1

DEPARTMENT OF PROSTHODONTICS
INCLUDING
CROWN & BRIDGE AND IMPLANTOLOGY

SEMINAR
ON

OCCLUSION IN IMPLANTS

CONTENTS
Introduction
Significance of occlusion for osseointegrated implants
Differences between natural tooth and implant
Gnathological principles philosophy
Anatomical considerations
Occlusal schemes for natural tooth and implants
Occlusal materials
Reduction of implant loading using a modified centric
occlusal anatomy
Fixed or removable restorations with opposing natural
dentition
Fixed or removable implant supported prosthesis
Maxillary denture opposing an implant overdenture or
fixed prosthesis
Functionally generated path technique for maxillary
removable prosthesis
Single implant occlusion
Occlusion for free standing, fixed bridges (Kennedy
classes I-IV inclusive)
Occlusal materials
Conclusion
References

INTRODUCTION :
The introduction of osseointegrated implants in the early 1980s altered
the way in which partially and fully edentulous patients are treated
prosthetically. Dentures are more stable with attachments on the implants,
and implants can act along with the natural dentition as abutments or can
stand alone to support fixed prosthesis. The development of an appropriate
occlusion plays a vital role in the success of both the implant and prosthesis
attached to it.
Occlusion is critical for implant longevity because of the nature of the
attachment of the bone to the nature of the attachment of the bone to the
titanium surfaced implant. In the natural dentition, the periodontal
ligament has the capacity to absorb stress or allow for tooth movement, but
the bone implant interface seemingly has no capacity to allow movement of
the implant. Any stress from occlusion must be borne totally by the
interface. If occlusal force exceeds the capacity of interface to absorb
stress, the implant will fail.
Because of the special conditions unique to implants, it is important
to understand and develop an occlusion that places minimal stress on both
implant bone interface and the prosthesis. Implant prosthodontics deals not
only with the technical aspects of fabricating in implant supported
prosthesis but also with proper application of occlusal principles for implant
selection and placement and for the prosthetic phase of the treatment.
Specifically occlusion must be considered in three major means :
occlusal determinants, occlusal design and materials and occlusal forces and
their transmission to supporting tissues.

NATURAL TOOTH VS IMPLANTS

(Characteristics under load)
Criterion
1. Impact force
2. Mobility

Tooth
Implant
Decreased
Increased
Variable (Anterior > None

3. Diameter
4. Cross section
5. Modulus of elasticity

Posterior teeth)
Large
Not round
+ Cortical bone

6. Hyperemia
7. Orthodontic

+
+

Small
Round
5-10 times greater than
trabecular bone
0
0

movement
8. Fremitus
9. Radiographic changes

+
PDL and cortical

0
0

10.Progressive loading
11.Wear
12.Occlusal awareness

bone
Since childhood
More
High detection of

Shorter loading period

Less
Low, higher loads to

premature contacts

premature occlusal

13. Stress

PDL shock breaker

contacts
Captures stress at rest

14. Apical movement

15.Lateral movement

effect
Intrudes 28 m
50-180 m

No initial movement
10-50 m

According to the dentists desk reference

1) Alignment of crown with implant root is a definite prosthodontic
requirement in order that occlusal loads are directed along the long
axis of implants.
2) Minimum width of implant crowns : The occlusal table should be not
wider than the implant root, again to minimize occlusal loads on
implant fixtures. Equal widths of occlusal table of an implant crown

and of the implant root permit optimal transmission of stress along

the fixture.
3) Cusp height : Cusp height or cusp angle is closely related to width of
occlusal table. Cusp height should be minimized to provide only
centric function, thus decreasing lateral stress that may be applied to
the implant fixtures and their supporting osseous tissues.

ANATOMICAL CONSIDERATIONS
I. Arch form :
It describes the configuration of the arch when viewed from the
occlusal aspect. It is the geometric shape of dental arch. The differences in
arch form, varying from square to V shaped, affect the positions in which
the implants can be placed. The resulting occlusion is affected by the
opposing arch form.
The visibility and resultant tooth arrangements are more pronounced
in the anterior aspects of the arch than in the posterior areas. For example, in
a narrow maxillary V shaped arch. The amount of available room for the
mesiodistal placement of implants is considerable less than in a broad
square shaped arch. For such a situation, the position of implants in
relation to the superimposed teeth may represent a compromise position in
that ideal incisal guidance is precluded because of vertical overjet
configuration. Additionally the placement of implants also has a bearing on
anteroposterior position of teeth which also influences the incisal guidance
owing to the amount of horizontal overjet.
In the posterior areas of discrepancy between the maxillary and
mandibular ridges may prevent the formulation of an ideal occlusion and a
cross bite type of occlusion may have to be developed. Cross bites are not
unusual when posterior maxillary or mandibular areas have had excessive
resorption.

II. Inter arch distance and jaw relationship :

Interarch or inter-ridge distance may prevent the development of an
acceptable occlusal scheme. The space may be diminished owing to over
eruption of the teeth into an opposing edentulous space or malplaced
implants, or the space may be exaggerated because of the excessive
resorption of maxillary or mandibular bone before the placement of
implants.
Decrease in the amount of space available may influence the type of
tooth form used. Thus tooth form dictates the type of occlusion developed.
An increase in the interarch space requires close attention to lateral forces
acting on the implants owing to the increased length of lever arm that that
results.
Significance that has been given to crown-to-root ratio of natural
teeth may be as important in projecting an implant to crown ratio.
In attempting to reduce the lateral forces on implants, modifications
to occlusal scheme must be made. Maintaining the correct interarch distance
in establishing the vertical dimension of occlusion and allowing for a
distinct rest position are essential.
When posterior alveolar bone resorbs in the mandible, the remaining
basal bone is in a more lateral position to the remaining maxillary bone,
requiring a cross bite relationship of teeth in that area.
In the anterior part of mandible, resorption results in the remaining
basal bone being more anterior to maxillary basal bone. This discrepancy
can be further aggravated by placement of mandibular implants in the
symphysis, which forces the setting of artificial mandibular dentition in a
further labial position. This anterior placement also influences the
development of anterior guidance and affects the occlusal scheme.

Similar resorptive processes occur in partially edentulous patients. In

the maxilla, for instance, the architecture resulting from these patterns of
resorption may results in implants being palatally placed to achieve
anchorage of implants in solid bone. This positioning of implants has a
bearing on the type of occlusion developed for the individual patient as well
as on tongue placement and phonetics.
III. Soft tissue attachments :
The health of the soft tissue is influenced by the occlusal scheme that
is developed. The maintenance of the soft tissues around the supporting
structures of a prosthesis has always occupied a central position in the
restorative procedures. Unless the soft tissues can be maintained, long term
survival of implants is in jeopardy.
Developing an occlusion that is non traumatic to the soft tissues by
designing an occlusal form that reduces the loading on the implants, is
complemented by proper contours to avoid traumatizing the surrounding
soft tissues, and ensures open embrasures to facilitate maintenance of the
soft tissues by the patient while adhering to strict aesthetic requirements.
An important aesthetic consideration in the anterior arch is the
emergence profile of the restoration. The challenge in this area is to
fabricate an aesthetic restoration that is acceptable in size, shape and
contours and capable of being maintained by the patient and that does not
place adverse stresses on the underlying implants.
IV. Orientation of the occlusal plane :
The orientation of occlusal plane depends on anterior placement of
teeth to ensure proper incisal guidance. Placement of posterior teeth is done
to ensure proper mastication.
For patient with implants, however, the amount of resorption of
residual alveolar ridges, the location of the available bone for implant

placement, aesthetic considerations and biomechanical considerations

influences the development of an acceptable occlusal plane.
It should always be kept in mind that the arch in which implants are
placed usually becomes the dominant arch. That is, the opposing edentulous
arch now becomes the weaker arch. The plane of occlusion must be
developed to take this in the consideration when the opposing arch has
received an implant supported prosthesis. The arch without implants
subsequently becomes the arch that may have to be favored with fine tuned,
non-intefering occlusal patterns.
V. Mandibular movements :
Movements of the mandible that are out of the normal also influence
the development of the occlusal plane. Depending on patients individual
needs, existing dental condition and records obtained, group function or
cuspid disclusion may be used to achieve the goal of lateral force
dissipation
VI. Condylar guide angle and incisal guide angle :
Regardless of which occlusal philosophy followed the condylar
angles should be recorded so that occlusion developed is in harmony with
the angles.
The incisal guide which is controlled by the clinician, plays a key role
in the proper placement of the anterior dentition. Cusp height, cusp
angulation and compensating curves are affected by these determinants and
affect the final aesthetic result.
VII. Phonetics :
The position of teeth and the contour of palate relate to non-intrusive
placement of implants in proper articulation the tongue must contact these

structures correctly to achieve favourble speech. Variations in articulation

required to produce certain sounds should be considered when occlusal
scheme is being developed.
The area of greatest difficulty is the maxillary arch. The relative
narrowing of the maxillary arch owing to bony resorption usually results in
the implants being placed in a palatal position in relation to natural dentition
resulting in crowding of tongue and improper articulation.
The contour of the palate may be adversely affected by implants
placed in the resorbed anterior maxilla. This results in implants being placed
distally in relation to the position of natural dentition. This steepens the
anterior palatal curve, crowding the tip of tongue and prevents proper
tongue placement during articulation.
Implant maintenance in a fixed-implant-borne prosthesis requires that
a space of varying dimensions be provided between the prosthesis at the
crest of ridge. This space in the maxillary arch presents a unique problem in
phonetics by disrupting normal articulation.
VIII. Occlusal schemes :
The goal of an occlusal scheme is to maintain the occlusal load that
has been transferred to implant body within physiologic limits of the patient.
The implant dentist can dissipate these forces by selecting the proper
implant size, number, and position, using stress relieving elements,
increasing bone density by progressive loading, and selecting the
appropriate occlusal scheme.
The accepted ideal occlusal schemes include balanced occlusion,
mutually protected occlusion and group function occlusion.
OCCLUSION FOR OSSEOINTEGRATED PROSTHESIS :
Aims :

10

1) Direct forces in long axis of implant.

2) Minimize lateral forces on the implant.
3) Place lateral forces when necessary as far anterior in the arch as
possible.
4) When it is impossible to minimize or more lateral forces anteriorly,
distribute them over as many teeth and implants as possible.
Minimal occlusal goals for implant prosthodontics are :
1) Bilateral simultaneous contact.
2) No prematurities in retruded contact position. (RCP)
3) Smooth, even, lateral, excursive movement with no nonworking
interferences.
4) Equal distribution of occlusal forces.
5) Freedom from deflective contacts in intercuspal position (IP).
6) Anterior guidance.
OCCLUSAL SCHEMES :

Mutually protected occlusion :

According to GPT-7, it is defined as an occlusal scheme in which the
posterior teeth prevent excessive contact of the anterior teeth in maximum
intercuspation and the anterior teeth disengage the posterior-teeth in all
mandibular excessive movements.
This occlusal scheme was advocated by Stuart and Stallard (1960),
based on work by DAmico. The anterior guidance is critical to the success
of this occlusal scheme.
The features of MPO are
- Uniform contact of all teeth around the arch when mandibular
condylar process is in its most superior position.
- Stable posterior tooth contacts with vertically directed resultant forces
- CR coincident with maximum intercuspation

11

- No contacts of posterior teeth in lateral or protrusive movements.

In maximum intercuspation, posterior teeth protect anterior teeth. In
protrusive movement anterior teeth protects the posterior teeth and during
lateral movements canine protects the posterior teeth. This type of occlusion
can be used in fully bone anchored prosthesis and posterior free standing
FPD supported by osseointegrated implants.
DAmico (1988) conducted a study a canines in animals and human
beings and advocated canine guidance occlusion. It is defined as the form of
mutually protected articulation in which the vertical and horizontal overlap
of canine teeth disengage the posterior teeth in the excursive movements of
the mandible.
Mandibular eccentric movements were guided by the canines except
in protrusive, so the canine is a key elements in occlusion. Anatomical
evidence to support the canine as the key includes, the good C-R ratio, the
amount of compact bone surrounding the tooth and the location for
from TMJ, thus receiving less stress.
The term mutually protected occlusion was changed to ORGANIC
OCCLUSION by Stallard and Stuart in 1961. In organic occlusion, CR
position and MI are coincident. Each functional cusp contacts the occlusal
fossa at 3 point, while anterior teeth disoclude by 25. In protrusive
movement, the maxillary 4 incisors guide the mandible and disocclude the
posterior teeth.
Advantages :
1) Esthetically, the arrangement most closely resembles the patients
natural dentition.
2) Penetration of the bolus of food has been reported to be better,
therefore requiring less occlusal force.
3) Opposing inclines provide buccolingual stability, preventing tongue
pressure from tilting a tooth buccaly.

12

4) Forces are closer to long axis of each tooth.

Disadvantages :
1) With the number of contacts on each tooth, precise patient records are
necessary to transfer to the articulator.
2) Occlusal contacts on cuspal inclines during excursive movements are
more apt to occur because of the number of posterior inclines present.
If these inclines are not removed, they present a destructive force
transmitted to the fixture-bone interface.
3) Because of the number of contacts on each posterior tooth it is
difficult to evaluate bilateral simultaneous contact.

LINGUALIZED OCCLUSION :
It was advocated by GYSI because of its ability to direct the forces of
mastication vertically onto the ridge. The occlusal scheme is based on the
use of the maxillary lingual cusp as the stamp cusp, which occludes with a
shallow mandibular central fossa. At no time is there contact of the
maxillary buccal cusp or mandibular lingual cusp. The effect creates a
mortar-and-pestle style of occlusion.

Advantages :
1) Mortar and Pestle type style of interdigitation provides for effective
mastication of food. The steep maxillary cuspal inclination decreases
the need for unfavourable horizontal movement in mastication.
2) Elimination of mandibular cusp tip function eliminates the potential
for lateral interferences in excursive movements.
3) A shorter maxillary buccal cusp eliminates its interference in
excursive movement.

13

4) Limited number of occlusal contacts on each tooth makes the task of

establishing, even distribution of forces easier and more attainable.
Disadvantages :
1) Lingualized occlusion is less natural in appearance than cusp to fossa
occlusion.
2) There is a possible reduction in masticatory efficiency.

BILATERALLY BALANCED ARTICULATION :

It is defined as the bilaterally, simultaneous, anterior and posterior
occlusal contact of teeth in centric and eccentric positions.
Balanced articulation has all teeth in contact in maximum
intercuspation and during eccentric movements. It has been referred as a
fully balanced or bilateral balanced occlusion. It is ideal for complete
dentures but frequently used in osseointegrated prosthetic treatment.
When principles of B.B.A. were applied to the natural dentition and
in FPD, it proved to be extremely difficult to accomplish, even with great
attention to detail and sophisticated articulators.
In addition high failure rate resulted like,
- An increased rate of occlusal wears.
- Increased periodontal breakdown
- Neuromuscular disturbance
The masticatory movements for B.A is based on the theory that forces
are generated horizontally instead of vertical. Masticatory movement
generates harmful lateral forces on teeth that are detrimental from a
periodontal viewpoint. To reduce lateral pressures, they should be
distributed widely to limit forces physiologically. For those reasons, a
maximum contact area in intercuspation and all eccentric movements is
necessary.

14

During

maximum

intercuspation

and

mandibular

eccentric

movements, all teeth contact in BA. This occlusal scheme helps to distribute
lateral forces through out all teeth and condyles during mastication. It has
both cross tooth and cross arch balance. It can be used for over dentures
supported by osseointegrated implants
. Guidelines for position, timing, and force of occlusal contacts :
By R.J. Chapman. DMD (Q.I. 20 : 7 ; 1989 ; 473 / 480)
Bilateral simultaneous contact can be obtained only with great
difficulty because there is no quantitative method for comparing the timing
of tooth contacts bilaterally.
The only available method of practically assessing force is through
the use of photocclusion wafers.
A recently developed computerized device (T- scan, Tekscan corp)
uses both time and force to quantify occlusal contacts. Its use enables
refinement of an occlusion that is bilateral and simultaneous in RCP or IP.
The computer identifies balancing contacts and displays the magnitude of
occlusal forces so that they can be properly distributed.
Instrument :
- T-scan is computer with colour monitor using a sensor technology
to quantify the occlusal contact data.
- Sensor is made of two layer of 25m mylar film printed with
horizontal and vertical silver traces to form a grid pattern. A force ink
between the silver traces allows increased current flow between the
traces when pressure is applied. A minimal current level is interpreted
by software as a contact.
- A 70A current is cycling through the sensor every 0.01 seconds, the
time of any occlusal contact can be determined within 0.01 second
time frame. The distance between the silver traces is 1.25mm,

15

therefore the location of any occlusal contact registered will be within

a radius of 0.67mm.
Two modes of display is present
1) Time mode displays all the contacts and highlights the first three
contacts with their relative time values.
2) Force more when the patient closes an sensor in the force mode,
electrical resistance decreases as occlusal pressure is applied.
Clinical applications :
1) To establish bilateral simultaneous contact at the time of insertion.
2) Develop smooth, even lateral contacts
3) Equalize the force of final contacts
Provide records to monitor occlusal contacts over time for both bilateral
simultaneous contact and force distribution.

GROUP FUNCTIONAL OCCLUSION :

It is defined as multiple contact relationships between maxillary and
mandibular teeth in lateral movements on working side, where by
simultaneous contact of several teeth acts as a group to distribute occlusal
forces.
SHCHUYLER (1929) introduced the fundamentals of group
function occlusion. This type of occlusion occurs where all facial ridges of
working side teeth do not contact. In this type, excessive contact occurs
between all opposing posterior teeth on the laterotrusive (working) side
only. On mediotrusive (nonworking) side, no contact occurs until the
mandible has reached the centric relation.
In this occlusal arrangement the load is distributed among the
periodontal support of all posterior teeth on the working side. Posterior teeth
on non-working side do not contact in excessive movement. In protrusive
movement, no posterior tooth contact occurs.

16

LONG CENTRIC :
The concept of allowing some freedom of movement in an anterior
and posterior direction is known as long centric.
Schuyler thought it was important for posterior teeth to be
harmonious gliding contact when the mandible translates from centric
relation forward to make anterior tooth contact.
Long centric is 0.5-0.75 m free space between maximum
intercuspation and CR position without change in vertical dimension of
occlusion. This type of occlusion creates uncertain stability with the
anteroposterior slide. But when sharing load on the working side, the molar
bears a greater burden and not all the teeth share the same amount of load.
Some of the characteristics of this type of occlusion are :
1) Teeth should receive stress along the tooth long axis.
2) Total stress should be distributed among the tooth segment in lateral
movements.
3) Proper interocclusal clearance should be maintained
4) Teeth contacts in lateral movement without interference
Characteristics of group function occlusion include :
1) The theory of long centric
2) The concept of all working side teeth sharing lateral pressure during
lateral movements.
3) The concept of non-working side teeth free from contacts during
lateral movements.

IMPLANT PROTECTIVE OCCLUSION (IPO) :

This was previously presented as medial positioned lingualized
occlusion and was developed by MISCH. This concept refers to an

17

occlusal plane that is often unique and specifically designed for the
restoration of endosteal implants, providing an environment for improved
clinical longevity of both implant and prosthesis.
There are 4 main factors for the I.P.O. they are
a)

Occlusal table width

b)

Crown contour depending upon the type of bone

c)

Influence of surface area

d)

Design of weakest arch

Occlusal table width :

A wide occlusal table favours offset contacts during mastication or
parafunction. Wider root form implants can accept a broader ranger of
vertical occlusal contacts while still transmitting lesser forces at the permucosal site under offset loads. Therefore in IPO the width of occlusal
table is directly related to the width of implant body.
Eg : Sharp knife less force know occlusal table
Dull knife more force wider occlusal table
Hence wider the occlusal table, the greater the force developed by the
biologic system to penetrate the bolus of food. The restorations mimicking
the occlusal anatomy of the natural teeth often result in offset loads,
complicated homecare and increased risk of porcelain fracture. As a result in
non-esthetic regions of the mouth, the occlusal table should be reduced in
width compared with natural teeth.
Crown contour depending upon the type of bone :
Once the maxillary teeth are lost, width of the edentulous ridge
resorbs in a medial direction as it evolves. The maxillary posterior implant
permucosal site may be lingual to the opposing natural mandibular teeth.
The maxillary posterior implant most often is positioned under the central
fossa region of natural teeth in division A bone.

18

A maxillary implant opposing a natural mandibular molar may have

the lower buccal cusp as primary contact with the central fossa of the
maxillary implant crown. The lingual aspect of the maxillary implant crown
often is reduced in height and width when the implant is under the maxillary
central fossa, to reduce the lingual offset loads in the posterior region.
The primary contact of occlusion on a mandibular implant in division
B bone opposing a natural posterior maxillary tooth is the lingual cusp of
maxillary posterior tooth. The maxillary lingual cusp tip is modified to load
the implant body more axially. The buccal cusp of mandibular implant
crown is located over the more medial division B implant body to
dramatically reduce the occlusal table.
The medial positioned division B mandibular implant may even
require a single cusped crown directly over the implant body.
In conclusion, the implant body should be loaded in an axial
direction. In a division a maxillary ridge the implant can be placed under the
central fossa region of natural teeth. As a result of buccal cusp of natural
teeth in mandibular arch is the dominant occluding cusps. The palatal
contour of the maxillary posterior implant crown is reduced to eliminate
offset loads.
The position of buccal cusp should remain similar to that of original
tooth for proper esthetics and should remain out of occlusion in centric
relation and all mandibular excursions. When further resorption occurs ridge
evolves into division B,C or D the maxillary palatal cusp becomes the
primary contact area, situated directly over the implant body.
Hence the occlusal contacts differ from those of a natural tooth and
may even be positioned more medial than the natural palatal cusps when
implant is placed in division C or D bone.
Influence of surface area :

19

An important parameter in IPO is the adequate surface area to sustain

the load transmitted to prosthesis.
When implants of decreased surface area are subject to angled or
increased loads, the magnified stress and strain magnitudes in the interfacial
tissues can be minimized by placing an additional implant in the region of
concern, which will reduce some of the complications.
Wider diameter root form implants have a greater area of bone
contact at the crest than narrow implants. As a result, for a given
occlusal load, the mechanical stress at crest is reduced with wider implants
compared with narrow ones.
Design of the weakest arch :
Any complex engineering structure will typically fail to its weakest
link and dental implants are no exception. Thus all treatment planning
decisions for IPO should be based on careful consideration of
1) Identifying the weakest link in the overall restoration
2) Establishing occlusal and prosthetic schemes to protect that
component of structure.
The amount of force distributed to a system can be reduced by stressrelieving components that may dramatically reduce implant loads to the
implant support. The soft tissue of a traditional completely removable
prosthesis opposing an implant prosthesis displaced more than 2mm and is
an efficient stress reducer. Lateral loads do not result with as great a crestal
load to the implants, because the opposing prosthesis is not rigid. As a
result, the occlusal concept may be designed to favour the complete
removable denture, which is the weakest arch.
The weakest component philosophy applies to axial occlusal
contacts in the regions of the implant bodies, when cantilevers or offset
loaded areas are present. Heavier contacts are applied over the implant
bodies to reduce the magnification of the compressive forces from the most

20

distal cantilever and the tensile and shear forces on the most anterior
implant abutment.
The weaker component occlusal concept also applies to most
anterior maxilla implant reconstruction. The implant restored anterior
maxilla is often the weakest section of all other reconstructed or natural
tooth regions of the mouth.
Methods to help reduce force on maxillary anterior implants opposing
a fixed dentition or restoration include excursive forces distributed to at
least two splinted implants.
Disocclusion :
It is defined as separation of opposing teeth during eccentric
movements of the mandible.
Twin-stage procedure, the new prosthetic procedure has been
redeveloped based on the twin-tables technique initially described by
HOBO. His procedure has been developed to reproduce disocclusion and
anterior guidance more precisely.
HOBO and H. TAKAYAMA proposed the following guidelines based
on their clinical results
1) With natural anterior teeth present and fixtures implanted in the
posterior region disclusion must be created.
2) When the fixtures are implanted in the anterior region and natural
molars are present, group function must be created.
3) For edentulous cases, a balanced articulation must be created.
Basic concept of twin-stage procedure :
The cusp angle should be shallower than the condylar path to provide
disclusion. To make this in a restoration, it is necessary to wax the occlusal
morphology to produce balanced articulation, so the cusp angle becomes
parallel to the cusp path of opposing teeth during eccentric movement.

21

The cast with removable anterior segment is fabricated. First,

reproduce the occlusal morphology of posterior teeth without anterior
segment and produce a cusp angle coincident with the standard values of
effective cusp angle.
Secondarily, reproduce anterior morphology with the anterior
segment and provide anterior guidance which procedures a standard amount
of disclusion.
This application of 2 stages to fabricate the cusp angle and anterior
guidance is called TWIN-STAGE. The twin hoby arriculator is exclusively
used for this.
This is contraindicated in
- Abnormal curve of Spee
- Abnormal curve of Wilson
- Abnormally rotated teeth

Reduction of implant loading using a modification

centric occlusal anatomy
By Lawrence. A. Weinberg [IJP. 1998 : 11: 55-69]
When the muscles of mastication occlude teeth, there are several
interrelated factors that determine the subsequent direction and magnitude
of force distributed to supporting bone.
The anatomy of occluding surfaces, or impact area, determines the
direction of resultant line of force, while the location of that resultant line of
force, relative to the implant or natural tooth root and the supporting bone,
will determine the character of applied load.
When a cusp occludes with a flat fossa, the resultant line of force
passes vertically close to or in line with supporting bone.
When a cusp impacts an incline, the resultant line of force passes
obliquely away from the supporting bone. This creates a lateral force

22

component that has been thought to be more deleterious to the supporting

bone than vertical loading.
This concept can be applied to implant or tooth supported
prostheses.
Production of torque :
The measurement of torque in a natural tooth is the force (F) times
the perpendicular distance (D) from the center of rotation in apical third.
There dimensional finite element stress analysis indicates that
inclined loading applied to the implant results in a concentration loading to
the crestal bone rather than distribution along the entire implant surface.
There is usually more torque produced in the maxillary arch than
in mandibular arch. Eg. A vertical over lap in the anterior of the mouth
produces more torque as the distance from resultant line of force is greater
than distance in mandible.

METHODS TO REDUCE TORQUE

1) Reduction of cusp inclination
One of the most significant factors in the production of torque is cusp
inclination, which can be reduced in tooth supposed as well as implant
supported prostheses.
Eg : Reduction in maxillary cusp inclination the resultant force falls
closer to implant than when there is a more acute cuspal inclination
2) Modification of location :
With natural teeth the location of occlusal surface may be dictated by
pulpal anatomy. There is much more flexibility in location of the occlusal
surface with an implant supported prosthesis.
Eg : A posterior maxillary implant is offset too for lingually
(regardless of cusp inclination) the resultant line of force passes at a greater

23

distance from the maxillary implant and supporting bone that it does from
the mandibular implant.
Torque can be reduced on maxillary implant by placing the prosthesis
in cross occlusion, which decreases the distance of the resultant line of force
from the implant and supporting bone.
However, crossocclusion can inadvertently reverse the situation and
increase the torque on the mandibular implant by increasing the distance of
resultant line of force from implant and thus increase the torque on the
mandibular implant by increasing the distance of resultant line of force from
implant and thus increase the torque. This can be prevented by reducing the
mandibular lingual cusp inclination before maxillary arch is restored.
3) Modification of anterior anatomy
When there is an anterior vertical overlap, the resultant line of force
passes at an exaggerated distance from the implant and supporting bone.
The lingual surface of maxillary restoration can be modified to
provide a horizontal lingual stop for the mandibular incisor. The resultant
line of force falls closer to the implant and supporting bone, producing less
torque.
This design helps prevent screw breakage.
4)Modification of posterior occlusal anatomy to reduce torque
With typical posterior occlusal anatomy, buccal and lingual cusp
inclines meet in an occlusal groove that provides no flat horizontal surface.
The

posterior

cusp-to-fossa

occlusal

relationship

is

biomechanically favourable. The hypothesis is that buccal and lingual

component lines of force produce a vertical resultant line of force that is
biomechanically favourable.

24

This is only correct theoretically because such repeatably precise fit is

unattainable clinically because occlusal contact in centric relation has been
shown to be a small are ( 0.4 mm) and has been demonstrated to vary over
period of time.
As a result, the slightest physiologic variation in position will result in
only one incline contact producing a laterally inclined resultant line of force.
So to be more compatible with physiologic variation of centric relation, a
modified centric occlusal anatomy should be used to provide a true
horizontal fossa rather than line angles.
It is suggested that occlusal line angles and grooves should be
reshaped to contain a 1.5 mm horizontal fossa. The advantage of this
occlusal anatomy is immediately negated if the opposing cusp is not
narrowed. When narrowed cusps fit into the flat horizontal fossae, a true
cusp-to-fossa impact area is produced that is consistent with physiologic
variability. This effectively produces vertical lines of force within an area of
contact in centric occlusion.
5)Modification of typical incisal pin :
A typical hanau incisal table is rotated to provide protrusive guidance
while the lateral adjustable guide planes provide lateral inclination.
The incisal pin itself is usually flat (from front) and as it moves on the
incisal table it combines with the condylar guidances to generate the
standard buccal and lingual cusp inclines that join in a central groove.
The incisal pin can be simply modified to produce a horizontal 1.5
mm fossa on any adjustable articulator. The portion of the incisal pin that
touches the plane can be beveled approximately 1mm on both sides as
observed from the frontal view.
After this reduction in width, as the incisal pin is moved laterally it
remains on flat plane until it contacts the angulated lateral guide planes of
the table. During the portion of lateral movement (i.e., on flat plane) a

25

corresponding horizontal fossa is created in the posterior occlusion. With

this simple modification of incisal pin, bilateral lateral movements on
articulator produce a truly horizontal central fossa of approximately1.5 mm
in width.
Increasing the width of bevel on the incisal pin or over grinding it to a
point will excessively widen the horizontal fossa.
6) Modification of typical semiadjustable articulator settings
Semiadjustable articulators use protrusive check bite records to
establish protrusive condylar inclination. Since these instruments do not
usually have an adjustable intercondylar distance, lateral check bite records
would be difficult to transfer accurately.
With these lateral records, the Bennett angle is calculated by HANAU
formula. This procedure on the articulator is the mechanism that provides
the lateral Bennett movement of working condyle. The working posterior
cusp inclinations that are produced with this method are usually too flat.
This negative error can be corrected by eliminating the lateral Bennett
movement on the articulator.
The posterior working-side negative error, associated with typical
settings containing a lateral side shift, can be corrected by simply
eliminating the Bennett angle on the instrument (rotating the condylar posts
laterally to 0). This will increase the posterior working cusp inclines. This
simple adjustment on articulator (no lateral side shift) significantly reduces
the chair time required for intraoral occlusal adjustment of prosthesis.
7) Laboratory articulator concepts and technique
When the lateral guiding inclines are harmonious, nonworking-side
contact will be produced during lateral excursions. Non-working-side
contact can be avoided by correction of the opposing occlusion before
restorative procedures are instituted. This procedure will also prevent the

26

possible loss of centric occlusal contact as well as unnecessary occlusal

disharmony.
Eg. : To prevent non-working-side contact in the final maxillary implant
supported restoration, reduction of apposing mandibular buccal cusp incline
is done before restorative procedures. Non working side freedom is
confirmed when the patient moves into right lateral excursion.
8) Practical technique for obtaining 1.5 mm occlusal fossae in the
maxillary arch.
If a 1.5 mm fossa is planned for the maxillary arch opposing
unrestored standard occlusal anatomy in the mandibular arch, the modified
incisal guidance will remove centric contact on the maxillary lingual cusps.
The mechanism of this process is as follows :
1) When the incisal pin moves in lateral excursion, first along a flat path
to produce the horizontal fossa and then up the incline, the buccal
cusp incline will be formed.
2) So during working side movements the lingual cusp inclines will
reduce the lingual slope of maxillary lingual cusp.
3) When articulator is moved in the opposite nonworking direction, the
mandibular buccal cusp incline in harmony with incisal pin
movement.
4) The bilateral movement removes the maxillary lingual cusp from
centric contact when the incisal pin returns to centric contact.
9) Modification of opposing occlusion (Fossae preparation) before
restorative procedures :
Most restorative dentists are accustomed to reducing an opposing
over erupted tooth before initiating restorative dentistry to produce an
esthetic plane of occlusion.

27

Standard anatomy cannot be articulated with a prosthesis containing a

modified occlusal anatomy with 1.5 mm fossae without interfering with
centric occlusion-maintaining cusps.
Loss of centric occlusal contact can be prevented by preparing a
preoperative 1.5 mm fossa in all of the remaining unrestored teeth (or
restoring the teeth with class I restorations)
The principles of occlusal co-ordination :
a) A 1.5 mm horizontal fossa cannot be articulated with standard
occlusal anatomy.
b) Central grooves of the unrestored opposing occlusal surfaces should
be modified before prosthesis fabrication with a 1.5mm fossa
preparation and or class I restorations.
c) Conversion to a 1.5mm horizontal fossa occlusion does not require
complete mouth restorations, but does require occlusal preplanning
and the re-shaping of all of the remaining posterior occlusal surfaces.
d) Intraoral occlusal corrective procedures should follow placement of
the provisional and final restorations, and are required regardless of
the occlusal anatomy, the technique, and/or the instrumentation used.
10) Final incisal guidance transfer to the Articulator :
Transfer of functional and esthetic planning from the original
mounting to the provisional restorations is accomplished with the aid of
irreversible hydrocolloid impressions of waxed casts.
A face bow mounting is used to transfer the final maxillary cast to the
articulator, and mandibular cast is positioned with the centric record. The
protrusive inter arch registration is transferred to the articulator. The
maxillary final cast is removed from the articulator and stone castoff
intraoral provisional restoration is hand articulated with mandibular cast and
luted to articulator.

28

An unmodified incisal pin is positioned and should touch the incisal

table with the casts in centric occlusion. The casts are placed in protrusive
position, which causes the incisal pin to rise off the plane in proportion to
the degree of vertical overlap. The incisal table is rotated until it touches the
elevated incisal pin.
The casts are moved into (right) lateral position and luted. The pin
rises off the plane relative to the lateral inclination. The lateral guide plane
is elevated until it touches the incisal pin, and thus transfers the right lateral
incisal guidance. The procedure is repeated for the left lateral incisal
guidance.
FIXED OR REMOVABLE RESTORATION WITH OPPOSING
FIXED OR REMOVABLE IMPLANT SUPPORTED PROSTHESIS
For this case, ORGANIC OCCLUSION is recommended for the
following reasons :
1) It is easier to produce
2) If it is supported by mucosa and it we can achieve a disclusion as flat
as possible, the tension on the implants will be minimal.
3) If bilateral balanced occlusion is created there will be many contact
surfaces in lateral excursions. Thus increasing muscular contraction
force and the possibility of osseous resorption, which in turn will
destabilize the mucosa supported segment.
4) Since there is no posterior seal in cases of implant the restoration with
upper denture, the presence of B.B.A does not increase retention
during parafucntions which would help initial mastication.
The presence of canine guidance prevents posterior tooth wear, stabilizing
occlusion and avoiding parafucntions.

29

FIXED

OR

REMOVABLE

IMPLANT

SUPPORTED

RESTORATION WITH OPPOSING REMOVABLE FULL DENTURE

WITHOUT IMPLANTS
It is logical to advocate bilateral balanced occlusion in this case. In
conventional full dentures (without implants) teeth are arranged in
bilaterally balance, when the patient is not chewing, during parafunctions
and with teeth clenching in different positions. Forces are transmitted
evenly, resulting in a most stable prosthesis with increased adhesion and fit,
which will benefit the patient.

MAXILLARY DENTURE OPPOSING AN IMPLANT

OVERDENTURE OR FIXED PROSTHESIS
Edentulous patients often feel that the retention and stability of
maxillary dentures are acceptable and that mandibular denture presents
more problems. As a result, a common treatment plan for edentulous
patients includes implants to support the mandibular restoration and a
traditional soft tissue-supported maxillary denture.
Post insertion complications of removable maxillary restoration may
be anticipated. The patient complains of maxillary denture sore spots and
instability. The sore spots under the maxillary denture result in past because
patients with rigid fixated implant prosthesis are able to generate
masticatory forces approaching that of natural dentition, whereas complete
denture wearers have been shown to exert only 25% of this amount.
This condition in the implant supported mandibular overdenture
opposing maxillary mucosa supported complete denture is called as NEW
COMBINATION SYNDROME.
Maxillary denture instability is related to increased patient awareness
and the conditions of a more stable mandibular prosthesis. A conventional

30

complete removable mandibular prosthesis moves to accommodate

prematurities or inaccuracy of occlusion, and occlusal position is often
anterior to recorded centric relation occlusion.
In addition the patient is accustomed to the mandibular denture lifting
up in the posterior when the mandible goes into excursions and no posterior
teeth are in contact. On the contrary, with a rigid mandibular restoration, the
maxillary prosthesis moves to accommodate to the mandibular occlusion so
the occlusal concepts must be more accurate. This predisposes to maxillary
denture instability, soreness, mucosal changes and ultimately to resorption
of the ridge.
To decrease maxillary denture complication when opposing a
mandibular implant restoration several concepts have been developed.
These include
- Pre prosthetic surgery to improve the maxillary ridge anatomy
- Raising the posterior occlusal plane
- Placing the mandibular and maxillary teeth more medially.
- Establishing bilateral balanced occlusion in the final restoration.
Maxillary tissue evaluation :
The foundation of the maxillary denture is bone, the overlying sub
mucosa and the mucosa.
Denture support corresponds to the regions where fibrous connective
tissue is firmly attached to bone, namely, the edentulous ridge. The teeth are
set closer to this structure than to any other supporting region. Placing the
denture teeth directly over the edentulous crest reduces the amount of force
and improves stability under vertical forces.
The premaxillary segment of edentulous maxilla is a most important
structure to ensure stability of the prosthesis. The denture stability is
severely compromised without a vertical component to the premaxilla.

31

Prosthetic considerations :
1) Maxillary incisal edge position :
The plane of occlusion is an important prosthodontic consideration
for a maxillary denture opposing an implant overdenture. The anterior
position of occlusal plane is determined by incisal edge position.
The position of maxillary incisal edge primarily reflects esthetic and
phonetic requirements. A significant decrease of maxillary tooth length
exposure is relative to age, especially between 30-40 yrs. The younger
patient exposes more than 2mm of maxillary central incisor. A conventional
denture on a division D maxilla may require incisal edge position slightly
superior and / or inward, closer to the edentulous ridge, to improve anterior
stability. In these patients, the labial gingival contour can be slightly
increased to improve lip support and slightly elevated the lip.
2)Occlusal plane :
The occlusal plane is defined in three dimensions : occlusal gingival,
anteroposterior, and buccolingual. The buccolingual dimension is parallel
with a line drawn through the pupils of the eyes. The anteroposterior and the
occlusal gingival dimensions are established by the incisal edge and the
position of the posterior occlusal plane.
Controversy exists as to where teeth should be located in these three
directions. There are usually two approaches which propose different
solutions to each plane 1) the application of biomechanics or 2) the
duplication of natural architecture.
The result of various studies is an occlusal plane inferior to natural
teeth position. In principle, this improves the stability of a lower denture.
The lowered plane of occlusion helps decrease moment forces on the lower
denture, and the tongue rest position is above the posterior teeth. But when
the mandibular restoration is implant supported, this same technique is not

32

indicated, as it places the posterior maxillary teeth lower than the original
tooth position and makes the maxillary denture more unstable.
The posterior plane of occlusion with natural teeth is either parallel to
or above campers line. The posterior occlusal plane corresponds to the bone
division, the retentive form of the arch, and to a plane from the midline to
upper portion of the tragus of the ear to the inferior portion of the ala of
nose.
If the posterior occlusal plane is positioned too high, the maxillary
denture base may be driven forward on the tissues during the mandibular arc
of closure. Therefore the ideal plane of occlusion for a denture opposing an
implant supported prosthesis is similar to that found with the natural teeth.
3) Tooth position :
Maxillary anterior prosthetic teeth are positioned forward of the
anterior supporting bone to satisfy phonetic and esthetic requirements.
Due the maxillary and mandibular anterior teeth are set on the wax
rims, the posterior tooth position is determined, the steepness of the
compensating curve for a balanced occlusion. The greater the anterior
guidance, the greater the posterior compensating curve. It is easier to
establish anterior guidance with a minimal curve. Therefore, setting a
shallow incisal guide for phonetics, esthetics and function of the anterior
teeth offers significant advantages.
4) Posterior tooth position :
The maxillary edentulous posterior ridge resorbs in a medial direction
as it transforms from division A to B, B to C and division C to D bony
support. There fore the maxillary denture tooth gradually becomes more
cantilevered off the bone support, even when positioned in the same spatial
location.

33

The mandibular edentulous posterior ridge also resorbs in a medial

direction as it transforms from division A to B, but then resorbs laterally
from division B to C and more lateral as it resorbs from division C to D.
In complete dentures, the position of mandibular teeth is often
determined first. Bone support concept of occlusion often position the
mandibular teeth perpendicular to the edentulous ridge. The positions of
central fossa of posterior mandibular teeth more medial than that of their
natural predecessors in division B, but more facial in division C, and very
facial in division D compared with the natural tooth placement.
Mandibular dentures in neutral zone record the tongue position and
also result with posterior teeth more buccal in resorbed arches than the
natural tooth placement. The maxillary teeth are then situated facially than
the original teeth, if a normal cusp fossa relation is maintained.
Consequently maxillary denture teeth are always placed lateral to the
resorbing bony support, and the condition is compounded in cases of
advanced atrophy.
The basic concept of lingualized occlusion was first introduced by
Gysi. Payne suggested the maxillary buccal cusps of posterior teeth
should be reduced, so only the lingual cusps would be in contact. Pound
placed the lingual cusp of mandibular posterior teeth between lines drawn
from the canine to each side of retromolar pad. Consistent in their
philosophy was the belief that the lingual cusp was the only area of
maxillary tooth contact.
These occlusal schemes were designed to narrow the occlusal table
and improve mastication reduce forces to the underlying bone, and help
stabilize a lower denture. The techniques of Payne and pound were modified
further to medial positioned lingualized occlusion by
MISCH.

34

In all patients the position of posterior lingual tooth extended to a line

drawn from the canine to the medial aspect of retromolar pad. In the
majority of patients, the lingual cusps extended 2 mm beyond the line, while
in approximately 10% they extended 3mm and in another third, were 1mm
beyond the line. Therefore, denture teeth get more medial to the retromolar
pad is more similar in position suggested by pound helps stabilize a
mandibular denture. The more medial the posterior denture teeth, the more
vertical are the occlusal forces over the maxillary bone, which reduces
tipping forces and makes the upper denture more stable during occlusal
contacts.
The mandibular posterior teeth are placed so that the central fossa is
over the line drawn from the mandibular canine to the lingual side of
retromolar pad.
The occlusal centric contacts follow the guidelines of lingualized
occlusion given by Pound and Payne. Only the lingual cusps of the
maxillary posterior teeth are in contact during centric occlusion. Because the
primary contact is the lingual cusp of maxillary teeth rather than the buccal
cusp of mandibular teeth, an additional stabilizing factor for the maxillary
denture teeth relative to the underlying bone is evidenced. In addition a
narrower occlusal table is observed, which decreases the force required to
penetrate food and simplifies the occlusal adjustment process. The maxillary
posterior teeth are positioned closer to the natural tooth position, as they
follow the more natural positioned mandibular teeth.
Bilateral balance is suggested to improve denture stability
during parafunction. Once food is introduced between the teeth, the
balanced occlusion is of less benefit for stability. Since the lower implant
denture is more stable than its maxillary counterpart, the maxillary denture
may rotate and become dislodged during parafunction. This causes
additional stress on the premaxilla and may result in more anterior

35

resorption. It is more important to balance the occlusion

within the functional range of mandibular movement,
rather

than

to

the

extremes

of

lateral

border

positions.
The resultant factors or raising the posterior occlusal plane, Medial
position of the teeth, lingual occlusion, and bilateral balance help
stabilize the weakest member of the removable prostheses, the maxillary
denture.

The single, anterior tooth implant is now an accepted and a highly

predictable means of tooth replacement.
The occlusion required for the single tooth replacement is similar, but
not identical, to the natural dentition. In centric occlusion, the implant
supported crown should have a clearance of 30 m. The clearance is
important since the natural teeth can be intruded in their sockets under
heavy loads whereas the implant retained prosthesis will not intrude. Failure
to build in this appropriate occlusal clearance would expose the implant
retained fixed prosthesis to excessive forces under heavy loading conditions.

OCCLUSAL MATERIALS :
The materials selected for the occlusal surface of the prosthesis affect
the transmission of forces and the maintenance of occlusal contacts. In
addition, occlusal material fracture is one of the most common
complications for restorations on natural teeth or implants. Impact loads
give rise to brief episodes of increased force, primarily related to the speed
of closure and the dampening effect of the occlusal materials.
Occlusal materials may be evaluated by esthetics, impact force, a
static load, chewing efficiency, fracture wear, interarch space requirements,

36

and accuracy of castings. The three most common groups of occlusal

materials are porcelain, acrylic and metal.
1) Esthetics
2) Impact force
3) Static load
4) Chewing efficiency
5) Fracture
6) Wear
7) Interach space
8) Accuracy

Porcelain
+

+
+
-

Gold
+

+
+
+
+
+

Resin
+
+

Skalak explained, A stiff prosthesis is preferable over a flexible one

in the superstructure which is supported by osseointegrated implants and
will distribute loads more effectively to the supporting abutments. The use
of a shock-absorbing material, such as acrylic resin in the form of artificial
teeth on the surface of the denture, can provide adequate shock protection to
the stiff and close connection of an osseointegrated implant to supporting
bone.
To reduce such peak forces, energy should be diffused by a layer of
softer material placed in the path of the force transmission. Resin, in the
form of plastic teeth, has a much lower modulus of elasticity than metals
and provides internal damping to reduce the impact forces.

CONCLUSION :
According to English 1988
Accurate occlusion is essential to the long term success of an
implant treatment, implants cannot bailout our faulty occlusion

37

The purpose of good occlusal practice is to reduce the risk of damage

occurring to the interselected tissues of masticatory system and so increase
the chances of a healthy function.
The goal is to design and provide an occlusion that is ideal ideal for
the important criteria of success of implant and the prosthesis.
OCCLUSION IS DENTISTRY: DENTISTRY IS OCCLUSION.
OCCLUSION IS THE MEDIUM OF DENTISTRY.
REFERENCES :
1) Misch Contemporary Implant Dentistry ; 2nd edition.
2) Hobo Osseointegration and occlusal Rehabilitation.
3) Q.I. 1994 : 25 : 3 : 177-180.
4) I.J.P. 1998 ; 11 : 55-69
5) Q.I. 1989 : 20 ; 7 : 473 / 480
6) Optimal implant positioning and soft tissue management for the
branemark system.
7) Sumiya Hobo Oral rehabilitation. Quintessence publishing co., inc.
page : 119-134.
8) Implant Prosthodontics Maurice. J. Fagan. Jr. Mosby : Year book
Inc, 217-237.
9) Occlusion : Principles and concepts Jose dos. Santos Jr. 2nd edition
Ishiyaku Euro America, Inc. U. SA. Pag 117-134.
10) JADA. Vol. 126 ; August ; 1995 : 1130 1133.
11) BDJ. 191.52001 : 233-245.
12) BDJ. 192 ; 2 : 2002 : 79 87.