Professional Documents
Culture Documents
Scs 0b013e31826b8267
Scs 0b013e31826b8267
16. Van Sickels JE, Peterson GP, Holms S, et al. An in vitro comparison
of an adjustable bone fixation system. J Oral Maxillofac Surg
2005;63:1620Y1625
T ooth and supporting structure loss has traditionally been reha-
bilitated using partial or complete dentures. However, patients
who have undergone these treatment modalities may not be satisfied
17. Ellis E. Condylar positioning devices for orthognathic surgery: are with function,1 and for these complaints, dental implants have shown
they necessary? J Oral Maxillofac Surg 1994;52:536Y552 advantages associated with implant-supported prostheses such as im-
18. Kleier C, Kleinheinz J, Stamm T, et al. Prospective cephalometric proved retention, stability, chewing efficiency, and quality of life.2
evaluation of an adjustable bone fixation system for the sagittal split
ramus osteotomy [in German]. Mund Kiefer Gesichtschir 2000;4:
Despite all the advantages presented by the implant anchorage
296Y300 and its high success rates in clinical trials, osseointegration failures
19. Landes CA, Stübinger S, Rieger J, et al. Critical evaluation of and complications have been reported. Failures are usually associ-
piezoelectric osteotomy in orthognathic surgery: operative technique, ated with bone loss around the implant platform,3,4 which occurs at
blood loss, time requirement, nerve and vessel integrity. early stages related to surgical procedures or, later, associated with
J Oral Maxillofac Surg 2008;66:657Y674 function overload.5
Bone loss around the implant platform may be caused by bac-
terial infection, trauma, or overload.3,4 As bacterial infection is
linked to poor hygiene habits of the individual and trauma to the
patient’s particular circumstances, both factors are poorly influenced
Elements of Implant-Supported by the actions of a dentist. However, in bruxers, the main cause of
failure could be related to implant overload, a factor that can be
Rehabilitation Planning in controlled by proper clinical management.4,6 When overload occurs,
the level of stress concentration at the implant-bone interface depends
Patients With Bruxism on several factors related to load transfer, such as the direction of
the functional loads, ie, axial and oblique forces, the resiliency
Hugo Ramalho Sarmento, DDS,
properties of the implant and alveolar bone, the implant macro-
Raquel Venâncio Fernandes Dantas, DDS, MSc, geometry and microgeometry, and the quality of the bone support.4,6
Tatiana Pereira-Cenci, DDS, PhD, Fernanda Faot, DDS, PhD Several studies have associated implant fractures or failures of
implant-supported prostheses with occlusal overload related to para-
Abstract: The rehabilitation of partial or completely edentulous functional habits or bruxism.7Y11 Bruxism is described as a diur-
patients with implant-supported prostheses has been widely used, nal or nocturnal parafunctional activity that includes clenching,
achieving high success rates. However, many studies consider the locking, and grinding between dental arches, characterized by re-
presence of bruxism as a contraindication for this treatment modality. petitive (phasic) or sustained (tonic) contractions of the masticatory
The purpose of this study was to revise the literature and identify risk muscles.12,13 In implant-supported rehabilitation treatment plan-
factors in implant-supported rehabilitation planning in subjects with ning, bruxism should be considered a determining factor since the
bruxism. Available literature was searched through Medline, with no consequences of parafunctional movements over dental implants
time limit, including only studies in English. Topics discussed were may compromise their longevity through marginal bone loss and the
etiology of bruxism and its implications on dental implants, biome- impairment of osseointegration.
Considering the necessity of gaining knowledge of and dealing
chanical considerations regarding the overload on dental implants, and with bruxism in patients with the necessity of implant-supported
methods to prevent the occurrence of overloads in implant-supported prosthesis, this study aimed to systematically search and critically
prostheses. The rehabilitation of bruxers using implant-supported review the literature to identify the factors that should be consid-
prostheses, using implants with adequate length and diameter, as well as ered when planning implant-supported rehabilitations in subjects
proper positioning seems to be a reliable treatment, with reduced risks with bruxism. A literature search was conducted using the Med-
of failure. Bruxism control through the use of a nightguard by rigid line database from January 1949 to October 2011. Full papers or
occlusal stabilization appliance relieved in the region of implants is reviews in English were included. The following search strategy
highly indicated. Although it is clear that implant-supported rehabili- was employed using Mesh terms: ((((‘‘Dental Implants’’[Mesh])
tation of patients with bruxism requires adequate planning and follow- OR ‘‘Dental Abutments’’[Mesh]) OR ‘‘Dental Prosthesis, Implant-
up, well-designed randomized controlled trials are needed to provide Supported’’[Mesh]) OR ‘‘Dental Implantation’’[Mesh]) AND
‘‘Bruxism’’[Mesh]. Among 62 retrieved documents, 3 full papers
reliable evidence on the long-term success of this treatment modality. and 8 reviews were included in this review. The excluded documents
were case reports, case series, or did not fit into the scope of this
Key Words: Dental implants, implant-supported dental prosthesis, review. A hand search was performed from the reference lists of
these included documents. This paper includes a discussion of topics
mouth rehabilitation, tooth diseases
related to the etiology of bruxism and its impact on dental implants,
biomechanical considerations regarding implant overload, and guide-
lines for clinical practice.
From the Graduate Program in Dentistry, Federal University of PelotasV
UFPEL, Pelotas, Brazil.
Received May 30, 2012. ETIOLOGY OF BRUXISM AND ITS
Accepted for publication July 24, 2012. INFLUENCE ON DENTAL
Address correspondence and reprint requests to Fernanda Faot, DDS, IMPLANT PLANNING
MSc, PhD, School of Dentistry, Federal University of Pelotas,
Gon0alves Chaves St., 457, Center, 96015560 Pelotas, RS, Brazil;
E-mail: [email protected] Bruxism is often considered a contraindication for implant ther-
The authors report no conflicts of interest. apy.11 However, practical guidelines are available to minimize the
Copyright * 2012 by Mutaz B. Habal, MD risk of failure. Although the etiology of bruxism is not yet well
ISSN: 1049-2275 established in the literature, there is a consensus about its multi-
DOI: 10.1097/SCS.0b013e31826b8267 factorial nature.13 Researchers used to believe that peripheral factors,
Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies The Journal of Craniofacial Surgery & Volume 23, Number 6, November 2012
mainly occlusal interference, were determinants in bruxism etio- and the amount of force applied is lower in the anterior region. In
logy,14 with treatment based primarily on irreversible occlusal inter- addition, the teeth increase in diameter in the premolars and again
ventions15 or the use of occlusal splints.16,17 Nowadays, a minor role in molar region, with an increasing volume of incident forces. To
has been attributed to peripheral factors,13 with increasing importance support the higher loads in the posterior region, the number of roots
of psychosocial (stress and level of education) and pathophysiolog- on natural teeth increases the more posterior they are located. These
ical (excitation during sleep and central nervous system disorders) factors result in a 300% increase in the surface area of molars com-
factors,18 which has resulted in the modification of treatment pared to anterior teeth.26
recommendations.13 In contrast, most available implant systems have increased sur-
Some studies have sought to investigate the prevalence of symptoms face area of only around 25% to 50% when the narrow and wider
of emotional background and its association with bruxism. Emotional diameters are compared.26 Thus, although large implants have a
stress and a high prevalence of bruxism in police officers has been greater surface area, it is lower compared to that of the natural posterior
50.25%,19 with slightly more than half aware of the disease. Emotional teeth,27 which could explain the less efficient transmission of stress
stress was observed in 45.69% of police officers, while almost half of between dental implants and the alveolar bone surface.
those said to grind their teeth during sleep or while awake. There was a In addition, prosthetic loads may be different in partially eden-
significant association between bruxism and emotional stress, regard- tulous patients compared to edentulous patients and in the different
less of the type of work performed by the professional. However, an- regions of the maxilla and mandible.28 A study evaluating single-
other study20 pointed out that the prevalence of self-reported stress was tooth implant prostheses found that implant fractures have occurred
not significantly different in healthy or bruxer men. only in the molar region and especially in the area of the first molar.29
Currently, the treatment of bruxism by conservative and revers- In the posterior region, the combination of increased mechanical load,
ible measures has become a consensus among researchers.12,13 buccolingual jaw movement, and the orientation of ridges and cusps
Thus, conflicting results regarding the clinical efficacy of occlusal can originate excessive force obliquely.8
splints21,22 and a lack of knowledge about the potential mechanisms While the average masticatory occlusal force in a dentate subject
that explain its apparent successful treatment for bruxism led to the varies by around 450 to 550 N in the second molar region, the force
observation that these devices represent a nonspecific therapy.22 decreases to 200 and 300 N in patients with an implant-supported
Thus, it has been suggested that occlusal splints are restricted to the removable prosthesis.30 However, the compressive strength of cor-
prevention and/or limitation of dental wear potentially induced by tical bone is approximately 100 MPa,31 and what causes bone loss
bruxism.13,22,23 in the region of the alveolar crest is, to some extent, predictable in
In a study performed in the USA in 1995,24 380 general dentists and patients rehabilitated by means of oral implants. A logical explana-
specialists were interviewed to determine what type of occlusal appli- tion for this is the absence of the periodontal ligament in implants,
ance was most prescribed and the number of occlusal splints made in the which is responsible for the absorption and dissipation of incident
previous year for patients with bruxism. The results indicated that, on forces to the alveolar bone.
average, 11 occlusal splints were indicated, and 14.5% of professionals
indicated soft occlusal devices only, while 59.4% used rigid devices. Overload and Dental Implants on Bruxers
Another study23 showed that 8% of dentists in Germany indicated soft
splints to bruxers, and 15% of specialists and 52% of generalists The limited proprioception around dental implants results in limited
presented mistaken scientific knowledge regarding the etiology of the jaw reflex response mechanisms and, consequently, the elevator
disease. This shows the need for continued education among dental muscles.32 Thus, it is possible to assume that the forces applied to
professionals concerning this disorder,23 as there is an increase in the implants during bruxism are higher than those exerted during
electromyographic activity in bruxers who wear soft splints.16 chewing, which can cause an overload and the consequent failure
of the implant.11 Warning signs for the failure of osseointegrated
OVERLOAD ON IMPLANTS implants are recognized by loosening or fracture of screws or abut-
ments, swelling or bleeding of peri-implant soft tissues, purulent
Nervous System Modifications After exudate in the peri-implant pockets, superstructure fractures or
Implant Placement cracks, vertical bone loss radiographically observed, and chronic
infection and necrotic soft tissue during the healing phase after the
When tooth loss occurs, even when replaced by implants, mechano-
first-stage surgery. Pain has been reported as a rare symptom but
receptors present on the periodontal ligament are lost. Clinical studies
may be present.33
have clearly demonstrated that patients with oral implants have im-
The forces imposed on dental implants are characterized by their
portant missing or injured sensory-motor functions when the peri-
magnitude and direction. The stress forces directed obliquely outside
odontal receptors are removed during tooth extraction since the
the long axis of the implant are considered the most harmful.34 In
functional reinnervation around implants is uncertain.18
vivo studies with subjects with dental implants have shown that
Although it is important to consider the clinical consequences of
higher vertical load is received in the premolars during daily chewing,
deficient motor control in the jaws of patients with oral implants,18
ranging from 60 to 120 N (semisolid to solid food). It has also been
the number of studies evaluating the reflex function caused by the
observed that the maximum intercuspal clenching between natural
stimulation of functional oral implants in animal and human models
teeth and implants results in maximum vertical forces of around
is very limited.25 Nevertheless, it is known that some brain stem reflexes
50 N on the implant.35
cannot be caused by stimuli on implants. Thus, although at the histo-
A study performed using finite element analysis showed that the
logical level the innervation of the bone-implant interface increases
horizontal components of forces applied to a superstructure resulted
rapidly after implant installation, these free nerve endings do not trigger
in moments of force ranging from about 90 N/mm for the palato-
a reflex when activated by low-intensity mechanical stimuli.18
buccal forces to about 170 N/mm for the buccolingual direction.
Anatomical and Functional Alterations After Thus, the forces in the buccolingual direction generated the highest
Implant Placement values of stress in the alveolar bone, reaching values greater than
6 MPa in the alveolar crest on its buccal surface. On the other hand,
Anatomically, it has been observed that natural teeth are narrower in mesiodistal forces resulted in a maximum tension of only 1 MPa.
the anterior region of the mouth in relation to the posterior region, However, the values of horizontal and vertical load on implants were
Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery & Volume 23, Number 6, November 2012 Brief Clinical Studies
measured considering conscious regular motor activity, while the be avoided since their presence has been suggested as a possible
values for patients who presented unconscious motor activity and trigger of bruxism.14 In Tosun et al,9 a clinical study with sleep
bruxism are not yet well defined.36 bruxism patients, mutually protected occlusion was employed to-
Another factor that can cause overload is the inadequate design gether with the use of occlusal splints during sleep. Although
of the prosthesis since a superstructure with cantilevers has been patients continued to perform grinding, mechanical complications
associated with implant fractures.28,37 Authors have recommended were avoided by adopting occlusal schemes that uniformly distrib-
minimizing or, when possible, eliminating cantilevers, allowing the uted masticatory forces.
directing of occlusal forces to the long axis of the implant.37,38 In
addition, lack of passive fit of prosthesis causes stress on the screw HOW TO REDUCE STRESS ON IMPLANTS
combined with a constant shear load on the implant, predisposing
it to fracture, usually preceded by fracture or loosening of the Rehabilitation Planning
screw.7,28 A superstructure with nonpassive entry creates undesir-
When an implant-supported rehabilitation is considered in bruxers,
able stress, which has often been linked to implant fractures.2,39,40 In
occlusal examination is essential. Premature and posterior contacts
short, the diameter and length of implant,4,41Y43 thread pitch, and
during mandibular excursions increase the potential for excessive
shape surface-treated implants44 are morphological parameters that
loads on teeth and implants.51 Thus, it is important to emphasize
affect load transfer characteristics.
the importance of clinical evaluation and accurate anamnesis to
identify the disease and, hence, to improve the longevity of implant-
Biomechanical Considerations supported rehabilitation treatment.52
Regarding doubts about the load time determination, though a
Severe bruxism modifies the normal chewing forces in duration
recent systematic review1 has evaluated the load protocols for dental
(hours rather than minutes), direction (lateral instead of axial), type
implants and concluded that there is no predictability in the use of
(shearing rather than compressive force), and magnitude (4 to 7 times
immediate or early loading on dental implants, it is recommended
higher).45 The overload on dental implants leads to consequences
defined as biological and mechanical complications. Biological com- to use caution when using any of these techniques, especially in
bruxers. Although there is no conclusive scientific evidence that
plications can be divided into premature or late failure.5 In cases of
bruxism causes overload on dental implants and their superstructure,
premature failure with insufficient osseointegration, the implant is
professionals should proceed cautiously when planning implant-
lost before the prosthetic treatment.11 However, a recent systematic
supported restorations in bruxers, mainly due to the severity of pos-
review46 concluded that implants that were immediately loaded
sible complications. All preventive measures should be aimed at
(within up to 2 weeks after surgery) failed more often than those
minimizing the forces that are applied to implants.11
loaded in the conventional way but less frequently than those who
A bruxer patient presents an increased risk of implant fracture
received early loading (6 to 8 weeks after surgery). Thus, it seems
over time since the magnitude of forces increases as the muscles
more appropriate to indicate the use of immediate rather than early
become stronger. Therefore, when a source of additional load on the
loading since a high degree of primary stability is achieved. On the
implant is identified, the treatment plan must be changed to mini-
other hand, premature failure can occur with immediate or early
mize adverse effects on the alveolar bone, implant, and definitive
loading in patients with bruxism.11
restoration.27
Late biological failures are characterized by pathological bone
A significant number of general dentists still use irreversible
loss after complete osseointegration. This bone loss is usually located
techniques such as occlusal adjustment, prosthetic restorations, or
around the initial thread of the implant and is considered excessive
orthodontic procedures for bruxism control, trying to act preven-
when it is greater than 0.2 mm per year, even after a year under
tively.12 However, these techniques are contraindicated, as there is
functional load.47 Animal studies have shown that dynamic overload
weak evidence to indicate the need for irreversible techniques in
generated by the grinding of teeth results in severe angular bone loss.48
bruxism control.21
Mechanical complications occur when 1 or more implants fail,
which may occur by fracture of the prosthesis, loosening or fracture Occlusal Devices
of screws, loosening or excessive wear of overdenture components,
or excessive wear and fracture of porcelain or acrylic resin.49 The While a number of authors have reported the effectiveness of hard
loosening of screws is a frequent failure, especially when occlusal occlusal stabilization devices, minimizing the damage caused by
forces exceed the stabilizing forces, which often occurs in cases of parafunction on the oral tissues, clinical results have shown no
overload generated by parafunction.50 Fractures of implants and differences compared to other types of devices.17 The only exception
their components, though they are considered infrequent,49 have is soft splints. Studies have indicated that soft splints can increase
been associated with overloads created by a combination of para- muscular activity in some patients with bruxism,16 although the
functional stresses, cantilevers, posterior implant location and di- literature is still controversial.21 A recent systematic review showed
ameter, bone resorption, and possible misfit in superstructures.7 that rigid occlusal appliances can be effective in controlling pain in
Balshi7 divided the causes of implant or abutment fractures into patients with temporomandibular disorders.21 A clinical study53
3 categories: defects in the design of the implant or material, non- evaluated the effect of rigid or soft occlusal appliances in subjects
passive fit of prosthetic infrastructure, and physiological or bio- without tooth loss. The use of soft occlusal splints led to a feeling of
mechanical overloads. A tendency for posterior contact during the muscle fatigue that was accompanied by a decrease in bite force after
execution of eccentric bruxism and a consequent increase in trans- removal of the device, while the use of rigid devices on natural teeth
lational forces may be relevant factors in this type of failure. Thus, did not cause tiredness or modification of the bite force.
it has been suggested that, in bruxers, balanced bilateral contacts When considering only natural teeth, nightguard occlusal splints
may be modified for posterior disocclusion to avoid side contacts used on the upper arch can be a useful diagnostic tool in evaluating
in this region.9 occlusal disharmony and its relationship with sleep bruxism. These
From a biological and biomechanical perspective, even minor devices also promote centric occlusal contacts along the arch and
occlusal discrepancies appear to be acceptable, and the occlusal posterior disocclusion during the anterior guidance at all mandibular
scheme on implant-supported restorations must be designed and excursions and should be made of acrylic resin with a thickness of
carefully balanced.35 In addition, premature occlusal contacts should 0.5 to 1 mm on the occlusal surface. If the occlusal splint becomes
Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies The Journal of Craniofacial Surgery & Volume 23, Number 6, November 2012
worn in a month, the influence of occlusion in bruxism should be more implants with a larger diameter help to maintain tension on the
directly observed in the patient. In this case, an occlusal adjustment bone on the smallest possible magnitude.33
should have little influence on bruxism reduction, as a proper occlu- With respect to the implant/abutment connection, the implants
sion provided by the splint failed to reduce the habit. If the acrylic are hollow, so the fracture resistance of hollow tubular bodies has to
resin is not worn, the parafunction is reduced and occlusal protec- be considered using the formula P/4I(Ed4 j Id4), where Ed is the
tion becomes significant. Thus, the reconstruction or modification outer diameter and Id is the inner diameter. Therefore, an increase
of occlusal restorations is justified.27 in the internal opening of the body of an implant decreases the
In contrast to teeth, implants do not extrude in the absence of implant resistance to the fourth part. Thus, an implant with an in-
occlusal contact. Thus, in partially edentulous patients, occlusal ternal hexagon connection with the largest internal diameter avail-
devices can be relieved around implant-supported restorations, with able is 40% less resistant compared to an external hexagon implant
the remaining natural teeth supporting the entire load. Thus, the with the same diameter. This makes an external hexagon more in-
implant is protected from any load incidence in both centric and man- dicated in patients with bruxism.27 It is important to highlight,
dibular excursions during the use of occlusal appliances.27 however, that clinical trials have not yet considered the use of the
The teeth are more efficient in dealing with stress than occlusal Morse taper in patients with bruxism.
implants, ie, because of the periodontal ligament. A mandibular pos-
terior cantilever in an overdenture can also be maintained in infra- Prosthesis Design
occlusion during the use of occlusal splints. Although soft occlusal Prostheses should be designed with the purpose of improving the
splints are not indicated, when posterior implants are supporting a stress distribution on implants, ie, implants must be installed per-
maxillary fixed partial denture, a soft liner material can be used in pendicularly to the curves of Spee and Wilson to favor direct con-
the relieved region of the occlusal splint and around the crowns to
tacts generated during the vertical function to the long axis of the
alleviate stress and decrease the impact force. implants.45 Occlusal contacts must be precise on the antagonist arch
However, when implant prostheses are in both the maxilla and and carefully informed to laboratory technicians in all laboratory
mandible, the splints must be made with occlusal contact only in steps.27
the anterior region during occlusion and mandibular excursions. The The occlusal surfaces of posterior teeth can be reduced from the
amount of muscular force remains low while bilateral posterior areas palatal surface of maxillary implants or the buccal surface of man-
are out of occlusion, which decreases stress on implants.27 Rigid dibular implants to prevent excessive lateral forces to reduce tension
stabilization splints contribute to optimally distributed loads and the during chewing, leaving more space for the tongue and cheek. The
redirecting of incident vertical forces during night habits of grinding cusp slope reduction of antagonistic natural teeth has often been
and clenching.33,34,50 indicated to improve vertical force distribution on implants.27 Most
Number and Location of Implants authors agree that prosthetic rehabilitation must provide single-point
contact close to the implant center whenever possible. The articu-
When rehabilitating bruxers, calculation of the number of implants lation shall be marked by cusps with mild slopes to protect the
is mandatory since most authors have recommended more implants implant system against the transverse components of forces that are
than necessary to obtain favorable biomechanics.33,50 This recom- common during the gnashing of teeth.34
mendation is justified by studies that indicate a reduction of forces
received on each implant individually when the number of implants CONCLUSIONS
is increased.54 Nevertheless, considering the financial costs and the
irreversible nature of the placement of a greater number of implants, The rehabilitation of bruxer patients through the use of implants is
a careful clinical decision-making process should be built into the a feasible alternative when implants present adequate length and di-
treatment plan. The mechanical union of 2 or more implants is also ameter and correct positioning, reducing the risk of treatment failure.
an interesting measure, leading to better force distribution and stress However, control of bruxism manifestations is important, and the
reduction in the bone around implants.55 use of a hard occlusal stabilization splint relieved in the region of
The use of 1 implant for each absent element also avoids canti- the implants during sleep is recommended. In addition, before any
lever situations,33,50 reducing or eliminating the occlusal contacts in treatment is conducted, patients should be warned about the need for
lateral movements and reducing the risk of fractures.56 The proper regular maintenance to avoid complications and accept the possi-
positioning and alignment of implants is also desirable to decrease bility of technical complications that may generate additional costs
the incidence of nonaxial loads and the flexion of components of of maintenance in either implant-supported or implant-retained crowns
the prosthesis-implant system.10 Regarding implant positioning, a in partial or complete dentures.
straight line may favor the incidence of fractures under severe oc-
clusal force.28 Furthermore, in patients who lack natural anterior
teeth and posterior teeth, a slight increase in the canine to eliminate REFERENCES
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