Good Occlusal Practice in the Provision of Implant Borne Prostheses

Go Top of Page S. J. Davies,1 R. J. M. Gray2 and M. P. J. Young3 The increased use of endosseous dental implants means that many dentists will encounter patients with dental implants in their everyday practice. Dental practitioners might be actively involved in the provision of implant borne prostheses at both the surgical and restorative phases, or only at the restorative stage. This section is written for all dentists and aims to e amine the sub!ect of occlusion within implantology. It aims to provide guidelines of good occlusal practice to be used in the design of the prosthesis that is supported or retained by one or more implants. "s implantology is a #new$ discipline of dentistry, there are fewer standard te ts and this section, therefore, is much more e tensively referenced than the sub!ects that have been considered to date. This is the last section of this series. 1*GDP, 73 Buxton Rd, ig! "ane, Sto#$%ort S&' (DR) P*+ "e#turer in Denta, Pra#ti#e, -niversity Denta, os%ita, o. Man#!ester, ig!er /a01ridge St.,Man#!ester M12 '3 ) 2 onorary 3e,,o4, -niversity Denta, os%ita, o. Man#!ester, ig!er /a01ridge St., Man#!ester M12 '3 3 Senior "e#turer and onorary /onsu,tantin Restorative Dentistry, -niversity Denta, os%ita, o. Man#!ester, ig!er /a01ridge St., Man#!ester M12 '3 */orres%onden#e to 5 Ste%!en Davies, 73 Buxton Rd, ig! "ane, Sto#$%ort S&' (DR Email: stephen.j.davies@man.ac.uk 6ven t!ose genera, denta, %ra#titioners 4!o are not i0%,ant %roviders are ,i$e,y in t!e .uture to 1e responsible for the maintenance o. i0%,ants

Osseointegration
3or osseointegration to o##ur %redi#ta1,y #,ini#a, guide,ines !ave 1een deve,o%ed to o%ti0ise su##ess rates51

+!e i0%,ant 0ust #onsist o. a suita1,e 1io0ateria, 4it! a%%ro%riate sur.a#e %ro%erties 7de8uate vita, 1one 0ust 1e %resent to su%%ort t!e i0%,ant 7 %re#ise surgi#a, .it 0ust 1e a#!ieved 1et4een t!e 1one and t!e i0%,ant +!e i0%,ant 0ust 1e inserted 4it! a ,o49trau0a te#!ni8ue to avoid over!eating o. t!e 1one during %re%aration o. t!e re#e%tor site

+!e i0%,ant s!ou,d not 1e su1:e#t to .un#tiona, ,oads during a !ea,ing %eriod o. 3;' 0ont!s <+!is traditiona, %roto#o, is no4 1eing 8uestioned=.

7,t!oug! t!ese guide,ines do not 0ention >o##,usion?, on#e integrated, denta, i0%,ants 0ust 1e restored sympathetically 4it! due regard to o##,usion sin#e un.avoura1,e ,oading !as 1een #ited as a 0a:or #ause o. .ai,ure. +!is %art o. t!e series 4i,, %resent t!e .a#tors t!at in.,uen#e t!e o##,usa, s#!e0es used .or %rost!eses su%%orted or retained 1y endosseous denta, i0%,ants. Sin#e re,ative,y .e4 studies !ave 1een designed 4it! t!e so,e ai0 o. #o0%aring di..erent o##,usa, s#!e0es, it is di..i#u,t to 1e #ertain 4!at is t!e 1est o##,usion .or a given #,ini#a, situation. /urrent te#!ni8ues and 0ateria,s tend to 1e 1ased on 4!at !as evo,ved over years o. #,ini#a, %ra#ti#e and ,a1oratory resear#!. +!ey are 1ased on 4!at is 1e,ieved, rat!er t!an 4!at is $no4n, to 1e good o##,usa, %ra#ti#e in i0%,anto,ogy. >@sseointegration? is t!e 1io,ogi#a, %ro#ess t!at resu,ts in a #,ose stru#tura, re,ations!i% 1et4een vita, 1one and a denta, i0%,ant. Su##ess.u,,y integrated and #are.u,,y ,oaded i0%,ants !ave 1een s!o4n to 1e #a%a1,e o. 1eing retained 1y t!e !ost tissues .or 0any years. @sseointegration 4as .irst de.ined as >t!e dire#t stru#tura, and .un#tiona, #onne#tion 1et4een ordered ,iving 1one and t!e sur.a#e o. a ,oad #arrying i0%,ant?.2 More re#ent,y t!is !as 1een de.ined as >a %ro#ess 4!ere1y a #,ini#a,,y asy0%to0ati# rigid .ixation o. a,,o%,asti# 0ateria,s is a#!ieved and 0aintained in 1one during .un#tiona, ,oading?.3 @1vious,y, t!e signi.i#ant di..eren#e 1et4een >osseointegration? and t!e atta#!0ent o. teet! to t!e a,veo,us is t!e a1sen#e o. a %eriodonta, ,iga0ent. 7,t!oug! axons !ave 1een identi.ied in %eri9i0%,ant regions, t!eir .un#tiona, signi.i#an#e is not #,ear,y understood.A 7t %resent, t!e %ro%rio#e%tive #a%a1i,ity o. restored i0%,ants is usua,,y attri1uted to 1one de.or0ation o. t!e %eriostea, 0e#!anore#e%tors on i0%,ant ,oading.2 Regard,ess o. t!e %re#ise 0e#!anis0 .or su#! %ro%rio#e%tion, it !as 1een s!o4n t!at t!e 1B 6ven t!ose genera, denta, %ra#titioners 4!o are not i0%,ant %roviders are ,i$e,y in t!e .uture to 1e res%onsi1,e .or t!e 0aintenan#e o. i0%,ants 70end0ent5 +!is %a%er is an u%dated version .ro0 t!e origina, %rinted version. Part o. t!e .ina, senten#e at t!e 1ase o. %age (' 4as o0itted and is no4 s!o4n !ere in .u,,. t!res!o,d o. ta#ti,e sensitivity is a%%roxi0ate,y eig!t ti0es ,ess t!an t!at o. natura, teet!.' Cn addition, t!e range o. >.ood9 !o,ding? .or#es .or %atients 4it! i0%,ants is signi.i#ant,y !ig!er t!an t!ose .or %atients 4it! natura, teet!.7 D!en %res#ri1ing or 0odi.ying o##,usa, #onta#ts .or i0%,ant %rost!eses, it s!ou,d 1e 1orne in 0ind t!at t!e %atient?s %er#e%tion o. o##,usa, irregu,arities and o##,usa, ,oads is 0u#! redu#ed and, t!ere.ore, s!ou,d not 1e so,e,y re,ied u%on. Implantology is based upon osseointegration

%urrent "pplication of Oral Implants

+!e #urrent a%%,i#ation o. i0%,ants is 0u#! 0ore extensive t!an 4!en i0%,ants 4ere .irst uti,ised. Cn star$ #ontrast to t!eir initia, a%%,i#ations E4!en %redo0inant,y on,y edentu,ous %atients 4ere treated 4it! .ixed denturesF, i0%,ants are no4 inserted into5

Partia,,y dentate %atients 4it! a !ea,t!y or #o0%ro0ised %eriodontiu0.

Posterior regions o. t!e 0axi,,a and 0andi1,e Sites in 4!i#! t!e 1one !as 1een aug0ented.

Cn addition, 0any di..erent ty%es o. %rost!eses 0ay no4 1e i0%,ant9su%%orted5

3ixed #ro4ns 3ixed 1ridges 3ixed dentures Pre#ision re0ova1,e dentures Re0ova1,e overdentures <0u#osa and i0%,ant su%%orted=

The absence of a periodontal ligament between an implant and the bone significantly reduces the patient$s sensory perception of the occlusal load

Implant &uccess
/riteria .or i0%,ant su##ess !ave 1een out,ined so0e years ago. +!ere s!ou,d 1e an a1sen#e o.5

Mo1i,ity 7sso#iated radio,u#en#y Pain Cn.e#tion or iatrogeni# neuro%at!ies. Peri9i0%,ant verti#a, 1one ,oss G 1.B 00 in t!e .irst year o. ,oading G B.2 00 %er annu0 t!erea.ter.

Implant &uccess 's Implant &urvival

Cn re#ent years, >i0%,ant surviva,? <i0%,ant retention at t!e end9%oint o. t!e study= a%%ears to 1e in#reasing,y used 4!en re%orting treat0ent out#o0es.(917 +!is ter0 0ig!t 1e 0ista$en,y inter%reted as 1eing synony0ous 4it! implant success as de.ined a1ove.1( /riteria .or su##ess are not a,4ays #,ear,y de.ined and 0ig!t 1e >syste0 s%e#i.i#?. Sin#e i0%,ant surviva, is a #rude 0easure o. i0%,ant !ea,t!, resear#! t!at uses t!is ter0 #annot 1e #onsidered to 1e as 0eaning.u, as t!at 4!i#! de.ines and 0easures i0%,ant su##ess. +!ere.ore, 4!en eva,uating #,ini#a, resear#! studies, a #riti#a, a%%raisa, 0ust 1e 0ade. Des%ite nu0erous ear,y studies t!at re%orted su##ess rates in ex#ess o. HBI, 0ore re#ent,y ,o4er su##ess rates !ave 1een re%orted.1H +!is 0ig!t 1e ex%,ained 1y t!e use o. i0%,ants in 0ore de0anding #ir#u0stan#es, %oor o%erator te#!ni8ue, or t!e use o. an i0%,ant syste0

4it! an un%roven tra#$ re#ord. 7 .urt!er .a#tor 0ig!t 1e t!e ,eve, o. ex%erien#e o. t!e surgeons t!at %rovide i0%,ant treat0ent.2B Implant survival does not e(ual implant success

The )ailing Implant

D!i,st t!e e..i#a#y o. i0%,ants !as 1een a0%,y de0onstrated .or #ertain syste0s, .e4er studies are avai,a1,e .or any i0%,ant syste0 to su%%ort t!eir e..e#tiveness in >rea, ,i.e? studies 4!ere, .or exa0%,e, se,e#tion #riteria 0ig!t 1e 0ore re,axed.21 7s .or a,, 0edi#a, and denta, treat0ents, 4e #an ex%e#t t!e %roven e..e#tiveness o. i0%,ants to 1e ,ess t!an t!eir %roven e..i#a#y. 7gainst t!is 1a#$ground, it is i0%ortant not on,y to de.ine i0%,ant .ai,ure, 1ut a,so to exa0ine !o4 it 0ig!t 1e %revented. 7 .ai,ing i0%,ant #an 1e de.ined as one in 4!i#! t!e #riteria .or su##ess are not 0et. >Perii0%,ant? in.,a00ation <%eri9i0%,antitis= %resents a si0i,ar #,ini#a, %i#ture to %eriodonta, in.,a00ation, 4it! 1one ,oss as a $ey .eature. >Peri0u#ositis?, !as 1een reserved .or so.t tissue in.e#tion around an i0%,ant, 4!i,st >%eri0%,antitis? i0%,ies a##o0%anying 1one ,oss <#,assi.i#ation and revie4 o. i0%,ant .ai,ures=.22922 +!e >.ai,ing? i0%,ant o.ten %resents as a #!roni# t!en ter0ina, #ondition u,ti0ate,y ,eading to i0%,ant ex.o,iation. +!e stages o. i0%,ant .ai,ure !ave 1een suggested to 1e <a.ter Je40an=52' 1. Gingiva, in.,a00ation 2. Gingiva, !y%ertro%!y 3. Progressive dee%ening o. %o#$ets A. Progressive atta#!0ent ,oss 2. Progressive 1one ,oss '. /!ange in 0i#ro1ia, 0i#ro.,ora 7. >@sseo9disintegration? 4it! 0o1i,ity and %erii0%,ant radio,u#en#y (. C0%,ant ex.o,iation +!e suggested aetio,ogi#a, .a#tors .or i0%,ant .ai,ure are5

Redu#ed !ost resistan#e P,a8ue a##u0u,ation @##,usa, stress Syste0i# .a#tors eg dia1etes and s0o$ing

7,t!oug! a 4ide range o. te#!ni8ues !as 1een e0%,oyed to sta1i,ise .ai,ing i0%,ants, it is re#ognised t!at t!e eviden#e to su%%ort t!ese interventions a%%ears %oor at %resent.27

%ase *esponsibility
+!e deter0ination o. #ase res%onsi1i,ity is an i0%ortant #onsideration .or t4o reasons. 3irst,y, i0%,ants #an and do .ai, and t!e #auses o. .ai,ure are not #o0%,ete,y understood. Se#ond,y, t!e %rovision o. an i0%,ant 1orne restoration is o.ten a tea0 e..ort. C. t!e sa0e #,ini#ian #arries out 1ot! surgi#a, and restorative %!ases, t!e res%onsi1i,ity .or design and exe#ution o. t!e treat0ent, toget!er 4it! an a%%ro%riate 0aintenan#e %rogra00e is une8uivo#a,. o4ever, 4!en i0%,ant treat0ent is de,ivered as a >tea0? <at one or 0ore sites= t!e 8uestion o. res%onsi1i,ity .or i0%,ant .ai,ure 1e#o0es 0ore #o0%,ex and indeed 0ore #ontentious. 3ai,ure under t!is regi0e 0ay resu,t in a de1ate 4!i#! does t!e %ro.ession no #redit. D!en i0%,ant t!era%y is de,ivered 1y a >tea0?, #,ose #o,,a1oration 1et4een t!e surgeon, restorative dentist and denta, te#!ni#ian is essentia,. +!e surgeon 0ust as$ .or guidan#e as to t!e o%ti0a, restorative i0%,ant ,o#ation. 68ua,,y, t!e restorative dentist 0ust a%%re#iate t!e anato0i#a, #onstraints 4!en giving so0e guidan#e on t!e idea, %osition 4it! regards to t!e %ro%osed o##,usa, %,at.or0. +!e i0%,ant te#!ni#ian 0ust !ave so0e #on#e%t o. %re.erred o##,usa, s#!e0es i. a%%ro%riate o##,usa, #onta#ts are to 1e in#or%orated into t!e i0%,ant su%%orted %rost!esis. Cn su#! situations, it is suggested t!at t!e 0ost ex%erien#ed 0e01er o. t!e i0%,ant tea0 1e#o0es t!e >tea09,eader?, 4!et!er t!ey 1e surgeon or restorative dentist. +!e team leader 0ust ensure t!at t!e :oint treat0ent %,an 0ini0ises t!e ris$ o. i0%,ant .ai,ure. +!is is %arti#u,ar,y i0%ortant sin#e t!e #urrent eviden#e to su%%ort t!e e..i#a#y o. i0%,ant9res#ue te#!ni8ues is 4ea$. +!e degree o. res%onsi1i,ity 4i,, vary a##ording to t!e ex%erien#e o. t!e tea0 0e01ers, 1ut t!e %rin#i%,e t!at a %atient?s treat0ent s!ou,d not su..er t!roug! a ,a#$ o. #o00uni#ation 1et4een t!e #,ini#ians invo,ved is %ara0ount. +!e >tea0 ,eader? is res%onsi1,e .or ensuring t!at t!e a%%ro%riate #o00uni#ation exists to satis.y t!e needs o. t!e #ase.

Occlusal Overload as a %ause of Implant )ailure

Ct !as 1een esta1,is!ed t!at trau0a .ro0 o##,usion 0ay 1e a .a#tor in t!e aetio,ogy o. i0%,ant .ai,ure.22;2( Ct !as 1een suggested t!at a radio,ogi#a, a%%earan#e o. >sau#erisation or .urro4ing? is asso#iated 4it! o##,usa, over,oad <3ig. 1=.2H

3ig. 1 7 %ossi1,e sign o. o##,usa, over,oad5 >.unne,,ing? or >sau#erisation?. D!ereas t!e natura, dentition is #a%a1,e o. %!ysio,ogi#a,,y ada%ting to trau0ati# o##,usions, t!e a1sen#e o. a %eriodonta, ,iga0ent 0eans t!at denta, i0%,ants are 0ore easi,y over,oaded and t!is #an to ,ead to i0%,ant .ai,ure. "e.t untreated, an over,oaded i0%,ant 4i,, u,ti0ate,y ex.o,iate. Re0edia, a#tion 0ust 1e s%eedi,y underta$en to redress t!e un.avoura1,e ,oading #onditions. +!e #auses o. o##,usa, stress are nu0erous and in#,ude5

Cnade8uate nu01er o. i0%,ants to su%%ort t!e %rost!esis .itted eavy o##,usa, #onta#ts in #entri# o##,usion Dor$ing9side inter.eren#es <as o%%osed to 1a,an#ed #onta#ts= Jon94or$ing side inter.eren#es 6x#essive 1u##a, or ,ingua, #anti,ever <t!e o##,usa, ta1,e too 4ide .or t!e i0%,ant dia0eter=

The &urgeon$s Tale >+!e i0%,ants 4ere su##ess.u,,y integrated, 1ut .ai,ed 1e#ause o. ex#ess ,oads? or The *estorative Dentist$s Tale >+!e i0%,ants 4ere %oor,y integrated and so .ai,ed under nor0a, 0asti#atory ,oads? either way

+!e Patient?s +a,e >My i0%,ants !ave .ai,ed K?

Techni(ue
*ecommendations for Occlusal &chema for Implant &upported Prostheses

Ct is t!e nature o. osseointegration t!at deter0ine t!e .eatures o. an >idea,? o##,usion .or an i0%,ant su%%orted %rost!esis. +!e .unda0enta, nature o. osseointegration <no %eriodonta, ,iga0ent= 0eans t!at %ro%rio#e%tive and a%ta%tive %otentia, is ,ess t!an 4it! natura, teet!5

+!e i0%,ant is rigid,y atta#!ed and 4i,, 0ove or intrude 0u#! ,ess 7,t!oug! #onne#tions to t!e #entra, nervous syste0 are 1e,ieved to exist, it is a##e%ted t!at %ro%rio#e%tion is redu#ed 7n i0%,ant #annot undergo ort!odonti# 0ove0ent

7n idea, o##,usa, s#!e0e .or .ixed i0%,ant su%%orted %rost!eses !as 1een re#o00ended53B

7 #entri# o##,usion >#us% to #entra, .ossa? #onta#t 4!i#! is ,ig!t 7n idea, anterior guidan#e5 t!at is #anineguidan#e or grou%9.un#tion) no %osterior inter.eren#es 7xia, ,oading o. t!e i0%,ants

istori#a,,y, it !as 1een re#o00ended t!at non9axia, ,oads s!ou,d 1e dissi%ated 1y t!e use o. inter9i0%,ant s%,inting, 1y 0eans o. 1ars or .ixed91ea0 stru#tures, and >dou1,e9 #onstru#tion? te#!ni8ues. o4ever, in re#ent years t!is %rin#i%,e !as 1een 8uestioned31 and 0u,tii0%,ant #ases are no4 1eing restored as 0u,ti%,e, non9s%,inted, sing,e teet! i0%,ants. +!is a%%roa#!, !o4ever, is a re#ent deve,o%0ent and t!e eviden#e 1ase is #orres%onding,y ,ig!t. 7s it is 4ide,y a#$no4,edged t!at t!e 1one o. t!e %osterior 0axi,,a is %oor in 8ua,ity, t!e use o. nons%,inted, 0u,ti%,e i0%,ants restored 4it! .ixed %rost!eses in t!is region is #onsidered to #arry a greater ris$ o. .ai,ure. /are.u, ,oading in t!e %osterior regions see0s es%e#ia,,y i0%ortant to sustain a##e%ta1,e i0%,ant su##ess rates. The absence of a periodontal membrane is believed to be the reason why endosseous implants appear to tolerate non+a ial loads poorly

To %onform or to *e+Organise,
+!e de#ision to %rovide an o##,usion in >an i0%,ant #ase?, eit!er #on.or0ing to t!e %reexisting o##,usion or re9organising t!e o##,usion, 4i,, 1e 0ade in exa#t,y t!e sa0e 0anner as in any ot!er restoration treat0ent %,an. +!is de#ision90a$ing %ro#ess is des#ri1ed ear,ier. +4o guide,ines are %ara0ount5

C. it is %ossi1,e to .o,,o4 t!e #on.or0ative a%%roa#! t!is is t!e sa.est route

C. an o##,usion is to 1e re9organised, esta1,is!ing and re#ording /entri# Re,ation is t!e essentia, .irst ste%.

%lassification of Osseointegrated Prostheses

+!e $ey .eatures o. an a%%ro%riate o##,usion 4i,, in %art de%end u%on t!e ty%e o. %rost!esis. +!e di..erent ty%es o. %rost!eses 4i,, 1e #onsidered under t!e .o,,o4ing #,assi.i#ation5

Sing,e9toot! i0%,ant 3u,,9ar#!, i0%,ant su%%orted %rost!esis 3ree9standing, .ixed9%rost!esis &ennedy #,asses C, CC, CCC, CL C0%,ant9retained overdenture C0%,ant M toot!9retained, .ixed9%rost!esis

- . - amine D . Design - . - ecute % . %hec/

0. &ingle Tooth *eplacement by Implant *etained %rown

+!e sing,e, anterior toot! i0%,ant is no4 an a##e%ted and a !ig!,y %redi#ta1,e 0eans o. toot! re%,a#e0ent. -nti, re#ent,y, 0o,ar toot! re%,a#e0ent 1y an endosseous denta, i0%,ant 4as #onsidered #ontra9indi#ated. Prior to t!e deve,o%0ent o. >4ide9dia0eter? i0%,ants, 0o,ars 4ere restored using t4o narro4 i0%,ants. Re#ent studies indi#ate t!at si0i,ar su##ess rates #an 1e ex%e#ted .or dou1,e or sing,e i0%,ant 0o,ar re%,a#e0ents.3293A 7 %oor o##,usa, s#!e0e is ,i$e,y to in#rease t!e ris$ o. i0%,ant .ai,ure in t!e %osterior region, sin#e t!e #!e4ing .or#es in t!is region great,y ex#eed t!ose in t!e anterior region, and 1e#ause 1one 8ua,ity is %oorer.

Ideal Occlusion for &ingle Tooth Implant

"ig!t ,oad <in.ra9o##,usion 1y 3B N0= under !eavy #,en#!ing @##,usa, .or#e dire#ted do4n t!e ,ong axis o. i0%,ant "ig!t or no o##,usa, #onta#t during ex#entri# ex#ursions.

Discussion of Requirements of Ideal cclusion for !in"le #ooth Implant $%i". &' 1. +!e o##,usion re8uired .or t!e sing,e toot! re%,a#e0ent is si0i,ar, 1ut not identi#a,, to t!e natura, dentition. Cn #entri# o##,usion, t!e i0%,ant su%%orted #ro4n s!ou,d !ave a #,earan#e o. 3B N0. +!is #,earan#e is i0%ortant sin#e t!e natura, teet! #an 1e intruded in t!eir so#$ets under !eavy ,oads 4!ereas t!e i0%,ant retained %rost!esis

4i,, not intrude. 7ny #,ini#ian 4!o is used to ad:usting #onventiona, #ro4n and 1ridge4or$ using s!i0sto#$ < t!i#$ness (N0 = 4i,, re#ognise t!at 3B N0 is a signi.i#ant #,earan#e. 3ai,ure to 1ui,d in t!is a%%ro%riate o##,usa, #,earan#e 4ou,d ex%ose t!e i0%,ant9retained .ixed%rost!esis to ex#essive .or#es under heavy loadin" conditions. -n.ortunate,y, t!e %atient #annot 1e re,ied u%on to re%ort t!at an i0%,ant su%%orted #ro4n is >!ig!? 1e#ause t!e a1sen#e o. a %eriodonta, 0e01rane 0eans t!at t!ere is ,i0ited %ro%rio#e%tion in t!e i0%,ant9a,veo,ar 1one syste0. 2. 6ndosseous i0%,ants are 1est a1,e to 4it!stand .or#es t!at are dire#ted do4n t!e ,ong axis o. t!e i0%,ant, 1e#ause o. t!e a1sen#e o. t!e %eriodonta, ,iga0ent s,ing. +!is re8uire0ent is not %ure,y a #onsideration in t!e restorative %!ase o. t!e treat0ent, t!e %,a#ing o. an i0%,ant s!ou,d 4!erever %ossi1,e ta$e a##ount o. t!e eventua, o##,usa, ,oading. 3. "ig!t ex#entri# #onta#ts are a vita, re8uire0ent to avoid non9axia, ,oading. )ig. 1 Predictability of success for a single tooth implant Cdeal %ase

+oot! a1sent -R1

7etio,ogy o. toot! ,oss O a#ute trau0a

Lerti#a, 1one ,oss O ni, 7de8uate 1one 4idt!

7de8uate %osterior o##,usion 71sen#e o. %re0aturities in /R

/anine9guided dis#,usion

Protrusive #onta#t s!ou,d 1e even,y distri1uted on t!e in#isors /,ass1in#isor re,ations!i% anterior #,earan#e 3B P0 in #entri# o##,usion Predicted &uccess is 'ery 2igh

Guide,ine5 /on.or0 to existing o##,usion 4!i#! is atrau0ati# <+!e /on.or0ative 7%%roa#!= 3on+Ideal %ase

+oot! a1sent -R1

7etio,ogy o. toot! ,oss5 root .ra#ture <%revious,y %ost9retained #ro4n=

Lerti#a, 1one ,oss O ni,, 7de8uate 1one 4idt!.

Severe #us%a, attrition o. a,, .our #anines

Mu,ti%,e teet! 4it! 0irror9.a#eting

Redu#ed verti#a, di0ensions

Posterior o##,usion ex!i1its very 4ide 1ased o##,usa, #onta#ts

6dge to edge in#isor re,ations!i%

Grou% .un#tion ex!i1ited in ,atera, ex#ursion

Jo %osterior dis#,usion in %rotrusive ex#ursions

Predicted &uccess is 4uestionable (uideline: 6xisting o##,usion is un.avoura1,e and 0ay !ave #ontri1uted to t!e ,oss o. t!is toot!, so i0%,ant treat0ent is #ontra9indi#ated unti, t!e natura, o##,usion is #!anged to 1eing a 0ore idea, one <ie t!e re9organised a%%roa#! =. +!e a,ternative is to %ro#eed 4it! i0%,ant treat0ent a.ter 0a$ing t!e %atient a4are t!at t!e i0%,ant 4i,, 1e %,a#ed into a #o0%arative,y !osti,e environ0ent.. /ertain,y i. toot! sur.a#e ,oss #ontinues, t!e i0%,ant 4i,, 1e#o0e !ig!,y sus#e%ti1,e to over,oad. Ct is %ossi1,e to >!ide? t!e i0%,ant 4it!in t!e natura, o##,usion 1y s,ig!t in.ra9o##,usion, so t!e sing,e toot! i0%,ant #an easi,y 1e %rote#ted .ro0 0e#!ani#a, over,oad. 7d:a#ent natura, teet! s!ou,d 1e >re#ruited? to %rovide %ro%rio#e%tive %rote#tion .ro0 ex#ess ,oads.
1. )ull+"rch, Implant &upported Prosthesis

+4o o##,usa, s#!e0es !ave 1een des#ri1ed and re#o00ended .or t!e restoration o. .u,,9 ar#! i0%,ant su%%orted, .ixed9 %rost!eses532 1. Mutua,,y %rote#ted o##,usion <MP@= 2. "ingua,iQed o##,usion <"@=

0. 5utually Protected Occlusion6 5PO7 +!is #on#e%t re#o00ends t!at in #entri# re,ation t!ere is on,y %osterior toot! #onta#t. +!e 0axi,,ary %a,ata, #us%s and 0andi1u,ar 1u##a, #us%s s!ou,d o##,ude 4it! t!eir o%%osing o##,usa, .ossae. +!us, anterior teet! %ositive,y dis#,ude t!e %osterior teet! in a,, ex#entri# ex#ursions, %rote#ting t!e %osterior teet! <or i0%,ants= .ro0 !ar0.u, ,atera, .or#es. +!is ty%e o. 0utua,,y %rote#ted o##,usion !as 1een re%orted to 1e t!e 0ost e..i#ient in ter0s o. 0asti#ation, #o01ined 4it! 4!at is 4ide,y regarded to 1e t!e o%ti0a, aest!eti# a%%earan#e. +!is >gnat!o,ogi#a,? s#!e0e is 1e,ieved to #,ose,y re%resent t!e >%er.e#t? natura, o##,usion. D!ereas 0ost o. us #an des#ri1e t!is ty%e o. o##,usion, to .a1ri#ate, .it and 0onitor su#! an o##,usion re8uires #onsidera1,e ,a1oratory and te#!ni#a, ex%ertise, su1stantia, #,ini#a, s$i,,s and a0%,e #!air9side ti0e. MP@ re8uires t!at a ,arge nu01er o. #onta#ts 1et4een t!e %osterior teet! s!ou,d o##ur si0u,taneous,y. +!e #onta#ts 1et4een t!e 1a#$ teet! s!ou,d 1e tri%oda, #us%to9 .ossae. 7na,ysing and 0odi.ying su#! #o0%,ex #onta#ts is genera,,y #onsidered very di..i#u,t in .u,,9ar#! i0%,ant su%%orted %rost!eses. /!airside o##,usa, e8ui,i1riation 4i,, a,0ost a,4ays 1e ne#essary. (uideline: )void non*a+ial loadin" ,henever possi-le. !hallo, central fossae ,ith tripodal cuspal contacts should -e attained. #he presence of rid"e*lappin" should -e minimised ,henever possi-le and the distal len"th of a cantilever has -een empirically recommended -et,een ./ and &/ mm. 0ore recently1 it has -een su""ested that the optimal distal cantilever is in the re"ion of just 2 mm. 3hen e+ceedin" this len"th1 clinicians should carefully consider the num-er1 location and precise arran"ement supportin" implants.45 1. 8inguali9ed Occlusion 68O7 Sin#e it is a#$no4,edged t!at MP@ is di..i#u,t and ti0e9#onsu0ing to .a1ri#ate, .it and 0aintain, a,ternative o##,usa, s#!e0es !ave 1een %ro%osed. S%e#i.i#a,,y, >,ingua,iQed o##,usion? !as 1een re#o00ended .or t!e restoration o. .u,,9ar#! denta, i0%,ants. +!e ai0s are t!e sa0e 1ut t!e 0a:or 1ene.its o. t!is o##,usa, s#!e0e are t!e #o0%arative si0%,i#ity 4it! 4!i#! it #an 1e esta1,is!ed and 0aintained, and its a1i,ity to dire#t 0asti#atory ,oads axia,,y onto t!e su%%orting denta, i0%,ants. +!e $ey .eature is t!e arrange0ent o. t!e %osterior teet! so t!at on,y t!e ma+illary palatal #us%s <!en#e5 >,ingua,iQed? o##,usion) or s!ou,d it !ave 1een #a,,ed >palatalised? o##,usionR= o##,ude 4it! shallo, 0andi1u,ar #entra, .ossae. +!ere is no #onta#t 1et4een t!e 0andi1u,ar 1u##a, #us% and %a,ata, 0axi,,ary #us%s 4!i#! 0ig!t resu,t in a in#,ined <non9axia,= #onta#t. "a1oratory .a1ri#ation ti0e is redu#ed and t!is s#!e0e re%resents a %osterior o##,usion t!at #an 1e 0ore readi,y o1served in 1ot! t!e ,a1oratory and #,ini#a, environ0ents t!ere1y ena1,ing any un.avoura1,e o##,usa, #onta#ts to 1e identi.ied and #orre#ted 0ore easi,y.

7 very 0inor disadvantage o. ,ingua,iQed o##,usion is t!e #reation, 1y de.inition, o. a s,ig!t 1u##a, s%a#e 1et4een t!e 1u##a, #us%s o. t!e 0andi1u,ar teet! and t!eir 0axi,,ary #ounter%arts. o4ever, sin#e t!is s%a#ing o##urs in t!e %osterior region o. t!e ar#!es, t!e aest!eti# i0%,i#ations are 0ini0a,. (uideline: )void non*a+ial loadin" ,henever possi-le. !hallo, mandi-ular central fossae ,ith ma+illary palatal cuspal contacts should -e attained. #he presence of rid"e*lappin" should -e minimised ,henever possi-le and the len"th of a cantilever should not e+tend further than 2 mm -eyond the most distal implant $!ee later for an e+planation of rid"e lappin"'.
:. )ree+standing, )i ed+Bridges 6 ;ennedy %lasses I +I' Inclusive7

1.

;ennedy %lass I (uideline: In these -ilateral free end saddle cases -oth posterior sections of the arch are restored ,ith osseointe"rated -rid"es. #he anterior "uidance ,ill -e provided -y the natural dentition as lon" as the implant supported -rid"es are desi"ned to allo, adequate posterior disclusion. #here is a conflict in the desi"n of these -rid"es1 ,hich is impossi-le to resolve. n the one hand there is an indication to make the occlusal stops on the posterior -rid"es li"hter -y a-out 4/ 6m than those in the remainin" natural teeth. n the other hand1 $"iven that there is "eneral a"reement that it is more ideal that the -ack teeth contact harder than the front teeth' this ,ill not -e possi-le if the posterior occlusion is e+clusively provided -y the implant supported -rid"es. It is not unusual for clinicians to have such issues to reconcile. #he -est treatment outcome is likely to -e provided -y those clinicians ,ho realise that there is a dan"er of trauma from occlusion and so ,ill carefully monitor the situation.

1. ;ennedy %lass II (uideline: #his clinical situation $unilateral free end saddle' can -e re"arded as a very favoura-le application for a fi+ed prosthesis -ecause the natural teeth ,ill provide the occlusion7 ,hilst the contralateral unilateral free end saddle can -e restored ,ith implant supported -rid"e,ork that has 4/ 6m clearance. :. ;ennedy %lass III (uideline: 3here there are -ounded posterior saddles the use of implants is a"ain ideal -ecause the adjacent natural teeth that -ound the edentulous space ,ill allo, the construction of the restorations ,ith the 4/ 6m clearance7 and the anterior teeth ,ill provide the ideal anterior "uidance. <. ;ennedy %lass I' (uideline: #his is an anterior -ounded saddle. 3hen there is as a lar"e span $for e+ample 8R9 $.9' to 8:9$&9' it is very difficult to restore ,ith a fi+ed -rid"e

-ecause of the e+cessive torque that is a result of the cantilever. In contrast1 the insertion of four to si+ anterior implants can easily and predicta-ly treat this situation. #he implant*supported ;ennedy <lass I= -rid"e must provide an appropriate anterior "uidance ,hich achieves posterior disclusion1 and a shallo, anterior "uidance is recommended. In addition1 is advisa-le to prescri-e sli"htly "reater freedom in centric occlusion than for natural anterior teeth.
<. Overdentures

verdentures may -e used for -oth ma+illary and mandi-ular edentulous cases. (uideline: In the upper arch it is usual to use a minimum of four implants for denture retention and full palatal covera"e is employed for additional support and retention. >o,ever1 in vie, of the "enerally softer -one in the ma+illa than in the mandi-le1 si+ implants ,ould -e prefera-le1 in order to reduce the functional load on each implant. In the mandi-le1 t,o implants may -e sufficient. #he occlusion recommended in either denture is fully -alanced lin"uali?ed occlusion. +!e %arti#u,ar %ro1,e0 o. designing an o##,usion 1et4een a 0u#osa su%%orted u%%er #o0%,ete denture and an i0%,ant retained ,o4er #o0%,ete denture are dis#ussed under >Je4 #o01ination syndro0e? <Se#tion 3/<iii= o. t!e se#tion on Good @##,usa, Pra#ti#e in Re0ova1,e Prost!odonti#s=.
=. Implant and Tooth+*etained, )i edprosthesis

+!e #on#e%t o. ,in$ing natura, teet! to i0%,ants to su%%ort a .ixed 1ridge !as sti0u,ated #onsidera1,e de1ate and resear#!. Ct is 4ide,y a##e%ted t!at t!is situation is ,ess t!an idea, sin#e it re8uires rigid 1one9an#!ored i0%,ant<s= to 1e :oined to a re,ative,y 0o1i,e natura, toot!. +!e reason 4!y it is extre0e,y di..i#u,t to design an idea, o##,usion .or a .ixed 1ridge t!at is su%%orted in t!is 4ay is t!at t!e 1ridge 4ou,d 1e a rigid ,in$ 1et4een t4o tota,,y di..erent atta#!0ents to 1one. Rea#tion to o##,usa, ,oad is de%endant u%on t!e .or0 o. t!e atta#!0ent to 1one. Sin#e t!e atta#!0ents o. teet! and i0%,ants are so di..erent, the reaction to occlusal load is -ound to differ) and t!is #an !ave an adverse e..e#t on t!e atta#!0ents and*or t!e %rost!esis. +!e CMST i0%,ant syste0 <3RC7D6J+ 7G, Man!ei0, Ger0any= %ossesses a #o0%ressi1,e #o0%onent t!at redu#es t!e i0%a#t o. an o##,usa, .or#e to t!e su%%orting i0%,ant.37 Ct !as 1een suggested t!at t!is >stress91rea$ing? .eature ,ends itse,. to ,in$age 4it! natura, teet!. o4ever, intrusion o. t!e natura, su%%orting toot! !as 1een re%orted 4!en CMST i0%,ants in #o01ination 4it! natura, teet! are used to su%%ort .ixed 1ridges.3( 7,t!oug! t!is syste0 see0s to over#o0e t!e in!erent %ro1,e0s o. ,in$ing teet! to i0%,ants, it is 4ide,y a#$no4,edged t!at t!e s#ienti.i# eviden#e .or t!is is ,i0ited at %resent. 7s a #onse8uen#e, .ixed %rost!eses su%%orted 1y teet! and i0%,ants s!ou,d 1e avoided 4!enever %ossi1,e.

%onsiderations of %ase Planning

+!e re,ations!i% 1et4een t!e o##,usion and t!e i0%,ant*1one t!at 4i,, su%%ort it is extre0e,y i0%ortant. Restoration 1y t!e %rovision o. i0%,ant su%%orted %rost!esis %resents a #!a,,enge, 1e#ause t!e #,ini#ian !as t!e o%%ortunity to5

De#ide t!e siQe and s!a%e o. t!e o##,usa, ta1,e /!oose t!e nu01er, %osition, siQe and orientation o. t!e i0%,ants Modi.y t!e 8uantity and ar#!ite#ture o. t!e 1one.

+!ese variations are not, o. #ourse, 4it!out ,i0it and t!ere 4i,, 1e #onstraints i0%osed 1y t!e %atient?s #ondition. Jevert!e,ess t!e 0any di..erent ty%es and designs o. %rost!eses, t!e #onsidera1,e nu01er o. avai,a1,e i0%,ant syste0s and t!e %ossi1i,ity o. 1one aug0entation o..er #onsidera1,e #!oi#e .or ea#! and every #ase. #hese choices can only -e enjoyed -y patients of those dentists ,ho plan ahead. +!is ,arge nu01er o. varia1,es t!at exists 4it!in t!ese design o%tions e0%!asise t!e need .or #are.u, treat0ent %,anning and #o00uni#ation 4it!in t!e treat0ent tea0 <surgeon, restorative dentist, ,a1oratory te#!ni#ian and 0ay1e !ygienist and * or genera, denta, %ra#titioner=. +!e %ro#ess .o,,o4s t!e %revious,y des#ri1ed 6D6/ %rin#i%,e. Presented 1e,o4 are so0e o. t!e varia1,es and t!eir re,ations!i% to o##,usion.
0. *elationship Between Occlusal Table and Implant Diameter

/anti,evered .or#es 0ay resu,t .ro0 extending t!e %rost!eses 1eyond 4!ere t!e i0%,ants are ,o#ated or arise 0ore su1t,y in t!e .or0 o. ridge9,a%%ed .ixed %rost!eses <3ig. 3=. Bot! are a sour#e o. non9axia, ,oading and, t!ere.ore, %otentia,,y ris$ i0%,ant .ai,ure. /,ear,y, t!e re,ations!i% 1et4een i0%,ant dia0eter and o##,usa, di0ensions are ,in$ed to non9axia, ,oading <3ig. A and 2a,1=.3B9AB Jon9axia, ,oading is to 1e avoided i. at a,, %ossi1,e. Ridge "a%%ing +!e %attern o. 1one resor%tion is not on,y a%i#a,, 1ut a,so ,ingua,. So an i0%,ant is ,i$e,y to 1e %a,ata, to t!e %osition Cdea, ridge .or0 .or t!e i0%,ant to su%%ort aest!eti# #ro4n

4!i#! 4ou,d a,,o4 t!e 0ost aest!eti# re%,a#e0ent o. t!e 0issing toot!. +!ere is a tenden#y, t!ere.ore, to %,a#e t!e #ro4n onto t!e i0%,ant in a %osition t!at is ,a1ia, to t!e i0%,ant ie t!e i0%,ant 4i,, over,a% t!e ,a1ia, 1order o. t!e ridge. en#e Uridge ,a%%ingU +!e danger o. ridge ,a%%ing is t!at it is, in e..e#t, a ,a1ia, #anti,ever on t!e i0%,ant. Resor1ed ridge .or0 resu,ting in ex#essive ridge ,a%%ing <.or aest!eti# reasons=

Cn t!is exa0%,e, t!e 0ost aest!eti# %,a#e0ent o. t!e #ro4n is ,a1ia, to t!e %osition o. i0%,ant, 4!i#! !as 1een restri#ted 1y t!e resor%tion o. t!e a,veo,us in a %a,ata, dire#tion. +!is resu,ts in a #anti,evered o##,usa, .or#e on t!e i0%,ant and 0ay a,so 1e asso#iated 4it! in.,a00ation o. t!e 0argina, gingivae. +!is 0ay 1e detri0enta, to t!e i0%,ant and #ause .ai,ure.

/ro4n

Bone

C0%,ant

3ig. Aa9# C. t!e i0%,ant is inserted 1e.ore verti#a, 1one ,oss !as o##urred, a nor0a, #,ini#a, #ro4n ,engt! 4i,, resu,t <see 3ig. 'a=

3ig. 21 Dista, vie4 o. t!e sa0e i0%,ant 3ig. 2a Bu##a, vie4 o. .ai,ed i0%,ant t!at su%%orting #ro4n 4it! ex#essive 1u##a, 4as su%%orting an o##,usa, ta1,e 4it! a #anti,ever. -nsur%rising,y t!is i0%,ant s,ig!t dista, #anti,ever dra0ati#a,,y .ai,ed. C. t!e ridge is narro4, 1e#ause o. resor%tion, t!e so,ution 0ay 1e5
o o

Jot on,y a narro4 i0%,ant, 1ut a,so a narro4 #ro4n Bone aug0entation or 1one 0ani%u,ation, to a,,o4 a 4ider i0%,ant to 1e inserted.

1.

Ideal Occlusal 5orphology Provide an Occlusion >hich is? o

Ba,an#ed o##,usion 4it! ,o4 #us%a, ang,es and .reedo0 in #entri# o##,usionA1 /o0%,i0entary to t!e existing o##,usion

o o

7#!ieva1,e <,ingua,ised o##,usion 0ay 1e easiest= 3ree o. any non9axia, .or#es <ie no in#,ined #onta#ts and %osterior inter.eren#es=.

:.

The &ignificance of Implant 8ength+%rown 8ength *atio

Cn si0%,e ter0s, a #ro4n ,engt! to i0%,ant ,engt! ratio o. 152 is idea,. +o a#!ieve t!is, ear,y i0%,ant %,a#e0ent 1e.ore verti#a, 1one !eig!t !as 1een ,ost is re#o00ended. C00ediate, or de,ayed i0%,ant insertion <at ' to 12 4ee$s a.ter extra#tion in t!e a1sen#e o. 1one %at!o,ogy= usua,,y .a#i,itates t!e o%ti0a, #ro4n*i0%,ant ratio. Cn %ra#ti#e, t!is 0eans t!at t!e i0%,ant o%tion needs to 1e #onsidered 1e.ore t!e extra#tion o. a toot!. Dit! in#reasing verti#a, 1one ,oss t!e i0%,ant#ro4n ratio 4i,, 1e#o0e %rogressive,y ,ess .avoura1,e <3ig. 'a9#=, not :ust in ter0s o. ,oading 1ut a,so in ter0s o. aest!eti# resu,ts and !ygiene 0aintenan#e. @n#e t!e i0%,ant9#ro4n ratio a%%roa#!es 151 a re0ova1,e %rost!esis s!ou,d 1e #onsidered. 7,t!oug! t!e re,ations!i% 1et4een t!e !ead o. t!e i0%,ant and t!e o##,usa, %,ane !as o1vious ,oading i0%,i#ations 4!i#! are ,i$e,y to a..e#t i0%,ant su##ess rates, t!ere are no %u1,is!ed studies in t!is area.

3ig. 'a9# C,,ustration o. !o4 t!e i0%,ant to #ro4n ratio 1e#o0es %rogressive,y 4orse <,oading and aest!eti#s= 4it! in#reasing verti#a, 1one ,oss. <Ye,,o4 ,ine is t!e 1one ,eve, and t!e red ,ine is t!e gingiva, 0argin= (uideline: 0a+imise the implant to cro,n ratio ,hen anatomically possi-le. 3ith si"nificant vertical -one loss1 a fi+ed prosthesis may not -e feasi-le unless pre*

implant -one "raftin" is accepta-le to re*esta-lish favoura-le inter*arch vertical relationships.

<. The &ite and 3ature of the Implant Bed

Ct is $no4n t!at .or osseointegration to o##ur %redi#ta1,y #ertain #onditions 0ust 1e 0et5
o o

+!e i0%,ant 0ust #onsist o. a suita1,e 1io0ateria, 4it! a%%ro%riate sur.a#e %ro%erties 7de8uate vita, 1one 0ust 1e %resent to su%%ort and integrate 4it! t!e i0%,ant &ummary of Occlusal Guidelines?

Se,e#t t!e 4idest dia0eter i0%,ant Provide a verti#a, e0ergen#e %ro.i,e 4it! no ridge ,a%%ing to avoid nonaxia, ,oading Cn narro4 ridges #onsider a re0ova1,e %rost!esis, ridge aug0entation, or a1andoning i0%,ant treat0ent +!e o##,usa, ta1,e s!ou,d 1e designed not to over,oad t!e 1one9 i0%,ant inter.a#e

7 %re#ise surgi#a, .it 0ust 1e a#!ieved 1et4een t!e 1one and t!e i0%,ant

- . - amine D . Design - . - ecute % . %hec/ /,ini#a, studies and ex%erien#e !ave s!o4n t!at i0%,ants %,a#ed into t!e %osterior 0axi,,a #an 1e ex%e#ted to s!o4 ,o4er su##ess rates,1H,A2 t!is 0ay 1e #aused 1y t!e %otentia,,y !ig!er o##,usa, ,oads at t!e 1a#$ o. t!e 0out!. 68ua,,y, an i0%,ant site t!at !as 1een aug0ented <regard,ess o. t!e 0ateria, or te#!ni8ue used= #an 1e ex%e#ted to %ossess a redu#ed a1i,ity initia,,y to 4it!stand o##,usa, ,oad. +!is e..e#t 0ig!t 1e %er0anent or te0%orary, de%ending u%on t!e 0ateria, used and t!e a1i,ity o. t!at 0ateria, to 1ond 4it! or 1e#o0e re%,a#ed 1y vita, 1one. (uideline: #he a-ility of the implant -ed to support occlusal load is dependant upon:
o o

Site <o##,usa, ,oad %otentia,,y in#reases to4ards t!e 1a#$= Vua,ity o. su%%orting 1one <sta1,e autogenous 1one 4it! no aug0entation is t!e >go,d standard?=.

=.

The Importance of 5onitoring of Occlusal 8oad

Sin#e osseointegrated i0%,ants #annot 0ove 1y nature o. t!eir re,ations!i% 4it! 1one, t!ere is a #onsidera1,e te0%tation to #onsider t!at restored i0%,ants re8uire ,itt,e i. any 0onitoring. o4ever, t!e nature o. o##,usa, #onta#ts and re,ations!i%s #an #!ange as a resu,t o. 0any .a#tors in#,uding toot! and %rost!esis 4ear <3ig. 7=, ,oss o. teet! or i0%,ants, and 0u#osa, atro%!y. A3

3ig. 7 Prost!esis 4ear. Six years o. use !ave severe,y 4orn t!is i0%,ant su%%orted denture. /o0%are t!e 4orn denture <3ig. 7a= against t!e s%are denture <3ig. 71= 4!i#! 4as 0ade at t!e sa0e ti0e. (uideline: Re"ularly evaluate the occlusal relationships of the implant supported prosthesis $at short intervals1 typically 4@5 months'. #he provision of any treatment that has the potential to chan"e the occlusion any,here in the mouth should -e the tri""er to check the occlusion of an implant supported prosthesis. )ccurate occlusal records of the startin" point are e+tremely helpful.
Pre+Treatment - amination and %ase #>or/ @p$

Jot a,, #ases 4i,, need a,, o. t!e stages ,aid out 1e,o4. +!ese stages are %resented as guide,ines to ensure t!at t!e o##,usion %rovided 1y a %rost!esis su%%orted 1y i0%,ants is 4e,, to,erated 1y t!e %atient. E+amination 7 s!ort exa0ination o. t!e %atient?s arti#u,atory syste0 <+MJ, 0us#,es, o##,usion= is needed to diagnose any %re9existing +MD. +!is 4i,, in#,ude any signs o. an a#tive %ara.un#tion <tongue s#a,,o%ing and #!ee$ ridging=. Cn %arti#u,ar, a note 4ou,d 1e 0ade o.

any eviden#e t!at o##,usa, .a#tors #ontri1uted to t!e ,oss o. teet! .or 4!i#! i0%,ant treat0ent is 1eing #onsidered. +!is #ou,d a,ter t!e treat0ent %,an #onsidera1,y. 7 8ua,itative and 8uantitative assess0ent o. t!e %otentia, i0%,ant 1ed 4i,, in.,uen#e t!e ty%e o. t!e %rost!esis and t!e o##,usa, ta1,e t!at it #an %rovide. <ase 3ork 8p$ !tudy models 0ounted on a se0i9ad:usta1,e arti#u,ator a.ter .a#e1o4 re#ord 4i,, 0a$e it 0u#! si0%,er to exa0ine t!e existing o##,usion and to design an a%%ro%riate o##,usa, s#!e0e ) dia"nostic ,a+*up or %re9i0%,ant diagnosti# %rost!esis 4i,, !e,% t!e restorative #,ini#ian and t!e ,a1oratory te#!ni#ian %,an t!e eventua, %rost!esis. Ct 4i,, a,so 1e an aid in t!e #onstru#tion o. any te0%orary or %rovisiona, restorations. ) sur"ical stent is a devi#e t!at ena1,es t!e idea, %osition o. t!e i0%,ants to 1e visua,ised at t!e surgi#a, %!ase o. treat0ent. Cts use is 0ore t!an si0%,y a surgi#a, aid, it e01odies t!e %rin#i%,e t!at t!e %osition o. t!e i0%,ants s!ou,d <4it!in t!e %!ysi#a, #onstraints o. t!e a,veo,ar 1ed= 1e deter0ined 1y t!e aest!eti# and o##,usa, o1:e#tives o. t!e .ina, restorations. 7 diagnosti# 4ax u% <see se#tion on Good @##,usa, Pra#ti#e in 7dvan#ed Restorative Dentistry= 4i,, great,y .a#i,itate t!e #onstru#tion o. a use.u, surgi#a, s%,int. +!e %rin#i%,e t!at t!e %osition o. t!e i0%,ants 4i,, 1e deter0ined 1e.ore t!e surgi#a, a%%oint0ent and 1y .a#tors in#,uding t!e aest!eti# and o##,usa, o1:e#tives o. t!e treat0ent %,an is %ara0ount. 1. Buser D, Du,a &, Be,ser -, irt P, Bert!o,d . "o#a,ised ridge aug0entation using guided 1one regeneration 1. Surgi#a, %ro#edure in t!e 0axi,,a. Cnt A Beriod C Rest Dent 1HH3) 135 2H9A2 2. 7de,, R, "e$!o,0 -, Ro#$,er B, Brane0ar$ P C. 7 129year study o. osseointegrated i0%,ants in t!e treat0ent o. t!e edentu,ous :a4. Int A ral !ur" 1H(1) 1B5 3(79A1'. 3. Sar1 G. @sseointegration5 a re8uie0 .or t!e %eriodonta, ,iga0entR Int A Beriod C Rest Dent 1HH1) 115 ((9H1. A. Deiner S, &,ein M, Doy,e J ", Brunner M. Cdenti.i#ation o. axons in t!e %erii0%,ant region 1y i00uno!isto#!e0istry. Int A ral 0a+illofac Implants 1HH2) 1B5 '(H9 'H2. 2. Ja#o1s R, van Steen1erg!e D. /o0%arison 1et4een i0%,antsu%%orted %rost!eses and teet! regarding %assive t!res!o,d ,eve,. Int A ral 0a+illofac Implants 1HH3) (5 2AH9 22A. '. a00er,e / , Dagner D, Bragger - et a,. +!res!o,d o. ta#ti,e sensitivity %er#eived 4it! denta, endosseous i0%,ants and natura, teet!. <lin ral Implants Res 1HH2) '5 (39HB.

7. +ru,sson M, Gunne S. 3ood9!o,ding and 1iting 1e!avior in !u0an su1:e#ts ,a#$ing %eriodonta, re#e%tors. A Dent Res 1HH() 775 27A92(2. (. Rosen P S, Su00ers R, Me,,ado J R et a,. +!e 1one9added osteoto0e sinus .,oor e,evation te#!ni8ue5 0u,ti#enter retros%e#tive re%ort o. #onse#utive,y treated %atients. Int A ral 0a+illofac Implants 1HHH) 1A5 (239(2(. H. &e,,er 6 6, +o,0an D 6, 6#$ert S 6. Maxi,,ary antra,9nasa, in,ay autogenous 1one gra.t re#onstru#tion o. #o0%ro0ised 0axi,,a5 a 129year retros%e#tive study. Int A ral 0a+illofac Implants 1HHH) 1A5 7B79721. 1B. Meri#s$e9Stern R, Perren R, Rave! J. "i.e ta1,e ana,ysis and #,ini#a, eva,uation o. ora, i0%,ants su%%orting %rost!eses a.ter rese#tion o. 0a,ignant tu0ors. Int A ral 0a+illofac Implants 1HHH) 1A5 '739'(B. 11. "e$!o,0 -, Gunne J, enry P, igu#!i &, "inden -, Bergstro0 /, van Steen1erg!e D Cnt Surviva, o. t!e Brane0ar$ i0%,ant in %artia,,y edentu,ous :a4s5 a 1B9year %ros%e#tive 0u,ti#enter study. A ral 0a+illofac Implants 1HHH) 1A5 '3H9 'A2. 12. Ba,s!i + J, Do,.inger G J, Ba,s!i S 3. Se#ond 7na,ysis o. 32' %terygo0axi,,ary i0%,ants in edentu,ous ar#!es .or .ixed %rost!esis an#!orage. Int A ral 0a+illofac Implants 1HHH) 1A5 3H(9AB' 13. 3rou0 S J, +arno4 D P, Da,,a#e S S, Ro!rer M D, /!o S /. Sinus .,oor e,evation using anorgani# 1ovine 1one 0atrix <@steoGra.*J= 4it! and 4it!out autogenous 1one5 a #,ini#a,, !isto,ogi#, radiogra%!i#, and !isto0or%!o0etri# ana,ysis. Part 2 o. an ongoing %ros%e#tive study. Int A Beriodontics Restorative Dent 1HH() 1(5 22(9 2A3. 1A. Cvano.. / J, Gronda!, &, Senner1y ", Bergstro0 /, "e$!o,0 -. Cn.,uen#e o. variations in i0%,ant dia0eters5 a 39 to 29year retros%e#tive #,ini#a, re%ort. Int A ral 0a+illofac Implants 1HHH) 1A5 17391(B. 12. Morris 3, @#!i S ydroxya%atite#oated i0%,ants5 a #ase .or t!eir use. A ral 0a+illofac !ur" 1HH() 2'5 13B39 1311. 1'. &ar,sson -, Got.redsen &, @,sson / 7 29 year re%ort on 0axi,,ary and 0andi1u,ar .ixed %artia, dentures su%%orted 1y 7stra +e#! denta, i0%,ants. 7 #o0%arison o. 2 i0%,ants 4it! di..erent sur.a#e textures. <lin ral Implants Res 1HH() H5 23292A2. 17. Datson R, Marine,,o /, &:e,,0an @, Rund#rantQ +, 3a!raeus J, "it!ner B. Do !ea,ing a1ut0ents in.,uen#e t!e out#o0e o. i0%,ant treat0entR 7 t!ree9year 0u,ti#enter study. A Brosthet Dent 1HH() (B5 1H391H(. 1(. 7,1re$tsson +, Sar1 G 7, Dort!ington P, 6ri$sson 7 R. +!e ,ong9ter0 e..i#a#y o. #urrent,y used denta, i0%,ants5 a revie4 and %ro%osed #riteria o. su##ess. Int A ral 0a+illofac !ur" 1H(') 15 11922.

1H. Datson / J, +ins,ey D, @gden 7 R, Russe,, J ", Mu,ay S, Davison 6 M. 7 39 to A9 year study o. sing,e toot! !ydroxy,a%atite #oated endosseous denta, i0%,ants. Dr Dent A 1HHH) 1(75 HB9HA. 2B. Preis$e, D, +so,$a P. +reat0ent out#o0es in i0%,ant t!era%y5 t!e in.,uen#e o. surgi#a, and %rost!odonti# ex%erien#e. Int A Brosthodont 1HH2) (5 273927H. 21. Deyant R J. +!e #ase .or #,ini#a, registries. Cn +rot0an / 7, M#Ja0ara J 7. <eds= rthodontic treatment: outcome and effectiveness. 1st ed %% 31H93A3. 7nn 7r1or5 -niversity o. Mi#!igan. 22. e, 7s$ary 7 S, Me..ert R M, Gri..in + D!y do denta, implants failE Bart I. Implant Dent 1HHH) (5 17391(2. 23. 6s%osito M, "aus0aa J, irs#! J M, +!o0sen P. Sur.a#e ana,ysis o. .ai,ed ora, titaniu0 i0%,ants. A Diomed 0ater Res 1HHH) A(5 22H92'(. 2A. 6s%osito M, +!o0sen P, 6ri#son " 6, "e$!o,0 -. isto%at!o,ogi# o1servations on ear,y ora, i0%,ant .ai,ures. Int A ral 0a+illofac Implants 1HHH) 1A5 7H(9(1B. 22. @?Ma!ony 7, S%en#er P. @sseointegrated i0%,ant .ai,ures. A Ir Dent )ssoc 1HHH) A25 AA921. 2'. Je40an 1H(( Je40an M J, 3,e00ig 3 +. Periodonta, #onsiderations o. i0%,ants and i0%,ant asso#iated 0i#ro1iota. A Dent Educ 1H(() 225 737. 27. 27. 6s%osito M, irs#! J, "e$!o,0 -, +!o0sen P. Di..erentia, diagnosis and treat0ent strategies .or 1io,ogi# #o0%,i#ations and .ai,ing ora, i0%,ants5 a revie4 o. t!e ,iterature. Int A ral 0a+illofac Implants 1HHH) 1A 5 A739AHB. 2(. Csidor 3. isto,ogi#a, eva,uation o. %erii0%,ant 1one at i0%,ants su1:e#ted to o##,usa, over,oad or %,a8ue a##u0u,ation. <lin ral Implants Res 1HH7) (5 19H. 2H. Pa,0er R, Pa,0er P, o4e ". Denta, i0%,ants5 Part 1B. /o0%,i#ations and 0aintenan#e.Dr Dent A 1HHH5 1(75 '239'2(. 3B. M Jorton. 3ixed 1ridge re!a1i,itation. In M.Jorton Denta, Implants: a "uide for the "eneral practitioner. 1st ed. %% (191BA. "ondon5 Vuintessen#e Pu1,is!ing /o "td,1HH2. 31. Mu.tu 7, /!a%0an R J. Re%,a#ing %osterior teet! 4it! .reestanding i0%,ants5 .our9 year %rost!odonti# resu,ts o. a %ros%e#tive study. A )m Dent )ssoc 1HH() 12H 5 1BH7911B2. 32. Ba!at @, ande,s0an M. -se o. 4ide i0%,ants and dou1,e i0%,ants in t!e %osterior :a45 a #,ini#a, re%ort. Cnt J @ra, Maxi,,o.a# C0%,ants 1HH') 115 37H9 3('. 33. Ba,s!i + J, ernandeQ R 6, PrysQ,a$ M /, Rangert B 7 #o0%arative study o. one i0%,ant versus t4o re%,a#ing a sing,e 0o,ar. Int A ral 0a+illofac Implants 1HH') 115 372937(.

3A. S#!4artQ97rad D, Sa0et J. Sing,e toot! re%,a#e0ent o. 0issing 0o,ars5 a retros%e#tive study o. 7( i0%,ants. A Beriodontol 1HHH) 7B5 AAH9A2A. 32. ReitQ J L. "ingua,iQed o##,usion in i0%,ant dentistry. Fuintessence Int 1HHA) 225 17791(B. 3'. RodrigueQ 7 M, 78ui,ino S 7, "und P S, Ryt!er J S, Sout!ard + 6. 6va,uation o. strain at t!e ter0ina, a1ut0ent site o. a .ixed 0andi1u,ar i0%,ant %rost!esis during #anti,ever ,oading. A Brosthodont 1HH3 ) 25 H391B2. 37. /!a%0an R J, &irs#! 7 Lariations in o##,usa, .or#es 4it! a resi,ient interna, i0%,ant s!o#$ a1sor1er. Int A ral 0a+illofac Implants 1HHB) 25 3'H937A. 3(. Gar#ia " +, @ester,e " J. Jatura, toot! intrusion %!eno0enon 4it! i0%,ants5 a survey. Int A ral 0a+illofac Implants 1HH() 135 2279231. 3H. Dein1erg " 7, &ruger B. 7n eva,uation o. tor8ue <0o0ent= on i0%,ant*%rost!esis 4it! staggered 1u##a, and ,ingua, o..set. Int A Beriodont Restor Dent 1HH') 1'5 2229 2'2. AB. Dein1erg " 7 Redu#tion o. i0%,ant ,oading using a 0odi.ied #entri# o##,usa, anato0y. Int A Brosthodont 1HH() 115 229'H. A1. &au$inen J 7, 6dge M J, "ang B R. +!e in.,uen#e o. o##,usa, design on si0u,ated 0asti#atory .or#es trans.erred to i0%,ant9retained %rost!eses and su%%orting 1one. A Brosthet Dent 1HH') 7'5 2B922. A2. Ja..in R 7, Ber0an / ". +!e ex#essive ,oss o. Brane0ar$ i0%,ants in ty%e CL 1one5 a 29year ana,ysis. A Beriodontol 1HH1) '25 29A. A3. Dario " J. o4 o##,usa, .or#es #!ange in i0%,ant %atients5 a #,ini#a, resear#! re%ort. A )m Dent )ssoc 1HH2) 12'5 113B91133.

The %ompleted 8ist of Guidelines of Good Occlusal Practice

1. +!e exa0ination o. t!e %atient invo,ves t!e teet!, %eriodonta, tissues and arti#u,atory syste0. 2. +!ere is no su#! t!ing as an intrinsi#a,,y 1ad o##,usa, #onta#t, on,y an into,era1,e nu01er o. ti0es to %ara.un#tion on it. 3. +!e %atient?s o##,usion s!ou,d 1e re#orded, 1e.ore any treat0ent is started. A. /o0%are t!e %atient?s o##,usion against t!e 1en#!0ar$ o. idea, o##,usion. 2. 7 si0%,e, t4o di0ensiona, 0eans o. re#ording t!e %atientUs o##,usion 1e.ore, during and a.ter treat0ent is an aid to good o##,usa, %ra#ti#e. '. +!e #on.or0ative a%%roa#! is t!e sa.est 4ay o. ensuring t!at t!e o##,usion o. a restoration does not !ave %otentia,,y !ar0.u, #onse8uen#es.

7. 6nsuring t!at t!e o##,usion #on.or0s <to t!e %atient?s %re9treat0ent state= is a %rodu#t o. exa0ination, design, exe#ution and #!e#$ing <6D6/= (. +!e >reorganised a%%roa#!? invo,ves .irst,y t!e esta1,is!0ent o. a >0ore idea,? o##,usion in t!e %atient?s %retreat0ent teet! or %rovisiona, restorations) and t!en ad!ering to t!at design using t!e te#!ni8ues o. t!e >#on.or0ative a%%roa#!? H. 7n >idea, o##,usion? in re0ova1,e %rost!odonti#s is one 4!i#! redu#ed de9 sta1i,ising .or#es 1B. +!e o##,usa, o1:e#tive o. ort!odonti# treat0ent is not #,ear, 1ut a ,arge dis#re%an#y 1et4een #entri# o##,usion and #entri# re,ation s!ou,d not 1e an out#o0e o. treat0ent 11. 7n >ort!odonti#? exa0ination o. t!e o##,usion s!ou,d in#,ude5 t!e dyna0i# o##,usion) and t!e :a4 re,ations!i% in 4!i#! t!e %atient !as #entri# o##,usion 12. +!e o##,usion o. %eriodonta,,y #o0%ro0ised teet! s!ou,d 1e designed to redu#e t!e .or#es to 1e 4it!in t!e ada%tive #a%a1i,ities o. t!e da0aged %eriodontia 13. Good o##,usa, %ra#ti#e in #!i,dren is deter0ined 1y t!e needs o. t!e deve,o%ing o##,usion, #onse8uentia,,y >restoration at a,, #osts? 0ay not 1e t!e 1est %o,i#y. 1A. Jot a,, toot! sur.a#e ,oss needs treat0ent, 1ut e..e#tive 0onitoring is essentia, 12. Dento9a,veo,ar #o0%ensation !as o.ten o##ured in %atients exi1iting 0ar$ed toot! sur.a#e ,oss. 1'. +!e o##,usa, %res#ri%tion o. an i0%,ant su%%orted restoration needs to ta$e a##ount o. t!e .eatures o. osseointegration 17. +!e o##,usion s!ou,d 1e %,anned 1e.ore i0%,ants are %,a#ed Re%rinted 4it! %er0ission. Britis! Denta, Journa, Lo,u0eWW, Jo.WWW, DateWWWWWWW