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Occlusion for Implant-Supported Fixed Dental Prostheses in Partially Edentulous Patients: a Literature Review and Current Concepts

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Occlusion for Implant-Supported Fixed Dental Prostheses in Partially Edentulous Patients: a Literature Review and Current Concepts Journal of Periodontal Review Article JPIS & Implant Science J Periodontal Implant Sci 2013;43:51-57 • http://dx.doi.org/10.5051/jpis.2013.43.2.51 Occlusion for implant-supported fixed dental prostheses in partially edentulous patients: a literature review and current concepts Judy Chia-Chun Yuan*, Cortino Sukotjo Department of Restorative Dentistry, University of Illinois at Chicago College of Dentistry, Chicago, IL, USA Implant treatment has become the treatment of choice to replace missing teeth in partially edentulous areas. Dental implants present different biological and biomechanical characteristics than natural teeth. Occlusion is considered to be one of the most important factors contributing to implant success. Most literature on implant occlusal concepts is based on expert opin- ion, anecdotal experiences, in vitro and animal studies, and only limited clinical research. Furthermore, scientific literature re- garding implant occlusion, particularly in implant-supported fixed dental prostheses remains controversial. In this study, the current status of implant occlusion was reviewed and discussed. Further randomized clinical research to investigate the cor- relation between implant occlusion, the implant success rate, and its risk factors is warranted to determine best clinical prac- tices. Keywords: Dental implants, Dental occlusion, Fixed partial denture, Implant-supported dental prosthesis, Review INTRODUCTION odontal ligament (PDL) and are more susceptible to bending loads compared to the natural dentition [7,8]. Several risk fac- Implant-supported fixed dental prostheses (ISFDPs) have tors have been associated with the occlusal overloading of become a desirable treatment option for replacing missing ISFDPs, such as occlusal morphology and scheme [7,9-13], teeth in partially edentulous patients due to their high pre- nonaxial loading, prostheses with cantilever extensions [1,14- dictability and success rates [1-4]. The goal of the ISFDP is to 20], an unfavorable crown-to-implant (C/I) ratio [7,21-25], oc- restore esthetics, form, and function. Occlusion plays a role clusal materials [26-30], and the parafunctional activity of the in the functional and biological aspects of the implant sup- patient [31-47]. These factors may lead to more biological, ported prosthesis. A well-controlled and maintained occlu- technical, or mechanical complications for the ISFDP [7,16,41, sion could reduce mechanical and biological complications, 42,48,49], or may lead to unfavorable loading of the dental thus increasing the longevity of the prosthesis [5]. implant. Therefore, ISFDP occlusion should be carefully con- The occlusal concepts of the ISFDP seem to be extrapolated trolled to increase clinical success rates [7,12,50,51]. from the natural dentition and complete denture occlusions Most literature on implant occlusal concepts is based on with some modifications [6]. However, compared to natural expert opinion, anecdotal experiences, and in vitro and ani- teeth, dental implants present different biological and bio- mal studies [52]. Well-performed longitudinal clinical studies mechanical characteristics [7,8]. Dental implants lack a peri- on ISFDP are insufficient [53,54]. In addition, little evidence Received: Mar. 11, 2013; Accepted: Mar. 22, 2013 *Correspondence: Judy Chia-Chun Yuan Department of Restorative Dentistry, University of Illinois at Chicago College of Dentistry, Chicago, IL, USA E-mail: [email protected], Tel: +1-312-355-4027, Fax: +1-312-996-3535 Copyright © 2013 Korean Academy of Periodontology pISSN 2093-2278 This is an Open Access article distributed under the terms of the Creative Commons Attribution www.jpis.org Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/). eISSN 2093-2286 52 Implant occlusion in fixed dental prosthesis Journal of Periodontal JPIS & Implant Science supports specific occlusal concepts for implant-supported plants, and reduce stress on the implant and the implant/ prostheses [52,55]. However, cautionary approaches lead by abutment interface [9-11]. experts in the field have been practiced with clinically accept- The correlation between occlusal overloading and peri-im- able outcomes [56]. Therefore, the purpose of this article is to plantitis, which consequently results in implant failure, has review the occlusal concepts of ISFDPs in the available litera- been controversial [66-76]. Supra-occlusal axial and lateral ture and their current clinical applications. loading has been shown to create some crater-like bone de- fects lateral to the implants and loss of osseointegration LOADING ON TEETH VERSUS IMPLANTS [68,69,74]. However, it should be noted that the loss of osseo- integration observed in those studies could have been attrib- The biological differences between teeth and dental im- uted to the use of short and narrow implants, impractically plants are clear. The natural tooth is suspended by the PDL high-occlusion, or excessive lateral overload [68,69,74]. Further- whereas the dental implant is in direct contact with the bone more, it could be that the implants evaluated were smooth [57]. Under loading, the resilient PDL provides a shock-ab- surface implants instead of rough surface implants that have sorbing feature for the teeth. On the other hand, for implants, a more favorable success and survival rates [77-81]. On the a high stress concentration occurs at the crestal bone when other hand, some studies have indicated that axial and lateral loaded, due to the lack of a PDL [58]. The mean value for axial occlusal overload leads to no differences from nonloaded mobility of the teeth is 25 to 100 µm, whereas the axial dis- sites according to clinical, radiographic, and histologic obser- placement of osseointegrated implants is 3 to 5 µm [8,15,58]. vations [73,82]. No crestal bone loss was observed. Occlusal During lateral loading, the tooth moves at the apical third of forces are hardly in the vertical direction; mastication involves the root [59], and the force is instantly dissipated from the side-to-side action as well [52]. Evidence does not support crest of the bone along the root [60]. Conversely, the implant that nonaxial loading has a detrimental effect on osseointe- moves at 10–50 µm laterally; and the concentration of forces grated implants [83,84]. However, occlusal overload may con- is at the crestal bone [58]. Clinical signs of occlusal overload- sequently lead to mechanical complications [51,83,85], such as ing of teeth include widening of the PDL, fremitus, and mo- loss of veneering acrylic and porcelain fractures [5]. This may bility of the tooth [15]. On the other hand, signs of inflamma- consequently result in failure of the implant and its support- tion [61] and crater-like bone defects [62] have been associat- ed prosthesis [85]. Therefore, ongoing maintenance and peri- ed with the overloading of implants. Occlusal overloading of odic evaluation of an ISFDP are important in order to moni- implants may also lead to mechanical complications of the tor any changes and manage potential mechanical complica- supported prostheses, such as screw loosening or fracture, tions [7,86]. abutment or prosthesis fracture, or even implant fracture [63]. Besides bilateral balanced occlusion for complete denture fabrication [87], group-function occlusion, and mutually pro- OCCLUSAL SCHEME AND MORPHOLOGY tected occlusion for the natural dentition with and without fixed prostheses [88,89], implant-protected occlusion has There is little evidence to suggest that a specific occlusal been suggested for implant-supported prostheses [90]. The scheme for ISFDPs is superior, since changes in occlusion implant-protected occlusion concept aims at protecting the may be easily adopted by the complex neurophysiological implants by reducing occlusal force on implant prostheses mechanism in the jaw muscle system [56]. In addition, occlu- [90]. Some other occlusal scheme designs for ISFDPs have sal scheme design has minor or no importance to marginal been adopted and modified from existing concepts. The bone loss of implant-supported prostheses [64]. General rec- guidelines are summarized in Table 1 [15,20,56,91-93]. Pre- ommendations for occlusal morphology include flat fossa scription of a night guard after delivery of an ISFDP is recom- and grooves for wide freedom in centric [11], shallow occlusal mended, especially for those diagnosed with parafunctional anatomy, a narrow occlusal table, and reduced cuspal inclina- activities [20]. tion [15]. It is recommended that the size of the occlusal table be 30% to 40% smaller for molars [7,12,13]. Widths greater PROSTHESES WITH EXTENSION UNITS than the implant diameters may generate cantilever effects and some bending movement in single unit implant-sup- The beliefs and recommendations regarding cantilever ex- ported prostheses [7,12,13]. A narrow occlusal table may in- tensions of ISFDPs have been inconsistent [1,16-18]. The ma- crease axial loading and decrease nonaxial loading for the jor limitations of prostheses with extensions include possible implants [7,65]. The reduced cuspal inclination can decrease complications such as prosthesis debonding [16], potential the bending moment, increase the axial loading force of im- overload of the supporting implants [14,51], and higher stress Journal of Periodontal Judy Chia-Chun Yuan and Cortino Sukotjo 53 JPIS & Implant Science concentrations around the adjacent implants with extensions plant-supported prostheses was acrylic resin with a gold alloy [19]. A minimal cantilever
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