Occlusal Loading for Implant Dentistry and Improving Prognosis
One of the most frequent patient issues we deal with in Implant Dentistry is parafunction. Patients force factors can vary greatly: from 50 Ncm to 300 Ncm. A six fold variation! Men put more stress on their teeth than women and what opposes a dental implant are also two key factors in addition to parafunction. An opposing denture is the least stressful/least force, and an implant prosthesis is the most stressful/low proprioception. Melo et al, J Prosthodont, 2018.
Commonly we all see fractured teeth, excessively worn dentitions, cracks in teeth, fractured porcelain/restorations, and most commonly a lack of anterior guidance and/or posterior supporting teeth, that have a root/implant to bear the stress of parafunction (bridges and partials don’t count!). In addition I routinely evaluate masseter muscle thickness: the thicker the muscle, the greater likelihood of parafunction destruction of dentition. Kiliaridis et al, Int J Oral Implantol, 2019.
All too often, more treatment that was originally planned has to be done. A failed distal implant, in a maxillary “All on 4” case comes to mind resulting in the need to graft the sinus and place an extra implant yielding an “All on 5”. As you would guess, I believe when in doubt, overbuild the case: Narrow occlusal tables, extra implants, short cantilevers, bone augmentation, occlusal guards, durable prosthetic materials and retaining teeth where feasible for proprioception are some of the methods to attenuate occlusal stress that we can’t control.
Lastly being sure the patient understands the risks they take when partial treatment is what they desire. All too often, a patient will want one tooth replaced due to fracture and they are missing a number of posterior supporting teeth.
Greg Kammeyer, DDS, MS, DABOI Board Certified American Board of Oral Implantology
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