to decrease stresses
and develop an occlusal scheme to allow the restoration to
function in harmony with the rest of the stomatognathic
system and to maximize the longevity of the implants and
prosthesis.

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Cite this article as: Verma M, Nanda A, Sood A. Principles of occlusion in
implant dentistry. J Int Clin Dent Res Organ 2015;7:27-33.
Source of Support: Nil. Conflicts of Interest: None declared.

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